cms_WV
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37 rows where "inspection_date" is on date 2017-03-01
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 39 | 39 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 157 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based resident, staff and physician interviews and clinical record review, the facility failed to notify the physician timely of a resident incident for one resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifiers: #260. Facility census 145. Findings include: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regard… | 2020-09-01 |
| 40 | 40 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 164 | E | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain visual privacy during one (1) of three (3) dressing change observations for Resident #177. The facility failed to maintain privacy for medication packages for three (3) residents (Resident #38, #195 and #185). Resident identifiers: #177, #38, #195, and #185. Facility census 145. Findings include: a.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., Registered Nurse (RN) #137 and Licensed Practical Nurse (LPN) #64 entered the room to perform the dressing change. Resident #177 was in the bed by the window. The window blind was open and facing at street level a parking lot. RN #137 nor LPN #64 closed the window blind. RN #137 pulled the privacy curtain part of the way around the foot of the bed but leaving the mirror over the sink exposed to the resident's roommate. LPN #64 instructed Resident #177 to roll over onto her stomach. LPN #64 removed the dressing exposing a large stage IV pressure ulcer on the resident's coccyx. RN #137 was preparing the new dressing items. The resident's roommate face was seen in the mirror. The roommate had two (2) visiting family members. The roommate stated, you can pull the curtain, so she can have her privacy. LPN #64 then pulled the curtain completely to provide privacy from the mirror. During an interview, on 02/23/17 at 1:08 p.m., RN #137 stated she had thought about closing the window blind during the dressing change but just didn't do it. RN #137 stated she didn't realize the privacy curtain had not be pulled completely to provide privacy. During an interview, on 02/23/17 at 3:03 p.m., the Director of Nursing (DON) stated her expectation was all staff were to provide full visual privacy during dressing changes. b) A random observation of the 800 Hall on 02/23/17 at 8:15 a.m. revealed three (3) visible empty medication cards/packets in the trash can of the medication cart. The following medication cards contained th… | 2020-09-01 |
| 41 | 41 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 272 | D | 0 | 1 | TKXD11 | Based on staff interview, record review, resident interview, and observation, the facility failed to complete an accurate comprehensive assessment for one (1) of eighteen (18) sample residents. The dental status assessment of one (1) resident was inaccurate on the comprehensive minimum data set (MDS). Resident identifier: #33. Facility census: 145. Findings include: a) Resident #33 During the stage 1 observation and interview of Resident #33 conducted on 02/22/17 at 1:00 p.m., she said she had a broken front tooth and used to wear a partial denture. Her mouth had several teeth in various states of wear and decay, with missing teeth evident. During the medical record review performed on 02/28/17, there were dental consultation notes with the following information: --08/09/16 Exam: Generalized Decay; Generalized Periodontal Disease The attached treatment plan included options for replacing missing teeth, specifically dental implants and partial dentures. --08/30/16 Presents for exam and x ray with extractions Further interview with Resident #33 on 02/28/17 at 10:13 a.m. revealed she was looking into getting a new partial and was awaiting an appointment. On 02/28/17 at 12:30 p.m. a review of the most recent comprehensive (annual) MDS with an assessment reference date (ARD) of 09/24/16 found section L Oral/Dental Status with the following assessment: B. No natural teeth or tooth fragment(s) (edentulous). Registered Nurse Assessment Coordinator #102 was interviewed on 02/28/17 at 1:00 p.m. and said the oral assessment in section L was an error. She provided evidence that a correction was made to the MDS prior to the survey exit. | 2020-09-01 |
| 42 | 42 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 280 | D | 0 | 1 | TKXD11 | Based on resident interview, medical record review and staff interview, the facility failed to revise a care plan for one (1) of eighteen (18) stage 2 sample residents. The facility did not revise a Brief Interview for Mental Status (BIMS) score. Resident identifier: #12. Facility census 145. Findings include: a) Resident #12 Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/02/16 revealed a BIMS score of fifteen (15) which indicates the resident is cognitively intact. The residents most recent care plan indicated a BIMS score of five (5) which indicates severely cognitive impaired. On 02/21/17 at 1:00 p.m., Resident #12 was able to answer stage one interview questions without difficulty. During interview on 02/28/17 at 3:45 p.m., registered nurse (RN) #17 stated the BIMS score on the care plan had not been updated from the residents admission and should have been updated to the current BIMS score of 15. | 2020-09-01 |
| 43 | 43 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 323 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews and review of safety data sheets, the facility failed to prevent accidents by failing to use proper transfer technique for 1 of 1 residents reviewed for accidents, resulting in pain. (Resident #260.) The facility failed to prevent accident hazards by storing chemicals safely (Resident #177.)and storing medications safely. Census 145. The findings are: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--Norco 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and Norco. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., … | 2020-09-01 |
| 44 | 44 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 371 | E | 0 | 1 | TKXD11 | Based on observations, staff interview and review of FDA food code, the facility failed to serve foods in a sanitary manner. One (1) dietary aide was serving food with polished nails without wearing gloves and one dietary aide was wearing rings with stones on each hand while serving food. This has the potential to more than an isolated number of residents. Facility census: 145. Findings included: On 02/28/17 at 12:15 p.m., Dietary Aide (DA) #132 was plating resident food. DA #132 had polished finger nails and was not wearing gloves. DA #132 stated her nails were natural and were polished. Additionally, on 02/28/17 at 12:15 p.m., DA #26 was plating resident food on resident trays. DA #26 was wearing a diamond like ring on her left ring finger and a pearl like ring on her right ring finger. DA #26 stated she usually wore the rings when working in the kitchen. The Dietary Supervisor #125 instructed DA #26 to remove her rings. DA #26 removed her rings. The Dietary Supervisor instructed DA #132 to put on gloves, which she did. Review of the 2013 FDA Food Code Chapter 2 page 50 states: Unless wearing intact gloves in good repair, a FOOD EMPLOYEE may not wear fingernail polish or artificial fingernails when working with exposed FOOD. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. | 2020-09-01 |
| 45 | 45 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 431 | E | 0 | 1 | TKXD11 | Based on observation and staff interview, the facility failed to properly store medications. The facility did not ensure resident's medications delivered from the pharmacy were put away in a inaccessible and locked area and did not ensure a medication cart on the 800 Hall was locked. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #15, #92, #184, and #187. Facility census: 145. Findings include: a) A random observation of the 200 Hall on 02/23/17 at 7:50 a.m. revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs). --Resident #92 - Phenytoin EX 100 mg (56 capsules). --Resident #184 - Clonidine HCL 0.1 mg (56 tablets). --Resident #187 - Celecoxib 200 mg (56 capsules). An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m., revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. b) A random observation of the 800 Hall on 02/23/17 at 8:05 a.m., revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m., revealed the medication cart should always be locked when not in sight of the nurse. | 2020-09-01 |
| 46 | 46 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 441 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow proper hand hygiene techniques during medication administration for one (1) of twenty six (26) opportunities observed. In addition, the facility failed to perform proper cleaning technique on reusable equipment during one (1) of three (3) dressing change observations. This failed practice affected an isolated number of residents who received medications administered by the facility and of those who had pressure ulcers. Resident identifiers: #126 and #177. Facility census: 145. Findings include: a) Resident #126 An observation of medication administration on 02/28/17 at 08:24 a.m., revealed Licensed Practical Nurse (LPN) #44 attempted to pop a [MEDICATION NAME] 25 milligram (mg) tablet out of the packaging into a medicine cup for Resident #126. The pill missed the cup and fell to the floor. LPN #44 picked up the pill with her bare hands and discarded it. She then popped out a second [MEDICATION NAME] 25 mg tablet into the medication cup and continued with her medication administration for Resident #126 without washing or sanitizing her hands. On 02/28/17 at 10:59 a.m. this matter was discussed with Employee #4, who was responsible for infection control. She agreed that it was an infection control issue. She provided the facility policy titled Handwashing/Hand Hygiene last revised (MONTH) (YEAR). This policy stated to use alcohol-based hand rub or soap and water Before preparing or handling medications. b.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., RN #137 removed scissors from her uniform pocket and cut kling soaked with acetic acid which LPN #64 was using to pack resident #177 coccyx stage IV wound. RN #137 did not clean the scissors prior to use. At the end of the dressing change procedure, RN #137 placed the scissors back into her uniform pocket without cleaning them when she left the room. During an interview, on 2/23/17 at 1:08… | 2020-09-01 |
| 47 | 47 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-03-01 | 514 | D | 0 | 1 | TKXD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately for two (2) of eighteen (18) sample residents. Behavior monitoring and bowel pattern tracking was not consistently and/or accurately documented for one (1) resident and a second resident had incomplete medication administration records. Resident identifiers: #258 and #260. Facility census: 145. Findings include: a) Resident #258 1. Behavior sheets A medical record review for Resident #258 on 02/27/17 revealed she had physician's orders [REDACTED]. This medication was first administered on 02/03/17 at 8:00 p.m. She also had an order for [REDACTED]. Although the orders were initiated on 02/03/17, the Behavior/Intervention Monthly Flow Sheet were not documented until night shift of 02/04/17 for both [MEDICATION NAME] and [MEDICATION NAME]. In addition, there were multiple blanks holes on both sheets. The director of nursing (DON) was interviewed on 02/27/17 at 4:39 p.m. and she acknowledged the holes on the sheets were where nursing had not completed the forms. 2. Bowel patterns During the medical record review for Resident #258 on 02/27/17, there were several missing entries in the nurse aide documentation for Bowel Patterns. In addition, the documentation reflected no record of the resident having a bowel movement from night shift on 02/17/17 until evening shift on 02/23/17, as the nurse aides had documented 0 meaning No Bowel Movement. Nurse manager #21 was interviewed on 02/28/17 at 3:05 p.m. and she said that the documentation was inaccurate. She also agreed that the holes in the record resulted in the record being incomplete. c.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligram… | 2020-09-01 |
| 4007 | 4007 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 223 | K | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, incident/accident reports review, facility reportable allegation(s) of abuse review, policy and procedure review, and staff interviews, the facility failed to ensure residents were free from sexual abuse. This was true for seven (7) residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s), who received nonconsensual sexual contact by Residents #10, #11, and/or #62 which were reviewed during the Quality Indicator Survey (QIS) and complaint investigation. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. 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 deficient practice 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.) A reasonable person, if touched inappropriately by another person … | 2020-03-01 |
| 4008 | 4008 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 224 | K | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids… | 2020-03-01 |
| 4009 | 4009 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 225 | E | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, policy and procedure review, accident/incident reports review, allegations of sexual abuse review, and staff interviews, the facility failed to ensure incidents of sexual abuse were identified, thoroughly investigated and reported to the appropriate State agencies. The failure to identify and investigate allegations of sexual abuse also resulted in a failure to ensure alleged victims were protected from further potential abuse. This was true for seven (7) female residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s) who were the recipients of nonconsensual sexual contact by Residents #10, #11, and/or #62. Facility census: 61. Findings include: a) Resident #26 1. Review of the resident's medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (name of Resident #26) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. A review of the report sent to the State agencies contained the immediate reporting form, the five-day follow up report, and the report to the Ombudsman and Adult Protective Services (APS). In an interview with the Social Worker (SW) on 02/24/17 at 11:38 a.m., when asked for the witness statements for this incident, she responded, I don't have any witness statements. When asked if the Director of Nursing (DON) or the Nursing Home Administr… | 2020-03-01 |
| 4010 | 4010 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 226 | K | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids… | 2020-03-01 |
| 4011 | 4011 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 241 | D | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to promote care for residents in a manner that maintained or enhanced dignity and respect by dating and initialing a wound dressing adhered to a resident's body, and by not clothing a resident from the waist down while in bed. This practice was found for two (2) of twenty-six (26) Stage 2 residents. Resident identifiers: #74 and #49. Facility census: 61. Findings include: a) Resident #74 On 02/21/17 at 9:10 a.m., at the conclusion of wound care/treatment the Assistant Director of Nursing (ADON)/Wound Care nurse secured the wound dressing to Resident #74's coccyx. The ADON then proceeded to write the date and her initials on the wound dressing adhered to Resident #74's bottom. During an interview with the ADON immediately following this observation, she confirmed she had written on the dressing after adhering it to Resident #74's body and should have labeled the dressing prior to applying it to the resident. Wound care observations were reviewed with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m. The DON confirmed the dressing should have been dated and initialed prior to adhering it to Resident #74's bottom. During a review of the wound care observation with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m., she confirmed dating and initialing of the dressing should have been done prior to it being placed on the resident's bottom. b) Resident #49 On 02/22/17 medical record review found the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03), indicating severe cognitive impairment. This resident, who lacked capacity for medical decision-making, had pertinent [DIAGNOSES REDACTED]. On 02/21/17 at 9:50 a.m., an observation of the resident's incontinence care was completed. Nurse Aides (NA) #157 and #145 provided perineal care to the resident… | 2020-03-01 |
| 4012 | 4012 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 253 | E | 1 | 0 | WA6611 | > Based on observation and resident interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Walls in multiple resident rooms and bathrooms had bubbled and peeling paint, unpainted patches, resident furniture had scratched/marred areas with missing finish in multiple resident rooms. A bathroom door facing had scratched/marred areas with missing paint revealing rust stains on the interior near the floor. Metal plates under the sinks in several resident rooms were not secured and hanging partially open revealing dust and grime. Stained, discolored, and/or cracked tiles were on bathroom floors, showers, and hallways. The vinyl wallboard had separated from the bathroom wall in residents' bathrooms. These findings affected twelve (12) of twenty-four (24) resident rooms and the main hallway on the first floor of the nursing home unit, and two (2) of seventeen (17) resident rooms on the second floor of the nursing home. Room Numbers: #1, #2, #3, #7, #8, #25, #26, #29, #31, #35, #39, #41 #202 and #204. Facility census: 61. Findings include: a) Observation of the facility during Stage 1 and Stage 2 of the Quality Indicator Survey revealed the following rooms had environmental concerns and cosmetic imperfections. 1. Room #1 Large pieces of loose peeling and bubbled paint on the wall between the entrance door and the bathroom door, that broke off easily when touched. 2. Room #2 Bed A had a four (4) drawer chest with scratched areas and missing finish on the veneer. 3. Room #3 There was peeling paint in the bathroom behind the toilet, bubbled paint with holes by the grab bar/safety handle on the right side of the toilet and peeling paint under the resident room sink. 4. Room #7 The chest in the room had a large area measuring 5 inches by 8 inches area with missing veneer finish on the top drawer and scratched/marred edges along the top of chest with missing veneer finish. 5. Room #8 The bathroom door facing had scratched/marred areas … | 2020-03-01 |
| 4013 | 4013 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 309 | H | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observations, review of incident reports, resident interview, and staff interview, the facility failed ensure female residents were provided care and services to enable them to physical and mental well-being. The facility failed to ensure it had an effective system to ensure incidents of nonconsensual sexual contact were identified and effectively managed to ensure dependent, cognitively impaired women did not experience loss of dignity, or become anxious or fear additional unwanted contacts. As a result of this systemic failure, Residents #26, #39, #51, #49, #24, #37, and #1 were determined to have experienced actual harm. The facility also failed to ensure a resident (#10) received his scheduled daily morning insulin as prescribed by the attending physician. Eight (8) of twenty-six (26) residents were affected. Resident identifiers: #10, #26, #39, #51, #49, #24, #37, and #1. Facility census: 61. Findings include: a) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02), indicating severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. The MDS identified her as needing extensive assistance of two (2) persons for bed mobility and for transfer, total dependence for dressing, toilet use, personal hygiene, bathing, and limited assistance of one (1) person with eating. She sometimes understood others and could sometimes understand others. Confidential interviewees (CI) CI #3 and CI #4, in separate interviews, both said they had witnessed male Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touche… | 2020-03-01 |
| 4014 | 4014 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 314 | G | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and policy review, the facility failed to provide care and treatment to a resident to promote healing of existing pressure ulcers and to prevent new sores from developing. There was no system in place to ensure skin assessments were completed timely and accurately, that interventions were implemented, monitored, and revised as appropriate, and changes in condition were recognized, evaluated, and reported to the physician, and that staff were knowledgeable in identifying and caring for pressure ulcers. Resident #74 was admitted with pressure ulcers on both elbows and his history identified a recent pressure ulcer to his coccyx. Failure to provide preventative measures resulted in actual harm to the resident by the redevelopment of the sacral pressure ulcer, a deep tissue injury to the left heel, and multiple toe wounds. Additionally, during an observation of wound care for Resident #74's, the nurse did not employ appropriate infection control techniques to reduce the risk of infecting the wound. This affected one (1) of three (3) residents reviewed for pressure ulcers. Resident identifier: #74. Facility census: Findings include: a) Resident #74 1. Review of the resident's medical record at 8:12 a.m. on 02/16/17, revealed this eighty-two (82) year old resident was admitted to the facility on [DATE] from an acute care setting. The acute care discharge summary dated 12/18/16 stated the resident presented to the hospital with increased weakness, loss of appetite and weight loss, and the inability to perform his activities of daily living (ADLs). His discharge [DIAGNOSES REDACTED]. The plan of care included in the discharge summary include, Sacral decubitus ulcer, Protect skin from further breakdown and compromise, and Frequent repositioning, keep patient active, and enforce aggressive wound care. The nursing physical assessment admission note dated 12/19/16 stated Resident #74 was admitted fr… | 2020-03-01 |
| 4015 | 4015 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 323 | E | 1 | 0 | WA6611 | > Based on observation and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. The hard plastic-type corridor handrail outside of the pantry room in the first floor main hallway had a missing end piece leaving a sharp jagged edge on the existing center piece. In a resident's bathroom, the grab bar/safety rail on the right side of the toilet was not secured to the wall. In another resident's bathroom, the vinyl wallboard pulled loose from the wall when the grab bar/safety rail was utilized. This had the potential to affect more than an isolated number of residents. Room numbers: #26 and #29. Facility census: 61. Findings include: a) A tour, accompanied by the Nursing Home Administrator #114, Maintenance Supervisor #42, and Housekeeping Supervisor #91 on 02/15/17 between 2:40 p.m. to 3:05 p.m., identified the following issues/concerns: 1. First floor of the nursing home unit -- Outside of the Pantry room door in the main hallway of the first floor of the nursing home unit, utilized by residents as a main thoroughfare, the hard plastic-type corridor handrail had a missing end piece leaving a sharp jagged edge on the existing centerpiece. -- Room #26 In the bathroom, the grab bar/safety rail on the right side of the toilet was loose and not secured to the wall. -- Room #29 In the bathroom, the vinyl wallboard pulled loose from the wall when the attached grab bar/safety rail was grabbed and/or pulled on. At the conclusion of the tour, the Nursing Home Administrator agreed the identified issues were a safety hazard for the residents. When asked whether they were aware of the issues, Maintenance Supervisor #42 stated, Yes I tour here every day and see this every day, but no repairs have been done. | 2020-03-01 |
| 4016 | 4016 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 520 | F | 1 | 0 | WA6612 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon observations, record reviews and staff interviews, the facility's Quality Assurance process failed to identify compliance issues and develop and implement appropriate plans of action to correct those deficient practices once they had been identified. The revisit survey found the facility had failed to identify and correct deficient practices identified and cited during the annual survey of 03/00/17. The facility's Quality Assurance process had failed to identify those issues with respect to which quality assessment and assurance activities were necessary, and the facility's Quality Assurance process subsequently failed to develop and implement appropriate plans of action to correct those quality deficiencies once they had been identified and cited. Seven (7) of twenty-five (25) deficient practices cited during the annual survey of 03/01/17 were found to remain out of compliance during the revisit survey. This had the potential to affect all residents. Facility census: 55. Findings include: a) The facility failed to operationalize its policies and procedures for training new employees regarding abuse/neglect. Eleven (11) nursing staff members on Unit 3, and the Housekeeping, Dietary, and Maintenance Departments were not included in abuse reporting and sexual abuse training. 1. Abuse Reporting/Sexual Abuse Training On 06/12/17 at 11:07 a.m., after a review of the P[NAME] which stated, Staff have been reeducated on policies and procedures of abuse reporting and notification of changes on 3/2/17 through an outside consulting firm and/or Social Service worker, with all staff having completed reeducation by 4/26/17. Any staff on leave of absence will have reeducation by the Social Worker/designee prior to performing any work duties. A continuing review of the P[NAME] revealed eleven (11) nursing staff members (Employees #110, #109, #105, #101, #100, #95, #68, #64, #63, #103, and #121) who work on the Third Floor (an acute care floor) d… | 2020-03-01 |
| 4037 | 4037 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 157 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to notify the resident's responsible party and/or physician of incidents of sexual abuse. This was evident for seven (7) of eight (8) residents reviewed for abuse. Resident identifiers: #51, #49, #24, #37, #1, #39, #26, #10, #62, #52, and #11. Facility census: 61. Findings include: a) Resident #51 Confidential Interviewees (CI) #3 and CI #4, in separate interviews, both said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to whomever was the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. An incident report dated 12/08/16, described that Resident #51 was sitting in a recliner chair by the nurses' station, when male Resident #62 pulled up her shirt, and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. Review of the nurse progress report found no documentation on 12/08/16 about this incident between the two (2) residents. There was no evidence the facility informed the responsible party or the physician of these occurrences. b) Resident #49 During separate confidential interviews with CI #1, CI #2, CI #6, CI #10, and CI #11, all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Reside… | 2020-02-01 |
| 4038 | 4038 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 252 | E | 0 | 1 | WA6611 | Based on observation and staff interview, the facility failed to provide a homelike environment for residents by not having tablecloths and/or place mats on the dining tables. In addition, dinnerware and flatware were not removed from the individual serving trays during the breakfast meal. This practice had the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) On 02/14/17 at 8:33 a.m., a second dining observation of the breakfast meal on the first floor of the nursing home unit revealed twenty-five (25) residents seated at various tables in the dining room/solarium/activity room. The plastic tables and wooden tables did not have tablecloths or place mats covering the surfaces of the tables. Staff served the residents' breakfast meals with the dinnerware, flatware, and other items left on the individual serving trays. At 8:40 a.m. on 02/14/17, after observing the breakfast meal service on the first floor dining room/solarium/activity room, the Assistant Director of Nursing (ADON)/Wound Nurse #112 agreed it was not a homelike environment for dining. She stated, They are being served cafeteria style and we only have fine dining for lunch with tablecloths and removing the plates from the trays. She further commented that she would ensure this dining practice would be corrected for all meals. . | 2020-02-01 |
| 4039 | 4039 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 272 | C | 0 | 1 | WA6611 | Based on Minimum Data Set (MDS) review, review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), and staff interview, the facility failed to provide the dates of information used to complete the Care Area Assessments (CAA) for five (5) of five (5) residents reviewed during Stage 2. This affected all residents residing in the facility. Resident identifiers: #39, #26, #62, #11, and #10. Facility census: 61. Findings include: a) Resident #39 On 02/28/17 at 2:16 p.m., a review of the resident's annual MDS with an assessment reference date (ARD) of 06/16/16 revealed the CAA summary contained no dates of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record and see H&P (history and physical), but did not identify the dates of the referenced documents, interviews, or observations. b) Resident #26 A significant change MDS with an ARD of 11/25/16, contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. c) Resident #62 A significant change MDS with an ARD of 11/25/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. d) Resident #11 The resident's admission MDS with an ARD of 09/08/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained, interview/record, record, interview, interview/observation/record, Activity participation record, Medication Administration Record [REDACTED]. e) Resident #10 The annual MDS with an ARD of 03/24/16, contained no dates of the location of the CAA documentation. Areas that wer… | 2020-02-01 |
| 4040 | 4040 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 279 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop comprehensive and/or initial care plans based on the residents' current health condition/status that included measurable objectives and timetables to meet the resident's medical, nursing and psychosocial needs. Care plans lacked individualized goals and interventions for residents with, or at risk for pressure ulcers (Residents #74 and #75), and for a resident (#49) receiving antipsychotic medications. This practice was identified for three (3) of twenty-six (26) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #74, #75, and #49. Facility census: 61. Findings include: a) Resident #74 On 02/16/17 at 8:12 a.m., medical record review revealed this eighty-two (82) year old man was admitted to the facility after a thirteen (13) day stay in an acute care facility. The acute care hospital's discharge summary dated 12/18/16 listed [DIAGNOSES REDACTED]. The plan of care written in the discharge summary identified Resident #74's sacral decubitus ulcer. The plan stated, Protect skin from further breakdown and compromise. The interventions were, Frequent repositioning, keep patient active, and enforce aggressive wound care. The facility's admission physical assessment, written on 12/19/16 at 5:13 p.m. by Registered Nurse (RN) #153, stated, [AGE] year old male discharged from (Name) hospital and admitted to (Name) Nursing Care Facility II .with HX (history): Increased weakness. Pressure ulcers of sacral region .Incontinent to bowel and bladder .wears brief .Buttocks with old scar right proximal. Will continue to monitor. The Nurse Aide resident care record dated 12/19/16 at 9:57 p.m. noted Resident #74 required the assistance of one (1) with turning and repositioning, was a two (2) person transfer with a lift device, required assistance with all other activities of daily living (ADLS) including eating, and was … | 2020-02-01 |
| 4041 | 4041 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 280 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plan for one (1) of five (5) residents reviewed for unnecessary medications. Resident #34's care plan was not revised when her antipsychotic medication was discontinued. Resident identifier: #34. Facility census: 61. Findings include: a) Resident #34 Review of the medical record on 02/15/17 found diagnoses, which included [MEDICAL CONDITIONS], depression, and anxiety. Review of medications revealed she formerly received [MEDICATION NAME] (an antipsychotic) 50 milligrams (mg) in the morning and 75 mg at bedtime daily. Review of physician's orders [REDACTED]. During an interview with Registered Nurse #111 and the Director of Nursing (DON) on 02/15/17 at 2:30 p.m., they said she was getting very lethargic on the [MEDICATION NAME] and even wet herself in her sleep without knowing it. They said the physician discontinued the [MEDICATION NAME], and they had to work with the [MEDICATION NAME] in the interim to see how she did. The DON said the resident no longer received [MEDICATION NAME]. Review of the current care plan found one of her care plan interventions included [MEDICATION NAME] 75 mg daily and [MEDICATION NAME] 50 mg at bedtime. During a brief interview on 02/20/17 at 2:30 p.m., it was discussed with the DON that the [MEDICATION NAME] was discontinued on 12/26/16, but the care plan was not revised to indicate the medication was discontinued. The current care plan indicated the resident was receiving [MEDICATION NAME] 75 mg daily and [MEDICATION NAME] 50 mg at bedtime. She agreed the resident's care plan was not revised accordingly after the medication was discontinued. | 2020-02-01 |
| 4042 | 4042 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 282 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow the comprehensive care plan for three (3) of five (5) residents reviewed for unnecessary medications. For Residents #34 and #49's the facility failed to implement their care plans directing to utilize nonpharmacological methods to treat behaviors prior to administering medications, and to assess the effectiveness of the as needed (PRN) antianxiety medication. The facility failed to implement Resident #10's care plan directing administration of insulins as ordered by the physician for the [DIAGNOSES REDACTED].#34, #49, and #10. Facility census: 61. Findings include: a) Resident #34 Review of the resident's medical record on 02/15/17 found [DIAGNOSES REDACTED]. The physician prescribed an antianxiety medication, [MEDICATION NAME] one (1) milligram (mg) every eight (8) hours as needed (PRN). The comprehensive care plan review revealed numerous nonpharmacological interventions such as offering a quiet environment, 1:1 (one person to one person), offer fluid/foods, toileting, conversing, activities, observe for pain, and calm approach, before administering the PRN [MEDICATION NAME]. The care plan also directed to monitor the effectiveness of the PRN medications. Review of the medical record found several instances this quarter where the care plan was not followed. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/07/16 at 8:00 p.m. The nurse progress notes provided no evidence of what, if any, nonpharmacological methods were attempted prior to administering the PRN medication. Also, the medical record was silent as to whether or not the medication was effective. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/11/16 at 9:00 p.m. for anxiety. Review of the medical record found no evidence of what if any nonpharmacological methods were attempted prior to giving the PRN medication. - Review… | 2020-02-01 |
| 4043 | 4043 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 319 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident interview, and staff interview, the facility failed to ensure that a resident who displayed and/or was diagnosed with [REDACTED]. Resident #29 was admitted to the facility with a history of inpatient and outpatient treatment for [REDACTED]. The primary care physician #181 was notified of her aggressive behaviors and sexual comments on 10/18/16. Despite further notifications, no medication adjustments were made until 01/19/17. In addition, no psychological assessments or behavior management plan was provided when the resident's behaviors towards others increased in (MONTH) (YEAR). This was found for one (1) of one (1) residents reviewed for behaviors. The resident's behaviors had the potential to affect more than a limited number of the resident's fell ow residents. Resident identifier: Resident #29. Facility census: 61. Findings include: a) Resident #29 During an observation of the noon meal service on 02/13/17, Resident #29 was observed attempting to pinch a male nursing assistant's bottom as he escorted her to her table. Random observations on 02/22/17 and 02/23/17, found Resident #29 roaming freely throughout the unit and at times making inappropriate sexual comments to State Surveyors. Resident #29 repeatedly spoke about her desire for sexual relations as well as making comments about her lady parts. Licensed Practical Nurse (LPN) #119 was interviewed on 02/22/17 at 3:46 p.m. and reported Resident #29 was aggressive at times and had to be removed from activities because she makes loud inappropriate sexual comments about men and male visitors. Review of the medical record on 02/28/17 at 9:30 a.m., revealed Resident #29 was admitted to the facility in 2011. Her current [DIAGNOSES REDACTED]. She was independent with most of her activities of daily living and allowed to ambulate independently throughout the first floor of the facility. The nurses' behavior documentation from 09/01/16 thro… | 2020-02-01 |
| 4044 | 4044 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 329 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's medication regimen was free of unnecessary medications for two (2) of five (5) residents reviewed for unnecessary medications. Residents #34 and #49 received PRN (as needed) antianxiety medication without evidence of nonpharmacological methods attempted prior to the administration of the PRN medication. Nursing administered PRN antianxiety medications without evidence the behaviors warranted the PRN medication. Resident identifiers: #34 and #49. Facility census: 61. Findings include: a) Resident #34 Review of the resident's medical record on 02/15/17 found diagnoses, which included [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], depression, and anxiety. The physician prescribed an antianxiety medication, [MEDICATION NAME] one (1) milligram (mg) every eight (8) hours as needed (PRN). - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/07/16 at 8:00 p.m. There was no evidence in the nursing progress notes of what behaviors were present at that time, and what, if any, nonpharmacological methods were attempted prior to administering the PRN medication. The medical record was silent as to whether the medication was effective. There was no evidence to support the use of the PRN [MEDICATION NAME]. - Review of the medical record found a nurse administered 1 mg of [MEDICATION NAME] on 12/11/16 at 9:00 p.m. for anxiety and verbal abuse after nursing staff got her out from behind the nurses' station. There was no evidence of what behaviors were present at the time other than the staff did not want her behind the nurses' desk. There was no evidence of what, if any, nonpharmacological methods were attempted prior to giving the PRN medication. The nurse said only, Resident became verbally abusive with staff on redirection from behind the nurse's station. Then followed a staff aid to the kitchen asking for a cigarette. Th… | 2020-02-01 |
| 4045 | 4045 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 353 | F | 0 | 1 | WA6611 | Based upon family interview, staff interview, review of staffing documentation, review of payroll information, review of incident reports, and review of reports documenting the provision of incontinence care for dependent residents, the facility failed to deploy sufficient qualified nursing staff across all shifts to provide nursing and related services and to ensure resident safety. These findings had the potential to affect all residents residing in the facility. Resident identifiers: #21, #26, #52, and #49 Facility census: 61. Findings include: a) During the survey, complaints regarding staffing were voiced on both of the facility's two (2) units, the second floor unit (Nursing Care Facility Two (NCF2)) and Nursing Care Facility One (NCF1). The units are completely separate. NCF2 currently houses primarily residents who need assistance or are totally dependent on nursing staff for their activities of daily living (ADLs). NCF1 currently houses primarily residents who are more mobile, require less staff assistance with ADLs, but may have dementia, mental illnesses, and behaviors. Because of the unique needs presented on each unit, they were investigated for adequate staffing separately. b) NCF2 1. Two (2) family members voiced concern about inadequate staffing on NCF2 during the early stages of the survey. Interviewee #1 said there were often staffing concerns on day shift. The individual thought there were supposed to be two (2) nurses and three (3) Nurse Aides (NA) on day shift, but usually there were only two (2) NAs, and sometimes only one N[NAME] Interviewee #1 said there were many times when their family member had to wait a long time for needed care, and as a result was sometimes left to sit or lie in their own excrement. Interviewee #1 said the staff tried their best, but they just could not do it with only four (4) staff, let alone with three (3). Lots of the residents needed assistance, some needed the assistance of two (2) staff, and when things got busy, lots of residents waited long time for help. I… | 2020-02-01 |
| 4046 | 4046 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 356 | C | 0 | 1 | WA6611 | Based upon observation, staff interview, and review of staffing and payroll documentation, the facility failed to post complete and accurate staffing information. This had the potential to affect all residents and visitors. Facility census: 61. Findings include: a) On 02/13/17 at 11:10 a.m., during the initial tour of the facility, staffing sheets posted for review by residents and visitors were observed on the second floor unit, Nursing Care Facility Two (NCF2). The posting showed the facility name, the date, the shift, the census, and the total hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Nurse Aides (NA), but did not show the total number of RNs, LPNs, and NAs working the shift. b) The 02/13/17 posting for the day shift showed there were two (2) nurses and one (1) nurse aide working on the unit. When asked if there was only one (1) NA working the day shift, RN #141 said the posting was not correct, that someone had come down from the third floor to cover and there were two (2). She pulled the posting sheet off the bulletin board and began to correct it. c) Complaints about inadequate staffing on both the second floor unit (NCF2) and the basement unit (NCF1) led to a detailed review of the staff posting, the schedules, and the payroll data for the period from 01/29/17 through 02/21/17. Numerous, almost daily discrepancies were noted between the posting sheets designed to keep residents and visitors informed about how many staff were working each unit and the actual hours reflected in the payroll information provided. d) When questioned about the discrepancies on 02/20/17 at 2:20 p.m., the facility's Administrator, #114, said, Almost none of the staff postings are accurate. | 2020-02-01 |
| 4047 | 4047 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 371 | E | 0 | 1 | WA6611 | Based on observation, staff interview, and facility policy review, the facility failed to prepare and store foods under safe and sanitary conditions. The outside oven doors were soiled, three (3) large storage bins containing sugar, flour, and thick-it sitting next to the oven were coated with grime, and the tile floor in the kitchen cooking area was dirty and stained. In addition, the residents' snack refrigerator contained unlabeled stored foods and a used hot/cold gel pack was stored among the frozen foods. These findings had the potential to affect all residents receiving foods from this central location. Facility census: 61. Findings include: a) Kitchen An initial tour of the kitchen on 02/13/17 at 11:29 a.m. with the Food Service Supervisor, revealed the following: -- the outside of the oven doors were soiled with dirt and running water marks. -- three (3) large storage bins on wheels containing sugar, flour, and thick-it sitting next to the oven/stove were soiled with dried grease and grime along the lower outer sides of the containers. -- the kitchen tile floor in the cooking area was stained and visibly dirty. A follow up observation of the kitchen on 02/22/17 at 8:30 a.m. with the Food Service Supervisor found same observations. The Food Service Supervisor was interviewed at this time and agreed the oven doors were soiled, the outside of the food storage bins located next to the oven/stove were coated with dried grease and grime, and the tile floor around the oven needed scrubbed. Kitchen cleaning schedules for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 1st through the 14th, (YEAR) were reviewed with the Food Service Manager during an interview on 02/22/17 at 8:40 a.m. She acknowledged the cleaning schedules all said at the top of the form, Clean on a weekly basis (daily if needed) and please initial. The Food Service Manager agreed all of the cleaning schedules were incomplete, indicating the kitchen staff did not complete their assigned weekly cleaning duties. b) Snack refrigerator An observation of … | 2020-02-01 |
| 4048 | 4048 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 428 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician responded to a pharmacy recommendation for the gradual dose reduction of an antipsychotic medication in a timely manner. This practice was found for one (1) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Resident identifier: #10. Facility census: 61. Findings include: a) Resident #10 On 02/21/17 at 1:17 p.m., medical record review revealed this Resident #10, admitted on [DATE], had [DIAGNOSES REDACTED]. He was currently receiving Risperdal (an antipsychotic medication) 0.25 milligrams (mg) by mouth daily twice a day (BID) for schizoaffective disorder. The pharmacist's consultation report dated 02/03/16 noted the resident was receiving Risperdal 0.25 mg BID. The pharmacist recommended, Please consider a gradual dose reduction (GDR) while monitoring for re-emergence of target and/or withdrawal symptoms. The physician signed the report on 03/08/16 declining the recommendation of a GDR for the antipsychotic medication Risperdal (and provided the rationale for declining the recommendation). The Director of Nursing (DON) signed the report on 03/23/16. After reviewing the pharmacy consultation report on 02/27/17 at 12:40 p.m., the DON stated, I anticipate the GDRs being returned with physician decline or acceptance within two (2) weeks. Absolutely that is not a timely response as you can see it was over a month before he (Physician) filled out the form and longer for him (Physician) to return it to me, of course it is not timely. | 2020-02-01 |
| 4049 | 4049 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 431 | E | 0 | 1 | WA6611 | Based on review of controlled medication sheets, pharmacy reports, staff interview, and policy review, the facility failed to ensure controlled substance records were complete and contained information to show complete reconciliation by on-coming and off-going nurses. This was found for four (4) of four (4) narcotic books (two on nursing home unit 1 and two on nursing home unit 2) reviewed during medication storage. This practice has the potential to affect all residents. Facility census: 61. Findings include: a) Review of the four (4) shift change controlled substance inventory logs dated (MONTH) 27, (YEAR) through (MONTH) 15, (YEAR) on 02/16/17 at 8:45 a.m., found there were seventy-seven (77) blank signature spaces for reconciliation of the controlled medication counts at the change of shifts identified. The Director of Nursing (DON) reviewed the controlled substance logs during an interview on 02/16/17 at 9:28 a.m. She stated, There should not be any blanks for signatures on the narcotic sheets, and yes, there certainly are a lot. A review of the facility's Controlled Substance Policy and Procedure on 02/16/17 at 9:15 a.m. revealed on page 2, titled Procedure C. The change of shift audit will include 1) physical count and reconciliation by the oncoming nurse of the drugs and the Individual Resident's Narcotic Record and 2) inspection of the packaging to ensure integrity. The nurse going off duty shall witness the count and reconciliation. All counts will be documented on a change of shift signature record On 02/16/17 at 9:28 a.m., review of the monthly pharmacy reports for (MONTH) (YEAR) and (MONTH) (YEAR) found the controlled substance logs were not reconciled according to facility procedures and there were irregularities with accurate and complete reconciliation. During a follow-up interview on 02/16/17 at 11:37 a.m., the DON stated, Yes, pharmacy had told me about these irregularities and it also was reviewed in the QA (Quality Assurance) meetings. I had done education with the staff, but evidently, more e… | 2020-02-01 |
| 4050 | 4050 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 441 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, 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. Residents' briefs and toiletries were improperly stored on the bathroom floor. Dirty plungers were found behind the commodes, and bathrooms were not routinely checked and cleaned as needed. These findings had the potential to affect more than a limited number of residents residing in the facility. Resident identifier: #74. Facility census: 61. Findings include: a) Resident rooms 1. An observation of the restroom in room [ROOM NUMBER] on 02/13/17 at 2:53 p.m., revealed -- a package of briefs on the floor next to the commode -- bottles of shampoo, moisturizer, body wash, and lotion sitting on the floor between the toilet and shower. 2. The restroom in room [ROOM NUMBER], observed at 3:00 p.m. on 02/19/17, had: -- a plunger in an open plastic bag behind the toilet -- an open bag of briefs stored on the floor next to the garbage can. Registered Nurse #116 viewed the restrooms in rooms [ROOM NUMBERS] during an interview on 02/13/17 at 3:41 p.m. She reported storing briefs and toiletries on the restroom floor and leaving a plunger in the bathroom were infection control issues. Staff should be making rounds and checking the residents' rooms. 3. An observation of room [ROOM NUMBER] on 02/13/17 at 3:02 p.m. revealed: -- a soiled brief on the floor to the right of the toilet and a pair of pants on the floor on the left side of the toilet. A follow up observation of the restroom in room [ROOM NUMBER] on 02/14/17 at 9:48 a.m., revealed: -- a soiled brief and pair of sweat pants with visible stool on the floor by the commode. -- Remnants of stool were on the bathroom floor in front of the toilet where the resident's feet would rest when sitting on the commode. -- During a follow up observation of room [ROOM NUMBER] … | 2020-02-01 |
| 4051 | 4051 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 463 | D | 0 | 1 | WA6611 | Based on observation and staff interview, the facility failed to ensure all portions of the call light system were functioning. The call light system for two (2) resident bathrooms did not light up in the hallway above the doors to the rooms to alert staff of the residents' need for assistance. This was found for two (2) of thirty-five (35) resident bathrooms. Room numbers: #29 and #2. Facility census: 61. Findings include: a) Observations of the facility during Stage 1 of the Quality Indicator Survey revealed two (2) rooms did not have adequately functioning bathroom call light systems to allow residents to call for assistance. -- Room #29 On 02/14/17 at 3:00 p.m. during a bathroom observation, when the bathroom call light was pulled it sounded and lit up at the nurses' station, but did not light up above the resident's room to alert staff of the location. The Nursing Home Administrator (NHA) was present during this observation and verified the bathroom call light did not light up above the resident's door. The NHA commented maintenance would be notified to repair the light over the resident's door immediately. -- Room #2 At 4:39 p.m. on 02/14/17 observation found when the bathroom call light was activated, it sounded and lit up at the nurses' station, but did not light up above the resident's room to alert staff of the location. Registered Nurse #141 verified the bathroom call light did not light up above the resident's door. She said maintenance would be notified to repair the light over the resident's door. | 2020-02-01 |
| 4052 | 4052 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 468 | E | 0 | 1 | WA6611 | Based on observation and staff interview, the facility failed to maintain the corridors on the long hall and short hall on nursing home unit 1 with firmly secured handrails on each side of the corridors. Multiple handrails in the corridors utilized by residents in the main thoroughfares were discovered to be loose and/or pulled out of the wall when grabbed/pulled by hand or used as support to assist with locomotion. This had the potential to affect more than an isolated number of residents residing on nursing home Unit 1 who require assistance and/or were dependent with locomotion. Facility census: 61. Findings include: a) Short hall on nursing home Unit 1 The corridor handrail was loose and not secured to the wall on either side outside of: -- Room #2, -- Room #4, and -- Room #6. b) Long hall on nursing home Unit 1 The corridor handrail was loose and not secured to the wall on either side outside of: -- Room #32. -- Room #33, and -- Room #40, and actually came loose from the wall exposing a hole and the bolt used to anchor the handrail to the wall. -- The corridor handrail outside of the Pantry room door was missing an end piece exposing a sharp jagged edge on the remaining center handrail piece. -- The corridor handrail outside of the dining/solarium/activity room had a two (2) inch by two (2) inch hole with a depth of three and a half (3-1/2) inches on the wall on the underside of the handrail where an anchor bolt was removed and placed further up on the handrail. c) At the conclusion of the tour, accompanied by Nursing Home Administrator #114, Maintenance Supervisor #42, and Housekeeping Supervisor #91 on 02/15/17 between 2:40 p.m. to 3:05 p.m., all agreed the observed problems needed repaired and/or replaced. When asked whether they were aware of the issues, Maintenance Supervisor #42 stated, Yes, I tour here every day and see this every day, but no repairs have been done. | 2020-02-01 |
| 4053 | 4053 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 490 | F | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, resident interviews, family interviews, confidential interviews, staff interviews, record review, review of staffing and payroll information, policy review, review of facility documents, and record review, the facility was not being 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. The facility failed to notify residents' responsible party and or physician of incidents, failed to identify occurrences and protect residents from sexual abuse, failed to report occurrences of abuse and neglect to required State agencies, failed to ensure a safe environment, failed to ensure residents received appropriate care for pressure ulcers, and failed to provide sufficient staff across all units and shifts to meet the needs of residents. These finding had the potential to affect all residents living in the facility. Facility census: 61. Findings include: a) The facility failed to notify residents' responsible parties and/or physician of incidents of resident-to-resident sexual abuse, failed to identify incidents of sexual abuse and protect the subjects of the abuse, and failed to report incidents of abuse and neglect to required agencies. Medical record reviews, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, found the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse, and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated no… | 2020-02-01 |
| 4054 | 4054 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 514 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, confidential interviews, and policy review, the facility failed to maintain complete, accurately documented clinical records of each resident. Staff failed to accurately monitor and document Resident #75's, Resident #74's, and Resident #33's pressure ulcers, to include depth, any exudate (wound drainage) and a description of the pressure ulcer including surrounding tissue. Resident #74's medical record also contained an incorrect discharge date documented on the form used to document pressure ulcers. In addition, residents' medical records lacked documentation of incidents of sexual abuse. This practice had the potential to affect all residents residing in the facility. Resident identifiers: #75, #74, #33, #26, #39, #51, #49, #24, #37, and #1. Facility census: 61. Findings include: a) Resident #75 Review of the medical record on 02/15/17 at 9:07 a.m. found Resident #75, admitted on [DATE], had [DIAGNOSES REDACTED]. He was discharged from the facility to home on 01/18/17. The wound/pressure ulcer forms lacked documentation of any measurement of wound depth if present, exudate, description of the wound bed and surrounding tissue. -- On 12/27/17, the wound/pressure ulcer size was documented as 1 cm (centimeter) x (by) 1 cm -- On 01/02/17, the wound/pressure ulcer size was documented as 0.25 cm round -- On 01/9/17, the wound/pressure ulcer size was documented as not open -- On 01/16/17 the wound/pressure ulcer size was documented as not open The column titled Eschar/Necrotic was blank. The column titled site was documented on each of the previous dates as L (left) buttock. Also, a handwritten discharge date of [DATE] was documented on the form, when the resident was discharged from the facility on 01/18/17. After reviewing the wound/pressure ulcer forms for Resident #75 on 02/15/17 at 9:00 a.m., the Assistant Director of Nursing (ADON)/Wound Nurse #112 stated, No the form does not show an accurate measurem… | 2020-02-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );