cms_WV
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| Link | rowid | facility_name | facility_id | address | city ▼ | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8 | 8 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 253 | E | 1 | 1 | ELSQ11 | > Based on observation and staff interview, the facility failed to provide housekeeping and/or maintenance services necessary to maintain a comfortable and sanitary interior. This was evident for fifteen (15) of thirty-four (34) rooms observed during Stage I of the Quality Indicator Survey. Cosmetic imperfections or items in need of repair and/or cleaning in resident rooms included discolorations of the toilet bowl jets, debris noted on the floor for prolonged period of time, window sills and/or window blinds dirty/dusty in need of cleaning, a sliding curtain type bathroom door with a black-colored substance on the bottom portion, caulk missing around a toilet base, veneer missing from a bathroom door with the wood or particle board beneath it visible, cove base pulled away from the wall in a bathroom, the inside of a wall heating unit had a dirty vent with loose debris, and a piece of wallpaper not adhered to a wall. Affected rooms included room #101, #102, #103, #104, #105, #106, #111, #118, #126, #128, #129, #134, #141, #142, and #163. Facility census: 116. Findings include: a) Stage I findings During Stage I of the Quality Indicator Survey on 05/15/17 and on 05/16/17, thirty-four (34) resident rooms were observed. Of that number, fifteen (15) rooms were found with concerns related to maintenance and/or housekeeping issues. The identified rooms were toured with Housekeeping Manager (HM) #83 on 05/17/17 between 3:00 p.m. and 3:30 p.m., and with Maintenance Supervisor (MS) #88 between 3:30 p.m. and 3:45 p.m. Identified concerns were: - Room 101 The water jets in the toilet looked dirty. During a tour on 05/17/17, HM #83 said they had been using a type of acid-base cleanser to try to remove the discoloration as other products have not worked as well. A small piece of tissue lay on the floor at the head of the bed next to the window. Beneath that bed was what looked like a broken piece of hard, white colored vinyl. These objects were first observed on the floor on 05/16/17 at 11:14 a.m. On 05/17/17 at approximatel… | 2020-09-01 |
| 9 | 9 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 278 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an accurate quarterly minimum data set (MDS) assessment to reflect the resident's pain medication regimen. This was true for one (1) of thirty-two (32) residents reviewed. Resident identifier: #100. Facility census: 116. Findings include: a) Resident #100 Review of Resident #100's medical records revealed a physician's orders [REDACTED]. Record review revealed Resident #100 continued to receive this medication through the month of (MONTH) (YEAR). Review of a quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/05/17, revealed Resident #100 did not receive scheduled pain medication. On 06/01/17 at 5:46 p.m., the MDS coordinator, Registered Nurse (RN) #108, agreed the quarterly MDS with an ARD of 05/05/17 should have been coded to identify Resident #100 received scheduled pain medication. | 2020-09-01 |
| 10 | 10 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 279 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and family interview, the facility failed to develop a care plan for a resident with bruises and a skin tear (#92), failed to establish measurable objectives to monitor a resident's progress related to activities (#143) and range of motion (ROM) (#43), and failed to develop a care plan timely related to assessing a thrill and bruit for a resident with an arteriovenous graft (#45). Four (4) of thirty-two (32) residents on the sample were affected. Facility census: 116. Resident identifiers: #143, #92, #45, and #43. Findings include: a) Resident #143 The resident's medical record included a Brief Interview for Mental Status (BIMS) on which the resident scored ten (10), indicating moderate cognitive impairment. During a Stage 1 interview on 05/16/17 at 2:12 p.m., a family member verbalized Resident #143 liked to attend Church services. Resident #143, interviewed on 05/31/17 at 1:56 a.m., exhibited symptoms of confusion related to time, but with inquiry, verbalized she liked to go to church and wanted to go every Sunday. The resident expressed she did not care what denomination it was, just Christian. The care plan noted Resident #143 would indicate satisfaction in daily routine/activities as evidenced by verbalizing satisfaction, increase in affect during participation, increased focus and attention to activities of choice. The interventions included to assist, as needed, to activities of interest church, parties, socials, crafts, pets, music, and reading. During review of the resident's care plan with the administrator on 05/31/17 at 6:12 p.m., when asked how the facility measured increased affect, focus and attention, the administrator acknowledged the goal was not measurable, shook her head in a yes motion, and said, I get you. b) Resident #92 An observation on 5/16/17 at 1:08 p.m., revealed bluish red bruised from Resident #92's hand to upper arm. A bandage was present on t… | 2020-09-01 |
| 11 | 11 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 280 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to review and/or revise care plans timely related to an arteriovenous (AV) graft (#159), restorative ambulation (#141), and an actual falls (#115). This practice affected three (3) of thirty-two (32) Stage 2 residents. Facility census: 116. Resident identifiers: #159, #141, and #115. Findings include: a) Resident #159 Medical record review revealed a physician's orders [REDACTED]. Upon inquiry, Health Information Management Coordinator (HIMC) #50, interviewed on 05/30/17 at 4:03 p.m., provided information noting the AV graft had been placed when the resident went to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the medical record revealed the resident had discharge on 03/11/17 and re-entered the facility on 03/13/17. The care plan was not revised until after completion of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/11/17. The care plan noted a revision date of 04/17/17 to reflect Resident #159 had an arteriovenous graft. MDS Coordinator #108, interviewed on 05/24/17, verbalized it was the nursing staff's responsibility to update and/or revise the care plan with a change in condition. b) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. Medical record review revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. The intervention, dated 09/22/16, indicated Resident #141 would ambulate 200 feet twice a day, six (6) days a week. During an interview on 05/24/17 at 2:36 p.m., Nurse Aide (NA) #23 reviewed the restorative records and said Resident #141 walked… | 2020-09-01 |
| 12 | 12 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 282 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, visitor/family interview, staff interview, observation, and policy review, the facility failed to ensure services were provided according to the resident's written plan of care for five (5) of thirty-two (32) Stage 2 residents. Residents #27 and #141 did not receive planned restorative services. Resident #143 did not participate in activities as identied on her care plan. Resident #163 did not receive treatments in accordance with the plan of care, and Resident #124 did not receive foods in accordance with her plan of care. Facility census: 116. Resident identifiers: Resident #27, #143, #141, #163 and #124. Findings include: a) Resident #27 A medical record review related to accidents revealed a physician's orders [REDACTED].#27 required limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was a… | 2020-09-01 |
| 13 | 13 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 309 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure eight (8) of thirty-two (32) Stage 2 residents received care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being. The facility did not assess and monitor a resident's pain, did not ensure implementation of physician's orders [REDACTED].#163). Staff failed to properly position residents during meals and/or in bed (#76 and #101), did not ensure monitoring of residents receiving [MEDICAL TREATMENT] (#159 and #45), did not obtain neuro checks after a fall (#59), and did not follow physician's orders [REDACTED].#59). For Resident #100, the facility failed to monitor the resident's [MEDICATION NAME] as ordered and failed to provide physician ordered foods to Resident #124. Additionally, the facility failed to follow orders for restorative ambulation for and assessment of a pulse rate prior to administration of a medication. Additionally, the facility failed to follow physician's orders [REDACTED].#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141). Facility census: 116. Findings include: a) Resident #163 1. Medical record review revealed a physician's orders [REDACTED]. Another order noted to cleanse an unstageable wound to the right second toe with wound cleanser and apply sure prep daily. Observation of wound care on 05/18/17 at 10:21 a.m., with Licensed Practical Nurse (LPN) #72, revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. When asked whether the unit charge nurses completed treatments, the LPN said she completed the treatments for the entire facility. The medical record and treatment administration records, reviewed for (MONTH) and (MONTH) (YEAR), revealed no evidence the treatment for [REDACTED]. No … | 2020-09-01 |
| 14 | 14 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 312 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to provide necessary services to maintain good grooming for two (2) of thirty-two (32) sampled residents. Resident #117 had unshaven facial hair. Resident #76 had long unkempt hair, was unshaven, and wore the same clothing on successive days. Resident identifiers: #117 and #76. Facility census: 116. Findings include: a) Resident #117 Observation on 05/16/17 at 2:16 p.m. found this [AGE] year old resident had numerous long white hairs on her chin and lower jaw area. On 05/23/17, review of the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 04/13/17, found her Brief Interview for Mental Status (BIMS) score was three (3), indicating severe cognitive impairment. She required limited assistance with personal hygiene. Review of the resident's care plan found a focus statement identifying she was at risk for decreased ability to perform activities of daily living (ADL) functions due to generalized weakness, fluctuation in cognition/dementia with behaviors, and multiple other disease processes. Interventions included to provide assistance as needed, as the ADLs might fluctuate. Observation on 05/23/17 at 12:45 p.m. found she still had long white hairs on her chin and lower jaw area. When asked about the resident's chin whiskers, Nurse Aide (NA) #59 replied that just this morning he commented that the resident's beard was longer than his. He said he would shave her right away, and he did. During an interview on 05/23/17 at 4:20 p.m., the administrator said this resident's ADL abilities fluctuated due to her behaviors and dementia. No further information was provided about the resident's facial hair. b) Resident #76 A Stage 1 observation on 05/15/17 at 1:47 p.m., revealed Resident #76 was unshaven, and his hair was long, uncombed and unclean. Another observation on 05/16/17 at 8:30 a.m., revealed his beard grow… | 2020-09-01 |
| 15 | 15 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 315 | D | 0 | 1 | ELSQ11 | Based on a random observation and staff interview, the facility failed to provide care in a manner to prevent urinary tract infections. A staff member placed washcloths in the bathroom sink basin in preparation for incontinence care, creating a potential for introducing potential pathogens into the resident's urinary tract. This practice affected one (1) resident for whom incontinence care was observed. Facility census: 116. Resident identifier: #163. Findings include: a) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Licensed Practical Nurse unfastened the resident's brief revealing the resident had had an incontinence episode. Nurse Aide (NA) #102 obtained a stack of washcloths, placed them in the bathroom sink basin, and turned on the water. The NA wrung the washcloths and laid them on the left side of the sink near the faucet handle. NA #102 dried her hands, picked up the washcloths and gave them to Licensed Practical Nurse (LPN) #72 who utilized them to perform peri-care. | 2020-09-01 |
| 16 | 16 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 318 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) residents reviewed for range of motion received services to help prevent further decline. Resident #43 had contractures of the right hand, wrist, elbow, and shoulder, but had no range of motion or orthotics ordered to help prevent further decline or other negative outcomes. Resident identifier: #43. Facility census: 116. Findings include: a) Resident #43 Review of the resident's medical record on [DATE] found the resident's [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of [DATE], found she came to the facility with contractures of the right hand, wrist, elbow, and shoulder. Review of the most recent comprehensive assessment with an ARD of [DATE], found she was assessed with [REDACTED]. The facility assessed her as having received no therapy services, no restorative nursing services, and no hand or wrist splint/orthotic device during the look back period. Her Brief Interview for Mental Status (BIMS) score was eleven (11), indicating moderately impaired cognitive functioning. On [DATE] at 4:45 p.m., the administrator provided a copy of the resident's current care plan. Review of the care plan found a focus statement related to the right side extremities being weaker than the left, and contractures of the right shoulder, elbow, wrist, and hand. However, there was no goal related to what the facility hoped to achieve related to contracture maintenance, and no interventions on how the facility planned to ensure no worsening of the contractures, or no negative outcomes related to the contractures. During an interview on [DATE] at 4:01 p.m., Director of Rehabilitation Services #52 said this resident first began therapy services [DATE] through [DATE]. Their old record keeping was done on paper and they had transferred to electronic documentation sometime in (YEAR). She revi… | 2020-09-01 |
| 17 | 17 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 329 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident remained free of unnecessary drugs. The physician ordered a reduction of Resident #9's [MEDICATION NAME] more than two (2) months after the pharmacist recommended the reduction. Two (2) days after the ordered reduction, the medication was increased without any evidence the increase was needed. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #9. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report with a date of 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of [MEDICATION NAME] at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was sixty-four (64) day after the initial recommendation. On 04/13/17 the physician ordered a reduction to 0.25 mg at bedtime for one (1) week and then discontinue the [MEDICATION NAME]. On 04/15/17 the physician discontinued [MEDICATION NAME] 0.25 mg at bedtime and restarted [MEDICATION NAME] 0.5 mg at bedtime. Review of the behavioral flow sheet for (MONTH) of (YEAR) did not reveal behaviors related to anxiety. Review of nursing notes between 04/13/17 and 04/15/17 did not reveal documentation of the resident experiencing anxiety. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the records did not reveal any indication of a need for increasing the [MEDICATION NAME]. | 2020-09-01 |
| 18 | 18 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 353 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, visitor interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure sufficient staff to implement resident care plans and respond to residents' needs for thirty-four (34) of thirty-four (34) residents reviewed for restorative services (#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141) and twelve (12) residents (#93, #125, #34, #43, #103, #126, #41, #121, #22, 104, 189, and #93) observed during the dining experience. Facility census: 116. Findings include: a) Resident #76 Medical record review found a minimum data set (MDS) with an assessment reference date (ARD) of 05/09/17 that identified Resident #76 required the extensive assistance of one (1) person for bed mobility. The MDS indicated the resident had impairment on both sides of his upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. Nurse Aide (NA) #135, interviewed on 05/23/17, verbalized Resident #76 had gotten weak and now staff did more for him than he did for himself. She said he was not eating at all. Licensed Practical Nurse (LPN) #62 concurred the resident had a recent decline. A Stage 1 observation on 05/15/17 at 2:14 p.m. found Resident #76 leaning to the right side without support to maintain an upright position. On 05/23/17 at 9:12 a.m., the resident was in bed lying on his back with the head of the bed elevated to about 45 degrees. The resident had slid down in bed. At 2:44 p.m., an observation revealed Resident #76 slid down in bed and was eating lunch. An unidentified NA was feeding the roommate and his brother and sister-in-law were standing at the bedside. Licensed Practical Nurse (LPN) #62 observed the resident and confirmed he was not positioned correctly and needed pulled u… | 2020-09-01 |
| 19 | 19 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 362 | E | 0 | 1 | ELSQ11 | Based on observation, staff interview, resident interview, and review of the dining schedule, the facility failed to ensure sufficient staffing to prepare and serve food in the scheduled timeframes. This practice affected twelve (12) residents served in their rooms during lunch dining. Facility census: 116. Resident identifiers: Residents #93, #125, #34, #43, #41, #121, #22 #104, #189, and #63 Findings include: a) Residents #93, #125, #34, #43, #41, #121, and #22 The dining schedule indicated lunch meals were served to areas as follows: -- fine dining 11:25 a.m. -- rehab (restorative) 11:30 a.m. -- south hall 12:10 p.m. -- south hall 12:15 p.m. -- east hall 12:20 p.m. -- east hall 12:30 p.m. -- north hall 12:35 p.m. -- north hall 12:40 b) During a random observation on 06/01/2017 12:50 p.m., a staff member announced by the overhead page Lunch is now being served on east hall. Within a few minutes the food cart was delivered and parked by the entrance near the main dining room. The time was 30 minutes later than noted on the schedule for the first cart. The dining schedule indicated the trays shoud have been served at 12:20 p.m. Observation revealed no resident on the hallway had a meal tray. c) At 12:55 p.m. on 06/01/17, observation of the South Hall revealed staff passing trays from the food cart on the hallway. The dining schedule indicated the floor trays were served at 12:10 p.m. NA#34 was heard informing Residents #93 and #125 they would be helped soon. Upon inquiry, the NA said ten (10) residents required assistance with meals and two (2) nurse aides passing trays. The dining schedule indicated the meal trays would be served at 12:10 p.m. - At 12:58 p.m., NA #2 passed a tray to Resident #34 and began to feed her. - At 12:58 p.m., Registered Nurse (RN) #126 and the interim CNE said they would assist. The CNE passed a tray to Resident #93 and fed her. - At 1:02 p.m., RN #126 passed a tray to Resident #125 - At 1:07 p.m., RN #108 passed a tray to Resident #121 - At 1:10 p.m., Resident #41 was asleep, her meal … | 2020-09-01 |
| 20 | 20 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 428 | D | 0 | 1 | ELSQ11 | Based on record review and staff interview, the facility failed to act upon a pharmacist's recommendation in a timely manner. This was true for two (2) of five (5) residents reviewed for unnecessary medications. The physician did not respond to a pharmacist's recommendation for Resident #9 for over two (2) months. For Resident #45, the resident continued to receive the medication Reglan nearly three (3) months after it should have been discontinued. Resident identifiers: #9 and #45. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report dated 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of Clonazepam (a psychoactive medication) at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was 64 days from the initial recommendation. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the physician's response to the pharmacist's recommendation was not timely. b) Resident #45 A pharmacist review dated 02/09/17 identified Resident #45 received Reglan 5 mg every 8 hours and was also taking Protonix 40 mg daily with both medications being for gastroesophageal reflux disease (GERD). The pharmacist's recommendation was to consider tapering the Reglan while continuing the Protonix. The physician accepted the recommendation with a modification of discontinuing the Reglan on 02/25/17. Review of the Medication Administration Record [REDACTED]. On 05/31/17 at 1:36 p.m., the DON agreed the resident continued to receive Reglan after the physician noted to discontinue the medication on 02/25/17. | 2020-09-01 |
| 21 | 21 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 431 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the Centers for Disease Control (CDC) and Prevention guidelines, and review of manufacturer's guidelines, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of Purified Protein Derivative (PPD - a test to aid in the detection or [DIAGNOSES REDACTED]. This had the potential to negatively impact the safety and/or potency of the medication, and had the potential to affect any resident who might receive an injection from this vial. One (1) of two (2) medication storage room refrigerators contained a vial of PPD serum that was not labeled when initially opened. Facility census: 116. Findings include: a) East wing medication room refrigerator Observation of the East wing medication room refrigerator on 05/17/17 at 7:56 a.m., accompanied by Licensed Nurse (LN) #55, found an opened, partially used vial of Purified Protein Derivative (PPD) serum which contained no date indicating when it had first been opened. When full, the vial contained enough serum for ten (10) tests. The nurse said the vial should have been dated when it was first opened, so that staff could determine how long the vial had been in use. She said they should discard all opened vials of PPD after they were opened for thirty (30) days. She immediately discarded the opened vial of PPD. During an interview with the director of nursing on 05/17/17 at 5:00 p.m. she said the nurse informed her of the opened undated vial of PPD. She said their policy directed that all multi dose vials be dated initially when opened, and discarded in accordance with the manufacturer's guideline. The Centers for Disease Control and Prevention (CDC) guidelines include, If a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for … | 2020-09-01 |
| 22 | 22 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 441 | E | 0 | 1 | ELSQ11 | Based on observations, staff interview, and policy review, the facility failed to maintain an effective infection control program to prevent the transmission of disease and infection to the extent possible. Staff failed to utilize proper hand hygiene, failed to utilize personal protective equipment (PPE) when required and/or dispose of PPE properly, and failed to handle medication properly. These practices affected nine (9) of the one hundred sixteen (116) residing in the facility and had the potential to affect additional residents. Facility census: 116. Resident identifiers: #25, #189, #127, #76, #104, #42, #31, #163, and #158. Findings include: a) Residents #25, #189, #127, #76, #104, and #42 During a lunch meal observation, Nurse Aide (NA) #75 touched items in the room of Resident #25, returned to the cart, poured a cup of coffee and placed it on top of the cart. The NA entered the room of Resident #189 who was in contact isolation for clostridium difficile (a highly contagious organism). The NA did not don personal protective equipment (PPE) prior to entering the room. Upon completion of the tray set-up, NA #75 washed her hands for a count of eight (8) seconds. The NA exited the room and poured coffee for Resident #68. Without performing hand hygiene, the NA passed trays to Resident #76 and assisted NA #135 with Resident #104. Upon completion, the NA washed her hands for a count of seven (7) seconds, then passed a tray to Resident #42. b) Resident #25 On 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 performed care for Resident #25. Upon completion, the NA bagged soiled items. With the same gloves the NA pulled up the resident's covers, picked up the bed remote from the floor and attached the call bell to the bed cover. c) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Nurse Aide (NA) #102 assisted Licensed Practical Nurse (LPN) #72 with wound care. The resident held Resident #163's hands. When the nurse unfastened the resident's brief, she found the resident had an incontinence episode… | 2020-09-01 |
| 23 | 23 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 514 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records. For Resident #190, neurological assessments were incomplete. For Resident #163, documentation regarding treatments, response to pain medication, and a voiding diary were incomplete. For Resident #159, [MEDICAL TREATMENT] communication sheets and activities of daily living (ADLs) date were incomplete. ADL sheets were incomplete for Resident #76 and meal/snack percentages were not documented for Resident #143. This was true for five (5) of thirty-two (32) records reviewed. Resident identifiers: #190, #163, #159, #76, and #143. Facility census: 116. Findings include: a) Resident #190 Review of the resident's medical record on 05/30/17 found he sustained an unwitnessed fall in his room on 04/10/17 at 5:05 p.m. As a result of the fall, he incurred an abrasion and a skin tear to the back of his left arm between his elbow and shoulder. The facility initiated a neurological assessment flow sheet right away. On 04/11/17 at 4:30 p.m. and at 8:30 p.m., the flow sheet was silent for neurological assessments, vital signs, observations, or staff signatures. The assessment resumed on 04/12/17 at 12:30 a.m. On 05/30/2017 at 4:04 p.m., after reviewing the neurological assessment flow sheet, the director of nursing (DON) agreed there was incomplete documentation on 04/11/17 at 4:30 p.m. and at 8:30 p.m. with no documented refusals, and noted the night shift picked it back up as did the day shift, with no abnormalities noted. b) Resident #163 1. Review of the resident's medical record and treatment administration records for (MONTH) and (MONTH) (YEAR), found no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed for seven (7) of forty (40) opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05… | 2020-09-01 |
| 24 | 24 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 558 | D | 0 | 1 | 8Y4111 | Based on observation, resident interview and staff interview, the facility failed to provide appropriate accommodation of needs regarding storage and accessibility of Resident #23's personal items. This was evident for one (1) randomly observed resident. Resident identifier: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser drawer was found to be in disrepair and not functionable. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The broken drawer was hanging in such a way that it also blocked access to the bottom dresser drawer. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her personal items in the middle or bottom dresser drawers due to the front of the middle drawer falling apart and hanging in the way. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get what ever supplies he will need to fix it today. | 2020-09-01 |
| 25 | 25 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 580 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and policy review, the facility failed to promptly notify the physician when a resident experienced a change in condition. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). Resident (R#33) refused physician ordered wound dressing for multiple days without the physician being notified. This practice had the potential to effeect a limited number of residents. Resident identifier: R#33. Facility census: 111. Findings included: During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound drainage and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wo… | 2020-09-01 |
| 26 | 26 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 584 | D | 0 | 1 | 8Y4111 | . Based on policy review, resident interview, staff interview and record review, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment. Through a random opportunity for discovery, it was found Resident #23 had a busted up air conditioning unit that was in disrepair. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser and HVAC (centralized heating ventilation and air conditioning system) unit in her room were found to be in disrepair and maintained in an unsafe manner. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The Resident's HVAC unit in her room was found to be in poor condition with the plastic framing that enclosed the heating busted in several places, along the top and sides. The HVAC unit was loose and had came unattached from the right-hand side of the heating unit sliding down over the temperature control knob, causing the temperature control knob to be very difficult to turn. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her dresser drawers due to the front of the middle drawer falling apart. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer, and she was unable to adjust the heat on the HVAC unit due to the broken plastic frame, so she just left it on one setting (high heat) and had gotten used to hot temperature. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, … | 2020-09-01 |
| 27 | 27 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 585 | D | 0 | 1 | 8Y4111 | Based on policy review, Resident interview, staff interview and record review the facility failed to make prompt efforts by the facility to resolve grievances the resident may have. This was true for two (2) of four (4) reviewed in the care area of personal property. Identified Resident's #115 and #82. The facility census was111. Findings included: a) Facility policy Facility Grievance/Concern Policy with a revision date of 03/01/18 stated: --The purpose for grievance /concern reporting is ensure that any patient/patient representative has the right to express a grievance/concern without fear of restraint, interference, coercion, discrimination, or reprisal in any form. --To assure prompt receipt and resolution of the grievance/concern. --Notify the person filling the grievance/concern of resolution within 72 hours. b) Resident #115 During an interview on 06/04/19 at 12:51 PM, Resident #115 stated, that while at the hospital her TV and google home was reported to be missing when she returned, but nothing has been done about it. A review of the Grievance/Concerns reports revealed that there was not a form filled out about the missing items. During an interview on 06/06/19 at 11:30 AM, Administrator was asked about a Grievance/Concern report on this missing TV and Google home. He stated that an employee that is no longer here spoke to Resident # 115, about her missing items, but for whatever reason there was not a form completed. During an interview on 06/10/19 at 9:11 AM, Administrator provided a completed Grievance/ Concern form, dated 06/06/19, he stated that he did look for Resident # 115 missing items and they could not be located. He stated, that the facility will have to replace them. b) Resident #82 During an interview on 06/03/19 at 1:45 PM, Resident #82 stated, that her red satin [NAME]et with a white strip has been missing for a while and that she did tell the Administrator, but nothing has been done. She went on to say, that some of the staff said, that they have looked for it, but all they did was put … | 2020-09-01 |
| 28 | 28 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 656 | D | 0 | 1 | 8Y4111 | Based on observation record review and staff interview, the facility failed to develop a care plan for discharge planning. This was true for one (1) of one (1) reviewed in for the care area of discharge planning. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #117. Facility Census: 111. Findings included: b) Resident #117 A review of the medical record on 06/05/19 for Resident #117 revealed the comprehensive care plan had not been developed to include discharge planning. In an interview on 06/05/19 at 3:22 PM, Social Services Specialist (SSS) #101 verified the care plan for Resident #117 was not developed to include discharge planning. | 2020-09-01 |
| 29 | 29 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 657 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan related to refusal of care and non-compliance. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). This practice had the potential to effect more than a limited number. Resident identifier: #33. Facility census: 111. Findings include: a) Resident #33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatmen… | 2020-09-01 |
| 30 | 30 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 676 | D | 0 | 1 | 8Y4111 | Based on resident interview, staff interview, observation and record review, the facility failed to ensure care and services for the following activities of daily living; Hygiene, bathing, dressing, grooming, and oral care for Resident #33 and #78. This was true for two (2) of two (2) reviewed in the care area of ADLS. Also, the facility failed to provide a communication board for Resident #105. This was true for one (1) of one (1) in the care area of communication. Resident identifiers: #33 and #78. Facility census: 111. Findings included: a) Resident #33 During an interview on 06/03/19 at 10:56 AM, Resident #33 said, that it is hard to get the aides to help him with a shower, they seem to pass him to another aide, and they take a lot of smoke brakes. He stated, that he must give himself a bed bath. When asked how long it had been since his last shower, he stated, that he did not know only that it has been too long. A review of the of the ADL records revealed that Resident #33 is scheduled to get a shower on Wednesdays and Saturdays, and he had no showers or baths for the month of April, and one (1) shower in the month of May. There was 15 days between his last shower until the shower he received on 06/06/19. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL recorded and agreed that Resident #33 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff members. b) Resident #78 During an interview on 06/03/19 at 12:14 PM, Resident #78 complained that it was hard to get a shower, and it had been ever since the one shower has been broken. He stated that the shower had been for down for months. He had below the shoulder length hair that appeared oily. A review of the ADL record revealed Resident #78 was scheduled to have showers on Tuesdays and Fridays. Review of ADL records revealed Resident # 78 in the month of (MONTH) he went 20 days without a shower or bath, and from (MONTH) 24th to (MONTH) the 6th that was 12 days without a shower or bat… | 2020-09-01 |
| 31 | 31 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 684 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and policy review, the facility failed to ensure and provide needed care and services in accordance with professional standards of practice for two residents reviewed during the annual LTCSP (Long Term Care Survey Process). This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who was not provided education on wound care and infection control. This was true for one (1) of five (5) sample residents reviewed for falls that was not provided neuro checks appropriately after a fall. This practice had the potential to affect a limited number. Resident identifier: R#33 and R#60. Facility census: 111. Findings included: a) R#33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainag… | 2020-09-01 |
| 32 | 32 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 689 | D | 0 | 1 | 8Y4111 | Based on observation, staff interview, and Policy review the facility failed to ensure an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifier: #53. Facility census 111. Findings included: a) Resident #53 1. Policy review Facility Waste Management policy directed personnel to: --Discard contaminated sharps immediately be disposed in a sharp's container. --Not discard sharps in routine trash. 2. Observation During an interview on 06/04/19 at 9:40 AM, with the Resident #53's roommate, this surveyor observed Resident #53 in her wheelchair at the sink with the water running. Resident #53 then moved herself over to the window. Licensed Practical Nurse (LPN) #85 entered the room and asked if she could turn off the water. She turned off the water and picked up a blue razor from the sink and threw it in the trash can under the sink. Resident #53 wheeled herself to the sink and removed the razor from the trash can. With the razor on her lap she wheeled herself back in front of her window and began the shave her left leg. Upon closer observation it was noted that her left ankle was bleeding. 3. Interviews This surveyor asked a passing employee get a nurse and distracted the resident with conversation. LPN #85 returned to the room and looked at Resident #53's left. LPN #85 left the room to retrieve supplies to treat the cuts to Resident #53's legs. There were seven (7) cuts on her left leg from the razor. On 06/04/19 at 10:00 AM, LPN #85 and Nurse Unit Manager (NUM) #61 returned to the room with supplies to treat the wounds. LPN #85 was asked how it Resident #53 had access to a razor. She said she uses the razor for the hairs on her chin, but she does it for her. Resident # 53 stated, that she does not remember where she got the razor from. During an interview with Administrator… | 2020-09-01 |
| 33 | 33 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 690 | D | 0 | 1 | 8Y4111 | Based on observation, staff interview, and policy review the facility failed to ensure a resident's Foley Catheter drainage tubing was securely anchored. This was true of one (1) of three (3) sample residents reviewed for catheter care. This practice had the potential to effect more than a limited number. Resident identifier: R#68. Facility census: 111. Findings include: Observations of Licensed Practical Nurse (LPN#84) providing catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed the Foley catheter drainage tubing was not secured or anchored in anyway. LPN#84 first provided pressure ulcer wound care to R#68 for three (3) different areas on the resident's buttocks prior to providing catheter care. During the provision of care the resident was assisted to turn multiple times from side to side. The Foley catheter drainage tube was not secured to the resident's leg. Observations, during the repositioning of the resident to expose the areas being cared for, revealed strong tension, pulling, and stretching of the drainage tubing was occurring at times. The Foley catheter drainage tube's taut tension, pulling, and stretching had the potential to cause injury to the resident's urethra and urinary meatus. After LPN#84 stated she was finished doing catheter care, this surveyor asked what method the facility used to secure the Foley catheter drainage tube. LPN#84 then acknowledged the resident did not have an anchor device on and should have, and that she also forgot to anchor and secure the tubing when she did the catheter care. LPN#84 confirmed the catheter drainage tubing was supposed to be secured so it did not pull. Review of the facility's Catheter: Indwelling Urinary - Insertion policy revealed #25 stated Ensure the catheter tubing is secured with catheter tube holder or leg strap. Keep the drainage bag below the level of the patient's bladder and off the floor. | 2020-09-01 |
| 34 | 34 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 695 | D | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to provide necessary respiratory care and services. This was true for one (1) of two (2) residents reviewed for respiratory services during the investigation phase of the survey process. It was observed R28 was not receiving her oxygen therapy at the prescribed flow rate. Resident identifier: #28. Facility census: 111. Findings included: a) Resident #28 A medical record review for Resident #28 on 06/04/19 revealed a physician's orders [REDACTED]. During an observation on 06/04/19 at 7:56 AM, it was discovered the oxygen concentrator for R28 was administering one and a half (1.5) liters of oxygen via nasal cannula and not the prescribed two (2) liters. Licensed Practical Nurse (LPN) #110 on 06/04/19 at 7:59 AM verified the oxygen concentrator for R28 was set on (1.5) liters and not the prescribed two (2) liters. | 2020-09-01 |
| 35 | 35 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2019-06-10 | 880 | E | 0 | 1 | 8Y4111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to ensure and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection to the extent possible. This was true for observations made in the laundry room regarding an inadequate negative air pressure. This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who had an exposed open draining wound. This was true of one (1) of three (3) sample residents reviewed for catheter care where a disposable contaminated wipe was placed back in the package with other uncontaminated disposable wipes. This was true for one (1) of four (4) sample residents reviewed for feeding tubes, who had a soiled feeding tube syringe laying out in the open not bagged. This was true for random observations made on two (2) separate occasions for a resident with a Foley catheter; one (1) observation revealed the Foley catheter drainage bag on the floor and one (1) observation revealed the Foley catheter drainage tubing on the floor. This practice had the potential to effect more than a limited number. Resident identifier: R#33, R#68, and R#23. Facility census: 111. Findings included: a) Laundry Room Inspection of the laundry room on 06/06/19 at 09:26 AM with the Environmental Services Director and the Director of Maintenance revealed the laundry room exhaust fan that provided the negative airflow in the dirty laundry room was not working properly. The Director of Maintenance after inspecting the exhaust fan said the exhaust fan was barely pulling air. The Environmental Services Director and the Director of Maintenance both acknowledged there was not adequate negative air flow in the dirty laundry room due to the poor performance of the exhaust fan. Both the Environmental Services Director and the Director of Maintenance confirmed the inadequate negative air … | 2020-09-01 |
| 36 | 36 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 684 | D | 0 | 1 | KVZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview, the facility failed to provide appropriate treatment and care in accordance with physician orders [REDACTED]. This affected one (#160) of one sampled resident reviewed as a new admission. The facility census was 113. Findings included: Resident #160 was observed sitting up in bed on 07/16/18 at 10:15 AM. At the time of the observation, Resident #160 was interviewed. He stated he had not received his pain medication when he was admitted to the facility. Resident #160 also stated he did not get all his routine medications in a timely manner. He stated his sister brought in his medications from home and he took those. The medical record review for Resident #160 was completed on 07/19/18 at 5:30 PM. The census tab of the electronic record documented Resident #160 was admitted on [DATE] at 8:13 PM with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The Medication Administration Record [REDACTED]. The documentation revealed Resident #160 did not receive the aspirin until one day after admission on 07/15/18 at 10:00 PM. The [MEDICATION NAME] was administered three days after admission on 07/18/18 at 6:00 AM. The [MEDICATION NAME] bisulfate was administered two days after admission on 07/16/18 at 9:00 AM. The [MEDICATION NAME] was administered four days after admission on 07/18/18 at 9:00 AM. the Tylenol administered two days after admission on 07/16/18 at 12:15 AM. Review of the weights and vitals summary on 07/19/18 at 5:30 PM revealed Resident #160 had vital signs documented approximately 5 hours after admission on 07/15/18 at 1:12 AM. The second set of vital signs was dated four days later at 07/18/18 at 7:32 PM. There was no documentation of any vital signs taken upon admission. An interview was conducted with the unit manager, Registered Nurse (RN) #23 on 07/18/18 at 6:10 PM. She stated according to the electronic record, Resident #160 was admitted on [DATE]… | 2020-09-01 |
| 37 | 37 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 801 | D | 0 | 1 | KVZF11 | Based on staff interviews, the facility failed to employ a full-time Dietary Manager that met the qualifications to manage the food and nutrition services. The facility census was 113. Findings included: On 07/18/18 at 5:00 PM, Food Service Director #121 was interviewed. Food Service Director #121 stated he was not a certified dietary manager. He stated he took the position of Food Service Director one week ago. He was not currently enrolled in a program for certification. Food Service Director #121 stated he was told he was going to be enrolled in the training program but did not know when. Food Service Director #121 verified he did not have any nutrition schooling or a college degree in nutrition. He verified he was not a certified food service manager and did not have a national certification for food service management and safety from a national certifying entity. On 07/19/18 at 1:27 PM, Regional Vice President #144 was interviewed. He verified Food Service Director #121 did not meet the qualifications for food service management and was not currently enrolled in a program for certification. | 2020-09-01 |
| 38 | 38 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-07-19 | 812 | E | 0 | 1 | KVZF11 | Based on observations, staff interview, review of cleaning logs and review of the facility policy, the facility failed to maintain the kitchen environment and equipment in a sanitary manner. This affected one of one kitchen. The facility census was 113. Findings included: On 07/17/18 at 10:57 AM, observations were made in the kitchen with Food Service Director #121. Observations revealed a build-up of food debris on the outside of the cabinet where the hot plate bases were stored. Additionally, a stainless table that holds the toaster had food debris build-up. The lower base cabinets under the prep sink on the back wall of the kitchen had food debris build up. The outside of a warming unit cabinet had a build-up of food debris and the windows around the prep area and prep sink had splatters that looked like food debris. Food Service Director #121 verified the food debris build-up on the hot plate holder cabinet, stainless table, lower base cabinets under the prep sink and the dirty windows. Immediately following the observations on 07/17/18 at approximately 11:00 AM, Food Service Director #121 provided the daily and weekly cleaning logs for (MONTH) (YEAR). The daily and weekly cleaning logs revealed daily and weekly cleaning tasks for the kitchen. The Cleaning Scheduled record revealed no documentation the equipment and work areas including the tables were cleaned by the evening cook assigned to do the task. On 07/11/18, the external plate warmer, bread warmer and work areas, including tables were not documented as being cleaned by the morning cook. On 07/11/18, the weekly cleaning of the base cabinets was not documented as being cleaned by the evening cook. Food Service Director #121 verified documentation of the cleaning was not complete and stated they (the staff) may have just wiped the areas with a rag and sanitizer but did not clean the areas thoroughly to remove the build-up of food debris. Food Service Director #121 was not sure if the cooks had followed the cleaning schedule due to the lack of documentat… | 2020-09-01 |
| 1286 | 1286 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 641 | D | 0 | 1 | Z38R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed and coded for two (Residents #71 and #163) of 26 sampled residents whose MDS assessments were reviewed. The facility's census was 180 residents. Findings include: a) Resident #71 On 01/08/19 at 12:55 PM, the clinical record of Resident #71 was reviewed. Resident #71 had [DIAGNOSES REDACTED]. physician's orders [REDACTED].#71's feeding tube was to be checked for placement before water flushes each shift. The quarterly Minimum Data Set (MDS) assessment, dated 11/13/18, documented Resident #71 had moderate impairment in cognitive skills for daily decision making. Section J documented a pain assessment interview should be conducted. However, Resident #71's pain status including pain presence, pain frequency, pain effect on function and pain intensity was not been assessed through an interview. Additionally, section K 0510 documented the resident did not have a feeding tube. The comprehensive care plan, most recently reviewed/revised on 11/20/18, documented the Resident #71 had problems pertaining to his potential for pain and his risk for complications related to his feeding tube . On 01/08/19 at 3:52 PM, the findings regarding the MDS assessment dated [DATE] were reviewed with MDS Coordinator #86. She reviewed the assessment and stated Resident' #71's pain status had not been assessed and should have been. She further stated the resident did have a feeding tube and the assessment was not accurate regarding the coding of no feeding tube. 2. Resident #163 On 01/08/19 at 10:15 AM, the clinical record of Resident #163 was reviewed. It documented the resident had [DIAGNOSES REDACTED]. The admission, comprehensive MDS assessment, dated 09/18/18, documented Section B0100 that Resident #163 was not in a persistent vegetative state/no discernible consciousness. The assessment had no documentation that Section C-cognitive patter… | 2020-09-01 |
| 1287 | 1287 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 656 | D | 0 | 1 | Z38R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to implement a comprehensive person-centered care plan to prevent falls. Specifically, the facility failed to follow the care plan for non-skid socks for one (Resident #41) of 26 sampled residents. The facility census was 180. Findings included: a) Resident #41 Review of the face sheet on 01/14/19 at 7:00 AM for Resident #41 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/01/18, revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score 1 of 15. Review of the care plan on 01/14/19 at 7:00 AM, revised 11/04/18, revealed potential for injuries from falls, history of frequent falls and fall with fracture, muscle weakness, unsteady gait, dementia, decreased functional mobility, episodes of incontinence, [MEDICAL CONDITION] drug use. Interventions included: resident to wear non-skid socks when out of bed (created 12/25/18). Resident #41 was observed in her room on 01/08/19 at 1:37 PM. She was standing at the sink washing her hands with Licensed Practical Nurse (LPN) #23 by her side. The LPN helped her to a chair next to the sink and then to the bed. She was observed having difficulty with walking. The resident was observed with pink fluffy socks on her feet. When asked if the resident was wearing non-skid socks, the LPN said, Yes. She had a pair like that at home. The LPN went over to Resident #41 and lifted her feet. The socks did not have the skid free strips. The LPN confirmed the socks were not skid free. She then replaced with the appropriate socks. Certified Nurse Aide (CNA) #84 was interviewed on 01/08/19 at 2:07 PM. She stated that she was the one who dressed Resident #41 this morning. When asked if the resident was a fall risk, she said Yes. The resident used to be independent. The CNA confirmed she put the pink fluffy socks on the … | 2020-09-01 |
| 1288 | 1288 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 675 | D | 0 | 1 | Z38R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure proper positioning in the dining room for one (Resident #95) of one sampled resident reviewed for positioning. The facility census was 180. Findings included: a) Resident #95 Review of the face sheet on 01/14/19 at 7:15 AM for Resident #95 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE] with readmission 08/22/18. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/29/18, revealed the resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score 2 of 15. Resident #95 was observed in the dining room on 01/08/19 at 8:26 AM. She was feeding herself breakfast. Her table was at chin height for the resident. Resident #95 had to lift her head and reach over the top of the table for her food. She was observed having difficulty with the milk carton. The staff placed the milk into a plastic cup. Resident #95 had to lift the beverages off the table and bring to her mouth, at a lower position. Resident #95 was observed on 01/08/19 at 11:38 AM. She was at a table putting the clothing protector on herself. When asked about the table height, Resident #95 stated, Can't expect them to lower the table for me. She said, she manages. -At 12:46 PM, the table was observed at chin height for the resident. Resident #95 had to lift her arm over the table to reach her food. -At 1:08 PM, Resident #95 was observed to eat very little of her meal. Unit Manager #102 was interviewed on 01/09/19 at 8:48 AM. When asked about the table height for the residents, she said that maybe Occupational Therapy (OT) or Speech Therapy (ST) would look at that. She thought the table height was appropriate. Rehab Manager (RM) #289 was interviewed on 01/09/19 at 9:13 AM. She st… | 2020-09-01 |
| 1289 | 1289 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 690 | D | 0 | 1 | Z38R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to assess for the removal of an indwelling catheter for one (Resident #106) of two sampled residents reviewed for catheters. Specifically, the facility did not assess for the removal of the indwelling catheter after pressure ulcers had been healed. The facility census was 180. Findings included: a) Resident #106 According to the Face sheet, reviewed on 01/08/19, Resident #106 was readmitted to the facility on [DATE]. Resident #106 had [DIAGNOSES REDACTED]. According to the 5-day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment, dated 11/30/18, Resident #106 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 14 out of 15. She required extensive to total assistance with all activities of daily living (ADL). She had an indwelling catheter. Resident #106 was interviewed on 01/08/19 at 8:10 AM. She said her catheter was placed when she was in the hospital a few weeks ago. She had sores behind her thighs and the hospital thought they would heal quicker if she had a catheter. Resident #106's care plans were reviewed on 01/08/19 at 8:21 AM. A care plan revised 11/30/18 identified the resident as having an indwelling catheter and there was potential for infection or dysfunction. Interventions included providing care every shift and as needed, emptying the catheter bag every shift and as needed, ensuring the catheter bag is positioned beneath the level of the bladder and observing for pain or discomfort. There was no rational for why the resident had a catheter. The 01/2019 physician's orders [REDACTED]. The orders included an order for [REDACTED]. There was no rationale for the use of the Foley in the orders. A physician's progress note, dated 11/28/18, documented the resident had an indwelling Foley catheter at the time for multiple pressure areas. The pressure areas included: open area to left posterior thigh, stage two pressur… | 2020-09-01 |
| 1290 | 1290 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 758 | D | 0 | 1 | Z38R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure behavior and side effect monitoring for the use of an antianxiety medication had been completed for one ( Resident #71) of five sampled residents whose clinical records were reviewed for unnecessary medications. The facility census was 180. Findings included: a) Resident #71 On 01/08/19 at 12:55 PM, the clinical record of Resident #71 was reviewed and stated the resident had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 11/13/18, documented Resident #71 had moderate impairment in cognitive skills for daily decision making, a staff mood score of 00 and had exhibited no behaviors during the seven days prior to the assessment dated . The assessment documented Resident #71 had received antianxiety and antidepressant medications on seven of seven days prior to the assessment date. A physician's orders [REDACTED].#71 was to be administered [MEDICATION NAME] 75 milligrams three times daily for anxiety. The care plan, most recently reviewed/revised 11/20/18, documented Resident #71 had a problem pertaining to his use of antianxiety medication related to behaviors of verbal complaints of nervousness due to his [DIAGNOSES REDACTED].#71 had potential for increased behaviors and/or side effects from medications. The antianxiety medication care plan documented target behaviors included crying and verbal complaints of nervousness. It documented side effects and antianxiety medication included dizziness, [MEDICAL CONDITION], nervousness, drowsiness, nausea and, if side effects were noted, the physician was to be contacted. The care plan documented staff were to monitor the resident for signs and symptoms of anxiety such as restlessness, wringing hands, tearfulness, rapid heartbeat, rapid shallow breathing, flushed face, dizziness, etc. It documented target behaviors were to be monitored and recorded. The medication administration records (MARs), dated 11/2018,… | 2020-09-01 |
| 1291 | 1291 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 804 | E | 0 | 1 | Z38R11 | Based on observation, record review and interviews, the facility failed to ensure each resident receives food and drink that is palatable, and at a safe and appetizing temperature. Specifically, the facility failed to ensure residents received food that was proper temperature, the menu had variety and the food was palatable for nine randomly interviewed residents (Residents #167, #63, #165, #58, #14, #139, #111, #27, #7). The facility census was 180. Findings included: a) Residents #167, #63, #165, #58, #14, #139, #111, #27, #7 Resident #167 was interviewed on 01/07/19 at 8:21 AM. He said the only thing he could eat was the peanut butter and jelly. He said the food was bad for the smell, taste and texture. His wife brought in meals several times a week. Resident #63 was interviewed on 01/07/19 08:27 AM. When asked about the food she said, they try but it still tasted bad. Resident #165 was interviewed on 01/07/19 09:05 AM. When asked about the food, he said it's slop. I eat the eggs, but the sausage is horrible and not fit to eat. Resident #58 was interviewed on 01/07/19 at 10:21 AM. She said the food su***. The temperature was cold . the warmer it was the better it tasted. There were a lot of the same foods such as green beans, turkey, chicken and peas. Resident #14 was interviewed on 01/09/19 at 10:52 AM. She said the food was not too good. She was not able to eat heavy food. Resident #139 was interviewed on 01/09/19 at 11:01 AM. When asked about the food, she said Yuck. Most of the time the food was cold. It was not seasoned well. The foods were the same old, same old. She received imitation turkey a lot. The potatoes were cold and not seasoned. She ate in her room. Resident #111 was interviewed on 01/09/19 at 11:12 AM. She stated she did not like the food. It did not taste very good. The food was cold. Nobody from dietary had talked to her about the food. She ate in her room. Resident #58 was interviewed again on 01/09/19 11:16 AM. She said she did not like the food. It was not cooked well. Some of the vegeta… | 2020-09-01 |
| 1292 | 1292 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 812 | E | 0 | 1 | Z38R11 | Based on observation and interviews the facility failed to store, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure cold food was of proper temperature throughout meal service and ensure food preparation equipment was properly cleaned in one of one kitchen. The facility census was 180. Findings include: a) Temperatures The kitchen was observed on 01/09/19 at 11:44 AM. There was a tall rack with a tray of cottage cheese stored in several bowls. There was also a tray of pudding stored in bowls with whipped topping out at room temperature. There was no ice or refrigeration. -At 11:58 AM, the rack was observed with a tray full of seven bowls of cottage cheese and six bowls of pudding with whipped topping, out at room temperature. -At 12:21 PM, the Assistant Food Service Director (AFSD) #66 took the temperature of one bowl of cottage cheese. The temperature was 48.6 degrees Fahrenheit (F). She then disposed of the remaining cottage cheese. The Certified Dietary Manager (CDM) was interviewed on 01/10/19 at 9:45 AM. The stated the cold food items on the tray line should have had ice on it or stored in the refrigerator. Review of the Record of Food Temperatures policy on 01/14/19 at 7:39 AM, dated 11/27/17, revealed any cold food temperature above 41 degrees F requires corrective action. The cold food will be discarded. b) Equipment The kitchen was observed on 01/09/19 at 1:43 PM. Cook #127 was observed preparing the pureed texture. She was processing cabbage rolls. She placed one tray of processed cabbage rolls in the [NAME]ot Coupe (processor) container. When finished, she placed the [NAME]ot Coupe container with the blade and lid in the 2-pan sink. At 1:53 PM, she ran the water and took a cleaning rag out of the sanitizer bucket. She began cleaning the blade with the sanitizer rag at the same time rinsing under the running water. She laid the blade on parchment paper. She continued the same process with the [NAME]ot Coupe container.… | 2020-09-01 |
| 1293 | 1293 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 840 | D | 0 | 1 | Z38R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain a service contract with an outside service to provide [MEDICAL TREATMENT] services. This affected one (Resident #72) of one sampled resident reviewed for [MEDICAL TREATMENT]. The facility census was 180. Findings included: a) Resident #72 Review of the clinical record on 01/08/19 at 11:41 AM revealed an admission history form dated 12/29/18. The admission history documented Resident #72 was originally admitted to the facility on [DATE] with a readmission date of [DATE] following a [MEDICAL CONDITION] infarction. Resident #72 was originally admitted to the facility with a list of [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #72 had a Brief Interview for Mental Status (BIMS) of 10 out of 15 which documented moderate cognitive impairment. Resident #72 was independent with ambulation and needed supervision with his activities of daily living (ADLs). A physician's orders [REDACTED]. During the initial interview with Resident #72 on 01/07/19 at 10:05 AM, he stated that he was getting ready to go to his [MEDICAL TREATMENT] appointment. Resident #72 stated he goes to the Davita [MEDICAL TREATMENT] center. On 01/08/19 at 11:45 AM, Nursing Home Administrator (NHA) #256 was interviewed. NHA #256 stated the only contract the facility had was with a [MEDICAL TREATMENT] center other than Davita [MEDICAL TREATMENT] Center. NHA #256 stated that she was unaware that Resident #72 was going to the Davita center. On 01/08/19 at 11:55 AM, Licensed Practical Nurse (LPN) #230 was interviewed. LPN #230 confirmed Resident #72 received his [MEDICAL TREATMENT] from the Davita Center. On 01/08/19 at 12:03 PM, LPN #28 was interviewed. LPN #28 stated that as long as she had worked at the facility, Resident #72 had been receiving his [MEDICAL TREATMENT] at the Davita center. | 2020-09-01 |
| 1294 | 1294 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-01-10 | 880 | D | 0 | 1 | Z38R11 | Based on observation and interview, the facility failed to ensure nursing staff used proper infection control techniques to prevent cross contamination to one (Resident #36) of five sampled residents observed being administered medications. The facility census was 180. Findings included: a) Resident #36 On 01/08/19 at 7:39 AM, Licensed Practical Nurse (LPN) #247 was observed as she set up a total of nine tablets/capsules for Resident # 36 at the medication cart. LPN #247 donned one glove on her left hand. She punched medications from medication cards or poured the tablets/capsules from bottles directly into her gloved hand in lieu of dropping or pouring the medications into the medication cup. While setting up the medications, LPN #247 contaminated her gloved hand by handling medication cards/bottles and opening/closing the medication cart drawers. At 7:50 AM on 01/08/19, the observation was reviewed with LPN #247. She was asked if the medication cart drawers and medication cards/bottles she had handled with her gloved hand would be considered clean. She stated she had wiped down the cart prior to starting the medication pass. LPN #247 did not address placing the medications in her contaminated gloved hand. At 8:03 AM on 01/08/19, the observation was reviewed with the Director of Nursing. She stated the LPN had probably not used good infection control practice by handling the medication with her contaminated gloved hand. | 2020-09-01 |
| 1295 | 1295 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 550 | D | 0 | 1 | SW6S11 | Based on observation, record review, and staff interview the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. For Resident #[AGE], the facility failed to provide a dignified dining experience. This was a random opportunity for discovery. Resident identifier: #[AGE]. Facility census: 182. Findings include: a) Resident #[AGE] On 01/20/20 at 1:06 PM, Resident #[AGE] was observed to be placed by staff in the hallway of A-wing, near the entry door to her room. An over-the-bed table was placed in front of her. Resident #[AGE]'s lunch tray was placed and set up for her. Resident #[AGE] was observed to consume her lunch meal in the hallway. During an interview with Resident #[AGE] on 01/21/20 at 12:56 PM, Resident #[AGE] stated she did not want to eat in the hallway. She stated that staff had informed her that she could not eat in her room, since they were going to clean that room. Resident #[AGE] stated she does not like eating in the hallway. Resident #[AGE]'s Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19 noted the resident had a score of Brief Interview for Mental Status (BI[CONDITION]) of 15. A BI[CONDITION] score of 15 is the highest score possible indicating that the resident is cognitively intact and has capacity. During the observation of the lunchtime meal on 01/21/20 at 1:07 PM, Resident #[AGE] did not have a tray. Employee #126, Registered Nurse (RN) / Assistant Director of Nursing (ADON), was overheard stating to the staff on A-wing that all trays had been passed. During an interview on 01/21/20 at 1:08 PM, ADON #126 was asked if all residents A-wing had been served lunch. ADON #126 responded that all residents had been served, with the exception of one resident who was currently out of the facility. ADON #126 was then asked why Resident #[AGE] did not receive a tray during the initial meal delivery on the unit. ADON #126 stated Reside… | 2020-09-01 |
| 1296 | 1296 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 558 | E | 0 | 1 | SW6S11 | Based on observation and staff interview, the facility failed to ensure a call light was accessible and within reach for four (4) residents. This was a random opportunity for discovery. Resident identifiers: #12, #132, #58, and #137 Facility census: 176. Findings include: a) Resident #12 On 01/20/20 at 10:48 AM, Resident #12's call light was observed to be clipped behind the left side of the headboard, and hanging behind the headboard. This placement was approximately 10 inches out of the resident's reach. On 01/20/20 at 10:49 AM, the Director of Nursing (DON) was called into Resident #12's room. The DON placed the call light in reach of Resident #12. b) Resident #132 On 01/20/20 at 10:49 AM, Resident #132 was observed to be sitting in her wheelchair, at the end of her bed, close to the door. Resident #132's call light was lying across Resident #132's bed placed near the head of her bed. On 01/20/20 at 10:50 AM Employee #25, Nursing Assistant (NA), was asked to come into the room. NA # stated that she would place Resident #132's call light closer to her. c) Resident #58 On 01/20/20 at 10:49 AM, Resident #58 was observed to be sitting in her wheelchair, at the end of her bed, close to her closet. Resident #58's call light was lying across Resident #58's bed and placed near the head of her bed. On 01/20/20 at 10:50 AM Employee #25, Nursing Assistant (NA), was asked to come into the room. NA # stated that she would place Resident #58's call light closer to her. d) Resident #137 On 01/20/20 at 10:53 AM, Resident #137 was observed to be sitting on his bed, facing the closet. Resident #137's call light was observed to be lying behind the bed and against the wall. Resident #137 was sitting on his bed, facing the closet. On 01/20/20 at 10:55 AM, Employee #126, Assistant Director of Nursing / Registered Nurse (ADON / RN), was asked to come into Resident #137's room. RN #126 stated that she would place the call light near Resident #137. e) On 10/28/19 at 12:43 PM the findings for Residents #12, 132, 58, and 137 were discus… | 2020-09-01 |
| 1297 | 1297 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 584 | E | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview the facility failed to provide a safe and comfortable and home like environment. This failed practice had the potential to affect more than a limited number of residents residing at the facility. This was a random opportunity for discovery. Facility census 176. Findings included: a) Shower room B On 01/22/2020 at 9:45 AM, a tour of the shower room revealed exposed wood and whole on the base of the wall, from missing tile, thick black substance around the base of the toilet, storage cabinet was unlocked, visible build-up of debris along the walls and floor, shower curtains were soiled. b) Shower room C On 01/22/2020 at 10:00 AM, Tour of the shower room C revealed an unknown brown substance on the shower curtain, along with other unidentified debris on the curtain, Director of Nursing shown the shower curtain, the bench inside the shower had a black/brownish substance around the hole on the seat, used gloves and wash clothes on the floor, heavy build-up of black debris around the toilet and along the wall. On 01/22/2020 at 10:15 AM, Director of Environmental Services was asked about the cleanliness of the shower rooms and he replied, the rooms are old and cannot be cleaned well. He went on to say that his staff clean the shower rooms three times a day and that he checks them himself. He was shown the soiled curtains, and he said, The aides should have taken care of that and the things on the floor. He was asked about the vent on the ceiling having silver duct tape on it and his answer was, Well this is West Virginia and you know what they say if it don't move put WD-40 on it and if it moves put duct tape on it. He went on to say the staff cleans the shower rooms three (3) times a day. It was pointed out to him that the heavy debris was easily moved by my shoe. c) Shower room F On 01/22/2020 at 10:30 AM, the tub room had feces on the floor in front of the toilet, and around the toilet seat. Director of Nursi… | 2020-09-01 |
| 1298 | 1298 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 625 | E | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to provide residents and/or their responsible party notification of bed hold at the time of transfer/discharge to a hospital. This was true for 2 of 4 residents reviewed for hospitalization s. This practice had the potential to affect more than a limited number of residents. Resident identifier: #139 and #36. Facility census: 176. Findings included: a) Resident (R#139) On 01/21/20 at 02:17 PM, an interview with Nurse Unit manager #215 revealed the only thing the nurses send with the resident when they are transferred to the hospital is the orders, medication list, face sheet, advance directives, and SNF/NF to hospital transfer form. She said nurse do not do bed holds, the business office takes care of that. Nurse Unit manager #215 provided the resident's 12/02/19 INTERACT transfer forms. Review of the INTERACT transfer forms revealed the transfer and discharge notice given to R#139 does not refer to any information concerning a bed hold. An interview with the Admission Director and an Admission Coordinator (AC#258) on 01/21/20 at 02:35 PM, revealed a bed hold is offered to the resident the next day after being transferred to the hospital. Admission Director said sometimes a hospital doesn't keep them and they come right back here. When asked if the resident or family representative was sent and/or received any notice of a bed hold with in twenty-four (24) hours of the resident's hospitalization on [DATE]. AC#258 replied they attempt to contact the resident and/or the medical power of attorney (MPOA) within 24 hrs (twenty-four hours) and offer the bed hold, when or if they do not get anyone to speak with them, then they automatically mark declined on the bed hold form. The Admission Director stated it is all explained to a resident when they are first admitted to the facility, they go over all that and the information is in the admissions book they receive. AC… | 2020-09-01 |
| 1299 | 1299 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 641 | D | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to accurately complete a comprehensive assessment for one (1) of thirty-five (35) Minimum Data Sets (MDS) reviewed during the investigation phase of the survey process. Resident #25 had a [DIAGNOSES REDACTED].#25 having no swallowing disorders. Resident identifier: #25. Facility census: 176. Findings included: a) Resident #25 A record review completed on 0120/20, revealed the Significant Change MDS with an annual reference date (ARD) of 10/16/19 did not code Resident #25 as having any swallowing difficulties. A review of the Care Plan had a Focus: Dysphagia with risk for aspiration and Interventions: Observe for coughing, shortness of breath, choking, labored respiration and lung congestion. Observe for difficulty swallowing, holding food in mouth. In an interview with the Corporate Nurse Consultant on 01/21/20 at 1:52 PM, verified the MDS did not accurately reflect any problems with swallowing or choking for Resident #25. | 2020-09-01 |
| 1300 | 1300 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 656 | E | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observations, record review, and staff interview the facility failed to implement a comprehensive care plan. Resident #91's care plan was not implemented related to falls. Resident #[AGE]'s care plan was not implemented related to Oxygen administration. Resident #91's care plan was not implemented related to respiratory care. Resident #95's care plan was not implemented with regard to communication. Resident #82's care plan was not implemented related to fistula care. Resident identifiers: #91, [AGE], 95, and 82. Facility census: 176. Findings include: a) Resident #91 (falls / accidents) On 01/20/20 at 12:36 PM, Resident #91's bathroom was toured. There were no skid strips placed in front of the toilet. On 01/20/20 at 12:37 PM, Employee #199, Social Worker, was asked to enter Resident #91's bathroom. SW #199 did not see any non-skid strips in front of Resident #91's toilet. A review of Resident #91's care plan revealed the following: Problem: -- At risk for falls due to: [MEDICAL CONDITION], Alzheimer's, Dementia,[MEDICAL CONDITION](hypertension), medication side effects, episodes of incontinence, and chronic pain. Goals associated with this problem include: -- Resident will have no falls with injury through next review. Interventions include: -- Non slip strips in front of toilet. On 01/22/20 at 8:14 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM. b) Resident #[AGE] On 01/22/20 at 12:54 PM, Resident #[AGE] was observed to be asleep in bed. Resident #[AGE]'s nasal canula was not in her nose, but rather lying on the bridge of her nose, close to her eyebrows. Resident #[AGE]'s concentrator was on a setting of 2.5 liters. On 01/22/20 at 12:55 PM, Employee #1[AGE], Licensed Practical Nurse (LPN) was called into Resident #[AGE]'s room. LPN #1[AGE] placed the nasal canula on Resident #[AGE]'s nose and stated that the oxygen setting should be at … | 2020-09-01 |
| 1301 | 1301 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 657 | D | 0 | 1 | SW6S11 | Based on record review and staff interview the facility failed to revise a care plan. This failed practice had the potential to affect one (1) out of 35 residents reviewed for care plans. Resident identifiers: Resident # 35. Facility census 176. Findings included: a) Resident # 35 During a review of medical records it was discovered that Resident #35 had three (3) pressure injuries on a readmission on 01/06/2020. The nursing notes stated, that upon arrival she had one on the left and right heels and the lower left buttock. On 01/22/20 at 10:35 AM, Director of nursing was asked if she had any more information she could provide for the care plan. She agreed the information about the pressure injuries should have been revised. | 2020-09-01 |
| 1302 | 1302 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 684 | E | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that each resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true for six (6) of thirty-five (35) sampled residents during the Long-term Care Survey Process (LTCSP). Resident identifiers: #104, #2[AGE], #6, #36 and #27. Facility census: 176. Findings include: a) Resident #104 Medical record review for Resident #104, reveals she was admitted to the facility on [DATE] from an acute care facility after receiving treatment for [REDACTED]. Admitting medications as directed by the discharge summary dated 09/28/19, included [MED] 10 milligrams (mg) daily,[MEDICATION NAME] mg twice daily, [MEDICATION NAME] 25 mg twice daily and [MEDICATION NAME] 0.3 mg three times daily. a.1.) [MED] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>Review of the September and October 2019 Medication Administration Record [REDACTED]. On 09/30/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order entered into computer program (point click care (PCC) as [MED] 15 mg daily. On [DATE] order changed to, [MED] 10 mg twice daily. On 10/25/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order changed to [MED] 10 mg twice daily. Discussed with the Assistant Director of Nursing (ADON) and Unit Managers to clarify order for [MED] dose with physician. On 10/25/19, order for [MED] 10 mg daily. a.2.)[MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read:[MEDICATION NAME](Isorbide [MEDICATION NAME]) 30 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 30 mg twice daily. This rec… | 2020-09-01 |
| 1303 | 1303 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 689 | D | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure the environment was free from accidents and hazards. These occurrences were a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifiers: #27, #137. Facility census: 176. Findings included: a) Resident #27 On 01/22/2020 at 10:56 AM, observation was made a of bottle of Nature's Bounty L-[MEDICATION NAME] 1000 mg Vitamin Supplement (L-[MEDICATION NAME] is a chemical building block amino acid used to cardiovascular conditions and erectile dysfunction) lying in the bed with the resident, on the Resident's left side near her hand while the resident was sleeping. At 10:57 AM on 01/22/2020, Licensed Practical Nurse (LPN) #253 was called into the Resident's room and stated the medication (Vitamin Supplement) did not belong to the facility, and she was unaware the resident had it in her room. The bottle of Vitamin Supplement contained 15 tablets as verified by LPN #253. The Resident did not have an active order the Vitamin Supplement, and the Vitamin Supplement was removed by LPN #253 and placed at the nurse's station. The resident stated she had not taken of the medication; however, she did take at home and wanted to ask the Doctor about taking it while in the facility. At 11:20 AM on 01/22/2020 a list of Residents the facility considered to be Wanderers for building #1 Wings E,F,G, that could have potentially accessed the Vitamin Supplement was provided by RN #55 to include Resident #41, Resident #13, Resident #152. Record review indicated a progress note was entered by LPN #253 on 01/22/2020 at 11:49 AM that stated, Resident noted to have a bottle of L-[MEDICATION NAME] 1000 mg in her bed shift. Educated resident on not taking her own medications or keeping medications in her room. Bottle of medication was taken and added to medication list per physician orders [REDACTED]. Review of the facility's Medicati… | 2020-09-01 |
| 1304 | 1304 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 695 | E | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide respiratory services within professional standards of care. Resident #[AGE] was administered Oxygen without a physician's orders [REDACTED]. Resident #27. Resident identifiers: #[AGE], 91, and 27. Facility census: 176. Findings include: a) Resident #[AGE] On 01/22/20 at 12:54 PM, Resident #[AGE] was observed to be asleep in bed. Resident #[AGE]'s nasal cannula was not in her nose, but rather lying on the bridge of her nose, close to her eyebrows. Resident #[AGE]'s concentrator was on a setting of 2.5 liters. On 01/22/20 at 12:55 PM, Employee #1[AGE], Licensed Practical Nurse (LPN) was called into Resident #[AGE]'s room. LPN #1[AGE] placed the nasal cannula on Resident #[AGE]'s nose and stated that the oxygen setting should be at 2 liters. During an interview on 01/22/20 at 1:04 PM, Employee #120, LPN, was asked what the oxygen order for Resident #[AGE] was, as the order was not listed in the electronic medical record, the Medication Administration Record (MAR), the Treatment Administration Record (TAR), and Oxygen was care planned. LPN #120 stated Resident #[AGE] should have an order for [REDACTED]. On 01/22/20 at 1:07 PM, LPN #120 stated that she could not find an order for [REDACTED].#[AGE]'s electronic medical record. A review of Resident #[AGE]'s care plan revealed the following: Problem: -- Oxygen: Resident requires oxygen use Shortness of Breath, chronic [MEDICAL CONDITION]. Goals associated with the problem include: -- Resident will remain free from complications associated with oxygen use during the forthcoming quarter. Interventions included: -- Observe resident for shortness of breath (cyanosis of the lips and nail beds, increased confusion, nasal flaring, retractions, or tachypnea) and notify physician if noted. -- Provide oxygen as ordered A further review of Resident #[AGE]'s medical record noted that an order for [REDACTED]. A review of Resi… | 2020-09-01 |
| 1305 | 1305 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 698 | D | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This was true for one (1) of one (1) residents reviewed for [MEDICAL TREATMENT]. Resident identifier: #82. Facility census: 176. Findings include: Review of Resident #82's medical records found he was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #82's comprehensive care plan found he had a fistula in his left upper arm and the nursing staff was to check for thrill/bruit q shift, monitor for changes of temperature in the extremity, presence of blood at site or rupture of site (call 911) and notify MD. - Auscultation/palpation of the AV fistula (pulse, bruit and thrill) to assure adequate blood flow; - Significant changes in the extremity when compared to the opposite extremity ([MEDICAL CONDITION], pain, redness). The development and implementation of interventions, based upon current standards of practice including, but not limited to documentation and monitoring of complications, pre-and post-[MEDICAL TREATMENT] weights, access sites, nutrition and hydration, lab tests, vital signs including blood pressure and medications. No documentation of the resident's fistula daily could be found. During an interview on 01/21/20 at 12:00 pm with Employee #55, Direct Care Supervisor (DCD) and Employee #21, Assistant Director of Nursing (ADON), Resident #2[AGE]'s medical records were reviewed and found the nursing staff not monitored the fistula daily as indicated. On 01/21/19 at 2:10 pm, the Director of Nursing (DON) and Nursing Home Administrator was informed of the above findings. | 2020-09-01 |
| 1306 | 1306 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 755 | E | 0 | 1 | SW6S11 | Based on record review, observation, and staff interview the facility failed to conduct appropriate reconciliation of a controlled substance at shift change for two (2) of two (4) medication carts reviewed for medication storage. This failed practice had the potential to affect more than an isolated number of residents. Facility Census: 176. Findings included: a) Medicaton Cart E Wing Even During observation of E wing even Medication Cart on 01/22/2020 at 8:49 AM, the Narcotic and Controlled substance shift count sheet was reviewed and found to be non-compliant. The Narcotic and Controlled substance shift count sheet was not completed and co-singed by both nurses (nurse coming on duty, nurse going off duty) for a total of thirteen (7) times for the time frame of 12/22/19 through 01/22/2020. Licensed Practical Nurse (LPN) #253 verified the records were incomplete for Medication Cart E Wing even, and that was the way the nursing staff verifies the narcotic/controlled substance to be accurate and accounted for at the end of each shift. The Narcotic and Controlled substance shift count sheet was incomplete for the following time slots: --12/22/19: 7A-7P - On Going Nurse --12/22/19: 7A-7P - Off Going Nurse --12/24/19: 7P-7A - On Going Nurse --12/25/19: 7A-7P - Off Going Nurse --12/30/19: 7A-7P - Off Going Nurse --01/13/20: 7P-7A - Off Going Nurse --[DATE]: 7A-7P - Off Going Nurse b) Medication Cart F Wing Even During observation of F wing even Medication Cart on 01/22/2020 at 900 AM, the Narcotic and Controlled substance shift count sheet was reviewed and found to be non-compliant. The Narcotic and Controlled substance shift count sheet was not accurately completed and co-signed by both nurses (nurse going off duty, nurse coming on duty) for a total of seventeen (7) times for the frame of [DATE] through 01/22/20. Inaccurate Narcotic and Controlled substance shift count sheet was verified as inaccurate by Licensed Practical Nurse (LPN) #253. The Narcotic and Controlled substance shift count sheet was incomplete for the… | 2020-09-01 |
| 1307 | 1307 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 756 | D | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, policy review and staff interview, the facility failed to the consultant pharmacist followed the process and steps that must be taken when he or she identifies an irregularity that requires urgent action to protect the resident. Resident identifier: #104. Facility census: 176. Findings include: a) Resident #104 Medical record review for Resident #104, reveals she was admitted to the facility on [DATE] from an acute care facility after receiving treatment for [REDACTED]. Admitting medications as directed by the discharge summary dated 09/28/19, included [MED] 10 milligrams (mg) daily,[MEDICATION NAME] mg twice daily, [MEDICATION NAME] 25 mg twice daily and [MEDICATION NAME] 0.3 mg three times daily. a.1.) [MED] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>Review of the September and October 2019 Medication Administration Record [REDACTED]. On 09/30/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order entered into computer program (point click care (PCC) as [MED] 15 mg daily. On [DATE] order changed to, [MED] 10 mg twice daily. On 10/25/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order changed to [MED] 10 mg twice daily. Discussed with the Assistant Director of Nursing (ADON) and Unit Managers to clarify order for [MED] dose with physician. On 10/25/19, order for [MED] 10 mg daily. a.2.)[MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read:[MEDICATION NAME](Isorbide [MEDICATION NAME]) 30 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 30 mg twice daily. This recommendation was not addressed until after this surveyor's intervention. a.3.) [MEDICATION NAME] Review of Resident #104's discharge summary, dat… | 2020-09-01 |
| 1308 | 1308 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 757 | D | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs and without adequate monitoring of physician ordered parameters. Resident identifier: 104. Facility census: 176. Findings include: a) Resident #104 Medical record review for Resident #104, reveals she was admitted to the facility on [DATE] from an acute care facility after receiving treatment for [REDACTED]. Admitting medications as directed by the discharge summary dated 09/28/19, included [MED] 10 milligrams (mg) daily,[MEDICATION NAME] mg twice daily, [MEDICATION NAME] 25 mg twice daily and [MEDICATION NAME] 0.3 mg three times daily. a.1.) [MED] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>Review of the September and October 2019 Medication Administration Record [REDACTED]. On 09/30/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order entered into computer program (point click care (PCC) as [MED] 15 mg daily. On [DATE] order changed to, [MED] 10 mg twice daily. On 10/25/19, the consultant pharmacist recommendation read: [MED] 10 mg daily on discharge summary. Order changed to [MED] 10 mg twice daily. Discussed with the Assistant Director of Nursing (ADON) and Unit Managers to clarify order for [MED] dose with physician. On 10/25/19, order for [MED] 10 mg daily. a.2.)[MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On 09/30/19, the consultant pharmacist recommendation read:[MEDICATION NAME](Isorbide [MEDICATION NAME]) 30 mg twice daily on discharge summary. Order entered into computer program (point click care (PCC) as [MEDICATION NAME] 30 mg twice daily. This recommendation was not addressed until after this surveyor's intervention. a.3.) [MEDICATION NAME] Review of Resident #104's discharge summary, dated 09/28/19, found an order for [REDACTED].>On … | 2020-09-01 |
| 1309 | 1309 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 761 | E | 0 | 1 | SW6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Five (5) of 11 multi-dose [MED]s located in the C-hallway and D-hallway medication carts were not dated to indicate when the medications were first opened. Residents identifiers: #14, #25, #120, #158, #40. Facility census: 176. Findings included: a) D-hallway medication cart On 01/21/20 at 8:00 AM, inspection of the D-hallway medication cart was conducted with Licensed Practical Nurse (LPN) #256. Two (2) of seven (7) multi-dose [MED]s located in the cart were not dated to indicate when they were first opened. These [MED]s were a multi-dose vial of Novalog [MED] for Resident #120 and a Tresiba [MED] Pen-Injector, which appeared to be empty, for Resident #40. Additionally, one (1) of seven (7) multi-dose [MED]s located in the D-hallway medication cart appeared to have been dated, but the writing had smeared, and the date was no longer legible. This [MED] was a multi-dose vial of Novalog [MED] for Resident #158. It is important to label multi-dose medications with the opening date because they must be discarded within 28 days of opening, unless the manufacturer specifies a different time frame for that medication. This is an infection control measure to decrease the risk of contamination of the medication vial and bacterial or fungal growth in the vial. LPN #256 verified the multi-dose [MED]s for Residents #120 and #40 were not dated when opened. She also verified the opening date for Resident #158's multi-dose [MED] was no longer legible. b) C-hallway medication cart On 01/21/20 at 1:52 PM, inspection of the C-hallway medication cart was conducted with Licensed Practical Nurse (LPN) #257. Two (2) of four (4) multi-dose [MED]s located in the cart were not dated to indicate when they were first opened. These [MED]s were a [MEDICATION NAME]Pen-injector for… | 2020-09-01 |
| 1310 | 1310 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 804 | D | 0 | 1 | SW6S11 | Based on observation, record review, and staff interview the facility failed to ensure each resident was provided that is palatable, attractive, and at a safe and appetizing temperature. For Resident #[AGE], the facility failed to provide food was that was an an appetizing temperature. This was a random opportunity for discovery. Resident identifier: #[AGE]. Facility census: 176. Findings include: a) Resident #[AGE] During an interview on 01/21/20 at 8:35 AM, Resident #[AGE] stated that food is not always appealing. Resident #[AGE] stated that sometimes the temperatures of the food is not what it is supposed to be. Resident #[AGE] noted that sometimes food that was supposed to be hot was somtimes cold and that food that is supposed to be cold is actually warm. Resident #[AGE]'s Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19 noted the resident had a score of Brief Interview for Mental Status (BI[CONDITION]) of 15. A BI[CONDITION] score of 15 is the highest score possible indicating that the resident is cognitively intact and has capacity. During the observation of the lunchtime meal on 01/21/20 at 1:07 PM, Resident #[AGE] did not have a tray. Employee #126, Registered Nurse (RN) / Assistant Director of Nursing (ADON), was overheard stating to the staff on A-wing that all trays had been passed. During an interview on 01/21/20 at 1:08 PM, ADON #126 was asked if all residents A-wing had been served lunch. ADON #126 responded that all residents had been served, with the exception of one resident who was currently out of the facility. ADON #126 was then asked why Resident #[AGE] did not receive a tray during the initial meal delivery on the unit. ADON #126 stated Resident #[AGE] eats in the dining room. After surveyor intervention, ADON #126 went to Resident #[AGE]s room and asked Resident #[AGE] if she had eaten lunch, to which Resident #[AGE] responded that she had not received her lunch. On 01/21/20 at 1:11 PM, ADON #126 returned from getting Resident #[AGE]'s tray from the tray cart sitt… | 2020-09-01 |
| 1311 | 1311 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 812 | E | 0 | 1 | SW6S11 | Based on observation and staff interview, the facility failed to maintain its kitchen in a safe and sanitary manner when they failed to discard outdated bologna and cheese and failed to date a large tub of diced peaches. This deficient practice was found during a random opportunity for discovery and had the potential to affect more than an isolated number of residents. Facility census: 176. Findings included: a) Initial Kitchen Tour An initial tour of the facility's main kitchen began on 01/20/20 at 10:47 AM. At 10:51 AM in a reach-in cooler, a large square plastic container with bologna inside had a handwritten label with the following information: 1-10-20/1-17-20. Next to the first container, a second large square plastic container with cheese inside had a handwritten label with the following information: 01-3-20 1-15-20. At 10:53 AM, Dietary Employee (DE) #266 stated, That's a no-no, upon viewing the containers. DE #266 then removed the containers from the reach-in cooler, confirming that the bologna container should have been removed after 01/17/20 and that the cheese container should have been removed after [DATE]. At 10:56 AM, a large metal tub of cubed peaches in liquid in a walk-in cooler was observed to have no date. At 10:58 AM, DE #268 stated that the peaches should have been dated. At 10:59 AM, DE #268 was observed writing a date on the container of peaches. The above concerns were discussed with the facility's Administrator on 01/21/20 at 10:53 AM, and no further information was provided prior to exit. | 2020-09-01 |
| 1312 | 1312 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 842 | D | 0 | 1 | SW6S11 | Based on medical record review and staff interview, the facility failed to ensure medical records were complete and accurate for one (1) of 35 residents reviewed during the long-term care survey process. Resident identifier: #7. Facility Census: 176. Findings included: a) #7 Review of Resident #7's medical records revealed a progress note written on [DATE] at 12:32 PM, which stated, X-ray to left foot reviewed by (name redacted), FNP (family nurse practitioner)- Acute bimalleolar fractures present. New orders: Non weight bearing until seen by ortho (orthopedic) to left ankle, Splint to be placed to left ankle by PT (physical therapy). PT aware. Vit (vitamin) D level on 10-3-19, Check pulses q (every) shift to left foot. Resident has capacity and is aware. The progress notes contained no explanation of the events leading to the necessity for the x-ray. A progress note written by the Nurse Practitioner on [DATE] at 11:21 PM and identified as a late entry note stated, (Name redacted) was seen today for routine follow up visit and it was reported that he had a fall and a follow up x-ray to the left ankle. An incident/accident report written on [DATE] at 5:00 AM stated, CNA (Certified Nursing Assistant} came to this nurse stating that resident had hurt his left ankle. Upon assessing resident, left ankle noted to be swollen. Resident unable to bear weight to left ankle. Resident stated that he was going back to hid (sic) bed after going to the bathroom and tripped and almost fell . He stated that he did not fall, but he did twist his ankle.Dr. (name redacted) notified, gave order for x-ray to left ankle. According to the incident/accident report, the document is not part of the Medical Record. During an interview on 01/22/20 at 10:30 AM, the Director of Nursing acknowledged Resident #7's progress notes did not contain an explanation of the incident which occurred on [DATE] and resulted in fractures of the resident's ankle. No further information was provided through the completion of the survey. | 2020-09-01 |
| 1313 | 1313 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 867 | E | 0 | 1 | SW6S11 | Based on record review, policy review and staff interview the facility failed to ensure the Quality Assessment and Assurance (QA&A) committee corrected quality deficiencies it had knowledge of. The facility had a Complaint Survey from 10/28/19 through 10/31/19 during which time they were issued citations that included F558, F5[AGE], F656, F689, and F[AGE]4. The facility submitted a plan of correction and indicated they would have everything corrected by 01/06/20. An annual survey was conducted from 01/20/20 through 0[DATE] at which time the following tags were recited F558, F5[AGE], F656, F689, and F[AGE]4. Therefore the facility's QA&A Committee failed to correct identified deficient practices. This practice has the potential to effect all residents currently residing in the facility. Facility census: 176. Findings include: a) Cross reference deficiency cited at F 558 b) Cross reference deficiency cited at F 5[AGE] c) Cross reference deficiency cited at F 656 d) Cross reference deficiency cited at F 689 e) Cross reference deficiency cited at F [AGE]4 During an interview on 0[DATE] at 8:29 AM with the Administrator, the findings related to Quality Assurance were discussed with the Administrator. The Administrator stated that they are currently reviewing the action steps related to the repeat deficient practices. The Administrator discussed future ways that they would track and trend, educate, and / or discipline regarding areas that were a repeat deficient practice. No further information was provided prior to the end of the survey on 0[DATE] at 11:00 AM. | 2020-09-01 |
| 1314 | 1314 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2020-01-23 | 880 | D | 0 | 1 | SW6S11 | Based on observation, staff interview the facility failed to ensure must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of two (2) residents reviewed for the care area of urinary catheter. Resident identifier: #6. Facility census: 176. Findings included: a) Resident #6 On 01/22/20 at 10:10 AM, indwelling urinary catheter care and pericare performed by Certified Nursing Assistant (CNA) #63 for Resident #6 was observed. CNA #63 wet two (2) washcloths using water from the resident's sink. A plastic washbasin with the resident's name on it was noted to be lying on the sink counter. CNA #63 placed the two wet washcloths directly on the resident's bedside table. She did not clean the table prior to placing the washcloths on it. CNA #63 used the washcloths from the bedside table, putting soap on them and using them to wipe the resident's periarea and catheter. The surface of the bedside table could contain infectious organisms that could be transferred to the resident during catheter care and pericare by the washcloths. On 01/22/20 at 10:20 AM, the Director of Staff Education was interviewed. She stated Nursing Assistants are taught to not place clean items directly onto residents' bedside tables without using a barrier. The Director of Staff Education stated in this situation, the Nursing Assistant should have used the resident's plastic basin to place the washcloths for catheter care and pericare. The facility's Director of Nursing was informed of the above findings on 01/22/20 at 10:34 AM, and no further information related to the deficient practice was provided by the end of the survey. | 2020-09-01 |
| 1315 | 1315 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 550 | D | 0 | 1 | WI9G11 | Based on observation and staff interview, the facility failed to ensure each resident was treated in a dignified manner. The indwelling urinary catheter urine collection bag was uncovered for one (1) out of two (2) residents reviewed for the care area of urinary catheter. Resident identifier: #402. Facility census: 177. Findings include: a) #402 On 02/13/18 at 4:31 PM, Resident #402's indwelling urinary catheter urine collection bag was noted to be hanging on her bed without a covering. Nurse Aide (NA) #123 verified Resident #402's indwelling urinary catheter urine collection bag did not have a covering. NA #123 stated urine collection bags should be covered. She stated she would have a covering applied. During an interview on 02/13/18 at 4:42 PM, the Director of Nursing stated a covering had been applied to Resident #402's indwelling urinary catheter urine collection bag. On 02/14/18 at 3:12 PM, Resident #402's indwelling urinary catheter urine collection bag was noted to be covered with a dark blue covering. | 2020-09-01 |
| 1316 | 1316 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 585 | D | 0 | 1 | WI9G11 | Based on resident interview, staff interview and a review of grievances the facility failed toe nurse one (1) of two (2) residents reviewed for the area of personal property had the right to file a grievances and receive prompt efforts to have the grievance resolved. In addition the facility did not ensure the resident was apprised of progress toward a resolution. Resident #142 had informed staff about missing clothing however, the staff had not documented these concerns or kept the resident apprised to details of a resolution to her concern. Resident identifier: #142. Facility census: 177. Findings include: a) Resident #142 During an interview, on 02/12/18 at 12:46 PM, Resident #142 said she had five (5) pair of missing pants. The resident said she had told staff but they had not done anything about it. On 02/14/18 at 12:06 PM, during an interview with Clinical Quality Consultant (CQC) #260, the CQC said she would talk with Assistant Administrator (AA)# 81 about the missing pants. CQC #260 later said AA #81 had no knowledge about the missing pants. During an interview with Resident #142 on 02/14/18 at 12:30 p.m. the resident said she did have five (5) pair of missing pants. She described them as blue, gray, black and two (2) pair of brown pants. She said she had hemmed them herself. Resident #142 said she had told everybody. Nurse Aide (NA) #34 was present during this interview and acknowledged that she had known the resident had missing pants. She told the resident she had looked in laundry for the pants. NA #34 said she told her supervising nurse about the missing pants but did not remember this nurse's name. On 02/14/18 at 1:00 PM the director of nursing asked the resident again about the missing pants. The resident's roommate had visitors at that time and the visitor confirmed the resident did have the pants and had worn them to therapy. The director of nursing completed a concern/grievance form on 02/14/18 regarding the missing pants. | 2020-09-01 |
| 1317 | 1317 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 600 | D | 1 | 1 | WI9G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, record review and staff interview the facility failed to ensure the rights to be free from neglect, including prevention from falls. Resident identifier: #447. Census 177. Findings included: a) Resident # 447 During an interview on 02/12/18 11:28 AM, the resident said that she fell last week while two nurses were loading her on a lift to take her to the scales for a weight. She stated she was still having some soreness in her lower back from the fall. She was not sure of the date, but thought it was a couple of days ago. When the surveyor asked if they had done an x-ray or anything to make sure that nothing was broken, she said, no they had not. On 2/13/18 at 09:30 AM, the DON#204 was aked about the accident and if she could find the report. On 02/13/18 at 11:00 AM, the DON #204 stated that she could not find any report because they only found out about the incident on Monday when the surveyor was interviewing the resident, because a nurse aide had overheard Resident # 447 describe the accident and reported it to a charge nurse. On 02/14/18 at 08:06 AM, the DON #204 said that she had instructed a nurse to make the report, but that the nurse had forgotten to do so. Record review showed an x-ray was ordered later on Monday 02/12/18 at 12:00 PM after the initial interview. Results on the x-ray were negative per DON #204. DON #204 said that she and Nurse Practitioner #261 interviewed the resident and felt the resident was confused. Record review revealed the Physicians determination of capacity for Resident # 447 signed on 02/08/18 states that she demonstrates CAPACITY. During an interview on 02/14/18 at 08:20 AM with Resident # 447 and her spouse, when asked whether she could remember what day it was or if there was a TV program on that day that could help her remember, her spouse said he had it written it down in his pocket calendar. He showed the surveyor his calendar where he had written she fell on [DATE] at ab… | 2020-09-01 |
| 1318 | 1318 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 609 | D | 1 | 1 | WI9G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and family interview, staff interview, and record review the facility failed to report an allegation violations related to neglect, immediately, or not later than two hours after the allegation was made. If the events that cause the allegation did not involve abuse or result in serious bodily injury, no later then twenty four hours. The report of all investigations to the administrator, including to the State Survey Agency, within five working days of the incident. Findings include: a) Resident # 447 Based on resident interview, record review and staff interview the facility failed to ensure the rights to be free from neglect, including prevention from falls. Resident identifier: #447. Census 177. Findings included: a) Resident # 447 During an interview on 02/12/18 11:28 AM, the resident said that she fell last week while two nurses were loading her on a lift to take her to the scales for a weight. She stated she was still having some soreness in her lower back from the fall. She was not sure of the date, but thought it was a couple of days ago. When the surveyor asked if they had done an x-ray or anything to make sure that nothing was broken, she said, no they had not. On 2/13/18 at 09:30 AM, the DON#204 was aked about the accident and if she could find the report. On 02/13/18 at 11:00 AM, the DON #204 stated that she could not find any report because they only found out about the incident on Monday when the surveyor was interviewing the resident, because a nurse aide had overheard Resident # 447 describe the accident and reported it to a charge nurse. On 02/14/18 at 08:06 AM, the DON #204 said that she had instructed a nurse to make the report, but that the nurse had forgotten to do so. Record review showed an x-ray was ordered later on Monday 02/12/18 at 12:00 PM after the initial interview. Results on the x-ray were negative per DON #204. DON #204 said that she and Nurse Practitioner #261 interviewed the resident and f… | 2020-09-01 |
| 1319 | 1319 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 655 | D | 0 | 1 | WI9G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that a summary of the baseline care plan was provided to the resident and the resident representative for one (1) out of six (6) baseline care plans reviewed. Resident identifier: #142. Facility census: 177. Findings included: a) Resident #142 Resident #142 was admitted to the facility on [DATE]. A baseline care plan was completed for Resident #142 on 01/04/18. However, the medical records did not contain documentation Resident #142 and her representative received a written summary of the baseline care plan. On 02/14/18 at 4:18 PM, Assistant Director of Nursing (ADON) #31 confirmed the medical records did not contain documentation that Resident #142 and her representative received a written summary of the baseline care plan. ADON stated Resident #142 was admitted on night shift, and the staff on night shift do not do many resident admissions. | 2020-09-01 |
| 1320 | 1320 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 656 | D | 0 | 1 | WI9G11 | Based on medical record review and staff interview, the facility failed to implement the person-centered care plan to meet the goals, and address the resident's medical, physical and psychosocial needs. This was true for one (1) of four (4) resident care plans reviewed for the care area of accidents. The care plan for Resident #7 had addressed the potential for injury from falls, with an intervention to apply Dycem to the geri chair. Resident identifier: #7. Facility census: 177. Findings include a) Resident #7 A record review for Resident #7 on 02/13/18 the care plan addressed potential for falls with injury. Among the interventions, included Dycem to seat of geri chair. Dycem is a non-slip matting used to stabilize a surface. During an observation on 02/14/18 02:05 PM, it was discovered Resident #7 was in her geri chair and no Dycem had been applied to the seat of her geri chair. The non-slip matting was used to assist in preventing Resident #7 from sliding out of her geri chair. An interview with Employee #240,Licensed Practical Nurse (LPN) on 02/14/18 at 2:20 PM, verified the Dycem had not been applied to Resident #7's geri chair. | 2020-09-01 |
| 1321 | 1321 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 657 | D | 0 | 1 | WI9G11 | **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 revision for one (1) out of 35 comprehensive care plans reviewed. Resident identifier: #113. Facility census: 177. Findings include: a) Resident #113 Resident #113 was receiving the antipsychotic medication [MEDICATION NAME] (aripiprazole) for hallucinations, visual aggression, and combativeness. On 02/08/18, Resident #113's [MEDICATION NAME] dosage was decreased from 2 milligrams (mg) one time a day to 1 mg at bedtime every other day. On 02/08/17, Resident #113's comprehensive care plan was revised to include the intervention to give [MEDICATION NAME] 1 mg every night. During an interview on 02/13/18 at 3:48 PM, the Director of Nursing (DON) reviewed Resident #113's comprehensive care plan containing the intervention to give [MEDICATION NAME] 1 mg every night. The DON also reviewed Resident #113's order for [MEDICATION NAME] 1 mg every other night. The DON had no further information regarding the matter. | 2020-09-01 |
| 1322 | 1322 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 684 | E | 0 | 1 | WI9G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of nine (9) residents reviewed for unnecessary medications received medication according to physician's orders [REDACTED].#23. Facility census: 177. Findings included: a) Resident #23 Review of the resident's Medication Administration Record [REDACTED]. The order directed staff to obtain the resident's blood sugars (BS) before meals (breakfast, lunch and supper) and hold the insulin if the resident's BS sugar is less than 100. A second order, directed staff to inject 15 units of [MEDICATION NAME], subcutaneously after meals and hold if BS before meals is less than 100. At 10:30 aAM on 02/14/18, Registered Nurse (RN) #191 said he interrupted the order as check the BS before meals and administer the [MEDICATION NAME] after meals and hold if BS is less than 100. He said he did not obtain the BS after the meal to determine if the [MEDICATION NAME] is to be held. He said it was an unusual order and assumed the order was written differently for this resident because, she has bottomed out before. At 10:37 AM on 02/14/17, the nurse practitioner (NP) said she had written the order and that was how she wanted the [MEDICATION NAME] to be administered. The NP said the resident's blood sugars really fluctuate. The staff were calling her frequently about the resident so she wrote a new order and added the parameters. She said the order is unusual but works for this resident. The NP reviewed the February, (YEAR), MAR indicated [REDACTED] --On 02/02/18, the resident's noon BS was 80. The [MEDICATION NAME] was initialed as given by the nurse. --On 02/05/18, the resident's noon BS was 74. The [MEDICATION NAME] was initialed as given by the nurse. --On 02/08/18, the resident's BS was 80 at noon, the nurse administered the [MEDICATION NAME]. --On 02/08/18, the resident's BS was 86 before the evening meal. The [MEDICATION NAME] was initialed as given by the nurse. --On 02/09/18 the … | 2020-09-01 |
| 1323 | 1323 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 689 | D | 0 | 1 | WI9G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record reviews the facility failed to ensure the residents environment remains as free from accidents for Resident # 447. Resident identifier: #447. FAciliy census: 177. Findings included: a) Resident # 447 During an interview on 02/12/18 11:28 AM, the resident said that she fell last week while two nurses were loading her on a lift to take her to the scales for a weight. She stated she was still having some soreness in her lower back from the fall. She was not sure of the date, but thought it was a couple of days ago. When the surveyor asked if they had done an x-ray or anything to make sure that nothing was broken, she said, no they had not. On 2/13/18 at 09:30 AM, the DON#204 was aked about the accident and if she could find the report. On 02/13/18 at 11:00 AM, the DON #204 stated that she could not find any report because they only found out about the incident on Monday when the surveyor was interviewing the resident, because a nurse aide had overheard Resident # 447 describe the accident and reported it to a charge nurse. On 02/14/18 at 08:06 AM, the DON #204 said that she had instructed a nurse to make the report, but that the nurse had forgotten to do so. Record review showed an x-ray was ordered later on Monday 02/12/18 at 12:00 PM after the initial interview. Results on the x-ray were negative per DON #204. DON #204 said that she and Nurse Practitioner #261 interviewed the resident and felt the resident was confused. Record review revealed the Physicians determination of capacity for Resident # 447 signed on 02/08/18 states that she demonstrates CAPACITY. During an interview on 02/14/18 at 08:20 AM with Resident # 447 and her spouse, when asked whether she could remember what day it was or if there was a TV program on that day that could help her remember, her spouse said he had it written it down in his pocket calendar. He showed the surveyor his calendar where he had written she fell on [DATE] … | 2020-09-01 |
| 1324 | 1324 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 842 | D | 0 | 1 | WI9G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete an accurate medical record for two (2) of thirty-five (35) residents whose records were reviewed during the long term care survey. Resident #39, who was receiving hospice services, had a physician's orders [REDACTED]. Resident #194's record was not completed indicating his discharge location. Resident identifiers: #39 and #194. Facility census: 177. Findings include: a) Resident #39 Medical record review on 02/14/18 at 8:30 AM, found a physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. --One, dated 08/26/15, noting the resident's prognosis was good. --The second order, dated 08/26/15, noted the resident's rehabilitation potential was good. Employee #196, a nurse, DCD (abbreviation unknown) said, I believe the doctor needs to update the orders, at 9:32 a.m. on 02/14/18. b) Resident #194 A review of Resident #194's medical record revealed a progress note, dated 11/14/17 at 9:54 AM, which stated, Therapeutic leave of absence with medications. This was the last progress note documented in the resident's medical record. An interview with Social Worker (SW #237) on 02/15/18 at 9:25 AM revealed SW #237 had no further information regarding Resident #194's discharge from the facility. She said she thought he had some family problems and that was why he left the facility. An interview with Business Office Manager (BOM) #54 on 02/15/18 at 9:30 AM revealed BOM #54 had a note in her activity report dated 11/20/17 which stated, (Resident #194) left facility on 11/14 LOA (leave of absence) for family emergency. There has been no contact with family regarding his return. LOA under Medicaid is a max of 6 day. Per (name), no need to keep LOA day in census, we can not bill for those days. Updating census to show discharge date of ,[DATE]. (Assistant Administrator #81) notified regarding this chance (change). During an interview, on 02/15/18 at 9… | 2020-09-01 |
| 1325 | 1325 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2018-02-15 | 880 | D | 0 | 1 | WI9G11 | Based on observation and staff interview, the facility failed to maintain infection control practices to prevent the development and transmission of communicable diseases and infections. The indwelling urinary catheter tubing was observed to be lying on the floor for one (1) of two (2) residents reviewed for the care area of urinary catheter. Resident identifier: #402. Resident census: 177. Findings include: a) Resident #402 On 02/13/18 at 4:31 PM, Resident #402's indwelling urinary catheter urine collection bag was noted to be hanging off her bed with the tubing lying on the floor. Nurse Aide (NA) #123 verified Resident #402's indwelling urinary catheter tube was lying on the floor. NA #402 stated urinary catheter tubing should not lie on the floor. She stated she would have the tubing. During an interview on 02/13/18 at 4:42 PM, the Director of Nursing stated Resident #402's indwelling urinary catheter urine collection bag and tubing had been changed. On 02/14/18 at 3:12 PM, Resident #402's indwelling urinary catheter tubing was observed to no longer be lying on the floor. | 2020-09-01 |
| 1326 | 1326 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 580 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and staff interview and review of the facility's policy, the facility failed to notify the physician when the nursing staff did not write the physician's orders [REDACTED]. Resident identifer: #4. Facility census: 181. Findings included: a) Resident #4 A review of the weekly wound evaluation found on 07/02/19 at 2:10 PM, Resident #4 had a Stage II pressure ulcer on her right posterior thigh measuring three (3) centimeters (CM) by three (3) CM with a depth of 0.1 CM. The nursing staff measured Resident #4's pressure ulcer the day after the resident was admitted , which was 05/21/19. A review of Resident #4's physician order [REDACTED].#4's right posterior thigh with in house wound care, pat dry, apply barrier cream ever shift and whenever needed (PRN). An interview was conducted on 07/02/19 at 2:34 PM, with Registered Nurse (RN) #240. This RN revealed Resident #4's pressure ulcer to her right posterior thigh was identified on admission. RN #240 said she had so many wound care orders to write that she had failed to write the wound care order the physician had given her for Resident #4's Stage II pressure ulcer to her right posterior thigh on 05/21/19, when she wrote all the rest of Resident #4's wound care orders. RN #240 confirmed that she did not realized the physician order [REDACTED]. RN #240 stated that, this is the reason why the physician order [REDACTED].#240 confirmed Resident #4 did not receive wound care for three (3) day. RN #240 was asked whether she had notified the physician once she identified the wound care order was not written and no wound care was provided to Resident #4's right posterior thigh pressure ulcer. RN #240 stated, No. A review of the facility's policy wound treatment guidelines finds the center will follow specific physician order [REDACTED].> | 2020-09-01 |
| 1327 | 1327 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 584 | D | 1 | 0 | X6R911 | > Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. The main dining room floor had one (1)piece of tile that was cracked with tile missing out of the center in which there was a hole that was uneven whenever anyone walked on this piece of tile. This had the potential to affect a limited number of residents. Facility census: 181. Findings included: a) Main dining room floor. Observation on 07/02/19 at 4:40 PM, found in the main dining room floor, one (1)piece of tile that is cracked with tile missing out of the center in which this made a hole that was uneven whenever anyone walked on this piece of tile. This tile lays in a high traffic area where the residents, family and the public walk on the floor of the main dinning room. Observation and interview with the Maintenance Director (MD)#23 on 07/02/19 at 4:45 PM, was asked, should this one (1)piece of tile that is cracked with tile missing out of the center in which this made a hole that is uneven whenever anyone walked on this piece of tile be fixed. The Director of Environmental Services (DES) said the concrete has settled and cracked the tile. The DES said the tile in whole dining room needs replaced. | 2020-09-01 |
| 1328 | 1328 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 585 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, family interview, and record review, the facility failed to identify and promptly address complaints/grievances to resolution and keep residents appropriately apprised of progress toward resolution. This was true when resident council notified the facility of complaints and grievances, discussed at the 2019 (MONTH) and (MONTH) resident council meetings, concerning nurse aides (NA) taking breaks at the same time leaving the units short staffed. The facility failed to provide re-education to all nurse aides (NA) as the facility designated as their corrective action regarding this on-going resident council grievance and concern. This was also true when the facility failed to address a grievance and allegation Resident (R#7)'s family member brought to the attention of a nurse concerning a NA allegedly treating R#7 disrespectfully and being verbally abusive toward the resident. This practice had the potential to affect more than a limited number of residents. Resident identifier: #7. Facility census: 181. Findings included: a) Resident council concerns On 07/01/19 at 1:35 PM, review of Resident Council meeting minutes dated 05/16/19 and 06/20/19, revealed an issue identified by residents concerning not having enough nurse aids (NA) on the floor to assist residents, due to NAs going on breaks together at the same time. In the (MONTH) minutes, attached was a 'Resident Council Concern' form with the corrective action listed Nursing assistance will be provided with re-education on taking breaks only during assigned times and to always report to the nurse when leaving their assigned area. An interview, on 07/03/19 at 12:21 PM, with the Director of Staff Education confirmed she was responsible for providing trainings, education, and re-education to staff. The Director of Staff Education verified she was aware of the residents' grievance concerning nurse aids leaving together on breaks and being short on staff during those tim… | 2020-09-01 |
| 1329 | 1329 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 607 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of reportable abuse/neglect allegations, grievance and complaint files, family interview, staff interview, and policy review, the facility failed to ensure they implemented their policy regarding identifying, investigating and reporting allegations of abuse/neglect. An allegation of verbal abuse was not identified, reported or thoroughly investigated. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: R#7. Facility census: 181. Findings included: Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#7) is dependent with activities of daily living (ADL). R#7 is incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. On 07/03/19 at 1:25 PM, an interview with resident R#7 daughter (Healthcare Surrogate) revealed several issues and concerns regarding the resident. The daughter said she felt the resident needed more supervised time on the omni cycle due to the beneficial effects it has on her Mom. The daughter stated the weekend prior to the resident going into the hospital on [DATE], words were exchanged between herself and restorative nurse aide (NA#1). The daughter stated on 06/15/19, the restorative aide refused to get the resident on the Omni cycle, even though the daughter explained how much Mom loves this cycle and how important it was for her to have her time on the cycle. The daughter said, The restorative NA#1 got an attitude, and pointing at mom said, I tried before and she swatted at me, and I am not going to cater to her. She was rude and disrespectful to mom, she was abusive and refused to get my mom on the cycle. The daughter was asked where this exchange of words occurred, and she replied in the common area beside the nurse's station in front of the other residents, visitors, and staff. When asked if she had reported the incident to anyone the daughter replied, Staff was standing around, … | 2020-09-01 |
| 1330 | 1330 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 609 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of reportable abuse/neglect allegations, grievance and complaint files, family interview, staff interview, and policy review, the facility failed to report to the state agency allegations of verbal abuse. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: R#7. Facility Census: 181. Findings included: Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#7) is dependent with activities of daily living (ADL). R#7 is incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. On 07/03/19 at 1:25 PM, an interview with resident R#7 daughter (Healthcare Surrogate) revealed several issues and concerns regarding the resident. The daughter said she felt the resident needed more supervised time on the omni cycle due to the beneficial effects it has on her Mom. The daughter stated the weekend prior to the resident going into the hospital on [DATE], words were exchanged between herself and restorative nurse aide (NA#1). The daughter stated on 06/15/19, the restorative aide refused to get the resident on the Omni cycle, even though the daughter explained how much Mom loves this cycle and how important it was for her to have her time on the cycle. The daughter said, The restorative NA#1 got an attitude, and pointing at mom said, I tried before and she swatted at me, and I am not going to cater to her. She was rude and disrespectful to mom, she was abusive and refused to get my mom on the cycle. The daughter was asked where this exchange of words occurred, and she replied in the common area beside the nurse's station in front of the other residents, visitors, and staff. When asked if she had reported the incident to anyone the daughter replied, Staff was standing around, they saw and heard it. On Monday morning (06/17/19), when I came back to visit mom, though I did tell the Unit Nurse Manager (RN#59). The daughter sa… | 2020-09-01 |
| 1331 | 1331 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 610 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of reportable abuse/neglect allegations, grievance and complaint files, family interview, staff interview, and policy review, the facility failed to identify, thoroughly investigate, or report an allegation of verbal abuse. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: R#7. Facility census: 181. Findings included: Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#7) is dependent with activities of daily living (ADL). R#7 is incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. On 07/03/19 at 1:25 PM, an interview with resident R#7 daughter (Healthcare Surrogate) revealed several issues and concerns regarding the resident. The daughter said she felt the resident needed more supervised time on the omni cycle due to the beneficial effects it has on her Mom. The daughter stated the weekend prior to the resident going into the hospital on [DATE], words were exchanged between herself and restorative nurse aide (NA#1). The daughter stated on 06/15/19, the restorative aide refused to get the resident on the Omni cycle, even though the daughter explained how much Mom loves this cycle and how important it was for her to have her time on the cycle. The daughter said, The restorative NA#1 got an attitude, and pointing at mom said, I tried before and she swatted at me, and I am not going to cater to her. She was rude and disrespectful to mom, she was abusive and refused to get my mom on the cycle. The daughter was asked where this exchange of words occurred, and she replied in the common area beside the nurse's station in front of the other residents, visitors, and staff. When asked if she had reported the incident to anyone the daughter replied, Staff was standing around, they saw and heard it. On Monday morning (06/17/19), when I came back to visit mom, though I did tell the Unit Nurse Manager (RN#5… | 2020-09-01 |
| 1332 | 1332 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 684 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and policy review, the facility fails to follow a physician order [REDACTED].#4. Facility census: 181. Findings included: a) Resident #4 A review of the weekly wound evaluation found on 07/02/19 at 2:10 PM, Resident #4 had a Stage II pressure ulcer on her right posterior thigh measuring three (3) centimeters (CM) by three (3) CM with a depth of 0.1 CM. The nursing staff measured Resident #4's pressure ulcer the day after the resident was admitted , which was 05/21/19. A review of Resident #4's physician order [REDACTED].#4's right posterior thigh with in house wound care, pat dry, apply barrier cream ever shift and whenever needed (PRN). An interview was conducted on 07/02/19 at 2:34 PM, with Registered Nurse (RN) #240. This RN revealed Resident #4's pressure ulcer to her right posterior thigh was identified on admission. RN #240 said she had so many wound care orders to write that she had failed to write the wound care order the physician had given her for Resident #4's Stage II pressure ulcer to her right posterior thigh on 05/21/19, when she wrote all the rest of Resident #4's wound care orders. RN #240 confirmed that she did not realized the physician order [REDACTED]. RN #240 stated that, this is the reason why the physician order [REDACTED].#240 confirmed Resident #4 did not receive wound care for three (3) day. RN #240 was asked whether she had notified the physician once she identified the wound care order was not written and no wound care was provided to Resident #4's right posterior thigh pressure ulcer. RN #240 stated, No. A review of the facility's policy wound treatment guidelines finds the center will follow specific physician order [REDACTED].> | 2020-09-01 |
| 1333 | 1333 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 686 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and policy review, the facility fails to timely provide the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of five (5) residents reviewed for pressure ulcer care. Resident identifer: #4. Facility census: 181. Findings included: a) Resident #4 A review of the weekly wound evaluation found on 07/02/19 at 2:10 PM, Resident #4 had a Stage II pressure ulcer on her right posterior thigh measuring three (3) centimeters (CM) by three (3) CM with a depth of 0.1 CM. The nursing staff measured Resident #4's pressure ulcer the day after the resident was admitted , which was 05/21/19. A review of Resident #4's physician order [REDACTED].#4's right posterior thigh with in house wound care, pat dry, apply barrier cream ever shift and whenever needed (PRN). An interview was conducted on 07/02/19 at 2:34 PM, with Registered Nurse (RN) #240. This RN revealed Resident #4's pressure ulcer to her right posterior thigh was identified on admission. RN #240 said she had so many wound care orders to write that she had failed to write the wound care order the physician had given her for Resident #4's Stage II pressure ulcer to her right posterior thigh on 05/21/19, when she wrote all the rest of Resident #4's wound care orders. RN #240 confirmed that she did not realized the physician order [REDACTED]. RN #240 stated that, this is the reason why the physician order [REDACTED].#240 confirmed Resident #4 did not receive wound care for three (3) day. RN #240 was asked whether she had notified the physician once she identified the wound care order was not written and no wound care was provided to Resident #4's right posterior thigh pressure ulcer. RN #240 stated, No. A review of the facility's policy wound treatment guidelines finds the center will follow specific physician order [REDACTED].> | 2020-09-01 |
| 1334 | 1334 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 689 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, list of wound care supplies, and policy review, the facility failed to ensure a resident environment remains as free of accident hazards as is possible, over which the facility had control concerning an unlocked wound cart out of an authorized personnel eye sight and loose hand rails down a corridor. This was a random opportunity for discovery. This had the potential to affect a minimum number of resident. Facility census: 181. Findings included: a) Wound cart on D Hallway Observation on 07/03/19 at 10:55 AM, found a wound cart in the middle of the D hallway on the left hand side, unlocked, with the pull out doors of the wound cart facing the hallway. There were no one within eye sight of the wound cart. Registered Nurse (RN) #15 came out of a closed resident's room on the D hallway. When RN #15 was asked why the wound cart was left unlock and out of her eye signt. RN#15 stated, that another nurse had unlocked her wound cart for her due to they all have the same key and that she did not have a key to lock and unlock the wound cart, so she had to leave the wound cart unlocked. The inside the wound cart there were the following items: -- Sani cloth bleach wipes. -- Marathon - liquid skin protectant. --Triple antibiotic ointment- used as a first aid antibiotic to prevent infections in minor cuts, scrapes, [MEDICAL CONDITION] your skin. -- Normal saline bullets, necessary in removing dirt, debris and tissue from the area. --Staple removal kit (2) -- Suture remover. -- Alchol pads. -- [MEDICATION NAME] - is used as a skin protectant. -- Sure prep wipes - Fast-drying skin protectant is vapor permeable and delivers protection from friction and incontinence. Transparent barrier may be used on periwound, [MEDICATION NAME] or areas that come in contact with bodily fluids. -- [MEDICATION NAME] - This medication is used to prevent minor skin infections caused by small cuts, scrapes, or burns. [MEDICATION NAME] wor… | 2020-09-01 |
| 1335 | 1335 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 880 | D | 1 | 0 | X6R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, and policy review, the facility failed to implement infection control practices and processes designed to prevent the transmission of disease, infection, and/or cross contamination concerning proper hand hygiene during wound care. This had the potential to affect one (1) of five (5) residents reviewed for pressure ulcer care. Resident identifers: #5 and #6. Facility census: 181. Findings included: a) Resident #5 A review of Resident #5's physician orders [REDACTED]. The wound is cleansed with in house wound cleanser, pat dry, apply [MEDICATION NAME], Acqual AG and bordered dressing every three (3) days and as needed. The resident's has a status [REDACTED]. Observation of Resident #5's wound care to her coccyx, and right knee was conducted on 07/02/19 at 10:00 AM. RN #54 went and washed his hands, then donned three(3) pair of gloves. RN #54 had prepped the over -the -bed table for Resident #5's wound care supplies. RN #240 assisted RN #54 to turn Resident #5 over onto her right side. RN #54 had touched Resident #5's back while turning her over. RN #54 then removed Resident #5's dressing, removed a pair of the gloves, sprayed the in house wound cleanser onto four (4) by four (4)gauge, cleansed Resident #5's coccyx area and applied a bordered dressing. RN #54 removed his gloves. RN #54 picked up the in house wound cleanser and sprayed the wound cleanser onto a four (4) by four (4), cleansed Resident #5's right knee, sprayed the liquid skin barrier onto the right knee surgical wound. RN #54 waved his hands over Resident #5's right knee surgical incision, then he removed his gloves. RN #54 was asked should you have performed wound care to Resident #5's surgical incision before performing pressure ulcer care to her coccyx. RN #54 acknowledged that he should have performed wound care to the resident's surgical site first, then performed wound care to Resident #5's coccyx. RN #54 was informed that he did not … | 2020-09-01 |
| 1336 | 1336 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-07-03 | 924 | D | 1 | 0 | X6R911 | > Based on observations, staff interviews, the facility failed to ensure the corridors had firmly secured handrails on each side. The corridor handrails on the G hallway were lose. This was a random opportunity for discovery. Facility census: 181. Findings included: a) Hand rail on the corridor of Hallway [NAME] Observation on 07/03/19 at 3:30 PM, found the corridor handrail on the G hallway on the right hand side had two (2) handrails one (1) one each on both sides of a the soiled utility room turn from side to side. The handrail was loose. Nurse Aide (NA) #203, was in the hallway. The NA observed the handrails turn from side to side. The NA commented the resident reach up and grab these handrails and this could cause them to fall. The NA was asked how long had the handrails in the corridor been loose. NA #203 stated the hand rails have been loose for a week or so. The NA mentioned that she thought someone had turned this in. In an interview and observation on 07/03/19 at 3:40 PM, with the Maintenance Director (MD) #23, he verified the handrails were loose and required another screw on the bottom of the handrail to make the handrail more steady. He said he would fix the handrails immediately. | 2020-09-01 |
| 1337 | 1337 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 550 | D | 1 | 0 | OVRC11 | > Based on observation and staff interview, the facility failed to maintain resident dignity during dining. Resident #9 was served breakfast with her brief exposed. In addition, her night gown was drooping exposing her upper body. This was a random opportunity for discovery. Resident identifier: #9. Facility census: 191. Findings included: a) Resident #9 On 10/31/19 at 8:55 AM, nursing assistant (NA) #63, delivered the breakfast tray to the resident in her room. NA #63 placed the resident's tray on her over-the-bed table and placed the resident in a sitting position. NA #63 left the resident room to continue serving trays. Resident #9's hospital gown was untied around her neck and the top of the gown was hanging below her neck exposing her white undergarment and her chest. Resident #9's legs were uncovered. An incontinence brief could be seen hanging between her legs, below the hem of the hospital gown, approximately mid-calf. Both could be seen from the hallway. At 10/31/19 at 9:03 AM, the resident's brief and uncovered upper portion of her body was still visible from the hallway and entryway to the resident's room. NA #63 continued to pass breakfast trays and did not return to adjust the resident's clothing and incontinence brief. On 10/31/19 at 9:05 AM, RN #77, Register Nurse (RN), was in the hallway at her med cart. RN #77 entered the residents room to give morning medications. RN #77 did attempt to tie the hospital gown and adjust it so that Resident #9's body was covered; however, RN #77 did not adjust the brief. On 10/31/19 at 9:06 AM, RN #77, confirmed the brief had a foul, strong urine odor and was visible from the hallways. RN #77 stated that she would assist the resident and take care of the incontinence brief. On 10/31/19 at 9:14 AM, the surveyor spoke with the Administrator regarding the findings and no further information was provided before the close of the survey on 10/31/19 at 3:00 PM. | 2020-09-01 |
| 1338 | 1338 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 551 | D | 1 | 0 | OVRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the person making medical decisions for Resident #159 had the legal authority to act in the resident's behalf. This was true for one (1) of two (2) residents reviewed for advance directives. Resident identifier: #159. Facility census: 191. Findings include: a) Resident #159 Record review revealed Resident #159 was admitted to the facility on [DATE]. The resident had capacity to make medical decisions upon admission. The medical record contained a copy of a combined Medical Power of Attorney (MPOA) and Living Will created by the resident on 01/17/18. This document was signed by the resident and completed prior to admission. On 08/19/19 the facility physician determined the resident lacked capacity to make medical decisions. On 08/29/19, a physician's orders [REDACTED]. In addition, the individual who completed the POST form was not appointment by any physician or court to make medical decisions for this resident. The POST form directed the resident receive comfort measures, no feeding tube, no IV (intravenous) fluids for a trial period of no longer than 72 hours and a do not resuscitate order. At 1:45 PM on 10/30/19, the Social Worker (SW) #169 confirmed the individual who completed the POST form was not the resident's responsible party. At 10:49 AM on 10/31/19, the administrator said the social worker had informed her of the problems with the Resident's POST form. At the close of the survey on 10/31/19 at 3:00 PM, no further information was provided. | 2020-09-01 |
| 1339 | 1339 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 558 | E | 1 | 0 | OVRC11 | > Based on observation and staff interview, the facility failed to ensure a call light was accessible and within reach for three (3) residents. This was a random opportunity for discovery. Resident identifiers: #2, #9, and #46. Facility census: 191. Findings include: a) Resident #2 On 10/28/19 at 9:37 AM, Resident #2's call light was observed to be clipped to the connector that goes into the wall. This connector and outlet is located behind the resident's bed and is approximately 20 inches away from the head of the bed out of the resident's reach. On 10/28/19 at 9:38 AM, Employee # 172, Activity Director, was called into room by the surveyor. Employee #172 confirmed that the resident's call light was not in reach of resident and was clipped to the cord plug located in the call light outlet / power [NAME] that was going into the wall behind the resident's bed. Employee #172 unclipped the call light from the cord near the cord plug-in as well as placed the call light close to the resident. b) Resident #9 On 10/28/19 at 9:40 AM, Resident #9's call light was observed on the floor under the bed, looped around the wheel of the bed. Employee #71, nursing assistant (NA), crawled on the floor and underneath the resident's bed. NA #71 pulled the call light from underneath the bed and placed in reach of the resident. c) Resident #46 On 10/28/19 at 9:41 AM, Resident #46's call light was located at the foot of her bed, beside the wall. The resident's bed was placed with one side against wall. Resident #46 was sitting in her wheelchair. Resident #46 was asked if she had her call light. Her responses was that she did not know where it was. Once the call light was identified at the foot of her bed and located against the wall, the resident was unable to reach call light. On 10/28/19 at 9:43 AM, Employee #225, Registered Nurse (RN), was observed in the hallway. RN #225 was asked to if she could come into Resident #46's room. RN #225 stated that she was a wound nurse, and this was not her patient. RN #225 did enter the resident's … | 2020-09-01 |
| 1340 | 1340 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 584 | E | 1 | 0 | OVRC11 | > Based on observation, resident interview and staff interview the facility failed to ensure the resident environment was not kept clean and homelike. The shower room on the B- Hall and C - Hall were not kept clean. The following residents had the potential to be showered in the B- Hall and C- Hall shower room on 10/31/19: #2, #185, #48, #76, #135, #152, #119, #154, #178, #121, #66, #11, #10, #157, #30, #82, and #128. Facility census: 191. Findings included: a) During the resident council meeting on 10/30/19 at 1:00 p.m. multiple residents complained about the shower rooms in Building 2 being filthy. The further elaborated by stating, they leave dirty wash cloths and clothes on the floor and sometimes there is poop in the floor when you go in to get a shower. b) Observations of the B- hall and C- Hall shower rooms beginning at 10: 53 a.m. on 10/31/19 with Licensed Practical Nurse (LPN) #45 found a used wipe in the floor of the C-hall shower with a brown substance on it. LPN #45 stated that should not be in the floor. She put on a glove and picked it up and placed it in the trash can. The B- Hall shower rooms had multiple soiled wash cloths in the floor and draped over the grab bar. Also in the floor was a soiled hospital gown. LPN #45 stated the shower room needed to be cleaned up. She indicated after every resident shower the Nurse Aide (NA) should pick up all soiled linen and place it in the soiled linen cart. She agreed this had not been done. | 2020-09-01 |
| 1341 | 1341 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 610 | D | 1 | 0 | OVRC11 | > Based on record review and staff interview the facility failed to ensure all allegations of abuse and/or neglect were thoroughly investigated. This was true for an allegation made by Resident #199. All staff members who had the potential to be alleged perpetrators did not provide a witness statement. This was true for one (1) of 4 (four) reportable incidents involving neglect. Resident identifier: #199. Facility census: 191. Findings included: a) Resident #199 A review of the reportable incidents found an incident dated 07/11/19. This reportable allegation was made by Resident #199. A review of the facility's Investigation Summary found the following written by Social Worker (SW) #151, under the section titled, Summary of Investigation: On 07/11/19, Pt. (patient) reported to evening shift RN (Registered Nurse) Manager, (First and Last Name of Registered Nurse #71), he had been spoken too in a harsh manner, handled roughly and a delay in call light response time. This was reported around 6:00 p.m. and that it had happened earlier in the day. Witness statements indicate staff checked on Pt. Pt. noted to have told CDM (Certified Dietary Manager) he was not staying in the facility and noted in the SS (Social Service) noted to be confused with some lethargy that day. It could not be determined Pt was handled roughly, that CNAs were rude or that there was a delay in call light response time. Further review of the investigation found SW #151 obtained statement from NA #16, NA #66, and NA #258. NA #16's statement read as follows: I (first and last name of NA #16) went into the room of (First and Last Name of Resident #199) with (First and Last Name of NA #258) to check his brief and see if he as Dry and he was, then we pulled him up in bed and got him another blanket because he was cold. NA #258's statement read as follows: I (First and Last Name of #258) went in (Resident #199's room number) room with (First and Last name of NA #16) to check resident to see if he needed changed. He was dry so we pulled him up in bed a… | 2020-09-01 |
| 1342 | 1342 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 656 | D | 1 | 0 | OVRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to implement the care plan for one (1) of six (6) residents reviewed for falls. Resident identifier: #88. Facility census: 191. Findings included: a) Resident #88 A review of Resident #88's medical record revealed several falls: - 8/19/2019 at 8:45 PM - nurse's note revealed the resident had an unwitnessed fall. Resident was up walking around. - 9/09/2019 at 2:00 PM - fall note revealed the resident had an unwitnessed fall. Resident was ambulating by herself getting into her closet - 9/25/2019 at 7:00 PM - fall note revealed the resident had a witnessed fall. The resident was ambulating without assistance Review of Residents #88's care plan found a focus/problem: Risk for falls and potential for injuries from falls r/t (related to) impaired mobility, muscle weakness, incontinence, cognitive impairment, SOB (shortness of breath), hx (history) falls, [MEDICAL CONDITION] drug use, poor safety awareness, recent left [MEDICAL CONDITION]. The goal associated with this problem: Resident will have no major injury from falls, such as fractures, head injury, or dislocations, through next review period. Interventions included: - Encourage resident to use a reacher when trying to get objects out of their reach. - Place bed in highest position while resident is out of bed to prevent resident from trying to get into bed without assistance. On 10/28/19 at 11:43 AM, observation of Resident #88's room revealed Resident #88's bed was not in the highest position. The resident was not in the room. On 10/28/19 at 11:47 AM, Nursing Assistant (NA) #105 accompanied the surveyor into the resident's room. NA #105 stated that the resident's bed was not in the highest position, and demonstrated by adjusting the bed to the highest position. NA #105 stated that she was unaware that Resident #88 was care planned to have her bed in the highest position when the resident was not in bed. NA #105 w… | 2020-09-01 |
| 1343 | 1343 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 677 | E | 1 | 0 | OVRC11 | > Based on observation, resident interview, record review, and staff interview, the facility failed to ensure personal care was provided for dependent residents. Residents #49 and #53 did not receive showers as scheduled. Resident #9 was wearing a heavily soiled brief that had fallen around her knees. This was a random opportunity for discovery. Resident identifiers: #49, #53 and #9. Facility census: 191. Findings included: a) Resident #49 An interview with the resident at 11:45 AM on 10/28/19, revealed she did not always get her showers as scheduled. At 10:15 AM on 10/31/19, the resident's shower documentation was reviewed with the assistant director of nursing (ADON) #115. According to the shower schedule, the resident receives showers every Monday and Thursday on the 3-11 shift. In (MONTH) 2019, the resident received scheduled showers until 08/14/19. No showers were recorded after this time period for August. In (MONTH) 2019, the resident received two (2) showers: 09/07/19 and 09/18/19. The documentation revealed the resident refused a shower on 09/21/19. On 09/11/19, the resident received a bed bath. In (MONTH) 2019, the resident received no showers. Documentation revealed only one refusal, 10/28/19. The resident received six (6) of the twenty-six (26) showers scheduled. Two showers were refused. One bed bath was provided instead of the scheduled shower. Only nine (9) of the 26 showers scheduled were accounted for. ADON #115 confirmed the above was the documentation on the shower schedule. b) Resident #53 During the Resident Council Meeting on 10/30/19 at 1:00 p.m. Resident #53 stated she has not been getting her showers like she would like. She stated the shower chair is too high and the shower chair which is the right height was too small and she could not fit into it. She stated the staff did not like to put her on the bench in the shower room and she does not like to use the shower chair that his too high for her so she does not get her showers. A review of Resident #53 medical record found she was schedu… | 2020-09-01 |
| 1344 | 1344 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 689 | D | 1 | 0 | OVRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure the environment, over which the facility had control, was as free from accidents as possible. This was a random opportunity for discovery. Resident identifiers: #159 and #88. Facility census: 191. Findings include: a) Resident #159 On 10/31/19 at 8:00 AM, a plastic medicine cup with a pink cream was on the nightstand in the resident's room. Observation of the cream found an indentation in the cream which appeared to be made by fingers scooping the cream from the cup. Resident #159 said it was the cream the nursing assistants used on her bottom after providing incontinence care. The resident said the cream had been left out for at least 2 days. Registered Nurse (RN) #77, observed the cream and said it was hydroguard cream. RN #77 said licensed nurses do not apply the cream, only the nursing assistants. RN #77 said the cream should not be left at bedside in a medicine cup. Resident #159's roommate has short-and long-term memory problems due to dementia. The roommate is mobile via her wheelchair. At 8:45 AM on 10/31/19, the findings were presented to the administrator. The administrator provided the Material Safety Data Sheet (MSDS) sheet for [MEDICATION NAME] ointment (the pink ointment at the resident's bedside.) The hazards identified on the MSDS sheet: For external use only. Not for deep puncture wounds. Avoid contact with eyes. Keep out of reach of children. In case of accidental ingestion contact a physician or poison control center immediately. If condition worsens or does not improve within 7 days, consult a doctor. At the close of the survey on 10/31/19 at 3:00 PM, no further information was provided. b) Resident #88 A review of Resident #88's medical record revealed several falls: - 8/19/2019 at 8:45 PM - nurse's note revealed the resident had an unwitnessed fall. Resident was up walking around. - 9/09/2019 at 2:00 PM - fall note revealed the resident had an unwi… | 2020-09-01 |
| 1345 | 1345 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 804 | D | 1 | 0 | OVRC11 | > Based on observation and staff interview, the facility failed to ensure food was served at an appetizing temperature. This had the potential to affect more than a isolated number of residents. Facility census: 191. Findings include: a) Resident Council meeting A resident council meeting was held at 1:00 PM on 10/30/19. Fifteen (15) residents attended the meeting. At least half of the residents who attended the meeting complained about the temperature of the food served at the facility. Residents complained hot foods were not hot and cold food were too hot at the time of service. b) Breakfast temperatures: Observation found the food cart for B hallway arrived on the unit at 8:45 AM on 10/31/19. At 9:06 AM, the dietary manager was asked to take the temperatures of the last tray served from the food cart. The temperatures are as follows: Milk, 54 degrees; Apple Juice, 62 degrees; Cream of wheat, 107 degrees; Biscuits and sausage gravy, 85 degrees. The dietary manager said she would expect the hot food items to be at least 120 degrees and the cold food items to be no more than 41 degrees. b) Noontime Meal The noon time meal on G- Wing of the facility was observed on 10/31/19. The observation began at 12:10 p.m. when the tray cart arrived on the hall. The nurse aides began serving the meals to the residents. At 12:31 p.m. on 10/31/19 the last tray was served and the temperature was obtained from the last remaining tray. The Certified Dietary Manager (CDM) obtained the temperatures for each item and the temperatures were as follows: -- Mashed Potatoes: 112 degrees Fahrenheit -- Country Fried Steak (Chopped) : 109 degrees F -- Green Beans: 109 degrees F The CDM stated that she would like for the temperatures to be above 120 degrees for the hot items. | 2020-09-01 |
| 1346 | 1346 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2019-10-31 | 880 | E | 1 | 0 | OVRC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and observation the facility failed to implement an effective infection control program to prevent the development and transmission of communicable diseases and infections. Resident #13, #112, and #194 all had orders for contact isolation. However there was no signage to alert staff, other residents, or visitors that extra percautionswere required when entering the residents room. Also Resident #186's soiled bed linen was placed directly on the floor when the staff member removed them from the bed. These were all random opportunities or discovery. Resident Identifiers: #13, #112, #194 and #186. Facility Census: 191. Findings Include: a) Resident #13 Review of Resident #13's medical record found a physicians order dated 10/29/19 for Contact Precautions. Further review of the record found the resident had a pending laboratory test for [MEDICAL CONDITION] (C- Diff). This was a current order at the time of this review. Observations of Resident #13's room with the Director of Nursing (DON) at 11:20 a.m. and 11:25 p.m. on 10/29/19 confirmed there was no signage to alert staff, visitors, or other residents that extra precautions were required when entering Resident #13's room. The DON confirmed there should have been a sign in the door to alert others of the contact precautions. b) Resident #112 Review of Resident #112's medical record found a physicians order dated 10/23/19 for Contact Precautions due to extended spectrum beta-lactamases (ESBL) in her urine. This was a current order at the time of this review. Observations of Resident #112's room with the Director of Nursing (DON) at 11:20 a.m. and 11:25 p.m. on 10/29/19 confirmed there was no signage to alert staff, visitors, or other residents that extra precautions were required when entering Resident #112's room. The DON confirmed there should have been a sign in the door to alert others of the contact precautions. c) Resident #194 Review of Resident #… | 2020-09-01 |
| 3669 | 3669 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2017-04-06 | 224 | D | 0 | 1 | X3BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and dental staff interviews, and resident interview, the facility failed to ensure Resident #84 received dentures the dentist had have made for the resident. The facility made no attempt to try and locate the dentures until surveyor intervention. In addition, the facility failed to identify this occurrence as neglect until after surveyor intervention. This failed practice affected (1) of three (3) residents reviewed for the care area of abuse during a Quality Indicator Survey (QIS) and concurrent complaint investigation. This practice had the potential to affect more than a limited number of residents. Resident identifier: #84. Facility census: 90 Findings include: a) Resident #90 On 04/05/17 at 9:49 a.m. review of the current care plan revealed resident at risk for mouth pain has had dental extractions, awaiting dentures to be made. Review of records revealed no notations or revisions concerning resident ever receiving dentures. On 04/05/17 at 10:55 a.m., during interview and review of records with unit manager RN #105, it was discovered that Resident #84 should have had upper and lower dentures of which the unit manager and the Health Service Workers (HSW) on the unit were not even aware and should have been aware. The current care plan revealed resident at risk for pain has had dental extractions, awaiting dentures to be made. The resident moved to the unit on 12/12/16 from another unit in the facility, and lived on the current unit one hundred fourteen (114) days before it was determined, through surveyor intervention, the resident was supposed to have dentures. Continued interview and record review with RN #105 that began at 10:55 a.m. on 04/05/17, revealed Resident #84 received dental services last year in (YEAR). The resident had his teeth extracted at the dentist's office on 01/15/16, and then on 02/02/16 at the dentist's office alveoplasty was performed (A minor oral surgical proce… | 2020-09-01 |
| 3670 | 3670 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2017-04-06 | 225 | D | 0 | 1 | X3BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility and dental staff interviews and resident interview, the facility failed to ensure Resident #84 received dentures the dentist had made for the resident; made no attempt to try and locate the dentures until surveyor intervention; and failed to identify this occurrence as neglect and/or timely report the occurrence to the appropriate state agencies until after surveyor intervention. This is true for (1) of three (3) residents, reviewed for the care area of abuse during a Quality Indicator Survey (QIS) anD concurrent complaint investigation, #WV 065. This practice had the potential to affect more than a limited number of residents. Resident identifier: #84. Facility census: 90 Findings include: a) Resident #84 On 04/05/17 at 9:49 a.m. review of the current care plan revealed resident at risk for mouth pain has had dental extractions, awaiting dentures to be made. Review of records revealed no notations or revisions concerning resident ever receiving dentures. On 04/05/17 at 10:55 a.m., during interview and review of records with unit manager RN #105, it was discovered that Resident #84 should have had upper and lower dentures of which the unit manager and the Health Service Workers (HSW) on the unit were not even aware and should have been aware. The current care plan revealed resident at risk for pain has had dental extractions, awaiting dentures to be made. The resident moved to the unit on 12/12/16 from another unit in the facility, and lived on the current unit one hundred fourteen (114) days before it was determined, through surveyor intervention, the resident was supposed to have dentures. Continued interview and record review with RN #105 that began at 10:55 a.m. on 04/05/17, revealed Resident #84 received dental services last year in (YEAR). The resident had his teeth extracted at the dentist's office on 01/15/16, and then on 02/02/16 at the dentist's office alveoplasty was performed (A minor … | 2020-09-01 |
| 3671 | 3671 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2017-04-06 | 241 | D | 0 | 1 | X3BK11 | Based on a random observation, observation, and staff interview, the facility failed maintain residents' dignity. Resident #1's catheter bag was uncovered and visible from the hallway. Residents seated together at a table were not served meals at the same time. This failed practice affected two (2) out of 17 Stage 2 sampled residents. Resident identifers: #1 and #14. Facility census: 90. Findings include: a) Resident #1 A medication observation, on 03/29/17 at 9:39 a.m., with Licensed Practical Nurse (LPN) #158 found Resident #1 lying in bed with the urinary catheter bag attached to the side of the bed. The bag was visible from the doorway and contained about 100 milliliters (ml) of yellow colored urine. The LPN said the bag was usually covered. The Director of Nursing (DON) stated during an interview, on 04/04/17 at about 2:30 p.m., the facility practice required the urinary catheter bag to be covered. b) Resident #14 Stage one (1) of the Quality Indicator Survey (QIS) dining observations, on 03/27/17 at 12:30 p.m., revealed Resident #66 and Resident #14 sitting at the same table discussing how hungry they were. On 3/27/17 at 12:38 p.m., Health Service Worker (HSW #13) served Resident #66 her meal, then went on to serve other tables, leaving Resident #14 without a tray. Resident #14 stared at Resident #66 the entire time Resident #66 was eating her meal. Resident #14 leaned over the table looking at the food on Resident #66's tray and staring at the bites of food Resident #66 was placing in her mouth. Resident #14 repeatedly asked Resident #66, Is that any good? or That looks good. Resident #66 kept eating and ignoring Resident #14. Resident #66 did not respond to any of Resident #14's questions or remarks but kept right on eating. At 12:42 p.m., HSW #115 brought Resident #14 a food tray. Interview with HSW#13, on 3/27/17 at 12:50 p.m., revealed the HSW was aware residents sitting at the same table should be served trays at the same time. HSW#13 agreed Resident #14 and Resident #66 were not served at the same ti… | 2020-09-01 |
| 3672 | 3672 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2017-04-06 | 246 | D | 0 | 1 | X3BK11 | Based on observation, staff interview and resident interview, the facility failed to ensure a resident received services with reasonable accommodation of their individual needs. This is true for one (1) of thirty five (35) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident #79, who was capable of using the call light, and did not have access to his call light. This practice had the potential to affect more than an isolated number of residents. Resident identifier: #79. Facility census: 90. Findings include: On 03/28/17 at 11:48 a.m., interview and observation of Resident #79 during Stage 1 of the QIS revealed the resident was not aware where his call light button was located. The room was designed to accommodate two (2) beds, however at the time of the observation only one (1) bed was in the room. During the interview, this surveyor was sitting under a wall light fixture that was located over an area where a second bed would have been placed, if there had been another resident residing in the room. When Resident #79 was asked to press his call light button to test if it's functioning, the resident responded he didn't know where his call light was. Resident #79 was sitting on the foot of his bed beside his wheel chair, and told the surveyor it would be easier for the surveyor to push the one dangling over the surveyor's head than for him to get up out of the bed and come over and push that call light button. This surveyor asked Resident #79 if the call light button dangling over the surveyor's head, on the other side of the room, was the call light he used when he needed staff. Resident #79 responded, If I have to. I don't know where mine is on this side. A Health Service Worker (HSW #65) was in the hallway outside the resident's room. This surveyor stepped out into the hall and requested the HSW to come into the room and ask the resident to push his call light to test whether it was functioning correctly. HSW #65 entered the room and asked Resident #79 to press his call light, and the r… | 2020-09-01 |
| 3673 | 3673 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2017-04-06 | 253 | E | 0 | 1 | X3BK11 | Based on observation and staff interview, the facility failed to provide maintenance and/or housekeeping services necessary to maintain a comfortable and sanitary interior. This was evident for fourteen (14) of thirty-two (32) rooms observed during Stage I of the survey, and three (3) common use shower rooms. Cosmetic imperfections, or items in need of repair and/or cleaning, in resident rooms and/or shower rooms included buckling paint on some walls, chipped paint on some window seals, scuffed door facing in need of repainting, missing strike plate on a door, chipped/broken areas on door seals, water stain marks on ceiling tiles, debris inside the grates on wall mounted heating/cooling units, a broken window blind, commode toilet bowl with dark stains, discolored grout around the toilet base, nurse unit desk fan extremely dusty and dirty, walls with small chunks broken, torn window screen, wardrobe with a missing door handle, broken cove base, door jam with scraped paint, loose base board in a toilet area, varnish coming off wooden storage units or stands, rust colored stains on bathroom walls, broken edge of over-bed tray, shower room with broken tile, brown/rust colored stains on bathroom tile, lack of caulking around the perimeter of a toilet, wall with chipped paint and wood beneath it visible, vinyl covering on door chipped and showing the wood beneath, rust stains at the bottom of a door frame, dirty looking grout in the shower room and an area of missing tile base. Affected rooms included #115, #117, #123, #128, #300, #301, #307, #308, #310, #311, #312, #313, #326, #330. Affected common use shower rooms included shower rooms #1 and #2 on the first floor, and common use shower room #312 on the third floor. Facility census: 90. Findings include: a) Stage I findings During Stage I of the Quality Indicator Survey on 03/27/17 and on 03/28/17, thirty-two (32) resident rooms were observed. Of that number, fourteen (14) rooms were found with concerns related to maintenance and/or housekeeping issues, or cosmetic … | 2020-09-01 |
| 3674 | 3674 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2017-04-06 | 272 | D | 0 | 1 | X3BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of the comprehensive assessment related to a resident with a [DIAGNOSES REDACTED]. Resident identifier: #38. Facility census: 90. Findings include: a) Resident #38 The medical record was reviewed on 04/04/17 and 04/05/17. Review of the annual minimum data set (MDS), with assessment reference date (ARD) of 11/16/16, found the area in which to record the resident's [DIAGNOSES REDACTED]. Similarly, the quarterly MDS with ARD of 02/14/17, also assessed the resident as not having depression. Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the current care plan revealed signs and symptoms of depression was identified as a problem area since 03/01/16. The care plan goal was for the resident to have decreased episodes of depression to zero times per week as evidenced by self-rating. Care planned interventions included to administer medications as ordered and monitor for adverse side effects. The care plan addressed she was at risk for side effects from [MEDICAL CONDITION] medication use, as first identified on 12/03/13. Interventions included to monitor for side effects of anti-depressant medication and report to the physician. The care plan listed anti-depressants [MEDICATION NAME] and [MEDICATION NAME] as current medications. An interview was conducted with the MDS registered nurse (RN) #89 on 04/04/17 at 12:45 p.m. He said the psychiatrist treats her for a mood disorder. He showed numerous interventions on the care plan for the issue of depression. A second interview was completed with RN #89 on 04/04/17 at 4:05 p.m. He reviewed of the quarterly MDS with ARD 02/14/17 and the annual with ARD 11/16/16. He agreed that he did not code section I on either MDS with depression. Upon inquiry as to why she takes antidepressants daily (as listed on MDS section N) he said [MEDICATION NAME] and [MEDICATION NAME] can … | 2020-09-01 |
| 3675 | 3675 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2017-04-06 | 280 | E | 0 | 1 | X3BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review, the facility failed to revise careplans related to nutrition, pain, lab refusals and [MEDICAL CONDITION] care for four (4) of seventeen (17) Stage 2 residents. Resident identifiers: Resident #26, #79, #12 and #89. Facility census: 90. Findings include: a) Resident #26 A medical record review revealed Resident #26 experienced a significant weight loss. The minimum data set (MDS) with an assessment reference date (ARD) of 01/24/17 indicated the resident was not on a physician-prescribed weight-loss regimen. The vitals weight record in the electronic medical record (EMR) noted the most current weight as 132 pounds on 03/03/17 and 144 pounds on 12/02/16. This was a nine point one percent (9.1%) loss in 90 days. The registered dietician (RD) consult, dated 02/071/17 indicated Resident #26 was seed for weight loss x 90 days. The recommendation included Boost after meals if 50% or less is consumed, continuing current diet, standing orders, and supplement, monitor oral intake, weight and laboratory reports. A follow-up RD progress note, dated 03/13/17 noted oral intake declined . The RD recommended Prostat one (1) serving per day mixed with juice. physician's orders [REDACTED]. The current care plan, with a next review date of 06/15/17, provided no evidence Resident #26 received either Boost or Prostat. The MDS Coordinator, interviewed on 04/04/17 at 12:10 p.m., said nurses are supposed to update the care plan on the unit in a handwritten format, and then he updated it electronically when the MDS was due. He reviewed the current care plan and confirmed it had not been updated and revised to note the change in condition noted by the RD on 02/017/17. He also confirmed it had not been revised to include orders for Prostat and Boost, when updated on 03/31/17. b) Resident #79 A medication regimen review of the electronic medical record revealed Resident #79 received a controlled substance for… | 2020-09-01 |
| 3676 | 3676 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2017-04-06 | 282 | D | 0 | 1 | X3BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the care plan related to monitoring the pulse and blood pressure as the physician ordered for Resident #38, and failed to assess the effectiveness of pain medication administration for Resident #79. This failed practice affected two (2) out of 17 Stage 2 sample residents. Resident identifiers: #38 and #79. Facility census: 90. Findings include: a) Resident #38 The medical record was reviewed on 04/04/17 and 04/05/17. [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] 25 milligrams (mg) daily for hypertension. physician's orders [REDACTED]. [MEDICATION NAME] works by relaxing blood vessels, so blood can flow more easily. It slows the heart rate, and reduces blood pressure. The care plan directed nursing to obtain the pulse rate prior to giving [MEDICATION NAME], and hold the [MEDICATION NAME] if the pulse rate is less than 60 beats per minute. The care plan further directed to monitor pulse and blood pressure as per the physician's orders [REDACTED].>On 04/05/2017 at 12:05 p.m., the computerized Medication Administration Record [REDACTED]. Of the 35 opportunities, four (4) times there was no evidence nursing obtained a blood pressure and/or pulse assessment prior to administering the [MEDICATION NAME]. Those dates were 03/03/17, 03/05/17, 04/02/17, and 04/04/17. The DON at the time of this medical record review said she could find no vital signs recorded anywhere on the computer on those four (4) dates. The DON said the vital signs are also hand written on the 24-hour report sheets, and may not have been entered into the computer. Review of the 24-hour reports at this time found the absence of heart rate assessments and/or blood pressure assessments on those four (4) dates. The DON confirmed that nursing staff documented they administered the [MEDICATION NAME] on those dates. Without first assessing the heart rate and blood pressure, it would not be possible to… | 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 );