cms_WV
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11077 | 11077 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 225 | E | 0 | 1 | CKVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not assure all newly hired employees were screened through the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was evident for five (5) of ten (10) randomly selected facility staff. Employee identifiers: #46, #135, #79, #59, and #23. Facility census: 89. Findings include: a) Employees #46, #135, #79, #59, and #23 On 06/02/09, a random sample of five (5) recently hired employees and five (5) employees hired greater than twelve (12) months ago were reviewed to determine whether the facility had checked each employee through the WV nurse aide abuse registry prior to their date of hire at the facility. The personnel files of three (3) licensed practical nurses (LPNs - Employees #46, #135, and #79) and two (2) registered nurses (RNs - Employees #59 and #23) contained no evidence of the facility having checked them against registry for findings of abuse, neglect, mistreatment of [REDACTED]. Employee #35 concurred there was no such evidence in the personnel file for those five (5) employees and subsequently obtained registry checks for them on 06/02/09. . | 2014-09-01 |
| 11078 | 11078 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 309 | D | 0 | 1 | CKVD11 | Based on observations of resident-staff interactions, staff interview, and review of medical records, the facility failed to ensure each resident was provided with the necessary care and services to attain or maintain his or her highest practicable level of well-being. A resident requested medication for a headache but did not receive the medication for more than twenty (20) minutes; the entire delay was not necessary. Additionally, this resident had recorded fluid output that far exceeded his fluid intake, and there was no evidence this had been recognized and assessed by staff. One (1) of fifteen current residents on the sample was affected. Resident identifier: #2. Facility census: 89. Findings include: a) Resident #2 1. On 06/02/09 at 12:56 p.m., while waiting to watch a nurse (Employee #53) do Resident #19's treatment, Resident #2 came to the nursing station and informed Employee #53 he needed something for a headache. The nurse, who was standing by the medication cart, told the resident she needed to go to the bathroom. While Resident #2 was waiting for the nurse's return, he was asked about his headache. He said he has a headache every day; if he does not have one (1) in the morning, he has one (1) in the evening. He said he had been hit in the back by a bottle rocket, and they did not know why he had the headaches. He added they gave him Extra Strength Tylenol for his headaches, and sometimes it worked and sometimes it did not. When she returned from the bathroom at 1:02 p.m., Employee #53 informed this surveyor she was going to get the things for Resident #19's treatment. She went down the hall and returned with the treatment cart. She then checked the treatment record a minute or two (2) later and said, "Hold on a minute, (Resident #2's first name)," and went inside the nursing station. She got a chart and talked to the registered nurse until 1:10 p.m.; the chart was not Resident #2's. At 1:12 p.m., the nurse returned to her medication cart and asked Resident #2 to rate his pain on a scale of 1-10. He s… | 2014-09-01 |
| 11079 | 11079 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 323 | E | 0 | 1 | CKVD11 | Based on observations and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible. White metal covers were covered with rugs but protruded above the level of the surrounding floor, creating trip hazards. A nurse left a medication cart unlocked in the hall in the presence of mobile residents. A bottle containing corrosive disinfectant (Quat-256) was found in an unlocked storage room on the West wing. These deficient practices had the potential to affect all independently mobile residents. Facility census: 89. Findings include: a) During the survey, observations found trip hazards in the entry hall and the 800 hall of the West wing. White metal covers on the floors protruded above the level of the surrounding tile floor. These were covered with rugs. A survey team member reported she had tripped over the one in the hall near the entry of the facility. b) On 06/02/09 at 12:56 p.m., the nurse (Employee #53) left a medication cart unlocked when she went to the bathroom. Although the cart was in the hall outside of the nursing station, staff at the nursing station were occupied and not watching the cart (and had not been asked to watch). The surveyor was able to open any drawer on the cart. In an interview at approximately 1:30 p.m. on 06/04/09, the director of nursing was informed. She state the nurse knew better than to leave the med cart unlocked. c) During the initial tour of the West wing, storage areas were found to be locked with the exception of one (1). The storage area contained grooming supplies and other items. On a shelf, approximately three (3) feet off of the floor and directly across from the door to the room, was a spray bottle of disinfectant (Quat-256). The label on the bottle included, "Danger Corrosive - Causes eye damage and severe skin irritation. Harmful if swallowed." . | 2014-09-01 |
| 11080 | 11080 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 441 | F | 0 | 1 | CKVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility's infection control program did not ensure staff employed practices to prevent the spread of infection. A nurse did not employ appropriate infection control techniques when changing Resident #19's dressing. A second nurse did not utilize good handwashing techniques during medication pass. A staff member contaminated the ice chest while passing ice water. These practices had the potential to affect all residents. Facility census: 89. Findings include: a) Resident #19 1. On 06/02/09 at 1:25 p.m., the nurse (Employee #53) was observed providing a treatment to Resident #19. She had contact with resident then, without removing her gloves, went to the treatment cart for scissors. She returned, cut off the old dressing, then put the scissors in her pocket. This created a potential for contamination of items in the treatment cart through transfer of organisms from the nurse's contaminated gloves. There was also a potential for transfer of organisms from the contaminated scissors to the nurse's pocket. 2. During this procedure, the nurse sprayed [MEDICATION NAME] onto some gauze 4 x 4s intended to cleanse the resident's wound. The spray bottle leaked, and the nurse used 4 x 4s to catch drips off of the bottle, then used the 4 x 4s on resident. This created a potential for microorganisms on the bottle to be transferred to the resident's wound. 3. Wearing contaminated gloves, the nurse retrieved a pen from her pocket, labeled the dressing, then put the pen back in her pocket. Again, this created a potential to transfer microorganisms from the resident's wound to the pen and her pocket and a potential for subsequent transfer of those microorganisms to others. b) Resident #84 On 06/02/09 at 8:23 a.m., during medication administration pass, a second nurse (Employee #34) was observed washing her hands. The nurse turned the water off with paper towels, then used the paper towels to dry her hands. This cr… | 2014-09-01 |
| 11081 | 11081 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 514 | D | 0 | 1 | CKVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure one (1) of fifteen (15) current residents on the sample had a determination of capacity form which contained conflicting information. The documentation indicated the resident had "capacity", and yet his "incapacity" was expected to be short term. Resident identifier: #2. Facility census: 89. Findings include: a) Resident #2 The "Physician Determination of Capacity" form, completed by the physician on 11/14/07, contained conflicting information. The physician had checked: "(The resident) demonstrates CAPACITY to make medical decisions." Below that, the form included, "Expected duration of incapacity: ____ short term ____long term." The physician had checked "short term". Under that was a prompt that read: "The decisions is based on the following: Cause (Diagnosis):"; "[MEDICAL CONDITION]" had been written as the cause of incapacity. It was unclear, due to this conflicting documentation, whether or not the resident possessed the capacity to make informed medical decisions. | 2014-09-01 |
| 11082 | 11082 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 465 | F | 0 | 1 | CKVD11 | Based on observations, the facility did not provide a comfortable environment for the residents, staff, and the public. The handrails throughout the building were in need of refinishing. Tile floors had gaps that could harbor bacteria. Wall repairs and painting had not been done neatly. The fan in the West wing women's bathing area was laden with dust and hair-like substances. The dining areas were dark and drab. And the overall appearance of the buildings interior was gloomy. All residents, staff, and the public had the potential to be affected. Facility census: 89. Findings include: a) During the initial tour of the facility, observation revealed the handrails throughout the building needed to be refinished. As one felt the surface, it was noted to be somewhat rough in many areas. In one area, there was a bit of thread stuck in the railing, as though it had been caught in the rough finish when cleaned. The handrails had a somewhat dark finish, but numerous areas were lighter, as though the stain had been removed. b) In many areas, the cove base, especially around the heating / ventilation units, had gaps in it and was in need of repair. c) Numerous areas around doors, floors, etc., had been caulked and painted. This had not been done neatly and was unattractive. d) There were areas on the floors that were uneven due to metal plates having been affixed to the floor resulting in uneven areas. e) A fan in the West wing women's central bath was heavily laden with dust and stringy, hair-like substances. f) Surfaces in the public bathrooms were dusty, especially near the doors to the rooms. g) The main dining room had dark table cloths, cabinets that were aged, and the overall presentation was not visually appealing. h) The doors to the residents' rooms had multiple areas where it was apparent things had been taped to the doors and the finish removed and/or residue from the tape remained. This was not visually appealing. i) In an interview with the administrator on the morning of 06/02/09, he acknowledged the facilit… | 2014-09-01 |
| 11083 | 11083 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 174 | E | 0 | 1 | CKVD11 | Based on observation and staff interview, the facility failed to provide a private location for a resident's phone call; this was true for one (1) of fifteen (15) sampled residents. A resident was observed utilizing the telephone at the facility's nursing station to have a conversation with a family member. The resident was observed to become tearful and visibly upset during the conversation. The resident was not offered a private location to have a phone conversation with a family member. This practice has the potential to affect more than an isolated number of residents, including those who wish to make and receive calls and do not have private telephones in their rooms. Resident identifier: #51. Facility census: 89. Findings include: a) Resident #51 On 06/04/09 at 11:30 a.m., Resident #51 was wheeled down to the west wing nursing station and handed the telephone receiver. Several staff members were observed standing near the resident. The resident was observed to become tearful and visibly upset during the conversation. The resident was not offered a private location to have a phone conversation with a family member. Staff interview with a licensed practical nurse (LPN - Employee #1), on 06/04/09 at 11:35 a.m., revealed the resident was not offered a private location for the phone call. The LPN further stated the west wing nurses' station does not have a cordless phone for the residents to use. The LPN stated the residents use the activity office to make personal calls at times, yet this option was not offered to Resident #51 for this phone call. . | 2014-09-01 |
| 11084 | 11084 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 248 | D | 0 | 1 | CKVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to provide an individualized activity program for one (1) of fifteen (15) sampled residents. A [AGE] year old, blind resident was not offered an activity program to meet his needs and interests. Resident identifier: #68. Facility census: 89. Findings include: a) Resident #68 Resident #68, when interviewed on 06/02/09 at 1:30 p.m. and on 06/03/09 at 3:00 p.m., reported he had a stroke approximately six (6) years ago resulting in [MEDICAL CONDITION]. The resident was divorced and rarely received any visitors. He had a fall resulting in a [MEDICAL CONDITION] in April 2009 and was admitted to the facility for rehabilitative therapy services. The resident reported his life work was sports, having been a sports writer for a newspaper and a golf coach, and his primary interest was in sports, but the facility did not provide any activities relating to his interest in sports. The resident stated he would like to listen to, or attend any sporting events, yet the facility did not offer any of these activities. The resident stated he had a television in his room but did not have access to the national sport channels, yet other residents in the facility did. (The facility administrator was notified of this by the surveyor, and his TV was reprogrammed on 06/02/09, allowing the resident access to sports channels.) He related facility staff did not offer to read any sports magazines to him. The resident also stated he would like to go for walks outside with staff, but this activity was also not offered to him. The activity director (Employee #64), when interviewed on 06/03/09 at 4:30 p.m., reported Resident #68's planned activities included listing to radio and TV, exercise, music, and coming into the activity office daily to drink coffee and have the obituaries read to him. Review of Resident #68's medical record, on 06/04/09 at 10:00 a.m., found the resident's curr… | 2014-09-01 |
| 11085 | 11085 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 371 | F | 0 | 1 | CKVD11 | Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 89. Findings include: a) During the initial tour of the dietary department at 2:00 p.m. on 06/01/09, plate covers, plastic cups, and steam table pans were noted to be stacked inside each other or inverted on trays prior to complete air drying. These items were observed with trapped moisture, creating a medium for bacterial growth. b) Flies were observed in the serving and food preparation area of the kitchen during the initial tour on 06/01/09. . | 2014-09-01 |
| 11086 | 11086 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 364 | F | 0 | 1 | CKVD11 | Based on the group interview, staff interview, and taste testing, the facility failed to assure foods were seasoned with salt as directed by the recipe. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 89. Findings include: a) During the confidential group interview at 1:30 p.m. on 06/02/09, residents expressed dissatisfaction with the flavor of the foods they received. Further inquiry revealed they felt the foods were not well seasoned. b) On 06/03/09, during the noon meal, mashed potatoes were taste tested . This testing was done with the dietary manager (DM). The mashed potatoes did not appear to have been seasoned. The DM tasted the mashed potatoes and confirmed they needed additional salt. Interview with the cook who prepared the potatoes revealed the directions on the container had not been followed relative to the amount of salt which should have been added to the mashed potatoes. . | 2014-09-01 |
| 11303 | 11303 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 386 | D | 1 | 0 | CKVD11 | Based on review of reports of allegations / investigations submitted to the Office of Health Facility Licensure and Certification (OHFLAC), medical records, staff interview, and review of the facility's investigation, it was determined a resident's physician did not document his visit until several days after the visit occurred. Resident identifier: #93. Facility census: 89. Findings include: a) Resident #93 This resident's closed medical record was selected based on a report of an allegation filed with OHFLAC. The resident had sustained a fall on 03/13/09. The fall had resulted in injuries to the resident in the form of a black eye and bruising of her elbows. The family alleged the resident had not received medical attention until they insisted she be sent out for x-rays. Review of the facility's investigation found the physician stated he had been in the facility on 03/14/09, and he had indicated he examined the resident. According to the report, the physician had stated the resident had a black eye and bruising to both elbows. He did not feel she needed any additional treatment. However, the physician's progress note, regarding his examination of the resident on 03/14/09, was not written until 03/18/09. . | 2014-07-01 |
| 10869 | 10869 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2009-06-17 | 514 | D | 0 | 1 | GPSU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident's medical record was completed and accurately documented. There was no documentation to indicate why nurses' initials on a resident's Medication Administration Record [REDACTED]. Resident identifier: #99. Facility census: 100 Findings include: a) Resident #99 Review of Resident #99's medical record revealed an order for [REDACTED]. Employee #75, when interviewed at 5:45 p.m. on 06/15/09, reported this resident refused this medication. She verified circling around a nurse's initials meant the resident did not take this medication. Employee #68, when interviewed, identified there was usually another form that goes with the MAR indicated [REDACTED]. . | 2014-11-01 |
| 10870 | 10870 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2009-06-17 | 272 | D | 0 | 1 | GPSU11 | Based on a review of the medical record and staff interview, the facility failed to conduct a thorough assessment of Resident #149's bladder functioning. This resident had an indwelling urinary catheter, and the resident's minimum data set assessment (MDS) triggered for further assessment through the urinary incontinence and indwelling catheter resident assessment protocol (RAP); however, there was no evidence this RAP was completed in accordance with Appendix C of the Resident Assessment Instrument User's Manual. This was true for one (1) of twenty-eight (28) sampled resident in Stage II of the survey. Resident identifier: #149. Facility census: 100. Findings include: a) Resident #149 Review of Resident #149's most recent comprehensive assessment revealed this resident had an indwelling Foley urinary catheter. In Section V of this MDS, the urinary incontinence and indwelling catheter RAP was checked to indicate the need for further assessment of triggered area. Review of the RAP summary, dated 06/12/09, for the use of this indwelling catheter, revealed the RAP documentation did not contain any assessment information related to the resident's need for an indwelling catheter. The RAP summary simply stated, "The resident has a Foley catheter and has incontinent episodes." This was not a thorough assessment of the resident's for the continued need of this indwelling catheter. The director of nursing (DON), when interviewed regarding a further assessment for the use of this catheter on 06/16/09 at 10:00 a.m., confirmed there was no further evaluation for the use of this indwelling catheter in the record. . | 2014-11-01 |
| 10871 | 10871 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2009-06-17 | 279 | D | 0 | 1 | GPSU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the medical record and staff interview, the facility failed to develop a plan of care to address the immediate care needs of a resident with an indwelling urinary catheter. The care plan did not contain specific information regarding the indwelling catheter, including the reason for its use, the size to be inserted, and the care to be provided to prevent complications associated with catheter use, including introduction of infectious organisms into the urinary tract. This was true for one (1) of twenty-eight (28) sampled residents in Stage II of the survey. Resident identifier: #149. Facility census: 100. Findings include: a) Resident #149 Review of Resident #149's medical record revealed this resident was admitted on [DATE]. Her admission physician's orders [REDACTED]. However, the order contained no instructions regarding the kind of catheter or the size to be used. Further review of the record revealed a care plan, dated 06/01/09, which stated, "Resident has Foley catheter. Potential for appliance dysfunction and/or infection daily." The goals for the use of this catheter included: "No adverse reaction noted r/t (related to) dysfunction and no s/s (signs / symptoms) of infection noted daily through next review period." There were the only two (2) interventions associated with these goals; these were: "Change q (every) 30 days, and Foley care q shift." During an interview on 06/17/09 at 10:00 a.m., the director of nursing (DON) identified the resident's medical record did not contain an assessment or care plan addressing the use of this indwelling catheter. The DON did find hospital records to support the use of the catheter, but this information was not carried forward to alert the staff as to the size of catheter to be used, the reason this catheter was needed, or the type of care to be provided to prevent complications. . | 2014-11-01 |
| 10872 | 10872 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2009-06-17 | 281 | D | 0 | 1 | GPSU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and a review of manufacturer's instructions for using a prescribed inhalation powder, the facility failed to assure medications were administered using appropriate techniques and in accordance with the manufacturer's instructions. Two (2) residents were observed receiving the [MEDICATION NAME] Diskus, and there were no attempts or instructions provided to rinse their mouths out with water and spit it out after this medication was inhaled. Failure to properly administer medications was observed for two (2) of ten (10) sampled residents. Resident identifiers: #26 and #28. Facility census: 100. Findings include: a) Resident #26 During medication pass on 06/09/09 at 9:30 a.m., the nurse was observed administering an [MEDICATION NAME] Diskus to this resident. The nurse prepared the inhaler by opening the container and clicking the button. The inhaler was then handed to the resident, who properly inhaled the medicated powder. The nurse then closed the container and left the room. The nurse did not offer the resident water to rinse out his mouth or provide instructions to the resident that he should rinse out his mouth. b) Resident #28 During medication pass on 06/09/09 at 10:03 a.m., the nurse was observed administering an [MEDICATION NAME] Diskus to this resident. The nurse prepared the inhaler by opening the container and clicking the button. The inhaler was then handed to the resident, who properly inhaled the medicated powder. The nurse then closed the container and left the room. The nurse did not offer the resident water to rinse out his mouth or provide instructions to the resident that he should rinse out his mouth. c) The nurse (Employee #28), when interviewed on 06/09/09 at 1:00 p.m., was made aware of the failure to prompt the residents to rinse their mouths following administration of the [MEDICATION NAME] Diskus. The nurse stated this was not done because these residents ref… | 2014-11-01 |
| 10873 | 10873 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2009-06-17 | 329 | D | 0 | 1 | GPSU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to the drug regimen, of one (1) of twenty-eight (28) sampled residents in Stage II of the survey, was free of unnecessary medications ([MEDICATION NAME]) without adequate indications for use. This was true for one (1) of twenty-eight (28) residents in the Stage II sample. Resident identifier: #99. Facility census: 100. Findings include: a) Resident #99 Record review revealed a physician's telephone order, dated 05/31/09 at 5:00 p.m., instructing staff to administer the medication [MEDICATION NAME] 1 mg two (2) tabs to equal 2 mg by mouth "now" for Anxiety Disorder. ([MEDICATION NAME] is an anti-anxiety medication which can be very sedating and should be used cautiously in the elderly.) Further record review revealed the monthly recapitulation of physician orders [REDACTED]. Review of the nursing notes for 05/31/09 found no documented behavioral episodes to indicate this resident exhibited increased anxiety. Review of the May 2009 daily behavior tracking form, on which staff was to record when the targeted behavior of "increased anxiety" was exhibited, revealed no evidence that this resident had any behaviors to necessitating the administration of [MEDICATION NAME]. During an interview on 06/16/09 at 4:00 p.m., the director of nursing (DON) verified there was no evidence to justify the administration of this medication. The DON interviewed the nurse who called the physician and administered this medication, and she verified she had not recorded anything about the resident's behavior the evening she called the physician, because she was busy and forgot to record it. . | 2014-11-01 |
| 10874 | 10874 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2009-06-17 | 309 | D | 0 | 1 | GPSU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the medical record and staff interview, the facility failed to ensure staff implemented planned interventions with respect to the care and treatment of [REDACTED]. This resident was identified in her care plan as having mood and behavior problems, including resisting care and refusing medications. There was no evidence the facility attempted planned interventions to address refusal of medication, when the resident refused her [MEDICATION NAME] on twenty-eight (28) days of thirty-one (31) days in May 2009. This practice was evident for one (1) of twenty-eight (28) sampled residents in Stage II of the survey. Resident identifier: #99. Facility census: 100. Finding include: a) Resident #99 Medical record review revealed this resident had a physician's orders [REDACTED]. A review of the May 2009 Medication Administration Record [REDACTED]. There was no explanation recorded on the reverse side of the MAR indicated [REDACTED]. (See also citation at F514.) Review of the resident's care plan, established on 10/05/07, found: "If the resident refuses her medication, staff need (sic) to try to calm her, talk in a calm voice, remain positive, and try medications at a different time to see if that helps. Try other redirections to help such as drinks, snacks etc." There was no evidence in the medical record that these interventions were attempted. During an interview on 06/16/2009 at 10:15 a.m., the director of nursing (DON) identified this resident refused the [MEDICATION NAME] nasal spray and became combative at times. The DON was unable to find evidence to reflect any of the interventions established in Resident #99's care plan, to address refusal of medication, had attempted without success or that any discussion had occurred with the physician regarding possible discontinuation of this medication in lieu of an alternate treatment for [REDACTED]. . | 2014-11-01 |
| 10875 | 10875 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2009-06-17 | 249 | C | 0 | 1 | GPSU11 | Based on staff interview and personnel file review, the facility failed to employ the services of a qualified professional to oversee the activities program. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #12. Facility census: 100. Findings include: a) Review of sampled personnel records, on 06/16/09 at approximately 10:00 a.m., revealed the facility's current activity director (Employee #12) did not have evidence to reflect she was qualified, by education or experience, to serve in this capacity. In an interview, Employee #12 reported she had completed a State approved training course which would have qualified her to perform the duties of an activity director; however, she could not locate any documents verifying course completion. The administrator indicated he was aware Employee #12 could not locate proof of her certification as an activity director. . | 2014-11-01 |
| 10937 | 10937 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 272 | D | 0 | 1 | HO2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to assure the accuracy of information recorded on the minimum data set assessment (MDS) for three (3) of thirteen (13) sampled residents. Resident identifiers: #38, #2, and #4. Facility census: 61. Findings include: a) Resident #38 Review of the resident's abbreviated quarterly MDS, dated [DATE], revealed, in Section M.1., that Resident #38 had one (1) Stage II pressure ulcer. Review of the nursing notes and body assessments for the two (2) weeks preceding 04/04/09 failed to find any evidence of a pressure sore. This was verified by the wound care nurse (Employee #46) during an interview at 10:00 a.m. on 06/16/09. During an interview with the MDS nurse at 10:45 a.m. on 06/16/09, she reviewed the record, acknowledged an entry error had been made, and stated she would correct it immediately. b) Resident #2 Review of the clinical record revealed Resident #2 had a physician's orders [REDACTED]. The director of nursing (DON) verified the resident could not remove the seat belt at will and acknowledged this device served as a physical restraint to promote safety. The resident was observed with the belt in place at 10:50 a.m. on 06/16/09. A review of the resident's abbreviated quarterly MDS, dated [DATE], revealed, in Section P.4., the resident did not have a physical restraint is use. When informed of this, the DON acknowledged this was an error and stated the MDS would be corrected to include restraint use. c) Resident #4 Record review, on 06/16/09, revealed an admission MDS completed on 01/23/09, in which the assessor indicated the resident had "pain less than daily". An abbreviated quarterly MDS, completed on 04/07/09, indicated the resident had "no pain". Review of the resident's clinical record, for the seven (7) day look-back time frame prior to the 04/07/09 quarterly MDS, revealed the resident did have pain; however, it was not daily. Interview in the morning on 06… | 2014-11-01 |
| 10938 | 10938 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 371 | F | 0 | 1 | HO2T11 | Based on observations and staff interview, the facility failed to assure foods were served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 61. Finding include: a) At 6:30 a.m. on 06/15/09, observations in the dietary department with the dietary manager (DM) revealed the steam table nesting pans were stacked inside of each other prior to air drying. These items were observed with trapped moisture, creating a medium for bacteria growth. b) Observations in the dry food storage area revealed a tray of empty cereal bowls that were stored right side up with the bowls not covered. The dietary manager stated the bowls had been placed in this area the night before. Observation of the five-gallon plastic container used for sugar storage revealed the cover was not put on securely; the sugar was not covered completely and prevented the food item from being stored in an air tight container. These two (2) food storage practices have the potential for not maintaining sanitary conditions that promote safe food handling. c) The DM confirmed the observations as seen by the surveyor. . | 2014-11-01 |
| 10939 | 10939 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 514 | D | 0 | 1 | HO2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain an accurate clinical record with respect to the resuscitation status of one (1) of fifteen (15) sampled residents. Resident identifier: #14. Facility census: 61. Findings include: a) Resident #14 Review, on 06/16/09, of the resident's current monthly recapitulation of physician orders [REDACTED]. Review of Section A of the Physician order [REDACTED]. This POST form was initially signed by the physician on 01/05/05. Review of the resident's annual history and physical, signed by the physician on 01/12/09, revealed: "CODE STATUS: Full Resuscitation". In an interview at 9:00 a.m. on 06/17/09, the director of nursing acknowledged the "full code" noted on the history and physical was an error, and the resident was currently receiving Hospice care. She confirmed the POST form and the June 2009 physician orders [REDACTED]. | 2014-11-01 |
| 10940 | 10940 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 274 | D | 0 | 1 | HO2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to recognize and complete a comprehensive assessment after a significant change in the resident's health status for one (1) of thirteen (13) sampled residents. Resident identifier: #38. Facility census: 61. Findings include: a) Resident #38 A review of Resident #38's clinical record revealed several changes in the minimum data set assessment (MDS) for the period ending 04/04/09 from the previous one completed on 01/29/09. The changes are as follows: - In Section B.5.f. - The resident's mental status varies over the course of the day. (She did not previously exhibit this.) - In Sections E.1.d. & l.) - The resident exhibits persistent anger with self or others and sad, pained, worried facial expressions up to five (5) days a week. (She did not previously exhibit this.) - In five (5) areas of activities of daily living (ADL) self-performance the resident declined from limited (2) to extensive (3) assistance required for performance. These were bed mobility, transfer, walking in the room, dressing, and toilet use. Because a comprehensive assessment was not completed, no resident assessment protocols (RAPs) were triggered for completion to address [MEDICAL CONDITION], mood, or ADL function. During an interview with the MDS nurse at 10:45 a.m. on 06/16/09, she acknowledged the differences were accurate but stated the computer had not alerted her to the need to complete a significant change in status assessment and, therefore, one was not done. . | 2014-11-01 |
| 10941 | 10941 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 329 | D | 0 | 1 | HO2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a gradual dose reduction (GDR) [MEDICATION NAME] attempted (to determine if symptoms could be managed by a lower dose or if the medication could be discontinued) and/or failed to ensure the physician recorded a clinical rationale for not attempting the GDR, for one (1) of thirteen (13) sampled residents. Resident identifier: #15. Facility census: 61. Findings include: a) Resident #15 A review of Resident #15's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. She had been receiving "Ambien 5 mg tablets daily at bedtime" since 10/29/08, for sleeplessness without an attempt at GDR. Review of the nursing notes failed to find any mention of the resident having problems sleeping during this time. Her behavior monitoring sheets also recorded no instances of sleeplessness. During the medication regimen review, the consultant pharmacist suggested a GDR be attempted on 01/29/09 and again on 02/20/09. Although the physician rewrote all the medication orders on 02/09/09, no changes were made in [MEDICATION NAME]. The director of nursing (DON) also made a recommendation, on 02/01/09, that the physician "consider identifying resident-specific non-pharmacologic interventions". He did not. There was no documented evidence in the physician's orders [REDACTED].#15. During an interview with the DON and the assessment nurse at 11:30 a.m. on 06/16/09, the DON reviewed the record and was unable to produce any additional documentation regarding why a GDR had not been attempted. Although she stated the resident requested [MEDICATION NAME] continued, she was also unable to show documentation of this. . | 2014-11-01 |
| 10942 | 10942 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 159 | B | 0 | 1 | HO2T11 | Based on record review and staff interview, the facility failed to obtain written authorization from the legal representatives, of five (5) of six (6) sampled residents with lack capacity, prior to holding and managing personal funds for these residents. Resident identifiers: #15, #23, #26, #39, and #41. Facility census: 61. Findings include: a) Resident #15 Medical record review revealed Resident #15 lacked capacity, and a representative from West Virginia Department of Health and Human Resources (DHHR) had been appointed as health care surrogate (HCS) to make medical decisions, because both the resident's daughter and her sister declined this responsibility. Resident #15 had $1,860.39 in a personal funds account being held and managed by the facility based on the signature of her daughter, although there was no evidence the daughter had the legally authority to either grant this permission or determine how the money would be disbursed. During an interview with the social worker at 4:00 p.m. on 06/16/09, she stated the resident's daughter had told her she was the resident's power of attorney (POA), but the daughter had never produced the documentation to verify this claim. b) Resident #23 Medical record review revealed Resident #23 lacked capacity to make medical decision, and a HCS was appointed to make these decisions for him. Resident #23 had $1700.63 in a personal funds account being held and managed by the facility based on the signature of the HCS, although there was no evidence the HCS had the legally authority to either grant this permission or determine how the money would be disbursed. (State law does not authorize a HCS to also make financial decisions on behalf of an incapacitated person.) During an interview with Employee #62, who was responsible for managing the personal funds accounts, she stated she was aware of this and that part of this money was to be paid to the funeral home for a burial plan. c) Residents #26 and #39 Residents #26 and #39, both of whom had been determined to lack capacity, h… | 2014-11-01 |
| 10943 | 10943 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 152 | D | 0 | 1 | HO2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ascertain a capacitated resident's wishes with respect to advance directives, allowed a medical power of attorney representative (MPOA) to make a health care decision on behalf of the resident without the legal authority to do so, and failed to identify and resolve conflicts between physician's orders [REDACTED]. Resident identifier: #4. Facility census: 61. Finding include: a) Resident #4 Review of Resident #4's medical record, on 06/17/09, revealed she was admitted to the facility on [DATE], with admitting orders signed by the physician for "Advance Directives: DNR (do not resuscitate)." Review of the "Physician Determination of Capacity", dated 01/11/09, revealed the resident had the capacity to understand and make her own informed health care decisions. The "staff member involved" with the completion of Resident #4's Advanced Directive Acknowledgment Form (Employee #63) marked an "X" at Item 6 indicating, "Do not perform cardiopulmonary resuscitation", and recorded, "Per conservation with POA (power of attorney) 01/09/09 2:50 PM." There was no signature of the form from the person making this health care decision on behalf of Resident #4, and there was no indication that Resident #4, who had the capacity to make this decision herself, was consulted regarding this matter. The "physician acknowledgement" of the form was signed by the physician on 01/09/09. Review of the resident's history and physical, dated and signed by the physician on 01/12/09 at 3:50 p.m., revealed: "CODE STATUS: FULL RESUSCITATION in the event of cardiopulmonary arrest, including intubation with mechanical ventilation and/or cardioversion pending her POST form and official DNR status. Will get further details from the long-term care unit." Review of the Physician order [REDACTED]. The form had been signed by the resident's MPOA - not the resident, and the MPOA's signature was not dated. The phy… | 2014-11-01 |
| 11215 | 11215 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2009-06-18 | 225 | E | 1 | 0 | 1MWP11 | Part I -- Based on review of facility documents and staff interview, the facility failed to immediately report and thoroughly investigate two (2) allegations of abuse / neglect in accordance with State law. This deficient practice affected two (2) former residents. Resident identifiers: #10 and #11. Facility census: 8. Findings include: a) Resident #10 Review of facility documents found that, on 01/31/09, Resident #10 reported to facility staff he had an incontinence episode because staff did not answer his call light in a timely manner. Further review found no evidence the facility had reported this allegation of neglect to Adult Protective Services or the State survey and certification agency in accordance with State law. The facility documents concerning the allegation did not contain evidence that a thorough investigation was conducted. No statements were obtained from staff members present during the alleged incident, nor was there evidence to reflect the facility attempted to determine if corrective action was needed to prevent future incidents. Interview conducted with Employee #3, on the afternoon of 06/18/09, confirmed the facility could provide no evidence that this allegation of neglect was reported and thoroughly investigated in accordance with State law. b) Resident #11 Review of facility documents found that, on 01/07/09, Resident #11 reported to a facility staff member that a nurse had been rough with her. Further review found no evidence the facility had reported this allegation of neglect to Adult Protective Services or the State survey and certification agency in accordance with State law. Interview conducted with Employee #3, on the afternoon of 06/18/09, confirmed the facility could provide no evidence that this allegation of abuse was reported in accordance with State law. --- Part II -- Based on random observation, staff interview, review of the list of skilled unit employees provided by the facility, review of staffing assignment sheets, and review of sampled employee personnel files, the f… | 2014-07-01 |
| 11330 | 11330 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2009-06-18 | 360 | D | 0 | 1 | 1MWP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the list of resident diets provided by the facility, and facility staff interview, the facility failed to assure one (1) of four (4) sampled residents received food that met the individual's special dietary needs. Resident identifier: #3. Facility census: 8. Findings include: a) Resident #3 Medical record review found Resident #3 was admitted to the facility on [DATE] for rehabilitation following a [MEDICAL CONDITION]. Further review found the treating physician prescribed a cardiac diet for Resident #3 due to multiple health problems. A nutritional follow-up note, written on 06/09/09, recommended to continue the cardiac diet. Review of the list of resident diets provided by the facility found the resident was documented as receiving a regular diet. A call to the dietary department, placed by Employee #3 during an interview conducted at 3:00 p.m. on 06/06/09, confirmed Resident #3 was receiving a regular diet. Employee #3 verified the diet had been entered incorrectly when the resident returned from having a skin graft. . | 2014-06-01 |
| 11331 | 11331 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2009-06-18 | 371 | F | 0 | 1 | 1MWP11 | Based on observation and facility staff interview, the facility failed to assure the dietary department, which stores, prepares, distributes, and serves food, was maintained in a sanitary condition. This deficient practice had the potential to all residents of the skilled nursing unit. Facility census: 8. Findings include: a) Observations of the dietary department, conducted beginning at 11:40 a.m. on 06/16/09, found the following unsanitary conditions: 1. In the corner on the floor of the dry goods storage area were packages of peanut butter and other food items attractive to mice and insects. 2. An inspection of the dietary walk-in freezer found staff utilized the floor beneath the shelving around the walls to store approximately twenty-six (26) cases of various foods. It was also noted the floor beneath the storage rack located in the center of the freezer was strewn with opened and unopened packages of vegetable and meat products, allowing both to spill out onto the floor. 3. An inspection of the three-compartment sink found no sanitizer in the sink allocated for its use. An interview with the dietary manager revealed the dispensing device was malfunctioning. 4. The wells and surrounding areas of the gas stove burners were noted to be packed with blackened, greasy debris and blackened, unidentifiable chunks of food items. Also, the drip pan was coated with hardened, greasy debris. 5. The knobs on the combination gas stove / grill were noted to be coated with a brown, gummy substance. 6. The handle of the tilt skillet was utilized to store approximately fifteen (15) sets of tongs. An inspection of the backs of the tongs found they were heavily soiled. An interview with a dietary staff member revealed the tongs were stored there and ready for use. 7. The backsplash to the combination gas stove / grill was noted to be heavily soiled with a greasy substance. 8. A member of the dietary staff was noted to be assisting with the noon meal service. This staff member was not wearing an effective hair restraint; the hai… | 2014-06-01 |
| 10750 | 10750 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 279 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop a plan of care to address the care and treatment of [REDACTED]. The staff caring for this resident was not aware she had a drug-resistant infection in her eyes and nares. There was no evidence that the facility had a plan to alert staff and visitors of special precautions needed with respect to having contact with the resident's body secretions. This affected one (1) of thirteen (13) sampled residents . Resident identifier: #32. Facility census: 75. Findings include: a) Resident #32 Review of Resident #32's medical record revealed she was admitted to the hospital on [DATE], for an altered level of consciousness. According to her hospital records, she had had a fever and drainage from her eyes, and she tested positive for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in her right eye and her nares. She was receiving antibiotics for her nares and her eyes and was still receiving this treatment when she came back to the nursing home. Observation of this resident revealed she was not in any type of isolation, and her care plan did not identify any special precautions to be taken when interacting with or caring for this resident. During an interview with the infection control nurse (Employee #26) on 06/24/09 at 3:00 p.m., she was made aware of the resident's infections. She confirmed this was missed when the resident returned from the hospital; the resident's infections were not record on the facility's infection control log, and no isolation precautions were initiated when she returned from the hospital. She also confirmed Resident #23 should have been placed in isolation. This resident's room was observed at 9:00 a.m. on 06/25/09. The nursing assistant was observed taking special precautions prior to entering the room to care for this resident. There was a sign placed on the door to see the nurse before entering the room. These precautions were … | 2014-12-01 |
| 10751 | 10751 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 328 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #72 received the proper respiratory care and treatment. Staff failed to utilize proper technique to administer a nebulizer treatment to a resident with a [MEDICAL CONDITION] (trach). Staff also did not ensure this resident's oxygen was administered in accordance with physician's orders [REDACTED]. Proper respiratory care and treatment was not provided for one (1) of thirteen (13) sampled residents. Resident identifier: #72. Facility census: 75. Findings include: a) Resident #72 1. During an observation of the medication administration for Resident #72 on 06/23/09, this resident was observed to have an order for [REDACTED].# 81) administered this treatment by holding a face mask over the resident's trach. Observation found the medicated aerosol coming out the sides of the mask, with very little actually going into [MEDICAL CONDITION]. The nurse, when questioned about the use of this mask, stated they have special tubing for the trach, but they were out and did not have the right ones available. The assistant director of nursing (ADON), when interviewed on 06/23/09, was asked to provide the facility's policy and procedure for administering a nebulizer treatment to a resident with a trach. The ADON provided a policy for administering hand-held nebulizer treatments but stated they did not have a policy for administering a nebulizer via a trach. The ADON reported they have a respiratory person who comes in and provides them with the equipment they need and shows them how to use it. She stated the facility does have special tubing and [MEDICAL CONDITION] to use for the residents with trachs. 2. Further observations of this resident, throughout the day on 06/23/09 and 06/24/09, revealed this resident did not use her oxygen during those days. The resident's O2 saturation, when checked, was at 98%. A review of the resident's medical record revealed [REDACTED].@ (at) four … | 2014-12-01 |
| 10752 | 10752 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 333 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents were free from significant medication errors. The nurse was preparing to administer 60 mg of the anticoagulant medication [MEDICATION NAME], instead of the 45 mg dose ordered by the physician. Receiving too much of this medication could result in internal hemorrhaging. Significant medication errors were found for one (1) of ten (10) residents observed during medication pass. Resident identifier: #66. Facility census: 75. Finding include: a) Resident #66 During medication administration, observation found a nurse (Employee #81) preparing medications for Resident #66. Review of the labels found a pre-filled syringe of [MEDICATION NAME] 60 mg /0.6 ml. The directions on the medication label stated to administer 0.5 ml (50 mg) sub-Q ( subcutaneously) bid (twice a day). While the nurse was preparing her medications, surveyor observed Resident #66's Medication Administration Record [REDACTED]." The nurse was observed to complete her preparation. As she was preparing to administer the medications to the resident, the surveyor intervened and asked the nurse to stop and double check the label against the MAR. The nurse then verified the dose she was preparing to administer was not correct. The nurse then calculated the correct dose and wasted the excess medication that was in the syringe. The nurse proceeded to tell the surveyor they had discussed this, but the [MEDICATION NAME] did not come from the pharmacy in the dose ordered. . | 2014-12-01 |
| 10753 | 10753 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 441 | F | 0 | 1 | 667111 | Based on a review of the facility's policies and procedures for infection control and isolation for residents with infections, observations of residents with infections, and staff interview, the facility failed to develop and implement an effective infection control program to prevent the potential spread of infections in the facility. The facility's policies and procedures were not periodically reviewed and revised to reflect changes in standards of practice, and the existing procedures were not consistently implemented to prevent the spread of infectious organisms. The facility's did not maintain a record of all residents with infections, including the infectious organism found and/or the type of isolation precaution to be used. The number of residents at the facility with facility-acquired (nosocomial) infections had increased, but there was no evidence to show the facility investigated this increase in nosocomial infections for the causative factors or implemented measures to prevent further incidents of residents contracting nosocomial infections. The absence of an effective infection control program placed all residents residing in the facility at risk of acquiring an infection. Facility census: 75. Findings include: a) Infection Control Program Review of the facility's infection control policies and procedures revealed the policies were not thorough and were not consistently implemented. The infection control policy (which did not contain an effective date) stated the purpose of the policy was to ensure the infection control program was effective for investigating, controlling, and preventing infections in order to provide a safe sanitary, and comfortable environment. The procedure for this stated the following: "1. LPN (Licensed Practical Nurse) on duty will report any signs / symptoms of infection to the physician. Along with any other information requested. "2. Obtain order for treatment. Check ER (emergency) box to see if medication ordered can be obtained. If not STAT medication to facility. "3. Notif… | 2014-12-01 |
| 10754 | 10754 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 226 | C | 0 | 1 | 667111 | Based on a review of the facility's policy titled "reporting abuse" and staff interview, the facility failed to ensure its "reporting abuse" policy addressed the identification, reporting, and prevention of resident neglect. This practice had the potential to affect all facility residents. Facility census: 75. Findings include: a) On 06/23/09 at approximately 10:00 a.m., the facility's policy titled "reporting abuse" was reviewed. The policy did not identify what constituted resident neglect, nor did it address how, when, or who would report such situations within the facility, and to what State agencies they would be reported outside of the facility. The policy also did not explain how the facility would prevent neglect from occurring. The policy basically only gave an understanding on what constituted abuse and how the facility would proceed with identifying, preventing, and reporting allegations involving abuse. The facility social worker and director of nurses both agreed the policy did not address allegations of resident neglect, including identification, reporting, and prevention. . | 2014-12-01 |
| 10755 | 10755 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 152 | E | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure, for three (3) of thirteen (13) sampled residents, a legal surrogate was appointed in accordance with State law for residents lacking the capacity to understand and make their own informed health care decisions. Determinations of incapacity were made solely based on a [DIAGNOSES REDACTED]. Resident identifiers: #50, #33, and #47. Facility census: 75. Findings include: a) Resident #50 On 06/24/09 at approximately 2:00 p.m., review of Resident #50's medical record revealed a physician's determination of capacity form indicating Resident #50 lacked the capacity to understand and make informed health care decisions. However, the cause of the incapacity had not been recorded on the form. b) Resident #47 On 06/23/09, review of Resident #47's medical record revealed a physician's determination of capacity form indicating Resident #47 lacked the capacity to understand and make informed health care decisions due to having a [DIAGNOSES REDACTED]. c) Resident #33 Review of Resident #33's medical record, on 06/23/09, revealed the physician determined she lacked the capacity to understand and make her own health care decisions; however, the cause of her incapacity was not recorded. d) According to '16-30-7. Determination of incapacity., "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a … | 2014-12-01 |
| 10756 | 10756 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 465 | F | 0 | 1 | 667111 | Based on observation and staff interview, the facility failed to maintain an environment for residents that was in good repair. All but one (1) hallway had doors in need of repair, the surface of an isolation table was unclean and in poor repair, and Resident #58's room and nursing equipment were not maintained in a sanitary manner. Facility census: 75. Findings include: a) On 06/25/09 at approximately 10:00 a.m., a tour of the inside of the building revealed the corridor doors of resident rooms were scarred and had some type of substance on them. The administrator said the doors had holes that had been filled (but not finished), and the filler was the substance that had been noted. He agreed the doors were not in good condition and commented that they were replacing the doors one (1) at a time, and he hoped to have all of them replaced soon. b) An isolation table was also observed to be in poor repair on the 200 hallway. The table was beaten and scratched up and appeared dirty. c) Resident #58 Observation, during a tour of the facility on 06/25/09, revealed Resident #58's room contained a suction machine that was not clean. The wall area in this room was also dirty, with splashes that ran down the wall. d) On 06/25/09 at approximately 1:00 p.m., the administrator indicated he was unaware of the dirty equipment and condition of the walls in Resident #58's room as well as the soiled table on the 200 hallway. The administrator indicated the areas and equipment would be cleaned as soon as possible. . | 2014-12-01 |
| 10757 | 10757 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 309 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents received medication in an amount as ordered by the treating physician. Resident identifier: #21. Facility census: 75. Findings include: a) Resident #21 During observations of the medication administration pass on 06/23/09 at 8:50 a.m., the nurse was monitored while preparing Resident #21's medications. The nurse was noted to place a [MEDICATION NAME] 325 mg (Iron) tablet into a plastic medication administration cup with her other medications. Review of the Medication Administration Record [REDACTED]. As the nurse locked her cart and prepared to enter the resident's room, she was asked to review the MAR. She agreed the resident should not be administered the [MEDICATION NAME] and discarded the medication. . | 2014-12-01 |
| 10758 | 10758 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 371 | F | 0 | 1 | 667111 | Based on observations and staff interview, the facility failed to ensure proper sanitation procedures were employed for manual warewashing, freezer units had internal thermometers to ensure food items were being stored at proper temperatures, and food (ice) was being handled with clean utensils when served. These practices have the potential to affect all residents, as all residents who consume food by oral means are served from this central location. Facility census: 75. Findings include: a) During the initial tour of the kitchen on the afternoon of 06/23/09, observation found the walk-in freezer did not contain an internal thermometer to ensure correct temperature levels were being maintained for safe storage of frozen foods. b) Also during the tour, observation found dietary staff had placed a sanitizer tablet in the water of the three-compartment sink for manual warewashing; the tablet had not dissolved. The surveyor questioned staff about the method used to sanitize, and the dietary staff indicated they used tablets that would dissolve in the water to the make the right concentration of sanitizer. Review of the manufacturer's directions for use of the tablets revealed staff needed to increase the amount of water in the sanitizing compartment of the three-compartment sink and use hot water to dissolve the tablets. The dietary manager and the consultant dietitian were present and instructed the staff member to add more water and use two (2) tablets, not one (1). Additionally, they directed the staff member to use hot water, not just warm water from the tap. c) During observations of the medication pass on 06/23/09 at 9:35 a.m., the nurse was observed to pour water (for a resident to take medications) from a clear plastic pitcher. Observation of the water pitcher noted the inner rim beneath the pitcher was coated with a black layer of grime. This same substance was present on the inner portion of the plastic handle. The nurse agreed the pitcher was not clean and stated she had not noticed it. She obtained a cle… | 2014-12-01 |
| 10759 | 10759 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 492 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and review of the West Virginia Health Care Decisions Act, the facility failed to ensure the physician orders [REDACTED]. Resident identifiers: #26 and #77. Facility census: 75. Findings include: a) Resident #26 Review of the medical record found a POST form completed on [DATE]. Section A was documented the resident was to receive cardiopulmonary resuscitation (CPR) should he suffer cardiac or [MEDICAL CONDITION] arrest. Further review noted Section B directed the resident receive comfort measures. This section specifically states: "Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location." The two (2) sections, as completed, conflicted with the resident's wishes to receive treatment to support cardiac and [MEDICAL CONDITION] function. The POST form did not comply with the West Virginia Health Care Decisions Act [DATE](b) which states, "...in accordance with that person's wishes...". b) Resident #77 The medical record of this female resident contained a POST form dated "2/ /09" (date was incomplete), which was not signed by either the resident or the resident's legal surrogate for health care decisions. This was discussed with the office manager on the afternoon of [DATE], who verified the form was incomplete and that there was not way to determine whether the directives otherwise noted on the form reflected the actual wishes of the resident. . | 2014-12-01 |
| 10760 | 10760 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 161 | E | 0 | 1 | 667112 | Based on a review of the facility's surety bond and staff interview, the facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. Facility census: 77. Findings include: a) A review of the facility's surety bond revealed the facility had increased the amount of the bond from $20,000 to $40,000 to assure the security of the residents' personal funds. There was no evidence this new surety bond had been approved by the AG for sufficiency of form and amount, as required. The administrator verified, at 09/07/09 at 4:00 p.m., the bond with the new amount had not been approved by the AG's office. . | 2014-12-01 |
| 10761 | 10761 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 225 | E | 0 | 1 | 667112 | Based on a review of the facility's reported abuse investigations and staff interview, the facility failed to ensure an allegation of neglect was thoroughly investigated. Resident #78's family reported the resident had arrived at 2:00 p.m. on 08/22/09, and they reported to the nurse at 6:00 p.m. that no staff member had been in her room since she arrived. The report also stated an indwelling Foley urinary catheter bag had been put in the bed with the resident. During the investigation, a written statement by the nursing assistant providing care for the resident on 08/22/09 indicated the family told her a "shake" was also thrown in the corner of the sink and not given to the resident. A review of the investigation into allegations of neglect involving this resident revealed no evidence to reflect the allegations related to the nutritional supplement not being given and the Foley catheter bag laying in the resident's bed were further investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. Resident identifier: #78. Facility census: 77. Finding include: a) Resident #78 According to the facility's abuse reporting records, on 08/22/09, Resident #78's son came to the nurse and wanted to see the charge nurse. That nurse told him she was the charge nurse, and he asked her to come in the resident's room. When the nurse went in the room, he told her his mother (Resident #78) had arrived at the facility at 2:00 p.m. that day, and no staff member had turned her since she arrived and that a Foley catheter bag had been put in bed with the resident. This was at 6:00 p.m. on 08/22/09, and he wanted to make sure this did not happen again. This incident was reported to the State agencies including the nurse aide registry for the nursing assistant responsible for providing care to the resident at that time. A review of the facility's investigation found the family member told the nursing assistant there was a "shake" (nutritional supplement) for 2:00 p.m. that was "thrown"… | 2014-12-01 |
| 10762 | 10762 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 508 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain radiology services in a timely manner as ordered by the treating physician for one (1) of thirteen (13) sampled residents. Resident identifier: #60. Facility census: 75. Findings include: a) Resident #60 Review of the medical record found a 02/19/09 physician's orders [REDACTED].-resistant Staphylococcus aureus (MRSA) had cleared. Review of the medical record found no evidence the facility had obtained the ordered radiology service for this resident. The director of nursing (DON) provided information which stated the CT would have been scheduled on 03/03/09. During an interview conducted on 06/25/09 at 9:15 a.m., the DON agreed staff should have either obtained the CT scan or called the physician. . | 2014-12-01 |
| 11048 | 11048 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 152 | E | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for four (4) of twenty-eight (28) sampled records, to ensure legal surrogates were designated in accordance with State law for residents who have been determined to lack the capacity to understand and make their own health care decisions. Additionally, the facility failed to ensure the correct legal surrogate was identified in the medical record and contacted when health care decisions needed to be made. Resident identifiers: #3, #113, #131, and #19. Facility census: 128. Findings include: a) Resident #3 Medical record review, completed on 06/24/09, revealed the face sheet (demographic sheet) identified the resident's son was his medical power of attorney representative (MPOA). Review of the resident's MPOA document revealed the wife was the primary MPOA and the son was the successor MPOA. Further review revealed, on 11/19/08, the facility sent a notice to the resident's son, informing him of an upcoming care plan meeting. When interviewed on 06/24/09 at 11:20 a.m., the social worker (Employee #22) identified that the correct legal representative was the wife and the medical record face sheet was incorrect. Shortly after this interview, the face sheet was corrected. b) Resident #113 Medical record review, on 06/23/09, revealed Resident #113 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 03/27/09. Documentation on the form entitled "Physician Determination of Capacity" stated the resident lacked capacity due to a "[MEDICAL CONDITION]" ([MEDICAL CONDITION] - stroke). The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The facility's director of nursing (DON - Employee #82), when provided this information on 06/25/09, was unable to provide … | 2014-09-01 |
| 11049 | 11049 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 253 | E | 0 | 1 | OJEL11 | Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services to ensure a clean, comfortable, homelike environment for two (2) of three (3) halls observed. Walls were observed to be dirty, and walls and doors were in need of repair and paint. Bathroom toilets were leaking at the tank and around the base, and two (2) toilets were noted to have towels placed at their bases to catch dripping water. Bathroom sinks were observed to have dripping faucets. These deficient practices affected more than an isolated number of residents. Facility census: 128. Findings include: a) Observations of the front entrance and 100 hall 1. On 06/24/09 at 9:10 a.m., observations of the front entrance to the building and the 100 hall revealed the following: - The front foyer was observed to have a dirty floor, especially around a metal plate covering a opening to drain system. - The public women's restroom was observed to have cracked and stained caulk at the bottom of the toilet, which was malodorous. - The 100 hall corridor was observed to be stained, with built-up dirt in cracks and along the cove base. 2. Observations of individual rooms on 100 hall revealed the following: - Room 102 - bathroom door was scratched up and did not close properly. - Room 104 - sink in the bathroom was dripping, floor stained, toilet running, spackling on the wall not sanded or painted, and noticeably dirty. - Room 105 - bathroom sink dripping, base of toilet had cracked and stained caulking, floor stained, bathroom was malodorous. - Room 106 - wall behind bed where new light had been installed needed to be patched and painted. - Room 107 - bathroom sink dripping, towel placed behind toilet bowl catching leaking water. - Room 109 - resident room dirty with visible dirt / debris along the cove base, bathroom sink dripping, base of toilet had stained and cracked caulking, bathroom was malodorous. - Room 110 - toilet running continuously, which did not stop with movement of the toilet handle. - Room… | 2014-09-01 |
| 11050 | 11050 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 272 | E | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Long Term Care News Safety Alert January 2005 issued by the State survey and certification agency, review of the [MEDICATION NAME] low air loss mattress manufacturer's operating manual, and staff interview, the facility failed, for ten (10) of twenty-eight (28) sampled residents, to complete bed safety assessments for residents using a speciality mattress in conjunction with side rails, in order to identify and mitigate bed safety hazards. Resident identifiers: #4, #33, #43, #51, #66, #84, #103, #104, #114, and #129. Facility census: 128. Findings include: a) Observation Initial tour of the facility, on 06/22/09 at 2:30 p.m., revealed the facility had in use several speciality air beds. Further investigation revealed the [MEDICATION NAME] low air loss mattress systems in use were owned (not rented) by the facility. --- b) Safety Alert In January 2005, the State survey and certification agency issued to all WV Medicare / Medicaid certified nursing facilities and licensed nursing homes a Safety Alert regarding bed safety and entrapment hazards, which contained the following: "... It is highly recommended that all licensed nursing homes and/or Medicare / Medicaid certified nursing facilities immediately inspect all beds to identify areas of possible entrapment and take immediate action to reduce the risk of entrapment. "In 1995, the U.S. Food and Drug Administration (FDA) issued a Safety Alert entitled 'Entrapment Hazards with Hospital Bed Side Rails' to several groups of health care providers, including all nursing homes and hospital administrators. In this Alert, the FDA made the following recommendation: 'Inspect all hospital bed frames, bed side rails, and mattresses as part of a regular maintenance program to identify areas of possible entrapment. Regardless of the mattress width, length, and/or depth, alignment to the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a pati… | 2014-09-01 |
| 11051 | 11051 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 309 | E | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide the necessary care and services to each resident, to assist them in attaining or maintaining the highest practicable physical well-being, by failing to obtain physicians' orders to define the parameters of use of specialty mattresses and/or side rails and failing to carry out a physician's order reducing the dosage of a medication. This affected four (4) of twenty-eight (28) sampled residents. Resident identifiers: #84, #129, #114, and #15. Facility census: 128. Findings include: a) Resident #84 During the general tour of the facility at 2:30 p.m. on 06/22/09, observation found Resident #84 in bed resting on [MEDICATION NAME] low air loss mattress with controls that allowed for different settings of firmness. Review of her care plan revealed an intervention, under the problem of wound care, for: "Pressure redistribution surfaces to bed." However, there was no evidence in Resident #84's record of a physician's order for use of this mattress or of the settings to be used. During an interview at 1:15 p.m. on 06/25/09, the director of nursing (DON - Employee #82) acknowledged the facility failed to obtain a physician's order for use of the specialty mattress and assumed the nurses were using the same settings that were being used for other residents. b) Resident #129 Medical record review, on 06/25/09, revealed Resident #129 was using a [MEDICATION NAME] mattress (for an alteration in skin integrity) in conjunction with side rails. Further review revealed there was no physician's order for the mattress or the side rails, and the facility did not complete a bed safety assessment or a side rail use assessment prior to implementing these interventions. (See also citation at F272.) c) Resident #114 Observation, at 11:00 a.m. on 06/25/09, revealed this resident was lying on a low air mattress which had a raised border surrounding it. The resident also had raised h… | 2014-09-01 |
| 11052 | 11052 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 329 | D | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of medication formularies, and staff interview, the facility failed to ensure each resident's medication regimen was free from unnecessary drugs given without adequate indications for use. Resident #35 was given a hypnotic (Ambien) without an assessment of possible causes for the sleeplessness and without first attempting the use of non-pharmacologic interventions to reduce or prevent the target behaviors prior to medicating the resident. Resident identifiers: #35. Facility census: 128. Findings include: a) Resident #35 1. Medical record review, on 06/23/09, revealed the physician [MEDICATION NAME](an hypnotic) on 03/10/09. Review of the nursing progress for 03/10/09 found documentation to indicate Resident #35 had exhibited increased agitation and was not sleeping at night. Further record review failed find when these behaviors were initially observed, nor did the record contain any assessments in an attempt to identify possible causal or contributing factors to the increased agitation and decreased ability to sleep at night. Additionally, the medical record contained no evidence of any non-pharmacologic interventions that had been attempted without success to reduce or prevent the agitation and difficulty sleeping, prior to institution of the hypnotic (Ambien). 2. According to http://www.rxlist.com/ambien-drug.htm: "Ambien ([MEDICATION NAME]) is indicated for the short-term treatment of [REDACTED].[MEDICATION NAME] been shown to decrease sleep latency for up to 35 days in controlled clinical studies. This medication is usually limited to short-term treatment periods of 1-2 weeks or less. "Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of [REDACTED]. The failure of [MEDICAL CONDITION] to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. … | 2014-09-01 |
| 11053 | 11053 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 502 | D | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's lab monitoring protocol, and staff interview, the facility failed to obtain routine lab studies for one (1) of twenty-five (25) sampled residents with a [DIAGNOSES REDACTED].#35. Facility census: 128. Findings include: a) Resident #35 Medical record review, on 06/23/09, revealed Resident #35 was a diabetic. Review of the laboratory testing completed revealed a Hemoglobin A1c completed in November 2008. According to the facility's lab monitoring protocol for diabetic therapy, Hemoglobin A1c is to be completed every four (4) months. Review of the resident's monthly recapitulation of physician orders [REDACTED]. On the afternoon of 06/25/09, the facility's director of nursing (DON - Employee #82), when interviewed, identified this resident had been in and out of the hospital during this period and the Hemoglobin A1c could have been due when she was in the hospital. Prior to survey exit, no additional information was provided regarding this concern. . | 2014-09-01 |
| 11054 | 11054 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 386 | E | 0 | 1 | OJEL11 | Based on medical record review and staff interview, the facility failed to ensure the attending physician, for four (4) of twenty-eight (28) sampled residents, reviewed the resident's total plan of care with each assessment visit by signing routine and telephone orders. Resident identifiers: #15, #35, #19, and #4. Facility census: 128. Findings include: a) Resident #15 The medical record of Resident #15, when reviewed on 06/23/09, disclosed the resident's attending physician wrote a progress note describing a regular assessment visit for this resident on 05/29/09. Further review disclosed the physician had failed to sign telephone orders given to facility staff on 01/10/09, 01/29/09, 04/03/09, 04/08/09, 04/15/09, 04/24/09, 04/28/09, 05/06/09, 05/08/09, and 05/12/09. This information was presented to the facility's director of nursing (DON - Employee #82) on 06/23/09 at 11:00 a.m., and she confirmed the physician should have signed and dated these outstanding orders. b) Resident #35 Medical record review, completed on 06/23/09, revealed the physician was in the facility and saw Resident #35 on 06/19/09. Further record review revealed telephone orders received prior to this visit which the physician did not sign, which had been given on 06/03/09, 06/08/09, 06/13/09, and 06/15/09. On the afternoon of 06/25/09, the DON, when interviewed, identified the physician recently came to her and told her he thought he was caught up with all documentation. The DON acknowledged at this time he must not be caught up with all the documentation. c) Resident #19 A review of the clinical record revealed verbal orders from the physician of Resident #19, given on 05/19/09, had not been signed by the physician as of 06/24/09, although he had visited the resident and had written a progress note on 06/05/09. During an interview with the administrator at 10:30 a.m. on 06/25/09, he acknowledged it appeared the physician had overlooked some of the orders. d) Resident #4 This resident had ten (10) telephone orders which had not been signed w… | 2014-09-01 |
| 11055 | 11055 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 225 | D | 0 | 1 | OJEL11 | Based on record review and staff interview, the facility failed to screen one (1) of nine (9) sampled employees (Employee #133) prior to hire, to ensure the individual had no findings that would indicate unfitness for service. Employee #133, a registered nurse (RN), indicated having licensure and prior work history in the State of Maryland. The facility failed to contact the Maryland RN licensing board to ensure Employee #133's RN license was not impaired. Facility census: 128. Findings include: a) Employee #133 A review of the personnel file of Employee #133 revealed she was hired as a RN on 04/06/09. Her written application indicated she was also licensed and had been employed in the State of Maryland. There was no evidence in her personnel file to indicate the facility verified the were no negative findings associated with Employee #133's RN licensed in Maryland. This was verified by the administrator at 10:45 a.m. on 06/25/09, who reported he was unaware of the need to verify the status of out-of-state professional licenses. . | 2014-09-01 |
| 11056 | 11056 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 247 | D | 0 | 1 | OJEL11 | Based on record review and staff interview, the facility failed to notify the resident or the responsible party prior to transferring the resident to another room. This affected one (1) of twenty-eight (28) sampled residents. Resident identifier: #84. Facility census: 128. Findings include: a) Resident #84 A review of the clinical record revealed Resident #84 had been determined to lack capacity to understand and make health care decisions, although she was alert, able to communicate, and able to make her needs known, as documented in nursing notes on 06/19/09. Her son was serving as her health care surrogate. She was transferred from a room on 200 Wing to a room on 300 Wing. However, there was no documentation in the medical record to indicate that either she or her son was consulted prior to the room change. The nursing notes, at 10:45 a.m. on 06/18/09, recorded, when the son called to question the transfer, "Informed was moved d/t (due/to) bed needs." During an interview with the director of nursing (DON - Employee #82) at 9:30 a.m. on 06/25/09, she reviewed the record and expressed surprise that prior notice was not documented. . | 2014-09-01 |
| 11057 | 11057 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 285 | B | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of applicants for admission were screened, in accordance with the Pre-Admission Screening and Resident Review (PASRR) program, prior to admission to the facility for three (3) of twenty-eight (28) sampled residents. Resident identifiers: #19, #74, and #113. Facility census: 128. Findings include: a) Resident #19 A review of the clinical record revealed Resident #19 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 04/10/09, as indicated by the dated signature in Section V. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he acknowledged this determination was made after the resident's admission to the facility. b) Resident #74 A review of the clinical record revealed Resident #74 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 01/12/09, as indicated by the dated signature in Section V. During an interview with the social worker at 11:00 a.m. on 06/24/09, he acknowledged the determination was made after the resident's admission to the facility. c) Resident #113 The medical record of Resident #113, when reviewed on 06/23/09, disclosed the resident was admitted to the facility on [DATE]. Further review disclosed, at Item 42 on page 6 of the PASRR form, that a determination with respect to a Level II evaluation was not made until 03/25/09, after the resident's admission to the facility. . | 2014-09-01 |
| 11058 | 11058 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 315 | D | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure one (1) of five (5) sampled residents with indwelling Foley urinary catheters had a valid physician's orders [REDACTED]. Resident identifier: #19. Facility census: 128. Findings include: a) Resident #19 A review of the medical record revealed Resident #19 was admitted to the facility from the hospital on [DATE], with an indwelling urinary catheter in place. The catheter was discontinued per physician's orders [REDACTED]. Resident #19 was readmitted to the facility on [DATE], with the catheter in place. There was no evidence of a physician's orders [REDACTED]. The resident was observed to have a urinary catheter in place at 2:00 p.m. on 06/22/09, while the resident's wife was being interviewed. This was confirmed by the director of nursing (DON - Employee #82) at 10:30 a.m. on 06/24/09, although she stated she had no explanation for the catheter's use in the absence of an order. . | 2014-09-01 |
| 11059 | 11059 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 441 | D | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the effectiveness of the infection control program by allowing two (2) of nine (9) employees to care for residents without an annual screening for [DIAGNOSES REDACTED] (TB). This has the potential to effect all residents. Employee identifiers: #124 and #155. Facility census: 128. Findings include: a) Employee #124 A review of the employee health file for Employee #124, a licensed practical nurse, revealed her most recent TB screening was in 2006. b) Employee #155 A review of the employee health file for Employee #155, a licensed practical nurse, revealed her most recent TB screening was dated 01/06/08. c) During an interview with the administrator at 10:45 a.m. on 06/25/09, he explained the person in charge of employee health had recently resigned unexpectedly, and he acknowledged he could not find any evidence to show these employees had received their TB annual screening. . | 2014-09-01 |
| 11060 | 11060 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 492 | D | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review and staff interview, the facility failed to provide information regarding Hospice to one (1) resident from a total sample of twenty-five (25), who recently received orders for "comfort measures only". This is required by W.V.C. 16-5C-20. Resident identifier: #4. Facility census: 128. Findings include: a) Resident #4 Medical record review, on 06/24/09, revealed this resident's Physician order [REDACTED]. Further review revealed no evidence the resident and family had been provided information regarding Hospice. Interview with the social worker, on the morning of 06/24/09, verified this information had not been provided as required. --- Part II -- Based on review of personnel files and staff interview, the facility failed to provide one (1) of three (3) certified nursing assistants, hired in 2009, with a copy of the Nurse Aide Abuse Registry legislative rule, as required by WV Legislative Rule 69-8.1. Employee identifier: #75. Facility census: 128. Findings include: a) Employee #75 A review of the personnel file of Employee #75, a nursing assistant who was hired on 06/08/09, failed to reveal any evidence that the facility had provided this employee with a copy of the Nurse Aide Abuse Registry legislative rule, as required by WV Legislative Rule 69-8.1. During an interview with the administrator at 10:45 a.m. on 06/25/09, he explained the person in charge of employee records had recently resigned unexpectedly, and he acknowledged he could not find any evidence to show this employee had received the required information. . | 2014-09-01 |
| 11061 | 11061 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 241 | D | 0 | 1 | OJEL11 | Based on observation and staff interview, the facility's staff failed to provide care to residents in a manner that maintains and/or enhances each resident's self-esteem and self-worth, by failing to respond in a timely manner to a resident's request for assistance. Four (4) staff members were randomly observed to pass by (and not answer) an activated resident call light on the 100 Wing of the facility. Resident identifier: #29. Facility census: 128. Findings include: a) Resident #29 At 11:35 a.m. on 06/24/09, a staff member (Employee #116) was observed to pass by a resident-activated call light in a room on the 100 Wing of the facility. The employee was approached by this surveyor and, when asked if all staff was responsible for answering call lights, she stated, "Yes." It was pointed out to her that she had just passed by one without responding. She stated she had not noticed it, and she returned to the room occupied by Resident #29 and answered the light, turning it off. The call light was re-activated almost immediately, and at 11:40 a.m., three (3) additional staff members were observed to walk past the light, not responding. One (1) of the three (3) employees (Employee #161) was approached and asked who was responsible for answering call lights. Employee #161 responded, "Everyone." When informed that she and her co-workers had just failed to answer the light to Resident #29's room, Employee #161 stated that she had not noticed it was ringing. . | 2014-09-01 |
| 11062 | 11062 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 280 | D | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed, for two (2) of twenty-five (25) residents sampled, to update the plan of care to reflect current needs. This included care received at an outside wound care clinic for one (1) resident and the use of a specialized air flow mattress for one (1) resident. Resident identifiers: #40 and #114. Facility census: 128. Findings include: a) Resident #40 The medical record of Resident #40, when reviewed on 06/23/09, disclosed the resident had acquired a Stage IV pressure ulcer during a hospitalization from which he was re-admitted to the facility on [DATE]. Shortly thereafter, the resident had begun weekly visits to and received treatments at an area wound care clinic. The resident's plan of care was reviewed. Although the plan did have interventions related to the resident's skin condition and care provided, the information was not correct at this time and did not mention the resident's weekly wound care clinic visits. This information was presented to the facility's director of nursing (DON - Employee #82) on 06/25/09, and no further information was available related to the a lack of revision to this resident's care plan. b) Resident #114 Observation, at 11:00 a.m. on 06/25/09, found this resident lying on a low air mattress with a raised border surrounding it. The mattress was a Stat 4000 Multizone Mattress which had a "coverlay" and required specific air flow settings. Review of the resident's care plan revealed the mattress was not currently identified on the care plan and had not been added to the care plan when its use was initiated on 05/20/09. . | 2014-09-01 |
| 11063 | 11063 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 281 | D | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility's "Do Not Crush" document, the facility failed to ensure one (1) of five (5) nurses administered medications in accordance with current professional standards of quality, by crushing and administering a medication that was noted to be in a form that should not be crushed. Resident identifier: #31. Facility census: 128. Findings include: a) Resident #31 A nurse (Employee #163) was observed performing medication administration at 8:35 a.m. on 06/24/09. This employee was noted to crush the medications she was preparing for Resident #31, which included [MEDICATION NAME], Vitamin D, [MEDICATION NAME], Sodium [MEDICATION NAME], and [MEDICATION NAME]. All of the medications were crushed with the exception of the [MEDICATION NAME], which Employee #163 stated the resident could swallow whole. Following the administration of the medication, the facility's "Do not crush" list available for nurse reference was requested and received from the facility's director of nursing (DON - Employee #82). Review of this document disclosed the medication [MEDICATION NAME] was a slow release medication and should not be crushed. The DON confirmed the findings when this information was provided at approximately 10:00 a.m. on 06/24/09. . | 2014-09-01 |
| 11064 | 11064 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 514 | E | 0 | 1 | OJEL11 | Based on medical record review and staff interview, the facility staff failed to maintain resident medical records in accordance with accepted professional standards, by failing to ensure all documents in the record displayed a date of entry for two (2) of twenty-five (25) sampled residents. Resident identifiers: #15 and #113. Facility census: 128. Findings include: a) Residents #15 and #113 The medical records for Residents #15 and #113, when reviewed on 06/23/09, disclosed on both records documentation on a "Progress Note" form with a signature that appeared to be a large "R". The documents were also signed by the resident's attending physician. The information contained on the forms was a recapitulation of each resident's condition, including weight, medications, etc. The forms displayed no date to indicate when they were written and placed in the residents' records. The facility's director of nursing (DON - Employee #82), when questioned about these forms and documentation on 06/23/09 at 11:00 a.m., stated these forms were completed by the facility's restorative nurse. The DON confirmed the lack of a date to indicate when these entries were written. | 2014-09-01 |
| 11065 | 11065 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 364 | F | 0 | 1 | OJEL11 | Based on observation, food temperature measurements, the confidential resident group interview, the facility's resident council meeting minutes, and staff interview, it was determined the facility failed to assure foods were attractive for residents on pureed diets, failed to assure hot foods were hot upon receipt by the resident, and failed to assure staff intervened when food were not hot enough. This practice had the potential to affect all facility residents who received nutrition from the dietary department. Facility census: 128. Findings include: a) Observation of the pureed foods, for the noon meal on 06/24/09, revealed all the foods were pale in color. When asked what the garnish was, the dietary manager (DM) stated the menu did not call for garnishes for pureed meals. After discussion, the pureed foods were garnished with parsley flakes, and a pureed apple slice was added to each plate. Dietary staff stated the food was much more attractive with the garnishes. b) Review of the past three (3) months of the facility's resident council meeting minutes revealed residents expressed concern regarding cold foods on 03/24/09. During the confidential group interview held with the residents at 1:45 p.m. on 06/23/09, five (5) of seven (7) responding residents stated that hot foods were not hot when they received them. During that meeting, residents also reported staff never offered to heat their meals for them. The residents said if they asked, staff would do this for them, but no offer was ever made. Observation revealed the meal service was begun at 11:40 a.m. on 06/24/09. The temperatures of the foods were not measured prior to beginning meal service. At 12:00 p.m., when more than half of the meals had not been served, food temperatures were measured. The pureed entree was 100 degrees Fahrenheit (F), pureed meat balls were 125 degrees F, potatoes were 130 degrees F, and mashed potatoes were 138 degrees F. Observations were made of tray delivery on the 100 hall, on 06/24/09. The cart arrived at 12:10 p.m. At 12:4… | 2014-09-01 |
| 11066 | 11066 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 363 | E | 0 | 1 | OJEL11 | Based on menu review, observation, and staff interview, the facility failed to ensure menus were followed for residents ordered consistent carbohydrate (CC) and renal diets. This practice affected twelve (12) residents ordered CC diets, and had the potential to affect one resident who was ordered a renal diet. Facility census: 128. Findings include: a) Menu review revealed that residents on CC and renal diets were to receive cubed steak instead of a sausage / egg / cheese puff on 06/24/09. b) Observation of the service of the noon meal, on 06/25/09, revealed there was no cubed steak prepared. Residents on CC diets were served the sausage / egg / cheese puff. c) This was brought to the attention of the dietary manager (DM) during the meal service. At that time, she asked the cook if cubed steak had been prepared for these diets. The cook stated she did not notice that on the menu. At that time, the renal diet had not yet been served; therefore, the DM intervened, and the resident ordered a renal diet did not receive a sausage / egg / cheese puff. . | 2014-09-01 |
| 11067 | 11067 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 371 | F | 0 | 1 | OJEL11 | Based on observation and staff interview, the facility failed to ensure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 128. Findings include: a) During the initial observation of the dietary department at 3:10 p.m. on 06/22/09, the following sanitation infractions were identified: 1. A staff member was using a container of filled with water to clean. When the water was tested , there was no sanitizing agent in the water. 2. A greasy substance was noted under the shelf at the food preparation sink. 3. Carrots from the previous meal were observed in the steam table water. 4. A large trash barrel had a large round hole cut in the lid. This practice caused the container to be an uncovered trash container in the kitchen. 5. One (1) male dietary employee did not have his mustache and beard covered to assure hairs did not fall into foods and/or onto food service items. Additionally, the female dietary personnel had loose hair outside of their hairnets. 6. Cakes were stored in the dry storage room. They were not covered to prevent possible contamination as staff went in and out of that room. 7. Steam table pans had not been fully air dried prior to stacking inside of each other, and these pans had crusty substances which could be scraped off with a fingernail, as well as a greasy debris on them. b) Observation revealed the meal service was begun at 11:40 a.m. on 06/24/09. The temperatures of the foods were not measured prior to beginning meal service. At 12:00 p.m., when more than half of the meals had not been served, food temperatures were measured. The pureed entree was 100 degrees Fahrenheit (F), pureed meat balls were 125 degrees F, potatoes were 130 degrees F, and mashed potatoes were 138 degrees F. To prevent the rap… | 2014-09-01 |
| 11068 | 11068 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 323 | E | 0 | 1 | OJEL11 | Based on observation, staff interview, and medical record review, the facility failed to assure one (1) of one (1) resident's side rail padding was applied correctly, and failed to assure an electrical cover was properly secured flush to the floor so as not to present a trip hazard. These practices had the potential to result in injury to the resident with the side rails, and in injury to any resident who was ambulating near the kitchen entrance. Resident identifier: #4. Facility census: 128. Findings include: a) Resident #4 During the initial tour at 2:30 p.m. on 06/22/09, this resident was observed lying in bed with a device between each of the side rails and the resident. The devices had slid down and were not fully covering the side rails. On 06/24/09 at 10:00 a.m., this resident was observed with a nursing assistant (NA) present. Upon inquiry, the NA stated the devices were to protect the resident, because he often leaned his face into the side rails. At that time, the NA noted the devices had slid down, exposing the side rails. The NA then repositioned the devices. During the afternoon of 06/25/09, the resident was again observed with the director of nursing (DON - Employee #82) present. When shown the devices, which again had slid off the side rails, the DON stated the devices were not properly applied. At that time, the DON demonstrated how the devices were supposed to be applied. They were supposed to be affixed with Velcro, which was a part of each device. When applied correctly, the safety devices remained in place and protected the resident from the side rails. b) Observation, on 06/23/09 at 10:00 a.m. and 06/24/09 during the early afternoon, revealed a metal electrical cover attached to the floor, in the hallway near the kitchen. This cover was not flush with the floor and created a trip hazard. Residents were observed ambulating in this area throughout each day of the survey. . | 2014-09-01 |
| 10685 | 10685 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2009-07-02 | 356 | C | 0 | 1 | DBCB11 | Based on observation and staff interview, the facility failed to ensure the daily nursing staffing posting was in compliance with the posting requirement set forth by section 941 of BIPA (benefits improvement and protection act) specified as sections 1819 (b)(8) and 1919 (b) (8) of the act. This practice has the potential to affect both residents and visitors to the facility. Facility census: 81. Findings include: a) On 07/01/09 at approximately 4:00 p.m., observation of the facility's nursing staff form, posted in the hallway of the first floor, revealed the facility had not updated the form to reflect the number of licensed / unlicensed nursing staff working on the evening shift. In addition, the facility did not have the total number of actual hours worked each day by nursing staff who were directly responsible for resident care. The director of nursing, when informed of the issue on 07/01/09 at approximately 4:30 p.m., indicated she was having a meeting the the nurse who was responsible for updating the staffing sheet on the evening shift. She reported she was unaware the form needed to reflect the total number of hours worked each day by direct care nursing staff. | 2015-01-01 |
| 10686 | 10686 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2009-07-02 | 323 | E | 0 | 1 | DBCB11 | Based on observation, a review of the material safety data sheets, and staff interview, the facility failed to ensure the locked unit, in which cognitively impaired residents resided, was kept safe and free from accident hazards. The janitor's closet on this unit was left unlocked, allowing access by the residents to its hazardous contents. This practice has the potential to result in more than minimal harm to all residents on this unit (Unit 3-C). Unit census: 17. Facility census: 81. Finding include: a) Unit 3-C During a tour of the locked unit (Unit 3-C) on 06/29/2009 at 2:00 p.m., the door to the janitor's closet was noted to be unlocked. This surveyor opened the door and looked around on the inside. The contents of this closet included heavy duty cleaner, disinfectant, floor cleaner, and Ajax. After the surveyor came out of the closet, a health services worker (Employee #111), who had been standing in the hall and observed the surveyor go into the closet, came and locked the door. She stated, "He must have forgot to lock the door. He took the residents outside to smoke." The housekeeping supervisor (Employee #14) was made aware of this observation on 07/01/09 at 10:00 a.m., and she was asked to provided the material safety data sheets (MSDS) for the chemicals observed in the unlocked closet. Review of the MSDS sheets revealed the chemicals in this unlocked closet could be hazardous to the residents if they ingested the products, got the Ajax on the skin, or inhaled the particles. . | 2015-01-01 |
| 10687 | 10687 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2009-07-02 | 279 | D | 0 | 1 | DBCB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to develop and implement care plans of two (2) of fourteen (14) sampled residents. Resident # 74 was receiving the sedating drug [MEDICATION NAME] for [MEDICAL CONDITION], and the resident had no assessment identifying this problem nor was a care plan developed for [MEDICAL CONDITION]. Resident #39 had a care plan developed for small meals and low caffeine, which was not communicated and implemented. Resident identifiers: #74 and #39. Facility census: 81. Findings include: a) Resident #74 Medical record review revealed this resident was receiving the sedating drug [MEDICATION NAME], 1 mg in the morning and 2 mg at bedtime. During an interview on 07/02/09 at 9:50 a.m., the assistant director of nursing (ADON - Employee #24) revealed this resident was receiving [MEDICATION NAME] to treat [MEDICAL CONDITION] only. Review of the resident's current care plan, provided by the minimum data set assessment (MDS) coordinator on 06/30/09, revealed no plan addressing the problem of [MEDICAL CONDITION]. Review of quarterly MDS assessments, with assessment reference dates of 03/15/09 and 06/14/09, found, in Section E, this resident had not been identified as having sleep-cycle difficulties. In a subsequent interview on 07/02/09 at 10:15 a.m., the ADON confirmed the use of [MEDICATION NAME] was for [MEDICAL CONDITION] only. A comprehensive plan of care had not been developed for this resident with [MEDICAL CONDITION], to include non-pharmacologic interventions to assist to promote sleep and efforts to identify and mitigate causative factors that altered the resident's ability to sleep. b) Resident #39 Review of the interdisciplinary care plan for this resident found a care plan established on 01/13/09, which had been continued and was to be reviewed again on 07/16/09, for gastric pain related to his hiatal hernia and [MEDICAL CONDITION] reflux disease (GERD). The interven… | 2015-01-01 |
| 10688 | 10688 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2009-07-02 | 156 | C | 0 | 1 | DBCB11 | Based on observation and staff interview, the facility failed to post all complete contact information for all applicable State advocacy agencies as required by the regulation. Only the regional ombudsman's name and contact information were posted for public view. This has the potential to affect all residents as all residents and families are to have access to this information. Facility census: 81. Findings include: a) On 07/01/09 at 2:30 p.m., review of posted contact information of all pertinent State client advocacy groups, observed on the third floor of the facility, revealed only the name, address and telephone number of the regional ombudsman. Phone numbers were listed for other agencies, but not addresses. Discussions with the administrator, on the afternoon of 07/01/09 and again on the morning of 070/2/09, revealed the addresses and phone numbers of the other advocacy groups were not posted in any other locations of the facility as well. The following information was omitted from the public postings: - The contact information for the State survey and certification agency (which is also the State licensure office); - The contact information for the State long-term care ombudsman; - The contact information for the protection and advocacy network; - The contact information for the Medicaid fraud control unit; and - A statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. . | 2015-01-01 |
| 10689 | 10689 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2009-07-02 | 246 | D | 0 | 1 | DBCB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to accommodate Resident #62's need for a larger chair. The resident had gained weight and required a larger chair, and this had not been implemented as yet. This was evident for one (1) of fourteen (14) residents in the sample. Facility census: 81. Findings include: a) Resident #62 Observation of the resident, at breakfast in the third floor auditorium / dining area on 07/01/09, revealed he was seated in a "go" chair that appeared much too small for his size. His feet were back under the chair, and a lap tray was applied in such a manner that a portion of his stomach was resting on the tray. There was no room between him and the sides of the chair or between his body and the tray. He was noticed to move one foot and make circles with his chair most of the time, but he could advance the chair in one direction as well. (There were no injuries noted related to his feet and the positioning in the chair.) Direct care staff, when questioned regarding the size of his chair, stated they could not get another chair for him and the tray was out as far as it would go. Record review revealed physician's orders [REDACTED]. The quarterly minimum data set (MDS) assessment from June 2009 revealed the resident does have range of motion problems with his arm, leg, and foot, and he had gained nine (9) pounds since the quarterly review in January 2009. The surveyor questioned the administrator and physical therapy staff about this on the morning of 07/02/09. The physical therapist submitted an evaluation, completed on 06/24/09, indicating the resident was observed in a "go" chair. The first thing noticed was the resident had gained weight since January and the chair would soon be much too narrow for him. The seat was worn as well. Recommendations were made for a dietary consult for weight reduction, to reverse the padded arm supports to create additional space on the sides of the chair, and to reuphol… | 2015-01-01 |
| 11364 | 11364 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 246 | D | MWZ111 | Based on observation, staff interview, and record review, the facility failed to ensure proper positioning of one (1) randomly observed resident in restorative dining. A resident in a scoot chair was observed eating lunch while the back of his scoot chair was in a reclined position. The reclined position of the chair back interfered with the resident's ability to reach his food. Resident identifier: #189. Facility census: 102. Findings include: a) On 06/29/09 at 12:25 p.m., observation found Resident #189 eating in the restorative dining room. The resident was seated in a scoot chair. The scoot chair's seat was low to the ground, and the backrest was observed to be in a reclined position. The table height was too high for the resident to comfortably reach his food. The resident, who was attempting to feed himself, was having difficulty reaching the food on the table and was spilling some food onto his chest. The resident, when observed on 07/02/09 at 12:30 p.m. in the restorative dining room., was again in the scoot chair seated at the table. The backrest to the chair was observed in a reclined position. The resident was observed having difficulty reaching the food on the table. When interviewed on 07/02/09 at 12:45 p.m., the speech language pathologist (SPL - Employee #17) stated the backrest to the scoot chair was "all the way up". She further stated, "I sometimes put pillows behind his back." The SPL walked over to the chair and raised up the backrest. The resident's medical record, when reviewed at 1:30 p.m. on 07/02/09, revealed a physician's for the scoot chair. A dietary note, dated 06/12/09, reported the resident consumes 59% of meals and requires supervision with meals. . | 2014-04-01 | ||
| 11365 | 11365 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 240 | B | MWZ111 | Based on resident interview, observation, and staff interview, the facility failed to ensure residents received fresh ice and water every shift. This was evident for four (4) of four (4) sampled residents, three (3) of whom were located on the same hall. Resident identifiers: #57, #108, #6, and #31. Facility census: 102. Findings include: a) Resident #31 During an interview on 06/30/09, Resident #31 voiced a complaint of not having ice for his pitcher. He said he could not stand to drink the water that was not cold and elaborated that he will awaken from sleep and crave a cold drink, but many times there was no ice in his pitcher. He said he had not voiced complaints about this to anyone. He felt the facility should know to provide ice water to people who cannot easily get their own. He said there have been many times he had to get cold water from the bathroom in order to have a cold drink, and this may happen by day or by night. At 8:55 a.m. on 07/01/09, observation of his water pitcher found it contained only water, no ice. His pitcher was checked for ice again at 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., and no ice was present on any of these observations. Observations of every water pitcher on the same hall found none of the residents on that hall had ice in their pitchers. During an interview on 07/01/09 at 4:30 p.m., a nurse (Employee #139) stated ice was supplied to residents every shift. When informed that sampled residents had received no ice in their pitchers on day shift today, and currently none of the residents on the hall in question had ice, she stated she would take care of it immediately. b) Resident #6 Record review revealed Resident #6 was dependent on staff for all activities of daily living (ADLs) except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. c) Resident #108 Record review revealed Resid… | 2014-04-01 | ||
| 11366 | 11366 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 252 | D | MWZ111 | Based on observation and staff interview, the facility failed to provide a clean environment free from unpleasant odors as evidenced by the presence of a persistent odor of urine in a room shared by two (2) incontinent residents. This was evident for two (2) of four (4) sampled residents. Resident identifiers: #6 and #108. Facility census: 102. Findings include: a) Residents #6 and #108 share a room. Observations of the residents' shared room on 06/30/09, at 8:05 a.m., 1:42 p.m., and 2:15 p.m., revealed an unpleasant odor of urine that could be detected immediately upon entering the room. At 8:05 a.m., the odor seemed to be the strongest from Resident #6. At 1:42 p.m., the odor seemed to be coming from an afghan on the bed and the curtain separating the two (2) residents. At 2:15 p.m., the odor of urine was noted also from the wheelchair pad belonging to Resident #108, who had been sitting in the wheelchair. On all three (3) instances, the smell of urine was easily noticeable and could be detected immediately upon entering the room. On 07/01/09 at 11:45 a.m., the distinct odor of urine was detected immediately upon entering the room. During an interview at this time, a nursing assistant (Employee #93) stated she and other aides had noticed a bad smell in the room yesterday and, subsequently, Resident #108's mattress was changed. After the floor was mopped and the resident was showered, they still noticed the odor. She stated she did not believe the odor was coming from the pad in Resident #108's wheelchair, but she agreed she could smell the odor of urine in the curtain separating the residents. She immediately notified housekeeping. The housekeeping, upon arrival, smelled the curtain and also agreed it smelled like urine. She said they do terminal cleaning once every month, which includes taking down the curtains and washing them. She said Resident #6 will yell and throw things when that curtain is removed, as she always wants it pulled. She related she would use the second curtain in the room as a divider betwe… | 2014-04-01 | ||
| 11367 | 11367 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 242 | D | MWZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, policy review, staff interview and record review, the facility failed to ensure one (1) of twenty-eight (28) Stage II sampled residents receive bi-weekly showers per resident request. Resident #133, who had an intestinal infection, reported she did not receive bi-weekly showers as requested, due to facility's infection control policy regarding [MEDICAL CONDITIONS] infection. Resident identifier: #133. Facility census: 102. Findings: a) Resident #133 Resident #133, when interviewed on 06/30/09 at 10:00 a.m., reported she has not been able to take a shower and get her hair washed for the past two (2) weeks. The resident stated she has an intestinal infection, and staff told her she could not take a shower due to the infection. Resident #133 stated, "This makes me feel dirty and my hair looks terrible." The director of nurses (DON - Employee #20) provided a copy of the facility's policy titled "[MEDICAL CONDITION] Protocol" on 07/01/09. Review of this, at 1:45 p.m. on 07/01/09, found no limitations on a resident's shower schedule during active infection. On 06/30/09 at 11:00 a.m., a licensed practical nurse (LPN - Employee #127), when interviewed, stated, "Residents with [MEDICAL CONDITION] do not get showers due to loose stools." On 07/01/09 at 2:45 p.m., the DON stated residents with [MEDICAL CONDITION] infection can have showers, and it is not the facility's policy to hold showers for residents with [MEDICAL CONDITION] infection. The DON further stated she needed to educate her staff regarding the current policy. Resident #133's medical record, when reviewed on 07/01/09 at 3:00 p.m., revealed a care plan for diarrhea dated 06/09/09. The interventions listed did not include withholding showers until the intestinal infection resolved. . | 2014-04-01 | ||
| 11308 | 11308 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2009-07-03 | 225 | E | 1 | 0 | HMYP11 | Based on record review and staff interview, the facility failed to immediately report and thoroughly investigate an allegation of neglect by Employee #33, a nursing assistant (NA), involving Resident #3, and failed to investigate the reasons six (6) additional current residents and five (5) discharged residents refused to be cared for by Employee #33. Resident identifiers: #3, #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53. Facility census: 47. Findings include: a) Resident #3 Review of facility records revealed an incident, occurring on 05/21/09, in which a NA (Employee #33) was observed, by the respiratory therapist (RT), pushing Resident #3 in a shower chair, with the resident's feet dragging under the shower chair twice. The RT stated the NA continued pushing the resident, even though the resident yelled, "My foot, my foot! You're hurting my foot!" The NA did not stop pushing the shower chair until the RT intervened. Additionally, the RT reported to the facility that Employee #33 "threw" briefs onto each resident's bed and that Employee #33 "had a bad attitude." After the RT reported the incident to the facility, but the facility did not report it to State agencies as neglect, nor did the facility thoroughly investigate the incident. The resident's roommate, whom the facility identified as "interviewable", was present, yet the facility did not interview this resident regarding the incident. In addition, there was no statement (written or dictated) from the alleged perpetrator (Employee #33). Facility staff interviewed another NA (Employee #36), who witnessed the briefs thrown on the beds and confirmed that Employee #33 "did throw the briefs onto each of the beds and that she (Employee #33) did have a bad attitude." According to the facility's grievance form, the social worker (SW) and director of nursing (DON) interviewed Employee #33, who denied the incident, said the resident's foot was caught only once, and that she "laid the diapers on the bed." Review of the grievance form, completed by the SW… | 2014-07-01 |
| 11309 | 11309 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2009-07-03 | 226 | E | 1 | 0 | HMYP11 | Based on record review, staff interview, and policy review, the facility failed to operationalize their policies and procedures regarding identification, investigation, and reporting of suspected neglect or abuse. Resident identifiers: #3, #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53. Facility census: 47. Findings include: a) Resident #3 Review of facility records revealed an incident, occurring on 05/21/09, in which a nursing assistant (NA - Employee #33) was observed, by the respiratory therapist (RT), pushing Resident #3 in a shower chair and dragging this resident's foot under a shower chair twice. According to the director of nursing (DON) at 12:00 p.m. on 07/03/04, the RT did not report the incident to anyone. The DON stated, "We heard rumors and sought her out." Review of the facility's abuse / neglect policy revealed, "All personnel must promptly report any incident or suspected incident of resident neglect, abuse..." This information is in the section of the policy entitled "Reporting". The RT was a hospital employee, not an employee of the nursing home; however, all personnel who work with residents in the nursing facility are required to know and operationalize facility abuse policies. In addition, the facility failed to operationalize its procedures to notify the appropriate State regulatory agencies, and failed to operationalize its procedures to investigate an allegation of neglect regarding this incident. b) Residents #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53 During the survey, it was discovered these residents refused to allow Employee #33 to provide care for them. The facility had not investigated the reasons why these residents were refusing care from Employee #33. At 12:15 p.m. on 07/03/09, the social worker (SW) was asked how the facility became aware that these residents did not want Employee #33 to provide their care. The SW stated the nurses informed them. When asked if the residents had been asked why they were refusing care by Employee #33, the SW stated they … | 2014-07-01 |
| 11310 | 11310 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2009-07-03 | 323 | D | 1 | 0 | HMYP11 | Based on observation and staff interview, the facility failed to identify and mitigate an accident hazard for one (1) of seven (7) sampled residents. Resident identifier: #36. Facility census: 47. Findings include: a) Resident #36 On 07/01/09 at 10:10 a.m., this resident was observed attempting to get out of bed. According to nursing staff present at that time, the resident was able to get out of bed unassisted and did so at will. The resident had full length gap guards on her bed. They ran from the top of the bed to the bottom of the bed. The resident was observed extending her legs over the guard at the foot of her bed, to get out of the bed. Due to the guard, the resident was unable to simply position herself on the side of the bed, allow her feet to touch the floor, then rise normally. Additionally, since the guards were not permanently attached to the bed, if one (1) of the guards happened to slide away from the side of the bed the resident was exiting, the resident could become entangled, causing a fall. . | 2014-07-01 |
| 10344 | 10344 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2009-07-16 | 371 | F | 0 | 1 | KV9O11 | Based on an observation and staff interview, the facility did not ensure employees do not store food and beverages in the refrigerator used to store resident food. This has the potential to affect all residents. Facility census: 64. Findings include: a) On 07/13/09 at 4:10 p.m., observation revealed a plastic bottle with fluid was stored in the refrigerator used to store food for the residents. An interview with dietary staff revealed the bottle of juice belonged to one (1) of the dietary workers. The dietary staff member told the owner of the bottle of juice to remove the bottle and that they were not permitted to have their personal items in the resident refrigerator. | 2015-05-01 |
| 10345 | 10345 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2009-07-16 | 241 | D | 0 | 1 | KV9O11 | Based on an observation and staff interview, the facility did not ensure one (1) resident of a sample of fifteen (15) was provided care in a manner that maintained or enhanced the resident's dignity. Resident #42 was observed out in the hallway with a facility night gown open, exposing the resident's entire back. Facility census: 64. Findings include: a) Resident #42 On 07/14/09 at 8:30 a.m., observation found Resident #42 self-propelling down the B hallway dressed in a facility night gown with the resident's back fully exposed. An interview with the administrator revealed the resident was to be dressed before staff removed the resident from his room to the hallway. . | 2015-05-01 |
| 10346 | 10346 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2009-07-16 | 225 | D | 0 | 1 | KV9O11 | Based on record review and staff interview, the facility did not ensure all allegations of resident neglect received by the facility immediately reported to State agencies as required by law. One (1) of thirteen (13) complaint records reviewed contained an allegation of neglect, which the facility did not identify as such and report as required. Facility census: 64. Findings include: a) A review of the facility's internal complaint records revealed that, on 01/14/09, a family member reported the following: "Daughter reports coming to feed her mother at 11:45 a.m. and found her with dried food / liquid all over her mouth, chin and neck." This complaint was submitted to the facility's social worker on at 3:45 p.m. on 01/14/09. This allegation of neglect were not immediately reported to the appropriate State agencies. In an interview on 07/14/09 at 2:00 p.m., the administrator (Employee #4) agreed the allegation of neglect received on 01/14/09 should have been reported to the appropriate State agencies. . | 2015-05-01 |
| 10746 | 10746 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2009-07-22 | 280 | D | 0 | 1 | UHKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to revise the care plans for two (2) of twenty-five (25) Stage II sampled residents. Two (2) residents, who recently had a significant weight loss, did not have their care plans revised to reflect the current interventions staff was implementing to monitor weight and prevent a further decline. Resident identifiers: #120 and #133. Facility census: 122. Findings include: a) Resident #120 Resident #120's medical record, when reviewed on 07/22/09 at 9:00 a.m., disclosed a [AGE] year old male who was admitted to the facility on [DATE]. The medical record stated the resident's admission weight, on 02/26/09, was 169 pounds. The resident's weight, on 07/18/09, was reported to be 154 pounds. The resident had a significant weight loss of 8.8 % in a four (4) month period of time. The resident's current care plan, with a revision date of 06/04/09, did not include all current interventions the facility staff was implementing to prevent further weight loss. The dietary manager (Employee #12), when interviewed on 07/22/09 at 11:00 a.m., reported the facility staff was implementing interventions to monitor the resident's weight and prevent a further decline. The dietary manager reviewed the current care plan (with a revision date of 06/04/09) and confirmed all current interventions were not listed on the current care plan. The care plan nurse (Employee #32), when interviewed on 07/22/09 at 2:00 p.m., reviewed the resident's current plan of care (with a revision date of 06/04/09) and confirmed the resident's current care plan was not revised to include all current interventions the staff was implementing to improve weight and prevent further decline. b) Resident #133 Resident #133's medical record, when reviewed on 07/22/09 at 10:00 a.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The resident's medical record stated the resident's weight, on 04/04/09, … | 2014-12-01 |
| 10747 | 10747 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2009-07-22 | 311 | D | 0 | 1 | UHKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, record review, staff interview, and resident interview, the facility did not ensure that one (1) resident of a sample of twenty-five (25) received care and services to maintain or enhance the resident's ability to ambulate. Resident #80 had a physician's orders [REDACTED]. Facility census: 122. Findings include: a) Resident #80 An interview with Resident #80, on 07/22/09 at 9:30 a.m., revealed the resident wanted the nursing assistants to assist her with ambulation. The resident stated, "The aides used to walk me, but they don't do it any more. I want to walk out in the hall, and they don't take me any more for my walk, and I need someone with me." An interview with the assessment coordinator (Employee #32), on 07/14/09 at 10:10 a.m., revealed the resident had an order to ambulate with a wheeled walker daily. She stated that, after talking with the nursing assistants, this morning they were not walking the resident every day. She was starting the resident on a walk-to-dine program that would require the nursing staff to walk the resident to the dining room for meals on a daily basis. Record review revealed a physician's orders [REDACTED]." A review of the facility's Resident Flow Record revealed the documentation was not accurate for the resident's ambulation. The nursing assistants were marking the area for ambulation with the word "up". An interview with a registered nurse (Employee #36), on 07/14/09 at 10:30 a.m., revealed the documentation for the resident's ambulation was not clear as to what was happening with the resident concerning her daily ambulation. She was uncertain as to how the nursing assistants were documenting. The form revealed that each day the nursing assistants were marking "up", and the RN did not have an explanation for the documentation. An interview with a licensed practical nurse (Employee #40), on 07/22/09 at 11:30 a.m., revealed a treatment aide usually ambulated the residents on the 3:00 … | 2014-12-01 |
| 10748 | 10748 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2009-07-22 | 492 | C | 0 | 1 | UHKM11 | Based on observation, facility records, and staff interview, the facility failed to post the nurse staffing as required by Section 941 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), which requires skilled nursing facilities and nursing facilities to post daily for each shift the number of registered nurses, licensed practical nurses, and unlicensed nursing staff directly responsible for resident care in the facility. This had the potential to affect all residents. Facility census: 122. Findings include: a) During the general tour at 1:00 p.m. on 07/20/09, observation revealed the nursing staffing posting contained only the number of licensed and unlicensed staff and total full-time equivalents (FTEs) for each shift. The posting failed to differentiate the categories of nursing staff by differentiating between licensed practical nurses and registered nurses. During an interview with the administrator and the director of nurses at 4:00 p.m. on 07/22/09, this lack of information was pointed out and they were given the source of the requirement. | 2014-12-01 |
| 10749 | 10749 | MOUND VIEW HEALTH CARE | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2009-07-22 | 371 | E | 0 | 1 | UHKM11 | Based on observation and staff interview, the facility failed to assure all kitchens contained hands-free garbage disposal equipment for dietary employee use at hand-washing stations. This was evident for one (1) of the two (2) kitchens and had the potential to affect all residents on the 500 Hall who receive nourishment from that kitchen. Facility census: 122. Findings include: a) During the initial tour on 07/20/09, an attempt to discard a used paper towel revealed the step-on trash can at the employee handwashing station in Kitchen #2 was not functioning. A dietary staff member (Employee #180) directed the surveyor to throw her paper towel onto a tray of food that she was going to discard. On 07/21/09 at 11:30 a.m., observation of Kitchen #2 revealed no trash receptacle at the employee handwashing station. Further observation of Kitchen #2 found a large black, round plastic trash can with a fitted lid in the dishwashing area. There were no other trash receptacles in the kitchen. On 07/22/09 at 4:00 p.m., a repeat observation of Kitchen #2 again found no trash receptacle at the employee hand-washing station. This surveyor reported the observation to Employee #12, and she explained that the step-on trash can broke yesterday. She threw her paper towel into the large black, round plastic trash can with a fitted lid that was housed in the dishwashing area. This surveyor did the same but could not avoid touching the trash can with her hand as she disposed of a used paper towel. . | 2014-12-01 |
| 11296 | 11296 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-07-27 | 356 | C | 1 | 0 | ONIB11 | Based on observation and staff interview, the facility failed to accurately post the actual resident census and actual numbers of licensed practical nurses (LPNs) and nursing assistants (NAs) working on the day shift on 07/26/09. Facility census: 112. Findings include: a) On 07/26/09 at 1:15 p.m., observation found a nursing staff posting form titled "Daily Nurse Staffing Form", dated 07/26/09, in the main dining room. The form did not specify the actual numbers of LPNs and NAs currently working in the facility on the day shift, nor did it specify the current resident census. The form reported fifteen and nine-tenths (15.9) NAs were on duty, yet observation revealed thirteen (13) NAs working on the day shift. The form also reported four and nine-tenths (4.9) LPNs were on duty, yet observation revealed four (4) LPNs working on the day shift. The day shift registered nurse supervisor (Employee #27), when interviewed on 07/26/09 at 2:00 p.m., confirmed the form was not accurate and complete. . | 2014-07-01 |
| 11297 | 11297 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-07-27 | 441 | E | 1 | 0 | ONIB11 | Based on observations, medical record review, policy review, and staff interviews, the facility failed to change each resident's oxygen tubing weekly, as required. This was true for two (2) of seven (7) sampled and seven (7) randomly observed residents prescribed oxygen therapy by their physician. Residents who were using oxygen therapy did not have their oxygen supply tubing changed weekly, as ordered by the physician and in accordance with the facility's infection control policy revised on October 2008. Resident identifiers: #2, #17, #46, #66, #77, #87, #91, # 97, and #107. Facility census: 112. Finding include: a) Resident #2 On 07/27/09 at 9:15 a.m., observation found Resident #2's oxygen tubing was dated 07/11/09. Resident #2's treatment sheet for July 2009, when reviewed on 07/27/09 at 10:00 a.m., disclosed the oxygen tubing was last changed on 07/06/09. b) Resident #17 On 07/27/09 at 8:45 a.m., observation found Resident #17's oxygen tubing was dated 06/09/09. c) Resident #46 On 07/27/09 at 9:20 a.m., observation found Resident #46's oxygen tubing was dated 07/07/09. d) Resident# 66 On 07/26/09 at 12:40 p. m., observation found Resident #66's oxygen tubing was dated 07/12/09. e) Resident #77 On 07/27/09 at 8:50 a.m., observation found Resident #77 in bed receiving oxygen therapy via nasal cannula at 2 liters per minute. The oxygen tubing was dated 07/11/09. f) Resident #87 On 07/26/09 at 12:45 p.m., observation found Resident #87's oxygen tubing was dated 07/07/09. g) Resident #91 On 07/27/09 at 7:45 a.m., observation found Resident #91 in bed using his oxygen via nasal cannula. The oxygen tubing was dated 07/11/09. The nursing supervisor (Employee #27), when interviewed on 07/27/09 at 7:50 a.m., confirmed the facility's policy was to "change the oxygen tubing weekly". h) Resident #97 On 07/26/09 at 2:30 p.m., observation found Resident #97 in her room using her oxygen via nasal cannula. The oxygen supply tubing was dated 07/11/09. i) Resident #107 On 07/27/09 at 7:45 a.m., observation found Resident #107'… | 2014-07-01 |
| 10826 | 10826 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2009-07-29 | 225 | E | 0 | 1 | 5UXH11 | Based on personnel file review and staff interview, the facility failed to screen, through a statewide criminal background check, three (3) of four (4) contracted agency employees for past criminal prosecutions prior to allowing them to have resident contact. Contract Employee identifiers: #84, #85, and #86. Facility census: 55. Findings include: a) Contract Employees #84, #85, and #86 On the afternoon of 07/28/09, a review of sampled personnel records of persons working at the facility within the past three (3) months revealed four (4) contracted employees who services were engaged through three (3) different temporary staffing agencies. Review of the personnel files of these four (4) contract employees revealed three (3) of the four (4) personnel files did not contain evidence to reflect the completion of a statewide criminal background check through the West Virginia State Police. On 07/28/09 at 3:00 p.m., the facility's director of nursing was informed that evidence of statewide background checks was not found in the personnel files of Contract Employees #84, #85, and #86. On 07/29/09 at 3:00 p.m., the facility's administrator had no additional information to provide to indicate that statewide criminal background checks were completed on these contract employees. | 2014-12-01 |
| 10827 | 10827 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2009-07-29 | 371 | F | 0 | 1 | 5UXH11 | Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 55. Findings include: a) On 07/29/09 at 2:00 p.m., observation found two (2) fans in the back of the walk-in refrigerator unit. Both fans had dirt and lint caked on the outside metal grate. Both fans were blowing air around inside the refrigerator which contained both cooked and raw foods. At this time, the dietary manager, who was touring with the surveyor, also observed the fans and agreed they were dirty. . | 2014-12-01 |
| 10580 | 10580 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 152 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the legal surrogate, of one (1) of thirteen (13) residents reviewed, exercised the resident's rights in accordance with State law. Resident #24 had designated a medical power of attorney representative (MPOA) to make health care decisions for her in the event she should lack the capacity to do so. The MPOA was making health care decisions on the resident's behalf, although there was no determination of incapacity in her record to reflect she was incapable of making these decisions for herself. Resident identifier: #24. Facility census: 60. Findings include: a) Resident #24 The medical record of Resident #24, when reviewed on 07/27/09, disclosed this [AGE] year old female had been admitted to the facility on [DATE], following hospitalization after a fall resulting in a subdural hematoma and cervical fracture. Review of the resident's admission documents, as well as the physician's orders [REDACTED]. The resident's medical record contained no document stating she herself did not have the capacity to make her own health care decisions. The facility's director of nursing (DON), when interviewed related to these findings on 07/29/09, confirmed that, although the resident was indeed unable physically and mentally to make her own decisions, there was no determination of incapacity completed by the attending physician for this resident. . | 2015-01-01 |
| 10581 | 10581 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 279 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to develop care plans, for three (3) of fifteen (15) residents reviewed, to reflect each resident's current needs. Resident #56 had experienced a substantial weight gain above her ideal body weight, and this was not reflected in the care plan. Resident #48 was receiving [MEDICAL CONDITION] treatments at an outside facility five (5) days per week, and the plan of care did not mention this. Resident #15 had developed a Stage II pressure ulcer, and this was not reflected in the plan of care. Facility census: 60. Findings include: a) Resident #56 The medical record for Resident #56, when reviewed on 07/28/09, disclosed the resident had been admitted to this facility from another facility on 01/12/09. At the time of admission, the resident was noted to weigh 102 pounds with a height of 62 inches. The initial note completed by the facility's registered dietitian stated her ideal body weight was 110 pounds. Her most recent minimum data set (MDS) assessment, and abbreviated quarterly assessment with an assessment reference date (ARD) of 07/09/09, revealed her weight during the assessment reference period was 119#. The resident's most recent care plan, revised on 07/09/09, stated the resident was "at nutritional risk related to disease process". The goal stated, "Resident will maintain weight." The interventions determined necessary to address this problem were: "Monitor intake and provide supplement PRN (as needed). Monitor weight, food and fluid intake. Provide food preferences upon request." The care plan had not been changed to reflect the resident's surpassing her ideal body weight. b) Resident #48 The medical record of Resident #48, when reviewed on 07/29/09, disclosed a physician's orders [REDACTED].@ 1300 (1:00 pm) last treatment 07/10/09." The resident's most current care plan, revised on 07/09/09, contained no mention of the resident's [MEDICAL CONDITION]. The faci… | 2015-01-01 |
| 10582 | 10582 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 280 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of fifteen (15) residents reviewed, to ensure each resident's plan of care was prepared by an interdisciplinary team including all staff involved in the care of the resident and as determined by the needs of the resident. The record record contained two (2) separate care plans, one (1) by facility staff and the other developed by the Hospice Agency contracted to provide care to the residents. Furthermore, the goals of the care plans and interventions to meet those goals were not integrated in a manner to provide the greatest benefit to the resident. Resident identifier: #3. Facility census: 60. Findings include: a) Resident #3 The medical record of Resident #3, when reviewed on 07/29/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE], and had been admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The resident's record contained two (2) separate care plans, one (1) developed by facility staff and another developed by the Hospice agency providing care to the resident. The facility's care plan, dated 07/02/09, recognized problems such as risk of alteration in comfort related to decreased mobility, arthritic joints, compression fracture; risk for impaired communication; risk for impaired skin integrity; etc. The Hospice document entitled "Interdisciplinary Plan of Care" recognized similar problems, but the interventions stated by the facility were not integrated with those of the Hospice. Neither plan of care displayed involvement of the other entity in its development. | 2015-01-01 |
| 10583 | 10583 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 281 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, review of the facility's "Do not crush list", and staff interview, it was determined one (1) of three (3) nurses observed (Employee #11) passing medications during the medication observation task failed to provide care for Resident #55 that met current standards of care, by crushing and administering two (2) medications on the list that were not formulated to be crushed. Resident identifier: #55. Facility census: 60. Findings include: a) Resident #55 During the medication pass observation on 07/27/09 at 3:30 p.m., the nurse (Employee #11) was observed preparing the following medications for Resident #55: [MEDICATION NAME] 400 mg, EC ([MEDICATION NAME] coated) Aspirin 81 mg, Senna tab, [MEDICATION NAME] 100 mg, and Vitamin C 500 mg. During the preparation, the nurse crushed all of these medications except [MEDICATION NAME] 100 mg. When this surveyor questioned the nurse which medications were crushed, the nurse stated, "I crushed everything except the [MEDICATION NAME]." Review of the facility's "Do not Crush list" revealed the [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON - Employee #4) confirmed [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. --- Part II -- Based on record review and staff interview, the facility permitted a nurse to function outside of her scope of practice, by allowing her to order a change in treatment for one (1) of thirteen (13) residents reviewed. Resident identifier: #11. Facility census: 60. Findings include: a) Resident #11 The medical record of Resident #11, when reviewed on 07/28/09, disclosed the resident had been experiencing increased difficulty swallowing, and a swallowing evaluation was completed at 12:35 p.m. on 07/27/09. Following the evaluation, the individual completing the evaluation (unable to read professional title) reco… | 2015-01-01 |
| 10584 | 10584 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 329 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, and review of OBRA's (Omnibus Budget Reconciliation Act of 1987) "Unnecessary Drugs in the Elderly", the facility failed to ensure the drug regimen of three (3) of thirteen (13) sampled residents was free from unnecessary drugs. Residents #12, #20, and #11 were receiving medications given in excessive doses, for excessive duration, and/or without adequate monitoring. Resident #12 was receiving [MEDICATION NAME], a sedating drug, in excessive doses not recommended for use in the elderly. Resident #20 had received [MEDICATION NAME], a sedating drug, for excessive duration. Resident #11 had received [MEDICATION NAME], an antipsychotic drug, in excessive doses not recommended for the elderly. Resident identifiers: #12, #20, and #11. Facility census: 60. Findings include: a) Resident #12 Medical record review, on 07/28/09, discovered this [AGE] year old resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On admission, the physician ordered [MEDICATION NAME] 1 mg po (by mouth) TID (three-times-a-day) for restlessness / anxiety. Review of July 2009 monthly physician orders [REDACTED]. - [MEDICATION NAME] 1 mg po every four (4) hours PRN (as needed) and may repeat in two (2) hours if not effective for anxiety, originally ordered on [DATE]; - [MEDICATION NAME] (an antipsychotic) 1 mg at HS (hour of sleep), originally ordered on [DATE] for agitation / restlessness; and - [MEDICATION NAME] 0.5 mg every morning, originally ordered on for dementia with agitation. Review of the Medication Administration Record [REDACTED]. Additionally, the resident received a total daily dose of 4 mg of [MEDICATION NAME] on 06/05/09, 06/06/09, 06/07/09, 06/08/09, 06/11/09, 06/27/09, and 06/28/09. According to OBRA's "Unnecessary Drugs in the Elderly," 2 mg is the maximum dose of [MEDICATION NAME] recommended for use in the elderly. This resident was receiving 3 mg routinely and with t… | 2015-01-01 |
| 10585 | 10585 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 386 | E | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the attending physician for seven (7) of thirteen (13) sampled residents failed to review the resident's total plan of care with each assessment visit by failing to co-sign visits made by a physician's assistant and other consulting physicians, acknowledging lab values, and acknowledging resident visits to the emergency room . Resident identifiers: #56, #1, #24, #20, #49, #15, and #12. Facility census: 60. Findings include: a) Resident #56 The medical record of Resident #56, when reviewed on 07/28/09, disclosed the resident's attending physician had visited on 07/26/09, which was the first visit in several months. At this time, the physician wrote a progress note but failed to acknowledge by co-signing physician's assistant visit to the resident in February or to acknowledge abnormal lab results that had been obtained since his last visit. There was no evidence the physician was aware of these abnormal lab values other than a statement on each "faxed Dr. (name) NCF I 1/13/09". There was no signature to signify who had faxed them or that the physician had received the fax. b) Resident #1 The medical record of Resident #1, when reviewed on 07/29/09, disclosed the resident's attending physician had visited on 07/10/09, which was the first visit in several months. At this time, the physician wrote a progress note but failed to acknowledge by co-signing two (2) visits made to the resident by a physician's assistant on 02/24/09 and 02/26/09. c) Resident #24 The medical record of Resident #24, when reviewed on 07/28/09, disclosed the resident's attending physician had visited the resident on 07/26/09, which was the first visit in several months. Although the physician wrote a progress note at this time, he failed to acknowledge by signing or co-signing a hospital discharge report from 05/04/09 and abnormal lab values obtained on 05/05/09 which had been reviewed by another physician. These documents… | 2015-01-01 |
| 10586 | 10586 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 387 | E | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the attending physician for seven (7) of thirteen (13) residents reviewed failed to complete a physician's visit at least once every thirty (30) days for the first ninety (90) days after admission and at least once every sixty (60) days thereafter, as required. Resident identifiers: #24, #56, #1, #41, #12, #49, and #15. Facility census: 60. Findings include: a) Resident #24 When reviewed on 07/27/09, the medical record disclosed this resident had been admitted to the facility on [DATE], following hospitalization for fall resulting in vertebral fracture and a subdural hematoma. Further review disclosed no evidence the resident was seen by her attending physician until 07/26/09. When interviewed on 07/27/09, the facility's director of nursing (DON - Employee #4) could provide no further evidence to reflect the physician had seen the resident at an earlier date. b) Resident #56 When reviewed on 07/28/09, the medical record disclosed this resident had been admitted to the facility on [DATE], having transferred from another facility. Further review disclosed the resident's attending physician had seen her and written a progress note on 01/16/09. A physician's assistant (PA) had visited the patient for a "chart review" on 02/26/09. The resident's physician had not made a second visit until 07/26/09. This was confirmed by the DON during an interview at 3:00 p.m. on 07/28/09. c) Resident #1 When reviewed on 07/29/09, the medical record disclosed this resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. A progress note, dated 07/10/08, was written by the resident's attending physician. Although the record disclosed numerous physician orders [REDACTED].#1 since that date (07/10/08), until 07/28/09. No evidence to the contrary could be provided by facility staff at the time of exit at 3:00 p.m. on 07/30/09. d) Resident #41 When reviewed on 07/29/09, the medical record disclo… | 2015-01-01 |
| 10587 | 10587 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 514 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility staff failed to maintain medical records, for three (3) of fifteen (15) fifteen residents reviewed, in a well organized, accurate, and complete manner. Medical documents and resident information related to services contracted through a hospice provider were not available on the resident's medical record for two (2) residents, and a document completed on an occupational therapy form incorrectly stated several resident diagnoses. Resident identifiers: #11, #3, and #56. Facility census: 60. Findings include: a) Resident #11 The medical record of Resident #11, when reviewed on 07/27/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The resident's medical record contained no information related to Hospice. A Hospice nurse (Employee #84) at the facility at that time explained that each Hospice patient had a separate chart for this information. The Hospice record was reviewed. A document titled "Interdisciplinary Group Meeting" (with no date) stated the Hospice chaplain visit frequency was "1 X month (once a month)". Further review disclosed no evidence the Hospice Chaplain had visited the resident. The Hospice nurse was again questioned and stated this documentation would be on his record at the Hospice office. The Hospice nurse agreed the information should be on the record at the nursing facility, and she called the Hospice office to have the documents faxed to the facility. b) Resident #3 The medical record of Resident #3, when reviewed on 07/29/09 at 3:00 p.m., disclosed this [AGE] year old male had been admitted to the facility on [DATE] and admitted to the services of Hospice on 06/11/09 with the terminal [DIAGNOSES REDACTED]. The Hospice record was reviewed. A document titled "Interdisciplinary Group Meeting" (with no date) stated the Hospice cha… | 2015-01-01 |
| 10588 | 10588 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 332 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. One (1) of three (3) nurses (Employee #11) observed administering medications, with forty (40) opportunities for error, incorrectly crushed two (2) medications for Resident #55 that were not formulated to be crushed. Resident identifier: #55. Facility census: 60. Findings include: a) Resident #55 During the medication pass observation on 07/27/09 at 3:30 p.m., the nurse (Employee #11) was observed preparing the following medications for Resident #55: [MEDICATION NAME] 400 mg, EC ([MEDICATION NAME] coated) Aspirin 81 mg, Senna tab, [MEDICATION NAME] 100 mg, and Vitamin C 500 mg. During the preparation, the nurse crushed all of these medications except [MEDICATION NAME] 100 mg. When this surveyor questioned the nurse which medications were crushed, the nurse stated, "I crushed everything except the [MEDICATION NAME]." Review of the facility's "Do not Crush list" revealed the [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON - Employee #4) confirmed [MEDICATION NAME] coated aspirin and [MEDICATION NAME] should not have been crushed. . | 2015-01-01 |
| 10589 | 10589 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 371 | F | 0 | 1 | OPXH11 | Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 60. Findings include: a) During the initial tour of the kitchen, on 07/27/09 at 1:15 p.m., observation found coffee cups stacked on top of each other on trays. The cups had been stacked prior to complete air drying and had trapped moisture, creating a medium for bacteria growth. b) During the initial tour of the kitchen on 07/27/09 at 1:15 p.m., and during further kitchen observations on 07/29/09 at 11:00 a.m., flies were observed in the food preparation and serving areas. This practice had the potential to result in food contamination and compromised food safety. c) During an interview on 07/27/09 at 1:30 p.m., the assistant dietary manager (Employee #82) confirmed there was trapped moisture in the coffee cups and flies were a problem in the kitchen due to use of the back door located in the kitchen area. . | 2015-01-01 |
| 10590 | 10590 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 469 | E | 0 | 1 | OPXH11 | Based on observation, resident interview, and staff interview, the facility failed to maintain an effective pest control program so the facility was free of flies in the kitchen and resident living areas. During the course of the survey, flies were observed in the facility kitchen and in resident care areas of the facility on the hospital side. A confidential resident interview revealed flies were a problem in resident rooms and in the facility dining areas. This had the potential to affect all residents who reside in the facility. Facility census: 60. Findings include: a) During the initial tour of the kitchen on 07/27/09 at 1:30 p.m., and during additional kitchen observations on 07/29/09 at 11:00 a.m., flies were noted in the food preparation and serving areas of the kitchen. In an interview on 07/27/09 at 1:30 p.m., the assistant dietary manager confirmed flies were a problem in the kitchen due to a back door used in the kitchen area. b) During the medication pass observation task on 07/27/09 at 3:30 p.m., a fly was observed around the medication cart in the hallway in the hospital side of the facility. c) During a confidential resident interview on 07/28/09 at 4:00 p.m., the resident complained that flies were occasionally a problem in both resident rooms and in the resident dining areas. d) During an interview on 07/30/09 at 2:15 p.m., the administrator was informed of the observation and complaint about flies in the facility. . | 2015-01-01 |
| 10591 | 10591 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 315 | D | 0 | 1 | OPXH11 | Based on record review and staff interview, the facility failed to ensure planned interventions for improving a resident's urinary continence status were implemented for one (1) of thirteen (13) residents reviewed. Resident identifier: #56. Facility census: 60. Findings include: a) Resident #56 A comparison of Resident #56's two (2) most recent minimum data set (MDS) assessments disclosed a decline in the resident's urinary continence status. On the MDS with an assessment reference date (ARD) of 04/19/09, the assessor entered a code of "1", indicating she was "occasionally incontinent". On the MDS with an ARD of 07/09/09, the assessor entered a code of "2", indicating she was now "frequently incontinent". Review of the resident's most current care plan, revised on 07/09/09, found the following problem statement: "Risk for alteration in patterns of Urinary Elimination RT (related to) disordered thought processes and infrequent urinary incontinence." The goal related to this problem stated: "Resident will not experience further loss of urinary function by review date." Interventions to achieve this goal included: "Implement bladder re-training program with all personnel, resident and family if indicated. Observe voiding pattern determine what stimuli precipitate voiding. Comprehensive evaluation of incontinence pattern to determine potential for management program." A nurse responsible for this resident on 07/29/09 at 3:00 p.m. (Employee #29), when questioned as to what steps were being taken with this resident related to her urinary incontinence, stated the nursing assistants documented each time the resident voids. When further questioned, this nurse stated the resident was not now and, as to her knowledge, never was on a bowel and bladder retraining program. . | 2015-01-01 |
| 10930 | 10930 | WEBSTER NURSING AND REHABILITATION CENTER, LLC | 515165 | ERBACON ROAD, PO BOX 989 | COWEN | WV | 26206 | 2009-07-31 | 364 | F | 0 | 1 | U4H311 | Based on observation, menu review, taste testing, and staff interview, the facility failed to assure meals were attractive and flavorful. Residents' foods were not varied in color, creating an unattractive presentation. In addition, the macaroni and cheese, as prepared, had no flavor. These practices had the potential to affect all residents who received nourishment from the dietary department. Facility census: 57. Findings include: a) Observations during the noon meal, at 11:45 a.m. on 07/28/09, revealed the following: 1. The foods were all pale yellow to light orange in color, even the garnish. The residents' plates contained fish nuggets and macaroni and cheese. The garnish, selected by dietary personnel, was a peach slice. The dessert was a pudding parfait. It had chocolate on the bottom, but the visible portion was the vanilla on top with a dollop of white whipped topping. 2. Residents requiring pureed diets did not have the benefit of a garnish. The menu did not include a garnish for pureed meals. 3. Taste testing of the macaroni and cheese revealed it had no flavor. The dietary manager (DM), when asked to taste the product, confirmed it was not a flavorful product. Further investigation revealed the method of preparation had changed. A new powdered cheese sauce was used. It had not been added in sufficient quantity to give the macaroni and cheese a cheesy flavor. Interview with the DM, at that time, revealed there had been no determination for the amount of the new cheese sauce, to assure the macaroni and cheese was flavorful. . | 2014-11-01 |
| 10931 | 10931 | WEBSTER NURSING AND REHABILITATION CENTER, LLC | 515165 | ERBACON ROAD, PO BOX 989 | COWEN | WV | 26206 | 2009-07-31 | 441 | D | 0 | 1 | U4H311 | Based on observation, the facility failed to ensure all staff members provided ice to residents in a manner to prevent the development and transmission of disease and infection. This practice affected one (1) resident but had the potential to affect other residents on A Hall. Facility census: 57. Findings include: a) On 07/30/09 at 3:55 p.m., a nursing assistant (Employee #12) was observed holding a pitcher over the ice chest when adding ice. This pitcher had been in a resident's room. This practice created a potential for contamination of the ice in the ice chest. Employee #52, another nursing assistant, intervened so no other resident was affected. When this was brought to the attention of supervisory nursing personnel, the ice chest was emptied and cleaned. | 2014-11-01 |
| 10932 | 10932 | WEBSTER NURSING AND REHABILITATION CENTER, LLC | 515165 | ERBACON ROAD, PO BOX 989 | COWEN | WV | 26206 | 2009-07-31 | 371 | F | 0 | 1 | U4H311 | Based on observation, food temperature measurement, and staff interview, the facility failed to ensure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 57. Findings include: a) During observations of the dietary department, at 11:45 a.m. on 07/28/09, the following sanitation infractions were found: 1. The front of the exhaust vents, in the exhaust hood, contained greasy, dusty debris. At the time of the observation, the dietary manager (DM) was asked when they had last been cleaned. The DM replied she was uncertain, as maintenance was responsible for the cleaning of the vents. 2. The top of the Rubbermaid food cart was dusty. 3. Pureed macaroni and cheeses was not reheated prior to being placed on the steam table, after mechanical alteration with cold milk. Just prior to food service, the temperature of the product was 120 degrees Fahrenheit. . | 2014-11-01 |
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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 );