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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11482 | 11482 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 371 | F | UFEY11 | Based on observations and staff interview, the facility failed to assure foods were served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 113. Findings include: a) At 2:30 p.m. on 01/05/09, observations, during the initial tour of the dietary department, revealed two (2) trays of cups and five (5) trays of cereal bowls; the cups and bowls were inverted on a synthetic shelving mat on flat trays prior to air drying. The cups and bowls were observed with trapped moisture, creating a medium for bacterial growth. The assistant dietary manager (Employee #45) was present and confirmed the identified problem. b) Observation with the dietary manager (Employee #42), on the afternoon on 01/07/09, again revealed inverted cups on a flat tray with a shelving mat which prevented the cups from proper air drying. The tray was observed under the area where the residents' food trays were served in the dining room. . | 2014-02-01 | ||
| 11483 | 11483 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 441 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review, staff interview, resident interview, and review of the infection incidence rate reports, the facility did not maintain an effective infection control program whereby infectious organisms leading to urinary tract infections (UTIs) were identified. Subsequently, the facility had no data by which analyze infection control data for trends and clusters. Organisms were not identified on the infection incidence log, nor were they tracked for infection control purposes. There was no evidence that clusters were identified. This was evident for four (4) of twenty (20) sampled residents. Resident identifiers: #11, #65, #75, and #35. Also, Resident #97 reported improper perineal care that could potentially cause a UTI from fecal contamination. Facility census: 113. Findings include: a) Residents #11 and #85 Resident #11 experienced repeated UTIs colonized with Escherichia coli (E. coli), bacteria found in feces. Record review revealed positive urine cultures for E. coli on the following dates: 05/18/08, 06/21/08, 08/28/08, 10/20/08, 12/07/08. Other organisms cultured included Alpha Streptococcus and [MEDICATION NAME] species on 07/25/08. Resident #11's roommate, Resident #85, also experienced UTIs as evidenced by positive urine cultures of E. coli with colony counts greater than 100,000 for the following dates: 09/23/08 and 11/03/08. Resident #85 also had a UTI identified in the emergency roiagnom on [DATE] (which was treated with Cipro), but the facility was unable to produce that culture report. Review of the facility's most recent quarter's infection incidence rate report (October, November, and December 2008) found Resident #11's E. Coli infections were not recorded for either October or December. With permission, perineal care was observed for Resident #85 on 01/07/09 at 1:45 p.m., after an episode of urinary incontinence. The nursing assistant used a [MEDICATION NAME] Care body wash / shampoo product for cleansing.… | 2014-02-01 | ||
| 11484 | 11484 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 328 | E | UFEY11 | Based on random observation, staff interview, and policy review, the facility failed to ensure that residents received proper care for the special service of respiratory care as per facility policy. This was evident for four (4) of six (6) residents on the 300 Hall (Residents #2, #21, #26, and #108) and three (3) residents on the 400 Hall (Residents #48, #62, and #105), whose oxygen delivery supplies were not being changed weekly in accordance with facility policy. Facility census: 113. Findings include: a) Residents #2, #21, #26, and #108 During initial tour of the 300 Hall on 01/05/09 at approximately 2:30 p.m., observation found four (4) of the six (6) residents on that hall had oxygen (02) concentrators with oxygen delivery tubing dated 12/20/08. This was true for Residents #2, #21, #26, and #108. Resident #108 also had a nebulizer tubing and mask dated 12/20/08. (A fifth resident was receiving oxygen but refused the surveyor admittance into her room.) These findings were reported to the nurse (Employee #27) at approximately 2:55 p.m. 01/05/09, who reported that oxygen tubing was to be changed weekly. After checking the above referenced residents, she said she would see they were taken care of and would notify the nurse covering the 300 Hall. b) Residents #48, #62, and #105 On the morning of 01/07/09, observation found two (2) residents on the 400 Hall (Residents #48 and #62) with had no dates on their oxygen tubings. Also on 400 Hall, Resident #105 had a nebulizer tubing dated 12/02/08. These findings were reported, and the tubings were shown to the nurse (Employee #35). When asked who typically changed the oxygen tubing, she replied they were changed weekly, and that Employee #16 usually changed them. c) On 01/06/09 at approximately 2:00 p.m., the facility's Oxygen Administration policy was reviewed. In the revised January 2006 Respiratory Practice Manual, under Section 6.2.1. Oxygen Administration, the policy stated: "Label nasal cannula (also humidifier) with resident name, date, and liter flow." Review o… | 2014-02-01 | ||
| 11485 | 11485 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 164 | E | UFEY11 | Based on observation, resident interview, confidential resident group interview, and staff interview, the facility failed to maintain resident privacy during showers. This was evident for three (3) of twenty (20) sampled residents and one (1) anonymous resident at the confidential resident group meeting. Resident identifiers: #51, #11, and #85. Facility census: 113. Findings include: a) Resident #51 During an interview on 01/06/09 at approximately 3:00 p.m., Resident #51 reported a lack of privacy in the shower room. She stated she was able to see the buttocks and breasts of other female residents, and that she, too, was exposed to another person in the adjoining shower. There was a big curtain separating the doorway from the shower stalls, but she stated you could see around the curtain where it was not fully block the view. b) Resident #11 On 01/07/09 at 9:25 a.m., Resident #11 was observed during a shower with her permission. She was in the left shower stall being bathed by a nursing assistant, while another resident was in the right shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. c) Resident #85 On 01/07/09 at 9:25 a.m., Resident #85 was observed during a shower with permission. She was in the right shower stall being bathed by a nursing assistant, while another resident was in the left shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. d) Confidential resident group meeting interview On 01/06/09 at 10:30 a.m., a resident who attended the confidential group meeting reported the shower was not private. She also reported she was not always fully dressed properly when brought out of the shower. When asked for clarification in a separate interview on 01/07/09 at 2:00 p.m. regarding how the sh… | 2014-02-01 | ||
| 11486 | 11486 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 221 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, a review of the incident / accident reports, and staff interview, the facility failed to assure that devices, applied and/or attached to a resident to restrict voluntary movement and/or normal access to one's body, were ordered by a physician to treat a medical symptom after the completion of a comprehensive assessment, to include the development and implementation of plans to systematically and gradually reduce the use of these physical restraints. Staff applied socks to Resident #10's hands, which restricted movement, without a physicians' order. Documentation in the medical records of Residents #36, #5, #28, and #85 inconsistently addressed the purpose of lap buddies applied to prevent rising and subsequent falls; throughout their charts, staff referred to these devices as "enablers" instead of physical restraints. Resident #36 consistently resisted the use of her lap buddy, injuring herself when her device was being applied; a plan to address this, as well as a plan for the systematic / gradual reduction of the use of this device, was not initiated. Devices were not adequately addressed for five (5) of twenty (20) sampled residents. Resident identifiers: #10, #36, #35, #28, and #85. Facility census: 113. Findings include: a) Resident #10 During an observation on 01/05/09 at 2:30 p.m., Resident #10 was laying in the bed with a sock applied to her right hand. This sock covered the resident's entire hand and was pulled up to the resident's elbow. Another observation, on 01/06/09 at 10:00 a.m., found socks present on both of the resident's hands, pulled up to her elbows. Review of the resident's medical record, including the monthly recapitulation of physician's orders (dated 01/01/09 through 01/31/09) revealed no active physician's order for any type of physical restraint, including the application of socks on this resident's hands. Review of Resident #10's current care plan, dated 11/25/08, found a plan … | 2014-02-01 | ||
| 11487 | 11487 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 285 | D | UFEY11 | Based on record review and staff interview, the facility failed to assure that a Level II evaluation was completed, when indicated, prior to the admission of one (1) of twenty (20) sampled residents. Resident identifier: #108. Facility census: 113. Findings include: a) Resident #108 Record review, on 01/07/09, revealed Resident #108 was admitted to the facility in 2008. The Pre-Admission Screening and Resident Review (PASRR) Determination, dated eleven (11) days prior to the current admission, stated that a Level II evaluation was required for this individual. However, the Level II evaluation itself was not completed prior to this admission to this facility. These findings were reported to Employee #8 on the morning of 01/08/09. She, in turn, referred the matter to the admissions / social worker to see if more information was on record in the social worker's office. On 01/08/09 at approximately 11:55 a.m., Employee #8 produced a Level II assessment signed by a supervised psychologist that was dated six (6) days after Resident #108's current admission. Employee #8 stated they thought the PASRR had been completed by the transferring facility. The finding of the delinquent pre-admission Level II evaluation was reported to the director of nursing at approximately 6:30 p.m. on 01/07/09. . | 2014-02-01 | ||
| 11488 | 11488 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 329 | D | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure the medication regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs without adequate indications for use. Resident #62 was under the care of a psychiatrist for her mood / behavior, having been evaluated on 05/09/08; in addition to medication changes, the psychiatrist recommended a follow-up appointment within nine (9) weeks or as necessary. Additional psychoactive medications ([MEDICATION NAME] and [MEDICATION NAME] ER) were added to the resident's medication regimen without first assessing for [MEDICATION NAME] / extrinsic factors that may have caused or contributed to changes in the resident's behavior and/or without contacting the psychiatrist. Resident identifiers: #62. Facility census: 113. Findings include: a) Resident #62 1. Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several psychoactive medications for mood / behavior, including [MEDICATION NAME], and [MEDICATION NAME]. Further review revealed a psychiatric evaluation was completed on 05/09/08, after which the psychiatrist recommended increasing her [MEDICATION NAME] and instructed the facility to watch her for serotoni[DIAGNOSES REDACTED], since she was already receiving [MEDICATION NAME] and [MEDICATION NAME]. The psychiatrist also recommended a follow-up appointment in nine (9) weeks, or sooner if needed. Subsequent to the psychiatric consult, the resident's attending physician increased the [MEDICATION NAME] to 0.5 BID on 05/10/08 and decreased her [MEDICATION NAME] to 5 mg BID on 05/15/08. 2. At the beginning of June, Resident #62 began to exhibit increased anxiety, and in July, she had a panic attack. The facility did not contact the psychiatrist regarding these events. 3. On 09/30/08, she exhibited increased behaviors and was given [MEDICATION NAME] 1 mg intramuscularly (IM). Nursing progress notes did not contain any documentation … | 2014-02-01 | ||
| 11489 | 11489 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 520 | E | UFEY11 | Based on medical record review, review of the facility's infection control tracking log, and staff interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that identifies quality deficiencies (of which it should have been aware) and develops / implements plans of action to correct these deficiencies. The facility had a high number of residents with urinary tract infections (UTIs). The QAA committee failed to identify deficits in the infection control program (with respect to tracking infectious organisms, identifying trends through analysis of the facility's infection control data, and investigating the UTIs to identify any underlying causal or contributing factors) and failed develop / implement measures to address these deficits. Facility census: 113. Findings include: a) Record review, during the facility's annual certification resurvey conducted from 01/05/09 through 01/08/09, revealed multiple residents with UTIs, several of whom had the same infectious organism and resided in the same location (same room and/or hall within the facility). On the afternoon of 01/06/09, the director of nursing (DON - Employee #2) was identified as the individual designated as responsible for infection control tracking. At this time, a copy of the November and December 2008 infection control tracking logs was requested and received. A review of the infection control tracking logs revealed the DON / infection control nurse failed to log the organisms identified through cultures as being responsible for each infection. In an interview with the DON and administrator (Employee #1) on 01/07/09 at 4:30 p.m., the DON acknowledged that she did not record infectious organisms on the tracking logs. During interview with the director of nursing (DON) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well a… | 2014-02-01 | ||
| 11490 | 11490 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 225 | D | UFEY11 | Based on a review of the facility's complaint files, observation, and staff interview, the facility failed to immediately report and/or thoroughly investigate injuries of unknown origin and allegations of abuse to the appropriate State agencies. For Resident #96, an allegation of abuse was reported to the facility and investigated, but the facility did not report the allegation to State agencies. Resident #75 had bruising of unknown origin to her leg and lower back area, and this was not reported or investigated. This was true for one (1) of six (6) randomly reviewed complaints (#96), and one (1) of twenty (20) sampled residents (#75). Facility census: 113. Findings include: a) Resident #96 Review of the facility's complaint files found a concern report, dated 12/02/08, documenting that this resident's daughter called and said her mother said her legs were hurting and, when the resident was given a shower, "the aids (sic) hurt her legs and were rough with her". The facility conducted an internal investigation and took statements from the aides, but the allegation of abuse / mistreatment was not immediately reported to State agencies as required, nor were the results of the facility's investigation forwarded to the State within five (5) working days of the incident. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she verified this incident was investigated but was not reported as abuse, stating it was already resolved by the time the concern was filed by the family. b) Resident #75 A record entry on a Physician Notification form, dated 01/07/09, noted bruises of unknown origin to the right inner thigh (measuring 18 cm x 0.25 cm) and the left inner thigh (measuring 1 cm x 8 cm) and a buttock abrasion (measuring 2.3 cm x 2 cm). The entry noted the physician was notified of these injuries at 8:40 a.m. on 01/07/09. During a review of the facility's incident / accident reports for that day, there was no evidence that an accident / incident report had been completed. There … | 2014-02-01 | ||
| 11491 | 11491 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 313 | D | UFEY11 | Based on observation, record review, and resident interview, the facility failed to assist residents with the use of assistive devices needed to maintain hearing or vision. Residents were observed without their assistive devices in place, which could affect their abilities to interact with their environment. This occurred for two (2) of twenty (20) sampled residents. Resident identifiers: #65 and #36. Facility census: 113. Findings include: a) Resident #65 On 01/07/09 at 10:00 a.m., Resident #65, when observed in physical therapy (PT), was not wearing eyeglasses. During resident interview, Resident #65 stated she needed her glasses both to read and to "see all the time". Staff members were present at the time this surveyor was questioning the resident, and one (1) staff member went to get the resident's glasses and returned to PT. She then placed the eyeglasses on the resident's face. b) Resident #36 During initial tour of the facility on 01/05/09 at 2:30 p.m., this surveyor spoke to Resident #36. The resident did not answer questions and looked at the surveyor with a puzzled look. The surveyor introduced herself and asked what her name was. She did not answer or give any sign that she understood what was being asked of her. During another visit on the morning of 01/06/09, Resident #36 was observed sitting up in her wheelchair; she had just finished eating her breakfast. This surveyor spoke to the resident, and again she looked puzzled as if she did not understand what was being said. The surveyor the leaned down and spoke louder and directly into the resident's left ear, asking how her breakfast was. The resident immediately started discussing her breakfast and responded appropriately to each question subsequently asked of her when it was spoken directly into her ear. The resident stated, "I don't hear well." After this, all communication was understood by this resident. In a nursing note entry, dated 01/07/09 at 10:00 p.m., the nurse recorded, "Resident noted to refuse to interact with staff members for brief p… | 2014-02-01 | ||
| 3510 | 3510 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2019-04-17 | 584 | E | 0 | 1 | 280911 | Based on observation and staff interview, the facility failed to provide a comfortable and homelike environment during meals in the dining room. The dining room environment did not offer stimulation such as television, music, or any activities, while the residents waited for their meals. This practice affected more than a limited number of residents. Facility census: 19. Findings included: a) Observations An observation of the dining room, on 04/15/19 at 11:40 AM, revealed residents were brought in for the lunch dining service. There were approximately fourteen (14) residents. There was no stimulation in the dining room. The room was quiet. Five (5) residents were observed sleeping in their chairs. The lunch trays were not served until 12:05 PM. An observation of the dining room, on 04/16/19 at 11:45 AM, revealed residents were brought in for the lunch dining service. There were approximately thirteen (13) residents. There was no stimulation in the dining room, The room was quiet. Six (6) residents were observed to be asleep in their chairs. A female resident asked the staff what am I supposed to be doing right now? b) Interviews An interview with Nurse Aide (NA) #25, on 04/16/19 at 12:15 PM, revealed they never play music or do activities with the residents before meals in the dining room. An interview with the Administrator, on 04/16/19 at 1:45 PM, revealed they used to play music in the dining room but stopped a few years ago due to complaints. The Administrator stated they had not tried to reintroduce the music or any dining room stimulation since the complaints were voiced. | 2020-09-01 |
| 3511 | 3511 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2019-04-17 | 641 | D | 0 | 1 | 280911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview the facility failed to accurately complete an assessment, reflective of Resident #3 status at the time of the assessment. The facility failed to check depression on the MDS section I Active Diagnosis. The failed practice affected one (1) of ten (10) residents. Resident identifier: #3. Facility census: 19. Findings included: a) Resident #3 An observation of Resident #3, on 04/15/19 at 11:00 AM, revealed Resident #3 was socially withdrawn from facility activities. An interview with Resident #3, on 04/15/19 at 11:00 AM, stated he felt tired all the time. Resident #3 stated that he participated in rehab but rehab wore him out so he doesn't participate in facility activities. A record review, on 04/16/19 at 09:40 AM revealed a current [DIAGNOSES REDACTED]. The minimum data set (MDS) dated for 02/27/19 revealed that depression was not marked as an active [DIAGNOSES REDACTED]. An interview with MDS Coordinator, on 04/16/19 at 10:00 AM, confirmed depression should have been marked on the MDS. MDS Coordinator stated I do not have depression marked, I missed it. | 2020-09-01 |
| 3512 | 3512 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2019-04-17 | 684 | D | 0 | 1 | 280911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to have written physician orders for residents receiving [MEDICAL TREATMENT] and hospice. This practice affected two (2) of ten (10) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #6 and #11. Facility census: 19. Findings included: a) Resident #6 An interview with Licensed Practical Nurse (LPN) #30, on 04/16/19 at 9:00 AM, revealed the Resident was in hospice. A review of the Resident's physician orders, on 04/16/19 at 9:15 AM, revealed there was not an order in the record for hospice services. An interview with the Director of Nursing (DON), on 04/17/19 at 8:30 AM, revealed the resident was admitted to the unit on 12/10/18 with continuing hospice services. The DON stated the facility failed to obtain the written order from the physician when the resident was admitted on [DATE]. The DON obtained the order from the physician on 04/16/19 when it was requested during the LTCSP. b) Resident #11 A record review, on 04/16/19 at 2:31 PM, revealed a care plan that stated Resident #11 required [MEDICAL TREATMENT] 3 days a week on Tues, Thurs and Sat at 11:20AM @Fresenius [MEDICAL TREATMENT] Center in Dunbar, WV. Further record review of physician orders, on 04/16/19, revealed no physician order for [REDACTED].>An interview with the DoN, on 04/17/19 at 8:36 AM, confirmed there was no written physician order for [REDACTED]. | 2020-09-01 |
| 3513 | 3513 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2019-04-17 | 812 | E | 0 | 1 | 280911 | Based on observation, staff interview and policy review the facility failed to store, distribute and serve food in accordance with professional standards for food service safety. Butter was found in the dining room condiment station not refrigerated and an employee in the kitchen did not wear a beard restraint in the food production area. The failed practice had the potential to affect more than a limited number of residents. Facility census: 19. Findings included: a) Butter An observation in the dining room, on 04/15/19 at 12:12 PM, revealed individually wrapped butter stored in the condiments station. The wrapper stated contains cream and milk. Butter was warm to touch and not refrigerated. An interview with Dietary Manager, on 04/15/19 at 12:16 PM, revealed that butter is real and that it should have been refrigerated. b)[NAME]Restraint During the initial tour of the kitchen, on 04/15/19 at 10:10 AM, observed a male kitchen staff (KS) #1 was not wearing a beard restraint over his goatee. An immediate interview with Dietary Manager (DM), on 04/15/19 at 10:10 AM, revealed that he does not normally wear one, as it is is usually not that long. A review of the facility's policy titled Food Safety and Hygiene Policy was conducted on 04/16/19 at 9:05 AM. The policy stated, Keep beard and mustaches neat and trimmed.[NAME]restraints are required in any food production area. | 2020-09-01 |
| 3514 | 3514 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2019-04-17 | 842 | D | 0 | 1 | 280911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to have complete and accurate medical records. There were no written physician orders for residents receiving [MEDICAL TREATMENT] and hospice in their medical records. This practice affected two (2) of ten (10) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #6 and #11. Facility census: 19. Findings included: a) Resident #6 An interview with Licensed Practical Nurse (LPN) #30, on 04/16/19 at 9:00 AM, revealed the Resident was in hospice. A review of the Resident's physician orders, on 04/16/19 at 9:15 AM, revealed there was not an order in the record for hospice services. An interview with the Director of Nursing (DON), on 04/17/19 at 8:30 AM, revealed the resident was admitted to the unit on 12/10/18 with continuing hospice services. The DON stated the facility failed to obtain the written order from the physician when the resident was admitted on [DATE]. The DON obtained the order from the physician on 04/16/19 when it was requested during the LTCSP. b) Resident #11 A record review, on 04/16/19 at 2:31 PM, revealed a care plan that stated Resident #11 required [MEDICAL TREATMENT] 3 days a week on Tues, Thurs and Sat at 11:20AM @Fresenius [MEDICAL TREATMENT] Center in Dunbar, WV. Further record review of physician orders, on 04/16/19, revealed no physician order for [REDACTED].>An interview with the DoN, on 04/17/19 at 8:36 AM, confirmed there was no written physician order for [REDACTED]. | 2020-09-01 |
| 3515 | 3515 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2018-06-21 | 656 | D | 0 | 1 | TL6L11 | Based on observation, record review and staff interview, the facility failed to ensure staff implement care plan interventions for incontinence care and failed to fully develop another care plan for a resident receiving Hospice services. This was true for two (2) of eleven (11) care plans reviewed during the annual Long Term Care Survey Process. Resident identifier: #2, and #17. Facility census: 20. Findings included: a) Resident #2 Review of an annual minimum data set (MDS) with an assessment reference date (ARD) of 03/10/18 revealed a resident with dementia, bladder and bowel incontinence, totally dependent for toileting, transferring, and bathing; as well as needing extensive assistance for all other activities of daily living (ADL). Observations of Nurse Aide (NA) #51 and NA #18 providing perineal incontinence care to Resident #2, on 06/19/18 at 02:28 PM, revealed the NA's did not apply skin cream to the resident's skin after providing peri-care. Perineal care is usually called peri care. Peri-care refers to washing the perineal area, the genitals and anal area. Peri-care helps prevents skin breakdown of the perineal area in those incontinent of bladder and bowel. On 06/19/18 at 03:59 PM, review of Resident #2's care plan, revealed incontinence care was addressed. One of the interventions included apply skin cream after each incontinent episode. During an interview, on 06/19/18 at 04:03 PM, NA #51 reported being aware skin cream was to be applied after each incontinent episode. When inquired if skin cream was applied after providing incontinence care to Resident #2, NA#51 said, I'll be honest with you I didn't apply the skin cream. I forgot . b) Resident #17 Review of a significant change minimum data set (MDS) with an assessment reference date (ARD) of 05/23/18 revealed a resident with dementia, dependent with bathing and needing extensive assistance for all other activities of daily living (ADL). The resident's Brief Interview for Mental Status (BIMS) score is five (5) out of 15 indicating the resident is s… | 2020-09-01 |
| 3516 | 3516 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2018-06-21 | 657 | D | 0 | 1 | TL6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure they revised two (2) of twelve (12) care plans when a resident's health status and needs changed. Resident #120's care plan was not revised to include a nutritional intervention and Resident #13's care plan was not revised to reflect a change in the time of transport for [MEDICAL TREATMENT]. Resident identifiers: #13 and #120. Facility census: 20. Findings included: a) Resident #120 The medical record review for Resident #120 revealed a physician's orders [REDACTED]. The resident had a care plan developed for risk of weight loss due to being new to the facility. This plan was started on 05/31/18. The care plan for nutrition was not revised to reflect the addition of Ensure Plus as an intervention for weight loss. On 06/21/18 at 9:45 AM Registered Nurse #61 was asked if the Ensure Plus was included under the interventions for the care plan area of nutritional risk of weight loss. She said it had not been included yet. b) Resident #13 An interview with the Assistant Director of Nursing (ADON), on 06/18/18 at 11:48 AM, revealed Resident #13 received [MEDICAL TREATMENT] services from a [MEDICAL TREATMENT] center. When asked how the facility communicates with the [MEDICAL TREATMENT] center, the ADON said a [MEDICAL TREATMENT] communications notebook was kept. The [MEDICAL TREATMENT] communications notebook had vital signs, POST (Physician order [REDACTED]. The ADON said an ambulance service provided transportation for the resident to and from [MEDICAL TREATMENT]. On 06/20/18 at 03:53 PM, interview with Licensed Practical Nurse (LPN#35), revealed what the nurse did when Resident #13 returns to the facility from [MEDICAL TREATMENT]. LPN#35 said she assesses the resident, checks for pain, and sees if the dressing on his catheter port site is clean. LPN#35 stated she checks the communication sheets, that are returned with the resident from [MEDICAL TREATMENT], to see if … | 2020-09-01 |
| 3517 | 3517 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2018-06-21 | 689 | D | 0 | 1 | TL6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure a resident's environment, over which it had control, was as free from accident hazards as possible. A Nurse Aide (NA) left a resident, with a history of falls, unattended in their bed in a high position. This was true for one (1) of twelve (12) residents reviewed during the annual Long Term Care Survey Process. Resident identifier: #13. Facility census: 20. Findings included: a) Resident #13 Review of Resident #13's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/25/18 revealed the resident's Brief Interview for Mental Status (BIMS) score is fourteen (14) out of fifteen (15) indicating the resident is cognitively intact. The resident needs extensive assistance for activities of daily living (ADL). Pertinent [DIAGNOSES REDACTED]. Resident #13 is receiving [MEDICAL TREATMENT] services from a [MEDICAL TREATMENT] center. Observations on 06/21/18 at 09:28 AM, revealed NA #52 assisting Resident #13 with personal hygiene and ADL's. While NA #52 was providing the care the resident's bed was observed in the high position. On 06/21/18 at 09:35 AM, the resident was observed alone in his room lying in his bed, with the bed still in the high position. During an interview Resident #13 was lying in his bed, which positioned him well above this surveyor's waist. The resident was asked some questions about [MEDICAL TREATMENT], and then asked if his bed is usually left in the high position. Resident#13 replied No, it never is. While waiting outside Resident #13's room for NA #52 to return, on 06/21/18 at 09:43 AM, observed NA #51 walking in the hallway carrying soiled linen. NA #51 was asked to come to Resident #13's room doorway and inquired the resident's bed was to be left that high with no one in the room. NA#51 replied, No Ma'am it is not. NA #51 continued down the hall to dispose of the soiled linen. At 09:45 AM, NA #51 returned and enter… | 2020-09-01 |
| 3518 | 3518 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2018-06-21 | 711 | D | 0 | 1 | TL6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify a discrepancy in an order regarding the route of administration of insulin via an insulin pen for a diabetic resident. This was true for one (1) of five (5) residents reviewed during the annual Long Term Care Survey Process for unnecessary medications. Resident identifier: #3. Facility census: 20. Findings included: Review of Resident #3's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/20/18, on 06/21/18 at 08:00 AM, revealed the resident's Brief Interview for Mental Status (BIMS) score is six (6) indicating resident is cognitively severely impaired. The resident needs extensive assistance for activities of daily living (ADL), except resident needs supervision with eating. Pertinent [DIAGNOSES REDACTED]. Review of orders for Resident #3 revealed an order for [REDACTED]. The order read Basaglar KwickPen 100ml (milliliters) three (3) ml SQ (subcutaneous) (35 U (units) IM (intramuscular) Q (every) D (day) DM (for Diabetes Mellitus)). Review of the manufacturer's (Eli Lilly) instructions, revised on 04/20/17, approved by the U.S. Food and Drug Administration, revealed the following instructions. Step #10 of the instructions read, BASAGLAR is injected under the skin (subcutaneously) of your stomach area, buttocks, upper legs or upper arms. On 06/21/18 at 12:21 PM, interview with Licensed Practical Nurse (LPN#47), revealed the resident receives Basaglar at 4:00 PM every day. LPN#47 said she works days shift and is not at the facility when the resident receives Basaglar at 4:00 PM. This surveyor requested LPN#47 to review the order. LPN#47 said after the order was reviewed said, Thats wrong, you would not give it IM. Review of records, on 06/21/18 at 12:23 PM, revealed medication regimen reviews, were completed by the Pharmacy on dates 06/07/18, 05/03/18, 03/30/18, and 03/01/18. On 06/21/18 at 12:40 PM Director of Nursing (DON), agreed Basagla… | 2020-09-01 |
| 3519 | 3519 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2018-06-21 | 726 | E | 0 | 1 | TL6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the competency of licensed nursing staff who were responsible for administering medications to residents. The nursing staff failed to identify and clarify an order regarding a discrepancy in the route of administrating insulin to a diabetic resident. Nursing staff documented giving insulin multiple times using an intramuscular (IM) route instead of the appropriate recommended route of subcutaneous (sq). This was true for one (1) of five (5) residents reviewed during the annual Long Term Care Survey Process for unnecessary medications. Resident identifier: #3. Facility census: 20. Findings included: a) Resident #3 Review of Resident #3's orders, on 06/21/18 at 12:04 PM, revealed an order for [REDACTED]. The order read Basaglar KwickPen 100 ml (milliliters) three (3) ml SQ (subcutaneous) (35 U (units) IM (intramuscular) Q (every) D (day) DM (for Diabetes Mellitus)). Review of the manufacturer's (Eli Lilly) instructions, revised on 04/20/17, approved by the U.S. Food and Drug Administration, revealed the following instructions. Step #10 of the instructions read, BASAGLAR is injected under the skin (subcutaneous) of your stomach area, buttocks, upper legs or upper arms. According to the American Diabetes Association (ADA), insulin cannot be taken as a pill because it would be broken down during digestion just like the protein in food. Insulin Basics, according to the ADA, includes insulin must be injected into the fat under your skin (subcutaneous) for it to get into your blood. On 06/21/18 at 12:21 PM, interview with Licensed Practical Nurse (LPN#47), revealed the resident receives Basaglar at 4:00 PM every day. LPN#47 said she works days shift and is not at the facility when the resident receives Basaglar at 4:00 PM. This surveyor requested LPN#47 to review the order. After reviewing the insulin order for Resident #3 LPN #47 said, That's wrong, you would not give it IM. LP… | 2020-09-01 |
| 3520 | 3520 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2018-06-21 | 756 | D | 0 | 1 | TL6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the pharmacist failed to identify or report irregularities during the monthly medication review for one (1) of five (5) residents reviewed for unnecessary medications, during the annual Long Term Care Survey Process. The pharmacist failed to identify irregularities on the Medication Administration Record [REDACTED]. Resident identifier: #3. Facility census: 20. Findings included: a) Resident #3 Review of Resident #3's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/20/18, on 06/21/18 at 08:00 AM, revealed the resident's Brief Interview for Mental Status (BIMS) score is six (6) indicating resident is cognitively severely impaired. The resident needs extensive assistance for activities of daily living (ADL), except with eating, the resident needs only supervision. Pertinent [DIAGNOSES REDACTED]. Review of Resident #3's orders, on 06/21/18 at 12:04 PM, revealed an order for [REDACTED].S. Food and Drug Administration, revealed the following instructions. Step #10 of the instructions read, BASAGLAR is injected under the skin (subcutaneous) of your stomach area, buttocks, upper legs or upper arms. According to the American Diabetes Association (ADA), insulin cannot be taken as a pill because it would be broken down during digestion just like the protein in food. Insulin Basics, according to the ADA, includes insulin must be injected into the fat under your skin (subcutaneous) for it to get into your blood. Review of records, on 06/21/18 at 12:23 PM, revealed medication regimen reviews, were completed by the Pharmacy on dates 06/07/18, 05/03/18, 03/30/18, and 03/01/18. On 06/21/18 at 12:40 PM Director of Nursing (DON), agreed Basaglar insulin is not to be given IM, but only SQ. Review of the Medication Administration Record [REDACTED]. A nurse signed each day in (MONTH) and May, the insulin was given according to the order on the MAR. The DON agreed the order should have been… | 2020-09-01 |
| 3521 | 3521 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2018-06-21 | 842 | D | 0 | 1 | TL6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure they maintained an accurate and complete medical record for two (2) of twelve (12) residents whose medical records did not contain complete and accurate information. Resident identifiers: #15 and #120. Facility census: 20. Findings included: a) Resident #15 A medical record review for Resident #15 revealed this resident had two (2) diet orders listed in their medical record. The resident had an order dated 03/15/17 for a regular diet and an order dated 05/21/18 for a mechanical soft diet. A physician's orders [REDACTED]. Resident #15 also had a physician's orders [REDACTED]. On 06/19/18 at 1:40 PM during an interview with Dietary Manager (DM) #41 the DM said the resident only received the mechanical soft diet for a brief period after having had teeth extracted. On 06/20/18 at 10:00 AM the assistant director of nursing (ADON) provided a copy of an interdisciplinary note dated 06/19/18 at 1:47 PM which stated, Clarification Order: Mech (mechanical) soft diet ordered 5/31/18 was for one week only related to tooth extraction, regular diet since 6/8/2018. Confirmed by dietary manager. b) Resident #120 A medical record review for Resident #120 revealed the resident had a physician's orders [REDACTED]. The resident's medical record contained the following weights: 05/31/18 150.80 lbs., 06/01/18 150.30 lbs. and 06/15/18 147.20 lbs. There was no weight recorded in the medical record for 06/07/18 or 06/08/18. On 06/20/18 at 10:09 AM the Director of Nursing and Registered Nurse (RN) #61 located a book that contained weights for residents. Resident #120's weight was record was 150.2 on 06/07/18. This weight had not been recorded in the medical record. | 2020-09-01 |
| 3522 | 3522 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2018-06-21 | 880 | D | 0 | 1 | TL6L11 | Based on observation and staff interview, the facility failed to maintain an effective infection control program to provide a safe and sanitary environment to help prevent the development and transmission communicable diseases and infections. A random observation discovered an improperly stored bedpan in a resident bathroom. This practice had the potential to affect a limited number of residents. Resident identifiers: #15. Facility census: 20. Findings included: a) Resident #15 A random observation on 06/19/18 at 10:05 AM, revealed a bedpan in Resident#15's bathroom was not properly stored in a plastic bag. The bedpan was lying upside down on top of and against the commode lid of a bed side commode stored in the resident's bathroom. Registered Nurse (RN#50) was asked to look in to the resident's bathroom and see if there were any issues. RN #50 immediately identified the unbagged bed pan as an issue. RN#50 said the bed pan should be bagged and agreed it was an infection control issue. On 06/19/18 at 02:50 PM, an interview with the Assistant Director of Nursing (ADON), revealed the ADON is responsible for infection control program. The ADON agreed the bed pan found in Resident#15's bathroom breeched infection control principals by not being stored properly in a plastic bag. | 2020-09-01 |
| 3523 | 3523 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2017-08-10 | 278 | D | 0 | 1 | 7U2711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate quarterly minimum data set (MDS) for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #12. Facility census: 20. Findings include: a) Resident #12 Review of the residents Medication Administration Record [REDACTED] --[MEDICATION NAME] 25 - 100 milligrams (mg), take 2 tablets three times a day (TID) for [MEDICAL CONDITION]. --Comtan 200 mg, 1 tablet, TID for [MEDICAL CONDITION]. --Requip 2 mg, 1 tablet, TID for [MEDICAL CONDITION]. --[MEDICATION NAME] 25 mg, 1 tablet at nighttime (qhs) for dementia with behaviors The resident refused medications on the following occasions: --06/07/17 the 2:00 p.m. dosage of [MEDICATION NAME] 25 - 100 mg --06/08/17 the 9:00 p.m. dosage of [MEDICATION NAME] 25-100 mg --06/07/17 the 2:00 p.m. dosage [MEDICATION NAME] mg --06/08/17 the 9:00 p.m. dosage [MEDICATION NAME] mg --06/07/17 the 2:00 p.m. dosage of Requip 2 mg --06/08/17 the 9:00 p.m. dosage of Requip 2 mg --6/08/17 the 9:00 p.m. dosage of [MEDICATION NAME] 25 mg Review of the last MDS, a quarterly, with an assessment reference date (ARD) of 06/10/17, found the facility failed to code the refusal of medications in Section E, entitled Behavior, on the MDS. The question on Section [NAME] of the MDS reads, Did the resident reject evaluation or care (e.g. blood work, taking medications, ADL assistance) that is necessary to achieve the residents goals for health and well being? During the 7 day look back period (06/04/17 to 06/10/17) required for completion of the 06/10/17 MDS, the resident had refused medications on two (2) separate days. The correct coding for the 06/10/17 MDS should be, behavior of this type occurred 1 to 3 days. The facility coded the MDS as behavior not exhibited. At 1:18 p.m. on 08/09/17, the assistant director of nursing (ADON) had no comments regarding the competition of the MDS. The … | 2020-09-01 |
| 3524 | 3524 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2017-08-10 | 279 | D | 0 | 1 | 7U2711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans to accurately reflect the assistance required for transfers for two (2) of ten (10) resident's whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #6 and #18. Facility census: 20. Findings include: a) Resident #6 Review of the resident's current care plan, dated 11/18/16, for ADL (activities of daily living) function / rehabilitation potential, identified a problem: (name of resident) has impaired mobility related to generalized weakness/fatigue, history of fracture right femur and right elbow, [DIAGNOSES REDACTED]. Interventions on the care plan included: (name of resident) transfers with one/two person assist for all transfers via stand and pivot. Further review of the residents Care Guide for the nursing assistants, noted, Transfers and ambulation / mobility: 2 person assist for transfers. Geri chair for mobility when out of bed. At 2:05 p.m. on 08/08/17, the director of nursing (DON) verified the care plan needed to be corrected. The DON verified the resident requires two (2) staff members at all times to assist with transfers. b) Resident #18 A review of Resident #18's medical record at 3:40 p.m. on 08/08/17, found a care plan intervention which read, Resident is a one to two person assist with transfers. When asked, How a residents care needs are relayed to the Nurse Aides, the staff indicated they have a Resident ADL/Daily Care List in the computer, and each Nurse Aide can see this list and know what care to provide the residents. A review of Resident #18's daily care list found the following, Transfers and ambulation mobility: 1 assist with transfers and wheelchair. An interview with the Director of Nursing at 9:00 a.m. on 08/10/17 confirmed Resident #18's care plan did not match the residents transfer status. She indicated the resident was to only be transferred with the assistance of one (1) st… | 2020-09-01 |
| 3525 | 3525 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2017-08-10 | 280 | D | 0 | 1 | 7U2711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #4's care plan was revised when his preferences changed as to when he would like to take his medications. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #4. Facility Census: 20. Findings include: a) Resident #4 A review of Resident #4's medical record at 9:00 a.m. on 08/09/17, found the following care plan intervention related to his status as a [MEDICAL TREATMENT] patient, Please give following medications after 4:00 p.m. when (Name of resident) returns form HD ([MEDICAL TREATMENT]), Provella, Vit D3, vitamin B - 12, [MEDICATION NAME], [MEDICATION NAME], and nepro shake. Review of the residents Medication Administration Record [REDACTED]. An interview with the Director of Nursing at 1:26 p.m. on 08/09/17 found the residents care plan needed to be revised. She stated at one point Resident #4 wanted these medications given after [MEDICAL TREATMENT] because he felt they would dialyze out and he would refuse to take them. She stated since his most recent readmission the resident has changed his preference and does not care to take the medication prior to [MEDICAL TREATMENT]. She stated the care plan was not revised when Resident #4's preferences changed. . | 2020-09-01 |
| 3526 | 3526 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2017-08-10 | 282 | E | 0 | 1 | 7U2711 | Based on record review and staff interview the facility failed to ensure that Resident #9's care plan was implemented in regards to her transfer status. This was true for one (1) of four (4) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey. Resident Identifier: #9. Facility Census: 20 Findings Include: a) Resident #9 A review of Resident #9's medical record, at 9:51 a.m. on 08/08/17, found a lift assessment completed on 11/13/16. This lift assessment indicated the safest way to transfer Resident #9 was with a total mechanical lift. A review of Resident #9's care plan found the following intervention, (First name of Resident) transfers with a full body lift two person assist for all transfers. A review of Resident #9's nurse aide daily flow sheets from 01/01/17 through 08/08/17, found the following occasions when Resident #9 was transferred inappropriately: On the following occasions Resident #9 was transferred with extensive assist with a one person physical assist. (Please note extensive assist means the resident was not transferred via a mechanical lift.) -- 01/02/17 at 7:54 p.m. -- 01/04/17 at 4:41 a.m. -- 01/05/17 at 11:30 a.m. -- 01/10/17 at 9:25 p.m. -- 01/15/17 at 3:23 a.m. -- 01/20/17 at 9:33 p.m. -- 01/21/17 at 2:07 a.m. -- 01/27/16 at 1:52 a.m. -- 01/29/17 at 10:29 p.m. -- 02/03/17 at 3:56 p.m. -- 02/06/17 at 9:02 p.m. -- 02/13/17 at 12:49 a.m. and 6:46 a.m. -- 02/16/17 at 10:52 p.m. -- 02/17/17 at 4:46 p.m. -- 02/21/16 at 2:39 p.m. -- 03/01/17 at 1:23 p.m. -- 03/02/17 at 10:23 p.m. -- 03/04/17 at 3:26 a.m. and 4:28 a.m. -- 03/06/17 at 9:22 p.m. -- 03/13/17 at 9:11 p.m. -- 03/14/17 at 11:29 a.m. and 8:06 p.m. -- 03/15/17 at 1:37 p.m. -- 03/17/17 at 8:35 p.m. -- 03/19/17 at 11:17 a.m. -- 03/21/17 at 8:10 p.m. -- 03/23/17 at 2:03 p.m. -- 03/28/17 at 11:35 a.m. -- 03/30/17 at 11:58 a.m. -- 03/31/17 at 3:21 a.m. -- 04/04/17 at 8:07 a.m. -- 04/06/17 at 9:13 a.m. -- 04/09/17 at 3:33 a.m. -- 04/12/17 at 2:41 a.m. -- 04/16/17 at 4:29 a.m. -- 04/21/17 at 2:00 p.m. … | 2020-09-01 |
| 3527 | 3527 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2017-08-10 | 323 | E | 0 | 1 | 7U2711 | Based on record review and staff interview the facility failed to ensure that Resident #9's environment over which the facility had control was as free from accident hazards as possible. Facility staff failed to transfer Resident #9 in a manner which was deemed safe for her transfers. This was true for one (1) of four (4) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey. Resident Identifier: #9. Facility Census: 20 Findings Include: a) Resident #9 A review of Resident #9's medical record, at 9:51 a.m. on 08/08/17, found a lift assessment completed on 11/13/16. This lift assessment indicated the safest way to transfer Resident #9 was with a total mechanical lift. A review of Resident #9's care plan found the following intervention, (First name of Resident) transfers with a full body lift two person assist for all transfers. A review of Resident #9's nurse aide daily flow sheets from 01/01/17 through 08/08/17, found the following occasions when Resident #9 was transferred inappropriately: On the following occasions Resident #9 was transferred with extensive assist with a one person physical assist. (Please note extensive assist means the resident was not transferred via a mechanical lift.) -- 01/02/17 at 7:54 p.m. -- 01/04/17 at 4:41 a.m. -- 01/05/17 at 11:30 a.m. -- 01/10/17 at 9:25 p.m. -- 01/15/17 at 3:23 a.m. -- 01/20/17 at 9:33 p.m. -- 01/21/17 at 2:07 a.m. -- 01/27/16 at 1:52 a.m. -- 01/29/17 at 10:29 p.m. -- 02/03/17 at 3:56 p.m. -- 02/06/17 at 9:02 p.m. -- 02/13/17 at 12:49 a.m. and 6:46 a.m. -- 02/16/17 at 10:52 p.m. -- 02/17/17 at 4:46 p.m. -- 02/21/16 at 2:39 p.m. -- 03/01/17 at 1:23 p.m. -- 03/02/17 at 10:23 p.m. -- 03/04/17 at 3:26 a.m. and 4:28 a.m. -- 03/06/17 at 9:22 p.m. -- 03/13/17 at 9:11 p.m. -- 03/14/17 at 11:29 a.m. and 8:06 p.m. -- 03/15/17 at 1:37 p.m. -- 03/17/17 at 8:35 p.m. -- 03/19/17 at 11:17 a.m. -- 03/21/17 at 8:10 p.m. -- 03/23/17 at 2:03 p.m. -- 03/28/17 at 11:35 a.m. -- 03/30/17 at 11:58 a.m. -- 03/31/17 at 3:21 a.m. -- 04/04/17 at 8:… | 2020-09-01 |
| 3528 | 3528 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2017-08-10 | 371 | F | 0 | 1 | 7U2711 | Based on observation and staff interview, the facility failed to ensure foods were stored in a safe and sanitary manner to prevent the outbreak of foodborne illness. Foods were not dated to indicate when they were opened. In addition, foods items were expired and needed to be discarded, yet they remained available for use. This had the potential to effect all residents residing at the facility. Facility census: 20. Findings include: a) Initial tour of the kitchen During the initial tour of the kitchen with Employee #54, the dietary manager (DM) at 9:30 a.m. on 08/07/17, the following food items were found to be expired or were not dated with a date the item was opened or the date to discard: b) Walk in refrigerator: Sour Cream, stamped with a manufactures expiration date of 07/31/17, A Ziploc bag of sliced cheese with no dates to indicate when the cheese was opened and no date of expiration, A jar of Pesto, stamped with a manufactures expiration date of 07/17/17, A jar of Horseradish with no date to indicate when the item was opened or when the item expired. c) Kitchen area A bottle of Classic Cesar dressing was found on a serving tray beside the steam table, stored among other sauces not requiring refrigeration. The instructions on the bottle directed refrigeration after opening. The bottle was room temperature to touch. DM #54 said she would discard the above items immediately. d) Residents pantry refrigerator Observation of the residents refrigerator, with the director of nursing (DON) at 9:45 a.m. on 08/07/17, found the following expired items: A bottle of prune juice belonging to resident #23, with an expiration date of 07/09/17. A package of cheese sticks belonging to a discharged Resident, with an expiration date of 07/13/17. | 2020-09-01 |
| 3529 | 3529 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2017-08-10 | 504 | D | 0 | 1 | 7U2711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure laboratory tests were obtained on the date ordered by the physician. Resident #4 had two (2) [MEDICATION NAME] time/ international normalized ratio (PT/INR) tests ordered for one (1) week from the previous test, however the test was obtained in four (4) days instead of one (1) week as ordered by the physician. 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 #4. Facility Census: 20. Findings include: a) Resident #4 A review of Resident #4's medical record at 9:00 a.m. on 08/09/17 found, two PT/INR test results dated 07/20/17 and 07/31/17. On both lab tests the physician wrote, Repeat in one week. Further review of the record found the lab test ordered to be repeated in one week from 07/20/17 was obtained on 07/24/17, and the lab test ordered to be repeated in one week from 07/31/17 was obtained on 08/03/17. Both were obtained in only four (4) days instead of one (1) week as ordered by the physician. An interview with the Director of Nursing (DON) at 10:59 a.m. on 08/09/17, confirmed both pt/inrs were not obtained as ordered. She confirmed both labs were obtained three (3) days prior to the order date. | 2020-09-01 |
| 4870 | 4870 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2016-07-18 | 272 | D | 0 | 1 | S2TR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and a dental consultant report, the facility failed to conduct an accurate comprehensive minimum data set (MDS) assessments for one (1) of three (3) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The comprehensive assessments for Resident #16 did not accurately identify the resident's dental status. Resident identifiers: #16. Facility census: 18. Findings include: a) Resident #16 Observations of Resident #16's oral cavity on 07/13/16 at 9:00 a.m., revealed the resident had broken and missing teeth. A review of Resident #16's annual MDS with an assessment reference date (ARD) of 05/09/16 was reviewed on 07/13/16 10:04 a.m. The MDS did not reflect the residents as having been missing or broken teeth. The nursing assessment with the date of 12/16/13 found the resident had been missing teeth. Observation of Resident #16's oral cavity on 07/13/16 at 10:22 a.m. with the assistant director of nursing (ADON) #48, found the resident had broken and missing teeth. The ADON confirmed the MDS was inaccurate due to the resident having these broken and missing teeth for some time. On 07/13/16 at 12:00 p.m., Registered Nurse/Minimum Data Set Coordinator (RN-MDSC) confirmed the resident nursing assessment form dated 12/16/13 finds the resident has some missing teeth. The RN-MDSSC stated, The monthly summary dated 04/19/16 does not identify missing or broken teeth. She stated, I went to do an oral examine, but I could not get the resident to open up his mouth, so I could not really identify whether there was missing or broken teeth. The resident was seen by the dentist on 04/12/16. The note revealed the resident had broken teeth. The teeth was [MEDICATION NAME] to prevent further chipping, and cutting the resident's lip or cheek. The dental exam revealed the area where he has been missing teeth. | 2019-07-01 |
| 5785 | 5785 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2015-07-10 | 225 | F | 0 | 1 | 0TIA11 | Based on employee personnel file review and staff interview, the facility failed to ensure all employees were thoroughly screened for histories that would indicate the individual was unfit for service in a nursing home through the use of a Statewide criminal background check. This was true for one (1) of five (5) newly hired employees reviewed for Statewide criminal background checks. This had the potential to affect all residents. Employee identifier: #32. Facility census: 19. Findings include: a) Nurse Aide #32 On 07/09/15 11:00 a.m., after reviewing personnel information received from the facility, there was no evidence found to verify Nurse Aide (NA) #32 had a Statewide criminal background check. The individual's hire date was 05/04/15. At 12:45 p.m., on 07/09/15, after attempting to find the statewide background check documentation for Employee #32, the facility administrator stated there was no record of the statewide background check being completed. The Affordable Care Act includes: (3) REQUIRED FINGERPRINT CHECK AS PART OF CRIMINAL HISTORY BACKGROUND CHECK -The procedures established under subsection (b)(1) of such section 307 shall- (A) require that the long-term care facility or provider (or the designated agent of the long-term care facility or provider) obtain State and national criminal history background checks on the prospective employee through such means as the Secretary determines appropriate . The procedures established under subsection (b)(1) of such section 307 shall- (A) require that the long-term care facility or provider (or the designated agent of the long-term care facility or provider) obtain State and national criminal history background checks on the prospective employee . provide for a provisional period of employment by a long-term care facility or provider of a direct patient access employee, not to exceed 60 days, pending completion of the required criminal history background check and, | 2018-08-01 |
| 5786 | 5786 | ARTHUR B HODGES CENTER, THE | 515193 | 300 BAKER LANE | CHARLESTON | WV | 25302 | 2015-07-10 | 279 | D | 0 | 1 | 0TIA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan with measurable goals for the treatment of [REDACTED]. Resident identifier: #11. Facility census: 19. Findings include: a) Resident #11 Review of medical records, on 07/08/15 at 12:33 p.m., revealed Resident #11 was admitted to the facility on [DATE], after a [MEDICAL CONDITION]. Upon admission to the facility, the physician ordered [MEDICATION NAME] 7.5 milligrams (mg)/[MEDICATION NAME] 325 mg every four (4) hours as needed related to pain. Review of the resident's medication administration records (MAR) revealed Resident #11 received [MEDICATION NAME] 7.5mg/[MEDICATION NAME] 325mng for pain twenty-three (23) times during the month of (MONTH) (YEAR) and nine (9) times during the month of (MONTH) (YEAR). Review of the initial care plan, with a start date of 05/21/15, did not reveal a problem, goal, or interventions related to pain. Continued review of the care plan revealed a care plan problem, with a start date of 06/25/15, related to pain due to a recent [MEDICAL CONDITION] with surgical repair. On 07/08/15 at 1:50 p.m., Registered Nurse #6, stated she neglected to include the problem of pain in Resident #11's care plan from 05/21/15 until 06/25/15. | 2018-08-01 |
| 11217 | 11217 | BARBOUR COUNTY GOOD SAM. CTR. | 515116 | ROUTE 3, BOX 15C | BELINGTON | WV | 26250 | 2011-03-30 | 225 | D | 1 | 0 | SIMK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the immediate reporting to the administrator of the facility, and to other officials in accordance with State law through established procedures, all alleged violations involving mistreatment, neglect, or abuse. This was evident for one (1) of five (5) sampled residents. Resident identifier: #52. Facility census: 49 Findings include: a) Resident #52 I. Record review of an incident report dated [DATE] revealed that Resident #52 was being transferred from a seat on the activity bus to a wheelchair by nursing assistant #43, when the resident experienced a "popping sound that appeared to come from R (right) side of {sic}rib cage" and she "felt something move (rib) when (sic) sound was heard". Further review of the incident report revealed that the family and physician was notified on [DATE], the administrator notified on [DATE], and it was coded as not requiring notification to a State/Agency. Pertinent [DIAGNOSES REDACTED]. Review of Interdisciplinary Progress Notes dated [DATE], revealed the resident complained of tenderness to the touch in the right rib area, and a new order was received for an x-ray of the right ribs, which was completed at the facility on [DATE]. Review of Interdisciplinary Progress Notes, dated [DATE], revealed x-ray results of anterior rib fractures, sixth through eighth ribs; the physician was notified, and he ordered a Hoyer lift for future transfers. Review of physician orders [REDACTED]. every one (1) hour prn (as needed) was increased to Roxinal 10 (ten) mgs. every one (1) hour prn on [DATE]. Additionally, on [DATE], the physician gave a new order for Roxinal 10 (ten) mgs. sublingually scheduled three (3) times daily prior to transferring at 7:00 a.m., 11:00 a.m., and 4:00 p.m. due to the fractured ribs. These pain medications were in addition to the twice daily [MEDICATION NAME] ER (Extended Release) 30 mgs. tablets prescribed on [DATE], and th… | 2014-07-01 |
| 8295 | 8295 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 157 | D | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible party and/or physician of changes in health status for one (1) of 45 sampled residents. Resident identifier: #33. Facility census: 52 Findings include: a) Resident #33 1. Review of the medical record revealed that Resident #33 had a fever of 99.1 axillary on 03/14/12. The nurse documented, on 03/14/12 at 3:25 a.m., that she had faxed the physician and requested an order for [REDACTED]. Further record review found no evidence of a fax copy sent to the physician with the request for the urinalysis or evidence the physician replied to the fax. There were no urinalysis reports for Resident #33 in March 2012. Interview with Employee #44, the director of nursing (DON), on 07/23/12 at approximately 11:00 a.m., found that she, assisted by Employee #17 (ward clerk) and Employee #43 (director of health information management), could find no evidence in the medical record of a fax to the physician on 03/14/12 related to Resident #33's temperature elevations or the need for a urinalysis. Additionally, they were unable to find any new physician orders [REDACTED]. Employee #17 stated that faxes were filed in the back of residents' medical records, but there was none found for the alleged 03/14/12 fax. Employee #44 stated the nurse, who documented she faxed the physician on 03/14/12 to alert him to the fever and to request a urinalysis to rule out a urinary tract infection, was no longer employed by the facility. She also stated they have no policy related to how frequently to recheck temperatures when there has been an elevation, and do not routinely notify the responsible party or physician for a fever below 101 degrees. When asked if the temperature elevations and the fax to the physician were placed on the 24 hour report for follow-up, Employee #44 said Those reports are not part of the medical record, so are kept for only a few days and then shredded. Therefore, t… | 2016-07-01 |
| 8296 | 8296 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 161 | F | 0 | 1 | TTVD11 | Based on facility record review and staff interview, the facility failed to provide a surety bond approved by the appropriate state agency, as required by West Virginia (WV) State Law, to ensure compensation of the resident for any loss of residents' funds managed by the facility. This had the potential to affect all residents (36) with funds managed by the facility. Facility census 52. Findings include: a) Review of facility records, at 1:30 p.m. on 07/17/12, failed to show evidence that the $37,000.00 surety bond on file, for protection of the residents' funds being managed by the facility, had been submitted and approved by the WV Attorney General's Office. The Trial Balance of the Resident Fund account, provided by Employee #22 (Office Manager), indicated, Balances as of: 07/16/12 shows a balance in the account of: $11,220.08. An inquiry to the State office was made. An email, received at 2:15 p.m. on 07/17/12, stated the agency had no surety bond issued for this facility since 2010. It is required annually. During an interview with Employee #37 (Administrator) and Employee #22 who is responsible for handling residents' funds, at 9:15 a.m. on 07/18/12, they acknowledged the statement was correct. Employee #37 stated he had already informed the corporate office and this would be rectified as soon as possible. | 2016-07-01 |
| 8297 | 8297 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 166 | D | 0 | 1 | TTVD11 | Based on resident interview, record review, and staff interview, facility failed to investigate and resolve a grievance related to an allegation of missing clothing for one (1) of forty-five (45) Stage II sample residents. Resident identifier: #10. Facility census: 52. Findings include: a) Resident #10 Interview with Resident #10, on 07/16/12 at 9:37 a.m., revealed the resident had missing items such as pajama pants, socks, and underwear. Resident #10 stated the facility investigated the situation, but the situation was not resolved to her satisfaction. Complaints and grievances were reviewed. The files did not contain a complaint regarding Resident #10's missing clothing. Employee #63, the director of social services, was interviewed on 07/23/12 at 2:35 p.m. regarding the resident's missing items. She stated the facility did not keep a record of missing items, as they were usually found in another resident's drawer. This method of handling missing items does not ensure each grievance is acknowledged, acted upon, and the results communicated to the resident. The facility had no means to provide evidence the resident's complaint was acknowledged, no evidence the facility investigated the complaint and/or actively sought a resolution, and no evidence the resident was informed of the facility's findings. | 2016-07-01 |
| 8298 | 8298 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 167 | C | 0 | 1 | TTVD11 | Based on family interview, observation, and staff interview, the facility failed to make survey results readily available to residents for examination, and failed to post a notice of their availability. This had the potential to affect all residents and families desiring to view this information. Facility census: 52. Findings include: a) Resident #54 During an interview with a family member of Resident #54, on 07/17/12 at 1:25 p.m., it was revealed he was unaware of the availability of the survey results and was not aware of where they were located. An observation was made of the facility, on 07/17/12 at 1:45 p.m A notice regarding the availability of the survey results was not found during this observation. On 07/17/12 at 1:50 p.m., Employee #22, the office manager, was interviewed regarding the location of the survey results. At that time, Employee #22 confirmed there was no notice of the availability of the survey results. Upon inquiry, this employee was unsure of the location of survey results, and stated they possibly are located at the nurses' station. | 2016-07-01 |
| 8299 | 8299 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 225 | E | 0 | 1 | TTVD11 | Based on record review, policy review, and staff interview, the facility failed to make reasonable efforts to uncover information about any past criminal prosecutions of potential employees by not including a West Virginia (WV) statewide investigation for two (2) of the five (5) sampled employees hired in 2012. This practice had the potential to affect more than an isolated number of residents. Employee identifiers: #41 and #67. Facility census 52. Findings include: a) Employee #41 A review of the personnel files, at 1:00 p.m. on 07/17/12, revealed no evidence that a statewide criminal background check had been completed on Employee #41, who was employed as a nursing assistant on 07/09/12. This person was involved in direct resident care. b) Employee #67 A review of the personnel files, at 1:00 p.m. on 07/17/12, revealed no evidence that a statewide criminal background check had been completed on Employee #6, who was employed as a nursing assistant on 07/11/12. This person was involved in direct resident care. c) An interview was conducted with Employee #22, the office manager, at 11:55 a.m. on 07/18/12. She stated, after searching the files and consulting Employee #44 (the director of nursing), that there was no record of a criminal background check on these employees. At the time of exit on 07/24/12, no further information had been produced regarding criminal background checks for these employees. | 2016-07-01 |
| 8300 | 8300 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 272 | D | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility's interdisciplinary team failed to conduct comprehensive assessments that accurately reflected each resident's health status/condition for two (2) of forty-five (45) sampled residents. Resident identifiers: #42 and #32. Facility Census: 52. Findings include: a) Resident #42 On 07/23/12 at 1:15 p.m., review of the hospital discharge summary, dated 06/16/11, revealed this resident had been admitted with a [MEDICAL CONDITION], a history of multiple falls with fractures, and a pressure ulcer. Review, on 07/23/12 at 2:00 p.m., of admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/29/11, found Section H did not indicate the resident had an ostomy, Section J indicated the resident had not had any falls or fractures in the last six (6) months, and Section M had been left blank, which indicated the resident had no pressure ulcers. An interview conducted with Employee #33, the registered nurse MDS coordinator, on 07/24/12 at 9:40 a.m., verified that sections H, J, and M of the admission MDS assessment had been inaccurately completed. b) Resident #32 Chart review revealed that resident's most recent minimum data set (MDS), with an assessment reference date (ARD) of 04/08/12, did not identify the resident's recurrent urinary tract infections. Section I, Item I2300, did not identify she had had a urinary tract infection [MEDICAL CONDITION] in the last 30 days. The resident had urinary tract infections identified on 03/10/12 and 03/29/12. Both of these UTIs were identified within 30 days of the ARD and should have been reflected on the assessment. | 2016-07-01 |
| 8301 | 8301 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 279 | E | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's interdisciplinary team failed to develop a comprehensive care plan to address the care needs and to describe the services needed for residents to maintain a safe environment, to prevent further decline, and to prevent complications in their conditions. The care plans were not complete and/or did not contain measurable interventions to provide care in areas of pressure ulcers, intravenous fluids, [MEDICAL TREATMENT], hydration, discharge changes, and accident/falls. This was evident for five (5) of forty-five (45) Stage II sample residents. Resident identifiers: #33, #63, #10, #42, and #20. Facility census: 52. Findings include: a) Resident #33 Review of a history and physical from the hospital, dated 04/16/12, revealed this resident was admitted with [DIAGNOSES REDACTED]. Record review found she had a low potassium level ([DIAGNOSES REDACTED]) upon admission to the hospital, and an elevated BUN (blood urea nitrogen) and creatinine, the latter two of which are indicative of dehydration. Upon discharge from the hospital, on 04/19/12, she was prescribed intravenous fluids (IV) with potassium supplement of twenty milliquivalents (20 MeQ) to infuse at 75 cc an hour. Medical record revealed there was no care plan related to intravenous fluid administration with potassium supplement for this resident, or for her recent hospitalization with fluid volume depletion, urinary tract infection [MEDICAL CONDITION], and electrolyte imbalance. Review of the history and physical from the hospital, dated 04/23/12, found an admitting impression of acute [MEDICAL CONDITION], as well as volume in her lungs with bilateral pleural effusions and crackles, the latter of which was indicative of fluid excess in her lungs. Review of the discharge summary from the hospital, dated 04/26/12 revealed she had [MEDICAL CONDITION] (elevated potassium level) upon admission on 04/23/12. During an interview with the Employ… | 2016-07-01 |
| 8302 | 8302 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 280 | E | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan to include changes in health status, for one (1) of forty-five (45) Stage II sample residents. Resident identifiers: #33. Facility census: 52 Findings include: a) Resident #33 1) Review of physician orders, for this resident's re-admission to the facility on [DATE], revealed an order for [REDACTED]. These physician orders [REDACTED]. Review of the care plan found it only stated the knee braces were to be applied to both knees for six (6) hours while in bed for the night. This was not as ordered by the physician. During an interview with Employee #44 (the director of nursing), on 07/23/12, at approximately 11:00 a.m., she said the care plan was incorrect related to the braces. Employee #44 stated the resident's family member asked to have the leg braces applied only in the day time while the resident was up in the chair, and not at night while in bed, because the braces were interfering with the resident's sleep. Employee #44 confirmed this care plan should have been revised. 2) Review of the medical record found a physician's orders [REDACTED].#33. The care plan contained an intervention for restorative nursing to ambulate the resident five (5) times weekly PRN (as needed or desired) with a gait belt and staff assistance of two (2) when the resident was able to be ambulated. When interviewed on 07/23/12, at approximately 11:00 a.m., Employee #44 also confirmed this care plan should have been revised, but was not. | 2016-07-01 |
| 8303 | 8303 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 282 | E | 0 | 1 | TTVD11 | Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure a qualified professional assessed pressure ulcers and/or wounds for three (3) of forty-five (45) Stage II sample residents. The assessments were conducted by staff members who were not qualified to complete assessments of residents without oversight. In addition, the assessments were not completed by qualified personnel as directed in the facility's wound care policies and procedures. Resident identifiers: #63, #48, and #53. Facility census: 52. a) Resident #63 On 07/23/12 at 9:00 a.m., this resident's 05/30/12 care plan was reviewed. It contained a handwritten note, dated 07/04/12, which described an unstageable wound on the left heel which measured 3 cm long by 3 cm wide. The note also described a Stage 2 wound to the right heel which was 4.5 cm long by 5 cm wide. The note was signed by a licensed practical nurse (LPN), Employee #45. The care plan, dated 06/27/12, contained no mention of a pressure ulcer; although other medical record review revealed the areas remained on the resident's heels. Review of the wound flow sheets revealed Employee #45 (LPN) completed wound measurements and characteristics of the left and right heels on 06/21/12, 07/04/12, and 07/16/12. The flow sheet contained no evidence a registered nurse (RN) completed any part of the wound assessment. The sections requiring an RN signature on the wound assessments did not contain a signature. The facility's policy and procedure, Wound Flow Sheet, was reviewed. The section entitled Use, required at least a weekly assessment when skin integrity was impaired or there was an open area, such as a pressure ulcer or surgical wound. An LPN was to complete the wound measurements and describe the characteristics of the wound. An RN was to complete the assessment of the wound, including a determination of the type of wound. The Instructions section directed the RN to, Check the box for pressure ulcer or wound type. This section also sated the RN … | 2016-07-01 |
| 8304 | 8304 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 309 | G | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on record review and staff interview, the facility failed to ensure consistent assessment, monitoring, and evaluation of a resident receiving intravenous fluids. Additionally, the facility failed to ensure timely medical intervention when a resident experienced deterioration in health status. The facility ' s failure to provide the necessary care and services for this resident resulted in harm. This practice affected one (1) of 45 Stage II sample residents. Resident identifier: #33. Facility census: 52. Findings include: a) Resident #33 Medical record review revealed Resident #33 began receiving intravenous (IV) fluids with 20 MeQ (milliquivalents) of potassium at 75 cc per hour shortly after midnight on 04/20/12. Factors which placed her at higher risk for potential adverse reactions from receiving IV fluid therapy included a [DIAGNOSES REDACTED]. Despite the increased risk of adverse reactions, record review revealed that nursing staff were not consistently assessing lung sounds or early signs of fluid overload. Review of a hospice note, written by a registered nurse from hospice, found notation that the resident's lung sounds were clear when assessed on 04/20/12. Further medical record review found no evidence of lung sound assessments by facility staff on any of the three (3) shifts on 04/20/12, 04/21/12, or 04/22/12. The 04/23/12 nurse's notes for 3:00 a.m. noted the resident's respiratory rate had been 32 breaths per minute at 10:00 p.m., and lung sounds were diminished bilaterally in the lower lobes. Later, at 8:45 a.m. on 04/23/12, the hospice aide notified the nurse that the resident was coughing. The nurse assessed the resident ' s moist lung sounds and noted rhonchi present bilaterally. The nurse ' s note indicated the hospice nurse was called to come in and evaluate the resident. Upon her arrival to the facility at 10:30 a.m., the hospice nurse assessed the resident with slight expiratory wheezing. Neither the physician n… | 2016-07-01 |
| 8305 | 8305 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 315 | G | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to provide care and services to prevent infections related to catheter usage, failed to assess for and implement interventions to restore bladder continence to the extent possible, and/or failed to ensure there were valid medical justifications for the use of catheters for two (2) of 45 Stage II residents. Additionally, there was no evidence of ongoing assessment and/or implementation of individualized interventions in an effort to discontinue the catheter and/or to provide services to restore normal bladder function for these residents. There was no evidence the facility assessed the residents for causal factors for the incontinence, as urinary incontinence is a symptom of a condition which may be reversible. Additionally, there was no evidence the facility managed the Foley catheters in a manner which reduced complications, such as urinary tract infections (UTIs), which are a known complication related to catheter usage. Resident identifiers: #32 and #70. Facility census: 52 Findings include: a) Resident #32 Medical record review revealed a bladder assessment dated [DATE]. At that time restorative retraining was not recommended due to urge incontinence. There was no evidence that possible causal factors for the urge incontinence had been explored. According to the medical record, the resident had a Foley catheter inserted on 12/31/10, at the request of Hospice, for [MEDICAL CONDITION]. There was no evidence of [MEDICAL CONDITION] at the time of insertion of the catheter, and there was no evidence of a urology consultation before or since the Foley catheter was inserted. Additionally, there was no evidence of any attempts to remove the Foley catheter and initiate interventions in an effort to restore normal bladder functioning. An interview was conducted with a licensed practical nurse (LPN), Employee #45, at 10:20 a.m. on 07/18/12. She stated bladder train… | 2016-07-01 |
| 8306 | 8306 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 323 | F | 0 | 1 | TTVD11 | Part I Based on observation, staff interview, staff-assisted checks of facility water temperatures, review of the Guidance to Surveyors found in the State Operations Manual (SOM) published by the Centers for Medicare & Medicaid Services, and the West Virginia Nursing Home Licensure Rule, the facility failed to provide a resident environment as free of accident hazard as possible. Water temperatures were measured by the maintenance director, using the facility's thermometer, to be as high as 120 degrees Fahrenheit (F) at the hand sinks in various residents' rooms and a shower room sink. This had the potential to affect more than an isolated number of residents due to the potential for scalding/burn injuries, especially for independently mobile residents with cognitive impairment and/or decreased sensitivity to pain and extreme temperatures. Facility census: 52. Findings include: a) On 07/23/12 at 10:40 a.m., a surveyor informed the maintenance supervisor the hot water in resident sinks felt too hot to touch and requested the hot water temperatures be checked using a facility thermometer. A check of the hand sinks, on 07/23/12 between 10:50 a.m. and 11:10 a.m., located in the following resident rooms, found the excessively hot water temperatures registered as follows: Room #100 - 120 degrees F Room #105 - 120 degrees F Room #202 - 120 degrees F Room #211 - 120 degrees F Room #302 - 120 degrees F Room #313 - 120 degrees F Shower room on 200 Hall - 120 degrees F The maintenance supervisor stated he had been told by his predecessor the water temperatures were to be maintained between 115 and 120 degrees (F). He further stated he visually checked the water temperatures each day but had no written evidence of the temperatures. Information in the Guidance to Surveyors for this requirement, found in Appendix PP of the CMS State Operations Manual, revealed the following: Water Temp - Time Required for a 3rd Degree Burn to Occur 155 degrees F - 1 sec 148 degrees F - 2 sec 133 degrees F - 15 sec 127 degrees F - 1 min 124 deg… | 2016-07-01 |
| 8307 | 8307 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 325 | D | 0 | 1 | TTVD12 | Based on medical record review, resident interview, and staff interview, the facility failed to provide nutritional care and services to prevent unplanned weight loss for one (1) of twenty sample residents. The facility failed to recognize, evaluate, and address the individual nutritional needs of this resident to ensure she maintained an acceptable nutritional status. Resident identifier: #10. Facility census: 49 Findings include: a) Resident #10 An interview was conducted with the resident on 10/03/12 at 9:00 a.m. When asked about her meals, the resident stated she did not like the food. She stated the food did not taste good to her. When she was asked about an alternate meal, she stated there were no alternates. Medical record review, on 10/04/12, revealed Resident #10 had a severe unplanned weight loss of 6.3% in a thirty-seven (37) day period which was not addressed by the facility. On 08/01/12, the recorded weight was 175 pounds. On 09/07/12, the weight recorded was 164 pounds. This was an eleven (11) pound weight loss. The dietitian noted the weight loss on 09/11/12, and ordered weekly weights for four (4) weeks. The dietitian's notes described the resident as obese and above her ideal body weight recommendation, which was 102 to 112 pounds. The nursing assistants' meal tracking showed the resident frequently refused breakfast, and the overall meal consumption was frequently less than fifty (50) percent. Review of the medical record revealed the resident's care plan was not updated to address the weight loss or poor meal consumption. The care plan did not include any interventions to encourage the resident to eat. There were no interventions to offer alternatives when she refused to eat, or ate less than a certain percentage of her meals. An interview was conducted on 10/04/12, with the director of nursing (DON), regarding the weekly weights. The DON was unable to locate the weekly weights. The DON contacted the certified manager (CDM), who was also unable to produce weekly weights for the resident. There … | 2016-07-01 |
| 8308 | 8308 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 327 | G | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide one (1) one of 45 Stage II sample residents with sufficient fluid intake to maintain proper hydration and health. The resident's care plan did not contain interventions to ensure the resident was provided and accepted sufficient fluids daily. Additionally, there was no ongoing monitoring of the resident's fluid intake to determine if her intake was adequate and/or if there was a need for interventions to ensure adequate fluid intake. The resident was hospitalized with dehydration. Resident identifier: #33. Facility census: 52. Findings include: a) Resident #33 Record review revealed this [AGE] year old resident had [DIAGNOSES REDACTED]. Record review also revealed this resident was dependent on staff for feeding and fluid intake. Review of the most recent care plan, dated 01/25/12, found an intervention to offer fluids frequently while awake. This intervention did not provide a distinct action plan for offering fluids, or improving fluid intake. Review of the former care plan, dated 10/26/11, found another generic intervention to Encourage adequate fluid intake q. (every) shift. Review of the consultant registered dietitian (RD) notes, dated 02/16/12, revealed a description that the most recent lab results indicate pos (possible)/slight dehydration. The RD recommended staff to encourage fluid intake and monitor for changes. Record review revealed the most recent BMP (basic metabolic profile) the dietitian referred to was completed on 01/28/12. The BUN (blood urea nitrogen) was elevated at 32, with the normal reference range between 8 and 27. The BUN/creatinine ratio was elevated at 42, with the normal reference range between 11-26. These values can be indicative of dehydration. Record review found no further dietitian notes prior to discharge from the facility on 04/23/12. Review of a discharge summary from the hospital, dated 04/19/12, revealed Resident #33 was admitt… | 2016-07-01 |
| 8309 | 8309 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 328 | D | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure proper care for special resident needs for one (1) of forty-five (45) Stage II sample residents. A hand-held nebulizer [MEDICATION NAME] treatment was not effectively administered. Resident identifier: #29. Facility census: 52. Findings include: a) Resident #29 Observation on 07/16/12, from 2:00 p.m. through 2:34 p.m., found Resident #29 lying in bed on his back with his head lying on the pillow leaning slightly toward the right. A medicated aerosol nebulizer treatment was being administered via a mouthpiece that was lying on a towel placed across his chest. Supplemental oxygen was being administered by a nasal cannula. During this observation, the mouthpiece was noted beneath the resident's right arm, while the nebulizer machine was still running. No staff were in attendance. A licensed nurse, Employee #45, entered the resident's room at 2:34 p.m. to perform a decubitus ulcer treatment. When asked if the resident was supposed to be getting a nebulizer treatment, she stated, He's supposed to, but obviously not, as she removed the mouthpiece from beneath his right arm. The medicine cup still had some of the medication present when the nurse lifted the mouthpiece and tubing back to the nebulizer machine. Employee #45 said the nebulizer treatment was prn (as needed), rather than scheduled. When asked if the resident had been wheezing or short of breath, Employee #45 said she would have to ask his nurse, Employee #14. The resident's medical record was reviewed, on 07/17/12. The resident had [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. The space provided on the back of the MAR for the result, or progress of the treatment was left blank. During a meeting with Employee #44 (Director of Nursing) and Employee #37 (Administrator) on 07/18/12 at 4:00 p.m., the report of this finding was discussed. No further information was provided prior to exit. | 2016-07-01 |
| 8310 | 8310 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 329 | D | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of consultant pharmacist reports, and of the current recommendations for the maximum dose of Tylenol ([MEDICATION NAME]), the medication regimens for three (3) of forty-five (45) Stage 2 sample residents were not free from unnecessary medications. The facility failed to ensure there were adequate indications for the use, reasons for not implementing a gradual dose reduction of a psychoactive medication, and failed to ensure residents were not provided excessive doses of medications. Resident identifiers: #67, #32, and #10. Facility census: 52. Findings Include: a) Resident #67 This resident was admitted to the facility from the hospital on [DATE], with an order for [REDACTED]. Review of the consultant pharmacist report, dated 06/08/12, revealed the suggestion, Please consider reducing the dose of [MEDICATION NAME] to 0.5 mg hs (hour of sleep), with the eventual goal of discontinuation, if possible. There was no evidence the facility made an effort to determine why the resident was ordered this medication, and no evidence the facility reevaluated the use of the [MEDICATION NAME], in an effort to reduce or discontinue the medication. b) Resident #32: Medical record review revealed this resident's orders for Tylenol and [MEDICATION NAME] had no dosing parameters in place. This created a potential for the resident to receive 4550 mg of [MEDICATION NAME] in a 24 hour period, which exceeds the maximum recommended safe amount over a 24 hour period. The resident had physician's orders [REDACTED]. This would be 3900 mg, if the resident received the allowed six (6) doses of 650 mg of [MEDICATION NAME]. The resident also had an order for [REDACTED]. Two (2) of these daily would be 650 mg of [MEDICATION NAME]. The two (2) of these together are equivalent to 4550 mg of [MEDICATION NAME]. c) Resident #10 Medical record review revealed this resident's orders for Tylenol and [MEDICATION NAME] had no dosing parameters in… | 2016-07-01 |
| 8311 | 8311 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 371 | F | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of policies and procedures, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. Opened and undated foods were observed in the kitchen refrigerator and freezer. Food carts were left open and unattended in the dining room and on the units. Spices were found open without indication of when they were opened. Effective hair restraints were not worn while in the food preparation/serving area. Tube feeding formulas and nutritional supplements were stored in an unsecured building which had extreme temperature fluctuations. Soiled food service items were in contact with clean items. Hands were not washed as necessary. Foods were handled with bare hands. These practices had the potential to affect all residents who resided at the facility. Facility census: 52. Findings include: a) During the initial observation of the kitchen, on July 15, 2012 at 4:30 p.m., the following sanitation infractions were observed: -The walk-in freezer contained opened and undated packages of meat and broccoli. -The walk-in refrigerator had opened and undated packages of cottage cheese and strawberry yogurt on the shelf. This information was discussed with the dietary manager (DM), Employee #46, on 07/16/12. At that time, the DM verified the opened and undated items in the freezer. b) During the first dining observation, on 07/15/12, the food cart on the 300 hall was left open and unattended while trays were being served. c) During additional dining observations, on 07/16/12 and 07/18/12, staff members were observed entering the kitchen into the area with the steam table without effective hair restraints. d) During the initial dining room observation, on 07/15/12 at 4:28 p.m., the following sanitation issues were observed: - Two (2) dirty coffee cups were observed sitting on a tray with clean coffee cups. - Kitchen doors were open and numerous employees entered without wearing effect… | 2016-07-01 |
| 8312 | 8312 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 425 | E | 0 | 1 | TTVD11 | Based on observation and staff interview, the facility failed to ensure the safe provision of pharmaceutical services. The disposition of expired medications was not timely, resulting in a potential to administer expired medications. The medication cart had an expired bottle of ear drops for one (1) resident, and expired influenza virus vaccine was found in the medication room. This practice had the potential to affect more than a limited number of residents. Resident identifier: #26. Facility census: 52. Findings include: a) Resident #26 During a visual check of the medication cart, on the 200 hall at 5:00 p.m. on 07/15/12, an opened bottle of Carbamoxide ear drops, labeled for this resident, was observed. Its label noted the date the ear drops were opened, which was more than 18 months ago, on 01/01/11. Employee #42 (registered nurse) was present at the time of the observation. She acknowledged the medication was opened over a year ago, and should have been discarded. b) On 07/15/12 at 4:15 p.m., observation of the medication room revealed seven (7) vials of influenza virus vaccine in a plastic bag labeled expired 5/31/12. An interview was conducted with a registered nurse (RN), Employee #42, on 07/15/12 at 4:25 p.m. Employee #42 stated expired medications were supposed to be sent back to the pharmacy. This employee stated the pharmacy came to the facility every night. | 2016-07-01 |
| 8313 | 8313 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 428 | D | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the consultant pharmacist failed to report medication irregularities for two (2) of forty-five (45) Stage II sample residents. These residents had physician's orders [REDACTED]. Resident identifiers: #32 and #10. Facility census: 52 Findings include: a) Resident #32 Medical record review revealed this resident's orders for Tylenol and Percocet had no dosing parameters in place. This created a potential for the resident to receive as much as 4550 mg of acetaminophen in a 24 hour period, which exceeds the maximum recommended safe amount over a 24 hour period. The resident had physician's orders [REDACTED]. This would be 3900 mg, if the resident received the allowed six (6) doses of 650 mg of acetaminophen. The resident also had an order for [REDACTED]. Two (2) of these daily would be 650 mg of acetaminophen. The two (2) of these together are equivalent to 4550 mg of acetaminophen. Review of the resident's medication review revealed the pharmacist failed to identify and report there were no dosing limitations on the medications containing acetaminophen. Interview with Employee #44, the director of nursing (DON), confirmed these irregularities were not identified by the consultant pharmacist. The DON also stated the pharmacist was responsible for identifying the potential for overdoses, and for placing dosing alerts on the medical record. b) Resident #10 Medical record review revealed this resident's orders for Tylenol and Percocet had no dosing parameters in place. This created a potential for the resident to receive 4550 mg of acetaminophen in a 24 hour period, which exceeds the maximum recommended safe amount over a 24 hour period. The resident had physician's orders [REDACTED]. The two (2) of these together are equivalent to 4550 mg of acetaminophen. Review of the resident's medication review revealed the pharmacist failed to identify and report there were no dosing limitations on the medica… | 2016-07-01 |
| 8314 | 8314 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 431 | E | 0 | 1 | TTVD11 | Based on observation, policy review, review of the guidelines in Appendix PP of the State Operations Manual, and staff interview, the facility failed to ensure the consultant pharmacist maintained a formal system for safe and secure use and storage of medications. 1) Multi-dose medication vials were not labeled with the date they were first opened; 2) There was no permanently affixed storage container in the refrigerator for the secure storage of controlled medications; and 3) The biohazard storage refrigerator in the medication preparation room was not clearly identifiable as such with a visible label. These practices affected Residents #32 and #69, and had the potential to affect more than an isolated number of residents. Facility census: 52. Findings include: a) Resident #32 During a visual check of the medication cart on the 200 Hall, at 5:00 p.m. on 07/15/12, a previously opened bottle of Brimonidine eye drops with a label indicating that they were for Resident #32 was observed. There was no date written on the bottle to indicate when they had been opened. b) Resident #69 During a visual check of the medication cart on the 200 Hall, at 5:00 p.m. on 07/15/12, a previously opened bottle of Carbamoxide ear drops with a label indicating that they were for Resident #69 was observed. There was no date written on the bottle to indicate when they had been opened. c) Employee #42 (registered nurse) was present at the time of the observations regarding Residents #32 and #69. She acknowledged the medications should have been labeled with the date of opening, and stated it was the policy of the facility, in order to set the expiration date. d) Observation, on 07/15/12 at 4:15 p.m., revealed the medication refrigerator contained two (2) clear plastic boxes. One (1) box contained six (6) vials of Lorazepam which had a blue numbered break away lock. The other box was empty. Both boxes were freely moveable in the refrigerator. Another observation, on 7/24/12 at 10:15 a.m., revealed the medication refrigerator had four (4) s… | 2016-07-01 |
| 8315 | 8315 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 441 | E | 0 | 1 | TTVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record reviews, and review of manufacturer's instructions, the facility failed to maintain a safe and sanitary environment to help prevent the development and transmission of disease and infection. The facility did not ensure the proper disinfectant was used on the shower cart after showering a resident with Clostridium difficile (C. diff); failed to ensure proper hand sanitation during food service; failed to conduct medication pass in a sanitary manner; and failed to ensure nebulizer equipment was cleaned and stored in a manner to prevent the spread of infectious organisms. These practices affected five (5) five of forty-five (45) Stage II sample residents, and had the potential to affect all residents who received showers on Hallway 2, all residents who received nebulizer treatments, all residents who received medication, and all residents who received meals in the dining room. Resident identifiers: #48, #20, #29, #30, and #17. Facility census: 52. Findings include: a) Resident #48 Medical record review revealed this resident was positive for Clostridium difficile (C. diff). During an interview, on 07/18/12 at 2:45 p.m., Employee #21, a nursing assistant, stated after showering Resident #48, the shower cart was cleaned with a disinfectant spray. She stated housekeeping placed the container of disinfectant on the wall, and this was what they used. On 07/18/12, at approximately 2:30 p.m., the director of maintenance (Employee #58) was interviewed. He stated the disinfectant placed in the shower room container was a product called Cen-Kleen IV. He also reported the isolation rooms were cleaned with a product called Virasept. On 07/24/12 at 1:45 p.m., Employee #29, a nursing assistant, stated after showering Resident #48, the shower cart was cleaned with the disinfectant in the container on the shower wall and then rinsed with warm water. Review of the labels for these products revealed Cen-Klee… | 2016-07-01 |
| 8316 | 8316 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 465 | F | 0 | 1 | TTVD12 | Based on observation and staff interview, the facility failed to ensure sanitary conditions were maintained in the refrigerator of the resident snack room. When opening the door to the refrigerator, a smell of spoiled milk was noted. White debris was found on the shelf where milk cartons were stored. This practice had the potential to affect all residents in the facility. Facility census: 49 Findings include: a) On 10/03/12 at 9:00 a.m., observation of the resident snack room found the refrigerator smelled of spoiled milk. White debris was found on the shelf where milk cartons were being stored. The dietary manager (DM) was interviewed, on 10/03/12 at 9:30 a.m., in the resident snack room. When the DM opened the refrigerator door, she stated, This smells, and needs to be cleaned. She agreed the refrigerator smelled of spoiled milk. | 2016-07-01 |
| 8317 | 8317 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 490 | F | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility was not administered in a manner in which its resources were used effectively and efficiently to ensure optimum quality of care for each resident. The facility failed to provide individualized services to assist each resident in attaining or maintaining the highest practicable physical, mental, and/or psychosocial well-being. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34, the Quality Assurance (QA) committee contact person, at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been presented to the facility's QA committee. The facility's administrative personnel were part of the QA committee. The facility's administrative personnel did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDIC… | 2016-07-01 |
| 8318 | 8318 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 514 | D | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an accurate medical record for two (2) of twenty (20) residents in the sample. The monthly recapitulation orders did not contain revisions and changes made from one month to the next. Resident identifiers: #53 and# 42. Facility census 49. Findings include: a) Resident #53 A review of the medical record revealed the physician's orders [REDACTED]. During an interview with the director of nurses (DON), at 8:50 a.m. on 10/4/12, she stated the resident no longer had pressure ulcers. She said they were healed in August and treatment was discontinued. She located evidence of this in the record. Upon review of the record, she agreed the orders for treatment had not been deleted from the record. b) Resident #42 Review of the resident's medical record, at 10:00 a.m. on 10/03/12, revealed the October 2012 recapitulation orders contained five (5) orders that had been discontinued. The orders on the recapitulation were indicated accurate by the director of nursing services (DON), Employee #20, on 09/28/12. Additionally, the physician approved the orders, by signature, on 10/01/12. An order was present for monitoring an incision site on the resident's back for signs and symptoms of infection due to status [REDACTED]. Review of the treatment administration record (TAR) revealed this treatment was discontinued on 09/28/12. Interview with the treatment nurse (Employee #48) at 10:15 a.m. on 10//03/12 confirmed this area was healed on the date indicated on the TAR. There was an order for [REDACTED].#20, on 10/04/12 at 12:00 p.m., she clarified the resident went to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The resident's physician's orders [REDACTED]. According to the TAR, the stage II pressure ulcer was healed on 08/23/12. During the interview with Employee #48, at 10:15 a.m. on 10/03/12, she confirmed the pressure ulcer was healed on the date indicated on the TAR. An … | 2016-07-01 |
| 8319 | 8319 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 517 | F | 0 | 1 | TTVD11 | . Based on facility policy review and staff interview, the facility failed to maintain an up to date, complete, and easily accessible written plan and procedure manual to meet potential emergencies. This had the potential to affect all residents. Facility census: 52. Findings include: a) A review of the Emergency Manual was done at 8:00 a.m. on 07/24/12. The manual was presented to the surveyors by Employee #58 (director of maintenance), who stated he was responsible for overseeing the employee training of emergency procedures and providing staff drills to ensure resident safety. A front sheet entitled Annual Review and Update of The Disaster Plan contained annual signatures of the Administrator starting with 09/06/05 and ending with 04/05/11. There was no index, tabs, or other method for easy and quick access to the various procedures contained in the manual. During an interview with Employee #58, at 8:45 a.m. on 07/24/12, he stated he had gotten the manual from the nurses' station and that, as far as he knew, it was the only one available in the facility. He stated he was not sure who was in charge of the policies it contained. During an interview with Employee #62 (registered nurse), at 9:15 a.m. on 07/24/12, she verified there was only one (1) emergency manual and it was kept on a shelf at the nurses' station. There was no evidence the manual was periodically reviewed or revised as evidenced by the following: 1) There was no order to the policies. 2) There were multiple policies in various locations in the manual, such as: a) A Fire Plan (Number VII.2a) issued July 1998 with an effective date of April 2001 b) An undated Fire Plan (it contained a policy entitled Heat Emergency Plan with an effective date of 10/10/1983), which was different than a and it had an addendum dated 1990. c) There was a third Fire Plan, dated 2001. 3) The manual contained two (2) different, undated, Disaster Evacuation Plans. 4) The manual contained four (4) different plans for the procurement of fresh water in an emergency. One (1) o… | 2016-07-01 |
| 8320 | 8320 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 518 | C | 0 | 1 | TTVD11 | Based on facility policy review, personnel records review, and staff interview, the facility failed to adequately train employees in emergency procedures by failing to use the current Fire Plan as the basis for the training. This had the potential to affect all residents. Facility census: 52. Findings include: a) After a review of the personnel records, at 2:00 p.m. on 07/17/12, a meeting was held with Employee #52 (Registered Nurse and Staff Development Coordinator). She explained all of the required in-services for both orientation purposes and annual in-services were completed by using a computerized video training program which was provided by the corporate office. The exception to this was the emergency, fire, and disaster training, which Employee #52 stated was provided by the Maintenance Director. A review of the Emergency Manual was done at 8:00 a.m. on 07/24/12. The manual was presented to the surveyors by Employee #58 (Director of Maintenance), who stated he was responsible for overseeing the employee training of emergency procedures and providing staff drills to ensure resident safety. There was no evidence the manual was periodically reviewed or revised as evidenced by the multiple Fire Plans it contained. 1) A Fire Plan (Number VII.2a) issued July 1998 and effective April 2001 2) An undated Fire Plan (it contained a policy entitled Heat Emergency Plan with an effective date of 10/10/1983), which was different than 1 and an it had an addendum dated 1990. 3) A third Fire Plan was provided, and it was also dated 2001. Employee #52, the staff development coordinator, was asked for the teaching aids used for the emergency procedures training. She provided a Fire Plan at 10:35 a.m. on 07/24/12. The fire plan Employee #52 stated was used in the training was not the current Fire Plan. The plan being used for training was the undated plan described in 2 above. During an interview with the Administrator, at 9:40 a.m. on 07/24/12, he had no comments about the concerns above, and expressed his thanks that the in… | 2016-07-01 |
| 8321 | 8321 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 520 | F | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility's quality assurance program failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34 (QA Committee Contact Person), at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been addressed with the Quality assessment and assurance committee (QA Committee). The plan of correction referred to submitting results to the QA committee as part of their correction. The QA committee did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDICAL TREATMENT] care as instructed on the care plan and according to the facility's policy. c) Medical record review and staff interview revealed the facility failed to update … | 2016-07-01 |
| 8322 | 8322 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2013-08-01 | 253 | E | 1 | 0 | 7GX311 | Based on observation, staff interview, and record review, the facility failed to ensure housekeeping services were provided to maintain a clean shower room. The shower room on the 200 hall had dried white debris going down from the shower panel and a black moist mold-like substance against the molding on the bottom of the wall and floor. A clear colored substance had leaked out from underneath the shower panel. This had the potential to affect more than a limited number of residents as any resident could shower in the 200 hall shower room. Facility census: 50. Findings include:a) Observation of the 200 hall shower room, on 07/29/13 1:00 p.m., revealed a shower panel on the left side of the wall with dried white debris going down from the shower panel to the floor. The white debris covered an area which measured three (3) feet in length by two (2) feet in width. A black moist mold-like substance was on the tile floor below the shower panel measuring one (1) foot by one (1) foot. This substance was also on the molding against the bottom of the wall and measured two (2) feet in length by one (1) foot in width. There was clear leakage coming from underneath the shower panel. On 07/30/13 at 2:30 p.m. and 07/31/13 at 09:45 a.m., observations found the condition of the shower unchanged.Observations of the shower room on the 200 hall, were made on 07/31/13 at 09:48 a.m., with Employee #62, a registered nurse (RN). When asked what was on the wall and the floor, she stated it was a dried white chemical from the shower panel that was leaking, and there was some kind of black mold-like substance on the molding against the bottom of the wall and on the floor. A tour of the 200 hall shower room was conducted on 07/31/13 at 09:50 a.m., with Employee #15, the environment assistant (EA). She agreed it looked like a mold-like substance on the floor, and stated the white substance on the wall looked like the chemical cleaner they used on the shower panel.During a tour of the 200 hall shower room with Employee #2, the housekeeping a… | 2016-07-01 |
| 9919 | 9919 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 241 | E | 1 | 0 | 943L11 | . Based on observation and staff interview, the facility failed to provide an environment which maintained or enhanced each resident's dignity. The privacy curtains were too short to provide privacy for all residents. This had the potential to affect all residents in B beds. Facility census: 53 Findings include: a) B beds Observation during the initial tour, on 07/11/12 at 2:30 p.m., found the privacy curtains in the residents' rooms were pulled. Observation revealed they were too short to provide privacy for residents in the B beds (Beds in semi-private rooms are often referred to as A and B). The maintenance director stated in an interview, on 07/11/12 at 3:30 p.m., that all of the curtains in all of the rooms were the same and fit around every B bed the same way. The maintenance director said it had been that way for 8 years. The findings were verified with Employee #44 (DON) at 3:00 p.m. on 07/11/12. . | 2015-08-01 |
| 9920 | 9920 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 463 | E | 1 | 0 | 943L11 | . Based on observation and staff interview, the facility failed to provide a functioning call system for residents residing on the 100 Hall and residents utilizing the resident bathroom on the 100 Hall. This had the potential to affect more than an isolated number of residents. Facility census: 52. Findings include: a) On 07/11/12 at 1:50 p.m., the resident bathroom call light, on the 100 Hallway, was observed blinking red and no staff were visible in the hallway. This was observed for five (5) minutes. A resident in the room was heard asking, " someone out there? " At that time the ward clerk (Employee #17) was told a resident needed assistant in the bathroom. When asked how the call system worked, Employee #17 went to the wall telephone, directly across from the nurses station, and stated the system was working because the call light was noted on the LED screen. When asked if the call system had an audible alarm, she confirmed it should be sounding, but was not. Employee #58 (maintenance director) was paged to the desk and stated, "There was a problem with the call cord in room 103 earlier, and maybe it was not the right cord and caused the audible alarm malfunction." He took the unit off the wall, turned it over, and stated he thought it might be the battery. He said he did not want to shut down the system because it was so busy. Employee #58 verified the system for the 100 Hall was not working in regard to the audible alarm. He informed staff at the nurses station the audible alarm was not working on the 100 Hallway. At approximately 3:30 p.m., the maintenance director stated the call lights on the 100 hallway were working and thought it might be from interference with some electrical cord close to the call system phone, He stated he would take care of this in the morning by drilling a hole and relocating the wire. When checking the call bell system in room 103, with Employee #58, he pulled the call light cord out of the panel and no light came on. He explained when a call light cord is removed from the panel… | 2015-08-01 |
| 9921 | 9921 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-10-05 | 325 | D | 0 | 1 | TTVD12 | . Based on medical record review, resident interview, and staff interview, the facility failed to provide nutritional care and services to prevent unplanned weight loss for one (1) of twenty sample residents. The facility failed to recognize, evaluate, and address the individual nutritional needs of this resident to ensure she maintained an acceptable nutritional status. Resident identifier: #10. Facility census: 49 Findings include: a) Resident #10 An interview was conducted with the resident on 10/03/12 at 9:00 a.m. When asked about her meals, the resident stated she did not like the food. She stated the food did not taste good to her. When she was asked about an alternate meal, she stated there were no alternates. Medical record review, on 10/04/12, revealed Resident #10 had a severe unplanned weight loss of 6.3% in a thirty-seven (37) day period which was not addressed by the facility. On 08/01/12, the recorded weight was 175 pounds. On 09/07/12, the weight recorded was 164 pounds. This was an eleven (11) pound weight loss. The dietitian noted the weight loss on 09/11/12, and ordered weekly weights for four (4) weeks. The dietitian's notes described the resident as obese and above her ideal body weight recommendation, which was 102 to 112 pounds. The nursing assistants' meal tracking showed the resident frequently refused breakfast, and the overall meal consumption was frequently less than fifty (50) percent. Review of the medical record revealed the resident's care plan was not updated to address the weight loss or poor meal consumption. The care plan did not include any interventions to encourage the resident to eat. There were no interventions to offer alternatives when she refused to eat, or ate less than a certain percentage of her meals. An interview was conducted on 10/04/12, with the director of nursing (DON), regarding the weekly weights. The DON was unable to locate the weekly weights. The DON contacted the certified manager (CDM), who was also unable to produce weekly weights for the resident. Ther… | 2015-08-01 |
| 9922 | 9922 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-10-05 | 465 | F | 0 | 1 | TTVD12 | . Based on observation and staff interview, the facility failed to ensure sanitary conditions were maintained in the refrigerator of the resident snack room. When opening the door to the refrigerator, a smell of spoiled milk was noted. White debris was found on the shelf where milk cartons were stored. This practice had the potential to affect all residents in the facility. Facility census: 49 Findings include: a) On 10/03/12 at 9:00 a.m., observation of the resident snack room found the refrigerator smelled of spoiled milk. White debris was found on the shelf where milk cartons were being stored. The dietary manager (DM) was interviewed, on 10/03/12 at 9:30 a.m., in the resident snack room. When the DM opened the refrigerator door, she stated, "This smells, and needs to be cleaned." She agreed the refrigerator smelled of spoiled milk. . | 2015-08-01 |
| 9923 | 9923 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-10-05 | 514 | D | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure an accurate medical record for two (2) of twenty (20) residents in the sample. The monthly recapitulation orders did not contain revisions and changes made from one month to the next. Resident identifiers: #53 and# 42. Facility census 49. Findings include: a) Resident #53 A review of the medical record revealed the physician's orders [REDACTED]. During an interview with the director of nurses (DON), at 8:50 a.m. on 10/4/12, she stated the resident no longer had pressure ulcers. She said they were healed in August and treatment was discontinued. She located evidence of this in the record. Upon review of the record, she agreed the orders for treatment had not been deleted from the record. . b) Resident #42 Review of the resident's medical record, at 10:00 a.m. on 10/03/12, revealed the October 2012 recapitulation orders contained five (5) orders that had been discontinued. The orders on the recapitulation were indicated accurate by the director of nursing services (DON), Employee #20, on 09/28/12. Additionally, the physician approved the orders, by signature, on 10/01/12. An order was present for monitoring an incision site on the resident's back for signs and symptoms of infection due to status [REDACTED]. Review of the treatment administration record (TAR) revealed this treatment was discontinued on 09/28/12. Interview with the treatment nurse (Employee #48) at 10:15 a.m. on 10//03/12 confirmed this area was healed on the date indicated on the TAR. There was an order for [REDACTED].#20, on 10/04/12 at 12:00 p.m., she clarified the resident went to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The resident's physician's orders [REDACTED]. According to the TAR, the stage II pressure ulcer was healed on 08/23/12. During the interview with Employee #48, at 10:15 a.m. on 10/03/12, she confirmed the pressure ulcer was healed on the date indicated on the TAR.… | 2015-08-01 |
| 9924 | 9924 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-10-05 | 520 | F | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility's quality assurance program failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34 (QA Committee Contact Person), at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been addressed with the Quality assessment and assurance committee (QA Committee). The plan of correction referred to submitting results to the QA committee as part of their correction. The QA committee did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDICAL TREATMENT] care as instructed on the care plan and according to the facility's policy. c) Medical record review and staff interview revealed the facility failed to update … | 2015-08-01 |
| 9925 | 9925 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-10-05 | 490 | F | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observations, staff interviews, and policy review, the facility was not administered in a manner in which its resources were used effectively and efficiently to ensure optimum quality of care for each resident. The facility failed to provide individualized services to assist each resident in attaining or maintaining the highest practicable physical, mental, and/or psychosocial well-being. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34, the Quality Assurance (QA) committee contact person, at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been presented to the facility's QA committee. The facility's administrative personnel were part of the QA committee. The facility's administrative personnel did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MED… | 2015-08-01 |
| 10021 | 10021 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 225 | D | 0 | 1 | 4T1611 | . Based on a review of personnel files and staff interview, the facility failed to thoroughly screen one (1) of ten (10) sampled employees for findings of abuse or neglect, by failing to make an inquiry to the WV Nurse Aide Registry as required before the new employee was permitted to begin work at the facility. Employee identifier: #75. Facility census: 50. Findings include: a) Employee #75 A review of the personnel file for Employee #75, on the morning of 02/09/10, revealed that she was hired as a nursing assistant on 10/05/09. However, there was no evidence to reflect this individual was screened through the WV Nurse Aide Registry for findings of resident abuse / neglect. When interviewed on 02/09/10 at 3:00 p.m., the director of nursing (Employee #7) confirmed there was no evidence the required registry check was made prior to the employment of Employee #75. . | 2015-07-01 |
| 10022 | 10022 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 496 | D | 0 | 1 | 4T1611 | . Based on review of sampled personnel records and staff interview, the facility failed to receive registry verification that individuals met competency evaluation requirements before allowing them to serve as nurse aides. This was found for one (1) of ten (10) records reviewed. Employee identifier: #75. Facility census: 50. Findings include: a) Employee #75 Review of the personnel records of Employee #75 (a nursing assistant), on the morning of 02/09/10, revealed she started working on 10/05/09. The facility had no evidence this nursing assistant was registered with the WV Nurse Aide Registry as having completed the State-required minimum training and competency evaluation. During an interview on 02/09/10 at 3:00 p.m., the director of nursing (DON - Employee #7) confirmed that Employee #75 had been performing direct patient care while the facility had no verification she had successfully completed the training and competency evaluation as required by the State. . | 2015-07-01 |
| 10023 | 10023 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 152 | D | 0 | 1 | 4T1611 | . Based on medical record review and staff interview, the facility failed to ensure the rights of one (1) of twelve (12) sampled residents, who had been determined to lack capacity to make informed health care decisions, were exercised by an individual appointed in accordance with State law. The physician appointed two (2) individuals to serve jointly as Resident #49's health care surrogate (HCS); however, WV State Code 16-30-8 allows a physician to appoint only one (1) HCS. Additionally, the facility allowed a family member who had not been appointed to the role of HCS to make health care decisions on Resident #49's behalf. Facility census: 50. Findings include: a) Resident #49 Medical record review revealed the physician appointed two (2) persons to serve jointly as Resident #49's HCS, to make health care decisions for this resident. In addition, record review also revealed health care decisions were being made by the resident's mother, who was had not been appointed to serve as HCS. In an interview with the administrator and the person in charge of resident funds (Employee #5) at 2:15 p.m. on 02/10/10, they acknowledged understanding the State law only allows for the appointment of one (1) person to serve as HCS for an incapacitated individual, and they acknowledged the resident's mother was not the resident's legal representative. They state they would see that all staff was made aware of this. According to WV Code 16-30-8. Selection of a surrogate.: "(a) If no representative or court-appointed guardian is authorized or capable and willing to serve, the attending physician or advanced nurse practitioner is authorized to select a health care surrogate." "(b)(1) Where there are multiple possible surrogate decisionmakers at the same priority level, the attending physician or the advanced nurse practitioner shall, after reasonable inquiry, select as the surrogate the person who reasonably appears to be best qualified." This State law does not allow for the simultaneous appointment of more than one (1) person to s… | 2015-07-01 |
| 10024 | 10024 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 156 | D | 0 | 1 | 4T1611 | . Based on record review and staff interview, the facility failed to provide to written notification to one (1) of five (5) randomly reviewed residents, who had been discharged from Medicare-covered skilled services, when the skilled services were discontinued and the resident's payer status changed. Resident identifier: #7. Facility census: 50. Findings include: a) Resident #7 A review of facility records reveals Resident #7 was discharged from Medicare-covered skilled services on 10/11/09, but there was no evidence she received a liability notice to inform her of the reason for the discontinuation of skilled services. This was verified by the nurse case manager (Employee #9) at 3:10 p.m. on 02/09/10, who stated that, because the resident had exhausted her one hundred (100) skilled days, she did not receive an notice. A request was made to the nurse to supply evidence the resident or her responsible party had been notified of this change in payer status. During an interview with the director of nurses, Employee #9, and the administrator at 11:10 a.m. on 02/11/10, Employee #9 acknowledged, after reviewing the record, that she could not state the responsible party had been clearly notified of the change in Resident #9's payer status. . | 2015-07-01 |
| 10025 | 10025 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 159 | D | 0 | 1 | 4T1611 | . Based on record review and staff interview, the facility failed to obtain valid written authorizations prior to handling the personal funds of two (2) of twelve (12) sampled residents, and failed to provide quarterly statements of account activity to one (1) of these residents, who was alert and oriented. Resident identifiers: #49 and #44. Facility census: 50. Findings include: a) Resident #49 A review of the financial records revealed the written authorization on file allowing the facility to manage the personal funds of this resident, who has been determined to lack the capacity to make health care decisions, was signed by her mother, who was the resident's health care surrogate (HCS) on admission to the facility. The WV Health Care Decisions Act does not convey to a HCS the authority to make decisions on behalf of an incapacitated individual other than those related to health care (e.g., financial decisions). b) Resident #44 A review of the clinical records for Resident #44 revealed she was alert and oriented to person, place, and time and had been determined by the physician to have the capacity to make her own healthcare decisions. Review of the resident's financial records found the resident's daughter signed the authorization for the facility to manage the resident's personal funds. Upon questioning at 11:30 a.m. on 02/09/10, the office manager (Employee #5) also stated the quarterly statements of account activity were mailed to the daughter. She verified she does not supply a statement to the resident, although she agreed the resident would understand the statement. During an interview with the administrator and the office manager at 2:15 p.m. on 02/10/10, they acknowledged the resident should have been informed of her financial status and given the option to make her own decisions about her personal funds. They related that this matter would be referred to the social worker next week, upon her return from vacation. Employee #5 also stated she would ensure the resident started receiving quarterly statem… | 2015-07-01 |
| 10026 | 10026 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 371 | F | 0 | 1 | 4T1611 | . Based on observation and staff interview, the facility failed to ensure the proper sanitation of the kitchen area to prevent potential contamination of food products by inadequate cleaning of the equipment. This had the potential to affect all residents. Facility census: 50. Findings include: a) During the general tour of the kitchen and dry storage room at 12:50 p.m. on 02/08/10, observation found the inner aspect of the steam table to be dirty, with dried food debris and stains visible. The backsplash of the stove was also covered with baked and dried food stains. During service of the noon meal at 11:15 a.m. on 02/09/10, observation found the steam table to be cleaner, but the stove was still very stained. The dietary manager was present during both observations and stated there was a schedule for cleaning the steam table, but it had been overlooked. She agreed the backsplash needed to be cleaned. . | 2015-07-01 |
| 10027 | 10027 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 387 | D | 0 | 1 | 4T1611 | . Based on record review and staff interview, the facility failed to assure one (1) of twelve (12) sampled residents was seen by a physician at least once in every sixty (60) days. Resident identifier: #1. Facility census: 50. Findings include: a) Resident #1 A review of the clinical record, completed on 02/09/10, revealed the last entry by a physician was dated 10/02/09. A review of the nurses' notes failed to reveal any other visits. During an interview with the director of nurses (DON) and the administrator at 11:10 a.m. on 02/11/10, the DON stated she had reviewed the record and questioned the nurses, but she could not show evidence to reflect the physician had seen the resident since 10/02/09. The administrator stated he would notify the physician and the quality assurance committee of this problem. . | 2015-07-01 |
| 10028 | 10028 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 278 | D | 0 | 1 | 4T1611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) assessments by failing to accurately encode the resident's skin condition and/or [MEDICAL TREATMENT] treatments on two (2) different assessments for one (1) of twelve (12) sampled residents. Resident identifier: #13. Facility census: 50. Findings include: a) Resident #13 1. A review of the clinical record revealed, in Section M4 of the 08/14/09 admission MDS, no entry for "Surgical wounds", although the admission nursing assessment dated [DATE] stated the resident was admitted with [DIAGNOSES REDACTED]. 2. A review of the clinical record also revealed, in Item P1b of the 11/13/09 quarterly MDS, no entry to indicate the resident received [MEDICAL TREATMENT], although the resident had orders for and received [MEDICAL TREATMENT] three (3) times weekly on a continuing basis. 3. In an interview with the director of nurses at 1:20 p.m. on 02/10/10, she reviewed the assessments and stated these were oversights and they would be corrected. . | 2015-07-01 |
| 10029 | 10029 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-03-21 | 225 | E | 1 | 0 | YLY611 | . Based on record review, review of concern forms, and staff interview, the facility failed to ensure all allegations involving mistreatment, neglect, abuse, and misappropriation of resident property, were reported immediately to officials in accordance with State law through established procedures. Allegations found in four (4) concern forms, from residents and/or families, included failure to provide mouth care and wound care, verbal abuse, stolen personal property, and failure to provide care for dentures. These allegations were not reported as required. Resident identifiers: #37, #70, #53, and #54. Facility census: 52. Findings include: a) Resident #37 Review of concern forms revealed the family of Resident #37 reported a concern on 10/12/11. The family expressed Resident #37's tooth brushing and oral care were not adequate. The family member alleged while brushing the resident's teeth, just prior to the evening meal, the resident had some type of green material still in her mouth. The family member also reported the previous weekend, when Resident #37 was at the emergency room , emergency room staff had to suction food out of the resident's mouth. This allegation of neglect was not reported to state agencies. On 03/21/11, at approximately 3:00 p.m., the social worker (SW), confirmed this allegation of neglect should have been reported. b) Resident #70 1) Review of concern forms revealed Resident #70 complained to staff, on 12/28/11, that her daily dressing change to a wound was omitted on 12/23/11. The report noted she "...had to 'fuss' at staff on 12/24/11 to get it changed because it leaked all over her slacks." This allegation of neglect was not reported to state agencies. On 03/21/11, at approximately 3:00 p.m., the SW confirmed this allegation of neglect should have been reported. 2) According to concern forms, Resident #70 complained to staff, on 12/28/11, that former nursing assistant, Employee #68, was rude to her when she was asked to change the resident. This allegation of verbal abuse was not repo… | 2015-07-01 |
| 10030 | 10030 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-03-21 | 226 | D | 1 | 0 | YLY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure their policies and procedures for identification and reporting of abuse were implemented. The facility required immediate reporting of abuse to the supervisor. A nursing assistant (NA) failed to immediately report two (2) witnessed incidents of abuse to the supervisor for more than two (2) months after witnessing the incidents. The alleged abuse was committed by the same NA, involving two (2) different residents. Resident identifiers: #24 and #36. Facility census: 52. Findings include: a) Resident #24 Record review revealed nursing assistant, Employee #27, reported to facility staff, on 02/24/12, during an investigation, she had witnessed a former nursing assistant, Employee #69, slap a resident. Employee #27 stated Employee #69 walked up behind Resident #24, who was being changed from soiled clothing, and "opened handedly slapped the resident on her bare behind." In response, the resident at first screamed aloud, then cursed at Employee #69. Employee #27 then allegedly verbally rebuked Employee #69. Record review revealed this incident allegedly occurred sometime between 11/30/11 and 02/10/12, but the allegation was not reported to facility staff until 02/24/11. Interviews with the social worker and the administrator, on 03/21/12, revealed the facility's expectation was for any allegation of abuse witnessed by staff be immediately reported to the supervisor. b) Resident #36 Record review revealed nursing assistant, Employee #27, reported on 02/24/12 during an investigation, she had witnessed former nursing assistant, Employee #69, [MEDICATION NAME] "in a sexual nature at a resident (Resident #36) embarrassing her," while personal hygiene care was being given by Employee #27. Employee #27 reported she told Employee #69 "to leave the room and stated to him that his actions was both inappropriate and unacceptable." Record review revealed this incident allegedly occurred… | 2015-07-01 |
| 10161 | 10161 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-02-23 | 318 | E | 1 | 0 | X35X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure four (4) of nine (9) sample residents received treatment and services to increase range of motion and/to prevent further decrease in range of motion. Three (3) residents were not ambulated as ordered and one (1) resident did not have knee braces applied as ordered. Resident identifiers: #56, #53, #24, and #02. Facility census: 55. Findings include: a) Resident #56 This resident had physician's orders [REDACTED]. This restorative service was ordered every day, and as needed, for strength and endurance. Review of the restorative nursing documentation, for the month of January 2012 to 02/23/12, revealed no evidence this service was done daily as ordered by the physician. b) Resident # 53 This resident had a physician's orders [REDACTED]. Review of documentation revealed no evidence the knee braces were applied as ordered every night. This resident also had an order, dated 01/24/12, for passive range of motion to each leg three (3) to five (5) times every week. During a review of the restorative nursing assistant documentation, on 02/22/12, it was discovered there was evidence of only two (2) days this service was provided between 01/24/12 and 02/22/12. The dates of service were 01/26/12 and 02/09/12. c) Resident # 24 This resident had physician orders [REDACTED]. During a review of the restorative documentation, from 01/01/12 through 02/22/12, it was discovered there was no evidence this service was done daily as ordered. Restorative documentation indicated the resident was walked only three (3) times between 01/01/12 through 02/22/12. d) Resident #2 This resident had a physician's orders [REDACTED]. The order noted the resident was to ambulate with a front wheeled walker. Staff members were to use a gait belt and to follow the resident with a wheelchair. Review of restorative documentation, from 01/01/12 through 02/22/12, revealed no evidence this service was do… | 2015-06-01 |
| 10397 | 10397 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2011-12-07 | 309 | E | 1 | 0 | OLNF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide treatment and services to attain the highest practicable physical well being for five (5) of forty-eight (48) sampled residents, by following physician's orders [REDACTED]. Residents affected: Residents #10, #17, #32, #37, and #47. Facility census: 48 Findings include: a) On 12/6/11 at 10:55 a.m., facility documentation regarding bowel movements was reviewed. The facility has transitioned to the exclusive use of an electronic medical record for the nursing assistants to document their provision of care, including bowel movements. There were fields in which to enter the date, the shift, continent/amount/type, incontinent/amount/type, No or independent/unknown, and the nursing assistant's name. The director of nursing confirmed on 12/6/11 at 10:50 a.m. that there was no other documentation available except for " Hands On " reports generated by the nursing assistants. The "hands on" report was reviewed for all residents for regular bowel movements for the time period of 11/1/11 through 12/5/11. Five (5) residents were found that did not have any documented bowel movements for days as follows: --Resident #10 had no recorded bowel movement for 11/7, 11/8, 11/9, 11/10, 11/11, and 11/12, a six (6) day period. --Resident #17 had no recorded bowel movement for 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, and 11/29, a seven (7) day period. --Resident #32 had no recorded bowel movement for 11/29, 11/30, 12/1, 12/2, 12/3, and 12/4, a six (6) day period. --Resident #37 had no recorded bowel movement for 11/26, 11/27, 11/28, 11/29, 11/30, and 12/1, a six (6) day period. --Resident #47 had no recorded bowel movement for 11/7, 11/8, 11/9, 11/10, 11/11, and 11/12, a six (6) day period. All of these residents were assessed on the current Minimum Data Set Assessment (MDS 3.0) as requiring limited to extensive assistance of two (2) staff for toileting. ------------ Current physician's orders… | 2015-04-01 |
| 10398 | 10398 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2011-12-07 | 312 | E | 1 | 0 | OLNF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility did not provide showers and/or baths per stated facility protocol to maintain personal hygiene for residents who could not bathe independently. This was found for thirteen (13) of forty-eight (48) current residents. Resident identifiers: REsidents #2, #7, #8, #11, #17, #20, #24, #25, #26, #32, #34, #35, #44. Facility census: 48 Findings include: a) Resident #13 was interviewed on 12/5/11 at 2:00 p.m. Resident #13 is a sixty-six (66) year old woman who was admitted to the facility on [DATE]. She has been determined to possess the capacity to make informed medical decisions, and was assessed as cognitively intact with a score of 15 on the brief interview for mental status (BIMS) conducted on 11/16/11. Her [DIAGNOSES REDACTED]. She was asked if she received a shower or bath at least two (2) times a week. She replied that she did, because she was able to speak up for herself and insist that she receive them. She said that she feels strongly that those residents who cannot speak for themselves do not always get their showers or baths as they should. ------------ On 12/5/11 at 12:00 p.m., facility documentation regarding shower/baths was reviewed. The facility has transitioned to the exclusive use of an electronic medical record for the nursing assistants to document their provision of care, including baths/showers. There are fields in which to enter the date, the shift, the type of bath given, not available or refused, and the nursing assistant's name. The director of nursing confirmed on 12/5/11 at 3:45 p.m. that there was no other documentation available except for the " hands on " reports generated by the nursing assistants. ------------ All residents were reviewed for the provision of showers/baths for the time period of 11/22/11 through 12/5/11, approximately a two (2) week period. Fifteen residents did not have documented showers/baths two (2) times each week as fo… | 2015-04-01 |
| 10399 | 10399 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2011-12-07 | 364 | E | 1 | 0 | OLNF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, review of West Virginia State Licensure regulation, and record review, the facility did not provide hot food served at a palatable temperature. This was found for one (1) resident at the evening meal on 12/4/11, and has the potential to affect all residents who eat their evening meal in the dining room. Facility census: 48. Findings include: a) The initial dining observation began on 12/4/11 at 5:15 p.m. Residents who were capable of independent dining began eating at approximately 5:15 p.m. Staff stated that residents who needed assistance or feeding came in later. Trays were seen in open tall carts in the kitchen adjacent to the open door to the dining room. The trays were being set up, were uncovered, and stored in the open racks until they were served to the residents. As a result, residents who came later to the dining room were served food that had been sitting in the racks for a longer period of time. As the observation continued, resident #36, immediately after being served her tray at 5:42 p.m., was heard to tell staff that her food was cold and it was decided to have it reheated. Her tray was taken to the kitchen, and dietary aide, employee #67, was immediately asked to take the temperature of the food. The corn was found to be at 132 degrees Fahrenheit, while the entree, turkey a la king, was found to be at 119 degrees Fahrenheit. These temperatures do not meet the 135 degree holding temperature requirements, and the food was not palatable to resident #36 when it was served to her. Although preferred temperatures for hot food may vary from person to person, West Virginia State Licensure regulations specify that food is not to be served to residents at less than 120 degrees Fahrenheit, and resident #36 obviously felt her food was served cold. Following this determination, with the remaining meal trays, it was observed that dietary staff began waiting until residents arrived … | 2015-04-01 |
| 2233 | 2233 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2018-03-21 | 758 | D | 0 | 1 | IUL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate indicators of use for an anti-depressant for Resident #60, one of 6 residents reviewed for unnecessary medications. Resident identifier: #60. Facility census: 78. Findings included: a) Resident #60 According to the 02/17/18 Minimum Data Set (MDS) assessment, Resident #60 had [DIAGNOSES REDACTED]. According to this assessment, Resident #60 exhibited no signs of mood or behavior issues and denied any issues with mood. Similarly, on the 06/02/17, 07/05/17, 07/11/17, 07/26/17, 09/2/17 and 12/01/17 MDS assessments, the resident denied any issues with mood and displayed no behavioral symptoms. Record review revealed the resident had received the anti-depressant [MEDICATION NAME] since at least 04/21/15. A Pharmacy Consultation, dated 03/06/17, identified the resident had been on [MEDICATION NAME] 10 milligrams (mg) since last decrease 10/12/16. The pharmacist recommended the physician consider a discontinuation of the medication. The physician accepted the recommendation and the [MEDICATION NAME] was discontinued on 3/16/17. The facility monitored the resident for adverse effects of the discontinuation of the medication however none were noted. Resident #60 was sent to the emergency roiagnom on [DATE] for a change in his health condition. He was admitted to the hospital and re-admitted to the facility on [DATE]. Records from the hospital, including the Hospital Urology Consultation, dated 06/21/17, and the Hospital Infectious Disease Consult Note, dated 06/26/17, identified Current Facility - Administered Medications as including [MEDICATION NAME] 10 mg. The hospital Discharge Summary, dated 06/28/17, included an order for [REDACTED]. The facility administered the anti-depressant to Resident #60 daily, with no indication for use. Staff monitored for signs and symptoms of depression, but noted none. More than eight months later, based on a Pharmacy Consultation… | 2020-09-01 |
| 2234 | 2234 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2018-03-21 | 805 | E | 0 | 1 | IUL911 | Based on observation, record review and staff interviews, the facility failed to follow recipes for pureed food items to ensure the pureed texture was prepared properly for eighteen out of 18 residents the facility identified as receiving pureed foods. Facility census: 78. Findings included: Observation on 03/20/18 at 9:40 AM revealed Cook #15 training Dietary Aide #104 on how to puree food items. Cook #15 had a recipe for pureed spaghetti noodles. The recipe was written for 25 servings. Cook #15 stated verbally there were only 19 residents who required a puree diet, so she would make the recipe for 19 residents. She scooped 19 servings of noodles, counting out loud, and then followed the rest of the recipe's instructions using the ingredients for 25 servings. The recipe called for 1/3 cup and 1 and 1/3 Tablespoons of butter. Cook #15 retrieved a liquid measuring cup and cut off a section of a solid block of butter. Dietary Aide #104 asked if the butter was supposed to be melted first. Cook #15 stated the recipe did not clearly indicate one way or the other, so she put the solid butter in the liquid measuring cup and began to cut more. She added more butter to the measuring cup, then looked at the surveyor who was taking notes and said, Maybe we should ask (Assistant Dietary Manager #7). Assistant Dietary Manager #7 was requested and she stated Cook #15 should melt the butter and then measure it out. Cook #15 melted and measured the amount of butter intended for 25 servings, then measured and added 1.5 cups and 1 Tablespoon of water, as called for by the recipe if making 25 servings. She blended it together well, looked at the recipe, then said to Dietary Aide #104, I have it all. It's done. She poured the pureed noodles into a pan, covered it with aluminum foil and placed it in the warmer. Cook #15 was then asked by the surveyor if she added the thickener, as called for in the recipe. She stated she forgot to do so, even after reviewing the recipe. She then added 1/2 cup and 2 Tablespoons of powdered thickener, … | 2020-09-01 |
| 2235 | 2235 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2018-03-21 | 880 | D | 0 | 1 | IUL911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of the Infection Control Policy the facility failed to maintain a sanitary environment to prevent the potential for transmission and spread of disease and infection. Staff failed to administer medications in a sanitary manner and did not use good infection control technique. This affected one of one residents who received medications via gastrostomy tube. Resident identifier: #50. Facility census: 78. Findings included: a) Resident #50 On 03/20/18 at 4:15 PM, observations were made of Licensed Practical Nurse (LPN) #110 administer medications to Resident #50 in her room via gastrostomy tube. LPN #110 removed [MEDICATION NAME] Chloride 5 milligrams (medication used for [MEDICAL CONDITION]) from the medication cart, crushed the tablet and placed it in a clear, plastic medication cup that was sitting on top of the medication cart. LPN #110 then removed a bottle of [MEDICATION NAME] Solution (medication for unspecified convulsions) and poured 7.5 milliliters of the liquid into a clear, plastic medication cup that was sitting on top of the medication cart. Both medications were observed in separate clear medication cups on top of the medication cart prior to administration. LPN #110 stacked the medication cups by placing the medication cup containing the liquid on top of the crushed medication in the clear plastic cup, carried them into the resident's room and placed them on the over bed table. The medication cups were unstacked and placed on top of the resident's over bed table. The medications were administered separately via the resident's gastrostomy tube. LPN #110 was interviewed after the medication administration at 4:25 pm. LPN #110 verified stacking and unstacking the medications on top of the medication cart and the resident's over bed table was not sanitary and could be an infection control issue. The Director of Nursing (DON) #61 was interviewed on 03/21/18 at 11:40 am. DON #61 stated … | 2020-09-01 |
| 2236 | 2236 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 550 | D | 0 | 1 | MO6K11 | Based on random observation and staff interview, the facility failed treat a resident with dignity while assisting the resident to eat. This is true for one (1) of one (1) residents observed. Resident identifier: #23. Facility census: 91. Findings include: a) Resident #23 On 06/10/19 at 3:08 PM nursing assistant (NA) #92 stood beside of seated Resident #23 while assisting the resident to eat a midday snack of egg salad. At this same time NA #92 agreed she should have been sitting while feeding the resident and obtained a chair to sit down and finished feeding Resident #23. | 2020-09-01 |
| 2237 | 2237 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 554 | D | 0 | 1 | MO6K11 | Based on observation and staff interview, the facility failed to ensure residents had been assessed to self-administer medications prior to having medication remain at the bedside. This was evident for two of 21 sampled residents. Resident identifiers: #64 and #54. Facility census: 91. Findings included: a) Resident #64 During the initial tour, on 06/10/19 at 12:00 PM, R# 64 was observed with a tube of Muscle Rub laying on the resident's bedside table in plain view. A review of the medical record, conducted 06/10/19 at 12:15 PM, noted no current order for a tube of Muscle Rub and no assessment for self-administration of the medication located in the medical record. An interview, on 06/10/19 at 12:35 PM, with LPN#21, verified there was no order for the medication found at the bedside and further stated the medication should not have been there. An interview on 06/10/19 at 12:40 PM, with the Assistant Director of Nursing (ADON #43), revealed there had been no self-administration assessment completed to determine if the resident could self-administer the medication observed at the bedside. Additionally, ADON #43 stated there was no order for the Muscle Rub found at the bedside and was unaware the medication was being kept in the room. b) Resident #54 During the initial tour on, 06/10/19 at 12:15 PM, R# 54 was observed with a bottle of Calcium Antacid laying on the resident's bedside table in plain view. A review of the medical record for R#54, conducted 06/10/19 at 12:20 PM, noted no current order for Calcium Antacid and no assessment for self- administration of the medication located in the medical record. An interview, on 06/10/19 at 12:35 PM, with LPN#21, verified there was no order for the medication found at the bedside and further stated the medication should not have been there. An interview on 06/10/19 at 12:40 PM, with the Assistant Director of Nursing (ADON #43), revealed there had been no self-administration assessment completed to determine if the resident could self-administer the medication observed at… | 2020-09-01 |
| 2238 | 2238 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 576 | E | 0 | 1 | MO6K11 | Based on Resident Council members interview, and staff interview, the facility failed to deliver mail to residents on Saturday. This has a potential to effect more than a limited number. Facility census: 91. Findings include: a) On 06/11/19 at 10:00 AM during a Resident Council meeting, Resident #26, #73, #31, #8, and #48 stated the facility does not pass mail out on Saturdays, and they would like to have their mail the day it is delivered. At 1:25 PM on 06/11/19 the activity director explained the mail delivery to the facility is between 4:00 PM and 8:00 PM on Saturdays. Due to the late delivery the mail is held and passed out on Sundays. She explained arrangements will be made for the mail to be given to the residents on the day it is delivered. | 2020-09-01 |
| 2239 | 2239 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 583 | D | 0 | 1 | MO6K11 | Based on staff interview and observation, the facility failed to ensure medication packets with pharmacy labels were not left on top of the medication cart when not in use. These medication packets contained personal identifiers including the resident's name, medication, physician, and diagnoses. This practice affected one (1) of five (5) residents observed during medication administration. Resident identifier: #44. Facility census: 91. Findings included: a) Resident #44 An observation of medication administration, on 06/11/19 at 7:45 AM, revealed two (2) medication packets, with pharmacy labels, were left on top of the medication cart while unattended. The medication packets were visible for anyone walking past to see. The medication packets contained the following information concerning the Resident: -Resident's name -Medication -Physician -Diagnoses An interview with Licensed Practical Nurse (LPN) #16, on 06/11/19 at 8:05 AM, revealed the medication packets should have been put back into the medication cart while she was giving out medications. The LPN stated I know better. | 2020-09-01 |
| 2240 | 2240 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 657 | D | 0 | 1 | MO6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise Care Plans for residents receiving pain medication and oxygen saturation levels. This practice affected two (2) of twenty-one (21) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #19 and #82. Facility census: 91. Findings included: a) Resident #19 A review of the Resident's physician orders, on 06/11/19 at 9:15 AM, revealed the order [MEDICATION NAME] HCL Tablet 50 milligrams every 12 hours as needed for moderate pain with an order date of 3/05/19. A review of the Resident's Care Plan, on 06/11/19 at 9:25 AM, revealed the problem Potential for pain with the interventions Administer as needed pain medications as needed and utilize the PAINAD Pain Scale for pain assessment. The Care Plan did not include what level of pain is considered moderate pain for the as needed pain medication. An interview with Assistant Director of Nursing (ADON) #43, on 06/11/19 at 3:15 PM, revealed the facility uses the Wong-Baker Faces Pain Rating Scale to assess the difference between mild, moderate, and severe pain. The ADON stated the pain scales are accessible at each of the nurses station. The ADON stated moderate pain is considered a pain level of 4 to 7 on the Wong-Baker scale. The ADON stated the staff should use the Wong-Baker Faces Pain Rating Scale to determine if Resident #19 was having moderate pain which warranted as needed pain medication. The ADON confirmed the Wong-Baker Faces Pain Rating Scale was not addressed on the Resident's Care Plan and should have been. b) Resident #82 A review of the Resident's physician orders, on 06/11/19 at 10:35 AM, revealed the order Oxygen Saturation above 90% is acceptable with an order date of 05/30/19. A review of the Resident's Care Plan, on 06/11/19 at 10:45 AM, revealed the problem Palliative Care due to [MEDICAL CONDITION] with the intervention Oxygen Saturation above 90% is acceptable. The… | 2020-09-01 |
| 2241 | 2241 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 684 | D | 0 | 1 | MO6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Physician orders [REDACTED]. This practice affected three (3) of twenty-one (21) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #19, #82, and #64. Facility census: 91. Findings included: a) Resident #19 A review of the Resident's physician orders, on 06/11/19 at 9:15 AM, revealed the order [MEDICATION NAME] HCL Tablet 50 milligrams every 12 hours as needed for moderate pain with an order date of 3/05/19. A review of the Resident's (MONTH) 2019 Medication Administration Record [REDACTED] -06/18/19 for a pain level of 0 -06/11/19 for a pain level of 2 An interview with Assistant Director of Nursing (ADON) #43, on 06/11/19 at 3:15 PM, revealed the facility uses the Wong-Baker Faces Pain Rating Scale to assess the difference between mild, moderate, and severe pain. The ADON stated the pain scales are accessible at each of the nurses station. The ADON stated moderate pain is considered a pain level of 4 to 7 on the Wong-Baker scale. The ADON stated the [MEDICATION NAME] should not have been given for a pain levels of 0 and 2 which was considered mild pain. b) Resident #82 A review of the Resident's physician orders, on 06/11/19 at 10:35 AM, revealed the order Oxygen Saturation above 90% is acceptable with an order date of 05/30/19. Further review of the medical record, on 06/11/19, revealed the Resident's oxygen saturation level was being monitored on the following dates: --05/22/19 --05/23/19 --05/24/19 --05/25/19 --05/29/19 --05/31/19 --06/01/19 --06/02/19 --06/06/19 --06/08/19 --06/09/19 --06/11/19 A review of the Resident's Care Plan, on 06/11/19 at 10:45 AM, revealed the problem Palliative Care due to [MEDICAL CONDITION] with the intervention Oxygen Saturation above 90% is acceptable. The physician o… | 2020-09-01 |
| 2242 | 2242 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 689 | E | 0 | 1 | MO6K11 | Based on observation, record review and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. The facility failed to ensure that medications were not kept at the bedside unless it was determined to be safe for a resident to self-administer and if so, kept in a secure place. The facility failed to ensure two bathrooms, accessible to residents, were equipped with an emergency call mechanism. These practices had the potential to affect more than a limited number of residents. Resident identifier: Resident #64 and Resident #54. Facility census: 91. Findings included: a) Resident #64 During the initial tour, on 06/10/19 at 12:00 PM, R# 64 was observed with a tube of Muscle Rub laying on the resident's bedside table, unsecured, in plain view. A review of the medical record, conducted 06/10/19 at 12:15 PM, noted no current order for the Muscle Rub and no assessment for self- administration of the medication located in the medical record. An interview, on 06/10/19 at 12:35 PM, with LPN#21, verified there was no order for the medication found at the bedside and further stated the medication should not have been there. An interview on 06/10/19 at 12:40 PM, with the Assistant Director of Nursing (ADON #43), revealed there had been no self-administration assessment completed to determine if the resident could self-administer the medication observed at the bedside. Additionally, ADON #43 stated there was no order for the Muscle Rub found at the bedside and was unaware the medication was being kept in the room. b) Resident #54 During the initial tour on, 06/10/19 at 12:15 PM, R# 54 was observed with a bottle of Calcium Antacid laying on the resident's bedside table unsecured, in plain view. A review of the medical record for R#54, conducted 06/10/19 at 12:20 PM, noted no current order for Calcium Antacid and no assessment for self- administration of the medication located in the medical record. An interview, on 06/10/19 at 12:35 PM, with LPN#21, verified there was … | 2020-09-01 |
| 2243 | 2243 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 695 | D | 0 | 1 | MO6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to deliver respiratory care services consistent with professional standards of practice. Physician orders [REDACTED]. This practice affected two (2) of five (5) residents reviewed for respiratory care during the Long Term Care Survey Process (LTCSP). Resident identifiers: #82 and #64. Facility census: 91. Findings included: a) Resident #82 A review of the Resident's physician orders, on 06/11/19 at 10:35 AM, revealed the order Oxygen Saturation above 90% is acceptable with an order date of 05/30/19. Further review of the medical record, on 06/11/19, revealed the Resident's oxygen saturation level was being monitored on the following dates: --05/22/19 --05/23/19 --05/24/19 --05/25/19 --05/29/19 --05/31/19 --06/01/19 --06/02/19 --06/06/19 --06/08/19 --06/09/19 --06/11/19 A review of the Resident's Care Plan, on 06/11/19 at 10:45 AM, revealed the problem Palliative Care due to [MEDICAL CONDITION] with the intervention Oxygen Saturation above 90% is acceptable. The physician order [REDACTED]. An interview with Nurse Aide (NA) #60, on 06/11/19 at 11:00 AM, revealed the NA was not sure when to monitor the Resident's oxygen saturation level. An interview with the Director of Nursing (DON), on 06/11/19 at 11:30 AM, revealed the order and care plan should have included how often to monitor the Resident's oxygen saturation levels. b) Resident #64 An observation on 06/10/19, at 12:00 PM, revealed R#64 receiving oxygen (O2) per nasal cannula at 6 liters per minute (L/min). An observation on 06/11/19 at 08:12 AM, revealed R#64 receiving O2 per nasal cannula at 6L/min. A review of the physician's orders [REDACTED]. On 06/11/19 at 08:12 AM, an interview with ADON#43, verified R#64's O2 was being administered at 6L/min and was not being administered in accordance with the physician's orders [REDACTED]. A review of the policy and procedure, Oxygen Administration, revi… | 2020-09-01 |
| 2244 | 2244 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 697 | D | 0 | 1 | MO6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure pain management was provided to a Resident consistent with professional standards of practice and the person centered care plan. A resident's care plan for pain gave no direction for assessing the varying levels of pain associated with ordered medications. The resident was also given unnecessary pain medication in accordance with their pain level. This practice affected one (1) of two (2) residents reviewed for pain management during the Long Term Care Survey Process (LTCSP). Resident identifier: #19. Facility census: 91. Findings included: a) Resident #19 A review of the Resident's physician orders, on 06/11/19 at 9:15 AM, revealed the order [MEDICATION NAME] HCL Tablet 50 milligrams every 12 hours as needed for moderate pain with an order date of 3/05/19. A review of the Resident's (MONTH) 2019 Medication Administration Record [REDACTED] -06/18/19 for a pain level of 0 -06/11/19 for a pain level of 2 A review of the Resident's Care Plan, on 06/11/19 at 9:25 AM, revealed the problem Potential for pain with the interventions Administer as needed pain medications as needed and utilize the PAINAD Pain Scale for pain assessment. The PAINAD Pain Scale does not specify what is considered moderate pain. The Care Plan did not include what specific level of pain is considered moderate pain for the as needed pain medication. An interview with Assistant Director of Nursing (ADON) #43, on 06/11/19 at 3:15 PM, revealed the facility uses the Wong-Baker Faces Pain Rating Scale to assess the difference between mild, moderate, and severe pain. The ADON stated the pain scales are accessible at each of the nurses station. The ADON stated moderate pain is considered a pain level of 4 to 7 on the Wong-Baker scale. The ADON stated the directive to use the Wong-Baker Pain Scale should have been included on the Care Plan. The ADON stated the [MEDICATION NAME] should not have been give… | 2020-09-01 |
| 2245 | 2245 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 730 | E | 0 | 1 | MO6K11 | Based on employee record review and staff interview, the facility failed to provide employees with required regular in-service education based on the outcome of these reviews. This was found true for four (4) of five (5) employees. Employee identifers: #36, #52, #20 and #23. Facility census: 91. Findings included: a) Nurse Aide (NA) regular in-service education. A review of the facility's employee regular in-service education found NA's #36 and #52 did not have twelve hours of in-service education per year. NA's #20 and #23 did not receive the abuse training. An interview with the Director of Nursing (DoN) on 06/12/19 at 11:00 AM, verified the above facility's NA's did not receive their regular in-service education. | 2020-09-01 |
| 2246 | 2246 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 757 | D | 0 | 1 | MO6K11 | **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 drug regimen was free from unnecessary drugs. A resident was given pain medication for moderate pain when they were assessed to be having mild pain. This practice affected one (1) of six (6) residents reviewed for unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident identifier: #19. Facility census: 91. Findings included: a) Resident #19 A review of the Resident's physician orders, on 06/11/19 at 9:15 AM, revealed the order [MEDICATION NAME] HCL Tablet 50 milligrams every 12 hours as needed for moderate pain with an order date of 3/05/19. A review of the Resident's (MONTH) 2019 Medication Administration Record [REDACTED] -06/18/19 for a pain level of 0 -06/11/19 for a pain level of 2 An interview with Assistant Director of Nursing (ADON) #43, on 06/11/19 at 3:15 PM, revealed the facility uses the Wong-Baker Faces Pain Rating Scale to assess the difference between mild, moderate, and severe pain. The ADON stated the pain scales are accessible at each of the nurses station. The ADON stated moderate pain is considered a pain level of 4 to 7 on the Wong-Baker scale. The ADON stated the [MEDICATION NAME] should not have been given for a pain levels of 0 and 2 which was considered mild pain. | 2020-09-01 |
| 2247 | 2247 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 761 | D | 0 | 1 | MO6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. A medication stored in a medication cart was unlabeled and undated as to when it was first used. This practice affected one (1) of five (5) residents reviewed during medication administration. Resident identifier: #44. Facility census: 91. Findings included: a) Observation An observation of Resident #44's medication during medication administration, on 06/11/19 at 7:35 AM, revealed the following: -One (1) opened, undated, and unlabeled [MEDICATION NAME] Pen. b) Interview An interview with Licensed Practical Nurse (LPN) #16, on 06/11/19 at 7:40 AM, revealed the medication should have been labeled with a name and an open date as soon as it was opened by the staff. The LPN then proceeded to label the medication with the current date. An interview with the Director of Nursing (DON), on 06/12/19 at 8:00 AM, revealed the medication should have been dated and labeled with initials when it was first opened by the staff. The DON stated LPN #16 should not have dated it with the current date upon discovering it was not appropriately labeled and dated. | 2020-09-01 |
| 2248 | 2248 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 801 | E | 0 | 1 | MO6K11 | Based on review of documentation and staff interview, the facility failed to ensure the person serving as Dietary Manager, enrolled in an approved program to become a certified dietary manager within 60 days of accepting responsibility for the position. This practice had the potential to effect more than a limited number of residents. Facility census: 91. Findings included: A review of documentation on 06/11/19 at 08:50 AM, showed a hire date for the Food Service Director as 09/13/2018. Through interview on 06/11/19, at 08:50 AM, the Food Service Director stated he had not enrolled in a program until (MONTH) 2019 and had no other food or nutrition related credentials. The Food Service Director stated further, his work responsibility made it hard to find time to complete the modules required. An interview with the Administrator, on 06/12/19 at 7:30 AM, verified the person serving as the Dietary Manager had not enrolled in an approved program in a timely manner | 2020-09-01 |
| 2249 | 2249 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2019-06-12 | 812 | E | 0 | 1 | MO6K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility contained several areas with undated, expired, and opened resident food items. These practices had the potential to affect more than a limited number of residents. Room identifiers: 100 Hall Nourishment Room, 300 Hall Nourishment Room, and 200 Hall Dining/Activity Room. Facility census: 91. Findings include: a) Observation An observation of the 200 Hall Dining/Activity Room, [DATE] at 8:10 AM, revealed the following items in the unlocked drawers: --Two (2) packs of undated French dressing. --One (1) pack of undated Italian dressing. --One (1) opened and undated pack of Thick and Easy Food Thickener. --Two (2) packs of undated Saltine Crackers. --Three (3) packs of undated jelly. --Four (4) packs of undated coffee creamer. --One (1) pack of undated whipped spread with the label Refrigerate for best quality. --One (1) container of opened and undated Iced Tea Mix. --Two (2) packs of undated Malt Vinegar. Further observations of the 100 and 300 Hall Nutrition Rooms, on [DATE], revealed: --Three (3) opened and undated loaves of bread. b) Interview An interview with the Dietary Manager (DM), on [DATE] at 9:00 AM, revealed all the food items in the activity room and nourishment rooms should not have been there. The DM stated all food items should have dates on them. | 2020-09-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );