cms_WV
Data source: Big Local News · About: big-local-datasette
108 rows where "filedate" is on date 2019-10-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4442 | 4442 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 223 | G | 0 | 1 | HB4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, family interview, resident interview, observations, and review of Appendix P of the State Operations Manual (SOM), the facility failed to ensure Resident #104, a cognitively impaired resident, was not inappropriately touched by Resident #147, who had a history of [REDACTED]. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficiency may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance). Based on the application of the reasonable person concept as identified in Appendix P of the SOM, a determination of actual harm was made for Resident #104, a cognitively impaired resident. A reasonable person, if touched inappropriately, fondled, and/or kissed without consent in one's residence, would feel fear, humiliation, anxiety, and/or stress. This affected one (1) of three (3) residents reviewed for abuse. Resident identifiers: #104 and #147. Facility census: 128. Findings include: a) Resident #104 Review of the clinical record for Resident #104, on 12/17/15 at 2:05 p.m., revealed the resident was severely impaired in cognition, required extensive assistance of two (2) staff members for activities of daily living, and the use of wheelchair. On 12/15/2015 at 6:00 p.m., attempts to interview Resident #104 were unsuccessful due to the resident's cognitive status. The resident placed her hand up in front of her face when this surveyor tried to assess her physical/emotional status. On 12/16/2015 at approximately 9:00 a.m., review of a progress noted dated 12/15/2015 at 7:13 p.m., revealed Social Service Supervisor #107 documented attem… | 2019-10-01 |
| 4443 | 4443 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 226 | G | 0 | 1 | HB4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, family interview, resident interview, and review of facility policy and procedures, facility failed to operationalize policies and procedures for the prevention, identification and investigation of abuse allegations. The facility failed to ensure a reported allegation of abuse for Resident #104, a cognitively impaired resident, who was reportedly inappropriately touched by Resident #147 was investigated and reported. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficiency may have had on a reasonable person in the resident ' s position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance). Based on the application of the reasonable person concept as identified in Appendix P of the SOM, a determination of actual harm was made for Resident #104, a cognitively impaired resident. A reasonable person, if touched inappropriately, fondled, and/or kissed without consent in one's residence, would feel fear, humiliation, anxiety, and/or stress. This affected one (1) of three (3) residents reviewed for abuse. Resident identifiers: #104 and #147. Facility census: 128. Findings include: a) Resident #104 Review of the clinical record for Resident #104, on 12/17/15 at 2:05 p.m., revealed the resident was severely impaired in cognition, required extensive assistance of two (2) staff members for activities of daily living, and the use of wheelchair. On 12/15/2015 at 6:00 p.m., attempts to interview Resident #104 were unsuccessful due to the resident's cognitive status. The resident placed her hand up in front of her face when this surveyor tried to assess her physical/emotional status. On 12/16/… | 2019-10-01 |
| 4444 | 4444 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 248 | E | 0 | 1 | HB4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the activity calendar and participation records, and interviews with facility staff and residents, the facility failed to provide an activity program that met the individualized needs of first floor residents. This affected one (1) of three (3) sampled residents whose activity participation was reviewed, and 45 of the facility's 128 residents that resided on the first floor of the facility. Resident identifiers: #263. Facility census: 128. Findings include: a) Resident #263 Review of the plan of care for Resident #263 revealed an admission date of [DATE]. Resident #263 resided on the first floor. The admission Minimum Data Set (MDS) for Resident #263 indicated the following personal preferences were either somewhat or very important to the resident: --choose clothes to wear; --care for personal belongings; --receive shower; --snacks between meals; --choose own bedtime; --stay up past 8:00 p.m.; --family and significant other involvement in care discussions; --place to lock personal belongings to keep things safe; --listen to music; --keep up with the news; --participate in favorite activities; --spend time away from nursing home; and --spend time outdoors. The activity care plan for Resident #263 indicated preferences for the same items listed on the MDS and the stated goal was, Resident will participate in activities of choice/preference through next review. The activity participation records for the month of (MONTH) (YEAR) showed a daily check mark for individual leisure. No specific notes were recorded detailing the leisure activity nor had any needs related to the leisure activities identified for the activity staff to provide assistance. Interview with Activity Staff #125, on 12/16/15 at 1:45 p.m., revealed the activity staff walk around the facility and greet residents each day. However, they do not keep any records regarding who they meet, special needs that arise during these tours or approaches that ar… | 2019-10-01 |
| 4445 | 4445 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 272 | E | 0 | 1 | HB4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of facility policies and procedures, the facility failed to ensure residents were accurately and comprehensively assessed. Resident #86 was not accurately and comprehensively assessed for pressure ulcers. Resident #112 was not accurately and comprehensively assessed for the use of an antipsychotic medication. Resident #176 was not accurately and comprehensively assessed for falls, weights pre- and post- [MEDICAL TREATMENT] services, and coordination of [MEDICAL TREATMENT] care due to laboratory test results. This affected 3 out of 39 residents reviewed for accuracy of comprehensive assessments. Resident identifiers: #86, #112, #176. Facility census: 128. Findings include: a) Resident #86 Review of Resident #86's clinical record on 12/17/15 at 4:00 p.m., revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the admission skin assessment, dated 09/19/15, indicated Resident #86 had an open area on the coccyx with no measurements indicated at that time. The Weekly Skin Alteration Measurement Tool, dated 09/21/15, assessed the resident had a Stage 2 Suspected Deep Tissue Injury measuring 2 centimeters long by 2 centimeters wide by 0.3 centimeter deep on the coccyx. The Section M0210 of the admission Minimum Data Set (MDS) assessment, dated 09/26/15, revealed the code No which indicated the resident did not have a pressure ulcer. Interview with the assessment Registered Nurse (RN) #132, on 12/17/15 at 4:15 p.m., verified the admission MDS, dated [DATE], section M was not coded correctly to reflect the presence of Resident #86's pressure ulcer. b) Resident #112 Review of the clinical record for Resident #112, on 12/17/ 15 at 4:20 p.m., revealed the resident's [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment revealed the following: --Section C of the annual Minimum Data Set (MDS) assessment, dated 07/16/15, indicated the resident had severely impair… | 2019-10-01 |
| 4446 | 4446 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 279 | D | 0 | 1 | HB4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to ensure comprehensive care plans were developed and/or accurate to address resident care needs based on comprehensive assessments. This affected four (4) out of 39 residents reviewed for the development of comprehensive care plans: Resident #195 did not have a comprehensive care plan for behaviors. Resident #251 did not have a comprehensive care plan for urinary continence status. Resident #176 did not have a comprehensive care plan for [MEDICAL TREATMENT] treatment. Resident #213 did not have a comprehensive care plan for nutritional needs. Resident identifiers: #195, #251, #176, #213. Facility census: 128. a) Resident #195 Review of the clinical record of Resident #195, on 12/17/15 at 5:00 p.m., revealed an admission date of [DATE] with the following relevant Diagnoses: [REDACTED]. The resident's physician orders [REDACTED]. --[MEDICATION NAME] 100 milligrams (mg) at bedtime; --[MEDICATION NAME] 500 mg at bedtime; --[MEDICATION NAME] 250 mg daily; and --[MEDICATION NAME] 0.5 mg as need, twice daily. The Psychiatric Med Check Follow Up, dated 11/18/15, revealed the resident was being seen for difficulties with [MEDICAL CONDITION], dementia, aggression, poor sleep, and [MEDICAL CONDITION]-type symptoms (labeled as a mood disorder, due to general medical condition). The resident was identified as verbally aggressive, and as being physically aggressive towards the roommate. The resident was noted to be [MEDICAL CONDITION] aggressive with the staff, yelling and shouting. The Psychiatric Med Check Follow Up, dated 10/22/15, revealed the resident rambled about random things such as being in the service. The resident's plan of care did not include the [DIAGNOSES REDACTED]. Interview with the Assistant Director of Nursing (ADON) #98, on 12/17/15 at 4:45 p.m., revealed Resident #195 could become physically and verbally aggressive with the staff. The ADON stated the … | 2019-10-01 |
| 4447 | 4447 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 280 | D | 0 | 1 | HB4W12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to evaluate and revise the care plan for one (1) of four (4) residents after the resident had treatment and health status changes. Resident #213's care plan was not revised to address additional possible sources of pain. Resident identifier: #213. Facility census: 133. Findings include: a) Resident #213 A review of the clinical record for Resident #213 found this resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. -- [MEDICATION NAME] HCL Tablet 10mg Give 10mg via Pe[DEVICE] three times a day for anxiety, -- [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 . Give 1 tablet via PE[DEVICE] four times a day for pain, -- [MEDICATION NAME] Tablet 0.5 . Give 1 tablet by mouth as needed for anxiety TID (three times daily) PRN (as needed), and -- Tylenol Liquid ([MEDICATION NAME]) Give 20.3 ml via PE[DEVICE] every 4 hours as needed for mild pain The care plan included a Focus (problem) of Pain management-ruptured ear drum, initiated on 05/13/15 and updated on 11/30/15. The interventions were directed only toward the ear and did not include other possible sources of pain such as limb movement. Registered Nurse (RN) #13 said in an interview at 1:55 p.m. on 02/17/16, she had cared for the resident since her admission and the resident did become agitated at times, attempted to move her head, and flailed her right arm. The nurse declined to say if this was due to pain, but did say there did not appear to be an obvious pain source (ex. joint movement). When asked if the resident had ear pain, the nurse said her ruptured eardrum was at the time of admission and only lasted a short time. She added that you could tell that at the time because the resident would favor her ear on that side. RN #13 did say the resident had less flailing movements and muscle spasms after her pain medication was administered. The Quarterly MDS, dated [D… | 2019-10-01 |
| 4448 | 4448 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 309 | D | 0 | 1 | HB4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to implement a bowel protocol for one resident with a history of constipation. This affected one (1) of three (3) residents reviewed for decline in incontinence. Resident identifier: #251. Facility census: 128. Findings include: a) Resident #251 Review of the clinical record for Resident #251, on 12/15/15 at 3:55 p.m., revealed a readmission date of [DATE]. The resident's relevant [DIAGNOSES REDACTED]. Section C of the most recent Admission Minimum Data Set (MDS) assessment, dated 11/04/15, revealed the resident had moderately impaired cognition. Section H0400 of this MDS assessed the resident as continent of bowel. The current plan of care included: --Problem of bowel and bladder deficits: frequently incontinent of bladder and constipation present --Goal for the problem of bowel and bladder deficits: the resident is to have a bowel movement every 2-3 days through next review --Interventions included bowel protocol as needed. Review of the bowel movement tracking for Resident #251 revealed the resident did not have a bowel movement for seven days from 11/17/15 through 11/24/15. During a resident interview, on 12/15/15 at 4:55 p.m., Resident #251 stated their stomach feels full and had issues with constipation. The resident acknowledged not having a bowel movement in the last four to five days and that their usual bowel pattern was about every 4 days. The resident stated they received medication for constipation that morning from the nurse. The resident further stated when at home they would alternate drinking orange juice and prune juice every other day. The resident stated they had only received prune juice once since being admitted to the facility. Review of the Long Term Care Physician order [REDACTED].#251, on 12/15/15 at 5:00 p.m., revealed the following orders, If no BM (bowel movement) day 2 give prune juice. Day 3 give [MEDICATION NAME] tab II PO and p… | 2019-10-01 |
| 4449 | 4449 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 315 | D | 0 | 1 | HB4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to implement interventions to promote improvement of residents bladder function. This affected one (1) resident out of three (3) residents reviewed for urinary incontinence. Resident identifier: #251. Facility census: 128. Findings include: a) Resident #251 Review of the clinical records for Resident #251, on 12/15/15 at 3:55 p.m., revealed an admission date of [DATE] with relevant [DIAGNOSES REDACTED]. Section C of the most recent Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with moderately impaired cognition. Section H0300 of the most recent Admission Minimum Data Set (MDS), dated [DATE], assessed the resident as frequently incontinent of bladder. Section C of the most recent Quarterly MDS, dated [DATE], assessed the resident as cognitively intact. Section H0300 of the most recent Admission Minimum Data Set (MDS), dated [DATE], assessed the resident as always incontinent of bladder. The Bowel and Bladder Continence Evaluation, dated 10/28/15, assessed the resident as having High Restorative Potential. The current plan of care included: --Problem of bowel and bladder deficits: frequently incontinent of bladder and constipation present --Goal for the problem of bowel and bladder deficits: the resident is to have a bowel movement every 2-3 days through next review --The interventions for the problem of bowel and bladder deficits: skin will be kept clean and dry with no new skin breakdown through next review, bowel protocol as needed, check and change program every 2 hours and as needed The plan of care did include interventions to improve the resident's urinary continence status. During an interview with Resident #251, on 12/15/15 at 4:58 p.m., he stated he only had urinary incontinence issues at night. He stated he goes to sleep and does not feel the urge to urinate and wakes up wet. He stated during the day he can feel the urge to ur… | 2019-10-01 |
| 4450 | 4450 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 329 | D | 0 | 1 | HB4W11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview and staff interview, the facility failed to ensure non-pharmacological interventions were attempted prior to administration of antianxiety medications. This affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #65. Facility census: 128. Findings include: a) Resident #65 Review of the medical record for Resident #65, on 12/16/15, revealed the resident's annual Minimum Data Set (MDS) assessment, dated 07/21/15, revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. The annual MDS indicated the resident was cognitively intact with no behaviors, and received antianxiety medication one time during the assessment period. Further review of the resident's electronic medical record, on 12/16/15 at 3:52 p.m., revealed [DIAGNOSES REDACTED]. Review of the current 12/2015 physician's orders [REDACTED]. Review of the medical record for Resident #65, on 12/16/15 at 4:01 p.m., revealed a plan of care for Medication Management Potential for adverse drug reactions due to multiple medication use for antianxiety. The plan of care goals stated the resident would not present with any side effects or adverse drug reactions related to current medication regimen and/or multiple drug usage through the next review and would receive the minimal effective dosage of prescribed [MEDICAL CONDITION] medication to maximize function both mentally and physically through review. The plan of care interventions included observation for any side effects related to drug regimen, report findings to physician/ physician extender and document the outcome in the clinical record. The care plan did not list any non-pharmacological interventions to address the resident's anxiety. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. There was no documentation of non-pharmacological interventions attempted prior to administration of the anti-anxiety medication.… | 2019-10-01 |
| 4451 | 4451 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2015-12-17 | 520 | E | 0 | 1 | HB4W12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, review of the facility's plans of correction for the [DATE] Quality Indicator Survey, and staff interview, the facility's Quality Assurance process failed to ensure the corrective actions identified in the facility's plan of correction ensured compliance with regulatory requirements. The revisit survey found the facility had failed to correct deficient practices cited during the annual survey of [DATE] related to accuracy of assessments, care plans to address the needs of residents, and unnecssary medications. Three (e) of eight (8) deficient practices cited during the annual survey of [DATE] had not been corrected by the facility's plan of correction date of [DATE]. This had the potential to affect more than an isolated number of residents. Findings include: a) Accuracy of assessments 1. Resident #213 Based on record review, observation, and staff interview, the facility failed to complete an accurate assessment of functional capacity for one (1) of three (3) residents reviewed. Resident #213's comprehensive minimum data set (MDS) assessment did not accurately represent the resident's physical functioning and structural problems. A review of the clinical record for Resident #213 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her discharge summary from acute care immediately prior to her admission to the facility included, . had [MEDICAL CONDITION] on [DATE]. Multiple rounds of CPR (cardiopulmonary resuscitation). Was in coma extended period of time. Progressed to 'minimally conscious state,' [MEDICAL CONDITION] and [DEVICE] (gastrostomy tube). Observation of Resident #213 at 8:00 a.m. on [DATE], found her non-verbal with [MEDICAL CONDITION] [DEVICE] in place, lying in bed. Various positioning devices were in place due to severe contractures of both arms and her left leg, which was drawn up to her abdomen. There was no outward indication the resident was aware of the two (2) care giver… | 2019-10-01 |
| 4452 | 4452 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2016-10-19 | 157 | D | 1 | 0 | 43HD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews, and the facility's procedure related to nursing management of [MEDICAL CONDITION] activity, the facility failed to notify the physician and/or a resident's representative for one (1) of seven (7) resident's reviewed for a significant change in [MEDICAL CONDITION] condition. Resident Identifiers: #27. Facility census 83. Findings include: a) Resident #27 A review of the medical record for Resident #27 found the resident, on 08/26/16 at 3:45 a.m., as having a [MEDICAL CONDITION] at this time with facial grimaces and tremors resolved approximately one (1) minute. No injuries resulted from this episode, oxygen saturation remained above 95% during this episode and the postitcal phases. Vital signs are within normal limits. See flow record. Written by licensed practical nurse (LPN) #115. This progress note did not reveal the physician and /or the resident's representative was notified. A review of Resident #27's physican order reveals the resident dad a [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] --[MEDICATION NAME] 50 milligram (mg) by mouth once a day --[MEDICATION NAME] sprinkles 1000 mg by mouth three (3) times a day; and --[MEDICATION NAME] Acudial gel 10 mg insert ten (10) mg rectally as needed for [MEDICAL CONDITION] greater than five (5) minutes. A review of Resident #27's physician progress notes [REDACTED].#27 had a [MEDICAL CONDITION] on 08/26/16 at 3:45 a.m. During an interview, on 10/18/16 at 9:13 a.m., charge nurse/Registered Nurse (RN) #17 stated, Yes, the physician and the resident's representative should have been notified. During an interview, on 10/18/16 9:35 a.m., the assistant director of nursing (ADON) stated, No, the physician and the resident's representative were not notified of this change in condition. The ADON stated, I would expect the nurse to notify the resident's representative and the physician. The ADON said the nurse who… | 2019-10-01 |
| 4453 | 4453 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2016-10-19 | 204 | E | 1 | 0 | 43HD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to assure residents are transferred from the facility to the hospital, and timely admission to the hospital when transfer is medically appropriate, and medical and other information was exchanged between the institutions. Resident #40 and #78 were transferred to the hospital after they experienced a change in their condition. Resident identifiers: #40 and #78. Facility Census: 83. Findings include: a) Resident #40 A review of Resident #40's medical record found on three (3) separate occasions (09/19/16, 09/23/16 and 10/13/16), the resident experienced a change in condition, which required the resident to be transferred to an acute care facility for treatment. The record contained no evidence the hospital received a transfer form, pertinent medical information including medications and current medical condition to direct the emergency room physician in providing appropriate and prompt medical care. On 10/18/16 at 11:30 a.m., the Director of Nursing was asked to provide a discharge/transfer policy. At 2:30 p.m. on 10/18/16, the Assistant Director of Nursing (ADON), confirmed they have no discharge/transfer policy. I then requested the practice or expectations of staff when the residents needed transferred and/or discharged . She confirmed there is nothing in writing to instruct the staff what to provide the transferring facility. At 3:50 p.m. on 10/18/16, the Administrator and the ADON confirmed the facility has no practice and/or policy to instruct the staff on the items needed to be sent with the resident at the time of transfer and or discharge. They also confirm their corporate office was unable to provide a transfer policy. On 10/19/16 at 8:35 a.m., the Administrator provided a Discharge/Transfer policy and an Acute Care Transfer Documentation Checklist. Review of the Discharge/Transfer Policy found the purpose of the policy to provide safe departure from the facility and to… | 2019-10-01 |
| 4454 | 4454 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2016-10-19 | 205 | D | 1 | 0 | 43HD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility did not provide a bed hold notice to the resident and/or family/responsible party for two (2) of two (2) residents reviewed for bed hold notification. Resident #40 was transferred to the hospital on [DATE], 09/23/16 and 10/13/16, after experiencing a change of condition. Resident #78 was transferred to the hospital on [DATE], after experiencing a change in condition. There was no evidence the facility provided a bed hold notice to the residents that specified the duration of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods. This deficient practice has the potential to affect more than an isolated number of residents. Resident identifiers: #40 and #78. Facility census: 83. Findings include: a) Resident #40 A review of Resident #40's medical record found on three (3) separate occasions (09/19/16, 09/23/16 and 10/13/16), the resident experienced a change in condition, which required the resident to be transferred to an acute care facility for treatment. On 10/18/16, the facility was asked for a copy of the bed hold sent with Resident #40, when hosptalized on [DATE], 09/23/16 and 10/13/16. At 4:15 p.m. On 10/18/16, a copy of the facility's bed hold policy was provided by the Assistant Director of Nursing (ADON). Review of the facility's bed hold policy found the following: --Any patient who leaves the (Facility name) for temporary hospitalization or therapies reasons may request that his/her bed be held open until his/her return. Bed holds will be granted in accordance with the policies outlined in a company approved resident admission agreement. --All residents, and their designated agents or legal representative, regardless of the patient's financial status, must be given notice of their bed hold options, rights and responsibilities at the time of hospitaliz… | 2019-10-01 |
| 4455 | 4455 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2016-10-19 | 520 | E | 1 | 0 | 43HD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility's quality assessment and assurance (QA&A) committee failed to identify and act upon quality deficiencies during the daily operation of the facility, in which it had, or should have had knowledge. Systematic problems were identified related to transfers/ discharges for two (2) of seven (7) sample residents. In the area of transfers/discharges the QA&A committee failed to ensure residents which needed to be transferred/ discharged from the facility were provided with a bed hold notice and a transfer form, face sheet, current medication list, change in condition progress note and advance directives as to ensure the residents receive prompt, safe transfer/discharge and continuity of care. This deficient practice has the potential to affect more than an isolated number of residents residing in the facility. Residents #40 and #78. Facility Census: 83. Findings include: a) Bed hold policy 1. Resident #40 A review of Resident #40's medical record found on three (3) separate occasions (09/19/16, 09/23/16 and 10/13/16), the resident experienced a change in condition, which required the resident to be transferred to an acute care facility for treatment. On 10/18/16, the facility was asked for a copy of the bed hold sent with Resident #40, when hosptalized on [DATE], 09/23/16 and 10/13/16. At 4:15 p.m. On 10/18/16, a copy of the facility's bed hold policy was provided by the Assistant Director of Nursing (ADON). Review of the facility's bed hold policy found the following: --Any patient who leaves the (Facility name) for temporary hospitalization or therapies reasons may request that his/her bed be held open until his/her return. Bed holds will be granted in accordance with the policies outlined in a company approved resident admission agreement. --All residents, and their designated agents or legal representative, regardless of the patient's financial status, must be given notice of their bed ho… | 2019-10-01 |
| 4456 | 4456 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2016-10-07 | 157 | E | 1 | 0 | HVK611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify the physician and/or responsible party for two (2) of eight (8) residents reviewed had a significant change in health condition or had an accident/incident resulting in an injury. There was no evidence Resident #98's medical power of attorney (MPOA) was notified when the physician ordered laboratory testing and x- rays for a change in condition, and when the resident had re-occurring elevated blood glucose readings which required changes in treatment. In addition, the physician was not notified when the resident's blood glucose readings were not within physician specified parameters. For Resident #100 there was no evidence the physician and or the responsible party were notified of accidents/incidents resulting in injuries. Resident identifiers: #98 and #100. Facility census: 96. Findings include: a) Resident #98 Record review at 8:00 a.m. on 10/06/16, found a sixty-seven (67) year old female resident whose [DIAGNOSES REDACTED]. The resident's last capacity determination, completed on 06/02/16, noted the resident demonstrated incapacity to make medical decisions. The resident had a West Virginia Medical Power of Attorney (MPOA) and living will completed on 10/16/08. Review of the physician's orders [REDACTED]. --On 07/29/16, 10 units of regular insulin, now subcutaneous for a blood glucose reading of 551. --On 07/31/16, 10 units of [MEDICATION NAME] now and increase [MEDICATION NAME] to 55 units every night at bedtime for a blood glucose reading of 585. --On 07/31/16, an urinalysis with a culture and sensitivity. --On 08/02/16, increased [MEDICATION NAME] to 60 units every night at bedtime and give 10 units of regular insulin now for a blood glucose reading of 554. --On 08/03/16, give 10 units of regular insulin now, and a one-time dose for a blood glucose reading over 500. --On 08/04/16, a chest x-ray and a complete blood count test in the morning for increased confu… | 2019-10-01 |
| 4457 | 4457 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2016-10-07 | 309 | E | 1 | 0 | HVK611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview and family interview, the facility failed to provide the necessary care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessments and plan of care for four (4) of eight (8) residents reviewed. The facility failed to follow physician order [REDACTED]. Resident #97 was given an extra dose of antianxiety ([MEDICATION NAME]) without notification of the physician and the facility failed to give a dose of Kayelalate as directed by the physician orders. For Resident #98 the facility failed to notify the physician when blood sugars were outside of the physician established parameters. For Resident #22, the facility failed to administer an antibiotic ([MEDICATION NAME]) as directed by the physician order. Resident identifiers: #100, #97, #98 and #22. Facility Census: 96. Findings include: a) Resident #100 Review of Resident #100's medical records, on 10/06/16 at 1:10 p.m., found a physician order [REDACTED]. Treatment Administration Record (TAR) reviewed for (MONTH) and (MONTH) (YEAR). Review found the TAR for skin checks were left blank on the following dates: 07/14/16, 07/15/16, 07/22/16, 07/23/16, 07/24/16, 07/28/16, 07/29/16, 08/04/16, 08/05/16, and 08/12/16. At 3:15 p.m. on 10/06/16, the director of nursing (DON) was asked to review the TAR. She said she could not determine if the skin assessments were completed or not. b) Resident #97 1. Medical record review at 10:26 a.m. on 10/05/16 found a nursing note dated 09/18/16 at 1:24 a.m., the resident was given [MEDICATION NAME] at approximately 10:00 p.m. by the previous shift licensed practical nurse (LPN). The nursing note further verified nurse aides (NA) came to his LPN and stated the resident had vomited a large amount. The whole [MEDICATION NAME] was found in the basin the resident had used to vomit in. The note stated the resident requested anot… | 2019-10-01 |
| 4458 | 4458 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2016-10-07 | 323 | E | 1 | 0 | HVK611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to complete root cause analysis of the residents bruising to determine the risk factors. The facility did not evaluate each bruise and/or skin injury to determine if identified interventions were in place at the time of the skin alterations and/or bruising. The facility did not evaluate the existing interventions to determine if the interventions would prevent Resident #100 from bruising and/or injuring herself. Resident identifier: #100. Facility census: 96. Findings include: a) Resident #100 Review of Resident #100's medical records, on 10/05/16 at 10:05 a.m., found a quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/19/16. This assessment revealed Resident #100 was a ninety-six (96) year old female readmitted to the facility on [DATE]. Resident #100's vision was highly impaired and she did wear glasses. Her cognitive status was severely impaired. No wondering behavior noted for the seven (7) day look back period. Resident #100 required total/dependent care with all activities of daily living (ADL). Always incontinent of bowel and bladder. [DIAGNOSES REDACTED]. Resident is a high risk for pressure ulcers. Review of physician orders [REDACTED]. -- Use breathable, flexible band aids on resident's skin not regular adhesive band aids due to sensitive skin initiated on 10/26/16. --Resident can have t-gel shampoo on shower days Wednesday and Saturdays on 6 am-2pm shift initiated on 04/06/16. --Arm protectors to bilateral arms at all times. (MONTH) remove for laundry and skin checks initiated on 02/03/16. --Resident may wear socks and shoes when up in wheelchair initiated on 03/24/16. --Resident to wear abductor wedge between legs while in bed. (MONTH) be removed for showers and hygiene initiated on 05/31/16. --Resident to wear left hip high sock and left knee brace at night. To be applied by evening shift LPN and one assistant between 7:00 p.… | 2019-10-01 |
| 4459 | 4459 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2016-10-07 | 514 | E | 1 | 0 | HVK611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to maintain an accurate and complete medical record for two (2) of eight (8) of residents reviewed. Resident #100's Treatment Administration Record (TAR) was left blank on several days in (MONTH) and (MONTH) of (YEAR) for daily skin checks and Resident #97's Medication Administration Record [REDACTED]. Resident identifier: #100 and #97. Facility Census: 96. Findings include: a) Resident #100 Review of Resident #100's medical records, on 10/06/16 at 1:10 p.m., found a physician order [REDACTED]. Treatment Administration Record (TAR) reviewed for (MONTH) and (MONTH) (YEAR). Review found the TAR for skin checks were left blank on the following dates: 07/14/16, 07/15/16, 07/22/16, 07/23/16, 07/24/16, 07/28/16, 07/29/16, 08/04/16, 08/05/16, and 08/12/16. At 3:15 p.m. on 10/06/16, the director of nursing (DON) was asked to review the TAR. She said she could not determine if the skin assessments were completed or not. b) Resident #97 Medical record review on 10/05/16 at 11:00 a.m., found the resident was admitted to the facility on [DATE]. The resident was admitted with the antibiotic,[MEDICATION NAME] milligrams to be given twice a day for four (4) days for a urinary tract infection. The medication was scheduled at 9:00 a.m. and 9:00 p.m. On 09/18/16, the Medication Administration Record [REDACTED]. At 4:42 p.m. on 10/05/16, the director of nursing (DON) was asked to review the MAR. She said she could not determine if the medication was given or not. No additional information was provided by the time of exit. | 2019-10-01 |
| 4460 | 4460 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 157 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, and staff interview, the facility failed to notify the responsible party when there was a significant change in a resident's physical status and the need to transfer the resident to the hospital for an admission. This was evident for one (1) of twenty-three (23) Stage 2 sampled residents. Resident identifier: #36. Facility census: 108. Findings include: a) Resident #36 On 05/03/16 at 11:07 a.m., during a family interview, Resident #36's responsible party said this resident was recently admitted to the hospital and he did not find out about the hospitalization until two (2) days after she was in the hospital. Medical record review on 05/10/16 at 10:25 a.m., revealed [DIAGNOSES REDACTED]. Further review of the medical record at that time found that on 03/17/16, she was admitted to the hospital immediately following a [MEDICAL TREATMENT] treatment. A nurse progress note dated 03/17/16. said the [MEDICAL TREATMENT] center notified the facility that the resident was sent to (name of hospital) for evaluation due to [MEDICAL CONDITION]. The (name of hospital) called the facility later in the afternoon, to request a copy of the resident's current medication orders. There was no evidence in the medical record that the responsible party was notified when the resident was hospitalized . The resident did not return to the facility until 03/24/16. Admission [DIAGNOSES REDACTED]. Review of the discharge minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/17/16, found staff assessment for mental status functionality indicated the resident demonstrated moderately impaired cognitive skills for daily decision-making. During an interview with the director of nursing (DON) on 05/10/16 at 11:02 p.m., when asked to show evidence of responsible party notification of the resident's transfer and admission to the hospital, she agreed she saw no evidence of family notification of the hospita… | 2019-10-01 |
| 4461 | 4461 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 221 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of the facility's restraint policy, the facility failed to ensure a resident's right to be free from physical restraints not required to treat the resident's medical symptoms. Resident #108 and Resident #30 wore lap belts while in their wheeled chairs. There was no physician's order for use of a lap belt for Resident #108. Neither resident had an assessment to determine the least restrictive restraint and/or alternatives to physical restraints. There was no evidence the resident and/or responsible party were informed of the risks and benefits of physical restraint use. This affected two (2) of twenty-three (23) sampled residents. Resident identifiers: #108 and #30. Facility census: 108. Findings include: a) Resident #108 On 05/02/16, observations of Resident #108 for over an hour before, during, and after the lunch meal found she sat in the dining room slightly reclined in a specialty chair. She wore a fastened lap belt across her abdomen the entire time she sat in the dining room, including time spent while a nursing student sat beside her and spoon fed her meal to her. Review of the resident's medical record on 05/09/16 at 11:00 a.m., found the absence of physician's orders for the use of a lap belt. The medical record contained no restraint assessment for use of a lap belt, and no informed consent from the responsible party for the risks and benefits of its use. Additionally, there were no staff directives of when and how often to use the lap belt, or when and how often to release the lap belt used on this resident. The resident's care plan contained no mention of lap belt use. Further review of physician's orders found an order for [REDACTED]. Review of the most recent quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 02/07/16, identified that a trunk restraint was not used when up in the chair. It also assessed that the chair di… | 2019-10-01 |
| 4462 | 4462 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 241 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to promote care for residents that enhanced each resident's dignity by maintaining lap belt usage during meals for three (3) randomly observed residents when the residents were directly supervised by staff. The residents sat in full view of other residents, staff, and visiting family members in the large, common-use dining room while wearing lap belts. This had the potential to negatively affect the dignity of those three (3) incapacitated residents, as it would for any reasonable person in that scenario. Resident identifiers: #108, #42, and #30. Facility census: 108. Findings include: a) Resident #108 1) During the lunch meal observation of the main dining room on 05/02/16, a nursing student sat in the chair beside the resident and spoon fed her meal. The resident sat in a specialty chair which was slightly tipped backward, and wore a fastened lap belt throughout the entire meal. Review of the medical record on 05/09/16 at 11:00 a.m. found [DIAGNOSES REDACTED]. The most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 02/07/16, assessed her brief interview for mental status (BIMS) score of ten (10). This indicated a moderate impairment of cognitive skills. She lacked capacity for medical decision-making. Further review of the medical record found no physician's orders for the use of a lap belt. The medical record contained no restraint assessment for lap belt use, and no responsible party's informed consent with education on the risks and benefits from its use. The resident's care plan contained no mention of lap belt use. The medical record contained no staff directives of when or how often to use the lap belt, or when or how often to release the lap belt. 2) During the lunch meal observation of the main dining room on 05/09/16, Nurse Aide (NA) #81 sat in a chair beside the resident at 12:34 p.m. She then began feeding the resident, who sat in a… | 2019-10-01 |
| 4463 | 4463 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 253 | E | 0 | 1 | UTVK11 | Based on observation, resident interview, and staff interview, the facility failed to provide effective housekeeping and maintenance services to ensure a sanitary, orderly, and comfortable interior. Residents' wheelchairs were unclean and/or in disrepair. Walls, floors, furniture, and privacy curtains were not clean and/or in disrepair in eleven (11) of the thirty-six (36) rooms inspected during Stage 1 of an annual Quality Indicator Survey (QIS). Resident Identifiers: #75, #96, and #85. Rooms: 114, 115, 139, 143, 146, 148, 157, 159, 161, 162, and 165. Facility census: 108. Findings include: a) Wheelchairs 1. Resident #75 On 05/03/16 at 09:37 a.m., an observation during an interview with Resident #75 revealed the wheelchair he was sitting in was in disrepair. A significant area of the wheelchair's left arm covering was missing, exposing the underlying padding. The left corner of the seat was ripped and frayed exposing the seat's padding. The resident stated he was actually sitting in his wife's wheelchair, who was also a resident of the facility and his roommate. Resident #75 stated the facility provided and maintained his wife's wheelchair. 2. Resident #96 An observation, on 05/03/16 at 11:08 a.m., revealed the middle of the right arm of Resident #96 wheelchair had a raised dried soiled area the size of a nickel. 3. Resident #85 On 05/03/16 at 10:20 a.m., an observation of Resident #85's wheelchair revealed it was in disrepair. The wheelchair's left arm covering was frayed and cracked open exposing the underlying padding. b) Room environment and furnishings 1. Room 114 On 05/03/16 at 2:02 p.m., observation revealed the wall beside the television had paint and plaster missing, with paint chips lying on the floor. The wall toward the bathroom was also scraped with paint missing. 2. Room 115 Observations on 05/03/16 at 11:35 a.m., revealed a privacy curtain soiled with droplets of a reddish brown substance. 3. Room 139 On 05/03/16 at 10:02 a.m., observation revealed the wooden board on the wall behind the head of t… | 2019-10-01 |
| 4464 | 4464 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 272 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, record review, and staff interview, the facility failed to conduct a comprehensive and accurate assessment of each resident's functional capacity. This was true for two (2) of twenty-three (23) Stage 2 residents. The Minimum Data Set (MDS) assessment for Resident #102's inaccurately assessed the resident's dental status and Resident #30's MDS was inaccurate regarding seatbelt usage. Resident identifiers: #102 and #30. Facility census: 108. Findings include: a) Resident #102 During a Stage 1 of the Quality Indicator Survey (QIS), an observation on 05/03/16 at 10:00 a.m., noted Resident #103 had missing teeth. A second observation of the resident's dental status on 05/05/16 at 9:30 a.m. identified most of his bottom teeth were missing, and the bottom center teeth were in various states of decay and broken off. During an interview at that time, Resident #102 stated his teeth had been like that for about twenty (20) years. He added that his dentist had told him to leave them as long as possible as long as they were not bothering him. Record review on 05/05/15 at 9:40 a.m., found the most recent comprehensive MDS, with an assessment reference date (ARD) of 12/08/15, identified the resident had no abnormalities in dental status. On 05/05/16 at 10:10 a.m., MDS Coordinator #3 stated when dental status was assessed, the MDS nurse went to the resident personally and entered the information into the MDS. He verbalized understanding that the dental status for Resident #102 was assessed inaccurately. b) Resident #30 Observation of the resident during Stage 1 of the Quality Indicator Survey, on 05/02/16 at 11:45 a.m., found the resident seated in a wheelchair with a seatbelt. The seatbelt continued to be in use during daily observations, including, but not limited to: - 05/03/16 at 11:00 a.m. and 2:55 p.m. - 05/04/16 at 11:30 a.m. - 05/05/16 at 12:15 p.m. - On 05/09/16 the resident was observed with the seatbelt in… | 2019-10-01 |
| 4465 | 4465 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 278 | D | 0 | 1 | UTVK11 | Based on medical record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of Resident #124's quarterly minimum data set (MDS) assessment completed the assessment accurately for the area of falls and nutrition. Resident identifier: #124. Facility census: 108. Findings include: a) Resident #124 1. Resident #124 triggered for review due to experiencing a weight loss since her admission to the facility. The medical record review, completed on 05/04/16 at 4:00 p.m., revealed Resident #124 had a quarterly MDS with an assessment reference date (ARD) of 03/30/16. The assessment reflected the resident was on a physician prescribed weight loss regimen. Further review of the medical record did not evidence the resident was on a prescribed weight loss regimen. During an interview on 05/04/16 at 4:30 p.m., the MDS coordinator agreed the resident was not on a physician prescribed weight loss program and verified this section of the MDS was inaccurate. 2. A review of Resident #124's medical record revealed the resident experienced a fall on 02/06/16. The discharge assessment with an ARD of 02/08/16, did not identify the resident had experienced any falls since readmission or the last assessment, whichever was more recent. On 05/05/16 at 11:47 a.m., the MDS coordinator agreed the discharge assessment did not accurately reflect the resident's falls. | 2019-10-01 |
| 4466 | 4466 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 279 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to develop care plans to address the needs of three (3) of twenty-three (23) sampled residents. The facility did not develop a care plan to address the use of a lap belt for Resident #108, use of supplemental oxygen therapy for Resident #2, and use of a urinary catheter for Resident #89. Resident identifiers: #108, #2, and #89. Facility census: 108. Findings include: a) Resident #108 On 05/02/16, Resident #108 was observed for over an hour as she sat in the dining room in a specialty chair that was slightly reclined. She wore a fastened lap belt across her abdomen the entire time she sat in the dining room, including time spent while a nursing student sat beside her and spoon fed an entire meal to her. Review of the resident's medical record on 05/09/16 at 11:00 a.m., found no mention in the care plan about the use of the lap belt, or staff directives of how often to utilize and/or release the belt. The most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 02/07/16, assessed that a trunk restraint was not used when the resident was up in the chair, and did not identify that the chair used for the resident prevented the resident from rising. The comprehensive admission MDS, with an ARD of 11/07/15, assessed the same. Observation of the lunch meal on 05/09/16 found this resident received her lunch tray at 12:34 p.m. Her lap belt was in place over her abdomen and fastened. Nurse Aide (NA) #81 sat in a chair beside the resident as she spoon fed her. During an interview with NA #81 on 05/09/16 at 12:45 p.m., she said this resident always wore a lap belt while sitting in a chair. She said this was nothing new, as the resident had always used a lap belt when up in a chair. She said staff did not remove the lap belt during meals or activities while the resident was directly supervised. The resident was unable to remo… | 2019-10-01 |
| 4467 | 4467 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 280 | E | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident review, the facility failed to afford residents the right to participate in their care plans and also failed to revise care plans to address residents' needs. Two (2) residents (#102 and #105) were not invited to participate in their care plan meetings. The care plans of four (4) residents (#89, #48, #124, and #85) were not revised to reflect new interventions after they were involved in accidents. This practice affected six (6) of twenty-three (23) Stage 2 residents. Resident identifiers: #89, #102, #85, #48, #105, and #124. Facility census: 108. Findings include: a) Resident #89 Record review on 05/09/16 at 2:50 p.m. noted Resident #89 was involved in an accident on 12/07/16 during which he sustained a skin tear. The director of nursing (DON), when interviewed on 05/13/16 at 9:30 a.m., provided evidence showing an intervention of applying geri sleeves to Resident #89 was to be put into place as a result of the accident. Review of the resident's care plan at that time did not find any revision to the care plan including application of geri sleeves. The DON also provided a Task List used by nurse aides to guide resident care. Geri sleeves were not added to the task list so staff would be informed of the safety measure to be put into place for Resident #89. b) Resident #102 During a Stage 1 interview on 05/03/15 at 9:30 a.m., the resident replied No. They don't explain things, when asked, Do staff include you in decisions about your medicine, therapy, or other treatments? MDS Coordinator #3, when interviewed on 05/04/16 at 2:00 p.m., said this resident was verbally invited to the care plan meetings and declined the invitation. He provided copies of the last three (3) care plan attendance sheets for Resident #102 and they were not signed by the resident, indicating Resident #102 did not attend. During a second interview with Resident #102 on 05/04/16 at 3:25 p.m., he said I've never been inv… | 2019-10-01 |
| 4468 | 4468 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 282 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of the facility's restraint policy, the facility failed to provide services for three (3) of twenty-three (23)residents whose plans of care were reviewed in accordance with the residents' written plans of care. Residents #30 and #42 did not have their seat belts removed every two (2) hours and Resident #85 was not provided thickened liquids as directed by their plans of care. Resident identifiers: #30, #42, and #85. Facility census: 108. Findings include: a) Resident #30 Medical record review, on 05/09/16 at 9:05 a.m., revealed a physician's orders [REDACTED]. The order stated Seat Belt to w/c for fall prevention, release q2hrs for 30min, and offer to toilet, assist to activities, assist with ROM/exercises. (Seat belt to wheelchair for fall prevention, release every two hours for 30 minutes, and offer to toilet, assist to activities, assist with range of motion/exercises). The resident's care plan in use at the time of the survey, dated 03/09/16, reviewed on 05/09/16 at 9:28 a.m., included the seat belt as a fall prevention intervention. The care plan stated Seat Belt to W/C for fall prevention, release q2hrs for 30min, and offer to toilet, assist to activities, assist with ROM/exercises. (Seat belt to wheelchair for fall prevention, release every two hours for 30 minutes, and offer assistance with toileting, activities, and range of motion and exercises). Observations of the resident on 05/09/16 found the following: - 10:08 a.m. The resident was in her wheelchair in the hallway with a seatbelt on. - 10:28 a.m. The resident was in her wheelchair in the dining room with a seatbelt on. - 10:45 a.m. The resident was in the dining room in her wheelchair with a seatbelt on. - 11:10 a.m. The resident was in the dining room in her wheelchair with a seatbelt on. - 11:35 a.m. The resident was in the dining room in her wheelchair with a seatbelt on. - 12:15 p.m. The resident was in the di… | 2019-10-01 |
| 4469 | 4469 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 309 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility's restraint policy, the facility failed to deliver the necessary care and services for three (3) of twenty-three (23) sample residents. Resident #30 and #42 did not have their seat belts removed for thirty (30) minutes every two (2) hours. Resident #85 did not receive thickened liquids as ordered by the physician and addressed in the plan of care. Resident identifiers: #30, #42, and #85. Facility census: 108. Findings include: a) Resident #30 Medical record review on 05/09/16 at 9:05 a.m., revealed a physician's orders [REDACTED]. The order stated Seat Belt to w/c for fall prevention, release q2hrs for 30min, and offer to toilet, assist to activities, assist with ROM/exercises. (Seat belt to wheelchair for fall prevention, release every two hours for 30 minutes, and offer to toilet, assist to activities, assist with range of motion/exercises). On 05/09/16 at 9:28 a.m., review of the care plan dated 03/09/16, in use at the time of the survey, included the seat belt as a fall prevention intervention. The care plan stated Seat Belt to W/C for fall prevention, release q2hrs for 30min, and offer to toilet, assist to activities, assist with ROM/exercises. (Seat belt to wheelchair for fall prevention, release every two hours for 30 minutes, and offer assistance with toileting, activities, and range of motion and exercises). On 05/09/16, the following resident observations occurred : -10:08 a.m. The resident was in her wheelchair in the hallway with a seat belt on. -10:28 a.m. The resident was in her wheelchair in the dining room with a seat belt on. -10:45 a.m. The resident was in the dining room in her wheelchair with a seat belt on. -11:10 a.m. The resident was in the dining room in her wheelchair with a seat belt on. -11:35 a.m. The resident was in the dining room in her wheelchair with a seat belt on. -12:15 p.m. The resident was in the dining room in her wheelchair… | 2019-10-01 |
| 4470 | 4470 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 329 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident did not receive an as needed (PRN) antianxiety medication without first identifying the targeted behavior and attempting nonpharmacological interventions. Additionally, the facility did not ensure the resident was monitored for potential untoward side effects of administering [MEDICATION NAME] at, or near, the same time as [MEDICATION NAME] and [MEDICATION NAME]. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #69. Facility census: 108. Findings include: a) Resident #69 Review of the medical record on 05/04/16 at 10:00 a.m. revealed pertinent [DIAGNOSES REDACTED]. On 04/27/16, she was sixty (60) inches tall and weighed 98 pounds, according to the most recent weight record on the computer. On 04/04/14, the physician ordered an antianxiety medication, [MEDICATION NAME] 0.5 milligrams (mg) one (1) tablet every six (6) hours as needed (PRN) for anxiety. Review of the (MONTH) and (MONTH) (YEAR) medication administration records (MAR) revealed she received three (3) doses of [MEDICATION NAME] 0.5 mg. Nursing administered a dose on 04/28/16 at 9:32 p.m., a dose on 04/30/16 at 8:30 p.m., and a dose on 05/03/16 at 8:17 p.m. Nurses documented each time that the medication was effective. Other psychoactive medications scheduled for 9:00 p.m. which were also administered included an antipsychotic medication, [MEDICATION NAME] ten (10) milligrams, and an antidepressant, [MEDICATION NAME] thirty (30) milligrams. Review of nurse progress notes found no identification or description of the behaviors exhibited, and no non-pharmacological methods attempted, prior to medicating her with the [MEDICATION NAME] on those three (3) occasions. Observation on 05/04/16 at 1:00 p.m., found her food plate was open and untouched, and the cutlery unwrapped, as it sat on her bedside table. She lay curled up in a fetal pos… | 2019-10-01 |
| 4471 | 4471 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 371 | F | 0 | 1 | UTVK11 | Based on observation and staff interview, the facility failed to ensure all foods in the dietary kitchen were stored, prepared, and distributed under sanitary conditions. Cups, bowls, and plastic glasses were stored directly on flat trays preventing drying before use. The broken cover of a storage bin for dried beans did not completely cover the bin, allowing for possible contamination of the stored beans. The snack refrigerators on both nursing units contained undated and outdated resident foods, and had soiled interiors. These infractions had the potential to affect any resident who partook of food from the dietary kitchen and/or snack refrigerators. Facility census: 108. Findings include: a) Dietary kitchen 1. The initial tour of the dietary kitchen on 05/02/16 at 11:00 a.m., found a full tray of plastic cups, a full tray of plastic bowls, and a full tray of plastic glasses stored upside down directly on plastic trays without benefit of mats to allow air drying. Each of the cups, bowls, and glasses contained water droplets on the interior surfaces with circular areas of pooled water on the trays as watery outlines from the rims of those items. The trapped moisture created a warm, moist environment for the rapid growth of potentially pathogenic microorganisms. During interview with the dietary manager at this time, she said she would obtain raised drying mats for future drying of the cups, bowls, and glasses. In the dry storage area, a white plastic storage bin with a see-through plastic lid contained dried red beans. The broken lid of the storage bin left an opening approximately two (2) inches wide. Because the dried beans were not securely covered, this created the potential for insects, rodents, or other contaminants to fall onto the dried beans. On 05/02/16 at 11:05 a.m., the dietary manager said she was aware of the broken lid, and that a new lid was ordered and on its way to the facility. On 05/10/16 at 12:00 p.m., the lid remained broken. When asked to provide the purchase order for the new lid, the die… | 2019-10-01 |
| 4472 | 4472 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 441 | E | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of manufacturer's instructions, and staff interview, the facility failed to ensure the implementation of an effective infection control program. Infection control issues were found on a medication cart, in a resident bathroom, and also with a resident's oxygen tubing. These infection control issues had the potential to affect more than an isolated number of residents. Facility census: 108. Findings include: a) Medication Cart On 05/02/16 at 3:15 p.m., an observation of the medication cart for D-hall noted unwrapped spoons stored in different directions in a plastic container. The lid did not completely cover the container. On 05/04/16 at 1:30 p.m., during an interview with Nurse Educator #20, he agreed having the spoons loosely placed in a container in different directions created a potential infection control issue. He agreed the part of the spoon that would enter the resident mouth could be touched when staff members were getting spoons out of the container. b) Resident #124's bathroom 1. On 05/03/16 at 1:20; p.m., observation of Resident #124's bathroom revealed a raised toilet seat with white tape wrapped around the metal part of the front bar. The seat of the commode touched the top bar where a black substance was observed when the lid was raised. On 05/04/16 at 1:30 p.m. during an interview with Nurse Educator #20, in reference to the commode chair in room [ROOM NUMBER]'s bathroom, Nurse Educator #20 agreed the tape was dirty and created a infection issue. Observation on 05/04/16 at 10:00 a.m., found the white tape, which had the black substance on it, was removed from the toilet seat. 2. Plunger On 05/03/16 at 1:57 p.m., an observation of Resident #124's bathroom revealed a unbagged toilet plunger (a tool used to clear blockages in drains and pipes). On 05/04/16 at 1:45 p.m., Nurse Educator #20 agreed the unbagged toilet plunger created a potential infection control issue. An unidentified staff member remo… | 2019-10-01 |
| 4473 | 4473 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2016-05-12 | 514 | D | 0 | 1 | UTVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were accurately documented. This was true for two (2) of twenty three (23) stage 2 residents. Three (3) Weekly Wound Evaluations were inaccurate for Resident #89. Resident #168's medical record had no documentation of the facility's response to an elevated blood pressure. Resident identifiers: #89 and #168. Facility census: 108. Findings include: a) Resident #89 Medical record review on 05/09/16 at 2:50 p.m., found he was admitted on [DATE] with three (3) unstageable pressure ulcers. On Page 1 of the Weekly Wound Evaluation dated 11/12/15, the response to Does this resident have one (1) or more unhealed pressure ulcer(s) at Stage 1 or higher? was marked as No. However, documentation on pages 1, 5, and 9, of the form described three (3) areas as unstageable pressure areas. Page 1 of the Weekly Wound Evaluation dated 11/30/15, also indicated the resident did not have any pressure ulcers at Stage 1 or higher, yet described three (3) areas as unstageable pressure areas on pages 1, 5, and 9. Documentation on page 7 of the form, described the second pressure area as having no exudate, however, the assessor documented the Color/Type of exudate as Purulent. Page 11 of the form described the third pressure area had no exudate, yet identified the Color/Type of exudate as Purulent Page 1 of the Weekly Wound Evaluation dated 12/14/15, had Yes and indicated the resident had two (2) Stage 4 pressure ulcers in response to the question whether the resident had one (1) or more unhealed pressure ulcer(s) at Stage 1 or higher. Documentation at the bottom of Page 1 described the first wound as an unstageable pressure ulcer, not a Stage 4 pressure ulcer. Documentation on Page 3 identified this ulcer had no exudate, but identified Purulent for the Color/Type of exudate. Page 2 of the for… | 2019-10-01 |
| 4474 | 4474 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2016-10-13 | 225 | D | 1 | 0 | D9EI11 | > Based on record review, review of facility policy and procedures, and staff interview, the facility failed to thoroughly investigate and/or report an incident of possible abuse and/or neglect by a staff member to the appropriate State agencies. This occurred for one (1) resident of nineteen (19) residents reviewed for unexpected events from 06/12/16 to 10/08/16. Resident identifier: #19. Facility census: 64. Findings include: a) On 10/12/16 at 4:30 p.m. and 10/13/16 at 8:30 a.m., review of incident/accident reports revealed the following: 1. Resident #19 On 08/30/16, Resident #19 sustained a 16-centimeter (cm) by (x) 4.5 cm wide imprint/abrasion to her left thigh. The description of the circumstances of the event was (typed as written): --CNA (certified nurse aide) roller resident over to take lift pad out from underneath resident (room number) and one of the straps was under her left thigh. CNA had reported to this nurse that she might have a bruise on left thigh @ (at) 0930 (9:30 a.m.) this morning. When resident was lifted back in bed with lift pad, and when changing Resident (room number) CNA's noticed that resident had a 16 cm x 4.5 cm wide imprint/abrasion on left thigh. The record was silent for witness statements. A review of Resident #19's medical record on 10/13/16 at 9:18 a.m. revealed she was totally dependent on staff for bed mobility, transfers, toilet use, personal hygiene, and other activities of daily living (ADLs). b) On 10/13/16 at 9:00 a.m., a review of the facility's Abuse Prohibition policy/procedure, with a revision date of 09/01/16 found it included: -- (Name of corporation) will prohibit abuse, neglect, involuntary seclusion and misappropriation of property for all patients through the following: .Identification of possible incidents or allegations which need investigation; --Investigation of incidents and allegations; -- .Reporting of incidents, investigations, and Center response to the results of their investigations. --Abuse is defined as the infliction or threat to inflict physical… | 2019-10-01 |
| 4475 | 4475 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2016-10-13 | 226 | D | 1 | 0 | D9EI11 | > Based on record review, review of facility policy and procedures, and staff interview, the facility failed to operationalize its policies for investigating and reporting possible abuse and/or neglect by staff members. This occurred for one (1) of nineteen (19) residents reviewed for unexpected events from 06/12/16 to 10/08/16. Resident identifier: #19. Facility census: 64. Findings include: a) Review of incident and accident reports beginning on 10/12/16 at 4:30 p.m. and continuing on 10/13/16 at 8:30 a.m. revealed the following: 1. Resident #19 On 08/30/16, Resident #19 sustained a 16-centimeter (cm) by (x) 4.5 cm wide imprint/abrasion to her left thigh. The description of the circumstances of the event was (typed as written): --CNA (nurse aide) roller resident over to take lift pad out from underneath resident (room number) and one of the straps was under her left thigh. CNA had reported to this nurse that she might have a bruise on left thigh @ (at) 0930 (9:30 a.m.) this morning. When resident was lifted back in bed with lift pad, and when changing Resident (room number) CNA's noticed that resident had a 16 cm x 4.5 cm wide imprint/abrasion on left thigh. There were no witness statements. A review of the medical record on 10/13/16 at 9:18 a.m. for Resident #19 revealed she was totally dependent on staff for bed mobility, transfers, toilet use, personal hygiene, and other activities of daily living (ADLs). b. On 10/13/16 at 9:00 a.m. a review of the facility ' s Abuse Prohibition policy with a revision date of 09/01/16 found it included: -- (Name of corporation) will prohibit abuse, neglect, involuntary seclusion and misappropriation of property for all patients through the following: -- Identification of possible incidents or allegations which need investigation; -- Investigation of incidents and allegations; -- Reporting of incidents, investigations, and Center response to the results of their investigations. -- Abuse is defined as the infliction or threat to inflict physical pain or injury on or the impris… | 2019-10-01 |
| 4476 | 4476 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2016-10-13 | 309 | D | 1 | 0 | D9EI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure care was provided in accordance with the resident ' s plan of care. The facility failed to ensure sufficient supplies were available to provide ordered wound care for Resident #65 and failed to ensure Resident #42 received medication for high blood pressure (hypertension) as ordered. This was found for two (2) of ten (10) sample residents. Resident identifiers: #65 and #42. Facility census: 64. Findings include: a) Resident #65 This [AGE] year-old resident, most recently admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The review of her record began on 10/11/16 at 1:10 p.m. The admission assessment of 10/05/16 identified the resident had an ulcer to mid abdomen 11 cm (centimeters) X (by) 11 cm with tunneling noted as 6 cm at 7 o'clock, 2 cm at noon, and 2cm depth (clock references are used to locate characteristics of wounds). Further investigation found Resident #65 had a ventral hernia repair at a regional medical center which was complicated by [DIAGNOSES REDACTED] (a rare flesh-eating disease) that required several debridements (removal of dead tissue). She developed [MEDICAL CONDITION] (systemic infection). A wound vac (vacuum) was eventually placed and she was returned to the facility for wound care on 09/05/16. The facility discharged her to psychiatric care on 09/20/16 related to making comments about hanging herself and changes in her personality. The facility sent her to the hospital due to her [DIAGNOSES REDACTED]. She returned to the facility on [DATE]. She had a care plan in place for (typed as written), Wound VAC to surgical wound on abdomen. The goal related to the concern was, Wound will remain free of s/s (signs/symptoms) infection times 30 days. Interventions initiated were, 1. [DEVICE] at 125 mmHg (millimeters of mercury) change every 72 hours continuous suction with white sponge used under black sponge. 2. Wound will be decreas… | 2019-10-01 |
| 4477 | 4477 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2016-10-13 | 314 | D | 1 | 0 | D9EI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, observation, and staff interview, the facility failed to provide care and treatment to promote healing of existing pressure ulcers. Negative pressure wound therapy (NPWT) supplies were not available for dressing changes as ordered for Resident #32. Resident #25's pressure ulcer was not staged and assessed to reflect the actual status of the wound which could impact the treatment modality. These findings affected two (2) of three (3) residents reviewed for pressure ulcers. Resident identifiers: #32 and #25. Facility census: 64. Findings include: a) Resident #32 Review of the resident ' s medical record on 10/12/16 at 9:00 a.m., revealed Resident #32 had a Stage 4 pressure ulcer on her coccyx since admission. A wound care center note dated 06/23/16 stated, Stage 4 pressure injury of sacrum. Apply wound vac (vacuum) dressing . change wound vac Monday, Wednesday and Friday .follow up in one month. These recommendations were ordered and followed until the facility ran out of supplies. The physician's orders [REDACTED]. Resident #32 returned to the wound care center on 08/11/16 for treatment of [REDACTED]. Recommendations from the wound care center were, Please keep vac (NPWT) on @ (at) all times. Please call (name) if running low on dressings. Change vac M-W-F (Monday-Wednesday-Friday) .Return in 4 weeks . (NPWT stands for negative pressure wound therapy or wound vac.) The weekly skin integrity report form noted the wound edges were macerated on 08/22/16. The Skin Integrity Report dated 10/10/16 noted the Stage 4 pressure sore measured 4 cm x 3.2 cm x 2.6 cm with 1 cm tunneling at 1-3 o'clock (clock times are used at times to document the location of a wound characteristic), heavy serosanguineous drainage, macerated wound edges, and surrounding tissue. The physician's orders [REDACTED]. Observation of wound care on 10/11/16 at 2:00 p.m. with … | 2019-10-01 |
| 4478 | 4478 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2016-10-13 | 431 | E | 1 | 0 | D9EI11 | > Based on observation, record review, and staff interview, the facility failed to maintain records of receipt and disposition of controlled substances and to store medications in a safe and secure manner. Controlled substance records were incomplete and/or lacked information to show complete reconciliation by on-coming and off-going nurses. The facility also failed to permit only authorized personnel to have access to the keys for the medication room and medication cart. This practice had the potential to affect more than a limited number of residents. Facility census: 64. Findings include: a) On 10/12/16 at 8:20 a.m., Licensed Practical Nurse (LPN) #39 explained the procedure for counting narcotics. The nurse said, . the off-going nurse and the on-coming nurse on each shift will count the narcotics to make sure the count is right and each nurse will sign the end of shift sheet. She explained this was done at every change of shift. A review of the narcotic shift count sheets/logs from 08/03/16 to 10/12/16 on 10/12/16 at 1:00 p.m., revealed two (2) blank signature/initial spaces for reconciliation of the controlled medication counts at the change of shifts identified on the 100 hall. The two (2) missing signatures on the count sheets/logs for 100 hall were: -- On 08/19/16 a missing signature under column Nurse going off Duty -- On 09/18/16 a missing signature under column Nurse going off Duty The three (3) blank signature/initial spaces at the change of shifts identified on the 200 hall were: -- On 08/07/16 a blank/missing signature under column Nurse Coming On Duty -- On 08/08/16 a blank/missing signature under column Nurse going off Duty -- On 09/14/16 an Lc under column Nurse going off Duty. The DON wondered what the Lc was too, and said either way it was not a signature. The Director of Nursing (DON) reviewed the controlled substance shift count sheets/logs during an interview on 10/12/16 at 1:30 p.m. She stated, Yes they (controlled substance shift count sheets/logs) should be signed at the beginning and end… | 2019-10-01 |
| 4479 | 4479 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2016-10-13 | 514 | D | 1 | 0 | D9EI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the completeness and accuracy of the clinical record for one (1) of five (5) residents reviewed. Resident #32's Medication Administration Record [REDACTED]. Additionally, blood pressure readings were not documented daily prior to the administration of cardiac medications with ordered parameters. Resident identifier: #32. Facility census: 64. Findings include: a) Resident #32 Review of the resident ' s medical record at 9:00 a.m. on 10/12/16, revealed this [AGE] year old woman ' s [DIAGNOSES REDACTED]. Her medication orders included [MEDICATION NAME] 20 mg (milligrams) daily for [MEDICAL CONDITION], [MEDICATION NAME] 2.5 mg daily for [MEDICAL CONDITION] hold if SBP (systolic blood pressure - when the heart contracts) less than 100, and [MEDICATION NAME] 3.125 mg twice a day for [MEDICAL CONDITION] hold if SBP less than 100. The Medication Administration Record [REDACTED]. - The daily 8:00 a.m. dose of [MEDICATION NAME] 20 mg was not signed off on 08/21/16. - The daily 8:00 a.m. dose of [MEDICATION NAME] 2.5 mg was not signed off on 08/03/16, 08/04/16, 08/06/16, 08/11/16, 08/12/16, and 08/13/16. In addition, there were no blood pressure readings recorded for these days. - The daily 8:00 a.m. dose of [MEDICATION NAME] 3.125 mg was not signed off on 08/03/16, 08/04/16, 08/06/16, and 08/11/16. No blood pressures were recorded on these days. The Director of Nursing (DON) reviewed the (MONTH) (YEAR) Medication Administration Record [REDACTED]. She said she could not determine whether Resident #32 received [MEDICATION NAME] on 08/21/16, [MEDICATION NAME] on 08/03/16, 08/04/16, 08/06/16, 08/11/16, 08/12/16, and 08/13/16, and [MEDICATION NAME] on 08/03/16, 08/04/16, 08/06/16, and 08/11/16. She also reviewed the vital signs records and acknowledged there were no blood pressure readings for these dates. The DON stated she would have to question the staff nurse as to why these sec… | 2019-10-01 |
| 4480 | 4480 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 223 | D | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to identify an allegation of physical abuse for one (1) of three (3) residents (Resident #34) reviewed for abuse. Resident #34 reported a nurse aide did not stop giving her a shower or adjust the water temperature when she complained of the shower water being too cold. Resident identifier: #34. Facility census: 48. Findings include: a) Resident #34 On 06/06/16 at 3:14 p.m., review of the resident's medical record found the Resident #34, admitted on [DATE], had [DIAGNOSES REDACTED]. A continuing review of the medical record revealed Resident #34 did have capacity to make health care decisions. In addition, according to the quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 04/16/16, Resident #27 had a score of 15 on the Brief Interview for Mental Status (BIMS). This score indicated the resident was cognitively intact. On 06/07/16 at 11:26 a.m., Resident #34 was heard in a loud, angry voice telling a Restorative Nurse Aide (RNA) #4, They gave me a cold shower. I kept telling (name) NA #34 the water was cold but she didn't stop. Resident #34 stated she asked the NA #34 to feel the water and when she did the NA #34 agreed the water was cold. In an interview with NA #4, on 06/07/16 at 11:32 a.m., she stated the resident (Resident #34) did allege she was given a cold shower. RNA #4 stated this was a form of neglect and she would need to report to her supervisor. On 06/07/16 at 1:41 p.m., during an additional interview with Resident #34, when asked if she received a cold shower that morning, she said Yes. When asked if she knew the name of the NA, she said NA #16's name. Resident #34 stated she told NA #16 that the water was cold and the NA #16 responded by stating, No, it is not cold. Resident #34 asked her to feel the water and when NA #16 felt the water, she stated the water was cold and continued to give the resident her shower… | 2019-10-01 |
| 4481 | 4481 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 241 | E | 0 | 1 | ENC511 | Based on observations and staff interview, the facility failed to ensure three (3) randomly observed residents were treated with dignity and respect. Staff entered the residents' rooms without knocking or otherwise asking permission to enter the residents' rooms. Resident identifiers: #18, #39, and #56. Facility census: 48 Findings include: a) Resident #18 On 06/08/16 at 2:38 p.m., during observations of the wound nurse preparing to do wound care for Resident #18 in the resident's room, behind a closed door, Nurse Aide (NA) #55 entered the resident's room without knocking or otherwise asking permission to enter. When the NA #55 realized the wound care nurse was with the resident, the NA left the room. When the wound nurse completed wound care, she left the room to find someone to help her reposition the resident in bed. The wound nurse returned and told the resident someone would come soon to help her lift the resident up in the bed. On 06/08/16 at 2:50 p.m., NA #55 knocked on the resident's door, at the same time as she was opening the door. NA #55 did not wait for a response to her knocking prior to entering the resident's room. b) Resident #39 A random observation on 06/07/16 at 10:55 a.m., revealed Licensed Practical Nurse (LPN) #15 knocked on Resident #39's door and entered without waiting for a reply or permission to enter from either resident residing in that room. On 06/07/16 at 11:12 a.m., LPN #15 was observed entering Resident #39's room without knocking or asking permission. c) Resident #56 A random observation, on 06/09/16 at 8:46 a.m., revealed two (2) NAs (NA #38 and NA #57) entering Resident #56's room without knocking or otherwise asking permission before entering resident's room. On 06/09/16 at 09:06 a.m., when asked how a resident's room was to be entered, NA #38 and NA #57 confirmed they were to knock on the door first, and then ask the resident if they could come in. | 2019-10-01 |
| 4482 | 4482 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 257 | E | 0 | 1 | ENC511 | Based on observations, resident interview, and staff interview, the facility failed to maintain comfortable room temperatures for residents in common areas of the facility. This had the potential to affect more than a limited number of residents. Facility census: 48. Findings Include: a) Random observations on 06/08/16 at 1:45 p.m., revealed multiple residents (at least eight (8)) sitting in wheelchairs and geri-chairs throughout the solarium. The director of nurses (DON) asked a resident, who was sitting in a wheelchair by the windows, if she was cold and the resident said she was cold. The DON went after a blanket and placed it around the resident. During this observation, another resident sitting in a wheelchair on the other side of the solarium, away from the windows, was heard to tell another resident she too was cold. b) On 06/08/16 at 1:55 p.m., upon request, the Director of Environmental Services (DES) #24 checked the temperatures of the solarium. DES #24 stated the temperature was registering 69 degrees Fahrenheit (F) in the solarium and 70.9 in the dining room; however due to the thermostats being placed on 74 degrees F, DES #24 said she thought the temperature would have been at least 72 to 73 degrees F. DES #24 confirmed room temperatures should be between 71 to 81 degrees F. DES #24 stated the facility monitored and logged the thermostat readings for the solarium and dining room temperatures, and agreed there was a discrepancy with the thermostat readings and the actually room temperatures. She stated the facility would have to start using her thermometer and monitor the room temperatures instead of relying on the thermostat readings. | 2019-10-01 |
| 4483 | 4483 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 272 | D | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to conduct accurate comprehensive assessments for one (1) of twenty-four (24) Stage 2 sampled residents. Resident #58's assessment did not identify antipsychotic medications. Resident identifier: #58. Facility census: 48. Findings include: a) Resident #58 On 06/07/16 at 8:15 a.m., review of the resident's medical record found the Medication Administration Record (MAR) noted Resident #58 had received [MEDICATION NAME] (an antipsychotic) for dementia since admission on 03/08/16. The admission minimum data set (MDS), with an assessment reference date (ARD) of 03/14/16, did not identify the resident received an antipsychotic during the look back period. Registered Nurse (RN) #61 reviewed the MAR and MDS during an interview on 06/07/16 at 1:28 p.m. and confirmed the MDS was coded incorrectly and did not reflect Resident #58's prescribed antipsychotic medication. | 2019-10-01 |
| 4484 | 4484 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 278 | D | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the health care professional completing and certifying the accuracy of Resident #29's quarterly minimum data set (MDS) assessments failed to complete the pressure ulcer assessment accurately. In addition, the required brief interview for mental status (BIMS) assessment was not completed on the quarterly MDS for Resident #27. Resident #69's assessments did not accurately reflect a surgical wound or the development of pressure ulcers. This practice was found for three (3) of twenty-four (24) Stage 2 sample residents whose MDSs were reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #29, #27, and #69. Facility census: 48. Findings include: a) Resident #29 Review of the resident's medical record on 06/07/16 at 12:25 p.m., found she was admitted to the facility on [DATE] for skilled care following a right femur (long bone in the upper leg between knee and hip) fracture and repair. The pressure ulcer/body audit completed on 02/22/16, indicated she developed a fluid filled blister on her right heel, Stage 2, measuring 3.7 centimeters (cm) in length and 3.7 cm in width. The wound, first observed on 02/20/16, was in-house acquired. Review of the 30-day MDS with an assessment reference date (ARD) of 02/25/16, found the assessment coded NO for Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? During an interview, on 06/07/16 at 1:15 p.m., Registered Nurse (RN) #47 (Treatment Nurse) stated, Yes I remember her because she (Resident #29) did develop a Stage 2 fluid filled blister on 02/20/16 and then it progressed to an unstageable which is a Stage 4 pressure ulcer. It was on the heel of her right leg where she had her fracture. The fracture happened in the facility. After reviewing the MDS on 06/07/16 at 2;45 p.m., MDS Coordinator #21 stated, Yes it is not accurate and should have been coded as a pressure ulcer but it wasn't. We talked about that since the… | 2019-10-01 |
| 4485 | 4485 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 279 | G | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to develop a comprehensive care plan with individualized measurable goals and interventions for pressure ulcer prevention for Resident #29 and failed to address Resident #27's weight loss and inability to eat foods served for lunch and dinner resulting in actual harm to these residents. This practice was found for two (2) of twenty-four (24) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #29 and #27. Facility census: 48. Findings include: a) Resident #29 Review of the resident's closed medical record on 06/07/16 at 12:25 p.m., found she was admitted to the facility on [DATE] for skilled care following a right femur (bone between the knee and hip) fracture and repair. The pressure ulcer/body audit completed on 02/22/16, identified she had developed a Stage 2 fluid filled blister on her right heel measuring 3.7 centimeters (cm) in length and 3.7 cm in width. The wound, first observed on 02/20/16, was in-house acquired Review of the admission MDS with an assessment reference date (ARD) of 02/04/16, found the resident assessed as at risk for the development of pressure ulcers and no pressure ulcer was present on admission. The coding on the resident's 30-day MDS with an ARD of 02/25/16, indicated NO for Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? The interim care plan dated 01/29/16, developed prior to the admission MDS assessment, did not have a focus (problem statement), goals and interventions related to pressure ulcer prevention. Focus, goals and interventions were initiated on 02/23/16 for the discovered appearance of a right heel pressure ulcer. During an interview and review of the record on 06/07/16 at 1:15 p.m., Registered Nurse #47 (treatment Nurse) stated, Yes I remember her because she (Resident #29) did develop a Stage 2 fluid filled blis… | 2019-10-01 |
| 4486 | 4486 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 280 | D | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to revise the care plan for Resident #46 after the resident experienced a decline in activities of daily living (ADL). In addition, Resident #6 was not given an opportunity to participate in the care planning process. Resident identifiers: #46 and #6. Facility census: 48. Findings include: a) Resident #46 On 06/06/16 at 3:04 p.m., medical record review found that Resident #46, admitted on [DATE], had [DIAGNOSES REDACTED]. A continuing review of the medical record revealed the quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/09/15, identified this resident was independent for the ADLs of bed mobility, transfer, dressing, and toileting. The MDS, with an ARD of 03/15/16, identified this resident required supervision for the ADLs of bed mobility, transfering, dressing, and toileting. A review of the care plan, on 06/08/16 at 3:21 p.m., revealed the care plan was not updated to reflect the increase in assistance needed by Resident #46 in the areas of bed mobility, transfering, dressing, and toileting. The care plan goal, dated 03/17/16, stated the resident would maintain the current level of function in bed mobility, transfering, dressing and toileting. In an interview with the Director of Nursing (DON) and the MDS/Care Plan Coordinator, on 06/08/16 at 3:56 p.m., both agreed the care plan had not been updated to reflect Resident #46's need for increased ADL assistance. b) Resident #6 During a Stage 1 interview on 06/01/16 at 3:36 p.m., the resident replied, No I have never been invited to care plan meeting, just bring in your medicine and just do what they want, and they don't tell you anything, when asked, Do staff include you in decisions about your medicine, therapy, or other treatments? Review of the resident's medical record on 06/08/16 at 8:10 a.m., revealed he was admitted on [DATE]. His [DIAGNOSES REDACTED]. The qu… | 2019-10-01 |
| 4487 | 4487 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 314 | G | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of information from the National Pressure Ulcer Advisory Panel, review of the Resident Assessment Instrument (RAI) Users Manual, review of information from the Wound Ostomy and Continence Nurses Society, and staff interview, the facility failed to ensure residents admitted without pressure ulcers, and identified to be at risk for the development of pressure ulcers, received the necessary preventative treatment and services to prevent the development of a pressure ulcer. This practice was found for two (2) of three (3) Stage 2 sample residents reviewed for pressure ulcers during the Quality Indicator Survey (QIS). Resident identifiers: #29 and #69. Facility census: 48. Findings include: a) Resident #29 Review of the resident's medical record on 06/07/16 at 12:25 p.m. found she was admitted to the facility on [DATE] for therapy following a right femur fracture and repair. She was discharged to home with her family on 05/07/16. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 02/04/16 found the resident assessed to be at risk for the development of pressure ulcers and had no pressure ulcers at the time of admission. The 30-day MDS with an ARD of 02/25/16, was also coded NO for Does the resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? The pressure ulcer/body audit completed on 02/22/16, indicated she developed a right heel fluid filled blister, Stage 2, measuring 3.7 centimeters (cm) in length and 3.7 cm in width. The wound was first observed on 02/20/16 and was in-house acquired. The wound progressed quickly to an unstageable wound according to a notation dated 02/26/16, then was documented as healed on 03/31/16. Although the resident was assessed as being at risk for pressure ulcers, the care plan dated 01/29/16 included no individualized measurable goals or established intervention to meet the immediate needs of the resident at the time of admissi… | 2019-10-01 |
| 4488 | 4488 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 323 | D | 0 | 1 | ENC511 | Based on observation, resident interview, and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control. The facility failed to correct an identified accident hazard in a resident's room, regarding spilled water puddled on the floor surrounding a resident's bed, in a timely manner. Resident identifier: #46. Employee identifiers: #56 and #09. Facility census: 48 Findings include: a) Resident #46 Random observations, on 06/07/16 at 10:50 a.m.,revealed puddled water on the floor around the foot and sides of Resident #46's bed. Resident #46, with an unsteady gait, was walking back and forth around her bed stepping in the puddled water, holding on to the foot board of her bed, and sometimes holding on to her over-bed table. The resident was encouraged to sit down on her bed and use the call bell to get assistance with cleaning up the water. Resident #46 continued to walk and track in the spilled water. Human Resources Coordinator (HRC) #56, who had passed by earlier, was stopped as she was returning back up the hall (this surveyor had passed Employee #56 earlier in the hall). This surveyor started to express concern over an observed accident hazard, when HCR #56 interrupted before the surveyor could mention the spilled water. She said, You mean the water on the floor in . (in Resident #46 room)? HCR #56 admitted she had noticed it when she had passed the room earlier and would get housekeeping to mop it up. HCR #56 went into the room and noticed Resident #46 was continuing to walk unsteadily through the puddled water and stated, I'll get it mopped up now, and went in the hall and got Nurse Aide (NA) #9, to get a mop and mop up the water. NA #9 mopped up the water around the resident's bed at 11:05 a.m. on 06/07/16. This was after surveyor intervention and at least 15 minutes after HCR #56 had first observed the spill, which posed a risk of a fall to the resident. | 2019-10-01 |
| 4489 | 4489 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 325 | G | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed address Resident #27's potentially avoidable and unplanned weight loss. The resident primarily ate Jello and cereal for lunch and dinner resulting in actual harm to the resident who wished to lose weight, but not this way. This was true for one (1) four (4) residents reviewed for weight loss during Stage 2 of the survey. Resident #27 experienced a significant unplanned weight loss in six (6) months. Resident identifier: #27. Facility census: 48. Findings include: a) Resident #27 On 06/06/16 at 3:14 p.m., a review of the resident's medical record found the Resident #27, admitted on [DATE], had [DIAGNOSES REDACTED]. A continuing review of the medical record revealed Resident #27 did have capacity to make health care decisions. In addition, according to the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 04/16/16, Resident #27 had a score of 15 on the Brief Interview for Mental Status (BIMS). This score indicated the resident was cognitively intact. Both of the quarterly MDSs identified Resident #27 was not on a physician ordered weight loss program. During an interview on 06/07/16 at 10:52 a.m., Resident #27 revealed she had requested to have breakfast, and cereal and Jello for lunch and dinner. Resident #27 stated she could not eat the food as it was prepared by the facility because it made her sick. When ask if she had lost weight she stated she weighed 209 pounds when she was admitted and how weighed 185. When asked if she had informed the Dietary Manager (DM) about issues with the food she said, Yes. I have even called the Ombudsman. Resident #27 explained the DM told her, We have to do what the state says. In addition, she stated she knew she was overweight, but I don't want to lose weight this way. On 06/07/16 at 11:11 a.m., a review of the Dietitian note dated 05/23/16 at 15:18 (3:18 p.m.) revealed the following Note Text: Nu… | 2019-10-01 |
| 4490 | 4490 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 329 | D | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure the physician responded to a pharmacy recommendation in a timely manner. This was true for two (2) of five (5) sampled residents whose drug regimens were reviewed for unnecessary medications. Resident identifiers: #9 and #58. Facility census: 48. Findings include: a) Resident #9 Review of medical records, on 06/08/16 at 4:09 p.m., revealed Resident #9's [DIAGNOSES REDACTED]. The resident received [MEDICATION NAME] nebulizer every 4 hours, [MEDICATION NAME] 250/50 mg (milligram) by mouth every 12 hours, and [MEDICATION NAME] nebulizer every 6 hour PRN (as needed) for management of [MEDICAL CONDITION]. On 06/08/16 at 4:35 p.m., medical record review found on 03/16/16 and again on 05/17/16, the pharmacist recommended the physician, .consider changing routine [MEDICATION NAME] to long-acting [MEDICATION NAME][MEDICATION NAME] therapy with [MEDICATION NAME] ([MEDICATION NAME] Handihaler) 18 mcg (microgram) one inhalation daily. The entire contents of one [MEDICATION NAME] capsule are to be inhaled orally once daily by taking two (2) separate inhalations from the Handihaler device . while continuing PRN [MEDICATION NAME] order. Rationale for recommendation: The (YEAR) Global Initiative for [MEDICAL CONDITION] (GOLD) [MEDICAL CONDITION] guidelines recommend regular treatment with long-acting [MEDICATION NAME][MEDICATION NAME] over treatment with short-acting [MEDICATION NAME][MEDICATION NAME] based on improved efficacy and convenience. Physician #79 did not respond either time to the request to consider the recommendation when it was requested on 03/16/16 and 05/17/16. Director of Health Information #68 said the pharmacy recommendations had been faxed to the physician's office three (3) times and the facility was still waiting on a response. b) Resident #58 Medical record review, on 06/07/16 at 8:15 a.m., revealed Resident #58 was admitted to the facility on [D… | 2019-10-01 |
| 4491 | 4491 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 334 | D | 0 | 1 | ENC511 | Based on record review, staff interview, and policy review, the facility failed to educate and/or obtain consent or refusal for an influenza vaccine. This was true for one (1) of five (5) sampled residents reviewed for influenza and pneumococcal immunizations. Resident identifier: #56. Census: 48. Findings include: a) Resident #56 Interview with Director of Health Information (DHI) #68, on 06/08/16 at 4:15 p.m., revealed the facility could not find a signed consent for Resident #56 for the influenza vaccine for the current flu season. On 06/08/16 at 6:00 p.m., review of the facility's policy and procedure for Immunizations for Residents revealed under Procedure for Annual Influenza Vaccination: #3 d. Inform resident or legal representative each year when the influenza vaccinations will be given and provide the Vaccination Information Statement from the CDC (Centers for Disease Control and Prevention) for the current year. The Vaccination Information Statement contains educational information about the benefits and potential side effects of influenza vaccination. DHI #68 could not provide any evidence the resident had been informed about the benefits and risks of an influenza immunization, or whether the resident had been given the opportunity to receive or to refuse the influenza vaccine. No documentation of any information or education was found in the resident's medical records regarding the benefits or risks of immunization, and/or the administration or the refusal of the vaccine, or any medical contraindications to the vaccine. | 2019-10-01 |
| 4492 | 4492 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 371 | E | 0 | 1 | ENC511 | Based on observation, refrigeration temperature log record review, review the United States Food and Drug Administration Food Code, and staff interview, the facility failed to monitor and maintain refrigerator temperatures to ensure refrigerated foods were stored safely to prevent the outbreak of foodborne illnesses. The facility's kitchenette refrigerator (located on 100 hall) and the activity room refrigerator were not always monitored or maintained at safe temperatures on numerous occasions. These practices have the potential to affect more than limited number of Residents. Staff Identifiers: #47 and #69. Facility Census: 48. Findings include: a) Kitchenette refrigerator Observations with Registered Nurse (RN) #47 on 06/01/16 at 2:51 p.m., revealed the nourishment pantry kitchenette refrigerator's temperature was 42 degrees Fahrenheit (F). RN #47 reviewed the facility's refrigeration temperature monitoring log, and verified the instruction on the facility's temperature log stated, Food: Refrigerators must be at 41 degrees F or below, Freezers 0 (zero)degrees F or below. RN #47 confirmed the kitchenette refrigerator's temperature was outside the designated parameters to ensure refrigerated foods are stored safely. The freezer was within safe parameters at minus 10 degrees F, but was in need of defrosting to ensure proper functioning of the freezer. The back wall of the freezer section of the refrigerator was covered with a heavy sheet of thick solid ice. RN #47 stated housekeeping was responsible to keep the unit defrosted and she would contact them immediately to defrost the unit. Review of the kitchenette refrigerator temperature monitoring logs for the months of March, April, and (MONTH) (YEAR) revealed on 03/08/16, 03/11/16, 03/14/16, 03/15/16, 03/17/16, 03/19/16, 04/29/16, and 05/29/16, the refrigerator temperature was 42 degrees F, and on 03/06/16 and 03/13/16 the refrigerator temperature was 46 degrees F. b) Activities Room Refrigerator On 06/01/16 at 3:05 p.m., interview with Activities Assistant #69 re… | 2019-10-01 |
| 4493 | 4493 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 387 | D | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review, the facility failed to ensure a resident was seen by a physician at least once every thirty (30) days for the first ninety (90) days after admission. This was found for (1) of twenty-four (24) residents reviewed in Stage 2 of the survey. Resident identifier: #38. Facility census: 48. Findings include: a) Resident #38 Medical record review, on 06/07/16, at 1:00 p.m., revealed this [AGE] year-old man had a history of [REDACTED]. He was admitted to the facility on [DATE] for aftercare following a [MEDICAL CONDITION]. Review of the physician progress notes [REDACTED].#76 completed his initial visit on 02/01/16 and a second visit on 02/26/16. Physician #76 visited Resident #38 again on 04/22/16. The resident was not seen by Physician #76 or any other doctor in (MONTH) (YEAR). During an interview at 3:08 p.m. on 06/07/2016, Director of Health Information (DHI) #68 reported Physician #76 visited the facility every sixty (60) days. DHI #68 reviewed the electronic records during this interview and confirmed Resident #38 was not seen by a physician once every thirty (30) days for the first ninety (90) days. The Director of Nursing (DON) reviewed the medical records on 06/07/16 at 4:08 p.m. and confirmed Resident #38 was seen by his physician on 02/01/16, 02/26/16, and 04/22/16. The DON agreed Resident #38 was not seen by any physician in March, so Resident #38 was not seen by a physician at least once every thirty (30) days for the first ninety (90) days. The physician services policy number II.P.7, dated (MONTH) 2012, under the section titled Physician Visits included, The resident will be seen personally by the attending physician at least once every 30 days for the first 90 days after admission | 2019-10-01 |
| 4494 | 4494 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 441 | E | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and policy review, the facility failed to maintain an effective infection control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Breaches in infection control practices were observed during Resident #39's wound care and during medication administration for Resident #27. These findings had the potential to affect more than an isolated number of residents. Resident identifiers: #39 and #27. Facility census: 48. Findings include: a) Resident #39 On 06/07/2016 at 2:17 p.m., Registered Nurse (RN) #47 was observed performing wound care on Resident #39's pressure ulcer. RN #47 covered the bedside table with a bath towel and set up her supplies of saline spray, gauze, washcloths, [MEDICATION NAME], gloves, tape, and a large dressing. After removing the old dressing, she washed her hands and changed her gloves. RN #47 sprayed the pressure ulcer wound with saline and then dried the wound with washcloths. [MEDICATION NAME] was applied to clean gauze, placed inside the wound and a dry outer dressing taped in place. In an interview conducted immediately after this observation, RN #47 acknowledged she had obtained the washcloths used to dry the wound from the linen cart and reported she had never considered this an infection control issue or a breach in aseptic technique. On 06/07/16 2:20 p.m., during a discussion about the wound care observation with Infection Control Nurse #61, she stated wound care should be done using clean 4 by 4 dressings and staff should never use a washcloth to dry the wound. The facility's policy titled Wound Dressing Change, issued (MONTH) 2012, stated under #12 of the procedure: Cleanse the skin and wound thoroughly with normal saline using gauze wipes, . b) Resident #27 On 06/07/16 at 8:35 a.m., Licensed Practical Nurse (LPN) #19 was observed dispensing pills from medication bottles and punch card… | 2019-10-01 |
| 4495 | 4495 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 490 | E | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review, resident interview, staff interview, and policy review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Two (2) newly admitted residents, #29 and #69, who were assessed as being at risk for the developement of pressure ulcers, experienced actual harm when the facility failed to provide preventative interventions and the residents developed in-house acquired pressure ulcers. The facility also failed to identify and address a significant unplanned weight loss for Resident #27, failed to ensure timely physician responses to pharmacy recommendations for Residents #9 and #58; failed to ensure a resident (#38) was seen by a physician every 30 days for the first 90 days; and failed to ensure medical records for Residents #67 and #70 included physician admission notes, progress notes, and discharge summaries. These deficient practices affected eight (8) of twenty-five (25) Stage 2 sample residents. Resident identifiers: #29, #69, #27, #9, #58, #38, #67, and #70. Facility census: 48. Findings include: a) During an interview on [DATE] at 4:50 p.m., Licensed Practical Nurse (LPN)/QA Coordinator #32 stated, We meet every third Tuesday of every month to discuss any facility concerns such as falls/accidents, pressure ulcers and grievances/concerns to name a few. We do not go over how often doctors visit, but we know it is a problem getting things signed and completed. Doctor visits and paper work have fallen through the cracks, Director of Health Information (DHI) #68 puts the paper work to be signed and completed in a folder, but the doctor never seems to do it and we all know that. Not sure if any audits are being done, but we try. b) The facility failed to ensure residents admitted without a pressure ulcer, but who were identified to be at risk … | 2019-10-01 |
| 4496 | 4496 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 514 | D | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain accessible, accurate, and/or complete and legible medical records for two (2) of twenty-four (24) Stage 2 sampled residents. Medical records lacked physician admission notes and progress notes, and discharge summaries were incomplete. Resident identifiers: #67 and #70. Facility census: 48. Findings include: a) Resident #67 On [DATE] at 9:00 a.m., review of the medical record revealed Resident #67 was admitted to the facility on [DATE] after hospitalization for recurrent aspiration pneumonia, stroke with severe dysphagia and recent feeding tube placement, diabetes with dehydration, hypertension, and [MEDICAL CONDITION] reflux. The resident expired on [DATE]. The medical record lacked a physician's admission note or any physician progress notes [REDACTED].#21 was incomplete under section 1 titled Physician Documentation. There was no final [DIAGNOSES REDACTED]. Section 2 titled Physician Signature was initialed by Physician #77 and dated 2/? The Director of Nursing (DON) reviewed the electronic records during an interview on [DATE] at 3:00 p.m. and confirmed Resident #67's medical record did not contain a physician's admission note or any physician progress notes [REDACTED]. The discharge summary lacked a final [DIAGNOSES REDACTED]. The DON acknowledged physician compliance with record documentation was a concern the facility needed to address. b) Resident #70 Review of the clinical record on [DATE] at 9:15 a.m., revealed Resident #70 was admitted to the facility on [DATE] for rehabilitation. [DIAGNOSES REDACTED]. Physician #77 reviewed Resident #70's medications and wrote a four (4) line progress note on [DATE]. The record did not contain a physician's admission note. The form titled Discharge Summary, electronically signed on [DATE], by Licensed Practical Nurse #39, noted a discharge date of [DATE]. Section 1, titled Physician Documentation, and section 2, tit… | 2019-10-01 |
| 4497 | 4497 | GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2016-06-09 | 520 | E | 0 | 1 | ENC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review, resident interview, staff interview, and policy review, the facility's Quality Assurance Committee (QAA) failed to identify and correct quality deficiencies of which they had knowledge or should have had knowledge. Two (2) newly admitted residents, #29 and #69, who were assessed as being at risk for the development of pressure ulcers, experienced actual harm when the facility failed to provide preventative interventions and the residents developed in-house acquired pressure ulcers. The facility also failed to identify and address a significant unplanned weight loss for Resident #27, failed to ensure timely physician responses to pharmacy recommendations for Residents #9 and #58; failed to ensure a resident (#38) was seen by a physician every 30 days for the first 90 days; and failed to ensure medical records for Residents #67 and #70 included physician admission notes, progress notes, and discharge summaries. These deficient practices affected eight (8) of twenty-five (25) Stage 2 sample residents. Resident identifiers: #29, #69, #27, #9, #58, #38, #67, and #70. Facility census: 48. Findings include: Findings include: a) During an interview on [DATE] at 4:50 p.m., Licensed Practical Nurse (LPN)/QA Coordinator #32 stated, We meet every third Tuesday of every month to discuss any facility concerns such as falls/accidents, pressure ulcers and , grievances/concerns to name a few. We do not go over how often doctor's visit, but we know it is a problem getting things signed and completed. Doctor visits and paper work have fallen through the cracks, Director of Health Information (DHI) #68 puts the paperwork to be signed and completed in a folder, but the doctor never seems to do it and we all know that. Not sure if any audits are being done but we try. b) The facility failed to ensure residents admitted without a pressure ulcer, but who were identified to be at risk for the development of pressure ulcers, rece… | 2019-10-01 |
| 4498 | 4498 | LEWISBURG CENTER | 515144 | 979 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2016-10-13 | 166 | D | 1 | 0 | HHR811 | > Based on staff interview, resident interview and medical record review, the facilty failed to ensure resident grievances were resolved for one (1) of eight (8) residents who had expressed concern with loud noises in the facility. A resident had expressed concern the roommate would play the television too loud at times which disturbed her. There was no evidence the staff had followed up and resolved this issue. This failed practice had the potential to affect a limited number of people. Resident identifier: #12. Census: 80. Findings include: a) Resident #12 (re: #73 roommate #73) A review of concern files revealed resident #12 expressed concern the roommate played the television too loud at times which disturbed her. The concern form, dated 09/13/16, said the roommate's (Resident #73) television was too loud. The concern form further stated the resolution to obtain ear phones for the roommate to use with her TV by 09/21/16 . Interview with resident #12, on 10/12/16 at 9:45 a.m., revealed she was under the impression the facility was going to get the roommate ear phones back in (MONTH) (2016), but they have not been purchased for the resident's use. Interview with the administrator and social worker, on 10/12/16 at 1:45 p.m., verified they had not obtained any type of headphone device for the roommate as yet. They had checked at several locations for ear phones but it was still not decided where to get them and who would pay to get them, the facility or the individual. On 10/16/16 at 2:00 p.m., the administrator after discussion with the surveyor, instructed the social worker to speak with Resident #73 about the headphones immediately. The social worker returned later that day and said at this time the resident did not wish to get them. The social worker said in September, Resident #73 had been agreeable to purchase and use headphones, but now had changed her mind. The facility staff had not followed up with either resident to ultimately get the issue resolved after it had been expressed about a month ago. | 2019-10-01 |
| 4499 | 4499 | LEWISBURG CENTER | 515144 | 979 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2016-10-13 | 309 | D | 1 | 0 | HHR811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, and record review, the facility failed to follow physician's orders for two (2) residents who did not receive medication according to their physician orders. Resident #17 and #36 were to receive [MEDICATION NAME] 15 milligram (mg) in the evening of 10/11/16, and medication count revealed the medication was not administered as prescribed. Resident identifiers: #17 and #36. Facility census 80. Findings include: a) Resident #17 Observation of the medication cart on the 200 hallway, on 10/12/16 at 8:20 a.m., with LPN #83 found one (1) medication packet with resident #17's name on the packet. The medication stated, [MEDICATION NAME] 15 mg for Tuesday 10/11/16 evening. Surveyor and LPN #83, at that time, counted the medication in the cart for Resident #17. No other medication packets were found for this resident as not administered. Review of the Medication Administration Record [REDACTED]. Review of the emergency and narcotic box sheet with LPN #83 revealed there were no [MEDICATION NAME] signed out of the emergency or narcotic box for Tuesday evening for resident #17. LPN #83 was asked why is there one (1) [MEDICATION NAME] 15 mg for Tuesday evening with the date of 10/11/16 on the packet remaining in the medication cart for Resident #17, and LPN #83 replied, The medication [MEDICATION NAME] was not given on Tuesday evening that is why the medication is still in the cart. A review of the physician order found Resident #17 started on [MEDICATION NAME] 15 mg by mouth in the evening for appetite on 10/04/16. A review of Resident #17's pharmacy delivery sheets found the pharmacy delivered seven (7) [MEDICATION NAME] 15 mg to the facility on [DATE]. The MAR indicated [REDACTED]. Further review revealed the pharmacy delivered one (1) [MEDICATION NAME] for Resident #17 on 10/11/16, in which this dose should have been given on 10/11/16. b) Resident #36 Observation of the medication cart on the 200 hallway, on 10/… | 2019-10-01 |
| 4500 | 4500 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2016-09-19 | 279 | D | 0 | 1 | 33R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop an initial care plan based on a resident's status at the time of admission. One (1) of three (3) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS) for the care areas of pressure ulcers was affected. The care plan for Resident #141 did not included interventions prevent further breakdown of the resident's boggy heels. Resident identifier: #141. Facility census: 102. Findings include: a) Resident #141 On 09/15/2016 at 8:59 a.m., medical record review revealed this resident was admitted on [DATE]. Her initial admitting nursing assessment dated [DATE], identified bilateral (right and left) boggy heels. Resident #141 developed an unstageable pressure ulcer with the appearance of a black blood blister identified on both the right heel and left heel on 06/22/16. The right heel measurements were 3 centimeters (cm) by (x) 3 cm and the left heel measured 1.5 cm x 2 cm. The care plan revealed no individualized measurable goals or established interventions to meet the immediate needs of the resident at the time of admission for the identified boggy heels. The care plan lacked any interventions for the prevention of pressure ulcers for this resident who was identified to be at risk for the development of pressure due to already having a deep tissue injury (DTI) to her coccyx and boggy heels on admission. During an interview with Licensed Practical Nurse (LPN) #29 on 09/19/16 at 10:40 a.m. she stated, I would hope that the intervention of elevating her heels would be on the initial admission care plan since she was admitted with boggy heels. After reviewing the initial admission care plan she agreed there were no interventions and/or preventative interventions in place to prevent the development of pressure ulcers to the resident's heels. | 2019-10-01 |
| 4501 | 4501 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2016-09-19 | 314 | G | 0 | 1 | 33R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of information from the National Pressure Ulcer Advisory Panel (NPUAP), review of information from Wound Educators, and staff interview, the facility failed to ensure Resident #141 who entered the nursing home with a deep tissue injury (DTI) to her coccyx and intact boggy heels. The facility failed to ensure the resident received care and services to promote healing of existing pressure areas and to prevent the development of new, or worsening of existing pressure sores, unless unavoidable. The facility failed to implement any preventative measures for Resident #141, until she developed pressure sores on her right and left heels, which were identified as unstageable black blood blisters when discovered. The resident's pressure ulcers could not be determined to be unavoidable due to the facility's failure to provide appropriate and timely interventions. The right heel wound required debridement and became infected, necessitating treatment with antibiotics. The facility's failure to provide needed care and services to Resident #141 resulted in actual harm to the resident. This practice was found for one (1) of three (3) sample residents reviewed for the care area of pressure ulcers during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #141. Facility Census: 102. Findings include: a) Resident #141 Review of the resident's medical record on 09/15/16 at 8:59 a.m., revealed this [AGE] year-old, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Her initial admitting nursing assessment, dated 06/17/16, identified a deep tissue injury (DTI) to her coccyx and bilateral (right and left) boggy heels. Resident #141 developed in-house unstageable pressure ulcers with the appearance of a black blood blister identified on both the right heel and left heel on 06/22/16. The right heel measurements were 3 centimeters (cm) by (x) 3 cm and the left heel measured 1.5 cm x 2 cm. The medical record was … | 2019-10-01 |
| 4502 | 4502 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2016-09-19 | 323 | E | 0 | 1 | 33R911 | Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as is possible by failing to adequately secure a clean utility room in the main hallway on B wing. The room contained various resident personal care items and the hallway was utilized by residents as a main thoroughfare, accessing the main dining room, lobby sitting area and other areas throughout the facility. This had the potential to affect more than an isolated number of residents. Facility census: 102. Findings include: a) On 09/13/16 at 10:43 a.m., a random observation during the initial tour of the facility found an unsecured door with a push button lock. The room contained various resident personal care items which included: -- Numerous bottles of mouthwash with precautions on the labels stating, Keep out of reach of children. In case of accidental ingestion, seek professional assistance or contact poison control. -- Two (2) boxes Efferdent tablets (used as a cleanser to soak dentures) with precautions on the package stating, Keep out of reach of children. case of accidental ingestion, seek professional assistance or contact poison control. -- Numerous bottles of pump spray antiperspirant deodorant with precautions on the label written in bold letters, EXTERNAL USE ONLY KEEP OUT OF REACH OF CHILDREN. At 10:45 a.m. on 09/13/16 Licensed Practical Nurse (LPN) #137 verified the door was open and stated, No it is supposed to be locked at all times to prevent resident access to all the things in there. We do have some confused residents and also some residents who wander, so it would not be safe to have the door unlocked. | 2019-10-01 |
| 4503 | 4503 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2016-09-19 | 372 | F | 0 | 1 | 33R911 | Based on observation and staff interviews, the facility failed to ensure two (2) of two (2) trash dumpsters remained closed and trash was properly contained within the dumpsters. This had the potential to affect all residents. Facility census: 102. Findings include: During the initial tour of the kitchen on 09/13/16 at 10:55 a.m., both the regular trash dumpster and cardboard dumpster lids were open. Cardboard trash, egg shells, and plastic bags were on the ground around the dumpsters. Flies were noted around the dumpsters and an empty animal trap was found behind the dumpsters. Dietary Consultant (DC) #112, on 09/13/16 at 10:55 a.m., closed the cardboard dumpster, but was unable to close the trash dumpster. DC #112 stated the dumpsters should be closed at all times. DC #112 stated she would have maintenance or housekeeping clean up the trash and close the dumpster. DC #112 stated the facility had a problem with stray cats being dropped off at the facility as the reason for the animal trap. | 2019-10-01 |
| 4504 | 4504 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2016-09-19 | 431 | E | 0 | 1 | 33R911 | Based on observation, staff interview, review of the facility policy and procedure for medication storage, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure a multi-dose vial of tuberculin solution was properly labeled. This practice had the potential to affect more than a limited number of residents. Facility census: 102. Findings include: a) On 09/14/16 at 9:15 a.m. accompanied by Licensed Practical Nurse (LPN) #66, an observation of the A wing medication room refrigerator labeled Vaccines discovered an open multiple dose vial of tuberculin (TB) solution. The vial was not labeled to indicate when it was opened or when it should be discarded. LPN #66 verified the open multiple dose vial was not labeled with the date of opening. She stated, Any vial is to have the date it was opened and I will notify my Director of Nursing (DON). LPN #66 proceeded to discard the TB solution vial in the sharps container. A review of the facility's policy and procedure for medication storage on 09/14/16 at 11:20 a.m. found it included the following: -- 5.Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened Review of the CDC's recommendations for multi-dose vials includes: Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopoeia (USP) General Chapter 797 (16 ) recommends the following for multi-dose vials of Sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days | 2019-10-01 |
| 4505 | 4505 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2016-09-19 | 441 | E | 0 | 1 | 33R911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and the facility's hand hygiene and isolation policy and procedures, the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Licensed Practical Nurse (LPN) #98 failed to maintain contact isolation precautions for Resident #44. LPN #23 failed to perform hand hygiene after giving medications for two (2) residents during medication administration. An uncovered urine collection bag and tubing were observed lying on the bare floor(Resident #24). This practice has the potential to more than a limited number of residents. Facility census: 102. Findings include: a) Resident #44 During a random observation on 09/13/16 at 3:29 p.m., Licensed Practical Nurse (LPN) #98 entered Resident #44's room and did not wear a gown or gloves. LPN #98 moved Resident #44 in a reclined gerichair to near her bed, placed a blanket on the resident and moved the resident's bed while touching the side rails. A stop sign was present on the resident's room door. An isolation cart containing gloves, masks, and gowns was present outside the resident's room. LPN #98 stated on leaving the room, I don't think the resident is still on isolation. During an interview on 09/13/16 at 4:14 p.m., LPN #137 confirmed Resident #44 remained in contact isolation precautions due to Clostridium difficile infection. During an interview on 09/14/16 at 9:00 am, Director of Nursing #140 confirmed Resident #44 had been in isolation until 09/14/16. A physician order [REDACTED]. DON provided copy of the 09/14/16 physician's orders [REDACTED]. Clinical record review, conducted on 09/14/16 at 10:25 am, revealed Resident #44 was readmitted from the hospital on [DATE] with a 09/08/16 physician order [REDACTED]. Resident #44's 08/13/16 significant change minimum data set assessment indicated the resident was incont… | 2019-10-01 |
| 4506 | 4506 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2016-09-19 | 468 | F | 0 | 1 | 33R911 | Based on observations and staff interview, the facility failed to ensure the handrails maintain in the corridors of A wing and B wing were firmly secured. Multiple handrails in the corridors utilized by residents in the main thoroughfares were not firmly secured to the walls. This had a potential to affect more than an isolated number of residents residing in the facility. Facility census: 102. Findings include: a) On 09/14/16 at 1:35 p.m., a random observation of a resident leaving the activity room on A wing found when the resident used the handrail in the hallway as support for locomotion, it was loose from the wall. At 2:15 p.m. until 2:30 p.m. on 09/14/16, accompanied by Maintenance Supervisor #2, a tour of the facility was conducted. At the conclusion of the tour, he agreed the corridor handrails were loose and not attached securely to the wall having the tendency to give way when used by the residents. He stated, The handrails will be secured to the walls as soon as possible, so they are stable when the residents use them. 1. A-wing's corridor handrails was loose and not secured to the walls: -- between the two (2) doors to the kitchen. -- between the resident activity room and the fire door. -- between rooms #203 and #205. -- between rooms #206 to #208. -- between the clean linen room and the storage room. -- by the nutrition room. -- between rooms #233 and #235. -- between rooms #235 and #237. -- between room #237 and #239. -- between the corner of the hallway and medication storage room. -- between the medication storage room and room #220. -- between rooms #222 and #224. -- between room #225 and #227. -- between room #226 and #228. 2. B-wing's corridor handrails was loose and not secured to the wall: -- outside of the Director of Nursing office. -- between the copy room and the main dining room. -- between the fire door to room #301. -- between rooms #301 and #303. -- between rooms #306 and #308. -- between the left hallway corner and the fire door. -- between the nutrition room and room #330. -- betwe… | 2019-10-01 |
| 4507 | 4507 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 166 | D | 0 | 1 | YR5K11 | Based on record review, family interview, resident interview, staff interview, and review of the facility's grievance policy, the facility failed to make prompt efforts to resolve a grievance concerning dentures for one (1) of three (3) residents reviewed for the care area of dental status and services. Resident identifier: #33. Facility census: 45. Findings include:a) Resident #33 During the Stage I interview with Resident #33 on 11/09/15 at 3:41 p.m., she stated, Somebody took my teeth. Doctor said next time he sees me, he would give me new teeth, can't imagine why anyone would take them. A review of Resident #33's inventory of personal effects on 11/11/15 at 9:00 a.m., revealed the resident had an upper denture plate, and a lower partial denture. On 11/11/15 at 9:05 a.m., a review of the nurse's documentation for Resident #33's quarterly minimum data set (MDS), revealed the resident's oral cavity was observed on 10/31/15 at 8:38 a.m. by Registered Nurse (RN) #88. RN #88's assessment revealed Resident #33 had no natural teeth or tooth fragment(s) (edentulous). The oral cavity assessment stated, The resident lost her dentures, family aware and will replace. Under dentures the section was marked resident does not have dentures. A progress note, dated 08/26/15, written by Licensed Practical Nurse (LPN) #31 on 11/11/2015 at 9:10 a.m., stated, Resident complains of dental pain at this time. Also her dentures are missing at this time. In an interview with Social Worker #34 on 11/11/15 at 10:55 a.m., Social Worker #34 was asked whether she was informed by the staff that Resident #33's upper denture plate and her lower partial were missing. She stated she was not informed by the staff. The social worker said she had a telephone log that indicated the resident's daughter left a message on 09/08/15 concerning Resident #33's missing her upper denture and lower partial. Social Worker #34 said when she called the resident's daughter back the next day, the daughter told the SW she had visited, and she thought someone had thr… | 2019-10-01 |
| 4508 | 4508 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 241 | E | 0 | 1 | YR5K11 | Based on observation, staff interview, and policy review, the facility failed to provide care in a manner and environment which maintained each resident's dignity during the dining process for fourteen (14) of fourteen (14) residents in the restorative dining room. Staff stood while assisting residents to eat and/or did not interact with residents while assisting them. Resident identifiers: #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. Facility census: 45. Findings include: a) Residents #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. During an observation of the lunch meal, from 11:15 a.m. to 12:00 p.m. on 11/09/15, the Speech Language Pathologist (SLP) set up the tray for Resident #35, and assisted Residents #23 and #22. The SLP did not attempt any social interaction with these residents. Nurse Aide (NA) #12 assisted Resident #12, NA #72 assisted Resident #84, and NA #80 assisted Resident #59 with their meals. The nurse aides did not converse with the residents while feeding them. Additionally, staff did not converse with any of the fourteen (14) residents in a social manner. b) During a dining observation of the dinner meal on 11/09/15 from 5:30 p.m. through 6:30 p.m., Resident #19 told NA #30 he did not care for his vegetable. NA #30 did not acknowledge the resident ' s comment and continued to tell him what else was on his tray. NA #68 assisted Resident #10, feeding him a few bites of food. The NA stood while feeding the resident. Resident #10 had to raise his head, stretching his neck to reach the utensil. NA #66 also stood while feeding Resident #23. c) Upon request, Licensed Practical Nurse (LPN) #35 completed an observation during the evening meal on 11/09/15, and confirmed staff should not stand while assisting residents to eat. The LPN instructed the nurse aides to sit while feeding the residents. The NAs informed her no chairs were available in the dining room. d) An interview with the director of nursing (DON), on 11/09/15 at 6:30 p.m., confirmed sta… | 2019-10-01 |
| 4509 | 4509 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 253 | E | 0 | 1 | YR5K11 | Based on observation and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior in the main dining room. Fifteen (15) of sixteen (16) chairs in the main dining room had parts of the chair covering missing exposing the wood and/or foam of the chairs. Facility census: 45. Findings include:a) Main dining room chairsObservation of the main dining room chairs with Administrator #46 and Maintenance Staff #48 on 11/11/15 4:15 p.m., found five (5) chairs with missing coverings. The missing coverings left the wood and/or foam on the back of the chairs exposed. The foam of the armrests of these chairs was also exposed. Ten (10) of the chair backs had missing coverings and wood and/or foam exposed. Three (3) of these chairs had a cracked seat where the foam was exposed. During this observation, Maintenance Staff #46 and Maintenance Staff #48 confirmed the chairs were in poor condition and needed replaced. | 2019-10-01 |
| 4510 | 4510 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 272 | D | 0 | 1 | YR5K11 | Based on observation, medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of twenty-four (24) residents reviewed. Resident #5 was inaccurately coded as edentulous. Resident identifier: #5. Facility census: 45. Findings include: a) Resident #5 A Stage 1 observation, on 11/09/15 at 3:24 p.m., revealed Resident #5 had gaps between his teeth with likely missing teeth. On 11/11/15 at 3:00 p.m., review of the most recent comprehensive admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/27/15, found a response of Yes for Section L, Item L0200B No natural teeth or tooth fragment(s) edentulous. Section L, Item L0200D - Obvious or likely cavity or broken natural teeth was not checked, indicating a response of No. Licensed Practical Nurse (LPN) #24, interviewed on 11/11/15 at 3:10 p.m., related the resident had his own teeth and said, I hope I have that many teeth when I am that old. MDS Coordinator #88, interviewed on 11/11/15 at 5:23 p.m., related she had coded the MDS Section L, Item L0200B as Yes, because the resident had likely cavities and tooth fragments, and indicated it was the correct response. At 5:31 p.m. on 11/11/15, a request was made for Section L of the Resident Assessment Instrument (RAI) Manual utilized for completion of the MDS. During a follow-up interview, at 6:08 p.m., MDS Coordinator #88 related the MDS was coded incorrectly. She confirmed the resident had teeth, and Section L, Item L0200 indicated the resident was edentulous (no natural teeth present). | 2019-10-01 |
| 4511 | 4511 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 278 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of Resident #6's quarterly minimum data set (MDS) assessment accurately assessed the status of one (1) of twenty-four (24) residents in Stage 2 of the Quality Indicator Survey (QIS). The assessment did not accurately reflect the resident's [MEDICAL CONDITION] disorder. Resident identifier: #6. Facility census: 45. Findings include: a) Resident #6 A review of the medical record for Resident #6 on 11/12/15 at 11:15 a.m., revealed the quarterly MDS assessment with an assessment reference date (ARD of 10/27/15, did not accurately reflect a [DIAGNOSES REDACTED]. During further review, it was noted the physician's orders [REDACTED].#6 had an order for [REDACTED]. An interview on 11/12/15 at 12:45 p.m., with the MDS coordinator verified Section I - Active Diagnoses, Item I3400 did not include the [DIAGNOSES REDACTED].#6. | 2019-10-01 |
| 4512 | 4512 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 323 | E | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible. The mechanical room door at the front of the 100 hallway was unlocked. This practice had the potential to affect more than a limited number of residents. Facility census: 45. Findings include: a) During an initial tour, on 11/09/15 at 11:16 a.m., when checking doors, the mechanical room door opened when the knob was turned. Upon inquiry, Housekeeper #53, who was in the area, related the door should have been locked. The housekeeper said he would find the maintenance man and let him know. Another observation, at 1:45 p.m. on 11/09/15, found the mechanical room unlocked. No one was in the area. Again at 3:30 p.m. and 5:25 p.m., the door was unlocked. At 5:25 p.m. on 11/09/15, the director of nursing (DON) related the door should have been locked. She said the door knob had been changed and should work properly. She checked the lock and said the door could be locked from the inside. The room contained an air compressor, a hot water heater, sprinkler system, electrical breaker boxes, hot water tank, a bed frame positioned on its side with a mattress floor, and telephone wires. An interview with Licensed Practical Nurse (LPN) #35 and LPN #24, on 11/09/15 at 5:41 p.m., revealed staff rarely entered the mechanical room, and it was kept locked. Upon inquiry, LPNs #35 and #24 related four (4) residents had a history of [REDACTED]. The residents were Residents #26, #12, #5 and #22. An interview and observation with Maintenance Director #48 and the administrator, on 11/11/14 at 4:31 p.m., again revealed the door was unlocked. He confirmed the room contained two (2) unlocked generators with multiple wires in each, six (6) electrical boxes, a sprinkler system, gas lines, and telephone lines. Additionally, a cart with an unlocked tool box was present in the room. The maintenance director related the door knob was jus… | 2019-10-01 |
| 4513 | 4513 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 332 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and, review of Omnicell (an automated medication dispensing system) usage reports, and staff interview, the facility failed to ensure a medication error rate of less than five percent (5%). The medication error rate was 12.5 percent with four (4) errors in thirty-two (32) opportunities for error. A resident received the wrong dosage of aspirin, two (2) doses of medication would have been missed if not for surveyor intervention, and one (3) dose of medication was omitted. Resident identifiers: #50 and #88. Facility census: 45. Findings include: a) Resident #50 During a medication administration observation, on 11/11/15 at 8:14 a.m., Licensed Practical Nurse (LPN) #42 administered the following medications to Resident #50: [MEDICATION NAME] 25 milligrams (mg) orally (PO), Aspirin 81 mg PO, [MEDICATION NAME] 100 mg PO, [MEDICATION NAME] 0.6 mg PO, [MEDICATION NAME] 25 mg PO, and [MEDICATION NAME] 5 mg PO. Review of the medical record, at 10:00 a.m. on 11/11/15, revealed an order for [REDACTED].>A follow-up interview with LPN #42 at 10:30 a.m. on 11/11/15, confirmed [MEDICATION NAME] should have been administered with the medication administration at 8:14 a.m. The LPN reviewed the medications in the medication cart and related none was available to give. Upon inquiry, LPN #42 related [MEDICATION NAME] was available in the Omnicell emergency kit, and acknowledged she could have administered the dose. Upon inquiry regarding administration of the multivitamin, LPN #42 related she did not realize she had not administered the medication. Review of the Omnicell usage report, at 12:30 p.m., on 11/11/15 revealed LPN #42 removed four (4) [MEDICATION NAME] 5 mg tablets from the Omnicell machine at 11:45 a.m. for administration to Resident #88. b) Resident #88 During another medication administration pass with Licensed Practical Nurse (LPN) #42, on 11/11/15 at 8:20 a.m., the LPN administered Aspirin 81 milligrams… | 2019-10-01 |
| 4514 | 4514 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 334 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on medical record review, staff interview, review of the facility's pneumococcal vaccine (PV) policy, the facility failed to administer a PV to one (1) of five (5) residents reviewed under the mandatory facility task for infection control/immunization review. A PV was not administered after receiving a telephone verbal/consent from a resident's medical power of attorney (MPOA) upon admission to the facility. Resident identifier: #46. Facility census: 45. Findings include: a) Resident #46 Review of the resident's medical record, on 11/12/15 at 8:15 a.m., found the resident was admitted on [DATE]. The resident's consent for the flu (influenza) vaccine, pneumonia vaccine, and [MEDICATION NAME] (TB) skin testing noted a telephone verbal/consent with the date of 04/29/15. The consent was checked Yes, I give my permission for the [MEDICATION NAME] (pneumonia vaccine) (PV) if not previously taken. A review of Resident #46's [MEDICAL CONDITION] screen/influenza/ pneumonia vaccination record on 11/12/15 at 8:30 a.m. revealed the Resident #46 did not receive a PV. A review of the facility's PV policy, on 11/12/15 at 8:45 a.m., revealed prior to or upon admission, residents would be assessed for eligibility to receive the PV and when indicated they would be offered the vaccine within thirty (30) days of admission to the facility unless medically contraindicated or the resident had already been vaccinated. The assessment of pneumococcal vaccination status would be conducted within five (5) working days of the resident's admission if not conducted prior to admission. In an interview on 11/12/15 at 9:00 a.m., with Registered Nurse (RN) #16, the RN was asked if she received consent to administer a PV for Resident #46. The RN stated, No. The RN was then asked, When would you expect to administer the vaccine after you received permission to administer a PV if it has not previously given? The RN stated, She would give the vaccine within that week. The R… | 2019-10-01 |
| 4515 | 4515 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 356 | E | 0 | 1 | YR5K11 | Based on observation, review of the facility's staff tracking sheet, nursing schedule, staff interview, and the facility's posting of nurse staffing policy, the facility failed to accurately post the total number and the actual hours worked for the licensed practical nurses (LPNs) who were responsible for direct resident care per shift. This had the potential to affect more than a limited number of residents. Facility census: 45. Findings include: a) Staff tracking sheet Observation of the staff tracking sheet, on 11/09/15 at 11:45 a.m., found the facility had written on the staffing tracking sheet that two (2) LPNs were working the 6:00 a.m. to 6:00 p.m. shift, and the actual combined total hours for these LPNs was twenty-four (24). Observation of the LPNs present on 11/09/15 at 11:46 a.m., revealed LPN #78, LPN #24, LPN #89, and LPN #35 were directly responsible for the residents' care. The DON reviewed the staff tracking sheet on 11/09/15 at 11:50 a.m. When asked whether the number of LPNs was accurate, she stated, No. She marked through the number two (2) under LPNs, and wrote a three (3) in the section. She revealed the LPNs combined total hours were 36. A review of the facility's LPN schedule on 11/09/15 at 11:55 a.m., found for the date of 11/09/15, LPN #78, LPN #24, LPN #89, and LPN #35 were scheduled to work from six 6:00 a.m. to 6:00 p.m. On 11/09/15 at 11:56 a.m., LPN #35 and LPN #78 confirmed LPNs #78, #24, #89, and #35 were working. These two (2) LPNs stated, The staff tracking sheet is inaccurate, there are four (4) LPNs working. The DON on 11/11/15 at 6:00 p.m., confirmed the staff tracking sheet should have had four (4) LPNs, and the LPN's total hours were forty-eight (48), not twenty-four (24), or thirty-six (36). A review of the facility's nurse staffing policy, on 11/11/15 at 6:15 p.m. revealed the policy stated the following in regards to the nurse staff posting, 8.14.i.1. The current date; resident census; and the total number and the actual hours worked by the following categories of license… | 2019-10-01 |
| 4516 | 4516 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 366 | D | 0 | 1 | YR5K11 | Based on observation and staff interview, the facility did not offer substitutes of similar nutritive value to two (2) of fourteen (14) residents served in the restorative dining room, and for one (1) randomly observed resident. Resident identifiers: #19 and #46. Facility census: 45. Findings include: a) Resident #46 A random observation of the lunch meal, on 11/09/15 at 12:05 p.m., revealed Resident #46 in his room with his lunch tray on the over-bed table in front of him. The resident was not eating. Another observation at 12:12 p.m. again revealed uneaten food. Nurse Aide (NA) #72 entered the room at 12:14 p.m. and asked Resident #46 if he was going to eat. The resident replied, I don't like it. The NA encouraged him to take a bite and he refused. NA #72 then removed the milk from his tray, placed it on the over-bed table and said, At least drink your milk. NA #72 did not offer the resident a substitute meal. b) Resident #19 During an observation of the dinner meal, Resident #19 related to Nurse Aide (NA) #68 he did not like his vegetable and removed it from his plate. NA #68 did not offer the resident a substitute. c) An interview with the director of nursing (DON), on 11/11/15 at 1:14 p.m., revealed staff should have offered substitutes of similar nutritive value when a resident refused a food item and/or meal. The DON further added, the facility always had items on hand such as soup and sandwiches. | 2019-10-01 |
| 4517 | 4517 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 371 | E | 0 | 1 | YR5K11 | Based on observation and staff interview, it was determined the facility had not ensured foods were stored, distributed and served under sanitary conditions. The kitchen staff did not store dishware and serving utensils in a manner that utilized proper sanitation techniques. In addition, the Speech Language Pathologist and nurse aides did not serve food to residents under sanitary conditions. Facility census: 45. Findings include: a) During the initial dietary tour on 11/09/15, the following items were not stored in a sanitary manner: 1. Plastic cups were stored wet in a wooden cabinet. This procedure allowed the potential for bacteria to grow in a moist environment. 2. Serving utensils were stored in drawers in a haphazard manner, which could lead to staff touching the serving portion of the utensil with their bare hands when retrieving the handle of a device. 3. Dishware had some chipped areas on the edges. This created the potential for improper cleaning and sanitization. These items were discussed with the dietary manager on 11/11/15 at midmorning. She confirmed that she was trained to determine these were sanitation issued. b) Residents #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. During an observation of the lunch meal, from 11:15 a.m. to 12:00 p.m. on 11/09/15, Speech Language Pathologist (SLP) #91 set up the tray for Resident #35, touching the resident's bread with bare hands. The resident was not eating and the therapist returned to the table and said, I'm going to fold your bread in half, okay? The SLP then folded the bread with bare hands. Additionally, SLP #91 removed the paper from Resident #35's straw and held the area from which the resident drank in the palm of her hand. SLP #91 assisted Resident #23, folding her bread with bare hands and touched the food of Resident #22. Nurse Aide (NA) #12 removed the a of bread from the plastic sheath for Resident #67, touching it with her bare hands. She also peeled a banana for Resident #10, and then grasped the edible part of the … | 2019-10-01 |
| 4518 | 4518 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 441 | D | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, and review of the Centers for Disease Control and Prevention Guidelines (CDC), the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection, to the extent possible. The facility did not ensure Personal Protective Equipment (PPE) was utilized when indicated, and/or did not ensure staff employed proper handwashing technique when performing a wound dressing change. These practices affected three (3) residents, but had the potential to affect more than a limited number of residents. Resident identifiers: #88, #50, and #5. Facility census: 45. Findings include: a) Resident #88 During an an Accucheck (fingerstick blood sugar), on 11/11/15 at 8:30 a.m., Licensed Practical Nurse (LPN) #42 entered the room of Resident #88 to complete the test. Without donning gloves, the nurse proceeded to complete the fingerstick blood sugar. After obtaining the blood sugar, the LPN wiped the excess blood from the resident's finger, still without donning gloves. b) Residents #88 and #50 When pouring medications for Resident #50 on 11/11/15 at 8:14 a.m., Licensed Practical Nurse (LPN) #42 placed each medication in her bare hand before placing it in the medication cup for administration. Medications included: [MEDICATION NAME] 25 milligram (mg) PO (by mouth), Aspirin 81 mg PO, [MEDICATION NAME] 100 mg PO, [MEDICATION NAME] 0.6 mg PO, [MEDICATION NAME] 25 mg PO, and [MEDICATION NAME] 5 mg PO. When completing the medication administration pass, on 11/11/15 at 8:20 a.m., LPN #42 poured Aspirin 81 mg, [MEDICATION NAME] 1 mg po, [MEDICATION NAME] 20 mg po, and [MEDICATION NAME] 2.5 mg po. The nurse placed each medication in her bare hand, and then dropped it into the medication cup. The medication was then administered to Resident #88. Aspirin, and [MEDICATION NAME] and were obtained from a bottle of medication … | 2019-10-01 |
| 4519 | 4519 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 464 | E | 0 | 1 | YR5K11 | Based on observation and staff interview, the facility did not furnish sufficient space to accommodate dining activities in the restorative dining room for fourteen (14) of fourteen (14) residents observed during the lunch meal. Resident identifiers: #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. Facility census: 45. Findings include: a) Resident #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. A lunch observation, on 11/09/15 from 11:15 a.m. until 12:00 p.m., revealed these fourteen (14) residents ate in the restorative dining room. Resident #59 was the last resident assisted into the dining room. All other residents had been served and were eating. Resident #59 was seated in a specialized recliner chair. Nurse Aide (NA) #30 attempted to position the resident at the far side of the first table to the left of the door upon entry of the dining room. The tables were positioned close together and residents were seated at each table. The NA was unable to position the chair due to the closeness of tables. After several attempts, and interrupting residents' dining, NA #30 removed Resident #59 from the dining room. She turned the chair around and entered again, once more disrupting residents' meals while positioning the resident at the table. An interview with the director of nursing (DON) on 11/11/5 at 1:14 p.m. confirmed the dining area was crowded. The DON related the facility was aware of the situation. Upon inquiry, the DON related the dining room had not been addressed in quality assurance, nor had an action plan had been developed to address the situation. | 2019-10-01 |
| 4520 | 4520 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2015-11-12 | 502 | E | 0 | 1 | YR5K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain a laboratory test for one (1) of five (5) residents reviewed for unnecessary medications. A fecal occult stool test was not obtained for Resident #48. Resident identifier: #48. Facility census: 45. Findings include: a) Resident #48 A medical record review, on 11/11/15 at 9:31 a.m., revealed Resident #48 received celecoxib ([MEDICATION NAME]) 100 milligrams (mg) orally twice daily. physician's orders [REDACTED]. Further review, also revealed an order dated 05/23/15, for a Fecal Occult Stool. No evidence was present in the medical record to indicate the test had ever been completed. An interview with Licensed Practical Nurse (LPN) #25 on 11/11/15 at 2:50 p.m. revealed the facility had a book which contained laboratory (lab) tests. The LPN related she and Registered Nurse (RN) #73 developed a system to ensure all laboratory tests were completed as ordered. Upon inquiry, LPN #25 related Resident #48 would not defecate in a hat, and would throw it away, if placed on the toilet seat. An interview with Resident #48, on 11/12/15 at 10:24 a.m., revealed the resident took herself to the bathroom, and said she would let staff know if she had a bowel movement. The director of nursing (DON), interviewed on 11/12/15 at 10:43 a.m., revealed if a resident was continent, staff would place a hat in the commode to collect stool. She agreed resident #48 would throw away the hat. Progress notes, reviewed on 11/12/15 at 10:44 p.m., revealed no evidence the resident had refused to comply with the fecal occult stool test. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 05/29/15, noted a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Additionally, Section [NAME] indicated the resident had exhibited no behaviors. Review of the care plan, on 11/12/15 at 11:00 a.m., revealed a focus relate… | 2019-10-01 |
| 4521 | 4521 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 242 | E | 0 | 1 | 8SXB11 | Based on observation, staff interview, family interview, and medical record review, the facility failed to accommodate a resident's choice concerning activities significant to the individual for one (1) of one (1) sample residents. Resident #51 was not afforded the opportunity to participate in religious activities to the extent possible. Facility census: 79. Findings include: a) Resident #51 During stage one observations of the Quality Indicator Survey, Resident #51 did not attend out of room activities. Observations on 06/28/16 at 9:17 a.m. and 12:30 p.m., revealed the resident in bed. Family Member (FM) #1, interviewed at 4:20 p.m., said the resident did not get out of bed until 2:00 p.m. During observations on 06/29/16 at 10:26 a.m., 11:23 a.m. and 11:52 a.m., Resident #51 was still in bed. On 07/05/16 at 12:15 p.m., observation revealed Resident #51 in bed. A family interview with FM #1 on 06/28/16 at 4:23 p.m., revealed Resident #51 hardly ever went to church, and related it was probably because she was not aware. FM #1 related the resident had enjoyed church services in the past. Nurse Aide (NA) #44, interviewed on 06/29/16 at 1:22 p.m., said Resident #51 understood some things and would follow directions such as to open her mouth if brushing teeth. The NA related the resident did not usually attend activities. Upon inquiry regarding religious activities, the NA related she would sometimes go to church and listen to them sing. The nurse aide said the facility had services on Sundays. NA #44 voiced residents would be assisted to activities if requested. Upon inquiry as to how it was known who should attend which activity, the NA related she did not know who should attend. The resident was seated in the rock-n-go wheelchair and NA #44 said Resident #51 would sometimes propel herself. Nurse Aide (NA) #52, interviewed on 06/30/16 at 8:14 a.m., voiced Resident #51 was sometimes up early and sometimes slept in late. The nurse aide related the resident did not usually attend activities, but the daughter would vis… | 2019-10-01 |
| 4522 | 4522 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 248 | D | 0 | 1 | 8SXB11 | Based on observation, staff interview, family interview, and medical record review, the facility failed to accommodate a resident's interests concerning activities for one (1) of one (1) sample residents. Resident #51 was not afforded the opportunity to participate in religious activities to the extent possible. Facility census: 79. Findings include: a) Resident #51 During stage one observations of the Quality Indicator Survey, Resident #51 did not attend out of room activities. Observations on 06/28/16 at 9:17 a.m. and 12:30 p.m., revealed the resident in bed. Family Member (FM) #1, interviewed at 4:20 p.m., said the resident did not get out of bed until 2:00 p.m. During observations on 06/29/16 at 10:26 a.m., 11:23 a.m. and 11:52 a.m., Resident #51 was still in bed. On 07/05/16 at 12:15 p.m., observation revealed Resident #51 in bed. A family interview with FM #1 on 06/28/16 at 4:23 p.m., revealed Resident #51 hardly ever went to church, and related it was probably because she was not aware. FM #1 related the resident had enjoyed church services in the past. Nurse Aide (NA) #44, interviewed on 06/29/16 at 1:22 p.m., said Resident #51 understood some things and would follow directions such as to open her mouth if brushing teeth. The NA related the resident did not usually attend activities. Upon inquiry regarding religious activities, the NA related she would sometimes go to church and listen to them sing. The nurse aide said the facility had services on Sundays. NA #44 voiced residents would be assisted to activities if requested. Upon inquiry as to how it was known who should attend which activity, the NA related she did not know who should attend. The resident was seated in the rock-n-go wheelchair and NA #44 said Resident #51 would sometimes propel herself. Nurse Aide (NA) #52, interviewed on 06/30/16 at 8:14 a.m., voiced Resident #51 was sometimes up early and sometimes slept in late. The nurse aide related the resident did not usually attend activities, but the daughter would visit and take Resident #51 ou… | 2019-10-01 |
| 4523 | 4523 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 272 | D | 0 | 1 | 8SXB11 | Based on medical record review and staff interview, the facility failed to complete accurate comprehensive assessments related to activities, showers, and wounds. This practice affected two (2) of fifteen (15) stage 2 sample residents. Resident identifiers: Resident #51 and Resident #127. Facility census: 79. Findings include: a) Resident #51 A family member (FM) #1 interview on 06/28/16 at 4:23 p.m., revealed Resident #51 hardly ever went to church, and related it was probably because she was not aware. FM #1 related the resident had enjoyed church services in the past. The family member said the resident enjoyed the outdoors, and would sometimes propel herself in the rock-n-go wheelchair. During the interview, the family member voiced the preference for showers as the method of bathing. Nurse Aide (NA) #44, interviewed on 06/29/16 at 1:22 p.m., said Resident #51 understood some things and would follow directions such as to open her mouth if brushing teeth. The NA related the resident did not usually attend activities. Upon inquiry regarding religious activities, the NA related she would sometimes go to church and listen to them sing. The nurse aide said the facility had services on Sundays. NA #44 voiced residents would be assisted to activities if transport was requested. Upon inquiry as to how it was known who should attend which activity, the NA related she did not know who should attend. The resident was seated in the rock-n-go wheelchair and NA #44 said Resident #51 would sometimes propel herself. The Activity Supervisor (AS) interviewed on 07/05/16 at 12:19 p.m., said staff got residents out of bed in the morning for care and staff assisted those residents to activities. With further inquiry, the AS voiced she did not provide a list of residents targeted for an activity. The electronic medical record, reviewed on 07/05/16 at 1:17 p.m., revealed an annual minimum data set (MDS) with an assessment reference date (ARD) of 06/20/16 which indicated Resident #51 preferred bed baths and sponge baths. Showers and… | 2019-10-01 |
| 4524 | 4524 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 278 | D | 0 | 1 | 8SXB11 | Based on medical record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of Resident #119's quarterly Minimum Data Set (MDS) assessment completed the assessment accurately for the area of falls. Resident identifier: #119. Facility census: 79. Findings include: A review of Resident #119's medical record revealed the resident experienced falls on 04/01/16, 04/04/16, and 04/28/16. The quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/27/16, did not identify the resident experienced any falls since admission or the last assessment, whichever was more recent. On 07/06/16 at 10:47 a.m., the Director of Nursing agreed the quarterly assessment did not accurately reflect the resident's falls. On 07/06/16 at 11:45 a.m., Registered Nurse-Minimum Data Set Coordinator (RN-MDS) #97 stated the quarterly assessment concerning falls for Resident #119 was incorrect. | 2019-10-01 |
| 4525 | 4525 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 279 | D | 0 | 1 | 8SXB11 | Based on observation, resident interview, medical record review, and staff interview, the facility failed to develop a comprehensive care plan for one (1) of fifteen (15) Stage 2 sample residents. The facility did not develop a comprehensive care plan for a resident who leaned on the siderail. Facility census: 79. Resident identifier: Resident #98 Findings include: a) Resident #98 During an observation on 07/05/16 at 1:03 p.m., Resident #98 was leaning toward the left on the side rail. No support device was present. The resident related she was uncomfortable. Additionally, she was seated in a reclined position attempting to eat her lunch meal. Resident #98 voiced she preferred to sit up and eat, and she was unable to see her food very well and was uncomfortable. Upon request, Registered Nurse (RN) #101 completed an interview and observation with Resident #98 at 1:08 p.m. on 07/05/16. The resident expressed she preferred to eat sitting up, and said leaning on the siderail was uncomfortable. No padding or support device was present. The RN then informed the resident, We straighten you up, but you always lean back over that way. Do you want repositioned? Upon request, the RN visualized the residents arm against the side rail, which was pressing into Resident #98's arm. The nurse confirmed the resident should have a support device in place. Review of the medical record, on 07/05/16 at about 3:50 p.m., revealed no evidence a care plan had been devised to address Resident #98 leaning left and/or leaning into the siderail. A follow-up interview with the RN confirmed a care plan should have been developed to address positioning related to leaning. | 2019-10-01 |
| 4526 | 4526 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 280 | D | 0 | 1 | 8SXB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to revise the plan of care for one (1) of fifteen (15) Stage 2 sample residents. The care plan related to medication administration was not revised for a [MEDICAL TREATMENT] resident to ensure medications were administered as ordered. Resident #98 did not receive medications scheduled for 9:00 a.m. on days she received [MEDICAL TREATMENT]. Resident identifier: Resident #98. Facility census: 97. Findings include: a) Resident #98 A medical record review related to unnecessary medication, reviewed on 07/06/16 at 3:00 p.m., revealed Resident #98 received [MEDICAL TREATMENT] treatments on Monday, Wednesday and Friday weekly. The medication administration records (MAR), reviewed for the months of April, May, (MONTH) and (MONTH) (YEAR) indicated the resident did not receive medications scheduled for 6:00 a.m. and 9:00 a.m., which included acidophilus, [MEDICATION NAME] (for [MEDICAL CONDITION]), gabepentin (for [MEDICAL CONDITION]), [MEDICATION NAME] Solution (elevated blood sugar), [MEDICATION NAME] (for [MEDICAL CONDITION]), Rena-Vite tablet (for end stage [MEDICAL CONDITION]), Vitamin C for wound healing, and [MEDICATION NAME] (for [MEDICAL CONDITIONS]). b) The care plan addressed [MEDICAL TREATMENT] and medications, but did not address the omission of medication on [MEDICAL TREATMENT] days. c) During an interview with Physician #1, on 07/06/16 at 4:06 p.m., the doctor related she was not aware Resident #98 did not receive her morning medications on [MEDICAL TREATMENT] days. The physician said it was important for the resident to have the medications and immediately reviewed them with Registered Nurse (RN) #97, changing times of administration, with the exception of [MEDICATION NAME]. | 2019-10-01 |
| 4527 | 4527 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 282 | D | 0 | 1 | 8SXB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to implement the care plan for two (2) of fifteen (15) Stage 2 sample residents. Resident #51 was not afforded the opportunity to participated in an activity of significance to the extent possible and Resident #46's feet were not elevated to relieve pressure. Facility census: 79. Findings include: a) Resident #51 During Stage 1 observations of the Quality Indicator Survey, Resident #51 did not attend out of room activities. Observations on 06/28/16 at 9:17 a.m. and 12:30 p.m., revealed the resident in bed. Family Member (FM) #1, interviewed at 4:20 p.m., said the resident did not get out of bed until 2:00 p.m. During observations on 06/29/16 at 10:26 a.m., 11:23 a.m. and 11:52 a.m., Resident #51 was still in bed. On 07/05/16 at 12:15 p.m., observation revealed Resident #51 in bed. A family member (FM) #1 interview on 06/28/16 at 4:23 p.m., indicated Resident #51 hardly ever went to church, and related it was probably because she was not aware. FM #1 related the resident had enjoyed church services in the past. Nurse Aide (NA) #44, interviewed on 06/29/16 at 1:22 p.m., said Resident #51 understood some things and would follow directions such as to open her mouth if brushing teeth. The NA related the resident did not usually attend activities. Upon inquiry regarding religious activities, the NA related she would sometimes go to church and listen to them sing. The nurse aide said the facility had services on Sundays. NA #44 voiced residents would be assisted to activities if transport was requested. Upon inquiry as to how it was known who should attend which activity, the NA related she did not know who should attend. The resident was seated in the rock-n-go wheelchair and NA #44 said Resident #51 would sometimes propel herself. Nurse Aide (NA) #52, interviewed on 06/30/16 at 8:14 a.m., voiced Resident #51 was sometimes up early and sometimes slept in late. The… | 2019-10-01 |
| 4528 | 4528 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 309 | E | 0 | 1 | 8SXB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to provide the necessary care and services to obtain or maintain the highest practicable well-being for four (4) of fifteen (15) Stage 2 sampled residents. The facility did not follow physicians orders related to parameters for holding insulin administration for Resident #104. The facility did not assess the abdomens or bowel sounds of Residents #104 and #64, both of whom went greater than three (3) days without having a bowel movement. The facility did not follow physician's orders [REDACTED].#46's heels while in bed. The facility failed to promote a comfortable environment and positioning for Resident #98. Resident identifiers: #104, #64, #46, #98. Facility census: 79. Findings include: a) Resident #104 1) Insulin Administration Medical record review for Resident #104 on 06/30/16 at 9:00 a.m. found physician's orders [REDACTED]. The physician directed to hold the insulin, and not administer the insulin at noon or 5:00 p.m., when the blood sugar level was less than 150 deciliters per milliliter (dl/ml). Review of the Medication Administration Record [REDACTED] -- In (MONTH) (YEAR), he received five (5) units of [MEDICATION NAME]with either lunch or dinner eleven (11) times when the blood sugar was less than 150 dl/ml. This includes the following dates for the noon doses: 12/02/15, 12/04/15, 12/05/15, 12/06/15, 12/10/15, and 12/20/15. This includes the following dates for the 5:00 p.m. doses: 12/01/15, 12/15/15, and 12/16/15. This also includes the noon and 5:00 p.m. doses on 12/25/15. -- In (MONTH) (YEAR), he received five (5) units of [MEDICATION NAME]either at lunch or dinner eight (8) times when the blood sugar was less than 150 dl/ml. This includes the following dates for the noon doses: 01/01/16, 01/09/16, 01/12/16, adn 01/23/16. This includes the following dates for the 5:00 p.m. doses: 01/08/16, 01/10/16, 01/14/16, and 01/31/16. -… | 2019-10-01 |
| 4529 | 4529 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 329 | E | 0 | 1 | 8SXB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide indications for withholding medications, administering medications beyond paremeters, and clearly identify the the indications for use of medications with care delivered and/or ordered by diverse sources such as consultants/providers/suppliers for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifer: Resident #98. Facility Census: 79. c) Resident #98 A medical record review, on 06/28/16 at 2:27 p.m., revealed Resident #98 received [MEDICATION NAME] 3.5 milligrams (mg) orally at bedtime on Monday, Wednesday, and Friday for [MEDICAL CONDITION] and [MEDICATION NAME] 2.5 mg orally every Sunday, Tuesday, Thursday and Saturday for [MEDICAL CONDITION] Fibrillation (irregular heartbeat), and Humalog 100 units/milliliter (ml) subcutaneously per sliding scale coverage (ssc) before meals and at bedtime. Further review of the medical record, on 07/06/16 at 3:00 p.m., indicated Resident #98 also received [MEDICATION NAME] 125 micrograms (mcg) by mouth (po) one time a day for [MEDICAL CONDITION], [MEDICATION NAME] 25 mg (give one half tablet to equal 12.5 mg) twice daily for atheroosclerotic [MEDICAL CONDITION] with instructions to hold the medication if the systolic blood pressure (b/p) was less than 100, diastolic b/p was less than 65 or the pulse was less than 60 beats per minute (bpm); [MEDICATION NAME] 75 mg po daily in the morning for [MEDICAL CONDITION], and [MEDICATION NAME] for low blood pressure. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview with Registered Nurse (RN) #97, at 3:50 p.m. on 07/06/16, the RN reviewed the medical record and voiced it provided no indication as to why the resident did not receive 9:00 a.m. medications on [MEDICAL TREATMENT] days. Physician #1, interviewed on 07/06/16 at 4:06 p.m., said she was not aware Resident #98 was not receiving medications on [MEDICAL TREATMENT… | 2019-10-01 |
| 4530 | 4530 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 371 | F | 0 | 1 | 8SXB11 | Based on observation and staff interview the facility failed to store, distribute and serve food under sanitary conditions. The kitchen equipment was visibly soiled. This practice has the potential to effect all residents who are served food from the kitchen. Facility census: 79. Findings include: On 06/27/16 at 11:15 a.m., observation of the the facility's kitchen revealed the following visibly soiled areas on kitchen equipment, and doorways. -- Fingerprints on the clear top of the storage bins for sugar, flour and beans. -- Four (4) two (2) shelf carts were visibly soiled and waiting to be used by the kitchen staff. -- Interior of exit doors to enter into the dining area were visibly soiled. -- Three (3) large garbage cans were visibly soiled on the exterior. -- The wall and baseboard behind the large garbage cans were visibly soiled. -- A vent in the ice machine and a ceiling vent near the ice machine was observed with visible dust. On 07/06/16 at 2:45 p.m., the dietary services supervisor, stated the kitchen is deep cleaned about every two months and that he had staff off sick and as soon as he has a full staff the kitchen will be deep cleaned. | 2019-10-01 |
| 4531 | 4531 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 428 | E | 0 | 1 | 8SXB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to act upon a consultant pharmacist recommendation for three (3) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #81, #64, #98. Facility census: 78. Findings include: a) Resident #81 Review of medical records for Resident #81 on 07/06/16 revealed a consultant pharmacist communication to the physician of the resident being prescribed both Bentyl and [NAME]anechol. The pharmacist went on to state these two (2) medications work against each other. The only response from the nurse practitioner was continue. There was no rationale to continue the medications. b) Resident #64 Review of medical records for Resident #64, on 06/30/16, revealed a consultant pharmacist communication to the physician with directions on how to prescribe Midodrine and a recommendation to decrease an antianxiety medication. The only response from the nurse practitioner on both medications was continue current dose. There was no rationale to continue the medication. On 7/6/16 at 10:10 a.m., the Director of Nursing (DON) agreed the nurse practitioner should have wrote a rationale for continuing the medications. c) Resident #98 A medical record review, on 06/28/16 at 2:27 p.m., revealed Resident #98 received coumadin 3.5 milligrams (mg) orally at bedtime on Monday, Wednesday, and Friday for deep vein thrombosis prophylaxis and coumadin 2.5 mg orally every Sunday, Tuesday, Thursday and Saturday for [DIAGNOSES REDACTED](irregular heartbeat), and Humalog 100 units/milliliter (ml) subcutaneously per sliding scale coverage (ssc) before meals and at bedtime. Further review of the medical record, on 07/06/16 at 3:00 p.m., indicated Resident #98 also received digoxin 125 micrograms (mcg) by mouth (po) one time a day for congestive heart failure, metoprolol tartrate 25 mg (give one half tablet to equal 12.5 mg) twice dail… | 2019-10-01 |
| 4532 | 4532 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2016-07-07 | 441 | E | 0 | 1 | 8SXB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and Centers for Disease Control and prevention guidelines, the facility did not maintain an effective infection control program to the extent possible. Staff did not use gloves when cleaning up unknown fluids from the floor, did not utilize proper handwashing technique and transported a bag of wound treatment items and bag of soiled items in the same hand. This practice had the potential to affect more than a limited number of residents. Facility census: 79. Findings include: a) Personal Protective Equipment A random observation, on 06/28/16 at 3:31 p.m., revealed a liquid substance on the floor beside the bed of Resident #96. Upon inquiry, Nurse Aide (NA) #78 related she did not know whether it was urine or water. The nurse aide obtained paper towels from the bathroom, placed them on the floor, then stepped on them with her right foot and began to wipe up the fluid by rubbing back and forth with her foot. She then bent down and with ungloved hands continued wiping the areas with the saturated towels. b) Resident #127 During an observation of a wound dressing change, on 06/30/16 at 11:58 a.m., Licensed Practical Nurse (LPN) #69 placed a plastic bag which contained wound care supplied on the over-the-bed table. The nurse washed her hands for a count of ten (10) seconds, donned gloves, placed a clean plastic garbage bag on the table as a barrier, then placed wound supplies on the barrier. The LPN removed the soiled dressing, which contained another dressing beneath, related she had done something wrong, removed the gloves and washed her hands for a count of four (4) seconds, turned off the faucet with bare hands, then obtained paper towels from the dispenser to dry her hands. The nurse donned a new pair of gloves, obtained a new garbage bag for soiled items, and placed it on the bed. The LPN sprayed the wound bed with wound cleanser, removed her gloves, started to apply new gloves, threw them away before d… | 2019-10-01 |
| 4533 | 4533 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 159 | E | 0 | 1 | OVQ111 | Based on record review, family interview, and staff interview, the facility failed to ensure each resident and/or responsible party who had a resident trust account with the facility was provided a financial record (statement) of the account on a quarterly basis and/or upon request. This was true for five (5) of five (5) resident reviewed for the care area of personal funds during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #7, #20, #1, #17, and #6. Facility Census: 36. Findings Include: a) Resident #7 During a family interview at 12:50 p.m. on 04/18/16, Resident #7's responsible party indicated that he was the resident's representative for financial decisions. When asked if the facility maintained a resident trust account for Resident #7, he said they did have an account for her in case she wanted to get her hair done or should she need anything. He was then asked, Does the facility give you a statement of how much money is in the resident's account? He stated, I don't recall them ever giving me anything like that. In the afternoon on 04/19/16, the facility was asked to provide any statements sent to Resident #7's responsible party and/or to Resident #7. The facility did not provide any statement for Resident #7 as of 04/21/16 at 1:00 p.m. at which time the facility was asked to provide a complete accounting of Resident #7's trust fund. Review of this accounting found the first money deposited into Resident #7's account was deposited on 10/14/15, which was six (6) months prior to this review. During an interview at 12:35 p.m. on 04/21/16, the Chief Financial Officer (CFO) confirmed the facility had sent no statements to Resident #7 or her responsible party. The CFO said they had provided all that they had as far as statements were concerned, and none were found for Resident #7. b) Resident #20 The facility provided a list of all residents who currently had a resident trust fund with the facility. Resident #20 was chosen as a random sample for review. On the afternoon of 04/19/16, the fac… | 2019-10-01 |
| 4534 | 4534 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 225 | D | 0 | 1 | OVQ111 | Based on review of the facility's reportable allegations of abuse/neglect, staff interview, and review of the facility's abuse policy, the facility failed to immediately report allegations of abuse/neglect to the appropriate State authorities as required by State law. This was true for one (1) of five (5) investigations of abuse/neglect reported by the facility within the past year. Resident identifier: #10. Facility census: 36. Findings include: a) Resident #10 Review of the facility's reportable allegations of abuse/neglect on 04/20/16 found the following documentation: On 05/02/15, Registered Nurse (RN) #11 completed a resident complaint/grievance form from Resident #10. The nurse documented on the grievance/concern form: Resident #10 said, . staff are making her feel bad when they come to change her after having bowel movements. She was able to describe 2 workers and denies any other problems with other staff. On 05/03/15, a second staff member, the Director of Nursing (DON), spoke with the resident regarding the complaint received on 05/02/15. The DON wrote the following statement on 05/03/15 (typed as written): This nurse to resident's room to speak with her concerning complaint she filed on 5/2/15. (Name of resident) had stated that two staff members 'made her feel bad' when she they come to her room to change her after having she had bowel movements. (typed as written). (Name of resident) stated that it had been happening for about a month or so. I reminded (name of resident) of the conversation I had with her regarding reporting instances such as this to me and she stated she 'hated to say anything.' (name of resident) stated 'When they diaper me, they go on and one about how I've pooped.' (Name of resident) stated 'the colored girl in the morning told me to quit taking my medicines because they make me have diarrhea.' (name of Resident) also stated she 'told the colored girl that I didn't want to take any more of that medicine and she that I didn't have to do anything I didn't want to do.' (Name of resi… | 2019-10-01 |
| 4535 | 4535 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 272 | E | 0 | 1 | OVQ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #39's comprehensive Minimum Data Set (MDS) assessment accurately reflected her behavioral status. Resident #43's comprehensive MDS did not accurately reflect her prognosis, and Resident #6's comprehensive MDS did not accurately reflect her pressure ulcers. This was true for three (3) of seventeen1(7) comprehensive MDSs reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #39, #43, and #6. Facility Census: 36. Findings include: a) Resident #39 A review of Resident #39's Significant Change MDS with an assessment reference date (ARD) of 12/24/15 found the resident assessed as having physical behavioral symptoms directed toward others for one (1) to three (3) days during the seven (7) day look back period. This MDS also indicated Resident #39 had wandered daily during the seven (7) day look back period and that this wandering had placed the resident at significant risk of getting into dangerous places. Further review of the medical record found no supporting documentation of the behaviors identified on the MDS with the ARD of 12/24/15. During an interview with the Social Worker on 04/20/16 at 9:35 a.m., she indicated that prior to completing the behavioral sections of the MDS, she would perform a chart review and staff interviews to determine what behaviors each resident exhibited. She said she did not necessarily only count occurrences of the behaviors which happened within the seven (7) day look back period. She said, If a resident is in the hospital for a few days during the look back period I will look at a few days prior to the beginning of the look back period. She was then asked to provide the basis for the answers she had chosen on the MDS with an ARD of 12/24/15. During and additional interview with the Social Worker at 10:38 a.m. on 04/20/16, she provided a Morning Nursing Assistant Flowsheet dated 12/22/15, which indicated… | 2019-10-01 |
| 4536 | 4536 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 278 | D | 0 | 1 | OVQ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the individual completing and certifying the accuracy of Resident #6's quarterly minimum data set (MDS) assessments failed to complete the pressure ulcer assessment accurately. This was found for one (1) of fourteen (14) MDSs reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #6. Facility census: 36. Findings include: a) Resident #6Review of the resident's medical record on 03/19/16 at 2:00 p.m., found she was admitted to the facility on [DATE]. The pressure ulcer assessment/body audit completed by Registered Nurse (RN) #33, indicated the resident had a Stage 2 pressure wound on the left shoulder measuring 1 centimeter (cm) in length and 0.3 cm in width. The wound, first observed on 01/10/16, was in-house acquired. Review of the resident's quarterly MDS assessment with an assessment reference date (ARD) of 04/08/16, found Section M identified the resident had one (1) Stage 2 pressure ulcer that was present on admission. Additionally, a zero (0), indicating none, was the response in Section S regarding in what setting did the pressure ulcer develop, and the assessment items for location and status of existing wounds were left blank.Interview with Registered Nurse (RN) #11, MDS Coordinator, on 03/19/16 at 3:15 p.m., confirmed the pressure ulcer assessments of the quarterly MDS with an ARD of 04/08/16 were inaccurately coded. She confirmed the left shoulder area had developed on 01/10/16 and was in-house acquired. She confirmed said she coded section M incorrectly and just missed placing the information in Section S.The director of nursing (DON) was informed on 03/19/16 at 4:30 p.m., of the inaccurately coded MDS with an ARD of 04/08/16 under sections M and S. No further information was provided as of exit at 4:00 p.m. on 04/21/16 | 2019-10-01 |
| 4537 | 4537 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 279 | D | 0 | 1 | OVQ111 | Based on record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) of three (3) resident's whose care plans were reviewed for the care area of vision during Stage 2 of the Quality Indicator Survey (QIS). Resident #8's comprehensive assessment indicated the resident would have a care plan developed for the care area of visual functioning. Resident identifier: #8. Facility census: 36. Findings include: a) Resident #8 Review of the most recent comprehensive minimum data set (MDS), an annual, with an assessment reference date (ARD) of 01/13/16, found the assessment identified the resident as having moderately impaired vision - defined as not able to see newspaper headlines, but can identify objects. Review of Section V, the Care Area Assessment (CAA) Summary, noted the resident triggered the care area of visual function and the facility would proceed to the care plan. During an interview with Registered Nurse (RN) #11, Minimum Data Set (MDS)Coordinator, at 9:30 a.m. on 04/19/16, she confirmed the resident's current care plan did not include any problems, goals, or interventions related to the resident's visual deficits. She stated, It was just an oversight on our part. | 2019-10-01 |
| 4538 | 4538 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 282 | D | 0 | 1 | OVQ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observation, the facility failed to ensure implementation of the care plans for two (2) of seventeen (17) Stage 2 sampled residents. Resident #7's care plan was not implemented in the area of fall interventions. Resident #6's care plan was not implemented in regards to her feeding tube and for devices related to range of motion services. Resident Identifiers: #7 and #6. Facility Census: 36. Findings Include: a) Resident #7 A review of Resident #7's care plan at 2:08 p.m. on 04/19/16, found a care plan problem dated 04/11/16 of, Fall. The goal associated with this problem was, Resident's needs will be identified and met and resident will remain safe through next review. Interventions related to this problem included, Tabs monitor at all times to bed and wheelchair. An observation on 04/19/16 at 4:25 p.m., with the Director of Nursing (DON) and Registered Nurse (RN) #11, found the resident up in her wheelchair sitting in the hallway. An activities worker was painting the resident's fingernails. During the time of this observation, the resident did not have a tabs monitor in place. RN #11 then went to Resident #7's room and found the tabs monitor on the resident's chest of drawers. The DON and RN #11 both confirmed the tabs monitor was not in place at the time of this observation. b) Resident #6 1. A review of Resident #6's medical record at 10:00 a.m. on 04/20/16, found a physician's orders [REDACTED]. Give one half (1/2) can (125 ml) every four (4) hours through gastrostomy feeding tube; follow with 75ml of water. Hold if residual is over 100 ml and notify physician. Review of Resident #6's care plan found it contained a focus statement dated 04/12/09 of (typed as written),Potential for complications due to needing feeding tube. Has vomiting, gagging after tube feedings The goals related to this focus statement with target dates of 01/16/15, were Resident will not exhibit signs/symptoms of … | 2019-10-01 |
| 4539 | 4539 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 309 | D | 0 | 1 | OVQ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident received care and services in accordance with the individual's plan of care. Resident #45 did not have her vital signs take every shift for 72 hours after admission as ordered by the physician. One (1) of twenty-one (21) Stage 2 sample residents were affected. Resident identifier: #45. Facility census: 36. Findings include: a) Resident #45 On 04/20/16 at 10:30 a.m., a review of Resident #45's medical record revealed she was admitted to the facility on [DATE] at 9:40 a.m. Her admission physician's orders [REDACTED]. A review of the electronic progress notes and vital signs record revealed Resident #45's vital signs were not obtained on the following dates: -- 04/14/16 - 7-3 shift and 3-11 shift. -- 04/15/16 - 7-3 shift and 3-11 shift -- 04/16/16 - 11-7 shift, 7-3 shift, and 3-11 shift During an interview on 04/20/16 at 12:08 p.m., the Director of Nursing (DON), confirmed the resident's vital signs were not taken every shift for 72 hours as ordered on admission. The DON further confirmed Resident #45's vital signs should have been obtained through 04/16/16. | 2019-10-01 |
| 4540 | 4540 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 318 | D | 0 | 1 | OVQ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure one (1) of three (3) residents who met the criteria to review for contractures, was provided services to increase range of motion and/or to prevent further decrease in range of motion. Observation of the resident found devices for prevention of further contractures were not in place as directed by physician's orders [REDACTED]. Resident identifier: #6. Facility census: 36. Findings include: a) Resident #6 Medical record review at 2:00 p.m. on 04/20/16, found the resident had been receiving Hospice services since 10/20/14 for a [DIAGNOSES REDACTED]. Further review of the physician's orders [REDACTED]. Review of the current care plan found a care plan problem of, Risk for body odor is totally dependent on staff with personal hygiene d/t (due to) dx.(diagnosis) advanced dementia (picks disease) with long and short term memory problems, inability to express wants and needs and is unable to make any decisions. has b/b (bowel and bladder) incontinence d/t profound cognitive and physical cognitive and physical deficits and is dependent upon staff for bed mobility. Has contractures bilaterally at hands, neck, hip, ankles and knees. Develops dependent [MEDICAL CONDITION] easily, risk for skin breakdown The goal associated with this problem was, Resident will have needs met by staff daily during the next review period . Approaches included: -- Rolled washcloths to contracted hands -- Place pillow between lower extremities, ankles and knees to prevent pressure. -- Position arms with pillows to prevent worsening of contractures and dependent [MEDICAL CONDITION] d/t crossing arms across chest-ROM to upper extremities 10 reps BID. Observation of the resident on the afternoon of 04/19/16, from 1:30 p.m. to 4:00 p.m., found the hand rolls to both hands and the pillows for positioning of the arms were not in use. At 4:00 p.m. on 04/19/16, Registered Nurse (RN) #11, minimum… | 2019-10-01 |
| 4541 | 4541 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2016-04-21 | 322 | G | 0 | 1 | OVQ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .NEED TO ADD ACTUAL HARM AND FINDINGS Based on observation, interview, and record review, the facility did not ensure that one (Resident #6) of one (1) sampled resident who had a gastrostomy tube received the appropriate treatment and services to prevent aspiration pneumonia. Resident #6 was observed receiving tube feeding without first checking the tube placement and residual prior to bolus feeding the resident on 04/20/16. During this observation the resident was observed gagging and coughing repeatedly and face became flushed. This practice resulted in actual harm. Resident identifier: #6. Facility census: 36. Findings include: a) Resident #6 Review of Resident #6's medical record at 10:00 a.m. on 04/20/16, found a physician's orders [REDACTED]. Give one half (1/2) can (125 ml) every four (4) hours through gastrostomy feeding tube; follow with 75 ml of water. Hold if residual is over 100 ml and notify physician. Review of Resident #6's care plan found it contained a focus statement dated 04/12/09 of (typed as written), Potential for complications due to needing feeding tube. Has vomiting, gagging after tube feedings The goal related to this focus statement with a target date of 01/16/15, was Resident will not exhibit signs/symptoms of complications due to enteral nutrition during next review. Interventions included (typed as written), Verify tube placement and check residual prior to administering feedings, flushes, and medications. This intervention was added to the care plan on 08/26/09. Review of Resident #6's Medication Administration Record [REDACTED]. Observation of tube feeding on 04/20/16 at 3:55 p.m., completed by Licensed Practical Nurse (LPN) #25, found the nurse failed to check the placement of the feeding tube and residual prior to administering the tube feeding. During this observation, the nurse allowed the tube feeding and flush to instill rapidly. The resident repeatedly coughed and gagged throughout the feeding. The resid… | 2019-10-01 |
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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 );