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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3324 | 3324 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 755 | E | 0 | 1 | KGJN11 | Based on policy review record review and staff interview, the facility failed to conduct appropriate reconciliation of a controlled substance at shift change for two (2) of two (2) medication carts reviewed medication storage. This practice has the potential to affect more than an isolated number of residents. Facility census: 57. Findings included: a) Long hall medication cart During observation of Long Hall medication cart on first floor on 04/09/19 at 1:35 pm, shift to shift narcotic key count record was reviewed and found to be non-compliant. Shift to shift narcotic key count was not completed and co-singed by both nurses (nurse coming on duty, nurse going off duty) for a total of thirteen (13) times for the time frame of 03/02/19 through 04/09/19. No records dating back any further than 03/02/19 were found for Long Hall medication cart. Licensed Practical Nurse (LPN) #30 verified the records were incomplete, and that is the way the facility verifies the narcotic count to be correct at the end of each shift and should be done each time a new nurse accepts keys to the mediation cart for use. During observation of Short Hall medication cart on first floor on 04/09/19 at 2:30 PM, shift to shift narcotic key count record was reviewed and found to be non-compliant. The shift to shift narcotic key count record log was not accurately completed and co-signed by both nurses (nurse going off duty, nurse coming on duty) for a total of seventeen (17) times since 01/09/19. Inaccurate shift to shift narcotic key count log was verified as inaccurate by Licensed Practical Nurse (LPN) #37, and LPN #37 stated that the shift to shift narcotic key count record should be completed at the end of every shift by the nurse responsible for that particular mediation cart. During an interview on 04/09/19 at 3:10 PM, Director of Nursing (DON) #14 verified the shift to shift key count record log used for reconciliation of narcotics at shift change were not completed in an accurate manner, and facility has no way of knowing if the proper r… | 2020-09-01 |
| 3325 | 3325 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 756 | E | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the consulting pharmacist identified and reported irregularities with Resident #12's drug regimen to the attending physician and the Director of Nursing (DON). This was true for one (1) of seven (7) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident Identifiers: #12. Facility Census: 57. Findings included: a) Resident #12 A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: -- Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. -- Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/08/18 - 6:01 p.m. blood sugar was 211. --10/08/18 - 8:02 p.m. blood sugar was 204. --10/10/18 - 1:11 p.m. blood sugar was 321. --10/11/18 - 8:03 a.m. blood sugar was 334. --10/11/18 - 12:09 p.m. blood sugar was 289. --10/12/18 - 8:17 a.m. blood sugar was 319. --10/12/18 - 4:27 p.m. blood sugar was 317. --10/12/18 - 8:13 p.m. blood sugar was 288. --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44… | 2020-09-01 |
| 3326 | 3326 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 758 | E | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #53's drug regimen was free from unnecessary antipsychotic medications. The attending Physician agreed to discontinue Resident #53's Risperadal on/or about 03/26/19 this medication was never discontinued. Also Resident #53 had an as needed (PRN) order for the antipsychotic medication of [MEDICATION NAME] which was in effect for greater than 14 days. Also the medical record did not identify what specific condition and/or behaviors this medication was to be used for. This was true for one (1) of seven (7) residents reviewed for the care area unnecessary medications. Resident Identifier: #53. Facility Census: 57. a) Resident #53 1. [MEDICATION NAME] A review of Resident #53's medical record at 1:52 p.m. on 04/09/19 found an admission physician's orders [REDACTED]. A review of the observation book for (Name of Attending Physician) found the following in regards to Resident #53, 03/26/19 Can we possibly change Respirdone on (last name of Resident #53) to at night or discontinue all together she is more alert when we had to hold it two times on 03/25/19 and 03/26/19. Very lethargic and unresponsive on it. Unable to any meds in her when she is taking all of this. The physician responded to this on/or about 03/27/19 and replied to discontinue this medication. Further review of the medical record found no evidence this medication was discontinued. In fact review of the Medication Administration Record [REDACTED]. An interview with the Physician at 9:17 a.m. on 04/10/19 confirmed that he intended for the [MEDICATION NAME] to be discontinued. He stated, With something direct like that I just answer it in the observation book and the nurses will write the order. An interview with the Director of Nursing (DON) at 10:30 a.m. on 04/10/19 confirmed the [MEDICATION NAME] should have been discontinued and was not. 2. [MEDICATION NAME] A review of Resident #53's medical record at … | 2020-09-01 |
| 3327 | 3327 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 770 | E | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain several laboratory reports ordered by physician. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #35. Facility census: 57. Finding included: a) Resident #35 Review of the medical record found the resident was admitted to the facility on [DATE]. On 03/04/19 the physician ordered the following laboratory reports to be obtained before (MONTH) 31st: --BUN (Blood Urea Nitrogen) --CBC (complete blood count) with differential --Comprehensive Metabolic Panel --CPK ([MEDICATION NAME] phosphokinase) --Creatinine --Electrolytes --Glycohemoglobin --Hepatic Panel --Lipid Panel --Magnesium level --Free, T ([MEDICATION NAME]) 4 On 4/10/19 at 11:43 AM, the director of nursing (DON) verified the labs have never been obtained as ordered by the physician. | 2020-09-01 |
| 3328 | 3328 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 804 | E | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and record review, the facility failed to provide food and drink at a safe and appetizing temperature. Residents reported being served cold food that was not palatable. This had the potential to affect more than a limited number of residents. Resident identifiers: #25. Facility census: 57. Findings included: a) Resident #25 During an interview on 04/08/19 at 3:15 PM Resident #25 stated, The food isn't very good, I can't see and by the time they get around to feeding me it's always cold. On 04/10/19 11:28 observation for test tray started when staff started passing trays in short hall first floor. At 11:33 AM all lunch trays were reported to have arrived on the unit (long/short hall) with three (3) certified nursing assistants passing trays at that time. At 11:38 AM just prior to being served, notified staff that the last lunch tray left on meal cart will be tested . Test tray temperatures obtained by Dietary Manager (DM) #87 at 11:40 AM consisted of: --Mashed potatoes temperature 135 degrees Fahrenheit (F). --Zucchini temperature 110 degrees (F). --Pork Loin meat temperature 100 degrees (F) --Roasted potatoes temperature 100 degrees (F) --Scalloped apples 80 degrees (F) --Milk in carton temperature 35 degrees (F) DM #87 agreed that the food temperatures she obtained were below appropriate temperature maintenance at the time of service to Resident. DM # 87 provided the following Service Line temperatures for the lunch meal tested on [DATE]: --Mashed potatoes temperature 177 degrees Fahrenheit (F). --Zucchini temperature 176 degrees (F). --Pork Loin meat temperature 187 degrees (F) --Roasted potatoes temperature 181degrees (F) --Scalloped apples 130 degrees (F) --Milk in carton temperature 35 degrees (F) | 2020-09-01 |
| 3329 | 3329 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 812 | E | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The kitchen and resident nutrition pantry had food that was expired, or opened an undated as to when it was opened. Also in the walk in cooler in the kitchen their was two 16.9 ounce bottles of water one of witch had been drank from which both belonged to employees and not residents. This practice has the potential to effect more than an isolated number of residents. Facility census: 57. Findings included: a) Initial tour of the kitchen at 11:00 a.m. on [DATE] with the Certified Dietary Manager (CDM) found the following: -- Two (2) 16.9 ounce bottles of water one of which had been drank from. When the CDM was asked if this was resident water or staff water she indicated that they belonged to the staff and should not have been in the walk in cooler. -- A 32 ounce container of honey thickened milk which had been opened an was not dated. -- Half gallon of Almond Milk which has been opened and not dated. A tour of the the first floor nutrition pantry (Refrigerator and items stored in the First Floor Medication room) at 11:15 a.m. on [DATE] found two (2) 32 ounce containers of vanilla med pass both had been opened. One was not dated as to when it was opened and the other one was dated to indicate it had been opened on [DATE]. When asked how long this item was good for after it had been opened the CDM stated it was only good for 72 hours. | 2020-09-01 |
| 3330 | 3330 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 835 | E | 0 | 1 | KGJN12 | Based on record review, policy review and staff interview the facility failed to ensure that it was administered in a manner that used its resources effectively to ensure that each resident was able to maintain and/or attain their highest practicable physical, mental and psychosocial well - being. The facility had a Long Term Care Survey from 04/08/19 through 04/11/19 during which time they were issued citations that included F600, F609, F610, F684, F 697, F732, F755 and F867. The facility submitted a plan of correction and indicated they would have everything corrected by 05/29/19. A revisit survey was conducted from 07/22/19 through 07/23/19 at which time the following tags were recited F600, F609, F610, F684, F 697, F732, F755 and F867. Therefore the facility's administration failed to use its resources to correct identified deficient practices. This practice has the potential to effect all residents currently residing in the facility. Findings included: a) Cross reference deficiency cited at F600 b) Cross reference deficiency cited at F609 c) Cross reference deficiency cited at F 610 d) Cross reference deficiency cited at F684 e) Cross reference deficiency cited at F697 f) Cross reference deficiency cited at F732 g) Cross reference deficiency cited at F755 h) Cross reference deficiency cited at F867 | 2020-09-01 |
| 3331 | 3331 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 838 | C | 0 | 1 | KGJN11 | Based on review of the Facility Assessment and staff interview, the facility failed to ensure the assessment contained all the necessary components to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require. Information regarding staffing levels and competencies, facility resources necessary to provide for resident needs, health information technology resources, evaluation of the physical environment, and community based risk assessment were not included in the Facility Assessment. This had the potential to affect all residents residing at the facility. Facility census: 57. Findings included: a) Facility Assessment review On 04/10/19 at 12:46 PM, the administrator and the company president, Employee #88 were interviewed regarding the Facility Assessment. Information regarding the following components required for the assessment were not included in the copy provided by the facility: The staff competencies that are necessary to provide the level and types of care needed for the resident population. An evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs. A competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across these staff assignments. An evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment should also include an evaluation of what policies and procedures may be required in the provision of care and that these meet cur… | 2020-09-01 |
| 3332 | 3332 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 867 | F | 0 | 1 | KGJN11 | Based on staff interviews and review of facility records, the facility failed to review/revise QAPI plan on an annual basis. This has the potential to affect all residents. Facility census 57. Findings included: a) Review of the QAPI plan revealed it was last reviewed (MONTH) 28, (YEAR). The QAPI stated it was to be reviewed and/or revised on an annual basis. b) During an interview on 04/10/19 at 1:57 pm, the administrator stated the QAPI plan had last been reviewed (MONTH) 28, (YEAR). | 2020-09-01 |
| 3333 | 3333 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 924 | E | 0 | 1 | KGJN11 | Based on observation and staff interview the facility failed to ensure the facility corridors had handrails which were accessible to all residents. This failure had the potential to effect 10 of 10 residents residing on the 2nd floor of the facility. This has the potential to effect more than an isolated number of Residents. Facility Census: 57. Findings included: a) A tour of the second (2nd) floor of the facility with the Nursing Home Administrator (NHA) on 04/10/19 at 11:20 a.m. found there were no handrails in the corridors. When asked about this the NHA stated, Yes we know that we need to get hand rails up here. We have talked to the owners and will hopefully have some soon. She further stated, We have never had handrails up here but definitely need too. b) An additional interview with the NHA found that the 2nd floor unit has always been designated as a long term care unit. It has not always had residents on the unit but it has always been designated for long term care residents. | 2020-09-01 |
| 3884 | 3884 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 225 | E | 0 | 1 | 5Q6I11 | Based on a random opportunity for discovery, staff interview, policy review, review of the abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities, and review of an employee disciplinary action form, the facility failed to thoroughly investigate and report allegations of neglect/abuse to the appropriate State agencies immediately in accordance with State law. This had the potential to affect more than an isolated number of residents. Resident identifiers: #91 and #77. Facility census: 75. Findings include: a) Employee disciplinary action form 1. On 08/16/16 at 4:00 p.m., an unrequested employee education and counseling form was found lying beside a surveyor's computer in the conference room where surveyors were working. No personnel files were in the room as there were times when no members of the survey team were present. How the document came to be in the conference room could not be determined. The employee education and counseling form included: - The name of Nurse Aide (NA) #74 - Date of the employee education and counseling form: 06/02/16 - The form required documentation for Area of Improvement: Define Situation. Poor Resident care-Resident's are being left up in wheelchairs without being checked on. Resident's are not being put to bed in a timely manner. (Name of Resident #91) reported that you were very hateful and rough putting her feet in the bed this evening. Also, she stated that last week you took her call light from her. (Name of Resident #77) does not want you to do her showers after your attitude last week. This is unacceptable work performance. Told oncoming CNA (certified nurse aide) that Resident didn't want her shirt off when in fact resident was never checked on. - The resolution for action taken: CNA needs to be aware that we are here to take care of the needs of the resident. This is the 2nd employee counseling/education form from this nurse. Next is written warning, followed by suspension and then termination if this problem isn't corrected. CNA needs t… | 2020-04-01 |
| 3885 | 3885 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 226 | D | 0 | 1 | 5Q6I11 | Based on a random opportunity for discovery, staff interview, policy review, review of the abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities, and review of an employee disciplinary action form, the facility failed to implement its policy for investigation and reporting of allegations of abuse and neglect. This had the potential to affect more than an isolated number of residents. Resident identifiers: #91 and #77. Facility census: 75. Findings include: a) Employee disciplinary action form 1. On 08/16/16 at 4:00 p.m., an unrequested employee education and counseling form was found lying beside a surveyor's computer in the conference room where surveyors worked when not out on the nursing units. No personnel files were in the room as there were times when no members of the survey team were present. How the document came to be in the conference room could not be determined. The employee education and counseling form included: - The name of Nurse Aide (NA) #74 - Date of the employee education and counseling form: 06/02/16 - The form required documentation for Area of Improvement: Define Situation. Poor Resident care-Resident's are being left up in wheelchairs without being checked on. Resident's are not being put to bed in a timely manner. (Name of Resident #91) reported that you were very hateful and rough putting her feet in the bed this evening. Also, she stated that last week you took her call light from her. (Name of Resident #77) does not want you to do her showers after your attitude last week. This is unacceptable work performance. Told oncoming CNA (certified nurse aide) that Resident didn't want her shirt off when in fact resident was never checked on. - The resolution for action taken: CNA needs to be aware that we are here to take care of the needs of the resident. This is the 2nd employee counseling/education form from this nurse. Next is written warning, followed by suspension and then termination if this problem isn't corrected. CNA needs to have better time ma… | 2020-04-01 |
| 3886 | 3886 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 241 | D | 0 | 1 | 5Q6I11 | Based on observations, resident interview, and staff interview, the facility failed to provide dignity for one (1) of three (3) residents for the care area of dignity. The facility failed to assist Resident #31 with removal of long hair on her chin, around her upper lip and the corners of her mouth. Resident identifier: #31. Facility census: 75. Findings include: Resident #31 Observations during Stage I of the Quality Indicator Survey on 08/16/16 at 9:55 a. m. revealed Resident #31 had long hair on her chin and around her upper lip and corners of her mouth. In an interview with the Resident #31 on 08/16/16 at 1:57 p.m., she stated, I am 62, and I cannot remove the hair off my chin or around my lips. They do not remove the hair. I will have to wait until I get out of here in order to have someone to remove the hair. In an interview and observation with Nurse Aide (NA) #117 on 08/16/16 at 2:06 p.m., she confirmed the resident did have long hair on her upper lip, around the corners of her lips, and on her chin. The NA confirmed that she took care of this resident and she had never removed the hair on the resident's face. On 08/16/16 at 2:15 p.m., review of Resident #31's admission minimum data set (MDS) assessment with the assessment reference date (ARD) of 06/09/16 found Resident #31 scored a 15 on her Brief Interview for Mental Status (BIMS - a test to help determine a resident's cognitive abilities), indicating the resident was cognitively intact. The MDS also identified the resident required the extensive assistance of staff to maintain her personal hygiene, which includes shaving. In an interview on 08/16/2016 2:33 p.m., Licensed Practical Nurse (LPN) #36 stated, Yes ma'am, she has hair on her chin, upper lip and corners of her mouth and I do not know if anyone has ever asked her if she would like to have them removed. She said she did not have to go and look at her she knew the resident had hair on her chin and around her lips. The LPN stated, The resident is blind and she cannot see the hair on her chin, and … | 2020-04-01 |
| 3887 | 3887 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 279 | D | 0 | 1 | 5Q6I11 | Based on record review and staff interview the facility failed to develop a comprehensive care plan that contained measurable objectives (goals) regarding his inappropriate sexual behaviors. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #24. Facility Census: 75. Findings Include: a) Resident #24 A review of his medical record on 08/17/16 02 at 12:30 p.m., found the resident's care plan included a focus statement (typed as written) of, Sexual inappropriateness, making comments about staffs body parts. Mades (sic) comments when they bend over or provide any type of continence care. Often says he cannot clean his private area when certain staff are working and demands that they provide the care although he can do so himself. This focus statement was added to his care plan on 09/01/15. The goal associated with this focus statement was (typed as written), Patient will have no complications from (SPECIFY) through next review date. This goal, initiated on 09/01/15, was reviewed/revised on 08/12/16, 07/28/16, 05/04/16, 02/12/16, 02/03/16, and 11/11/15. On none of these dates was there a measurable goal defined. In an interview at 3:24 p.m. on 08/17/16, the Director of Nursing (DON) confirmed the goal was never developed. She agreed they needed to specify what the targeted behaviors were instead of leaving the word specify on the care plan. | 2020-04-01 |
| 3888 | 3888 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 280 | D | 0 | 1 | 5Q6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revised the care plans for two (2) of twenty-one (21) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. The facility failed to revise Resident #31's care plan to address her refusal of her showers. In addition, the care plan for Resident #46 was not revised to address how often the resident's Foley catheter should be changed and by whom. Resident Identifiers: #31 and #46. Facility census: 75. Findings include: a) Resident #31 In an interview with Nurse Aide (NA) #117 on 08/16/16 at 1:57 p.m., she reviewed Resident #31's information on the kiosk (a computer system that displays information about a resident's care needs to direct care staff, where they document the care provided) and replied that Resident #31 had refused her shower that day. The NA confirmed the resident was to receive her showers on Tuesday and Friday. The NA said the resident often refused her showers. On 08/16/16 at 1:45 p.m., review of Resident #31's care plan found a plan initiated on 06/16/16 regarding the resident resisting care at times related to anxiety, adjustment to the nursing home, and that she could become verbally abusive toward staff. The care plan focus did not identify the resident refused showers, nor were individualized interventions established for what staff should do when the resident refused her showers. The care plan initiated on 06/14/16 related to the resident's activity of daily living self-care deficit due to [MEDICAL CONDITIONS], anxiety, and a history of falls did not address the resident's refusal of showers either. In an interview with the unit charge nurse, Licensed Practical Nurse (LPN) #36 at 2:27 p.m. on 08/16/16, when asked whether Resident #31 refused her showers, the LPN said the resident did not want her shower today. The LPN said the shower team asked for a NA on the floor to shower the resident in her room as the resident preferre… | 2020-04-01 |
| 3889 | 3889 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 282 | E | 0 | 1 | 5Q6I11 | Based on record review and staff interview, the facility failed to ensure implementation of his care plan in regards to his risk for dehydration. This was true for one (1) of three (3) residents reviewed for the care area of hydration during Stage 2 of the Quality Indicator Survey. Resident Identifier: #24. Facility Census: 75. Findings include: a) Resident #24 A review of Resident #24's medical record at 8:25 a.m. on 08/18/16 found a care plan focus initiated 12/04/15 of, (typed as written) (Resident #24's Name) has potential dehydration or potential fluid deficit r/t (related to) Diuretic use. The goal associated with this care plan was, (typed as written) Patient will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor through review period. This goal, last reviewed on 08/12/16, had no changes made to it since first initiated on 04/01/15. The interventions related to this focus statement and goal included, (typed as written) Monitor and notify physician of acute symptoms leading to or indicative of dehydration, including persistent symptoms of diarrhea; nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours; abnormal labs (laboratory). Further review of his medical record found the resident's intakes and outputs were recorded on a daily basis. Review of the intake and output records found the following: --On 05/11/16 - his output was 75 cubic centimeters (cc) greater than his intake. --On 05/12/16 - his output was 1750 cc greater than his intake. --On 05/13/16 - his output was 930 cc greater than his intake. --On 05/25/16 - his output was 1390 cc greater than his intake. --On 05/26/16 - his output was 170 cc greater than his intake. --On 05/27/16 - his output was 1140 cc greater than his intake. --On 05/28/16 - his output was 1470 cc greater than his intake. --On 06/17/16 - his output was 1940 cc greater than his intake. --On 06/18/16 - his output was 1180 cc greater than his intake. --On 06/19/16 - his output was 250 cc greater than his … | 2020-04-01 |
| 3890 | 3890 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 312 | D | 0 | 1 | 5Q6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living, received care and services for grooming. This was true for two (2) of three (3) residents reviewed for the care area of activities of daily living (ADL). Resident identifiers: #52 and #31. Facility census: 75. Findings include: a) Resident #52 Observation of the resident at 12:02 p.m. on 08/15/16 found she had multiple, noticeable, dark, long hairs on her chin. Review of the resident's most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 08/01/16, found the resident required the extensive assistance of one staff member for personal hygiene. Personal hygiene is defined on the MDS as combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). During an interview on 4:12 p.m. on 08/16/16, the resident's Nurse Aide (NA), NA #33, said the resident did not want anything done about the hairs on her chin. At 4:19 p.m. on 08/16/16, the resident was interviewed in her room with Licensed Practical Nurse (LPN) #55 present. The resident said she wanted the hairs gone - I don't want to look like a man. LPN #55 said he would get a razor and have NA #33 take care of the issue immediately. b) Resident #31 Observation on 08/16/16 at 9:55 a. m., during Stage I of the Quality Indicator Survey, revealed Resident #31 had long hair on her chin and around her upper lip and corners of her mouth. In an interview with Resident #31 on 08/16/16 at 1:57 p.m., she stated, I am 62, and I cannot remove the hair off my chin or around my lips. They do not remove the hair. I will have to wait until I get out of here in order to have someone to remove the hair. In an interview and observation with NA #117 on 08/16/16 at 2:06 p.m., NA #117 confirmed the resident did have long hair on her upper lip, around her lips … | 2020-04-01 |
| 3891 | 3891 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 412 | D | 0 | 1 | 5Q6I11 | Based on resident interview, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) resident's reviewed for the care area of dental services, received a follow up dental appointment. Resident identifier: #52. Facility census: 75. Findings include: a) Resident #52 Observation of the resident's oral cavity at 12:05 p.m. on 08/15/16, found the resident had several missing teeth and teeth that appeared to be broken off at the gum line. Review of the last annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 02/08/16 noted the resident assessed as having obvious or likely cavities or broken natural teeth. On 07/02/15, the resident had a dental consult. The consult noted the resident needed surgical extraction of teeth #03, #05, #18, #20, and #29 (teeth are numbered 1 through 32 beginning with the left upper molar). The resident had poor oral hygiene and generalized gingivitis. Further review of the medical record found no evidence the resident had received a follow up dental appointment to have the teeth extracted. On 08/17/16 at 8:13 a.m., Registered Nurse (RN) #95 was asked if the facility had scheduled a follow up appointment for the resident? At 9:17 a.m. on 08/17/16, RN #95 provided nursing notes dated 07/06/15 and 07/07/15 indicating the facility had tried to contact the resident's responsible party, the Department of Health and Human Services (DHHR). RN #95 said, I guess we dropped the ball, when they (the DHHR) never signed and returned the consent papers. RN #95 was unable to provide any evidence the facility pursued the removal of the resident's teeth after contacting the DHHR on 07/07/15. | 2020-04-01 |
| 3892 | 3892 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2016-08-19 | 514 | E | 0 | 1 | 5Q6I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, physician interview, and staff interview, the facility failed to ensure the medical records of four (4) of twenty-one (21) residents whose medical records were reviewed during Stage 2 of the Quality Indicator Survey were complete and accurate. Resident #1's medical record did not contain the results of an esophagogastroduodenoscopy (EGD). Resident #27's physician orders did not contain the milligrams (mg) of a medication ordered by the physician. Resident #82's medical record contained a physician's order that belonged to a different resident. Resident #52's medical record did not support an attempted Gradual Dose Reduction (GDR) failed. Resident Identifiers: #1, #27, #82, and #52. Facility Census: 75. Findings Include: a) Resident #1 A review of Resident #1's medical record at 1:18 p.m. on 08/16/16 found a nursing progress note dated 04/04/16 that was an appointment/return note. This note indicated that Resident #1 had returned from her scheduled EGD and the results of the EGD were sent back with the resident and reviewed at that time. Further review of the record revealed the results of the EGD were not contained in the medical record. On 08/17/16 at 11:05 a.m., Medical Records Assistant #16 provided a copy of the EGD results. When asked where these results were located, she indicated she had to call and get a new copy faxed to the on that day because the results received on 04/04/16 could not be located at the facility. b) Resident #27 Observation during the medication administration pass on 08/17/16 at 8:14 a.m., revealed Unit Charge Nurse - Licensed Practical Nurse (UCN-LPN) #108 administered Resident #27's Senna 8.6 milligram (mg) two (2) tablets via gastrostomy tube (a tube used to provide nutrition, fluids, and medications who cannot safely swallow.). A review of Resident #27's (MONTH) (YEAR) physician's order on 08/18/16 at 8:45 a.m., revealed the resident received Senna 2 tablets via [DEVICE] 2 times a day fo… | 2020-04-01 |
| 4507 | 4507 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 166 | D | 0 | 1 | YR5K11 | Based on record review, family interview, resident interview, staff interview, and review of the facility's grievance policy, the facility failed to make prompt efforts to resolve a grievance concerning dentures for one (1) of three (3) residents reviewed for the care area of dental status and services. Resident identifier: #33. Facility census: 45. Findings include:a) Resident #33 During the Stage I interview with Resident #33 on 11/09/15 at 3:41 p.m., she stated, Somebody took my teeth. Doctor said next time he sees me, he would give me new teeth, can't imagine why anyone would take them. A review of Resident #33's inventory of personal effects on 11/11/15 at 9:00 a.m., revealed the resident had an upper denture plate, and a lower partial denture. On 11/11/15 at 9:05 a.m., a review of the nurse's documentation for Resident #33's quarterly minimum data set (MDS), revealed the resident's oral cavity was observed on 10/31/15 at 8:38 a.m. by Registered Nurse (RN) #88. RN #88's assessment revealed Resident #33 had no natural teeth or tooth fragment(s) (edentulous). The oral cavity assessment stated, The resident lost her dentures, family aware and will replace. Under dentures the section was marked resident does not have dentures. A progress note, dated 08/26/15, written by Licensed Practical Nurse (LPN) #31 on 11/11/2015 at 9:10 a.m., stated, Resident complains of dental pain at this time. Also her dentures are missing at this time. In an interview with Social Worker #34 on 11/11/15 at 10:55 a.m., Social Worker #34 was asked whether she was informed by the staff that Resident #33's upper denture plate and her lower partial were missing. She stated she was not informed by the staff. The social worker said she had a telephone log that indicated the resident's daughter left a message on 09/08/15 concerning Resident #33's missing her upper denture and lower partial. Social Worker #34 said when she called the resident's daughter back the next day, the daughter told the SW she had visited, and she thought someone had thr… | 2019-10-01 |
| 4508 | 4508 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 241 | E | 0 | 1 | YR5K11 | Based on observation, staff interview, and policy review, the facility failed to provide care in a manner and environment which maintained each resident's dignity during the dining process for fourteen (14) of fourteen (14) residents in the restorative dining room. Staff stood while assisting residents to eat and/or did not interact with residents while assisting them. Resident identifiers: #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. Facility census: 45. Findings include: a) Residents #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. During an observation of the lunch meal, from 11:15 a.m. to 12:00 p.m. on 11/09/15, the Speech Language Pathologist (SLP) set up the tray for Resident #35, and assisted Residents #23 and #22. The SLP did not attempt any social interaction with these residents. Nurse Aide (NA) #12 assisted Resident #12, NA #72 assisted Resident #84, and NA #80 assisted Resident #59 with their meals. The nurse aides did not converse with the residents while feeding them. Additionally, staff did not converse with any of the fourteen (14) residents in a social manner. b) During a dining observation of the dinner meal on 11/09/15 from 5:30 p.m. through 6:30 p.m., Resident #19 told NA #30 he did not care for his vegetable. NA #30 did not acknowledge the resident ' s comment and continued to tell him what else was on his tray. NA #68 assisted Resident #10, feeding him a few bites of food. The NA stood while feeding the resident. Resident #10 had to raise his head, stretching his neck to reach the utensil. NA #66 also stood while feeding Resident #23. c) Upon request, Licensed Practical Nurse (LPN) #35 completed an observation during the evening meal on 11/09/15, and confirmed staff should not stand while assisting residents to eat. The LPN instructed the nurse aides to sit while feeding the residents. The NAs informed her no chairs were available in the dining room. d) An interview with the director of nursing (DON), on 11/09/15 at 6:30 p.m., confirmed sta… | 2019-10-01 |
| 4509 | 4509 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 253 | E | 0 | 1 | YR5K11 | Based on observation and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior in the main dining room. Fifteen (15) of sixteen (16) chairs in the main dining room had parts of the chair covering missing exposing the wood and/or foam of the chairs. Facility census: 45. Findings include:a) Main dining room chairsObservation of the main dining room chairs with Administrator #46 and Maintenance Staff #48 on 11/11/15 4:15 p.m., found five (5) chairs with missing coverings. The missing coverings left the wood and/or foam on the back of the chairs exposed. The foam of the armrests of these chairs was also exposed. Ten (10) of the chair backs had missing coverings and wood and/or foam exposed. Three (3) of these chairs had a cracked seat where the foam was exposed. During this observation, Maintenance Staff #46 and Maintenance Staff #48 confirmed the chairs were in poor condition and needed replaced. | 2019-10-01 |
| 4510 | 4510 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 272 | D | 0 | 1 | YR5K11 | Based on observation, medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of twenty-four (24) residents reviewed. Resident #5 was inaccurately coded as edentulous. Resident identifier: #5. Facility census: 45. Findings include: a) Resident #5 A Stage 1 observation, on 11/09/15 at 3:24 p.m., revealed Resident #5 had gaps between his teeth with likely missing teeth. On 11/11/15 at 3:00 p.m., review of the most recent comprehensive admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/27/15, found a response of Yes for Section L, Item L0200B No natural teeth or tooth fragment(s) edentulous. Section L, Item L0200D - Obvious or likely cavity or broken natural teeth was not checked, indicating a response of No. Licensed Practical Nurse (LPN) #24, interviewed on 11/11/15 at 3:10 p.m., related the resident had his own teeth and said, I hope I have that many teeth when I am that old. MDS Coordinator #88, interviewed on 11/11/15 at 5:23 p.m., related she had coded the MDS Section L, Item L0200B as Yes, because the resident had likely cavities and tooth fragments, and indicated it was the correct response. At 5:31 p.m. on 11/11/15, a request was made for Section L of the Resident Assessment Instrument (RAI) Manual utilized for completion of the MDS. During a follow-up interview, at 6:08 p.m., MDS Coordinator #88 related the MDS was coded incorrectly. She confirmed the resident had teeth, and Section L, Item L0200 indicated the resident was edentulous (no natural teeth present). | 2019-10-01 |
| 4511 | 4511 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 278 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of Resident #6's quarterly minimum data set (MDS) assessment accurately assessed the status of one (1) of twenty-four (24) residents in Stage 2 of the Quality Indicator Survey (QIS). The assessment did not accurately reflect the resident's [MEDICAL CONDITION] disorder. Resident identifier: #6. Facility census: 45. Findings include: a) Resident #6 A review of the medical record for Resident #6 on 11/12/15 at 11:15 a.m., revealed the quarterly MDS assessment with an assessment reference date (ARD of 10/27/15, did not accurately reflect a [DIAGNOSES REDACTED]. During further review, it was noted the physician's orders [REDACTED].#6 had an order for [REDACTED]. An interview on 11/12/15 at 12:45 p.m., with the MDS coordinator verified Section I - Active Diagnoses, Item I3400 did not include the [DIAGNOSES REDACTED].#6. | 2019-10-01 |
| 4512 | 4512 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 323 | E | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible. The mechanical room door at the front of the 100 hallway was unlocked. This practice had the potential to affect more than a limited number of residents. Facility census: 45. Findings include: a) During an initial tour, on 11/09/15 at 11:16 a.m., when checking doors, the mechanical room door opened when the knob was turned. Upon inquiry, Housekeeper #53, who was in the area, related the door should have been locked. The housekeeper said he would find the maintenance man and let him know. Another observation, at 1:45 p.m. on 11/09/15, found the mechanical room unlocked. No one was in the area. Again at 3:30 p.m. and 5:25 p.m., the door was unlocked. At 5:25 p.m. on 11/09/15, the director of nursing (DON) related the door should have been locked. She said the door knob had been changed and should work properly. She checked the lock and said the door could be locked from the inside. The room contained an air compressor, a hot water heater, sprinkler system, electrical breaker boxes, hot water tank, a bed frame positioned on its side with a mattress floor, and telephone wires. An interview with Licensed Practical Nurse (LPN) #35 and LPN #24, on 11/09/15 at 5:41 p.m., revealed staff rarely entered the mechanical room, and it was kept locked. Upon inquiry, LPNs #35 and #24 related four (4) residents had a history of [REDACTED]. The residents were Residents #26, #12, #5 and #22. An interview and observation with Maintenance Director #48 and the administrator, on 11/11/14 at 4:31 p.m., again revealed the door was unlocked. He confirmed the room contained two (2) unlocked generators with multiple wires in each, six (6) electrical boxes, a sprinkler system, gas lines, and telephone lines. Additionally, a cart with an unlocked tool box was present in the room. The maintenance director related the door knob was jus… | 2019-10-01 |
| 4513 | 4513 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 332 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and, review of Omnicell (an automated medication dispensing system) usage reports, and staff interview, the facility failed to ensure a medication error rate of less than five percent (5%). The medication error rate was 12.5 percent with four (4) errors in thirty-two (32) opportunities for error. A resident received the wrong dosage of aspirin, two (2) doses of medication would have been missed if not for surveyor intervention, and one (3) dose of medication was omitted. Resident identifiers: #50 and #88. Facility census: 45. Findings include: a) Resident #50 During a medication administration observation, on 11/11/15 at 8:14 a.m., Licensed Practical Nurse (LPN) #42 administered the following medications to Resident #50: [MEDICATION NAME] 25 milligrams (mg) orally (PO), Aspirin 81 mg PO, [MEDICATION NAME] 100 mg PO, [MEDICATION NAME] 0.6 mg PO, [MEDICATION NAME] 25 mg PO, and [MEDICATION NAME] 5 mg PO. Review of the medical record, at 10:00 a.m. on 11/11/15, revealed an order for [REDACTED].>A follow-up interview with LPN #42 at 10:30 a.m. on 11/11/15, confirmed [MEDICATION NAME] should have been administered with the medication administration at 8:14 a.m. The LPN reviewed the medications in the medication cart and related none was available to give. Upon inquiry, LPN #42 related [MEDICATION NAME] was available in the Omnicell emergency kit, and acknowledged she could have administered the dose. Upon inquiry regarding administration of the multivitamin, LPN #42 related she did not realize she had not administered the medication. Review of the Omnicell usage report, at 12:30 p.m., on 11/11/15 revealed LPN #42 removed four (4) [MEDICATION NAME] 5 mg tablets from the Omnicell machine at 11:45 a.m. for administration to Resident #88. b) Resident #88 During another medication administration pass with Licensed Practical Nurse (LPN) #42, on 11/11/15 at 8:20 a.m., the LPN administered Aspirin 81 milligrams… | 2019-10-01 |
| 4514 | 4514 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 334 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on medical record review, staff interview, review of the facility's pneumococcal vaccine (PV) policy, the facility failed to administer a PV to one (1) of five (5) residents reviewed under the mandatory facility task for infection control/immunization review. A PV was not administered after receiving a telephone verbal/consent from a resident's medical power of attorney (MPOA) upon admission to the facility. Resident identifier: #46. Facility census: 45. Findings include: a) Resident #46 Review of the resident's medical record, on 11/12/15 at 8:15 a.m., found the resident was admitted on [DATE]. The resident's consent for the flu (influenza) vaccine, pneumonia vaccine, and [MEDICATION NAME] (TB) skin testing noted a telephone verbal/consent with the date of 04/29/15. The consent was checked Yes, I give my permission for the [MEDICATION NAME] (pneumonia vaccine) (PV) if not previously taken. A review of Resident #46's [MEDICAL CONDITION] screen/influenza/ pneumonia vaccination record on 11/12/15 at 8:30 a.m. revealed the Resident #46 did not receive a PV. A review of the facility's PV policy, on 11/12/15 at 8:45 a.m., revealed prior to or upon admission, residents would be assessed for eligibility to receive the PV and when indicated they would be offered the vaccine within thirty (30) days of admission to the facility unless medically contraindicated or the resident had already been vaccinated. The assessment of pneumococcal vaccination status would be conducted within five (5) working days of the resident's admission if not conducted prior to admission. In an interview on 11/12/15 at 9:00 a.m., with Registered Nurse (RN) #16, the RN was asked if she received consent to administer a PV for Resident #46. The RN stated, No. The RN was then asked, When would you expect to administer the vaccine after you received permission to administer a PV if it has not previously given? The RN stated, She would give the vaccine within that week. The R… | 2019-10-01 |
| 4515 | 4515 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 356 | E | 0 | 1 | YR5K11 | Based on observation, review of the facility's staff tracking sheet, nursing schedule, staff interview, and the facility's posting of nurse staffing policy, the facility failed to accurately post the total number and the actual hours worked for the licensed practical nurses (LPNs) who were responsible for direct resident care per shift. This had the potential to affect more than a limited number of residents. Facility census: 45. Findings include: a) Staff tracking sheet Observation of the staff tracking sheet, on 11/09/15 at 11:45 a.m., found the facility had written on the staffing tracking sheet that two (2) LPNs were working the 6:00 a.m. to 6:00 p.m. shift, and the actual combined total hours for these LPNs was twenty-four (24). Observation of the LPNs present on 11/09/15 at 11:46 a.m., revealed LPN #78, LPN #24, LPN #89, and LPN #35 were directly responsible for the residents' care. The DON reviewed the staff tracking sheet on 11/09/15 at 11:50 a.m. When asked whether the number of LPNs was accurate, she stated, No. She marked through the number two (2) under LPNs, and wrote a three (3) in the section. She revealed the LPNs combined total hours were 36. A review of the facility's LPN schedule on 11/09/15 at 11:55 a.m., found for the date of 11/09/15, LPN #78, LPN #24, LPN #89, and LPN #35 were scheduled to work from six 6:00 a.m. to 6:00 p.m. On 11/09/15 at 11:56 a.m., LPN #35 and LPN #78 confirmed LPNs #78, #24, #89, and #35 were working. These two (2) LPNs stated, The staff tracking sheet is inaccurate, there are four (4) LPNs working. The DON on 11/11/15 at 6:00 p.m., confirmed the staff tracking sheet should have had four (4) LPNs, and the LPN's total hours were forty-eight (48), not twenty-four (24), or thirty-six (36). A review of the facility's nurse staffing policy, on 11/11/15 at 6:15 p.m. revealed the policy stated the following in regards to the nurse staff posting, 8.14.i.1. The current date; resident census; and the total number and the actual hours worked by the following categories of license… | 2019-10-01 |
| 4516 | 4516 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 366 | D | 0 | 1 | YR5K11 | Based on observation and staff interview, the facility did not offer substitutes of similar nutritive value to two (2) of fourteen (14) residents served in the restorative dining room, and for one (1) randomly observed resident. Resident identifiers: #19 and #46. Facility census: 45. Findings include: a) Resident #46 A random observation of the lunch meal, on 11/09/15 at 12:05 p.m., revealed Resident #46 in his room with his lunch tray on the over-bed table in front of him. The resident was not eating. Another observation at 12:12 p.m. again revealed uneaten food. Nurse Aide (NA) #72 entered the room at 12:14 p.m. and asked Resident #46 if he was going to eat. The resident replied, I don't like it. The NA encouraged him to take a bite and he refused. NA #72 then removed the milk from his tray, placed it on the over-bed table and said, At least drink your milk. NA #72 did not offer the resident a substitute meal. b) Resident #19 During an observation of the dinner meal, Resident #19 related to Nurse Aide (NA) #68 he did not like his vegetable and removed it from his plate. NA #68 did not offer the resident a substitute. c) An interview with the director of nursing (DON), on 11/11/15 at 1:14 p.m., revealed staff should have offered substitutes of similar nutritive value when a resident refused a food item and/or meal. The DON further added, the facility always had items on hand such as soup and sandwiches. | 2019-10-01 |
| 4517 | 4517 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 371 | E | 0 | 1 | YR5K11 | Based on observation and staff interview, it was determined the facility had not ensured foods were stored, distributed and served under sanitary conditions. The kitchen staff did not store dishware and serving utensils in a manner that utilized proper sanitation techniques. In addition, the Speech Language Pathologist and nurse aides did not serve food to residents under sanitary conditions. Facility census: 45. Findings include: a) During the initial dietary tour on 11/09/15, the following items were not stored in a sanitary manner: 1. Plastic cups were stored wet in a wooden cabinet. This procedure allowed the potential for bacteria to grow in a moist environment. 2. Serving utensils were stored in drawers in a haphazard manner, which could lead to staff touching the serving portion of the utensil with their bare hands when retrieving the handle of a device. 3. Dishware had some chipped areas on the edges. This created the potential for improper cleaning and sanitization. These items were discussed with the dietary manager on 11/11/15 at midmorning. She confirmed that she was trained to determine these were sanitation issued. b) Residents #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. During an observation of the lunch meal, from 11:15 a.m. to 12:00 p.m. on 11/09/15, Speech Language Pathologist (SLP) #91 set up the tray for Resident #35, touching the resident's bread with bare hands. The resident was not eating and the therapist returned to the table and said, I'm going to fold your bread in half, okay? The SLP then folded the bread with bare hands. Additionally, SLP #91 removed the paper from Resident #35's straw and held the area from which the resident drank in the palm of her hand. SLP #91 assisted Resident #23, folding her bread with bare hands and touched the food of Resident #22. Nurse Aide (NA) #12 removed the a of bread from the plastic sheath for Resident #67, touching it with her bare hands. She also peeled a banana for Resident #10, and then grasped the edible part of the … | 2019-10-01 |
| 4518 | 4518 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 441 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, and review of the Centers for Disease Control and Prevention Guidelines (CDC), the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection, to the extent possible. The facility did not ensure Personal Protective Equipment (PPE) was utilized when indicated, and/or did not ensure staff employed proper handwashing technique when performing a wound dressing change. These practices affected three (3) residents, but had the potential to affect more than a limited number of residents. Resident identifiers: #88, #50, and #5. Facility census: 45. Findings include: a) Resident #88 During an an Accucheck (fingerstick blood sugar), on 11/11/15 at 8:30 a.m., Licensed Practical Nurse (LPN) #42 entered the room of Resident #88 to complete the test. Without donning gloves, the nurse proceeded to complete the fingerstick blood sugar. After obtaining the blood sugar, the LPN wiped the excess blood from the resident's finger, still without donning gloves. b) Residents #88 and #50 When pouring medications for Resident #50 on 11/11/15 at 8:14 a.m., Licensed Practical Nurse (LPN) #42 placed each medication in her bare hand before placing it in the medication cup for administration. Medications included: [MEDICATION NAME] 25 milligram (mg) PO (by mouth), Aspirin 81 mg PO, [MEDICATION NAME] 100 mg PO, [MEDICATION NAME] 0.6 mg PO, [MEDICATION NAME] 25 mg PO, and [MEDICATION NAME] 5 mg PO. When completing the medication administration pass, on 11/11/15 at 8:20 a.m., LPN #42 poured Aspirin 81 mg, [MEDICATION NAME] 1 mg po, [MEDICATION NAME] 20 mg po, and [MEDICATION NAME] 2.5 mg po. The nurse placed each medication in her bare hand, and then dropped it into the medication cup. The medication was then administered to Resident #88. Aspirin, and [MEDICATION NAME] and were obtained from a bottle of medication … | 2019-10-01 |
| 4519 | 4519 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 464 | E | 0 | 1 | YR5K11 | Based on observation and staff interview, the facility did not furnish sufficient space to accommodate dining activities in the restorative dining room for fourteen (14) of fourteen (14) residents observed during the lunch meal. Resident identifiers: #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. Facility census: 45. Findings include: a) Resident #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. A lunch observation, on 11/09/15 from 11:15 a.m. until 12:00 p.m., revealed these fourteen (14) residents ate in the restorative dining room. Resident #59 was the last resident assisted into the dining room. All other residents had been served and were eating. Resident #59 was seated in a specialized recliner chair. Nurse Aide (NA) #30 attempted to position the resident at the far side of the first table to the left of the door upon entry of the dining room. The tables were positioned close together and residents were seated at each table. The NA was unable to position the chair due to the closeness of tables. After several attempts, and interrupting residents' dining, NA #30 removed Resident #59 from the dining room. She turned the chair around and entered again, once more disrupting residents' meals while positioning the resident at the table. An interview with the director of nursing (DON) on 11/11/5 at 1:14 p.m. confirmed the dining area was crowded. The DON related the facility was aware of the situation. Upon inquiry, the DON related the dining room had not been addressed in quality assurance, nor had an action plan had been developed to address the situation. | 2019-10-01 |
| 4520 | 4520 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 502 | E | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain a laboratory test for one (1) of five (5) residents reviewed for unnecessary medications. A fecal occult stool test was not obtained for Resident #48. Resident identifier: #48. Facility census: 45. Findings include: a) Resident #48 A medical record review, on 11/11/15 at 9:31 a.m., revealed Resident #48 received celecoxib ([MEDICATION NAME]) 100 milligrams (mg) orally twice daily. physician's orders [REDACTED]. Further review, also revealed an order dated 05/23/15, for a Fecal Occult Stool. No evidence was present in the medical record to indicate the test had ever been completed. An interview with Licensed Practical Nurse (LPN) #25 on 11/11/15 at 2:50 p.m. revealed the facility had a book which contained laboratory (lab) tests. The LPN related she and Registered Nurse (RN) #73 developed a system to ensure all laboratory tests were completed as ordered. Upon inquiry, LPN #25 related Resident #48 would not defecate in a hat, and would throw it away, if placed on the toilet seat. An interview with Resident #48, on 11/12/15 at 10:24 a.m., revealed the resident took herself to the bathroom, and said she would let staff know if she had a bowel movement. The director of nursing (DON), interviewed on 11/12/15 at 10:43 a.m., revealed if a resident was continent, staff would place a hat in the commode to collect stool. She agreed resident #48 would throw away the hat. Progress notes, reviewed on 11/12/15 at 10:44 p.m., revealed no evidence the resident had refused to comply with the fecal occult stool test. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 05/29/15, noted a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Additionally, Section [NAME] indicated the resident had exhibited no behaviors. Review of the care plan, on 11/12/15 at 11:00 a.m., revealed a focus relate… | 2019-10-01 |
| 4859 | 4859 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 157 | D | 1 | 0 | G6NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to notify the physician on two (2) incidents of improper medication administration for one (1) of six (6) residents reviewed. Resident identifier #52. Facility census 58. Findings include: a) Resident #52 A review of Resident #52's physician order [REDACTED]. A review of the Medication Administration Record [REDACTED] -- On 07/08/16, Resident #52 received her 9:00 a.m. dose of [MEDICATION NAME] at 2:57 p.m., due to waiting on tubing from the pharmacy. -- On 07/09/16, Residetn #52 received her 9:00 a.m. dose of [MEDICATION NAME] at 3:44 p.m., due to waiting for trough (laboratory results). Review of Resident #52's medical record, on 07/27/16 at 2:37 p.m., revealed Licensed Practical Nurse (LPN) #18 and LPN #80 did not notify the Resident's physician of the 9:00 a.m. dose of [MEDICATION NAME] 1,000 mg IV was not administered on 07/08/16 and 07/09/16 as ordered. In an interview with the Director of Nursing (DON), on 07/27/16 at 4:05 p.m., she stated, they ran out of of tubing on 07/08/16, and had to wait for the tubing to arrive from the pharmacy. The DON further stated the nursed had to do a trough (laboratory) level on 07/09/16, and had to wait on the results. The nurses. The DON revealed the nurses did not notifiy the physician the medication was administered late, nor did they receive a new physician order. The facility's policy for changing IV tubing revealed the intermittent administration set is change every twenty-four (24) hours. | 2019-07-01 |
| 4860 | 4860 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 225 | D | 1 | 0 | G6NZ11 | > Based on record review, staff interview, resident interview, and policy review the facility failed to investigate and report an allegation of neglect for one (1) of six (6) residents reviewed. Resident Identifier: #52. Facility census: 58. Findings include: a) Resident #52 In an interview with Resident #52, on 07/28/16 at 10:17 a.m., she revealed a morning in (MONTH) (YEAR) she had rang her call light due to she was incontinent of bowel and bladder. Nursing Aide (NA) #97 entered her room to assist her with her care. The resident said the NA cleaned her and left. She stated that she did not feel like she was cleaned properly. The resident said she reached over and used one (1) of her wipes and wiped herself and she had bowel movement on the wipe. The resident said she saw NA #91 walking down the hall, and yell out to her to come into her room. She said she told NA #91, she was not cleaned properly. She said she showed her the wipe in which had bowel movement on the wipe. She said the NA reported this to the Licensed Practical Nurse (LPN) #18. LPN #18 came into her room and she showed her the wipe she used which had bowel movement present. The resident said she told LPN #18, I was not cleaned by NA #97 properly. The resident revealed LPN #18 told NA #91 to clean her up. During a record review on 07/25/16 at 3:00 p.m., the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/16 found the resident scored a 15 on her brief interview for mental status (BIMS). The Brief BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. In an interview with NA #91, on 07/28/16 at 10:30 a.m., revealed Resident #52 yelled for her as she walked by the resident's room. She further revealed the resident showed her a wipe with bowel movement on it. NA #91 stated the Resident told her NA #97 did not clean her after incontinence care. NA #91 revealed she reported this to LPN #81. She said LPN #8… | 2019-07-01 |
| 4861 | 4861 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 226 | D | 1 | 0 | G6NZ11 | > Based on record review, staff interview, resident interview, and policy review the facility failed to implement their policy related to performing an investigate and report an allegation of neglect which had been brought to staff attention for one (1) of six (6) resident reviewed for allegation of neglect. Resident Identifier #52. Facility census 58. Findings include: In an interview with Resident #52, on 07/28/16 at 10:17 a.m., she revealed a morning in (MONTH) (YEAR) she had rang her call light due to she was incontinent of bowel and bladder. Nursing Aide (NA) #97 entered her room to assist her with her care. The resident said the NA cleaned her and left. She stated that she did not feel like she was cleaned properly. The resident said she reached over and used one (1) of her wipes and wiped herself and she had bowel movement on the wipe. The resident said she saw NA #91 walking down the hall, and yell out to her to come into her room. She said she told NA #91, she was not cleaned properly. She said she showed her the wipe in which had bowel movement on the wipe. She said the NA reported this to the Licensed Practical Nurse (LPN) #18. LPN #18 came into her room and she showed her the wipe she used which had bowel movement present. The resident said she told LPN #18, I was not cleaned by NA #97 properly. The resident revealed LPN #18 told NA #91 to clean her up. During a record review on 07/25/16 at 3:00 p.m., the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/16 found the resident scored a 15 on her brief interview for mental status (BIMS). The Brief BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. In an interview with NA #91, on 07/28/16 at 10:30 a.m., revealed Resident #52 yelled for her as she walked by the resident's room. She further revealed the resident showed her a wipe with bowel movement on it. NA #91 stated the Resident told her NA #97 did not… | 2019-07-01 |
| 4862 | 4862 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 280 | D | 1 | 0 | G6NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to revise a care plan to reflect a resident's status for the use of a Foley catheter, and ability to transfer for one (1) of six (6) resident reviewed. Resident identifier: #52. Facility census 58. Findings include: a) Mobility/Transfer Status In an interview on 07/25/16 at 11:00 a.m., with Resident #52. The resident revealed she transfers with the assistance of two (2) NAs and a gait belt. The resident said that she had previously used a Hoyer lift, but she now transfers with two (2) and a gait belt now. Record review for Resident #52, on 07/25/16 at 3:00 p.m., revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/16. This MDS noted the resident scored a 15 on her brief interview for mental status(BIMS). The BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. In an interview with Licensed Practical Nurse (LPN) #90, on 07/26/16 at 10:00 a.m., she stated, The resident does not use a lift. Record review of Resident #52's, on 07/27/16 at 3:23 p.m., found a care plan created on 11/19/15 related to inability to maintain health state independently due to generalized weakness and right knee replacement. The care plan was for the the resident to have the assistance of two (2) people, and a Hoyer lift. A review of Resident #52's Kardex (information NAs use in order to know how to care for residents) revealed the resident requires the use of a Hoyer lift with the assistance of two (2) people. Observation of the Resident #52 on 07/27/16 at 3:30 p.m., found NA #42 and #74 transfer the resident into her bed from her wheelchair. The resident tried to resist using a transfer belt while transferring. NA #74 asked resident if they could use the gait belt for safety and the resident allowed them to transfer her. The staff transf… | 2019-07-01 |
| 4863 | 4863 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 309 | E | 1 | 0 | G6NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview and policy review, the facilty failed to ensure each resident physician's orders were followed for four (4) out of six (6) residents reviewed for medication administration. Four residents were found to have numerous episodes of medication not being given in a timely manner as prescribed by the physician. Resident identifier: #52, #110, #43 and #49. Facility census: 58. Findings include: a) Resident #52 A review of Resident #52's Medication Administration Record [REDACTED]. Two (2) ouces of power pudding with medication administered once a day at 8:00 a.m.: --05/11/16 administered at 9:37 a.m. --05/13/16 administered at 9:02 a.m. --05/15/16 administered at 10:23 a.m. --05/16/16 administered at 9:24 a.m. --05/19/16 administered at 9:18 a.m. Aspirin delayed release 81 mg once a day at 8:00 a.m: --05/10/16 administered at 12:56 p.m. --05/11/16 administered at 9:37 a.m. --05/13/16 administered at 9:02 a.m. --05/15/16 administered at 10:23 a.m. --05/16/16 administered at 9:24 a.m. --05/18/16 administered at 10:04 a.m --05/19/16 administered at 9:18 a.m. --05/27/16 administered at 9:19 a.m. --05/28/16 administered at 10:16 a.m [MEDICATION NAME] 0.5 mg every twelve hours, give one (1) tablet by mouth twice daily at 7:00 a.m. and 7:00 p.m.: --05/27/16 administered the 7:00 a.m. dose at 9:19 a.m. --05/28/16 administered the 7:00 a.m. dose at 10:16 a.m. [MEDICATION NAME] 1 mg twice daily to be administered at 7:00 a.m. and 7:00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:26 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/05/16 the 7:00 p.m. dose administered at 1:40 a.m. --05/06/16 the 7:00 p.m. dose administered at 8:57 a.m. --05/11/16 the 7:00 a.m. dose administered at 9:27 a.m. --05/12/16 the 7:00 a.m. dose administered at 8:50 a.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 7:00 a.m. dose … | 2019-07-01 |
| 4864 | 4864 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 312 | D | 1 | 0 | G6NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility did not ensured residents received activity of daily living (ADL) care as ordered. Resident were not given baths and/or showers according to bathing schedules as required. This was evident for two (2) of six (6) residents reviewed. Resident identifers: #43 and #52. Facility census: 58 Findings include: a.) Resident #43 A review of Resident #43's bathing record showed she did not receive a shower on her shower day as required. Review of the nursing shower list revealed the resident's shower days were Tuesday, Thursday and Saturday. Resident #43 did not receive a shower on 05/28/16 (Saturday) as required. Interview with Registered Nurse (RN) #89 and the Director of Nursing #21, on 07/27/16 at 2:00 p.m. verified the resident did not receive a shower on the assigned day. The facility did not have a shower team of staff working that day to complete showers. b) Resident #52 In an interview on 07/25/16 at 11:30 a.m., with Resident #52. The resident stated, I did not get my shower on Memorial Day weekend. I was to receive a shower on Saturday and I did not get my shower until Tuesday. A review of the resident's shower schedule, found Resident #52 receives her shower on Tuesday, Thursday, and Saturday. The schedule is revised if the shower team is not available. The resident resides in room [ROOM NUMBER]-B, and she would receive her shower from 2:00 p.m. - 10: 00 p.m. if the shower team is not available. The form stated, IF A RESIDNET'(sic)' ( REFUSES A SHOWER YOU MUST INFORM THE NURSES ON DUTY AT THAT TIME, NOT AT THE END OF YOU SHIFT, YOU MUST APPROVE IT WITH NURSES BEFORE A RESIDNET '(sic)' IS GIVEN A BEDBATH, SCHEDULED SHOWERS MUST BE GIVEN EVERYDAY, THIS IS MANDATORY, IF NOT FOLLOWED DISCIPLINARY ACTION WILL BE TAKEN. A review of the facility's shower list, on 07/26/16 at 12:50 p.m., found on 05/28/16 (Saturday), Resident #52 did not receive a shower. A review of the activity of daily liv… | 2019-07-01 |
| 4865 | 4865 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 333 | D | 1 | 0 | G6NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident interview, staff interview, and review of the State Operations Manual Appendix PP, the facility failed to ensure that one (1) of six (6) residents reviewed were free of any significant medication errors. One (1) resident did not receive her antibiotic intravenous (IV) medication on time to maintain consistent blood levels while the resident was receiving the medication. Resident Identifier #52. Facility census 58. Findings include: a) Resident #52 Interview with Resident #52, on 07/28/16 at 10:17 a.m., she stated, I do not receive my IV as I should be. When asked what she meant, she said they do not give her antibiotic intravenous(IV)medication in the morning. She further stated the staff either gives her morning IV antibiotic late, or she will give the medication in the afternoon, and then later in the evening. She said they have to wait a long time on a trough (laboratory)level before they are able to give her medication. The resident said they just give my antibiotic medication at different times. A review of Resident #52's Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/15/16 found the resident scored a 15 on her brief interview for mental status (BIMS). The BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. A review of Resident #52's Medication Administration Record [REDACTED]. [MEDICATION NAME] 1,000 milligram (mg) administered every twelve hours from 06/29/16- 07/11/16. A review of (MONTH) medication MAR found: --07/01/16 the 5:00 a.m. dose administered at 6:02 a.m., had to wait for labs to be drawn before intravenous medication could be infused. -07/04/16 the 5:00 a.m. dose administered at 9:46 a.m., awaiting for trough results. -07/06/16 the 9:00 a.m. dose administered at 10:18 a.m. -07/07/16 the 9:00 a.m. dose administered at 10:16 a.m. -07/08/16 the 9:00 a.m. … | 2019-07-01 |
| 4866 | 4866 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 353 | E | 1 | 0 | G6NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview and policy review, the facility failed to deploy their staff in a manner that ensured medication were not administered late due to assisting with resident care, assisting with lunch and not being able to document on the time appropriately four (4) of six (6) resident reviewed for medication being administered in a timely manner. These residents were found to have multiple episodes of medication not being given in a timely manner. Resident Identifier #52, #110, #43 and #49. Facility census 58. Findings include: a) Resident #52 A review of Resident #52's Medication Administration Record [REDACTED]. Two (2) ouces of power pudding with medication administered once a day at 8:00 a.m.: --05/11/16 administered at 9:37 a.m. --05/13/16 administered at 9:02 a.m. --05/15/16 administered at 10:23 a.m. --05/16/16 administered at 9:24 a.m. --05/19/16 administered at 9:18 a.m. Aspirin delayed release 81 mg once a day at 8:00 a.m: --05/10/16 administered at 12:56 p.m. --05/11/16 administered at 9:37 a.m. --05/13/16 administered at 9:02 a.m. --05/15/16 administered at 10:23 a.m. --05/16/16 administered at 9:24 a.m. --05/18/16 administered at 10:04 a.m --05/19/16 administered at 9:18 a.m. --05/27/16 administered at 9:19 a.m. --05/28/16 administered at 10:16 a.m [MEDICATION NAME] 0.5 mg every twelve hours, give one (1) tablet by mouth twice daily at 7:00 a.m. and 7:00 p.m.: --05/27/16 administered the 7:00 a.m. dose at 9:19 a.m. --05/28/16 administered the 7:00 a.m. dose at 10:16 a.m. [MEDICATION NAME] 1 mg twice daily to be administered at 7:00 a.m. and 7:00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:26 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/05/16 the 7:00 p.m. dose administered at 1:40 a.m. --05/06/16 the 7:00 p.m. dose administered at 8:57 a.m. --05/11/16 the 7:00 a.m. dose administered at 9:27 a.m. --05/12/16 the 7:00 a.m. dose administered at 8:50 a.m. --05/13/16 the 7:… | 2019-07-01 |
| 4867 | 4867 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 356 | D | 1 | 0 | G6NZ11 | > Based on staff posting and staff interview, the facility failed to accurately post the combined hours on the posting form for one (1) of three (3) days staffing was reviewed. Facility census 58. Findings include: a) Staff posting combined hours. A review of the staff posting for 05/28/16 - 05/29/16, finds three (3) licensed practical nurses (LPN) worked from 6:00 a.m. - 6:00 p.m. for the total combined hours are 36 hours. The staff posting also revealed there is five (5) Nurse Aides (NA) working from 6:00 a.m. to 2:00 p.m., for a combined total hours of 37.50. There were three (3) LPN working from 6:00 p.m. to 6:00 a.m., combined total hours of 36 hours. In an interview with the Director of Nursing (DON) on 07/27/16 at 2:00 p.m., she confirmed they wrote on the staff posting form there were three (3) LPN'S, but one (1) of these LPNs assisted the assistive living unit from 4:00 p.m. to 6:00 p.m. Another LPN also provide care to the assisted living area from 6:00 p.m. to 6:00 a.m. She did not know how much time to take off the staff posting for the hours the LPN goes and works upstairs. The DON confirmed that there were four (4) NAs that worked from 6:00 a.m. to 2:00 p.m., and one NA came on duty on 05/28/16 at 8:55 a.m. to 2:00 p.m. The DON confirmed the combined hours were not accurate for the LPN and the NA due to the NA did not work the whole shift on the first floor unit and they counted her for the whole shift. They only count 7.50 hour for each aide. The DON confirmed that she may not know the number of hours the nurse worked upstairs in the assisted living, section from 4:00 p.m., to 6:00 p.m. and from 6:00 p.m. to 6:00 a.m. | 2019-07-01 |
| 4868 | 4868 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 428 | E | 1 | 0 | G6NZ11 | > Based on medical record review and staff interview, the pharmacist failed to identify medication errors for residents receiving medication late. The pharmacist also did not identify the medication were being administered too close to the next dose. There were no physician order to hold the medication or administer the medication at a later time. Resident identifiers: #52, #110, #43 and #49. Facility census: 58. Findings include: a) Resident #52 A review of Resident #52's Medication Administration Record [REDACTED]. A review of Resident #52's MAR for the month of (MONTH) (YEAR) found the resident received Vancomycin 1,000 milligram (mg) administered every twelve hours from 06/29/16 - 07/11/16. The medication was either administered late, held without a physician order, administered at a later date without a physician order, or administering medication too close to the next dose seven (7) times, on 07/01/16, 07/04/16, 07/06/16, 07/07/16, 07/08/16, 07/09/16, 07/11/16. The reason for the medication not being administered on time was due to waiting on labs, intravenous tubing from pharmacy, late due to being with physician. Interview with the Director of Nursing (DON) on 07/27/16 at 4:05 p.m., revealed The DON was asked whether the pharmacist had identified the medications were being administered late, or that staff have not been notifying the physician when they held mediation, administered medication at a later date, or administered medication too close to the next dose. The DON stated, No. The nurse provided evidence the consultant pharmacist did his monthly review for (MONTH) already, and he made no recommendation regarding any of the resident's medication being late, holding medication without an order, or administering medication without an order at a later date. b) Resident #110 A review of Resident #110's Medication Administration Record [REDACTED]. Resident #110 had 134 medications that was administered late due to assisting with a resident's care, or assisting with lunch meal. d) Resident #43 A review of t… | 2019-07-01 |
| 4869 | 4869 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2016-07-29 | 514 | D | 1 | 0 | G6NZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to accurately document in the medical record a medication that had not been administered. Documentation showed a resident received an intravenous (IV) medication, but after counting the medication, pharmacy inventory revealed the medication could not have been administered. Resident #52. Facility census 58. Findings include: a) Resident #52 A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. In an interview with the DON on 07/27/16 at 1:03 p.m., she was asked why the medication was not given on time. The DON stated the LPN that documented this evidence was not available, and I will have to call her at home. On 07/27/16, at 1:22 p.m. the DON stated LPN #18 confirmed she did not give the medication, due to waiting on a pharmacy to call with new dosing. The DON counted the [MEDICATION NAME] medication bags with the pharmacy inventory sheet and found the medication could not have been administered. She did confirm the written information in the MAR indicated [REDACTED]. | 2019-07-01 |
| 5298 | 5298 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2015-06-24 | 258 | E | 0 | 1 | FGRX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews and staff interviews the facility failed to provide comfortable sounds levels for five (5) of twenty-eight (28) residents on the B Unit. Resident identifiers: #10, #35, #37, #39, and #71. Facility census: 57. Findings include: a) Resident #10 During an interview, on 06/22/15 at 9:17 a.m., Resident #10 revealed it was loud in the facility in the evening. The resident stated some of the residents are loud and yell out in the evening. b) Resident #35 During an interview, on 06/22/15 at 9:48 a.m., Resident #35 stated the televisions were too loud after supper. c) On 06/23/15 at 6:50 p.m., the facility was entered to make observations of the noise levels in the facility. Upon entering the facility, a television on Unit B room [ROOM NUMBER] was playing extremely loud. d) An interview with Licensed Practical Nurse (LPN) #11, on 06/23/15 at 7:00 p.m., revealed the resident always turned the television up very loud every day, and they had to ask him to turn it down. LPN #11 stated the resident liked to listen to music loudly and liked to sing. e) Resident #37 During an interview, on 06/22/15 at 1:00 p.m., Resident #37 indicated it was noisy in the facility in the evenings and stated the televisions were loud. The resident stated she tells the staff, but they do not do anything. f) Resident #39 In an interview, on 06/23/15 at 7:11 p.m., the resident said staff were loud on the B Unit dining room in the evening and some of the resident ' s televisions were loud in the evening. g) Resident #71 During an interview, on 06/22/15 at 7:05 p.m., Resident #71 revealed it was very noisy in the facility in the evening. The resident stated she often heard small children yelling loudly and staff was loud at times. During the interview with Resident #71, children were heard yelling loudly from out in the hall. Upon observation, there were two (2) small children in the main dining room on the B Unit running and yelling loudl… | 2019-01-01 |
| 5299 | 5299 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2015-06-24 | 371 | F | 0 | 1 | FGRX11 | Based on observations and staff interviews, the facility failed to store food under sanitary conditions to prevent, to the extent possible, the outbreak of foodborne illness. This practice had the potential to affect all residents who received nutrition from the kitchen. Facility census: 57. Findings include: a) The initial tour of the facility was conducted on 06/22/15 at 6:50 a.m. The following sanitation infractions were identified and discussed with staff as indicated: 1. The floors around the cove molding in the kitchen had a large build-up of a black substance. 2. The milk cooler did not contain a thermometer. Dietary Employees #8 and #9 verified the milk cooler did not have a thermometer. They stated the milk cooler was new and they were not sure where to locate the thermometer. 3. Observation of the walk-in freezer revealed bags of dough balls and frozen vegetables which were stored in boxes open to the air. Dietary Employee #9 verified this at 7:05 a.m. 4. The walk-in cooler had a cardboard carton of macaroni salad and a box of sausage patties open to air. 5. Observation of the walk-in cooler revealed a box of more than 20 Health Shakes. An interview with Dietary Employee #9, regarding the system to thaw, serve, and dispose of the Health Shakes, revealed the employee was not aware of any policy. Dietary Employee #9 deferred to Dietary Employee #8. Interview with Dietary Employee #8, on 06/22/15 at 7:10 a.m., revealed the Health Shakes were taken out of the walk-in freezer and placed in the walk-in cooler to thaw. He stated the shakes were usually gone within a week or so. Employee #8 said he was unaware of any policy for how long they could be thawed prior to disposal. An interview with Dietary Manager (DM) #32, on 06/22/15 at 1:45 p.m., revealed the shakes placed in the walk-in cooler (from the walk-in freezer) were usually all gone within a week or so. Observation with DM #32, on 06/23/15 at 12:48 p.m., revealed two (2) boxes of Health Shakes in the walk-in cooler. One (1) box had (MONTH) 1st written o… | 2019-01-01 |
| 5300 | 5300 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2015-06-24 | 460 | F | 0 | 1 | FGRX11 | Based on observations and staff interviews, the facility failed to provide full visual privacy in 15 resident rooms observed on the A and B Units. The Stage 2 Sample was 24. Facility census: 57. Findings include: a) Rooms B1, B2, and B3 Observations of these rooms, on 06/22/15 between 2:00 p.m. and 4:00 p.m., revealed each room held two (2) beds. -- The privacy curtain went across the foot of the bed for the bed nearest the door. -- A second curtain was located between the beds from the wall at the head of the bed to about 4 feet from the opposite wall. -- There was no curtain that went across the foot of the bed of the resident nearest the window. -- The common bathroom was at the foot of the bed for the resident nearest the window. There was also a common sink, with a mirror above it, on the wall at which the middle privacy curtain did not reach. With that curtain pulled, residents could see each other on the opposite side of the curtain. b) The facility also had twelve (12) additional rooms with the same floor plan and bed arrangements. The privacy curtains in those rooms also failed to allow for full visual privacy. c) Observation with the facility Administrator and the Maintenance Supervisor, on 06/24/15 at 8:55 a.m., verified the resident in the bed next to the window did not have visual privacy from a roommate or anyone using the sink or common bathroom. The Administrator said, We have extra track and curtains. We will get that fixed. I have never looked at the curtains that way. | 2019-01-01 |
| 5301 | 5301 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2015-06-24 | 469 | F | 0 | 1 | FGRX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, and record reviews, the facility failed to maintain an effective pest control system to ensure the facility was free from pests. The facility was observed with small flying gnat-like insects in resident rooms, hallways, common areas, nurses ' stations, the elevator, dining room, and conference room. This practice had the potential to affect all facility residents. Facility census: 57. Findings include: a) Observations of the facility, from 06/22/15 through 06/24/15, revealed the continual presence of gnat-like insects in the conference room, common areas, hallways, nurse ' s station, elevator, and the dining room. b) Rooms B8, B10, and B12 Observations on the initial tour, on 06/22/15 from 7:00 a.m. to 7:30 a.m., revealed the presence of gnat-like insects in these rooms. During a follow up observation, on 06/23/15 at 3:20 p.m., gnat-like insects were seen again in room B12. Room B10 was having floor work done with the door closed so an observation was not possible. c) Resident #71 Interview with Resident #71, on 06/23/15 at 7:05 p.m., revealed there were a lot of small flying bugs of some kind in her room. She stated she swatted them away, but they always came back. She stated they had been bad for a few weeks, and she wished they would do something about them. d) Resident #39 Interview with Resident #69, on 06/23/15 at 7:09 p.m., revealed there were a lot of small flying insects around the facility. She stated they were in her room and in the dining room. She stated they fly around her food when she is eating and she wished the facility would get rid of them because they have been a problem for over a month. Interview with Resident #39, on 06/23/15 at 7:11 p.m., revealed there were several small flying bugs in her room. The resident indicated they were all over the facility in the halls and the dining room. She stated they got on her food when she ate. During the interview, the re… | 2019-01-01 |
| 5522 | 5522 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-09 | 241 | D | 0 | 1 | FJSP11 | Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one randomly observed resident, during a dinner time meal. One (1) nurse aid (NA) approached Resident #149 to set the resident up for the meal without speaking to the resident or letting the resident know what the NA was about to do. Resident identifier: #149 and #99. Facility census: 87. Findings include: a) Resident #149 Random observation during the dinner time meal, on 11/06/17 at 5:12 p.m., revealed Resident #149 was reclining in a geri chair beside a dinner table. Nurse Aide (NA) #44 came up behind Resident #149, and without saying anything to the resident or explaining what he was about to do changed the geri chair from a reclining position to a sitting position. The sudden quick movement from a reclining to a sitting position jarred the resident and caused the resident to scream out. b) Resident #99 Random observation during the dinner time meal, on 11/06/17 at 5:22 p.m., revealed NA #44 was feeding Resident #99 as she was leaning to the right side in her gerri-chair, with her head leaning forward. LPN #26 also in the dining room at the time and after observing NA #44 feeding Resident #99 agreed Resident #99 was not in good body alignment to promote feeding. LPN #26 proceeded to reposition the resident and prop the resident with folded blankets, after surveyor intervention, and instruct NA #44 on proper body alignment to promote feeding. | 2018-11-01 |
| 5523 | 5523 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-09 | 279 | D | 0 | 1 | FJSP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan had measurable and/or individualized objectives for a resident on anti-anxiety medication. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of fifteen (15) Stage II sampled residents. Resident identifier: #88. Facility census: 87. Findings include: a) Resident #88 The medical record was reviewed on 11/09/17. Physician orders [REDACTED]. at bedtime daily for anxiety. Review of the care plan found it lacked individualized, measurable goals for the use of anti--anxiety medications. The care plan did not identify the behaviors the facility intended to treat with the anti-anxiety medication. The care plan did not include measurable goals set for the resident's emotional and/or behavioral condition. Rather, the care plan focus stated (name of resident) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) anxiety disorder. The goals stated Patient will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Their only non-pharmacological interventions were to encourage him to vent his feelings, and listen to his concerns. On 11/09/17 at 9:58 a.m. an interview was conducted with the director of nursing (DON). She said this resident does have targeted behaviors, but they were not listed on the care plan. She acknowledged that there was no focus on the behaviors that caused him to need the [MEDICATION NAME]. She acknowledged that there were no individualized or measurable goals for any targeted behaviors they were treating. She said she would correct these issues right away. | 2018-11-01 |
| 5524 | 5524 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-09 | 371 | E | 0 | 1 | FJSP11 | Based on observation and staff interview, the facility failed to maintain kitchen equipment in a sanitary manner. This practice has the potential to affect more than limited number Residents. Staff Identifiers: #66. Facility Census: 87. Findings include: On 11/06/17 at 2:40 p.m., inspection of the kitchen with the dietary assistant #66, revealed an observation of the food lid to hot bar was dirty. The dietary assistant #66 agreed the food lid to hot bar was dirty and should not have been. | 2018-11-01 |
| 5525 | 5525 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-09 | 431 | D | 0 | 1 | FJSP11 | Based on observation and staff interview the facility failed to store and label medications. Resident: #48, #81 and #88. 11/08/2017 11:05:14 AM in medication room B and 2 medication carts, LPN #72 Levemir multi vail use wasn't labeled with opened date on vial for Resident #48, LPN #56 11/08/2017 11:15:31 AM Medication Room A and 2 medication carts, LPN #23 pens LPN #4 Humalog pen not labeled with opened date, Resident #81 Novolog pen not labeled with opened date, Resident #88 Based on observations and staff interview, the facility failed to collaborate with the pharmacist, to ensure safety and effective use of medications. An opened and partially used insulin vial was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication. This was evident for three (3) of thirty one (31) opened insulin vials and pens stored in two (2) of four (4) carts. Resident identifiers: #48, #81, #80. Findings include: a) Resident # 48 Observation on 11/08/2017 at 11:05 a.m., found a Levermir vial which belonged to resident # 48 was opened and partially used. There was no date indicating when the vial was intially opened, or the date it should be discarded. The Licensed Practical Nurse (LPN) #72 agreed the date that it was opened should have been on the vial. b) Resident #81 and #80 Observation on 11/08/2017 at 11:15 a.m. found a Humalog pen which belong to Resident # 81 was opened and partially used. There was no date indicating when the pen was was intially opened, or the date to discard. A novolog pen belonging to Resident #80 was opened and partially used. There was no date indicating when the pen was intially opened, or the date to discard. The LPN # 4 agreed that it should have been labeled when it was intially opened. There was a place on the pens to put the opened dates that were blank. Interveiw with the Director of Nursing was completed on 11/09/2017 at 10:30 a.m. she was aware of the findings of the insulin not being dated of when the medication was intially opened… | 2018-11-01 |
| 5570 | 5570 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-10-16 | 309 | D | 1 | 0 | ZDYQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility failed to provide one (1) of six (6) sampled residents care and services to ensure the highest practicable well-being. The resident's blood glucose was not monitored as ordered by the physician. Resident identifier: #51. Facility census: 53. Findings include: a) Resident #51 Clinical record review on 10/14/15 at 10:00 a.m., revealed Resident #51 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 09/23/15, the physician determined the resident had capacity to make health care decisions. The 09/23/15 physician's orders [REDACTED]. The 10/10/15 care plan goal for diabetes was Will remain free of signs/symptoms or complications related to diabetes as evidenced by labs and blood sugar checks will be in normal range. The clinical record contained no evidence staff performed the daily accu-checks as ordered. On 09/25/15, the resident's HB A1C ( laboratory test result for overall mean blood glucose) was 6.8. According to the providing laboratory standards, the normal range for HB A1C was 4.3 to 6.1. During an interview on 10/14/15 at 12:10 p.m., Director of Nursing (DON) #4 stated the facility failed to perform the accu-checks daily as ordered. The DON stated an accu-check was performed at 11:46 a.m. on 10/14/15. It was 262. On 10/14/15 at 12:45 p.m., Resident #51 confirmed the facility had not performed accu-checks daily. She said the first one was that day, on 10/14/15. | 2018-10-01 |
| 6185 | 6185 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 156 | B | 0 | 1 | O60P11 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 55 Findings include: a) On 09/17/14 at 10:10 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview was conducted on 09/17/14 at 1:20 p.m., with the Nursing Home Administrator. She was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2018-05-01 |
| 6186 | 6186 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 241 | D | 0 | 1 | O60P11 | Based on observation and staff interview, the facility failed to provide care to Resident #17 in a manner that promoted the resident's dignity and respect. While providing assistance with toileting to this resident, the staff member pulled the seat of the resident's pants to assist her with standing. Additionally, a laundry staff member opened the door to the bathroom without knocking while the resident was being toileted. This affected one (1) of twenty (20) residents observed in Stage 2 of the Quality Indicator Survey. Resident #17. Facility Census: 55. Findings include: a) Resident #17 An observation of incontinence care was conducted on 09/18/14 at 11:30 a.m. The resident was taken to the combination shower room / bathroom in front of the nurses' station by a nursing assistant (Employee #67). The nursing assistant provided cueing to the resident to stand and at the same time assisted her to stand by pulling up on the seat of her pants to help her stand. The nursing assistant was questioned about the method of transfer and was asked if they used gait belts. She stated they had some (gait belts) for some people, but she did not use them for this resident. She verified this was not a dignified manner to transfer the resident. During this same observation, on 09/18/14 at 11:32, the bathroom door was opened by a laundry staff member (Employee #20) who started through the door without knocking or announcing herself. When she observed there were people in the restroom, she immediately went back out closing the door. Resident #17 was sitting on the commode within sight of the door when it opened and anyone outside the door could have seen this resident sitting on the toilet. The administrator was made aware of this observation on 09/18/14 at 3:30 p.m. She verified they had gait belts and the staff should be using them on the residents who required assistance with transfers. She was also made aware of the observation with the laundry employee walking in the bathroom without knocking. She agreed staff should knock befo… | 2018-05-01 |
| 6187 | 6187 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 247 | D | 0 | 1 | O60P11 | Based on resident interview, staff interview, and record review, the facility failed to provide notice of a roommate change for two (2) of two (2) residents reviewed for admission, transfer and discharge. Resident identifiers: #75 and #41. Facility census: 55. Findings include: a) Resident #75 During a Stage 1 interview, on 09/16/14 at 11:16 a.m., Resident #75 related she had received a new roommate without notice. The resident said the facility transferred the new roommate from another part of the facility. An interview with the social worker (SW), on 09/17/14 at 1:48 p.m., revealed the facility's practice was for the resident, medical power of attorney, and/or health care surrogate to be notified prior to a room or roommate change. She reviewed the facility records and related the resident received a new roommate on 08/21/14. The social worker said the nursing staff usually notified a resident of roommate changes, but she had no evidence this resident was notified of the change. Employee #76, a registered nurse (RN), interviewed on 09/17/14 at 2:30 p.m., reviewed the chart of Resident #75 and the roommate. The nurse confirmed no evidence was present to indicate Resident #75 was notified she was receiving a roommate b) Resident #41 Resident #41, interviewed on 09/16/14 at 4:54 p.m., related she had received a roommate without notification. She said, They just brought her in. The social worker, interviewed on 09/17/14 at 1:55 p.m., reviewed facility records and confirmed the resident had received a new roommate on 09/05/14. She related the resident should have been notified prior to receiving a roommate and verified she had not notified Resident #41. Employee #76 (RN) reviewed the resident's medical record on 09/17/14 at 2:45 p.m., and confirmed no evidence was available to indicate Resident #41 was notified prior to receiving a new roommate. | 2018-05-01 |
| 6188 | 6188 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 253 | E | 0 | 1 | O60P11 | Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services in order to provide a sanitary, orderly, and comfortable interior. Cove molding and tiles were stained, loose, and/or missing. Walls had gouges and paint was missing in areas, exposing bare drywall. Furniture in resident rooms was in need of repair. This had the potential to affect more than an isolated number of residents. Facility Census: 55 Findings include: a) Cove molding: -- Room 105 - The cove molding had rough edges on the wall by the bathroom. -- Resident shower room - The cove molding and tiles were stained with a brown substance. -- Room 110 - The molding underneath the window was stained and had a brown substance on the molding and along the edge of the cove molding. -- Room 112 - The molding in the bathroom was pulled away from the wall exposing the drywall. -- Room 114 - The cove molding was broken away and protruding from the wall by the closet. -- The cove molding in the bathroom between Room 114 and Room 116 was broken and pulled away from the wall. -- Room 121 - The cove molding in the bathroom was soiled. There were brown stained areas along the floor . -- Room 130 - The cove molding had brown stained areas along the floor. -- The cove molding in the bathroom between Room 130 and 132 was cracked, broken, and had brown stained areas along the floor. b) Clothes or linens found on the floor of the closet. -- Room 123 - Resident clothing and unused briefs were on the floor of the closet. -- Room 124 - Resident clothing was on the floor of the closet. -- Room 127 - Folded linens were on the floor of the closet. Employee #43 picked up the linens and took them from the room. She stated The CNAs (certified nursing assistants) help with keeping the closets cleaned up, but these shouldn't be here. -- Room 132 - Resident clothing was on the floor of the closet. During an interview with Employee #43 on 09/17/14 at 3:00 p.m., she confirmed the resident's clothing should not be on the floor. c) The … | 2018-05-01 |
| 6189 | 6189 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 272 | D | 0 | 1 | O60P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct a complete and accurate initial comprehensive assessment. A resident's initial minimum data set (MDS) comprehensive assessment did not provide a complete assessment of urinary incontinence for one (1) of two (2) Stage 2 sample residents whose assessments were reviewed for the area of urinary incontinence. The Care Area Assessment (CAA) was not completed to assess the cause and type of incontinence experienced. Resident identifier: #17 Facility Census: 55. Findings include: a) Resident #17 This resident was admitted to the facility on [DATE]. Her initial Minimum Data Set (MDS) assessment had an assessment reference date (ARD) of 11/25/13. This date was seven (7) days following her admission to the facility. The assessment identified the resident had no problems with her cognition. Section H0300 of the assessment, was coded 2, indicating the resident was frequently incontinent of bladder. According to the instructions provided on the MDS, this indicated there were seven (7) or more episodes of urinary incontinence, but at least one (1) episode of continent voiding in the last seven (7) days prior to the ARD. Section V of the MDS indicated the Care Area of Urinary Incontinence was triggered and needed to be assessed further. It stated the location and date of the CAA documentation was the Urinary CAA summary assessment dated [DATE]. Review of the Urinary CAA summary assessment found it did not provide a further assessment of this resident's incontinence. There was no assessment to indicate what type of urinary incontinence the resident was experiencing or any information to assist with identifying the cause of her incontinence. The analysis of findings stated she had decreased mobility and used a diuretic. Based on this inadequate assessment, the resident was never placed on any type of toileting program to see if she could improve in the area of incontinence. During an i… | 2018-05-01 |
| 6190 | 6190 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 280 | D | 0 | 1 | O60P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to review and revise a resident's care plan for one (1) of twenty (20) sample residents. The resident's care plan was not revised in the areas of dental status and pain management for a resident with no lower dentures and who complained of knee pain and cervical pain. Resident identifier: #6. Facility census: 55. Findings include: a) Resident #6 During a Stage 1 interview, on 09/16/14 at 9:28 a.m., Resident #6 related she had no lower dentures because she had become angry and had thrown them away. She said she was saving money to get new teeth. The resident also related she had received therapy related to pain in her cervical spine, and that hot packs were very effective. Resident #6 said only therapy had utilized hot packs. Upon inquiry, she related nursing staff did not provide nonpharmacologic interventions, only medication. She further added she now had pain in her knees. An interview with family representative #1, on 09/17/14 at 9:50 a.m., revealed she had spoken with facility staff, was informed the resident had just received teeth about a year before, and was not able to request them again. The representative also related she had advocated for treatment of [REDACTED]. Review of the medical record, on 09/17/14 at 10:15 a.m. revealed nutrition notes, dated 08/12/14, indicated the resident received a mechanical soft diet with ground meat because she had lost her dentures. Another note, dated 05/13/14, also indicated a loss of dentures. Therapy notes, dated August 2014, indicated the resident had received therapy for cervical pain. There was no evidence knee pain had been addressed. During an interview with Employee #75, a nursing assistant (NA) on 09/17/18 at 1:20 p.m., The NA related he/she did not know the resident's dentures were missing, or of the resident's complaints of knee pain. She indicated the resident had received treatment from therap… | 2018-05-01 |
| 6191 | 6191 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 282 | D | 0 | 1 | O60P11 | Based on observation, policy review, medical record review, and staff interview, the facility failed to implement and follow the care plan for one (1) of two (2) Stage 2 sample residents reviewed for catheter use. The care plan indicated the resident's urinary catheter bag should be covered and kept off the floor. This had the potential to affect an isolated number of residents with a urinary drainage bag. Resident identifier: #91. Facility Census: 55. Findings include: a) Resident #91 Observations on 09/16/14 at 9:00 a.m., during an interview for Stage 1 of the Quality Indicator Survey, the resident's urinary catheter drainage bag lay on the floor in the resident's room. This was again observed at 2:02 p.m. and at 4:10 p.m. When Employee #37, the director of nursing, was shown the urinary drainage bag on the floor beneath the resident's chair at 9:10 a.m. on 09/17/14, she secured the urinary catheter bag to the bottom of the chair. Review of the resident's care plan, implemented on 08/17/14, found it included an approach of Keep drainage bag off the floor and covered for dignity. | 2018-05-01 |
| 6192 | 6192 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 309 | D | 0 | 1 | O60P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, and policy review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of three (3) residents reviewed for pain. The facility failed to accurately assess and identify pain, and failed to provide non-pharmacological interventions for a resident who voiced pain. Resident identifier: #6. Facility census: 55. Findings include: a) Resident #6 During an interview on 09/16/14 at 9:25 a.m., Resident #6 related she had been having discomfort in her legs, and still had knee problems. The resident also related she had occasional neck pain. Resident #6 indicated therapy had utilized heat therapy which was effective. Upon further inquiry, she said licensed nurses and nursing assistants did not provide non-pharmacological interventions for any of her pain. An interview with family member #1, on 09/17/14 at 9:50 a.m., revealed she had to follow up with the facility to ensure they intervened, after she informed the facility of the resident's complaint of pain. Family member #1 related she had told a nurse about the resident's complaint of pain in her neck and was told she would refer the resident to therapy. She said she called back and spoke with therapy, and they said she had not been referred. She came to the facility and during follow up on that date, the nurse completed the referral while she was there. Review of the July and August 2014 medication administration records revealed no evidence [MEDICATION NAME] was administered as per the as needed physician's orders [REDACTED]. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 08/05/14, indicated a resident interview was completed. It noted the resident voiced she had occasional pain which was rated as 05 during the five (5) day… | 2018-05-01 |
| 6193 | 6193 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 314 | D | 0 | 1 | O60P11 | Based on observation, a review of the Lippincott Nursing procedure manual, review of facility policy/procedure, and staff interview, the facility failed to provide treatment to a pressure ulcer in a manner to promote healing and prevent infection for one (1) of one (1) resident in the facility reviewed for the care area of pressure ulcers. The staff failed to ensure effective infection control techniques were employed while cleansing a wound creating a potential for the transfer of microorganisms into the wound. Resident identifier: #12. Facility Census: 55. Findings include: a) Resident #12 During a record review, it was identified Resident #12 had a Stage III pressure ulcer to her coccyx. Employee #50 (the treatment nurse) was observed providing treatment to this wound on 09/17/14 at 10:45 a.m. Employee #50 was observed to clean the wound after applying wound cleanser to a 4 x 4 dressing. She cleansed the outside around the wound first. Then, using the same 4 x 4 and the same area on the 4 x 4, the nurse wiped across the center of the wound. She did not use a different gauze for each cleansing stroke. The facility's policy and procedure for wound management titled Dressings. Dry/Clean last revised June 2005, was reviewed. The policy instructed in step #16 for cleansing the wound: If using gauze, use a clean gauze for each cleansing stroke. Clean from least contaminated area to the most contaminated area (usually from center outward). According to Lippincott Nursing Procedures (WOUND WISE: Basic wound cleaning step by step Nursing Made Incredibly Easy! September/October 2008 Volume 6 Number 5, Pages 30 - 31, found at www.nursingcenter.com/lnc/static?pageid= 4), to prevent contamination and potential infection when cleaning an open wound, such as a pressure ulcer, the area should be gently wiped in a circular motion starting directly over the wound and moving outward. Employee #50 was made aware of the observation of the technique used to clean the wound. She stated she was aware she cleaned the outside first but… | 2018-05-01 |
| 6194 | 6194 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 315 | D | 0 | 1 | O60P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the appropriate treatment and services to restore as much normal bladder function as possible. There were no interventions to decrease incontinence episodes for one (1) of two (2) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS) for the care area of urinary incontinence. The type and cause of the resident's urinary incontinence was not assessed. There was no toileting schedule or plan to decrease the episodes of incontinence for a resident who exhibited a potential for improvement. Resident identifier: #17. Facility Census: 55. Findings include: a) Resident #17 Resident #17 was admitted to the facility on [DATE]. Her initial Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/25/13, indicated the resident was frequently incontinent of bladder in Item H0300. According to the instructions provided on the MDS, this indicated there were seven (7) or more episodes of urinary incontinence, but at least one (1) episode of continent voiding in the last seven (7) days prior to the ARD. Section V of the MDS indicated the Care Area of Urinary Incontinence was triggered and needed to be reviewed further. It stated the location and date of the Care Area Assessment (CAA) documentation was the Urinary CAA summary assessment dated [DATE]. The Urinary CAA summary assessment was reviewed. The assessment did not provide a further assessment of this resident's incontinence. There was no assessment to indicate what type of urinary incontinence this resident was experiencing or any information to assist with identifying the cause of her incontinence. The analysis of findings stated only she had decreased mobility and received a diuretic. The most recent MDS, with an ARD date of 09/01/14, indicated the resident was frequently incontinent of bladder. Item H0200, regarding whether the resident was on a toileting program, was coded No. The care pl… | 2018-05-01 |
| 6195 | 6195 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 323 | D | 0 | 1 | O60P11 | Based on record review, observation, and staff interview, the facility failed to ensure the environment, for one (1) of two (2) sample residents in Stage 2 of the Quality Indicator Survey (QIS) reviewed for accidents, remained as free of accident hazards as possible and the resident received adequate supervision to prevent accidents. The facility did not ensure the resident's chair alarm was functioning properly to alert staff of the resident's need for assistance. Resident identifier: #71. Facility Census: 55. Findings include: a) Resident #71 On 09/17/14 at 1:45 p.m., a review of this resident's current medication administration record (MAR) found it did not include monitoring of her chair alarm to see if it was functioning properly every shift. An observation of Resident #71's wheelchair on 09/18/14 at 2:15 p.m., verified this resident had a chair alarm in place. On 09/18/14 at 2:30 p.m., a staff interview was conducted with Employee #12, registered nurse (RN). She explained the functioning of a bed and chair alarm was monitored every shift to make sure they were operating properly and documented on the MAR. She reviewed Resident #71's MAR and verified there was no documentation to ensure the resident's chair alarm was being monitored for proper functioning. | 2018-05-01 |
| 6196 | 6196 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 329 | D | 0 | 1 | O60P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's medication regimen was free of unnecessary medications for one (1) of five (5) residents reviewed. A resident received duplicate medication therapy for [MEDICAL CONDITION] reflux disease without adequate indications for their use. Resident identifier: Resident #41. Facility census: 55. Findings include: a) Resident #41 The medical record, reviewed on 09/16/14 at 3:48 p.m., indicated Resident #41 was admitted on [DATE]. The resident received three (3) medications for [MEDICAL CONDITION] reflux disease (GERD): [MEDICATION NAME] 20 milligrams (mg) by mouth (po) daily at bedtime, [MEDICATION NAME] DR (long acting) 40 mg po once a day, and [MEDICATION NAME] 10 mg po once a day. Employee #15, a licensed practical nurse, interviewed on 09/17/14 at 5:30 p.m., indicated staff would tell the nurse if there were changes in the resident's condition, and licensed staff assessed/evaluated on rounds and medication pass. She also related the resident was able to express herself. The nurse related medications were assessed for effectiveness through pharmacy review on a monthly basis, and more often if needed. She indicated staff monitored effects of medication to determine appropriate dose along with guidelines for administration. Further review of the medical record, on 09/17/14, at 2:00 p.m., revealed a monthly pharmacy review. No evidence was present to indicated the pharmacist addressed the use of duplicate therapy for the [DIAGNOSES REDACTED]. An interview with Employee #32 (LPN), on 09/18/14 at 2:45 p.m., revealed she did not know why Resident #41 received [MEDICATION NAME] DR, [MEDICATION NAME] and [MEDICATION NAME]; and did not know if it had been addressed with the doctor. An interview with the executive director, a registered nurse (RN), on 09/18/14 at 3:00 p.m., revealed she did not know why the resident was on the three (3) medications for the same diagn… | 2018-05-01 |
| 6197 | 6197 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 371 | E | 0 | 1 | O60P11 | Based on observation, staff interview, and policy review, the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to date and label food stored in the kitchen walk-in freezer; and a staff member did not properly sanitize her hands during the dining process in the day room. This had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Food storage During the initial tour of the kitchen, on 09/15/14 at 4:44 p.m., an observation found three (3) plastic bags containing food in the walk-in freezer. The bags of food were not labeled or dated. An interview with Employee #49 (dietary supervisor), at the time of the observation, revealed the bags contained crab cakes, barbecue patties, and breaded steak patties. Upon inquiry as to how she knew when they were opened or when they expired, she replied, I don't. They should have been labeled. b) On 9/15/14 at 6:20 p.m., the director of nursing was helping to deliver trays during the evening meal in the day room. She pushed her hair back from her face, then delivered trays from the cart to residents without washing her hands. | 2018-05-01 |
| 6198 | 6198 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 428 | D | 0 | 1 | O60P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of medical record review and staff interview, the pharmacist failed to report a medication irregularity to the attending physician and the director of nursing for one (1) of five (5) residents reviewed. The pharmacist failed to identify and report duplicate medication therapy which did not have clinical justification. Resident identifier: Resident #41. Facility census: 55. Findings include: a) Resident #41 The medical record, reviewed on 09/16/14 at 3:48 p.m., indicated Resident #41 received was admitted on [DATE] and received three (3) medications for gastroesophageal reflux disease (GERD): Pepcid 20 milligrams (mg) by mouth (po) daily at bedtime, Protonix DR (long acting) 40 mg po once a day, and Reglan 10 mg po once a day, for Employee #15, a licensed practical nurse, interviewed on 09/17/14 at 5:30 p.m., indicated medications were assessed for effectiveness through pharmacy review on a monthly basis, and more often if needed. Further review of the medical record, on 09/17/14, at 2:00 p.m., revealed a monthly pharmacy review. No evidence was present to indicate the pharmacist addressed the use of duplicate therapy for the [DIAGNOSES REDACTED]. Employee #12 (RN), interviewed on 09/18/14 at 3:20 p.m., reviewed the record and determined Resident #41 was admitted on all three (3) medications. When asked whether the pharmacist had identified the use of three (3) medications, the RN replied, To be honest, I'm surprised he didn't, he is usually really good about that. She further added, We usually try non-pharmacological interventions, like three (3) inch blocks or something like that. Employee #12 said she was going to ask the daughter about it. The RN returned about 3:35 and related she had spoken with the daughter and the daughter agreed to a medication reduction if the resident could tolerate it. She confirmed the pharmacist did not report irregularities regarding the use of duplicate therapy and/or by excessive dose (used longer than r… | 2018-05-01 |
| 6199 | 6199 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 441 | F | 0 | 1 | O60P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of disease and infection. Staff failed to perform hand hygiene when indicated and failed to follow isolation precautions consistent with accepted standards of practice. An ice scoop was placed inside cups in use by residents' during ice pass, and then stored the scoop in the ice chest. A staff member exited an isolation room while wearing personal protective equipment (PPE) and failed to adequately wash her hands. This had the potential to affect all residents. Facility census: 55. Findings include: a) Ice pass During a random observation on 09/16/14, between 10:15 a.m. and 10:45 a.m., Employee #3 (NA) passed ice to residents on the short hallway and the long hallway. The NA entered room [ROOM NUMBER], exited with the resident's drinking pitcher/drinking cup, opened the ice chest, removed the ice scoop from the ice and placed ice in the resident's cup, then placed the ice scoop into a holding container. She returned the water cup to the resident's room and exited again without sanitizing her hands. She passed ice in the same manner in Rooms #109 and #106. While passing ice for room [ROOM NUMBER], she placed the ice scoop inside of the resident's cup, then continued to use the scoop for other residents. While passing ice in room [ROOM NUMBER]b, Employee #3 added water to the pitcher before exiting the room to obtain ice. The NA turned the faucet on and off without utilizing a barrier, creating a potential for cross contamination. The resident in room [ROOM NUMBER]a required isolation precautions. The NA washed her hands, then turned off the faucet without utilizing a barrier, again creating a potential for cross contamination. Additionally, the NA only washed her hands about 10 seconds. Employee #3 entered ro… | 2018-05-01 |
| 6200 | 6200 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 469 | E | 0 | 1 | O60P11 | Based on observation and staff interview, the facility failed to ensure it maintained an effective pest control program so the facility was free of pests. Ant-like insects were observed in two (2) rooms during Stage 1 of the Quality Indicator Survey. This had the potential to affect more than a limited number of residents. Facility census: 55. Findings include: a) Ant-like insects During Stage 1 of the Quality Indicator Survey, the following were noted: -- Room 128 - Insects were crawling on the floor beside the bed closest to the window. -- Room 103 - Insects were crawling on the floor beside the bed closest to the window. b) During an interview with the housekeeping supervisor, Employee #43, on 09/17/14 at 3:10 p.m., she agreed the insects looked like ants and commented the residents often had food in their rooms. Employee #43 said a pest control service was provided by the facility and she would call them. | 2018-05-01 |
| 6605 | 6605 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2014-02-27 | 253 | E | 0 | 1 | UM8N11 | Based on observation and staff interview, the facility failed to ensure effective maintenance services. The physical environment was in poor repair with issues such as holes in walls, stained ceiling tiles, scuffed furniture, rust in the shower room, and missing baseboard. In addition, a shower room wall had a black substance, which had the appearance of mold. This had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) Observation of the facility during Stage 1 of the Quality Indicator Survey (QIS) revealed the following concerns: 1) Room B-12 The corner of the wall beside the bathroom had missing plaster and was scuffed and scratched. The wall beside the bathroom had deep scratches in the plaster and the television stand had chipped and scratched areas. 2) Room A-6 In room A-6, there were observations of cracked ceiling tile. Behind bed (B), an observation revealed a cracked wall and uneven plaster. The ceiling tile was cracked and the wall behind the B-bed had cracked and uneven plaster. In addition, an observation revealed a round area big enough to insert a pencil beside the call light mounted on the wall behind bed B. The nightstand and the television stand was scuffed and had missing veneer. 3) Room A-1 The vent under the window in room A-1 was taped with plastic wrap. The room also had stained ceiling tile. 4) Room A-3 Observation revealed the room had stained ceiling tile. 5) Room A-20 The two (2) bottom drawers on the wardrobe were off track and did not close. The floor tile beside the wardrobe had an indented area and a crack. The ceiling tiles were discolored. 6) Hallway on B-Unit The cove base molding across from the nurses' station was missing between the soiled and clean linen rooms. 7) Room B-11 An observation revealed a visible hole in the floor below the window. 8) B-Unit shower room The doorframe had rust around the shower door. The maintenance director (Employee #29) observed the identified issues on 02/26/14 at 3:00 p.m. No further info… | 2017-12-01 |
| 6606 | 6606 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2014-02-27 | 309 | D | 0 | 1 | UM8N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of one (1) residents who received [MEDICAL TREATMENT] treatment received the necessary care and services to maintain the highest practicable physical well-being. The resident had an order for [REDACTED]. Resident Identifier: #8. Facility Census: 57. Findings Include: a) Resident #8 On 02/26/14 at 10:39 a.m., a review of Resident #8's medical record revealed a physician's orders [REDACTED]. The date on the physician order [REDACTED]. It contained an order, Nepro (nutritional supplement) 8 oz (ounces) daily 4 days per week on non-[MEDICAL TREATMENT] days please do not include in 1000 cc FR (Fluid Restriction) daily. Further review of the medical record revealed a physician order, dated 01/23/14, which stated, Nepro four (4) times a day every sun (Sunday), tues (Tuesday), thu (Thursday), sat (Saturday) for CKD ([MEDICAL CONDITION]) Give 8 oz on non [MEDICAL TREATMENT] days per [MEDICAL TREATMENT] do not include in fluid restriction. The order was discontinued on 02/04/13. The medical record also contained a physician order, dated 02/04/14, which stated One time a day every sun, mon wed, fri for ckd give 8 oz daily on non [MEDICAL TREATMENT] days per [MEDICAL TREATMENT] do not include in fluid restriction daily. This order remained as the active order in Resident #8's medical record. A review of the Medication Administration Record [REDACTED] - 1/23/14: 5:00 p.m. and 9:00 p.m. - 1/25/14, 1/26/14, and 01/28/14: 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. - 02/1/14: 9:00 a.m., 5:00 p.m., and 9:00 p.m. - 02/02/14: 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. - 02/03/14: 9:00 a.m., 1:00 p.m., and 5:00 p.m. An interview, on 02/26/14 at 2:08 p.m., revealed Employee #50, director of nursing (DON), registered nurse (RN) confirmed the resident received 8 ounces of Nepro more often than she should have on 01/23/14, 01/25/14, 1/26/14, 1/28/14, 02/01/14, 02/02/14, and 02/03… | 2017-12-01 |
| 6607 | 6607 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2014-02-27 | 323 | E | 0 | 1 | UM8N11 | Based on observation and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible. The grab bar in the shower room on the A-hall was loose and moved easily with the slight touch of a hand. This had the potential to affect more than an isolated number of residents on the A-hall who used the shower room. Facility census: 57. Findings include: a) A-hall shower room Observation with the maintenance supervisor, Employee #29, at 3:00 p.m. on 02/26/14, found there was only one grab bar in the A-hall shower room. The grab bar was on the right side of the door leading out of the shower room. The grab bar was loose and moved up and down with the slight touch of a hand. Employee #29 said he would fix the bar. | 2017-12-01 |
| 6608 | 6608 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2014-02-27 | 463 | D | 0 | 1 | UM8N11 | Based on observation and staff interview, the facility failed to ensure one (1) of thirty (30) residents had a means of directly contacting caregivers. Nursing staff received resident calls through a pager communication system from resident rooms and toilet and bathing facilities. This resident did not have a functioning call system in her bathroom. Resident identifier: #5. Facility census: 57. Findings include: a) Resident #5 On 02/24/14 at 10:40 a.m., an observation in Resident #5's bathroom revealed a call system that did not function properly. Employee #39 (nurse aide) verified this call system did not work. The nurse aide had a pager designed to beep when residents pulled their call cords or pushed their call buttons. A demonstration of pulling the call cord in Resident #5's bathroom revealed the nurse aide's pager did not beep. Employee #39 also confirmed Resident #5 used her bathroom and was capable of using the call light. Employee #39 said if her pager did not alarm then she did not know a call light needed answered. All nursing staff carried pagers to alert them when call lights needed answered. Employee #39 said she would inform her supervisor the resident's bathroom call system did not work. | 2017-12-01 |
| 6609 | 6609 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2014-02-27 | 468 | E | 0 | 1 | UM8N11 | Based on observation and staff interview, the facility failed to ensure corridors were equipped with secured handrails. The A-Unit of the facility had handrails that were not securely affixed to the wall. This had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) Handrails on A-Unit Observation with the environmental services director, on 02/26/14, at approximately 3:00 p.m., found the handrail was loose between rooms A-17 and A-18 on the north hall, and the short hall on the A-unit. | 2017-12-01 |
| 6610 | 6610 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2014-02-27 | 514 | D | 0 | 1 | UM8N11 | Based on record review and staff interview, the facility failed to ensure medical records were complete and accurately documented, for one (1) of forty-nine (49) Stage 2 sample residents. A hospital discharge summary, which did not belong to Resident #30, was found in the resident's medical record. Resident identifier: #30. Facility census: 57. Findings include: a) Resident #30 The medical record review, at 10:30 a.m. on 02/25/14, for Resident #30, a male resident, revealed a female resident's discharge summary from a local hospital had been scanned into Resident #30's electronic medical record. An interview with Employee #50, the director of nursing, at 11:06 a.m. on 02/25/14, confirmed the discharge summary did not belong in Resident #30's medical record. | 2017-12-01 |
| 7317 | 7317 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 156 | D | 0 | 1 | KPNE11 | Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents selected for the liability notice and beneficiary appeal rights review were given information in writing when they were discharged from a skilled service covered by Medicare. Resident identifier: #20. Facility census: 51. Findings include: a) Resident #20 On 04/16/13 at 1:00 p.m., the billing clerk (Employee #74) assisted in a review of the liability notices and beneficiary appeal rights for three (3) residents. Two (2) of the three (3) residents selected for review were discharged to another skilled nursing facility. Resident #20 had refused to participate in the skilled therapy service. Employee #74 said the resident said she was too sick to participate. Employee #74 indicated she did not send the resident a written notice informing her of her discharge from a skilled service covered by Medicare. She said she did not think she had to send a written notice when the resident refused to participate. According to the Centers for Medicare and Medicaid Services (CMS) survey and certification letter 09-20: If a SNF provider believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable and necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services. | 2017-06-01 |
| 7318 | 7318 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 160 | D | 0 | 1 | KPNE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of financial records and staff interview, the facility failed to convey the resident's funds, and/or a final accounting of those funds, after the resident's death, to the individual or probate jurisdiction administering the individual's estate as provided by State law. This was found for one (1) of four (4) records reviewed for residents with personal funds deposited with the facility. Resident identifier: #66. Facility census: 51. Findings include: a) Resident #66 A review of the facility's financial records showing the balance in the resident trust accounts at the end of [DATE] revealed an account for one (1) resident who had expired on [DATE]. During an interview with Employee #74, the Billing Clerk, at 1:50 p.m. on [DATE], she stated Resident #66 had expired on [DATE], and a check for the balance of her account ($200.59) had been issued to the funeral home on [DATE], and another check for ($20.02 ) was sent to the funeral home on [DATE]. There was no evidence to reflect the probate jurisdiction administering the individual's estate had been issued a final accounting of the resident's personal funds or had approved the payments made by the facility from the resident's account. | 2017-06-01 |
| 7319 | 7319 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 225 | D | 0 | 1 | KPNE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, abuse/neglect policy review, and staff interview, the facility failed to ensure allegations of neglect were reported to the required entities, and investigated. One (1) of twenty-two (22) residents' medical records contained an allegation of neglect for which there was no evidence it had been thoroughly investigated or had been reported to the required State agencies. Resident identifier: #54. Facility census: 51. Findings include: a) On 04/18/13 at 10:00 a.m., a review of the medical record for Resident #54 revealed a skilled nursing note dated 01/26/13. The note included . Son states that he is not satisfied with care. States that physical therapy removed O2 (oxygen) NC (nasal cannula) and took resident to therapy. Son states that resident needs her O2. The medical record revealed the resident had a [DIAGNOSES REDACTED]. The director of nursing (Employee #47) indicated the facility had no documentation to show they had investigated or reported the allegation of neglect. The abuse policy procedure revealed the following statement The (facility name) will ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the appropriate authorities and to other officials in accordance with state law through established procedures (including to the state survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The facility did not have evidence of an investigation, nor did they have evidence the allegation was reported to the State survey and certification agency. | 2017-06-01 |
| 7320 | 7320 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 226 | D | 0 | 1 | KPNE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and staff interview, the facility failed to ensure it implemented its abuse and neglect policy. The facility failed to investigate and report an allegation of neglect. Resident identifier: #54. Facility census: 51. Findings include: a) On 04/18/13 at 10:00 a.m., a review of the medical record for Resident #54 revealed a skilled nursing note dated 01/26/13. The note included . Son states that he is not satisfied with care. States that physical therapy removed O2 (oxygen) NC (nasal cannula) and took resident to therapy. Son states that resident needs her O2. The medical record revealed the resident had a [DIAGNOSES REDACTED]. The director of nursing (Employee #47) indicated the facility had no documentation to show they had investigated or reported the allegation of neglect. The abuse policy procedure revealed the following statement The (facility name) will ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the appropriate authorities and to other officials in accordance with state law through established procedures (including to the state survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The facility did not have evidence of an investigation, nor did they have evidence the allegation was reported to the State survey and certification agency as required by their policy. | 2017-06-01 |
| 7321 | 7321 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 272 | D | 0 | 1 | KPNE11 | Based on medical record review and staff interview, the facility failed to ensure the minimum data set (MDS) assessments for one (1) of twenty-two (22) residents accurately reflected the resident's weight. Resident identifier: #35. Facility census: 51. Findings include: a) Resident #35 On 04/17/13 at 4:00 p.m., review of the minimum data set for a re-admission/return assessment, with an assessment reference date (ARD) of 12/15/12, found Section K (swallowing/nutritional status), item K0200 (weight) identified the resident weighed 168 lbs. The discharge/return not anticipated assessment, with an ARD of 12/22/13, also listed the resident's weight as 168. The dietitian (Employee #97) had completed a progress note for the resident on 12/10/12. The dietitian listed the resident's current body weight as 153.4 lbs. The weight record also listed the resident's weight as 153.4 on 12/10/12. On 04/17/13 at 5:00 p.m., Employee #1 (registered nurse) reviewed the above information and agreed the facility did not record the accurate weight on the two (2) MDS assessments. . | 2017-06-01 |
| 7322 | 7322 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 278 | D | 0 | 1 | KPNE11 | Based on medical record review and staff interview, the facility failed to ensure one (1) of twenty-two (22) residents had a minimum data set (MDS) assessment that correctly documented the resident's weight. Two (2) MDS assessments did not reflect the resident's accurate weight. Resident identifier: #35. Facility census: 51. Findings include: a) Resident #35 On 04/17/13 at 4:00 p.m., review of the medical record for Resident #35 noted an MDS re-admission/return assessment, with an assessment reference date (ARD) of 12/15/12. Section K (swallowing/nutritional status), item K0200 (weight) identified the resident weighed 168 lbs. The discharge/return not anticipated assessment, with an ARD of 12/22/13, also listed the resident's weight as 168. The dietitian (Employee #97) completed a progress note for the resident on 12/10/12. The dietitian listed the resident's current body weight as 153.4 lbs. The weight record listed the resident's weight as 153.4 on 12/10/12. On 04/17/13 at 5:00 p.m., Employee #1 (registered nurse) reviewed the above information and agreed the facility did not record the accurate weight on the two (2) MDS assessments listed above. . | 2017-06-01 |
| 7323 | 7323 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 280 | D | 0 | 1 | KPNE11 | Based on medical record review and staff interview, the facility failed to notify the resident and/or the resident's representative of a care plan meeting. One (1) of twenty-two (22) Stage 2 sample residents was affected. Resident identifier: #53. Facility census 51. Findings include: a) Resident #53 Medical record review, on 04/16/13 at 1:00 p.m., revealed the care plan meeting for Resident #53 was held on 02/26/13. No documentation was found to indicate the resident and/or the resident's representative had been invited and/or informed of the care plan meeting. During an interview with Employee #54, the social worker (SW), on 04/16/13 at 2:40 p.m., it was confirmed she had not notified the resident and/or the resident's representative of the care plan meeting scheduled on 02/26/13. | 2017-06-01 |
| 7324 | 7324 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 371 | F | 0 | 1 | KPNE11 | Based on observation and staff interview, the facility failed to ensure the emergency food supply was stored under sanitary conditions. The ceiling of the room where the facility stored the food had sustained a water leak. This had the potential to affect all residents. Facility census: 51. Findings include: a) On 04/17/13 at 11:00 a.m., the dietary manager (Employee #27) accompanied a tour of the area where the emergency food supply was stored. The emergency food supply was stored on the first floor of the assisted living unit. Observations of the ceiling in the room where the food was stored revealed two (2) areas where the ceiling had leaked. One area was larger than the other area. This larger area surrounded a light fixture. The ceiling had turned yellow, brown and grey. Parts of the paint/plaster had fallen down. The paint/plaster was bubbled and cracked. A large section of the paint/plaster had fallen and exposed another layer of the ceiling, which appeared grey with black specs. On 04/17/13 at 11:15 a.m., the dietary manager indicated she had requested repairs for this area and agreed this did not provide the most sanitary environment for storing food. | 2017-06-01 |
| 7325 | 7325 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 428 | D | 0 | 1 | KPNE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the pharmacist's recommendation for a dose reduction for Xanax, with which the physician had agreed, was acted upon. This affected one (1) of ten (10) residents reviewed for unnecessary medications. Resident identifier: #40. Facility census: 51 Findings include: a) Resident #40 A record review was completed for Resident #40 on 04/17/13 at 10:39 a.m. The review revealed the pharmacist had made a recommendation to evaluate the current dose of Xanax 0.5 milligrams 3 times daily on 03/11/13. The recommendation was to consider a gradual taper of this medication to ensure this resident was receiving the lowest possible effective and optimal dose. On 03/20/13, the attending physician agreed to the dose reduction of Xanax, but the response did not include an order for [REDACTED].>An interview was conducted, on 04/17/13 at 11:45 a.m., with Employee #40, the director of nursing. She reported the staff failed to carry out the recommended dose reduction of Xanax for this resident. | 2017-06-01 |
| 7326 | 7326 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-04-18 | 441 | F | 0 | 1 | KPNE11 | Based on observation, staff interview, and policy review, the facility failed to store residents' respiratory equipment in a sanitary manner. This practice affected seven (7) of twelve (12) residents observed who had respiratory care needs. Resident identifiers: #8, #13, #33, #40, #41, #45, and #81. Facility census: 51. Findings include: a) Residents #8, #13, #33, #40, #41, #45 and #81 On 04/15/13 at 12:32 p.m., during the initial tour of the facility, it was discovered Residents #8, #13, #33, #40, #41, #45 and #81 had nebulizer mouthpieces improperly stored after their breathing treatments. The mouthpieces were observed lying uncovered on the residents' nightstands where they were potentially exposed to environmental contaminants and/or could transfer organisms from the resident's respiratory tract to other objects. An interview was conducted on 04/16/13 at 9:14 a.m. with Employee #76, a Registered Nurse (RN) and Infection Control Coordinator. She verified the staff failed to store the residents' nebulizer mouthpieces in a sanitary manner to prevent transmission of bacteria between uses. On 04/16/13, Employee #40, the Director of Nursing (DON) provided the procedure for administering medications through a small (handheld) nebulizer. The policy for handheld nebulizer units included instruction that after each breathing treatment, the nebulizer mouthpiece was to be stored in a plastic bag with the resident's name and date on the bag. | 2017-06-01 |
| 7985 | 7985 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2013-11-08 | 465 | F | 1 | 0 | PPO411 | Based on observation, resident interview, and staff interview, the facility failed to provide a functional, sanitary, and comfortable environment for residents, staff and the public. Twenty-three (23) of twenty-three (23) residents' toilets observed were leaking and soiled around their bases. In addition, there was a lingering foul smelling odor in the toilet rooms which permeated throughout the building. This practice had the potential to affect all residents. Facility census: 59. Findings include: a) Upon entry into the facility, the purpose of the complaint investigation was discussed with the Administrator and the Home Office Environmental Coordinator (HOEC) They stated they were aware of the toilet issues. b) Observations of the toilets revealed they had been sealed at the base with silicone. The toilets were smaller than the hole cut out of the floor tile, creating a leveling problem. Some rooms had a black substance around the base of the toilet. The silicone was wet in some rooms. There was a consistent foul odor within the toilet rooms and throughout the facility. c) Rooms A02, A03 and A05, A04 and A06, A07 and A09, A08 and A10, A11, A12 and A14, A15, A16 and A17, A18 and A19, A20 and A21, A23 and A24, A25, B01 and B03, B02 and B04, B05 and B07, B06 and B08, B09 and B10, B11 and B12, B13 and B14, and B15: The twenty-one (21) toilets in the bathrooms used by residents in these rooms showed signs of leakage. The floor tile had heavy stains that appeared to permeate from below. The floor tile was cut to the outline of the toilet base instead of running tight to the toilet flange. The toilet base was sealed with silicone. The visual inspection revealed soiled tile, base and caulking. It could not be determined if this was from sewage leak, the result of poor housekeeping practices, or both. 2) Room A22 The toilet in the bathroom used by residents in this room showed signs of leakage. The floor tile had heavy stains that appeared to permeate from below. The floor tile was cut to the outline of the toilet base… | 2016-11-01 |
| 8018 | 8018 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-11-19 | 225 | D | 1 | 0 | OGFK11 | Based on a review of the abuse/neglect reportable allegations, the facility's abuse policy and procedure, and staff interview, the facility failed to ensure allegations of abuse/neglect were thoroughly investigated and reported to the appropriate State agencies. A review of six (6) allegations of abuse/neglect revealed the facility did not report or investigate one (1) allegation of neglect. Resident identifier: #5. Facility census: 48. Findings include: a) Resident #5 On 11/19/13 at 2:00 p.m., a review of the abuse/neglect reportable allegations revealed the facility had substantiated an allegation of neglect on 07/25/13. The facility determined Employee #86 (nurse aide) had neglected Resident #9 on 07/24/13. The facility terminated Employee #86 (nurse aide) because of this substantiation of neglect. A note dated 07/24/13, in the investigation file authored by the director of nursing (Employee #43), stated Employee #86 (nurse aide) was terminated on this day due to neglect of Resident care. Residents on her assigned list were found to be wet and uncared for from the oncoming shift. Social Worker had witnessed a resident in a social setting whose pants were saturated with urine at shift change and employee had already left. She was also informed by staff members of other Residents who had been neglected to be cared for by this c.n.a. (nurse aide). On 11/19/13 at 2:45 p.m., the social worker (Employee #53) was asked about the note she had written regarding neglect of residents by Employee #86. She said she had not reported the allegation of neglect to the State agencies and had not investigated any other residents who may have been neglected by Employee #86. At 3:00 p.m., the administrator (Employee #48) and director of nursing (Employee #43) said Employee #72 might have additional information related to the substantiated findings of neglect against Employee #86. An interview with Employee #72 (registered nurse), on 11/19/13 at 2:30 p.m., revealed she had worked on 07/24/13, the day of the incident. She said she w… | 2016-11-01 |
| 8019 | 8019 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-11-19 | 226 | D | 1 | 0 | OGFK11 | Based on a review of the abuse/neglect reportable allegations, review of the facility's abuse policy and procedure, and staff interview, the facility failed to operationalize its abuse policy and procedure. The facility failed to ensure all allegations of abuse/neglect were thoroughly investigated and reported in accordance with its policy. A review of six (6) allegations of abuse/neglect revealed the facility did not report alleged neglect by a nurse aide. Additionally, the facility did not conduct a thorough investigation the alleged neglect. Resident identifier: #5. Facility census: 48. Findings include: a) Resident #5 On 11/19/13 at 2:00 p.m., a review of the abuse/neglect reportable allegations revealed the facility had substantiated an allegation of neglect on 07/25/13. The facility determined Employee #86 (nurse aide) had neglected Resident #9 on 07/24/13. The facility terminated Employee #86 (nurse aide) because of this substantiation. A note dated 07/24/13 in the investigation file authored by the director of nursing (Employee #43) stated Employee #86 (nurse aide) was terminated on this day due to neglect of Resident care. Residents on her assigned list were found to be wet and uncared for from the oncoming shift. The Social Worker had witnessed a resident in a social setting whose pants were saturated with urine at shift change and the employee had already left. She was also informed by other staff members of other Residents who had been neglected to be cared for by this c.n.a. (nurse aide). The social worker (Employee #53) was asked about this occurrence on 11/19/13 at 2:45 p.m. She said she had not reported or investigated any other residents who may have been neglected by Employee #86. At 3:00 p.m., the administrator (Employee #48) and director of nursing (Employee #43) said Employee #73 might have additional information related to the substantiated findings of neglect against Employee #86. An interview with Employee #73 (registered nurse) on 11/19/13 at 2:30 p.m. revealed, she worked on 07/24/13, th… | 2016-11-01 |
| 8020 | 8020 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-11-19 | 253 | E | 1 | 0 | OGFK11 | Based on observation and staff interview the facility failed to ensure it maintained a safe, sanitary environment for residents. Residents' furniture had scratches and areas where the finish had worn off exposing the wood surface. The exposed wood surfaces could not be sanitized effectively. Sixteen (16) of thirty-one (31) resident rooms had furnishings that could not be cleaned and sanitized. Room numbers: #131, #114, #118, #126, #104, #106, #116, #127, #129, #123, #121, #124, #119, #132, #122, and #128. Facility census: 48. Findings include: On 11/19/13 at 10:45 a.m., observations of furniture in resident rooms revealed the following issues: a) Room #131: The finish was off the wooden drawers at the sink. The drawers at the sink had many scratches and gouges. The wood surface was worn off on the footboard of one of the beds leaving particle board exposed. b) Room #118: Resident #48's over-bed-table had the finish worn off which left the particle board exposed. The sink had brown stains in the basin. The counter top around the sink had the finish worn off and was discolored. The drawers at sink had wood exposed from several scratches/gouges. The footboard of the bed had the wooden finish worn off which left the particle board exposed. Room #116: The footboard of the bed had the finish worn off with the wood/particle board exposed. Room #127: The wood finish was worn off the drawers at the sink. The drawers had several scratches and gouges. Room #129: The finish was worn off the wood on the drawers on the sink. This left the wood exposed. There was a chip out of the countertop, particle board exposed Room #123: The chair in the room had the finish worn off the arms. The drawers at the sink had the wood finish worn off. The drawers had scratches/gouges, which left the wood exposed. Room #121: The finish was worn off the wooden sink drawers. The wooden drawers had numerous scratches/gouges. Room #124: The finish was worn off the wooden drawers at the sink. The drawers had several scratches/gouges. Room #119: Reside… | 2016-11-01 |
| 8031 | 8031 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2012-08-07 | 225 | D | 0 | 1 | CCLH11 | Based on review of sampled personnel records, staff interview, and review of the facility's abuse policy and procedures, the facility failed to make reasonable efforts to uncover information that would indicate an individual was unfit for service as an employee of a nursing home. The facility failed to adequately screen individuals for adverse actions by applicable professional licensing boards, and/or findings entered into the State nurse aide registry concerning abuse, neglect, or misappropriation of resident property before hiring. This was true for two (2) of ten (10) employee personnel files reviewed. Employee identifiers: #27 and #35. Facility census: 53. Findings include: a) Employee #27 Review of the personnel record of Employee #35 found this individual was employed by the facility as a licensed practical nurse on 10/19/2010. An interview with the administrator and the business office assistant, Employee #40, on 08/07/12 at 11: 00 a.m., found the facility was unable to provide verification this employee had been checked through the State nurse aide registry for any potential history of abuse, neglect, or misappropriation of resident property. The administrator was also unable to provide evidence Employee #27's nursing license was in good standing before employment. b) Employee #35 Employee #35 was employed by the facility, on 05/07/12, as an environmental service assistant. An interview with the administrator and the business office assistant, Employee #40, on 08/07/12 at 11:00 a.m., found the facility was unable to provide verification this employee had been checked through the State nurse aide registry for any past history of abuse, neglect, or misappropriation of resident property. c) Review of the facility's policy for, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident's/Reporting and investigation, found, section D, Procedures: The facility will screen potential new employees for a history of abuse, neglect or mistreating resident. This includes checking with the appro… | 2016-10-01 |
| 8032 | 8032 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2012-08-07 | 241 | D | 0 | 1 | CCLH11 | Based on observations, the facility failed to maintain dignity during the dining experience for one (1) of three (3) residents. A resident had to sit and watch while the other residents at the table were fed by staff. Resident identifiers: #19, #37, and #20. Facility census: 53. Findings include: a) Resident #19 Observation of the noon meal, on 07/30/12, found Residents #19, #37, and #20 seated at the same table. Each resident had a tray, but Resident #19 was not being fed. Employee #41 (nurse aide) was feeding Residents #37 and #20. Residents #37 and #20 consumed their entire meal before another employee came in to feed Resident #19. Resident #19's tray was sitting in front of her during this time, but she had no assistance with her meal until the second aide came into the dining area. | 2016-10-01 |
| 8033 | 8033 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2012-08-07 | 253 | E | 0 | 1 | CCLH11 | Based on observations and staff interview, the facility failed to ensure the floor tiles were in good repair in the A-hall shower room. This had the potential to affect more than a limited number of residents on A Floor who used this shower room. Facility census: 53. Findings include: a) On 07/31/12 at 11:15 a.m., observations of the A Hall shower room revealed severely cracked and missing tile work in the entryway and throughout the shower room floor. This would inhibit effective cleaning and sanitization of the area. On 08/01/12 at 1:45 p.m., Employee #16, the unit charge nurse, verified the cracked tile work and missing tiles. | 2016-10-01 |
| 8034 | 8034 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2012-08-07 | 257 | E | 0 | 1 | CCLH11 | Based on observation, resident interview, and staff interview, the facility failed to ensure comfortable and safe environmental temperatures were maintained in resident rooms on the B wing of the facility. During the initial tour of the facility, rooms were observed to be very warm. Residents stated they were not comfortable with the room temperatures. Resident identifiers: Residents #64, #28, #30, and #84. Facility census: 53. a) Resident #64 During the initial tour of the facility, on 07/30/12 at 12:50 p.m., it was noted the hallways and resident rooms on B wing were very warm. The afternoon sun was coming in the windows at that time. In the hallway, a thermostat was observed with a reading of eighty degrees (80). Resident #64 was observed in her room awake. With resident permission the room was entered and the resident was questioned regarding the environmental temperature. This resident stated she was very hot. She also voiced having a red rash on her back which started when it got hot in the facility a couple weeks ago. b) Resident #28 This resident was also interviewed regarding the environmental temperatures. She commented, at 2:28 p.m. on 07/30/12, she was too hot, and added, the fan don't help, it's been hot awhile. c) Resident #30 At 2:22 p.m. on 07/30/12, when asked about the environmental temperatures, this resident said she was burning up. d) Resident #82 At 2:30 p.m. on 07/30/12, this resident also voiced being too hot. The resident stated it had been that way awhile. e) At 2:40 p.m., Employee #60 (Environmental Supervisor), was asked to obtain environmental (air) temperatures. This employee, used an infrared gun device to measure the temperature in Resident #64's room. A reading of 89.4 degrees was obtained. (Infrared gun devices measure surface temperatures which may or may not coincide with ambient temperatures.) This employee confirmed this device was being the device used to check temperatures. On 07/31/12, in the morning, during a random tour of B wing, it was observed that all resident rooms … | 2016-10-01 |
| 8035 | 8035 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2012-08-07 | 323 | D | 0 | 1 | CCLH11 | Based on observation and staff interview, the facility failed to ensure residents were provided an environment free of accident hazards. Observations found the grab bars were loose in two (2) resident bathrooms. Resident identifiers: #52 and #37. Facility census : 53. Findings include: a) Residents #52 and #37 During Stage 2 of the survey, observations were made in room A-8A and room A-21A. Both Residents #52 and #37 used the grab bars to assist themselves in transferring on and off of the toilet. The grab bars next to the toilets were found to be loose and unstable. On 08/07/12, at approximately 9:15 a.m., Employee #63 (administrator) and Employee #60 (environmental supervisor) also observed both sets of grab bars. Employee #60 stated, they are all flexible, this is how they come from the manufacturer. She further added only two (2) rooms had grab bars in the facility. On 08/07/12, at approximately 9:45 a.m., Employee #60 was asked for the manufacturer's instructions for the grab bars. At approximately 3:00 p.m., on 08/07/12, the information requested still had not been provided by the facility. | 2016-10-01 |
| 8358 | 8358 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-08-16 | 441 | D | 1 | 0 | 2RNY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure staff practiced infection control techniques to prevent the spread of disease and infection. Staff failed to perform handwashing and glove changes when indicated during dressing changes on residents with wounds and infections. Additionally, a nurse put clean gloves in her potentially contaminated pocket, then used them during a dressing change. Additionally, the gloves were retrieved from her pocket which was underneath an isolation gown, potentially transferring pathogens to her uniform pocket. Two (2) of the seventeen (17) residents on the sample, chosen from the fifty-two (52) residents in the facility, were affected. Resident identifiers: #22 and #11. Facility census: 52. Findings include: a) Resident #22 During a treatment observation, on 08/14/13 at 10:10 a.m., Employee #63, a licensed practical nurse, and Employee #21, a licensed practical nurse (LPN), performed the dressing change on a resident in contact isolation for Clostridium difficile. Employee #63 gathered the dressing supplies from the treatment cart in the hallway outside of the resident's room and donned a pair of gloves and personal protective equipment and entered the resident's room. Employee #63 was observed placing gloves into her uniform top under her isolation gown. The dressing supplies were then placed on the bedside table without cleaning the area or placing a barrier. Employee #63 proceeded to remove a soiled dressing from Resident #22's left ankle that was visibly soiled with stool. She then cleaned the area with normal saline and dried it with a gauze pad. The LPN continued the dressing change with the same pair of gloves and reapplied a clean dressing to the ankle. This created a potential for transfer of microorganisms from the soiled dressing to the wound and to the clean dressing. After finishing the dressing to the ankle, the LPN then picked the call light up from the fl… | 2016-07-01 |
| 9116 | 9116 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2011-09-22 | 156 | E | 0 | 1 | REFP12 | Deficiency Text Not Available | 2016-02-01 |
| 9117 | 9117 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2011-09-22 | 170 | B | 0 | 1 | REFP11 | Based on an interview with the president of the resident council (Resident #1) and staff interview, the facility failed to afford residents with the right to promptly receive mail. The facility did not distribute resident mail on Saturdays, although mail was available for delivery to the facility on this day of the week. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 50. Findings include: a) An interview with the president of the resident council (Resident #1), on the afternoon of 09/14/11, elicited that the residents did not receive mail on Saturdays. An interview with the facility's bookkeeper (Employee #22), on the morning of 09/15/11, confirmed the facility does not distribute mail to residents on Saturdays. Employee #22 stated they have the post office hold the mail until Monday, in case the mail contains any money. According to Employee #22, the facility has both delivery at the facility and a post office box, and they do not check the post office box for mail on Saturdays. Mail is delivered to the front office, sorted, and given to the activity director to distribute to the residents. An interview with the activities director (Employee #38), at 9:25 a.m. on 09/15/11, revealed she does not go to the post office on Saturdays and mail is not delivered to the facility due to no one being in the front office to receive it. She agreed she did not check the post office box on Saturdays. | 2016-02-01 |
| 9118 | 9118 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2011-09-22 | 225 | E | 0 | 1 | REFP11 | Based on review of sampled employees' personnel records, review of facility documents, and staff interview, the facility failed, for two (2) of five (5) sampled employees, to make reasonable efforts to screen for criminal convictions in other states in which they had lived and/or worked, to ensure these individuals were not unfit for employment in a nursing facility. Employee identifiers: #16 and #75. Additionally, the facility failed to immediately report (to State officials in accordance with State law), thoroughly investigate, and/or take appropriate corrective action for four (4) of twelve (12) allegations of abuse / neglect. Resident identifiers: #64, #30, #16, and #22. Facility census: 50. Findings include: a) Employees #16 and #75 Review of sampled employees' personnel files, with Employee #55 on the afternoon of 09/19/11, found the facility failed to conduct criminal background checks in the previous states where Employees #16 and #75 had previously worked. -- b) Resident #64 Review of facility documents found that, on 06/15/11, three (3) nursing assistants were overheard discussing Resident #64's genitals in a public area of the facility. The staff members were alleged to have identified the resident by name and make explicit and embarrassing remarks about his penis within the hearing range of other residents and staff members. Further review found the facility failed to report this allegation of abuse, failed to conduct a thorough investigation to identify the individuals involved, and failed to take corrective action to assure this abusive behavior did not continue. -- c) Resident #33 Review of facility documents found that, on 05/12/11, a nursing assistant (Employee #52) was alleged to have tilted Resident #33's wheelchair backwards and frightened her. Resident #33 reported the nursing assistant scared her and she (the resident) thought she was going to fall out of her chair. Further review found no evidence the facility reported this incident as required by State law, nor was a thorough investigation… | 2016-02-01 |
| 9119 | 9119 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2011-09-22 | 246 | D | 0 | 1 | REFP12 | Based on observation, resident interview, and staff interview, the facility failed to ensure one (1) of twelve (12) residents resided in an environment that provided reasonable accommodations of individual needs and preferences. One (1) of twelve (12) residents had bedroom furnishings that were arranged in a manner that did not allow for independent functioning based on the resident's own needs and preferences. Resident #34 did not have access to her chest of drawers where many of her personal belongings and snacks were kept. Resident identifier: #34. Facility census: 50. Findings include: a) Resident #34 On 12/12/11, at approximately 2:00 p.m., a tour of the facility revealed Resident #34's bed was pushed up against her chest of drawers. The bed had wheels and had been pushed up against the chest and the wheels locked. The bed was positioned to face towards the window in the room. The resident's roommate had a bed that was positioned facing the sink and closet door. The director of nursing (DON) Employee #46 said Resident #34's bed was positioned by the wall, facing out toward the window to make more space in the room. The DON said Resident #34 did store personal items and snacks in the chest. On 12/12/11, at approximately 2:00 p.m., Resident #34 sat facing her bed watching her television. She said she could not get into her chest of drawers. Employee #18 (nurse aide) said the resident's bed was positioned against the chest of drawers because the resident might injure herself getting into the chest. On 12/12/11, at approximately 3:00 p.m., an observation of Resident #34's room revealed the bed had been moved to face in the same direction as the roommate's bed and the chest was moved against the wall which allowed the resident access to the items stored in the chest. On 12/12/11, at approximately 3:15 p.m., Employee #35 (laundry/housekeeping) said the nurse aide had brought the issue to her attention and they had moved the room around to give the resident access to her chest of drawers. Employee #35 said the nurs… | 2016-02-01 |
| 9120 | 9120 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2011-09-22 | 250 | D | 0 | 1 | REFP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and family interview, the facility failed to provide medically-related social services to one (1) of forty-five (45) Stage II sampled residents. The facility failed to offer provision of assistance to Resident #66 and her family in attending the funeral the resident's spouse. Additionally, the facility failed to conduct a thorough social history for one (1) of forty-five (45) Stage II sample residents in order to identify and assist in meeting unmet social service needs. Resident identifiers: #66 and #22. Facility census: 50. Findings include: a) Resident #66 On [DATE] at 11:50 a.m., observations were made of the difficulties family members experienced when attempting to transfer Resident #66 from a wheelchair to the front seat of a passenger car. The son was observed to struggle to lift his mother into the car. The resident's husband, who had shared a room in the facility with Resident #66, had died on [DATE], and family members were transporting her to his funeral. No staff members were present to assist the family in transferring the resident into the car. An interview with Family Member #1 revealed the facility had offered no assistance with arrangements in assuring Resident #66 was able to attend her husband's funeral. The family member stated Resident #66 was paralyzed on one (1) side and was very heavy. According to this family member, the facility offered no assistance other than getting the resident dressed, and the family had to buy a transport chair in order to wheel the resident into the church for the funeral. - Review of Resident #66's medical record found a quarterly minimum data set assessment (MDS), with an assessment reference date (ARD) of [DATE], identified the resident required the extensive assistance of two (2) or more staff for transfers, she had limited voluntary range of motion in the upper and lower extremities on one side, and she weighed 174 pounds. - During an interview on [… | 2016-02-01 |
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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 );