CMS-Nursing-Home-Full-Deficiencies

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid	facility_name	facility_id	address	city	state	zip	inspection_date	deficiency_tag	scope_severity	complaint	standard	eventid	inspection_text	filedate
9163	CLARY GROVE	515039	209 CLOVER STREET	MARTINSBURG	WV	25404	2013-01-23	224	G	1	0	71W211	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure residents were free of neglect by failing to assess, monitor, and provide medical intervention timely, for an [AGE] year old resident with diabetes and an existing pressure ulcer when she developed a blackened area on her right great toe. There was no evidence of assessments or interventions until six (6) days after the initial identification. This delay had the potential to adversely affect the progression of the wound and comfort of the resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 This [AGE] year old resident had [DIAGNOSES REDACTED]. She also had a had been receiving treatment for [REDACTED]. A progress note, dated 12/13/12, by Employee #126, a licensed nurse, identified the family's concern with the resident's great toe on the right foot. The nurse assessed the area, and noted a dark purple hematoma on toe. No evidence of any additional assessment or monitoring of the changes to the right great toe were found until six (6) days later on 12/19/12 at 5:47 a.m. On 12/19/12 at 5:47 a.m., a registered nurse (Employee #1), documented Resident has blackened area on right great toe and 4th great toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . No dorsal or post tibia pulse appreciated with Doppler. Left foot has sore on 2nd toe . Will report to MD (doctor). In an interview with Employee #126, on 01/23/13 at 8:50 a.m., she said she had faxed the physician about the right great toe on 01/13/12, and verbally passed the information to the oncoming shift. She said the right great toe looked purple, it seemed to have been a sudden change, and had given the appearance of perhaps having been bumped. Employee #82 (registered nurse) was interviewed on 01/23/13 at 9:05 a.m. She said they kept copies of faxes sent to the physician in the physicians' mailboxes until they received a response. They would re-fax the physician if there was no response. All resolved faxes were filed in a book at the desk. This book was thinned on occasion when it was getting larger, and the older ones were shredded. Review of the resolved fax book, on 01/23/13 at 9:10 a.m., found the faxes in the book only went back to 12/20/12. An interview with the director of nursing (DON), on 01/23/13 at 1:45 p.m., revealed the first time the condition of the resident's right great toe had been placed on the 24-hour report was on 12/19/12. This was after Employee #1 had written the entry about the condition of the resident's toe and noted to call the doctor. The DON said an appointment was then made with the podiatrist, who saw the resident on 12/19/12 at 4:45 p.m. She could find no evidence to support a physician had been notified, or had evaluated the toe, between 12/13/12 and 12/19/12. The podiatrist's progress note, dated 12/19/12, noted Resident #119 had dry gangrene of the right hallux (big toe). He recommended the resident be seen by an orthopedic physician as soon as possible. According to the resident's record, her medical power of attorney had made an appointment for 12/27/12 with an orthopedic surgeon. However, due to an increase in the resident's level of pain, she was sent to a local hospital on [DATE], at which time she was admitted . According to a 12/25/12 nursing progress note, the resident was transferred for pain evaluation due to uncontrolled pain in the right lower leg. Review of the admitting hospital's medical records, revealed that upon admission the resident was found to have avascular (having few or no blood vessels) right great toe with a lot of pain and color changes, and gangrene due to secondary diabetes mellitus. An orthopedic consultation dated 12/16/12 revealed an impression of dry gangrene, right foot, and a recommendation for a BKA ([MEDICAL CONDITION]) right lower extremity. She underwent a right [MEDICAL CONDITION] on 12/27/12. Resident #119 had been admitted to the facility in November 2012 with a Stage II pressure ulcer to the right heel. This was the same foot on which the great toe had a blackened area. Record review found the absence of a weekly body audit on 12/11/12, with the most recent body audit having occurred on 12/04/12, and the next on 12/17/12. Neither noted the condition of the right great toe. Record review also found the absence of a weekly measurement and assessment of the pressure ulcer to the right heel on 12/20/12, with the most recent one having occurred on 12/13/12, and no other prior to her transfer to the hospital on [DATE]. Interview with licensed nurse Employee #81, on 01/22/13 at 9:30 a.m., found that every resident was to have a skin audit done weekly. Although they were usually done by the treatment nurse, the floor nurses were to do them in the absence of the treatment nurse. During an interview with the Director of Nursing (DON), on 01/22/13 at 2:45 p.m., she produced weekly body audit sheets dated 12/04/12 and 12/17/12 for Resident #119. She was unable to locate a body audit sheet for 12/11/12 at that time, or prior to exit. She said that body audits were to be done weekly.	2016-01-01
9164	CLARY GROVE	515039	209 CLOVER STREET	MARTINSBURG	WV	25404	2013-01-23	280	D	1	0	71W211	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to revise an eight-five year old diabetic resident's care plan following a change in condition of her skin. One (1) of nine (9) sampled residents was affected. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Record review revealed a nursing progress note, dated 12/13/12, that identified the family's concern with the resident's right great toe. The nurse documented Noted dark purple hematoma on toe. Record review revealed the next documentation related to the right great toe occurred on 12/19/12 at 5:47 a.m., when Employee #1 (a nurse) identified in a nursing progress note, Resident has blackened area on right great toe and 4th toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . No dorsal or post tibial pulse appreciated with doppler. Left foot has sore on 2nd toe. A nursing entry, dated 12/19/12 at 9:16 a.m., noted the wound care nurse, Employee #136, had inspected the resident's toe. An appointment with a podiatrist was then requested on 12/19/12, and was obtained for 4:45 p.m. later that day. Review of the podiatrist's progress note for the 12/19/12 visit, revealed a [DIAGNOSES REDACTED]. A nurses' note indicated the medical power of attorney had secured an appointment with an orthopedic surgeon for 12/27/12. However, due to an escalation in the resident's level of pain, she was transferred to the emergency roiagnom on [DATE], where she was admitted . Review of the resident's care plan revealed the absence of any revisions related to the new problems identified with the skin, and/or circulation to the resident's right foot and toe. During an interview with the Director of Nursing (DON), on 01/23/13 at 1:45 p.m., she agreed the care plan for this resident had not been revised to include the change in condition of the right great toe first identified on 12/13/12.	2016-01-01
9165	CLARY GROVE	515039	209 CLOVER STREET	MARTINSBURG	WV	25404	2013-01-23	309	G	1	0	71W211	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide medical intervention timely, and/or ongoing monitoring and assessments, to a resident who had a change in condition. An [AGE] year old resident with diabetes developed a change in condition to her right great toe, with no known interventions and/or assessments until six (6) days after the initial assessment. This delay in treatment had the potential to adversely affect the progression of the wound and comfort of the resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 This [AGE] year old resident had [DIAGNOSES REDACTED]. According to the resident's medical record, this resident had been treated for [REDACTED]. A progress note, dated 12/13/12, by Employee #126, a licensed nurse, identified the family's concern with the resident's great toe on the right foot. The nurse assessed the area, and noted a dark purple hematoma on toe. Record review found no evidence of assessment or monitoring of the changes to the right great toe until six (6) days later on 12/19/12 at 5:47 a.m. A progress note, dated 12/19/12 at 5:47 a.m., by a registered nurse (Employee #1), revealed a change of condition note that assessed the Resident has blackened area on right great toe and 4th great toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . No dorsal or post tibia pulse appreciated with Doppler. Left foot has sore on 2nd toe . Will report to MD (doctor). During an interview with Employee #126 on 01/23/13 at 8:50 a.m., she said she faxed the physician about the right great toe on 01/13/12, and verbally passed the information to the oncoming shift. She said the right great toe looked purple, it seemed to have been a sudden change, and had given the appearance of perhaps having been bumped. During an interview with Employee #82 (registered nurse) on 01/23/13 at 9:05 a.m., she said they keep copies of faxes sent to the physician in the physicians' mailboxes until they received a response. They would re-fax the physician if there was no response. All resolved faxes were filed in a book at the desk. This book was thinned on occasion when it was getting larger, and the older ones were shredded. Review of the resolved fax book, on 01/23/13 at 9:10 a.m., found the faxes in the book only went back to 12/20/12. An interview with the director of nursing (DON), on 01/23/13 at 1:45 p.m., revealed that the first time the right great toe issue was placed on the 24-hour report occurred on 12/19/12, after Employee #1 wrote the entry and noted to call the doctor. The DON said an appointment was then made with the podiatrist, who saw the resident on 12/19/12 at 4:45 p.m. She could produce no evidence that a physician had been notified, or had evaluated the toe, between 12/13/12 and 12/19/12. Review of the podiatrist's progress note, dated 12/19/12, revealed his assessment that Resident #119 had dry gangrene of the right hallux (big toe). He recommended that the resident be seen by an orthopedic physician as soon as possible. Record review revealed the resident's medical power of attorney made an appointment for 12/27/12 with an orthopedic surgeon. However, due to an increase in the resident's level of pain, she was sent to a local hospital on [DATE], where she was subsequently admitted . According to a 12/25/12 nursing progress note, the resident was transferred for pain evaluation due to uncontrolled pain in the right lower leg. Review of the admitting hospital's medical records, revealed that upon admission she was found to have avascular (having few or no blood vessels) right great toe with a lot of pain and color changes, and gangrene due to secondary diabetes mellitus. An orthopedic consultation dated 12/16/12 revealed an impression of dry gangrene, right foot, and a recommendation for a BKA ([MEDICAL CONDITION]) right lower extremity. She underwent a right [MEDICAL CONDITION] on 12/27/12. Additionally, it was found that Resident #119 was admitted to the facility in November 2012 with a Stage II pressure ulcer to the right heel. This was the same foot on which the great toe had a blackened area. Record review found the absence of a weekly body audit on 12/11/12, with the most recent body audit having occurred on 12/04/12, and the next on 12/17/12. Record review also found the absence of a weekly measurement and assessment of the pressure ulcer to the right heel on 12/20/12, with the most recent one having occurred on 12/13/12, and no other prior to her transfer to the hospital on [DATE]. Interview with licensed nurse Employee #81, on 01/22/13 at 9:30 a.m., found that every resident is to have a skin audit done weekly. Although they are usually done by the treatment nurse, the floor nurses do them in the absence of the treatment nurse. During an interview with the Director of Nursing (DON), on 01/22/13 at 2:45 p.m., she produced weekly body audit sheets dated 12/04/12 and 12/17/12 for Resident #119. She was unable to locate a body audit sheet for 12/11/12 at this time, or prior to exit. She said that body audits were to be done weekly.	2016-01-01
9166	CLARY GROVE	515039	209 CLOVER STREET	MARTINSBURG	WV	25404	2013-01-23	314	E	1	0	71W211	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review, the facility failed to provide all necessary treatment or services to promote and monitor wound healing. This had the potential to affect any resident in the facility with pressure ulcers. The facility failed to observe and/or measure pressure ulcers at regular intervals, as evidenced by omission of a weekly wound measurement for six (6) of eight (8) sampled residents with pressure ulcers. The facility also failed to complete body audits every week for one (1) of nine (9) sampled residents. Resident identifiers: #119, #1, #2, #108, #107, and #4. Facility census: 88. Findings include: a) Resident #119 Record review found that Resident #119 was admitted to the facility in November 2012 with a Stage II pressure ulcer to the right heel. Record review found the absence of a weekly body audit on 12/11/12, with the most recent body audit having occurred on 12/04/12, and the next on 12/17/12. Record review also found the absence of a weekly measurement and assessment of the pressure ulcer to the right heel on 12/20/12, with the most recent one having occurred on 12/13/12, and no other prior to her transfer to the hospital on [DATE]. Interview with licensed nurse Employee #81, on 01/22/13 at 9:30 a.m., found that every resident is to have a skin audit done weekly. Although they are usually done by the treatment nurse, the floor nurses do them in the absence of the treatment nurse. During an interview with the Director of Nursing (DON), on 01/22/13 at 2:45 p.m., she produced weekly body audit sheets dated 12/04/12 and 12/17/12 for Resident #119. She was unable to locate a body audit sheet for 12/11/12 at this time, or prior to exit. She said that body audits were to be done weekly. During an interview with the DON, on 01/22/13 at 3:30 p.m., she said pressure ulcer assessments/PUSH scores are to be completed weekly for residents with pressure ulcers. After reviewing the Pressure Ulcer Healing Chart for this resident and for five (5) other residents with pressure ulcers, she agreed there was no pressure ulcer assessment/PUSH score completed on 12/20/12 for Resident #119. The last one completed on Resident #119 was on 12/13/12, and there were no others prior to her discharge to the hospital on [DATE]. Assessments were also recorded on a skin managment program assessment tool, but the DON was also not able to find assessments for 12/20/12 on that tool, either. During interview with the Director of Nursing (DON) on 01/23/12 at 1:30 p.m., she produced the Skin Process Flow sheet, which is part of their policy and procedure for assessing, planning, implementing and evaluating the condition of residents' skin. Review of this Skin Process Flow sheet, found that if a skin alteration is a pressure ulcer, the facility is to implement the PUSH Tool. The PUSH tool assesses the length by width of the pressure ulcer, exudate amount, and tissue type, which combined will produce a total score that can be used to monitor trends/scores over time. The DON said these are to be done weekly on all pressure ulcers. b) Resident #1 Record review revealed Resident #1 had a pressure ulcer to the coccyx with inception date 08/28/12. Record review found the absence of a weekly measurement and assessment of the pressure ulcer to the coccyx on 12/20/12. During an interview with the DON, on 01/22/13 at 3:30 p.m., she said pressure ulcer assessments/PUSH scores are to be completed weekly for all residents with pressure ulcers. After reviewing the Pressure Ulcer Healing Chart for this resident and for five (5) other residents with pressure ulcers, she agreed there was no pressure ulcer assessment/PUSH score completed on 12/20/12 for Resident #1. The last one completed on Resident #1 occurred on 12/13/12, and the next on 12/27/12, which is a two (2) week lapse. No other pressure ulcer assessments/measurements for 12/20/12 were produced prior to exit. Assessments are also recorded on a skin managment program assessment tool, but the DON was also unable to find assessments for 12/20/12 on that tool, either. c) Resident #2 Record review revealed that Resident #2 had a pressure ulcer to the coccyx with an inception date 11/28/12. Record review found the absence of a weekly measurement and assessment of the pressure ulcer to the coccyx on 12/20/12. During interview with the DON on 01/22/13 at 3:30 p.m. she said pressure ulcer assessments/PUSH scores are to be completed weekly for all residents with pressure ulcers. After reviewing the Pressure Ulcer Healing Chart for this resident and for five (5) other residents with pressure ulcers, she agreed there was no pressure ulcer assessment/PUSH score completed on 12/20/12 for Resident #2. The last one completed on Resident #2 occurred on 12/13/12, and the next on 12/27/12, which is a two (2) week lapse. No other pressure ulcer assessments/measurements for 12/20/12 were produced prior to exit. Assessments are also recorded on a skin managment program assessment tool, but the DON was also unable to find assessments for 12/20/12 on that tool, either. d) Resident #108 Record review revealed that Resident #108 had a pressure ulcer to the coccyx with inception date 11/20/12. Record review found the absence of a weekly measurement and assessment of the pressure ulcer to the coccyx on 12.20/12. During interview with the DON on 01/22/13 at 3:30 p.m. she said pressure ulcer assessments/PUSH scores are to be completed weekly for all residents with pressure ulcers. After reviewing the Pressure Ulcer Healing Chart for this resident and for five (5) other residents with pressure ulcers, she agreed there was no pressure ulcer assessment/PUSH score completed on 12/20/12 for Resident #108. The last one completed on Resident #108 occurred on 12/13/12, and the next on 12/27/12, which is a two (2) week lapse. No other pressure ulcer assessments/measurements for 12/20/12 were produced prior to exit. Assessments are also recorded on a skin managment program assessment tool, but the DON was also unable to find assessments for 12/20/12 on that tool, either. e) Resident #107 Record review revealed that Resident #107 had a pressure ulcer to the mid-[MEDICATION NAME] with inception date 12/07/12. Record review found the absence of a weekly measurement and assessment of the pressure ulcer to the mid-[MEDICATION NAME] area on 12/20/12. During interview with the DON on 01/22/13 at 3:30 p.m. she said pressure ulcer assessments/PUSH scores are to be completed weekly for all residents with pressure ulcers. After reviewing the Pressure Ulcer Healing Chart for this resident and for five (5) others, she agreed there was no pressure ulcer assessment/PUSH score completed on 12/20/12 for Resident #107. The last one completed on Resident #107 occurred on 12/13/12, and the next on 12/27/12, which is a two (2) week lapse. No other pressure ulcer assessments/measurements for 12/20/12 were produced prior to exit. Assessments are also recorded on a skin managment program assessment tool, but the DON was also unable to find assessments for 12/20/12 on that tool, either. f) Resident #4 Record review revealed that Resident #4 had a pressure ulcer to the coccyx with inception date 11/30/12. Record review found the absence of a weekly measurement and assessment of the pressure ulcer to the coccyx on 12/20/12. During interview with the DON on 01/22/13 at 3:30 p.m. she said pressure ulcer assessments/PUSH scores are to be completed weekly for all residents with pressure ulcers. After reviewing the Pressure Ulcer Healing Chart for this resident and for five (5) other residents with pressure ulcers, she agreed there was no pressure ulcer assessment/PUSH score completed on 12/20/12 for Resident #4. The last one completed on Resident #4 occurred on 12/13/12, and the next on 12/27/12, which is a two (2) week lapse. No other pressure ulcer assessments/measurements for 12/20/12 were produced prior to exit. Assessments are also recorded on a skin managment program assessment tool, but the DON was also unable to find assessments for 12/20/12 on that tool, either.	2016-01-01
9167	HILLTOP CENTER	515061	PO BOX 125	HILLTOP	WV	25855	2013-01-01	272	D	1	0	8XAM11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the accuracy of Section J of the Minimum Date Set (MDS) assessment, related to the number of falls and type of injury, for two (2) of five (5) sample residents identified as having falls. Resident identifiers: #32 and #111. Facility census: 110. Findings include: a) Resident #32 Review of the facility's Resident/Patient Incident Reports found Resident #32 had two (2) unwitnessed falls. These occurred on 10/04/12 and 10/16/12. The MDS review found a five (5) day Medicare MDS with an assessment reference date (ARD) of 10/23/12. Section J, item J1800, regarding health conditions, asked Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS), whichever is more recent? The assessor of the MDS coded the resident as having no falls between this assessment and the prior significant change MDS with an ARD of 09/12/12. Employee #15, the clinical care reimbursement coordinator, was interviewed on 12/31/12 at 3:30 p.m. She verified the MDS, with an ARD of 10/23/12, did not capture the resident's falls which occurred on 10/04/12 and 10/16/12. The director of nursing (DON), Employee #126, was also interviewed on 12/31/12 at 4:00 p.m. The DON provided no further information. b) Resident #111 Medical record review revealed Resident #111 was admitted to the facility on [DATE]. A review of the incident reports, nurses' notes, and the emergency room report revealed Resident #111 had fallen from bed, on 09/06/12 at 9:30 p.m., at the facility. Injuries sustained as a result of the fall were: hematoma and swelling on the left forehead and left upper and lower eyelids. A flap laceration was noted on the left elbow/forearm which was deep, involving muscle. Sutures to this area were attempted, but the resident's frail skin was unable to sustain the sutures. Review of the admission MDS, with an assessment reference date of 09/07/12, found the assessor noted the type of injury since admission under Section J1900 as follows: - Fall with no injury - one (1) - Fall with injury (except major) - none - Fall with major injury - none An interview was conducted on 12/31/12 at 1:30 p.m. with Employee #48, the MDS coordinator, who confirmed the above MDS was coded inaccurately regarding the extent of injury noted from falls since admission.	2016-01-01
9168	HILLTOP CENTER	515061	PO BOX 125	HILLTOP	WV	25855	2013-01-01	279	D	1	0	8XAM11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility's interdisciplinary team failed to develop a comprehensive care plan to address the care needs and to describe the services needed for one (1) of five (5) sample residents regarding accidents/falls. There was no care plan for fall prevention for this resident who had a history of [REDACTED].#111. Facility census: 110 Findings include: a) Resident #111 Review of Resident #111's medical record revealed this resident was admitted to the facility on [DATE]. According to the hospital discharge summary provided on admission, this resident had generalized weakness and a documented fall which occurred during her hospitalization . Facility admission orders [REDACTED]. A fall risk assessment, completed by the facility, on 09/01/12, noted the resident was at risk for falls. According to nursing notes and an incident report, dated 09/06/12 at 9:30 p.m., Resident #111 was sitting up on the side of the bed. Staff heard her fall. Upon entering the resident's room, she was found lying on her back. She had a bruise on her left forehead, and her left upper and lower eyelids were [MEDICAL CONDITION]. A deep skin tear was noted on her left elbow and left forearm. The resident stated she hit her head when she fell . She was transferred to the hospital for evaluation due to the deep laceration on her left elbow/forearm and possible head injury. The resident returned to the facility on [DATE] a 1:20 a.m. The hospital had been unable to suture the laceration on the left elbow/forearm. Review of the resident's care plan revealed no interim or immediate care plan regarding the resident's risk for falls at the time of the residents's fall on 09/06/12. The information was available in the hospital discharge summary provided on admission on 08/31/12. In addition, the facility completed a fall risk assessment, on 09/01/12, and noted the resident was at risk for falls. On 01/01/13 at 10:00 a.m., Employee #126, the director of nursing (DON), confirmed there was no interim or immediate care plan in place regarding fall prevention at the time of the resident's fall on 09/06/12. The DON could not provide any evidence direct care staff were aware of safety measures for this resident to prevent falls.	2016-01-01
9169	HILLTOP CENTER	515061	PO BOX 125	HILLTOP	WV	25855	2013-01-01	280	D	1	0	8XAM11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to review and revise a resident's comprehensive care plan to address changes in condition and needs for one (1) of five (5) sample residents. This resident's care plan was not updated to reflect a [MEDICAL CONDITION] with surgical repair when the resident was readmitted to the facility from the hospital. Resident identifier: #87. Facility census: 110. Findings include: a) Resident #87 review of the resident's medical record revealed [REDACTED]. The resident was admitted to the hospital on [DATE], with a [DIAGNOSES REDACTED]. The resident was readmitted to the facility, on 11/08/12, after the surgical repair of the fracture. Review of the current comprehensive care plan revealed it had not been updated to include the [MEDICAL CONDITION]/femur until 12/18/12. This was nearly six (6) weeks after the resident was readmitted from the hospital after the surgical repair of the fracture. During an interview with Employee #126, the director of nursing (DON), on 01/01/13 at 10:00 a.m., she was unable to provide evidence the care plan, regarding care and services required related to the [MEDICAL CONDITION]/femur, was updated prior to 12/18/12. The DON agreed the care plan should have been updated upon the resident's readmission to facility on 11/08/12.	2016-01-01
9170	HILLTOP CENTER	515061	PO BOX 125	HILLTOP	WV	25855	2013-01-01	282	D	1	0	8XAM11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure implementation of established care plans for one (1) of five (5) sample residents. The resident's care plan identified a specific intervention regarding the use of a soft helmet for this resident. This approach was to be implemented by the direct care staff (nursing assistants), but was not implemented. Resident identifier: #87. Facility census: 110. Findings include: a) Resident #87 Medical record review found an order written [REDACTED]. It read, Soft helmet at all times when OOB (out of bed). Review of the resident's current comprehensive care plan revealed the resident refused to wear the helmet as ordered. One of the interventions regarding this was, Staff to continue to encourage patient to wear soft helmet when awake. A confidential interview, conducted on 01/01/13 at 9:00 a.m., discovered nursing assistant (NA) communication regarding care plans was found in the activity of daily living (ADL) book. Each resident had a form known as a Kardex, which was located in front of their ADL flow sheets. This Kardex provided the NAs with information from the resident's care plan, which NAs were to implement when caring for the resident. Review of the ADL book containing Resident #87's ADL flow sheet revealed there was no Kardex. An interview conducted with Employee #126, the director of nursing (DON), confirmed there was no Kardex in front of Resident #87's ADL flow sheet. On 01/01/13 at 9:20 a.m. a Kardex for Resident #87 was provided by the DON. Review of the Kardex revealed there was no information regarding the soft helmet. At that time, the DON confirmed this care plan information was not on the Kardex for implementation by the NAs.	2016-01-01
9171	HILLTOP CENTER	515061	PO BOX 125	HILLTOP	WV	25855	2013-01-01	309	D	1	0	8XAM11	br>Based on closed medical record review, review of the facility's policy and procedure for neurological assessment, review of incident reports, and staff interview, the facility failed to monitor and assess neurological vital signs in accordance with facility policy after a resident fell out of bed and hit her head on the floor. This affected one (1) of five (5) sample residents reviewed who fell and hit their heads. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 Review of incident reports revealed a report, dated 09/06/12 at 9:30 p.m., which described this resident had fallen. The report included, Resident sitting up on side of bed prior to fall. Aide heard resident fall to floor. Resident found on floor beside bed. Resident alert and states hit head. One bruise on forehead and another on eye and cheek of left side. Skin tear (deep) on left elbow. Floor free of clutter. Head placed a foot away from night stand and resident between bed and sink. Lying on back. Resident denies pain and sat up to be put back to bed. fell out of right side of bed (side facing door). No mats in place. Bed low. Review of Resident #111's neurological assessment flow sheet, revealed neurological checks were completed as follows: -09/06/12- 9:30 p.m.-completed -09/06/12- 9:45 p.m.- completed -09/06/12-10:00 p.m.- completed -09/06/12-10:15 p.m.- Out of facility to acute care facility for evaluation -09/07/12-completed- Back in facility from acute care facility -09/07/12- completed No further entries were noted on the form. A review of facility's policy and procedures for neurological assessment revealed the following: Policy- Neurological assessment will be performed as indicated or ordered. When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessment will be performed: -every 30 minutes x two hours, then -every one hour x four hours, then -every four hours x 24 hours Purpose- To monitor patient for neurological compromise. An interview with Employee #126, the director of nursing, on 01/01/13 at 10:00 a.m., confirmed there were no further neurological assessments on the resident's flow sheet. She was unable to provide evidence the facility completed neurological assessments, as required by facility policy, on 09/07/12. .	2016-01-01
9172	HILLTOP CENTER	515061	PO BOX 125	HILLTOP	WV	25855	2013-01-01	323	D	1	0	8XAM11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to implement physician ordered safety interventions to prevent injuries in the event of a fall for one (1) of five (5) sample residents reviewed, who had fallen at the facility. The resident was known to be at risk for falls. She had a physician's orders [REDACTED]. The mats were not in place at the time of a fall on 09/06/12. The resident sustained [REDACTED]. Resident identifier #111. Facility census: 110. Findings include: a) Resident #111 Review of the resident's discharge summary, dated 08/31/12, from an acute care hospital revealed the resident had fallen from bed while in the hospital. Review of the resident's medical records revealed a physician's orders [REDACTED]. The facility also completed a fall risk assessment on 09/01/12, which indicated the resident was at risk for falls. Review of an incident, dated 09/06/12 at 9:30 p.m., for this resident, included the following information: Resident sitting up on side of bed prior to fall. Aide heard resident fall to floor. Resident found on floor beside bed. Resident alert and states hit head. One bruise on forehead and another on eye and cheek of left side. Skin tear (deep) on left elbow. Floor free of clutter. Head placed a foot away from night stand and resident between bed and sink. Lying on back. Resident denies pain and sat up to be put back to bed. fell out of right side of bed. No mats in place. Bed low. During an interview with Employee #126, the director of nursing (DON) on 01/01/13 at 10:00 a.m., she was informed of the findings related to this resident's fall. The DON was unable to provide evidence the mats were in place at the time of the fall on 09/06/12.	2016-01-01
9173	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	221	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, policy review, and staff interview, the facility failed to ensure each resident was free from any physical restraints not required to treat the resident's medical symptoms. One (1) of thirty-six (36) Stage II sample residents was placed in a beanbag chair (which prevented him from rising) without a written physician's order for its use to treat a medical symptom. Resident identifier: #62. Facility census: 90. Findings include: a) Resident #62 1. At approximately 3:00 p.m. on 01/24/11, observation found Resident #62 to be sliding out of his positional chair while located in the living room area. Only one (1) aide was present in the room, and she placed a beanbag chair that had been positioned adjacent to his chair under him, so that he slid out of the positional chair and onto the beanbag chair. At 4:30 p.m. on 01/24/11, this surveyor observed the resident still reclining in the beanbag chair receiving one-on-one (1:1) supervision by a nursing assistant (Employee #80) while a licensed practical nurse (LPN - Employee #43) worked nearby. The resident was very confused, making snoring sounds, and hitting out (ineffectively) at staff. During an interview with Employee #43 at this time, she stated they use the beanbag chair when the resident is so agitated that they cannot get him in any other chair without fear that he will throw himself out or turn the chair over. A subsequent review of incident reports verified this behavior. The incident reports indicated the falls were usually from his positional chair with a safety belt harness in place. The resident was strong and would shift his weight to one (1) side and, then, upset chair. He had six (6) reported falls of this type in the last two (2) months (on 01/24/11, 01/18/11, 12/15/10, 12/13/10, 12/05/10, and 12/01/10). A follow-up visit, at 5:45 p.m., revealed Resident #62 was in a positional chair being fed by a nurse aide. When he had finished eating, he was moved away from the other residents and was provided a 1:1 caregiver (Employee #60). He was still very awake and trying to rise, although the nurse (Employee #43) stated he had received [MEDICATION NAME] to help him calm down. -- 2. A review of Resident #62's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. -- 3. During interviews with a nurse (Employee #105) and a nursing assistant (Employee #46) at 11:00 a.m. on 01/25/11, they verified Resident #62 can upset his chair when he becomes agitated, and they stated he even calls out to staff of his intention to do so. The nurse stated that, because of his falls, she and the therapist have been investigating different types of chairs. She also stated that they used a beanbag chair at times and provide 1:1 direct supervision (which he was receiving on this day) when necessary. They both stated staff got the resident up early, and he would spend his day in the positional chair as he was no longer ambulatory, even with assistance. He was toileted by staff and could, at times, support his weight to pivot to the commode. This resident no longer ambulated, even with assistance, and this was evidenced in a note by the physical therapist on 09/29/10, which stated: Mr. (name of Resident #62) is no longer able to ambulate. Can bear wt. but does not do this functionally. -- 4. In an interview with the occupational therapist (Employee #149) at 9:30 a.m. on 02/01/11, she produced a manila envelope of materials about various types of chairs (including BRODA) that she had ordered in an attempt to prevent Resident #62 from overturning his chair. She stated several interventions had been tried without success (including a helmet), but as he was not currently a therapy patient (he was discharged from rehabilitative services on 11/01/10), she had kept no record of these actions and had no input into his current care plan. When asked about the use of the beanbag chair for Resident #62, Employee #149 stated beanbag chairs were used for extremely agitated residents who were thrashing about, to prevent their harming themselves by hitting the chair or turning over. Employee #149 further stated the use of this chair had been considered for Resident #62 and was ruled out, because of the curvature of his back from an old injury (which meant he needed extra support). When she was told of the surveyor's observations of Resident #62 in a beanbag chair, she expressed surprise and stated there was only one (1) resident in the facility with an order for [REDACTED]. -- 5. Review of the facility's Operational Policy and Procedure Manual for Restraints found: Policy Interpretation and Implementation 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 7.d. The Director of Nursing Services or designee has the authority to order the use of emergency restraints. The Attending Physician must be notified of such use and the reason for the order. 7.e. Orders for emergency restraints may be received by telephone, and shall be signed by the physician within forty eight 48) hours. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. -- 6. Review of Resident #62's current care plan revealed an entry, dated 07/02/10, stating, Belt restraint in chair for safety. Also has PRN (as needed) order for Velcro postural vest. This same information was also on the Life Skill Sheet (caregiver instruction sheet). The belt restraint was noted to be in place while he was in the positional chair, on several observations during the survey. -- 7. A review of the physician's orders for Resident #62 revealed the following restraint orders: Resident to be up in blue positioning chair with safety belt (in upright position) when out of bed. Check Q (every) 30 min for positioning and breathing checks. Q 2 hr (every 2 hours) releases for ambulation, bathroom, meals, skin inspection etc. NOC AM PM (night, morning, and evening). Notify Staff. Dx: resident with dementia causing him to be unaware of risk of injury by getting up unassisted, tipping chair and falling from chair. There was no physician's order or care plan for the use of the beanbag chair. There was no PRN order for the use of [REDACTED]. While the care plan recognized the use of the positional chair and the belt restraint and established a goal related to restraint use, there were no interventions for the use of restraints with this resident, as required by the facility policy. -- 8. During an interview with the director of nurses (DON), the administrator, and a registered nurse (RN) supervisor (Employee #28) at 4:20 p.m. on 02/01/11, the above findings were reviewed, and the DON expressed surprise that there were no restraint orders or care plan for Resident #62, stating she would review his record and follow-up with this surveyor. The administrator stated that beanbag chairs are never used without a physician's order. No additional information had been presented prior to this surveyor's exit on 02/02/11.	2016-01-01
9174	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	272	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to assure the accuracy of an initial physical assessment and a minimum data set assessment (MDS) for two (2) of thirty-six (36) Stage II sample residents. Resident #109's admission nursing assessment was inaccurate related to the absence of skin breakdown, and two (2) of Resident #34's MDS assessments were inaccurate related to the absence of contractures. Resident identifiers: #109 and #34. Facility census: 90. Findings include: a) Resident #109 When reviewed on 01/31/11, the medical record of Resident #109 divulged the resident had been admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Assessment by a facility nurse on the day of admission (12/22/10) stated the resident has had no foot problems or care in past seven (7) days. Review of the resident's care plan revealed that, shortly after admission on 01/05/11, a problem statement was added to address the presence of stage II pressure areas. (A Stage II pressure area is described by the National Pressure Ulcer Advisory Panel at www.npuap.org as a partial thickness of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open / ruptured serum filled blister.) A facility nurse (Employee #135), when interviewed on 02/01/11 at approximately 10:00 a.m., was asked why this skin breakdown was not recognized prior to progressing to Stage II. Another facility nurse (Employee #139) presented a written document, which identified as having been acquired from the hospital from where the resident had been discharged immediately preceding his admission to the nursing home. Employee #139 stated the information had been received upon request by the facility on the previous evening (01/31/11). This document included an evaluation of the resident dated 12/22/10 at 7:50 a.m., which noted patient heels pink and spongy bilat (bilaterally). The resident had been first assessed at the nursing home at 7:12 p.m. on 12/22/10, at which time the nursing assessment stated the resident has had no foot problems or care in past seven (7) days. Employee #135 confirmed, on 02/01/11 at 10:00 a.m., that the resident's skin condition had been inaccurately assessed by the facility nurse at the time of his admission to the nursing home. -- b) Resident #34 Resident #34, when observed on 01/25/11 at 9:30 a.m., appeared to be unable to execute virtually any voluntary movement. During an interview at 10:15 a.m. on 01/25/11, a facility registered nurse (RN - Employee #142) was asked whether Resident #34 had any contractures. Employee #142 responded in the affirmative, stating the resident had contractures in both hands. She further explained the resident was nearly incapable of any voluntary movement and was totally dependent upon staff for all activities of daily living (ADLs) and movement. The resident's MDS 3.0 assessments, with assessment reference dates (ARDs) of 11/02/10 and 01/27/11, were reviewed on the morning of 01/31/11. In each of these assessments, the assessor noted that Resident #34 had no contractures, although both assessments were encoded to indicate that Resident #34 had functional limitation in range of motion on both sides (in both upper and lower extremities) and that she was dependent upon staff for all ADLs, requiring the physical assistance of two (2) or more persons. When reviewed on 02/01/11 at 2:30 p.m., a physical therapy (PT) screening dated 12/31/09 documented the presence of contractures: hands held in MPC/IP flexion, with joint contractures noted. Staff are l w/ (with) skin hygiene and placement of palm protectors or rolled washcloths to prevent breakdown, and visual inspection done regularly . The facility's director of nursing (DON - Employee #30), when interviewed on 02/01/11 at 9:00 a.m., confirmed the resident definitely had contractures. The DON acknowledged the assessments with ARDs of 11/02/10 and 01/27/11 were coded inaccurately regarding contractures in Section S. On 02/01/11 at 4:13 p.m., the DON confirmed that the two (2) MDS assessments, which had inaccurately identified the absence of contractures, were corrected.	2016-01-01
9175	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	279	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to develop a comprehensive care plan that describes the services to be furnished to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being, for two (2) of thirty-six (36) Stage II sample residents. One (1) resident (#109) had a [MEDICAL CONDITION] with no mention of this device and its associated care needs in the resident's care plan. Another resident (#97) acquired an eye infection that was not included in the care plan. Resident identifiers: #109 and #97. Facility census: 90. Findings include: a) Resident #109 When reviewed on 02/01/11, the medical record for Resident #109 divulged she had been admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Review of the resident's physician orders [REDACTED]. The resident's care plan, when reviewed on 02/01/11, contained no mention of the resident's [MEDICAL CONDITION] or care needs related to it. Employee #135, a facility nurse and assistant director of nurses, when interviewed related to the resident's care plan to address [MEDICAL CONDITION] care on 02/01/11 at 9:35 a.m., confirmed the [MEDICAL CONDITION] and its care needs were not included in the resident's plan of care. Employee #135, later on 02/01/11, provided evidence that, although the [MEDICAL CONDITION] and its care were not included on the resident's care plan, the information related to its care was available to facility nursing assistants by way of their kiosk (computer terminal) system. -- b) Resident #97 When reviewed on 01/31/11, the medical record of Resident #97 revealed a lab report dated (as reported to the facility) at 4:10 p.m. on 10/08/10. This lab report of a culture of the resident's eye identified the presence of [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA), scant growth. The resident's care plan in effect at that time (October 2010) was reviewed, and there was no evidence the care plan had been revised to address the resident's eye infection. The facility's infection control nurse (Employee #139), when questioned on 01/31/11, confirmed the resident's care plan was not revised to address the resident's eye infection and special care needs associated with it.	2016-01-01
9176	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	280	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to revise the care plans for two (2) of thirty-six (36) Stage II sample residents when changes occurred in their healthcare status and/or service needs. Resident identifiers: #62 and #55. Facility census: 90. Findings include: a) Resident #62 1. At approximately 3:00 p.m. on 01/24/11, observation found Resident #62 to be sliding out of his positional chair while located in the living room area. Only one (1) aide was present in the room, and she placed a beanbag chair that had been positioned adjacent to his chair under him, so that he slid out of the positional chair and onto the beanbag chair. At 4:30 p.m. on 01/24/11, this surveyor observed the resident still reclining in the beanbag chair receiving one-on-one (1:1) supervision by a nursing assistant (Employee #80) while a licensed practical nurse (LPN - Employee #43) worked nearby. The resident was very confused, making snoring sounds, and hitting out (ineffectively) at staff. During an interview with Employee #43 at this time, she stated they use the beanbag chair when the resident is so agitated that they cannot get him in any other chair without fear that he will throw himself out or turn the chair over. A subsequent review of incident reports verified this behavior. The incident reports indicated the falls were usually from his positional chair with a safety belt harness in place. The resident was strong and would shift his weight to one (1) side and, then, upset chair. He had six (6) reported falls of this type in the last two (2) months (on 01/24/11, 01/18/11, 12/15/10, 12/13/10, 12/05/10, and 12/01/10). A follow-up visit, at 5:45 p.m., revealed Resident #62 was in a positional chair being fed by a nurse aide. When he had finished eating, he was moved away from the other residents and was provided a 1:1 caregiver (Employee #60). He was still very awake and trying to rise, although the nurse (Employee #43) stated he had received [MEDICATION NAME] to help him calm down. -- 2. A review of Resident #62's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. -- 3. During interviews with a nurse (Employee #105) and a nursing assistant (Employee #46) at 11:00 a.m. on 01/25/11, they verified Resident #62 can upset his chair when he becomes agitated, and they stated he even calls out to staff of his intention to do so. The nurse stated that, because of his falls, she and the therapist have been investigating different types of chairs. She also stated that they used a beanbag chair at times and provide 1:1 direct supervision (which he was receiving on this day) when necessary. They both stated staff got the resident up early, and he would spend his day in the positional chair as he was no longer ambulatory, even with assistance. He was toileted by staff and could, at times, support his weight to pivot to the commode. This resident no longer ambulated, even with assistance, and this was evidenced in a note by the physical therapist on 09/29/10, which stated: Mr. (name of Resident #62) is no longer able to ambulate. Can bear wt. but does not do this functionally. -- 4. In an interview with the occupational therapist (Employee #149) at 9:30 a.m. on 02/01/11, she produced a manila envelope of materials about various types of chairs (including BRODA) that she had ordered in an attempt to prevent Resident #62 from overturning his chair. She stated several interventions had been tried without success (including a helmet), but as he was not currently a therapy patient (he was discharged from rehabilitative services on 11/01/10), she had kept no record of these actions and had no input into his current care plan. When asked about the use of the beanbag chair for Resident #62, Employee #149 stated beanbag chairs were used for extremely agitated residents who were thrashing about, to prevent their harming themselves by hitting the chair or turning over. Employee #149 further stated the use of this chair had been considered for Resident #62 and was ruled out, because of the curvature of his back from an old injury (which meant he needed extra support). When she was told of the surveyor's observations of Resident #62 in a beanbag chair, she expressed surprise and stated there was only one (1) resident in the facility with an order for [REDACTED]. -- 5. Review of the facility's Operational Policy and Procedure Manual for Restraints found: Policy Interpretation and Implementation 1. 'Physical Restraints' are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 7.d. The Director of Nursing Services or designee has the authority to order the use of emergency restraints. The Attending Physician must be notified of such use and the reason for the order. 7.e. Orders for emergency restraints may be received by telephone, and shall be signed by the physician within forty eight 48) hours. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. -- 6. Review of Resident #62's current care plan revealed an entry, dated 07/02/10, stating, Belt restraint in chair for safety. Also has PRN (as needed) order for Velcro postural vest. This same information was also on the Life Skill Sheet (caregiver instruction sheet). The belt restraint was noted to be in place while he was in the positional chair, on several observations during the survey. -- 7. A review of the physician's orders for Resident #62 revealed the following restraint orders: Resident to be up in blue positioning chair with safety belt (in upright position) when out of bed. Check Q (every) 30 min for positioning and breathing checks. Q 2 hr (every 2 hours) releases for ambulation, bathroom, meals, skin inspection etc. NOC AM PM (night, morning, and evening). Notify Staff. Dx: resident with dementia causing him to be unaware of risk of injury by getting up unassisted, tipping chair and falling from chair. There was no physician's order or care plan for the use of the beanbag chair. There was no PRN order for the use of [REDACTED]. While the care plan recognized the use of the positional chair and the belt restraint and established a goal related to restraint use, there were no interventions for the use of restraints with this resident, as required by the facility policy. -- 8. During an interview with the director of nurses (DON), the administrator, and a registered nurse (RN) supervisor (Employee #28) at 4:20 p.m. on 02/01/11, the above findings were reviewed, and the DON expressed surprise that there were no restraint orders or care plan for Resident #62, stating she would review his record and follow-up with this surveyor. The administrator stated that beanbag chairs are never used without a physician's order. No additional information had been presented prior to this surveyor's exit on 02/02/11. -- b) Resident #55 1. A review of Resident #55's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Review of the resident's therapy note, dated 01/11/11, revealed the following: Received a screen request from nursing to look at pt's (patient's) L (left) hand for contracture management and consider orthotic placement. Informed nursing that pt has been looked at twice in the past for same issue and that she will NOT leave any orthotic in that hand. She uses her other hand to remove it. Therefore, there is a recommendation still in pt.'s care plan to place hand rolls (or rolled gauze) in pt's hands AS SHE TOLERATES, which this therapist agrees with continuing. The physician's order stated: Resident to have foam roll in right hand, apply in AM (morning) and leave in until HS (bedtime) as long as resident can tolerate NOC AM PM (night, day, evening). If unable to put foam roll in hand you may use a rolled up washcloth. The resident's current care plan included the following problem statement dated 07/17/09: Needs Total Assist with ADL's (activities of daily living). Has flexion contractures Rt (right) hand. A nursing interventions associated with this problem statement was: Wash / dry hands daily, apply foam roll to Rt hand, leave in hand until bedtime or as long as resident tolerates. There was no mention of any contracture management interventions to address the resident's left hand, as recommended by rehabilitative therapy staff. - 2. On 11/01/10, the resident was discharged from therapy with orders signed by the physician for: D/C (discontinue) calf / footboard. Resident to have no cushion to wheelchair. Dycem under resident, plus bilateral foot cradles on foot rests at all times when up in wheelchair. Transition to restorative program 6 X week for PROM (passive range of motion) to bilateral knees and ankles and proper w/c (wheelchair) positioning check. 6 x wk. Monday Tuesday Wednesday Thursday Friday Saturday first date: 11/01/2010 (occupational therapy). The care plan was reviewed and revised on 11/24/10, but there was no evidence that the above orders were included in the care plan. The Life Skill Sheet included the wheelchair information but contained nothing about providing PROM to the resident's knees and ankles. During an interview with the occupational therapist (Employee #149) at 9:30 a.m. on 02/01/11, she stated that when the restorative nursing program was discontinued, the administrator had made a nurse (Employee #28) the intermediary between therapy and nursing. She gives the nurse a pink order for restorative services to be provided by the nursing assistants after a resident is discharged from therapy. During an interview with two (2) facility nurses (Employees #137 and #139, who were responsible for the minimum data set assessments and care planning) at 10:00 a.m. on 02/01/11, they acknowledged, after reviewing the records, that these interventions had been omitted from the resident's care plan.	2016-01-01
9177	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	282	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews, the facility failed to implement the plan of care for one (1) of thirty-six (36) Stage II sample residents, by failing to ensure staff applied a hand roll to the resident's hand and provided passive range of motion (PROM) exercises to the resident's knees and ankles in accordance with physician orders. Resident identifier: #55. Facility census: 90. Findings include: a) Resident #55 1. Observation, at 2:00 p.m. on 01/24/11, found Resident #55 sitting up in a chair in her room. There was no hand roll (foam or rolled washcloth) in either hand, nor was any hand roll observed to be present in her room. She was observed again at 10:00 a.m. on 01/25/11, at 4:15 p.m. on 01/25/11, and at 11:00 a.m. on 01/31/11, with no hand roll in place. A review of Resident #55's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Further review of the medical record found the treatment administration records (TARs) for December 2010 and January 2011 were filled out daily indicating, by the nurse's initials, that a hand roll was applied to the resident's right hand on each shift. Review of the resident's therapy note, dated 01/11/11, revealed the following: Received a screen request from nursing to look at pt's (patient's) L (left) hand for contracture management and consider orthotic placement. Informed nursing that pt has been looked at twice in the past for same issue and that she will NOT leave any orthotic in that hand. She uses her other hand to remove it. Therefore, there is a recommendation still in pt.'s care plan to place hand rolls (or rolled gauze) in pt's hands AS SHE TOLERATES, which this therapist agrees with continuing. Review of the resident's physician orders [REDACTED]. If unable to put foam roll in hand you may use a rolled up washcloth. Review of the resident's current care plan found the following problem statement: Needs Total Assist with ADL's (activities of daily living). Has flexion contractures Rt (right) hand. The goal associated with this problem did not address contractures, and interventions included: Wash / dry hands daily, apply foam roll to Rt hand, leave in hand until bedtime or as long as resident tolerates. There was no reference to any contracture management interventions for her left hand, as had been recommended by the rehabilitative therapy staff. At 9:30 a.m. on 02/01/11, the resident was observed up in a chair in her room with her hands under a quilt, and a rolled and taped wash cloth on the overbed table. -- 2. Record review revealed, on 11/01/10, the resident was discharged from therapy with orders signed by the physician for: D/C (discontinue) calf / footboard. Resident to have no cushion to wheelchair. Dycem under resident, plus bilateral foot cradles on foot rests at all times when up in wheelchair. Transition to restorative program 6 x week for PROM to bilateral knees and ankles and proper w/c (wheelchair) positioning check. 6 x wk. Monday Tuesday Wednesday Thursday Friday Saturday first date: 11/01/2010 (occupational therapy). During an interview at 3:00 p.m. on 01/25/11, a nursing assistant (Employee #68) was asked how Resident #55 tolerated the PROM to her legs and where the provision of these exercises was documented. Employee #68 replied that she had no instructions to do this. This was the same answer received from a second nursing assistant (Employee #85) who was interviewed later that same day. A review of the medical record failed to reveal any documentation of PROM being done on this resident. There were also no nurses' notes in December or January documenting an assessment of the effectiveness of the PROM exercises. The resident's care plan was reviewed and revised on 11/24/10, but there was no evidence that the above orders were included in the care plan. The Life Skill Sheet for Resident #55 included the wheelchair information, but it contained nothing about providing PROM to the resident's knees and ankles. During an interview with a registered nurse (RN) supervisor (Employee #28) at 2:00 p.m. on 01/31/11, she acknowledged there was no documentation of the PROM exercises but stated it was done for all residents with their baths. Employee #28 did agree that the specific instructions found in the physician's orders [REDACTED]. She also agreed, after searching the computerized record that there was no area where the aides were reminded to document the provision of ROM exercises, and it would have to be entered under a narrative section. In an interview with a nurse supervisor (Employee #114) at 2:30 p.m. on 01/31/11, she stated that therapy did the treatments but, after being told that therapy services for Resident #55 had been discontinued on 11/01/10, Employee #114 had no reason for the lack of evidence of the treatments and/or assessments being done. During an interview with the occupational therapist (Employee #149) at 9:30 a.m. on 02/01/11, she stated that, when the restorative nursing program was discontinued, the administrator had made a nurse (Employee #28) the intermediary between therapy and nursing. She gives the nurse a pink order for restorative services to be provided by the nursing assistants after a resident is discharged from therapy. During an interview with two (2) facility nurses (Employees #137 and #139, who were responsible for the minimum data set assessments and care planning) at 10:00 a.m. on 02/01/11, they acknowledged, after reviewing the records, that these interventions had been omitted from the resident's care plan. During an interview with Employee #28 at 10:25 a.m. on 02/01/11, she stated the nursing assistants received their care instructions / responsibilities from the resident's Life Skills Form. This was verified by two (2) nursing assistants (Employees #26 and #68) at 10:30 a.m. on 02/01/11, who demonstrated how to enter the electronic medical record and go to Life Skills Sheet. They confirmed that this was the source of information of responsibilities for care of each resident. During an interview with the director of nurses (DON), the administrator, and Employee #28 at 4:20 p.m. on 02/01/11, they had no further evidence to present to show that the treatments were being done.	2016-01-01
9178	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	309	D	0	1	IEXL11	Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care, by not consistently using hand rolls as specified in the resident's active care plan. This was found for one (1) of thirty-six (36) Stage II sample residents. Resident identifier: #34. Facility census: 90. Findings include: a) Resident #34 1. During daily observations of Resident #34 each morning and each afternoon on 01/24/11, 01/25/11, 01/26/11, and the morning of 01/27/11, there were no hand rolls or splints observed. Resident #34, when observed on 01/25/11 at 9:30 a.m., appeared to be unable to execute virtually any voluntary movement. During an interview with a facility registered nurse (RN - Employee #142) at 10:15 a.m. on 01/25/11, she was asked whether Resident #34 had any contractures. Employee #142 responded in the affirmative, stating she had contractures in both hands. When asked if hand rolls or splints were being used, she replied they were no longer, used because they were no longer helpful. She explained that the resident was nearly incapable of any voluntary movement and was totally dependant upon staff for all activities of daily living (ADLs) and movement. When observations were attempted on 01/31/11, it was found that resident was moved to another wing. Subsequent observation of the resident this revealed, again, no hand rolls or splints in place. On 01/31/11 at 4:20 p.m., a nursing assistant (Employee #143) was asked about use of splints or hand rolls for the resident. She stated she knew they sometimes used to use wash cloths. On 02/01/11 at 8:00 a.m., resident was observed in the dining room for breakfast with hand rolls in place. Observation of resident, on 02/01/11 at 9:45 a.m., revealed no breakdown on fingers or insides of hands. Resident #34 now had Posey hand rolls in place. -- The resident's MDS 3.0 assessments, with assessment reference dates (ARDs) of 11/02/10 and 01/27/11, were reviewed on the morning of 01/31/11. In each of these assessments, the assessor noted that Resident #34 had no contractures, although both assessments were encoded to indicate that Resident #34 had functional limitation in range of motion on both sides (in both upper and lower extremities) and that she was dependent upon staff for all ADLs, requiring the physical assistance of two (2) or more persons. When reviewed on 02/01/11 at 1:00 p.m., the nursing assistant charting found documentation indicating the resident's need for the physical assistance of two (2) or more persons with little or no self-performance for all ADLs. When reviewed on 02/01/11 at 2:00 p.m., the social services notes documented the resident's condition on 08/06/09 as . usually in her geri-chair or bed seemingly oblivious to her environment. Some staff feel she does demonstrate facial movement which demonstrates some awareness of her surroundings. She has Dx (diagnosis) of early onset dementia which in (sic) now in advanced stage. When reviewed on 02/01/11 at 2:30 p.m., a physical therapy (PT) screening dated 12/31/09 documented the presence of contractures: hands held in MPC/IP flexion, with joint contractures noted. Staff are l w/ (with) skin hygiene and placement of palm protectors or rolled washcloths to prevent breakdown, and visual inspection done regularly . -- The facility's director of nursing (DON - Employee #30) was interviewed on 02/01/11 at 9:00 a.m. regarding the inconsistency of the record including the lack of clear documentation as to the presence of contractures and the provision of care to ameliorate the effects. She voiced understanding and was provided the opportunity to obtain additional documentation that might clarify the resident's condition and the appropriate care. When asked, she stated the resident definitely had contractures, and she stated she has emphasized with staff to use rolled washcloths to prevent the constant skin-to-skin contact that results if those interventions are not used. On 02/01/11 at 9:51 a.m., the DON presented copies of documents. She stated that, in June 2008, the resident's family expressed they did not want continued use of splints, which were subsequently discontinued. She provided documentation of that situation. She did state that the use of hand rolls was continued to prevent skin breakdown, and that they were supposed to be used as of today. She acknowledged that the assessments of 11/02/10 and 01/27/11 were apparently coded inaccurately regarding contractures in Section S. She stated the care plan problem of 05/18/09 was still an active problem and that her expectation was that hand rolls be in use. -- On 02/01/11 at 10:20 a.m., an RN (Employee #28) told surveyors that NA assignment sheets were called Life Skill Sheets, and that the NAs refer to those digital documents to guide their provision of care for each resident. A review of Life Skill Sheets for Resident #34, on 02/01/11 at 10:30 a.m., revealed no mention of the need to apply hand rolls. On 02/01/11 at 10:25 a.m., interviews with two (2) NAs (Employees #68 and #26) confirmed to surveyors that they used the Life Skill Sheets to guide their provision of care. On 02/01/11 at 10:35 a.m., the DON was asked about the use of Life Skill Sheets. She concurred these tools were the primary means of communicating assignments and care expectations to the NAs. She agreed that the use of hand rolls was not listed on the Life Skill Sheet for Resident #34 and that it should have been taken from the care plan and transcribed to the instruction sheet for the NAs. She further confirmed that, because the NAs were not properly instructed to apply the hand rolls, the care was not being provided consistently. When reviewed on 02/01/11 at 3:00 p.m., Resident #34's care plan was found to include a problem statement, dated 05/18/09, which stated: Self care deficit needs total assist with all adl's bed mobility transfers eating toilet use, contractures of hands. One (1) of the interventions under this item was: Hand rolls in place. On 02/01/11 at 4:13 p.m., the DON confirmed that the two (2) MDS assessments, which had inaccurately identified the absence of contractures, were corrected.	2016-01-01
9179	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	314	G	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed, for one (1) of thirty-six (36) Stage II sample residents, to provide care and services to prevent the development of pressure ulcers for a resident who entered the facility without pressure ulcers, but who was at risk of developing pressure ulcers. Resident #109 was admitted to the facility following hospitalization and surgery for [REDACTED]. This incorrect assessment delayed implementation of care to the areas which resulted in the development of Stage II pressure sores. These Stage II pressure sores subsequently worsened to Stage III pressure sores. Resident identifier: #109. Facility census: 90. Findings include: a) Resident #109 When reviewed on 01/31/11, the medical record for Resident #109 divulged this [AGE] year old male was admitted to the facility from an acute care hospital on [DATE], following surgery for [REDACTED]. Review of the discharge summary received at the facility from the acute care hospital revealed, under Discharge Disposition, We will have the patient up with assistance, weight bearing as tolerated, decubitus precautions up in chair at bedside, QPI's (unknown abbreviation) off bed and abduction pillows at all times. The resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 12/29/10, stated in the areas of Functional Status that the resident required the extensive physical assistance of two (2) or more persons for bed mobility and transferring to/from bed, chair, wheelchair, standing position. The resident had no ability to reposition himself. A nursing assessment completed on the day admission to the facility (dated 12/22/10 at 7:12 p.m.), stated the resident has had no foot problems or care in past seven (7) days. The resident's physician orders, when reviewed, disclosed orders for no pressure ulcer treatment or preventive measures at the time of admission. A nursing assessment entry, dated on 01/02/11 at 11:06 a.m., described the resident as having 2-1/2 cm intact water blister to right heel. 3 cm intact water blister to left heel with slight purple discoloration. This entry further stated, Partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stg. 2). This description was noted to apply to both the left and the right heel. Review of the resident's care plan disclosed no mention of pressure ulcers or pressure ulcer prevention was mentioned on the initial plan of care. However, fourteen (14) days after admission (on 01/05/11), a member of the interdisciplinary team added as a problem statement: Stage II pressure areas to heels, Potential for further skin breakdown. (A Stage II pressure sore is described, by the National Pressure Ulcer Advisory Panel (NPUAP) at www.npuap.org, as a partial thickness of dermis presenting as a shallow open ulcer with a pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister.) Interventions associated with this new problem statement included: 1. Assist with turning/reposition; elevate resident's heels off of bed, heel protectors in bed. 2. Air mattress to bed, check functioning q (every) shift. 3. Administer nutritional supplements as ordered. 4. Monitor / report changes in pressure areas, e.g.: s/s (signs or symptoms) of infection, increasing depth, size, etc. A nursing assessment entry, dated 01/16/11, described the resident's pressure ulcers in this manner: Location: left heel Full thickness of skin lost, exposing the SubQ (subcutaneous) tissues-presents as a deep crater (Pressure Stg. 3). (A Stage III pressure sore is described by the NPUAP as a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.) Tissue type: 0.5 cm necrotic area to left heel. Wound tissue: reddened Drainage: None present Length 4 Surrounding Tissue: white. Healing progress: Worsening Location: right heel Full thickness of skin lost, exposing the SubQ (subcutaneous) tissues-presents as a deep crater (Pressure Stg. 3). Length: 4/5cm in diameter Surface area: 0.7 - 1.0 cm sq. Depth: 0.1cm Wound tissue: reddened Tissue type: granulation tissue Drainage: light odorous Surrounding tissue: white Healing progress: Worsening A facility nurse (Employee #135), when interviewed on 02/01/11 at approximately 10:00 a.m., was asked why this skin breakdown was not recognized prior to progressing to Stage II. Another facility nurse (Employee #139) presented a written document, which identified as having been acquired from the hospital from where the resident had been discharged immediately preceding his admission to the nursing home. Employee #139 stated the information had been received upon request by the facility on the previous evening (01/31/11). This document included an evaluation of the resident dated 12/22/10 at 7:50 a.m., which noted patient heels pink and spongy bilat (bilaterally). The resident had been first assessed at the nursing home at 7:12 p.m. on 12/22/10, at which time the nursing assessment stated the resident has had no foot problems or care in past seven (7) days. Employee #135 confirmed, on 02/01/11 at 10:00 a.m., that the resident's skin condition had been inaccurately assessed by the facility nurse at the time of his admission to the nursing home at 7:12 p.m. on 12/22/11. This inaccurate assessment resulted in a delay in the care and treatment of [REDACTED]. Nursing documentation over the next thirty (30) days confirmed a worsening in the condition of the resident's heels, which subsequently deteriorated from Stage II to Stage III pressure sores. .	2016-01-01
9180	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	318	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to provide physician-ordered therapeutic measures intended to prevent further decline in range of motion (ROM) and failed to periodically re-evaluate the resident's status and revise the plan of care as needed for one (1) of thirty-six (36) Stage II sample residents. Resident identifier: #55. Facility census: 90. Findings include: a) Resident #55 1. A review of Resident #55's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. The resident's annual minimum data set assessment (MDS), with an assessment reference date (ARD) of 08/31/10, stated the resident had limited ROM of all extremities and that this was no change from the previous MDS. The quarterly MDS, with an ARD of 11/14/10, indicated the resident had functional limitations of all extremities. The resident received therapy until 11/01/10, when she was discharged with a note stating, Discharge planned following completed staff education for restorative PROM (passive range of motion) program. -- 2. Review of the resident's therapy note, dated 01/11/11, revealed the following: Received a screen request from nursing to look at pt's (patient's) L (left) hand for contracture management and consider orthotic placement. Informed nursing that pt has been looked at twice in the past for same issue and that she will NOT leave any orthotic in that hand. She uses her other hand to remove it. Therefore, there is a recommendation still in pt.'s care plan to place hand rolls (or rolled gauze) in pt's hands AS SHE TOLERATES, which this therapist agrees with continuing. Review of the resident's physician orders [REDACTED]. If unable to put foam roll in hand you may use a rolled up washcloth. Review of the resident's current care plan found the following problem statement: Needs Total Assist with ADL's (activities of daily living). Has flexion contractures Rt (right) hand. The goal associated with this problem did not address contractures, and interventions included: Wash / dry hands daily, apply foam roll to Rt hand, leave in hand until bedtime or as long as resident tolerates. There was no reference to any contracture management interventions for her left hand, as had been recommended by the rehabilitative therapy staff. Further review of the medical record found the treatment administration records (TARs) for December 2010 and January 2011 were filled out daily indicating, by the nurse's initials, that a hand roll was applied to the resident ' s right hand on each shift. Observation, at 2:00 p.m. on 01/24/11, found Resident #55 sitting up in a chair in her room. There was no hand roll (foam or rolled washcloth) in either hand, nor was any hand roll observed to be present in her room. She was observed again at 10:00 a.m. on 01/25/11, at 4:15 p.m. on 01/25/11, and at 11:00 a.m. on 01/31/11, with no hand roll in place. At 9:30 a.m. on 02/01/11, the resident was observed up in a chair in her room with her hands under a quilt, and a rolled and taped wash cloth on the overbed table. -- 3. Record review revealed, on 11/01/10, the resident was discharged from therapy with orders signed by the physician for: D/C (discontinue) calf / footboard. Resident to have no cushion to wheelchair. Dycem under resident, plus bilateral foot cradles on foot rests at all times when up in wheelchair. Transition to restorative program 6 x week for PROM to bilateral knees and ankles and proper w/c (wheelchair) positioning check. 6 x wk. Monday Tuesday Wednesday Thursday Friday Saturday first date: 11/01/2010 (occupational therapy). During an interview at 3:00 p.m. on 01/25/11, a nursing assistant (Employee #68) was asked how Resident #55 tolerated the PROM to her legs and where the provision of these exercises was documented. Employee #68 replied that she had no instructions to do this. This was the same answer received from a second nursing assistant (Employee #85) who was interviewed later that same day. A review of the medical record failed to reveal any documentation of PROM being done on this resident. There were also no nurses' notes in December or January documenting an assessment of the effectiveness of the PROM exercises. The resident's care plan was reviewed and revised on 11/24/10, but there was no evidence that the above orders were included in the care plan. The Life Skill Sheet for Resident #55 included the wheelchair information, but it contained nothing about providing PROM to the resident's knees and ankles. During an interview with a registered nurse (RN) supervisor (Employee #28) at 2:00 p.m. on 01/31/11, she acknowledged there was no documentation of the PROM exercises but stated it was done for all residents with their baths. Employee #28 did agree that the specific instructions found in the physician's orders [REDACTED]. She also agreed, after searching the computerized record that there was no area where the aides were reminded to document the provision of ROM exercises, and it would have to be entered under a narrative section. In an interview with a nurse supervisor (Employee #114) at 2:30 p.m. on 01/31/11, she stated that therapy did the treatments. After being told that therapy services for Resident #55 had been discontinued on 11/01/10, Employee #114 had no reason for the lack of evidence of the treatments and/or assessments being done. During an interview with two (2) facility nurses (Employees #137 and #139, who were responsible for the minimum data set assessments and care planning) at 10:00 a.m. on 02/01/11, they acknowledged, after reviewing the records, that these interventions had been omitted from the resident's care plan. During an interview with the director of nurses (DON), the administrator, and Employee #28 at 4:20 p.m. on 02/01/11, they had no further evidence to present to show that the treatments were being done.	2016-01-01
9181	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	323	E	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, review of facility incident and accident reports, and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control, by having room heating units in five (5) randomly observed resident rooms with surface temperatures exceeding 150 degrees Fahrenheit (F); by storing hazardous chemicals in an unlocked storage cabinet in the bathing room on the D Hall of the facility; and by failing to provide adequate supervision to one (1) of thirty-six (36) Stage II sample residents on B Hall of the facility to prevent reoccurring accidents. These practices had the potential to affect Residents #85, #69, #62, #70, and #65 (who had excessive heater temperatures), all cognitively impaired residents who wandered in the unsecured areas of the facility and had access to the unlocked chemicals on D Hall, and Resident #62 who was provided inadequate supervision to prevent reoccurring accidents. Facility census: 90. Findings include: a) Residents #85, #69, #62, #70 and #65 1. During an interview with Resident #85 in her room on D Hall at 5:30 p.m. on 01/24/11, testing found the surface temperature of the resident's heater, near the baseboard of her outside wall on the right side of her bed, was very hot to touch. The surface temperature, when measured with a thermometer, was found to be 162.9 degrees F. The resident, who currently occupied the bed nearest the heater, stated she knew it was hot and did not go over there. Observation found the thermostat which controls the heater in this room was set on 72 degrees F. This resident stated she did not adjust the thermostat herself. Following this observation, a random tour of the facility was conducted, and excessive surface temperatures were noted in rooms on each hallway of the facility as follows: 2. The heater in the room of Resident #69 (located on D Hall) was very warm to the touch. The surface temperature, when measured, was 84 degrees F. Resident #69, according to a facility incident / accident report dated 12/07/10, was found by staff with her foot on the heater, resulting in redness to the foot. This resident had been moved to the bed nearest the door, away from the heater. Another resident resided in the bed near the heater. The thermostat in this room was also noted to be set on 72 degrees F, and neither resident possessed the physical or cognitive ability to adjust the thermostat themselves. 3. The heater in the room of Resident #62 (located on B Hall) was found to have a surface temperature measuring 150 degrees F. This resident was not ambulatory, and the bed was not adjacent to the heater. Residents on the B Hall were, however, observed to be wandering from room to room at different times during the survey. 4. The heater in the room of Resident #70 (located on C Hall) was found to have a surface temperature of 150 degrees F. This was a private room, and Resident #70 stated she did not go on that side of the bed. The thermostat in this room was set on 80 degrees F. This resident stated she did adjust the thermostat herself. 5. The heater in the room of Resident #65 (located on A Hall) was found to be 160 degrees F. Employee #47, a nursing assistant assigned to this unit on the evening shift of 01/24/10, stated Resident #65 had the ability to ambulate independently in his room but needed assistance outside his room. She reported Resident #65 did not exit his bed on the heater side and that she had never observed him to be on that side of the bed. The facility's administrator (Employee #9) and assistant administrator (Employee #13) were interviewed related to these findings at 6:05 p.m. on 01/24/11. The administrator stated the heaters were ancillary heaters and the residents could self control them at times when the outside temperatures in this area were excessively cold. The administrator confirmed that, when the thermostats were turn up high, the surfaces of the heaters could be very warm. Although it appeared that all random observations at this time were of residents who could self protect or who were not ambulatory, residents in the facility were noted to be wandering, and different residents could be admitted to these rooms at any time or rooms re-assigned. -- b) During a random tour of the facility on 02/01/11 at 2:29 p.m., the bathing room on D Hall was observed to have cabinets at approximately waist height with locks that were not locked. In these cabinets was stored Penner Patient Care Whirlpool disinfectant cleaner. Precautions on the label stated: Danger, keep out of reach of children, causes irreversible eye damage and skin burns. Also found in the unlocked cabinets was a container of Elim-O odor eliminator, which stated on the label: Caution, keep out of reach of children not for internal use, harmful if swallowed, may cause eye and skin irritation. A facility assistant director of nurses (ADON - Employee #135), when asked to confirm the observations, agreed these chemicals could be harmful to wandering, cognitively impaired residents and should be stored in a locked cabinet. -- c) Resident #62 A review of Resident #62's medical record revealed this [AGE] year old male, who had resided at the facility since 07/02/07, had [DIAGNOSES REDACTED]. This resident had a history of [REDACTED]. The resident was strong and shifted his weight to one side, upsetting the chair. He had six (6) reported falls of this type in the last two (2) months (on 01/24/11, 01/18/11, 12/15/10, 12/13/10, 12/05/10, and 12/1/10). All but one (1) of the falls took place in the living room area of the hall. At approximately 3:00 p.m. on 01/24/11, the resident was observed by a surveyor to be sliding out of his positional chair, which was located in the living room area. A nursing assistant was present in the room, and she placed a beanbag chair (which had been located adjacent to his chair) under him, so that he slid out of the positional chair and onto the beanbag chair. During interviews with a nurse (Employee #105) and a nursing assistant (Employee #46) at 11:00 a.m. on 01/25/11, they verified that Resident #62 can upset his chair when he becomes agitated, and they stated he even calls out to staff of his intention to do so. They both stated the resident was gotten up early and spends his day in the positional chair in the living room area, as he was no longer ambulatory even with assistance. When asked if there was a policy that required a staff member to be present in the living room area at all times, both stated that it was not policy that they knew of, but they tried to do this. Review of the facility's incident / accident reports found nineteen (19) incidents (most often falls and acts of aggression towards staff or another resident) in the living room area on B Hall in January 2011; nine (9) of these incidents were recorded as having been unwitnessed events. During the general tour at 2:00 p.m. on 01/24/11, there were fourteen (14) residents located in the living room area. This was found to be the case during daily observations made on this unit throughout the course of this survey event. On several observations made by this surveyor, staff was not present in the living room area when residents were present. On 01/09/11, a suggestion was made, during an internal investigation into a fall by Resident #96, that the computer used by the nursing assistant be relocated from the hallway to the living room area, so they could monitor the residents in that room. During an interview with Employees #105 and #46 at 1:30 p.m. on 01/31/11, they admitted there were times when the residents were alone in the living room area, and they both agreed this could be when incidents were more apt to happen. During an interview with the director of nurses (DON), the administrator, and a registered nurse supervisor (Employee #28) at 4:20 p.m. on 02/01/11, the findings above were reviewed, and the DON stated it was facility policy that a staff member be present in the living room at all times. When informed of the interviews with Employees #105 and #46, the DON expressed surprise that staff members had denied knowledge of this policy. The DON presented the lunch and break schedules for the area, which did show staggered break times for staff on B Hall. However, the assignment schedule for 6:00 a.m. - 2:00 p.m.; 7:00 a.m. - 3:00 p.m.; and 12:00 p.m. - 8:00 p.m. all failed to show a requirement that a staff member be in the living room area. Only the assignment schedule for the 3 - 11 Floater stated: 8:00 - 9:00 Monitor B wing back (if nurse not available).	2016-01-01
9182	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	329	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to ensure physician orders [REDACTED]. Resident identifier: #28. Facility census: 90. Findings include: a) Resident #28 1. A review of Resident #28's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Her physician's orders [REDACTED].>- 04/07/10 - ([MEDICATION NAME]) [MEDICATION NAME] 2 mg/ml solution injection Dose Ordered: (0.5 ml/1 mg) intramuscular 1 mg q.6.h. (every 6 hours) p.r.n. first date 03/01/2010 FOR: Agitation. - 08/30/10 - ([MEDICATION NAME]) [MEDICATION NAME] 1 mg Tablet by mouth (1) 2 X wk. Sunday Wednesday 8:00 am first date: 09/01/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/14/10 - [MEDICATION NAME] 0.5 mg Tablet by mouth q.6.h. 8:00 am 2:00 pm 8:00 pm 2:00 am first date: 09/15/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/23/10 - ([MEDICATION NAME]) [MEDICATION NAME] 0.25 mg Tablet by mouth q.6.h. p.r.n. first date: 02/20/2010 FOR: Dementia-Related [MEDICAL CONDITION], organic mental syndrome, (Dementia-Related Psychoses) with behaviors of yelling out, spitting, screaming and resistive of personal care Notify staff. - 09/23/10 - ([MEDICATION NAME]) [MEDICATION NAME] 1 mg Tablet by mouth daily 8:00 am FOR: Dementia-Related [MEDICAL CONDITION] (Dementia-Related Psychoses) organic mental syndrome with psychotic or agitated behaviors first date: 07/01/2010. -- 2. The resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Also, there were no times or cumulative dosage limits set for giving either the PRN [MEDICATION NAME] or the PRN [MEDICATION NAME] along with the routine doses. -- 3. The facility policy entitled PRN MEDICATIONS, provided by the director of nurses at 8:00 a.m. on 02/02/11, stated: B. To assure the proper utilization of 'PRN' drug orders: 1. The frequency of normal use should be specified within the physician's orders [REDACTED]., q3hr PRN). This provides good guidelines to the nursing staff on how often a medication can and/or should be administered to be effective and sage. If a frequency of administration is not specified the order could be used too often or not often enough to achieve desired results. 4. The 'Indicators' published by Health and Human Services for surveyors say 'A pharmacist should comment on as needed (PRN) drug orders which are administered as directed every day for more than 30 days.' The meaning of this 'apparent irregularity' is that a physician's intent for PRN medications is that normally PRN orders should not be needed on a routine (daily) basis. 5. If a 'PRN' medication order has not been utilized in 60-90 days, the order should be re-evaluated by nursing for a possible recommendation to the physician for discontinuation. Therefore, 'PRN' orders that were appropriate three or more months ago might not be appropriate at the present time. 6. If a 'PRN' medication is NECESSARY to give daily, check with the prescriber to see if the order can be changed to a routine order. This will make the orders reflect the actual usage and will also save nurses the extra documentation involved with 'PRN' orders. -- 4. During an interview with a nurse supervisor (Employee #139) at 2:25 p.m. on 02/01/11, she agreed the orders for the PRN [MEDICATION NAME] and PRN [MEDICATION NAME] needed parameters and that the frequent use of the PRN [MEDICATION NAME] should have been addressed.	2016-01-01
9183	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	371	F	0	1	IEXL11	Based upon observation, review of facility documents, and staff interview, the facility failed to store, prepare, distribute, and serve food under sanitary conditions, by not ensuring that staff was properly trained and equipped to monitor the sanitization process in the 3-compartment sink. This had the potential to affect all residents. Facility census: 90. Findings include: a) The clean-up of the morning meal was observed at 8:30 - 9:00 a.m. on 01/26/11. The facility's cook (Employee #157) was asked about procedure for test strips to test sanitizer levels in the 3-compartment sink, which was used for any manual dish washing. She stated she tests all three (3) sinks every time she washes. She indicated that she did not know what color the strips should be or what the acceptable values were following the test. She stated she will get the answer. When asked to demonstrate the procedure she follows, Employee #157 tested the third sink (sink containing sanitizing solution) by immersing a test strip for approximately 30 seconds in the hot water. (The heater had just been turned off.) The posting adjacent to the sink directed staff to allow the water to cool to 75 degrees Fahrenheit (room temperature) prior to testing. During an interview on 01/26/11 at 11:32 a.m., the dietary manager (Employee #16) was asked what the acceptable parts per million (PPM) concentration was for the sanitizer solution test. She did not know what the minimum acceptable levels were. She referred to the label on the jug of chemicals, which stated an acceptable range of 150 to 400 PPM. During an interview on 01/26/11 at 11:00 a.m., the dietary assistant (Employee #59) was asked about the correct procedure for testing the sanitizer solution in the 3-compartment sink. She stated she was not familiar with the use of the sinks or strips and that she had only been at the facility for about six (6) months. Observations also determined that the posted testing instructions located adjacent to the sink differed from the instructions found on the container of test strips. The posting directed staff to immerse the test strip in the solution for 10 seconds; the container of strips directed staff to immerse the test strip in the solution for 90 seconds. Observation also found two (2) containers of testing strips from different manufacturers were on the shelf over the 3-compartment sink. First, there were test strips from Puritan: PhHydrion for testing quaternaries. Instructions stated to immerse the test strip 10 seconds, cool water to 75 degrees. These strips were noted to have an expiration date of 05/31/10. (These were the correct test strips for this facility's staff to use.) The other test strips were QAC Test Papers. The instructions stated to immerse the test strip for 90 seconds, then compare to container. These strips were from LaMotte Chemical Products. (Employee #157 used these strips.) The facility's policy and procedure regarding the use of the 3-compartment sink and orientation / training information for staff to use sinks / strips was requested on the afternoon of 01/26/11. During an interview with Employee #16 on 01/27/11 at 10:30 a.m., she provided the facility's policy and procedure for manual dishwashing. The sanitizing section was not specific, directing staff to measure the sanitizing chemical and test solution following the manufacturer's guidelines. The procedure did specify that only the third sink (the sanitizing sink) was to be tested . The sanitizing solution was to be tested every time dishes and/or cookware were washed, prior to placing them in the sanitizing sink, using manufacturer's suggested test strips to assure appropriate concentration level. Employee #16 provided a service detail report for 04/28/09, stating that the vendor provided staff education at that time. Under comments it stated: Inserviced staff on proper warewashing, presoaking, using new silverware, and dishracks. Employee #16 stated she did not include regular education on the sanitizing process in facility dietary meetings or inservices. She acknowledged that Employee #157 had not followed the correct procedure for the testing the concentration of sanitizing solution and that the presence of two (2) different testing strips was a cause of confusion. She agreed that the proper testing strips for the sanitizer had an expiration date of 05/31/10. When asked during the tray line observation on 01/25/11 at 11:40 a.m., the (Employee #150) and two (2) tray attendants (Employees #125 and #107) stated they usually do not use the 3-compartment sink. On 02/01/11, Employee #16 presented documentation of a training class by the county health department that covered hand washing, personal hygiene, cross contamination prevention, proper cooking temperatures, hot holding and cooling, thawing, and other food safety issues and practices. A sign-in sheet stated 3 compartment sink The training was conducted on 01/26/11.	2016-01-01
9184	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	428	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, policy review, and staff interview, the facility failed to ensure one (1) of thirty-six (36) Stage II sample residents was free of the potential for excessive dosages of psychoactive medications due to duplicate therapy, when the pharmacist failed to recognize irregularities in his physician's orders [REDACTED]. Resident identifier: #28. Facility census: 90. Findings include: a) Resident #28 1. A review of Resident #28's medical record revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Her physician's orders [REDACTED].>- 04/07/10 - (Ativan) Lorazepam 2 mg/ml solution injection Dose Ordered: (0.5 ml/1 mg) intramuscular 1 mg q.6.h. (every 6 hours) p.r.n. first date 03/01/2010 FOR: Agitation. - 08/30/10 - (Ativan) Lorazepam 1 mg Tablet by mouth (1) 2 X wk. Sunday Wednesday 8:00 am first date: 09/01/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/14/10 - Lorazepam 0.5 mg Tablet by mouth q.6.h. 8:00 am 2:00 pm 8:00 pm 2:00 am first date: 09/15/2010 FOR: Agitation and restlessness due to dementia Notify Staff. - 09/23/10 - (Risperdal) Risperidone 0.25 mg Tablet by mouth q.6.h. p.r.n. first date: 02/20/2010 FOR: Dementia-Related Psychosis, organic mental syndrome, (Dementia-Related Psychoses) with behaviors of yelling out, spitting, screaming and resistive of personal care Notify staff. - 09/23/10 - (Risperdal) Risperidone 1 mg Tablet by mouth daily 8:00 am FOR: Dementia-Related Psychosis (Dementia-Related Psychoses) organic mental syndrome with psychotic or agitated behaviors first date: 07/01/2010. -- 2. The resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Also, there were no times or cumulative dosage limits set for giving either the PRN Ativan or the PRN Risperdal along with the routine doses. -- 3. The facility policy entitled PRN MEDICATIONS, provided by the director of nurses at 8:00 a.m. on 02/02/11, stated: B. To assure the proper utilization of 'PRN' drug orders: 1. The frequency of normal use should be specified within the physician's orders [REDACTED]., q3hr PRN). This provides good guidelines to the nursing staff on how often a medication can and/or should be administered to be effective and sage. If a frequency of administration is not specified the order could be used too often or not often enough to achieve desired results. 4. The 'Indicators' published by Health and Human Services for surveyors say 'A pharmacist should comment on as needed (PRN) drug orders which are administered as directed every day for more than 30 days.' The meaning of this 'apparent irregularity' is that a physician's intent for PRN medications is that normally PRN orders should not be needed on a routine (daily) basis. 5. If a 'PRN' medication order has not been utilized in 60-90 days, the order should be re-evaluated by nursing for a possible recommendation to the physician for discontinuation. Therefore, 'PRN' orders that were appropriate three or more months ago might not be appropriate at the present time. 6. If a 'PRN' medication is NECESSARY to give daily, check with the prescriber to see if the order can be changed to a routine order. This will make the orders reflect the actual usage and will also save nurses the extra documentation involved with 'PRN' orders. -- 4. During an interview with a nurse supervisor (Employee #139) at 2:25 p.m. on 02/01/11, she agreed the orders for the PRN Ativan and PRN Risperdal needed parameters and that the frequent use of the PRN Risperdal should have been addressed. -- 5. A review of the resident's medication regimen reviews for August 2010 through January 2011 revealed the pharmacist failed to identify and/or question the Ativan and/or the Risperdal orders, either for frequency of use or for the lack of parameters for PRN use.	2016-01-01
9185	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	502	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed, for one (1) of thirty-six (36) Stage II sample residents, to obtain a physician-ordered laboratory procedure. Resident identifier: #32. Facility census: 90. Findings include: a) Resident #32 When reviewed on 01/26/11, the medical record of Resident #32 divulged the resident was receiving the medication [MEDICATION NAME] (an anti-platelet drug that helps to prevent the formation of blood clots). The record further disclosed a physician's orders [REDACTED]. The results of these lab tests, when reviewed, revealed they were provided to the facility on [DATE]. The report stated the quantity of the specimen was not sufficient for analysis of the CBC with diff and platelets. There was no evidence that a specimen had been resubmitted to carry out the physician's orders [REDACTED].>A facility nurse (Employee #28), when interviewed on 01/26/11 at approximately 2:00 p.m., confirmed staff had not resubmitted a sample in an attempt to carry out the physician's orders [REDACTED].>	2016-01-01
9186	CORTLAND ACRES NURSING HOME	515063	39 CORTLAND ACRES LANE	THOMAS	WV	26292	2011-02-02	514	D	0	1	IEXL11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to maintain accurate clinical information in each resident's medical record, as evidenced by incorrectly recording nursing interventions in the care plan that differed from the physician's orders [REDACTED]. Resident identifiers: #55 and #62. Facility census: 90. Findings include: a) Resident #55 A review of Resident #55's medical record revealed an [AGE] year old female with [DIAGNOSES REDACTED]. Review of the resident's care plan found the following problem statement established 07/17/09: Needs Total Assist with ADL's (activities of daily living). Has flexion contractures Rt (right) hand. The nursing intervention stated: Wash / dry hands daily, apply foam roll to Rt hand, leave in hand until bedtime or as long as resident tolerates. The physician's orders [REDACTED]. The physician's orders [REDACTED]. During an interview with the administrator, director of nursing (DON), and a nurse (Employee #28) at 4:30 p.m. on 02/01/11, they acknowledged there was a difference in the wording of the care plan intervention versus the actual physician's orders [REDACTED]. -- b) Resident #62 A review of Resident #62's monthly recapitulation of the physician orders [REDACTED]. Notify Staff. This order was written on 04/09/10, when the resident was receiving physical therapy services. Further record review revealed Resident #62 had not been ambulatory or used a Merry Walker since at least August 2010, although the order continued to be recorded on the monthly recapitulations for the physician to sign. A review of the record revealed documentation by nursing assistants on the Activities of Daily Living forms, indicating the resident walk(ed) in room daily from 12/01/10 through 02/02/11 and required the assistance of one (1) person on eight (8) occasions. The physical therapist (Employee #17), stated in her documentation on 09/29/10: (Resident #62) is no longer able to ambulate. (mobility) Total Assistance. During an interview with the occupational therapist (Employee #149) at 9:30 a.m. on 02/01/11, she verified the accuracy of this assessment. During interviews with a nurse (Employee #105) and a nursing assistant (Employee #46) at 11:00 a.m. on 01/25/11, they verified that Resident #62 was gotten up early and spent his day in the positional chair, as he was no longer ambulatory, even with assistance. He was gotten up for toileting and could, at times, support his weight to pivot to the commode. During an interview with a nurse (Employee #135) at 10:50 a.m. on 02/01/11, she acknowledged inconsistencies in the record of this resident and that these inconsistencies led to questions of which was the accurate assessment of the resident's mobility status. She stated that she would request therapy to do a screen of the resident.	2016-01-01
9187	PLEASANT VALLEY NSG. & REHAB C	515064	1200 SAND HILL ROAD	POINT PLEASANT	WV	25550	2011-09-21	156	B	0	1	2WLP11	Based on review of beneficiary liability notices and staff interview, the facility failed to complete the liability notices in accordance with CMS instructions. The facility was not documenting the reasons why Medicare-covered services were being discontinued and/or specific information regarding the delivery of the notices themselves. This was evident for three (3) of three (3) discharged residents whose beneficiary liability notices were reviewed. Resident identifiers: #147, #48, and #104. Facility census: 94. Findings include: a) Resident #147 Review of Resident #147's Notice of Medicare Provider Non-Coverage form found it did not contain any information regarding the reason the Medicare-covered services were being discontinued. The notice recorded the date the service was ending (05/08/11), and there was a note stating: Wife was notified by phone on 5-8-11. -- b) Resident #48 Review of Resident #48's Notice of Medicare Provider Non-Coverage form indicated the Medicare-covered services would end on 07/17/11. The notice also stated staff notified son (POA) (power of attorney) by phone on 7-17-11. -- c) Resident #104 Review of Resident #104's Notice of Medicare Provider Non-Coverage form found the Medicare-covered services were to be discontinued on 05/10/11. The only other notation was: Wife notified by phone 5-10-11. -- d) According to instructions from the Centers for Medicare & Medicaid Services (CMS), when completing the Generic Notice CMS- form, the facility is to insert the kind of services being terminated, such as skilled nursing, home health, hospice or comprehensive outpatient rehab. This information was not recorded on any of the forms reviewed. The instructions further stated that, if the provider is unable to personally deliver a notice of non-coverage to a person legally acting on behalf of a beneficiary, then the provider should telephone the representative to advise him or her when the beneficiary's services are no longer covered as follows: - The beneficiary's appeal rights must be explained to the representative, and the name and telephone number of the appropriate quality improvement organization (QIO) should be provided. - The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. - Place a dated copy of the notice in the beneficiary's medical file and document the telephone contact to include: name of person initiating the contact, name of the representative contacted, date and time of the contact and the telephone number called. - When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. - The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. - When notices are returned by the post office, with no indication of a refusal date, then the beneficiary's liability starts on the second working day after the provider's mailing date. These procedures also may be used where a beneficiary has authorized or appointed an individual to act on his or her behalf, and the provider cannot obtain the signature of the beneficiary's representative through direct personal contact. The specifics regarding the notification delivery to representatives was not included on any of the forms reviewed, and this information was not found recorded anywhere in the residents' medical records. -- e) Interview with the administrator (Employee #2) and the billing supervisor (Employee #9), at 2:30 p.m. on 09/15/11, revealed the beneficiary liability notices were usually given three (3) days in advance of the actually non-coverage, so wrong dates had been put on these documents. The dates showed that the notices were given the same day the services were discontinued. Employee #9 stated physical therapy staff will give them a notice of what is being cut, and they verbally notify the resident or responsible party of the reason, but this verbal notification was not documented on the form.	2016-01-01
9188	PLEASANT VALLEY NSG. & REHAB C	515064	1200 SAND HILL ROAD	POINT PLEASANT	WV	25550	2011-09-21	225	E	0	1	2WLP11	Based on personnel record review, staff interview, and review of a newsletter issued to all nursing facilities in WV by the State survey and certification agency, the facility failed to conduct a thorough criminal background check prior to hiring five (5) of five (5) employees in the past four (4) months. There was no evidence to reflect the facility had conducted a statewide criminal background check for these individuals, in an effort to uncover personal histories of criminal convictions that would indicate these individuals may be unfit to provide services to residents in nursing facilities. This had the potential to affect more than an isolated number of residents. Employee identifiers: #69, #13, #39, #47, and #54. Facility census: 94. Findings include: a) Employees #69, #13, #39, #47, and #54 Review of five (5) personnel records of employees who had been hired by the facility in the past four (4) months revealed no evidence that statewide criminal background checks had been initiated for these individuals through the WV State Police. During an interview with the facility's administrator (Employee #2) on the afternoon of 09/19/11, she confirmed that criminal background checks were not obtained by the facility through the WV State Police. According to a newsletter sent to all WV Medicare / Medicaid certified nursing facilities and licensed nursing homes in November 2004: . Regarding criminal background checks, both the State licensure rule and the Federal Medicare / Medicaid certification requirements mandate screening of applicants for employment in a nursing home or nursing facility. The licensure rule specifically requires nursing homes to conduct a 'criminal conviction investigation' on all applicants; the certification requirements require that nursing facilities 'must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law'; facilities are expected to 'make reasonable efforts to uncover information about any past criminal prosecutions'. To satisfy these requirements, OHFLAC will accept nothing less than a statewide criminal background check on all applicants. Individuals for whom criminal background investigations have been initiated may begin work at the facilities pending satisfactory outcomes of the checks. According to the WV State Police, they are the sole agency that can conduct a statewide criminal background check in WV, for which they require a set of ten (10) fingerprints from each individual for whom the criminal background check is to be performed. Employee #2 has been employed as the facility's administrator since prior to issuance of this newsletter in 2004.	2016-01-01
9189	PLEASANT VALLEY NSG. & REHAB C	515064	1200 SAND HILL ROAD	POINT PLEASANT	WV	25550	2011-09-21	279	D	0	1	2WLP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to use the results of a comprehensive assessment to develop a comprehensive care plan for two (2) of thirty-two (32) Stage II sample residents. Resident #33 had contractures of both hands, which had been identified in the comprehensive assessment, and a care plan had not been developed describing the services that were to be furnished to address these contractures. Resident #84 did not have a care plan to address the services to be furnished for urinary incontinence. Resident identifiers: #33 and #84. Facility census: 94. Findings include: a) Resident #33 Review of current physician orders [REDACTED]. An interview with the occupational therapist (OT - Employee #82), on 09/20/11 at 2:30 p.m., revealed this resident resisted having her hands opened and cleaned. The OT stated the resident yells, screams, and cries when staff works with her hands and tells staff she does not want to be bothered. The OT also reported that OT services were no being longer provided to this resident. Review of the resident's annual minimum data set assessment (MDS), with an assessment reference date (ARD) of 05/16/11, found the assessor encoded Section G to indicate the resident's upper extremities had impairment in range of motion on both sides. The assessor also encoded Section S of the MDS to reflect the resident had contractures of both hands. Review of the resident's current care plan, with a completion date of 08/18/11, found no plan had been developed to describe the care and services of the resident's contracted hands with goals and interventions developed, such as pain control, methods to relax the resident and the hands to make the treatment more acceptable to the resident. In an interview on 09/21/11 at 4:00 p.m., the facility's administrator (Employee #2) was informed of the lack of a comprehensive care plan for Resident #33's hand contractures. -- b) Resident #84 Review of the resident's most recent MDS, with an ARD of 09/05/11, found the assessor encoded Section H to indicate this resident was frequently incontinent of urine, occasionally incontinent of bowels, and that he was not on a toileting program. A review of the most recent interdisciplinary care plan, last revised on 09/06/11, found no problem statement, goal(s), or intervention(s) to address this resident's incontinence. The nursing assistant documentation, when reviewed, disclosed the nursing assistants were monitoring this resident's incontinence daily and recording in the medical record if the resident had been incontinent or continent on their shift. This information was then used to complete an assessment, which revealed he was continent on some days and incontinent on others. However, there was no evidence that this had been used to establish a plan or provide instructions for an appropriate toileting program. During an interview, the MDS coordinator (Employee #111) confirmed there was no care plan for this resident to address his incontinence, to include no toileting plan.	2016-01-01
9190	PLEASANT VALLEY NSG. & REHAB C	515064	1200 SAND HILL ROAD	POINT PLEASANT	WV	25550	2011-09-21	315	D	0	1	2WLP11	Based on observation, record review, and staff interview, the facility failed to assure a resident received an appropriate toileting plan to restore as much normal bladder function as possible. Resident #84 had experienced urinary problems in the past and received services from a urologist. The facility failed to monitor his urinary elimination pattern and did not establish a toileting program based on the type of incontinence this resident was experiencing. This was observed for one (1) of thirty-two (32) Stage II sample residents. Facility census: 94. Findings include: a) Resident #84 Review of the medical record revealed this resident had been seeing a urologist for complications he was experiencing with his urinary elimination status. He previously had an indwelling Foley catheter present and also had previously had a temporary supra-pubic catheter which is a catheter inserted directly into the bladder through the abdomen. The most recent follow up appointment was with the urologist on 06/01/11. He stated in his report that he was following this resident for a stricture and his report indicated the resident was discharged with his Foley removed. The directions stated, Watch voiding pattern. A nursing note written on 06/01/11 stated, return to the facility. nno (no new orders). There was no care plan or evidence that it was communicated that the physician instructed them to watch his voiding pattern. An interdisciplinary care conference held on 06/16/11, revealed that this resident's Foley catheter was removed and he had no problems with voiding at that time. There was no evidence that there had been a discussion or review of the residents incontinence and no evidence he was evaluated for a toileting program or a voiding diary was initiated to further evaluated the type of incontinence her experienced or ways prevent incontinent episodes. The most recent minimum data set assessment (MDS), with an assessment reference date (ARD) of 09/05/11, revealed in Item H0200 that this resident was frequently incontinent of bladdet. The assessment also revealed he was not on a toileting program, such as scheduled toileting or prompted voiding. The note was reviewed from most recent care conference held on 09/08/11. There was no evidence that the residents frequent episodes of incontinence was reviewed during this meeting. The plan of care was reviewed and there was no evidence that a toileting program to address this resident's frequent episodes of incontinence was implemented or discussed. During an observation on 09/13/11 at 10:00 a.m., it was noted that this resident was observed in his room in the bed. When this surveyor visited with the resident, he smelled of urine. When he was questioned about needed assist with toileting he replied, I do not need any help I go myself. He was ask if he has any problems getting to the bathroom he said, No. Employee #78 was interviewed at 10:45 on 09/20/11. She was the nursing assistant for Resident #84. She stated that the resident takes himself to the bathroom most of the time but sometimes they reminded him. She was asked if he was on a toileting program and she stated not that she was aware of. She said that if he was on a toileting plan it would be in his care plan. She showed the surveyor his care plan and verified that he is not on a toileting plan. She discussed the urinary documentation and stated that they only document if he was continent or incontinent on their shift. Even if he was incontinent only once, then they document incontinent. She stated that the resident ambulates with a walker and he is usually pretty good to go to the bathroom and is not incontinent that often. When the nursing assistant was asked how often, she showed the surveyor the bladder record that was recorded for this resident. Employee #111 was asked to provide the resident's voiding documentation. It was verified that the resident's bladder continence is recorded one time a shift. During review of this resident's record, it was verified this resident had been continent twenty-two (22) shifts since 09/01/11. This record also indicated that he had been incontinent seventeen (17) shifts during the same time frame. Employee #111 confirmed that there was no evidence that this had been included in the residents care plan or that his voiding pattern had been monitored and recorded other than once each shift. She verified that a toileting program had not been initiated for this resident to improve his urinary status or to prevent further episodes of incontinence.	2016-01-01
9191	PLEASANT VALLEY NSG. & REHAB C	515064	1200 SAND HILL ROAD	POINT PLEASANT	WV	25550	2011-09-21	367	E	0	1	2WLP11	Based on observation, menu review, and staff interview, the dietary staff did not serve therapeutic diets in accordance with the planned menus for those diets. Residents with orders for calorie-controlled diets received incorrect portion sizes for sweet potatoes and the wrong type of milk. This had the potential to affect thirty (30) residents with orders for 1200, 1500, 1800 and 2000 calorie-controlled diets. Resident identifiers: #49, #69, #99, #76, #67, #44, #9, #16, #93, #17, #64, #106, #31, #110, #22, #56, #114, #88, #20, #111, #132, #83, #45, #131, #92, #10, #102, #172, #156, and #100. Facility census: 94. Findings include: a) Residents #49, #69, #99, #76, #67, #44, #9, #16, #93, #17, #64, #106, #31, #110, #22, #56, #114, #88, #20, #111, #132, #83, #45, #131, #92, #10, #102, #172, #156, and #100. 1. Observations, during tray preparation for the noon meal on 09/12/11, found dietary staff placed cartons of 2% milk on the trays for the thirty (30) above-identified residents, all of whom were on calorie-controlled diets. According to a review of the facility's planned menu for the 1200, 1500, 1800 and 2000 calorie-controlled diets, these residents should have been served skim milk. As a result of being served 2% milk instead of skim milk, these residents would be receiving more fat exchanges than had been calculated into the menu pattern. When questioned, dietary staff reported the cartons of skim milk they had were out-dated and they could not serve the milk that was past its expiration date. - 2. Five (5) of these thirty (30) residents (#99, #44, #16, #31, and #88) had orders for 2000 calorie-controlled diets, which allowed them to receive 1/2 cup portions of sweet potatoes; there remaining twenty-five (25) residents were to have been served 1/3 cup portions of sweet potatoes. However, all thirty (30) of these residents were served 1/2 cup portions of sweet potatoes. The twenty-five (5) residents with orders for 1200, 1500, and 1800 calorie-controlled diets, consequently, were served more more carbohydrates than had been calculated into the menu pattern. The dietary manager (Employee #92), who accompanied the surveyor during these observations, verified the portions served to these residents were not in accordance with planned menu for these therapeutic diets.	2016-01-01
9192	PLEASANT VALLEY NSG. & REHAB C	515064	1200 SAND HILL ROAD	POINT PLEASANT	WV	25550	2011-09-21	371	E	0	1	2WLP11	Based on observation and staff interview, dietary staff failed to handle and serve food items in a sanitary manner. Staff was observed to handle food and non-food items with the same gloves while serving lunch on 09/12/11. This practice has the potential to affect all residents who consumed a diet of regular consistency on that date. Facility census: 94. Findings include: a) Observations, during tray preparation for the noon meal at 11:32 a.m. on 09/12/11, found a dietary staff member (Employee #91) wore food handlers gloves to serve food on the tray line. She then proceeded to the oven, retrieved a hand full of french fries from a pan, and carried them to the tray line area. She then placed the french fries on a plate for a resident. Those same gloves were worn when Employee #91 handled a wet rag that was lying on the steam table shelf, which was used to clean up spills.	2016-01-01
9193	PLEASANT VALLEY NSG. & REHAB C	515064	1200 SAND HILL ROAD	POINT PLEASANT	WV	25550	2011-09-21	502	D	0	1	2WLP11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to obtain laboratory services for one (1) of thirty-two (32) Stage II sample residents every three (3) months as ordered by the physician. Resident identifier: #88. Facility census: 94. Findings: a) Resident #88 Review of Resident #88's monthly recapitulation of physician orders [REDACTED]. Results of lab work completed in March 2011 were found, and the September lab work was scheduled to be obtained later in the week during the survey. However, no results could be found for lab work that should have been obtained in June 2011. Employee #111 reviewed the medical record, and at 2:20 p.m. on 09/20/11, she reported this lab had not been completed as ordered.	2016-01-01
9194	HARPER MILLS	515086	100 HEARTLAND DRIVE	BECKLEY	WV	25801	2013-01-10	225	D	1	0	UD9011	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, review of the facility's reported allegations and associated investigations, and record review, the facility failed to immediately report an allegation of abuse to the appropriate authorities for one (1) of eight (8) sample residents. Resident #148 was identified as sustaining a second fracture to his left arm/shoulder on 12/17/12. The facility reported the incident to the Office of Health Facility Licensure and Certification (OHFLAC) as an injury of unknown origin. During the investigation it was found the resident had reported an allegation of abuse to two (2) employees who failed to immediately report the incident to the administrator. Also, the facility failed to thoroughly investigate all staff members working with the resident on the day of the incident, and failed to submit the five (5) day investigation report in a timely manner. Resident #148. Facility census: 147. Findings include: a) Resident #148 The nursing progress notes for this resident were reviewed on 01/08/13 at 2:15 p.m. The notes, dated 12/17/12, described the resident was complaining of pain in the left shoulder. According to the notes, Upon assessment, left shoulder noted to have swelling, little active range of motion, and possible deformity of upper arm. The physician was notified and ordered an immediate x-ray at first, but then the physician ordered the resident to be sent to the emergency room for evaluation. Resident #148 went to the emergency room where he was diagnosed with [REDACTED]. He returned to the facility with orders for his arm to remain in a sling, and to discontinue physical therapy (PT) until the attending physician gave approval to restart PT. The resident was to do no lifting, pulling, or use the left arm. During an interview with Employee #219 (administrator), on 01/09/13, it was discovered the facility immediately began an investigation after the second fracture was confirmed on 12/18/12. The facility reported the incident to OHFLAC on 12/18/12, as an injury of unknown origin. Further review of the medical record, on 01/08/13 at 2:15 p.m., found on 12/19/12, Resident #148 was found in a puddle of blood with the surgical pin protruding through the skin on his left shoulder. He was immediately sent to the emergency room for evaluation. During an interview with the administrator, on 01/09/13 at 11:15 a.m., it was discovered two (2) nursing assistants reported Resident #148 had made an allegation of abuse related to his incident. The two (2) nursing assistants, Employee #23 and Employee #95, did not immediately report the incident to the administrator. The administrator stated, I found this out during the investigation of the injury of unknown origin. The administrator further stated, the power of attorney (POA) for Resident #148 had also reported an allegation of abuse to Employee #24 (social worker) on 12/20/12. Review, on 01/09/13 at 11:30 a.m., of the statement provided by the POA to the social worker on 12/2012 found the following: I stepped out into the hallway while they were getting him ready to go to the hospital. While in the hall, I spoke with a very nice nursing assistant, I can't remember her name, but I think it was (named the nursing assistant) Employee #95. She had sort of longer hair, kind of blondish-brown. She has cared for my husband before, actually I would love for Employee #95 to be the person who takes care of my husband all the time - she is just so nice. My husband would call her mashed potatoes. Employee #95 told me that someone did this to my husband because they handled him too rough and I (Employee #95) know who this person is and I (Employee #95) reported it to the nurse. On 01/09/13 at 11:30 a.m., the administrator confirmed Employee #95 (nurse aide) and Employee #23 (nurse aide) reported the allegation of abuse to her, but failed to immediately report the allegation of abuse. During this interview, the administrator was asked why the incident was not then reported as an allegation of abuse. No response was given. At 11:51 a.m. on 01/10/13, the administrator was asked if the two (2) nursing assistants who did not immediately report the allegation of abuse were reprimanded. She stated, It wasn't addressed in written form, we don't have that yet. Review of the investigation for the injury of unknown origin, on 01/09/13 at 11:30 a.m., discovered Employee #95 named the perpetrator as Employee #17 (nurse aide). Further review found the facility did not interview Employee #17 (nurse aide) related to the incident, which occurred on 12/17/12, until 01/07/13. The administrator was asked why Employee #17 (nurse aide) was not interviewed for such a long period of time. She stated, She works PRN (as needed). Further review of the investigation, on 01/09/13 at 11:30 a.m., found Resident #148 had therapy services on 12/17/12. There was no evidence therapy staff was interviewed related to the fracture. A facility statement provided during the investigation by Employee #190 (licensed practical nurse), revealed on 12/18/12, the resident's wife (and POA) asked her if her husband had fallen. The wife stated, I was just wondering because Employee #150 (licensed practical nurse) told me she found him in the bathtub with his clothes on. During an interview with Employee #17, a nursing assistant, on 01/10/13, at 11:51 a.m., Employee #17 stated the following: He had urinated and I rolled him so I could change him. His arm didn't feel right. I felt something so I went and got the nurse. It was my first time having him I believe. He was the easiest person I had. He was uncomfortable. I had heard the nurse earlier say maybe he had fallen in the the bathtub. I heard _________ (Employee #150,a licensed practical nurse) say this to his wife. I understood he was in the bathtub and there was no [MEDICATION NAME] and he was trying to get a bath. He was already complaining of pain before I touched him. I like that little guy. Immediately following the interview with Employee #17 on 01/10/13 at 11:51 a.m., the facility suspended the employee related to her failure to report the alleged fall in the bathtub. Following the interview with Employee #17, during an interview, at 11:58 p.m., with the director of nursing (DON), she stated she was not sure the room had a a bathtub. At that time, an observation was conducted, with the DON, of the room in which Resident #148 previously resided. Observation revealed there was a bathtub in this room. There was no evidence the facility ever followed up on the incident in the bathtub. Further review of the investigation report identified the five (5) day follow up was completed on 12/27/12, but was not submitted to OHFLAC until 12/31/12. Employee #219 confirmed the follow-up report was not submitted timely, on 01/10/12 at approximately 11:55 a.m.	2016-01-01
9195	HARPER MILLS	515086	100 HEARTLAND DRIVE	BECKLEY	WV	25801	2013-01-10	441	D	1	0	UD9011	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to maintain infection control precautions for two (2) of seven (7) residents. Observation of two (2) rooms of residents on isolation revealed no signage to notify staff and visitors of isolation procedures. Facility census: 147. Resident identifiers: #129 and #54. Findings include: a) Resident #54 Observation of Room #E13, on 01/08/13 at 11:30 a.m., found an isolation cart outside of the room. No signage was found to identify the resident was on isolation precautions. Review of the medical record for this resident identified she was on reverse (protective) isolation for chronic [DIAGNOSES REDACTED] (a condition characterized by abnormally low levels of a certain white blood cell that plays an essential role in fighting bacterial infections). During an interview with Employee #73 on 1/10/13, at 10:26 a.m., it was confirmed the sign should have been posted on the door. b) Resident #129 Observation of Room #B4, on 01/08/13 at 11:20 a.m., found an isolation cart outside of the room. No signage was found to identify the resident was on isolation precautions. Employee #95 was asked what the cart was for she stated, We have to wear gloves when we go in there, she's got something. Review of the medical record identified Resident #129 was on isolation related to methicillin resistant staphylococcus aureus (MRSA - an organism that is resistant to many antibiotics). During an interview with Employee #73, on 1/10/13, at 10:26 a.m., it was confirmed the sign should have been posted on the door.	2016-01-01
9196	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	156	C	0	1	MZQB11	Based on observation and staff interview, the facility failed to prominently display required information and post the names, addresses and phone numbers of all pertinent State client advocacy groups and information concerning how to file a complaint with the appropriate State agency(ies) concerning abuse, neglect or misappropriation of resident property in the facility. This practice has the potential to affect all residents and families desiring to view this information. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Finding include: a) During the initial tour of the facility at the onset of the complaint investigation on 05/18/11, this surveyor attempted to view the posting of the required information. The entire first floor was toured, and there was no evidence of any posting containing contact information for the required State agencies. The director of nursing (DON), when questioned about the posting at 3:20 p.m. on 05/18/11, stated the facility had been remodeling and the posting must have been temporarily taken down while this was being done. During the initial tour of the facility at the onset of the annual Medicare / Medicaid certification resurvey at 11:00 a.m. on 05/24/11, observation found the State agency contact information had been posted on the front office door. Access to the front lobby through double doors from the nursing unit was also restricted for any resident wearing a Wanderguard bracelet, so this information would not have been readily available to all residents even if it were posted.	2016-01-01
9197	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	224	G	0	1	MZQB12	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospital records, review of facility policies and clinical services notices, and staff interview, the facility failed to provide care and services necessary to avoid physical harm for two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall occurred, staff did not follow facility policy, by not moving the resident until he was examined by emergency personnel or a head injury was ruled out. Although a neurological evaluation form was initiated for this fall, the assessments recorded were not complete / accurate (e.g., several entries identified limitations in motor movement to the wrong limb), and times were not always recorded; as a result, it could not be verified that these neuro checks were being completed at progressive intervals as specified in the directions on the form. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. On [DATE], prior to the resident leaving the facility for an outpatient appointment with an orthopedist, the nurse was notified that the resident's international normalized ratio (INR - a system established by the World Health Organization for reporting the results of blood coagulation (clotting) tests) was critically high. The nurse noted an order to administer Vitamin K to promote blood clotting but did not administer it before allowing the resident to leave the facility, nor did the nurse communicate to the family or the orthopedist's office that the resident had a critically high INR which placed him at risk for uncontrolled bleeding. Upon leaving the orthopedist's office later that same day, the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was madedo not resuscitate by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with: bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use (created on [DATE]) G -minimize skin breakdown risks (created on [DATE]) I - . Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. (created on [DATE]) - P -Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising (created on [DATE]) G -Will have no adverse effects (created on [DATE]) andWill maintain lab values within therapeutic range (created on [DATE]) I -Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and report adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care. (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P -At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION] created on [DATE]) G - Minimize risk for falls (created on [DATE]) I -Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE]). None of the above interventions related to the resident's risk for falls identified the anticoagulant therapy as a factor affecting the extent of injuries that could be sustained as a result of falling. - 4. According to a document titledClinical Services FYI - Post Fall Evaluation (FYI File - [DATE] - Number 34): Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs during a patient's stay. In the event that a patient does fall, a comprehensive clinical evaluation by the nursing supervisor is important to determine the extent of injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Clinical system areas of focus for a post-fall evaluation may include: . Medication a) Anticoagulant therapy . Anticoagulant therapy combined with a head injury increases the risk for intracranial bleeding. Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient hits their head; following an un-witnessed fall when a head injury may be suspected and following non-fall patient events which result in known or suspected head injury such as a suspected hemorrhagic stroke. In the event of a fall with suspected head, neck or spinal injury, staff should keep the patient warm but NOT MOVE (both words in bold - not caps - in the original document) the patient until emergency personnel arrive or head, neck or spinal injury has been ruled out. The licensed nurse's evaluation of a patient's condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive patient outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptoms, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Documentation of changes in condition is completed using the SBAR (situation - background - assessment - recommendation) process. According to the directions on the neurological evaluation flow sheet:Complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours). More frequent evaluations may be necessary. Based on these directions, a resident should receive no less than seventeen (17) neuro checks completed at progressive intervals. - 5. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the residentmissed his chair and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. After the fall on [DATE], neuro checks were started at 5:05 p.m. These checks, which were to include assessments of the resident's level of consciousness, orientation, pupils, motor movement, communication, and vital signs, were not always complete and were not completed at the progressive intervals required by the directions on the neurological evaluation flow sheet as stated above: - On [DATE] at 5:05 p.m.; at 5:35 p.m.; at 6:05 p.m. (vital signs only); at 6:35 p.m. (vital signs only); at 7:35 p.m. (vital signs only); at 8:35 p.m. (vital signs only); at 9:35 p.m. (vital signs only); and at 10:35 p.m. (vital signs only). - On [DATE] at 6:30 a.m. and at 2:00 p.m. - On [DATE] at 2:00 a.m.; at 6:00 a.m.; and at 8:00 p.m. - On [DATE] at 4:30 p.m. and at 8:00 p.m. - On [DATE] at 8:00 a.m. None of the neuro checks recorded at these times contained abnormal findings. 6. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed):resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning. The LPN also noted the type of incident as a(f)all without injury (or minor injury) . Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, andresident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest. Contrary to the information outlined above in the document titledClinical Services FYI - Post Fall Evaluation , Resident #141 - whom staff witnessed hitting his head during the fall - was not evaluated by emergency personnel and there was no evidence that a head injury was ruled out. There was also no evidence that the nurse informed the physician or the family that Resident #141 had hit his head during this fall. - The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written):Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. Tx (treatment) initiated to (L) elbow. Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot. An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written):Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue. At 6:00 p.m. on [DATE], another nurse wrote:Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results. At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 7. After the fall on [DATE], neuro checks were started at 10:45 a.m. In spite of the fact that a nurse witnessed the resident hitting his head during this fall, these neuro checks were not always accurate or complete (with temperature readings being recorded in the spaces intended for pulse oximeter readings, and pulse oximeter readings being omitted on several occasions) and the times these checks were completed were not always recorded, making it impossible to determine whether they were completed at the progressive intervals required by the directions on the neurological evaluation flow sheet: - On [DATE] at 10:45 a.m.; at 11:15 a.m.; at 11:45 a.m.; at 12:15 p.m.; at 2:15 p.m.; and at 6:15 p.m. (A nursing note, at 9:00 p.m. on [DATE], stated Resident #141 was sent to the ER, and he did not return to the facility until the early morning of [DATE].) - On [DATE] (no time recorded); and at,[DATE] (no specific time recorded) - On [DATE] at,[DATE] (no specific time recorded); at,[DATE] (no specific time recorded); and at,[DATE] (no specific time recorded) - On [DATE] at,[DATE] (no specific time recorded) Beginning with the first entry on the sheet for this fall at 10:45 a.m. on [DATE], the nurse recorded(arrow pointing down) ROM to indicate an abnormal finding (decrease in range of motion) with respect to the motor movement of the right upper limb. This same notation was made with respect to an assessment of the motor movement of the right upper limb at 11:15 a.m., 11:45 a.m., and 2:15 p.m. on [DATE]; at 6:15 p.m. on [DATE], the nurse recorded(arrow pointing down) R as an abnormal finding for motor movement of the right upper limb. (Note: The injured arm was his left upper limb, not his right upper limb.) Beginning with the first entry on the flow sheet for [DATE] (with no time recorded) and continuing through the entry at,[DATE] on [DATE], the nurse completing the form noted a problem with motor movement of the left upper limb. No problems with motor movement of either upper or lower limbs were noted when the last two (2) entries were recorded on the form for [DATE] at,[DATE] and [DATE] at,[DATE] . No other abnormal findings were noted. - 8. An entry in the nursing notes, in the early morning of [DATE], stated:Resident brought back to facility . Resident also has large bruising area on buttocks D/T (due to) fall. After entries identified the presence of a skin tear to the left arm on [DATE] and the presence of a large area of bruising on the buttocks on [DATE], no additional entries made in the record during the remainder of his stay in the facility contained either a nursing assessment (or a physical description) of his appearance after the fall. There was no further mention of the large bruise on his buttocks and no description of physical findings about his head, which hit the door frame during the fall. There was also evidence in the nursing notes or care plan that were reflective of staff's recognition that the resident's anticoagulant therapy was a potential concern with respect to injuries associated with the fall. - 9. Prior to the fall on [DATE], Resident #141 had been self-ambulating frequently when awake and was able to feed himself independently. After this fall, he required 100% feeding by staff, was frequently refusing to eat or drink. Additionally, nursing entries on [DATE], [DATE], and [DATE] all contained phrases likeresting in bed with eyes closed;Resident resting quietly;resting quietly no acute distress; andresting in bed. There was no documentation in his record to reflect that staff observed the resident ambulating after [DATE], and the resident now required staff assistance with eating; these reflected a significant change in Resident #141's self-performance of activities of daily living. The resident's PT on [DATE] was 23.0 with an INR of 2.1. This was reported to the physician, and the resident's dosage of [MEDICATION NAME] remained the same with an order for [REDACTED]. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 10. Review of the physician's progress notes found the following entries, which appear as recorded (out of chronologic order) and are quoted as written: - On [DATE] at 11:50 a.m. -I saw the pt again today because (1) He fell a couple of nights ago & fractured L humerus (2) He continues to be restless since we have tapered off [MEDICATION NAME] (3) When I went into room - he was flushed and agitated. Temp 99.9 HR 70's irregular. Lungs with bibasilar crackles. Mouth looks a little dry. No LE (lower extremity) [MEDICAL CONDITION]. I spoke with his son - who also noted a 'wild' look in his Dad's eyes recently. We discussed fracture, need to change pain regimen and med strategies for his agitation. He is in agreement with the treatment (illegible) changes. - On [DATE] at 11:22 a.m. -Pt is sedated this morning - missed breakfast. O2 sat 94%. Lungs - coarse BS (breath sounds). Abd (abdomen) soft. Labs were basically OK - Will (check) CXR (chest x-ray) - but probably not a good idea to go for ride to ortho. Nursing aware. (This entry may have been incorrectly dated; it corresponds with a late entry record by nursing for [DATE].) - On [DATE] at 4:50 p.m. -New developments - (Resident #141) continued to poor PO intake and alertness although he did better at times. Not really SOB (short of breath). He continues not to leave arm immobilizer arm. Na (sodium) was 177 last night - he started IV fluids And it was down to 166. PT / INR was also elevated. So [MEDICATION NAME] on hold. His O2 Sat currently - 92% with HR (heart rate) 84. He gets a little restless at times. Lungs with fine basilar crackles. Mouth dry - but he actually looks better and more comfortable than last visit. Nursing comforting family - they agree with us trying to not linger and are discussing Code Status. Will go ahead and change antibiotic to [MEDICATION NAME] IV since we have IV access. Labs in AM (morning). Since stable at present - Will continue fluids - plan change to ? NS tomorrow. - A review of laboratory tests, completed on [DATE], revealed the following: Sodium - 167 (normal range 136 - 146) Chloride - 136 (normal range 98 - 110) Blood urea nitrogen (BUN) - 70 (normal range 8 - 21) Calcium - 11.4 (normal range 8.4 - 10.2) All of these values had the highlighted statement:Significantly different from previous result (previous results were dated [DATE]). The labs were repeated on [DATE] and were approximately the same. - 11. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written):Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%. The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated:Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]. The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated:(Name of transport service) here to p/u (pick up) for ortho appt. There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 12. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 13. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm. The report read:The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding. He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. The resident's laboratory values included the following: Lactic acid - 2.2 (normal range 0.5 - 2.0) Sodium - 159 (normal range 98 - 110) INR - 9.53 (normal range 2.5 - 3.5; over 4.9 is critically high) Hemoglobin - 7.9 (normal range 14.0 - 16.0) Hematocrit - 24.8 (normal range 41.0 - 53.0) He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. Per the history provided to the ER physician by the resident's son, the resident had had a functional decline and decreasing memory for the previous four (4) months. However, the son had noted a marked decrease in the resident's mental status in the previous week. According to the history, the son reported to the hospital physician that, only days ago, Resident #141 was walking and feeding himself. The son also informed the ER physician of the resident's recent falls and the resulting fracture to the left arm. - 14. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma wasold and she did not relate it to the fall (even though the CT report indicated the subdural hematoma wasprobably old and that alarge amount of acute bleeding was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). On the previous day ([DATE]), Employee #24 had been asked by this surveyor to explain how the resident got to the hospital. He stated then that he did not know, but he supposed that the residentwent bad in the ambulance and they took him there. When asked if he knew the resident's current health status or why he did not return to the facility, Employee #24 denied any such knowledge and stated that it was the policy of the facility that, if a resident did not return, to not make any inquiries. Employee #24 appeared surprised when informed that there had been no comprehensive nursing assessments during this resident's significant decline from [DATE] until his transfer from the orthopedist's office to the hospital on [DATE] (which was arranged by his son). - 15. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, and would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma wasold, and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team'sright to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 16. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: Resting in bed with eyes closed. Easily aroused. Afebrile. Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H20 given with meds. There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain. There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility. The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed): . This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated . Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. Under t	2016-01-01
9198	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	241	D	0	1	MZQB11	Based on observation, resident interview, and staff interview, the facility failed to provide care in an environment at meal time that provided and maintained each resident's dignity. Three (3) of thirty-eight (38) Stage II sampled residents were not treated in a dignified manner at meal time. Resident #228 was not provided with a bedside table for use during meals and was, instead, provided a small plastic isolation cart with wheels; the height of the isolation cart was not adjustable, and the resident spilled food on her gown and bed linens as she attempted to feed herself. Resident #70 was served her meal well after her roommate, was asked if she wanted a bib, and was not given adaptive utensils as per her tray slip. Resident #85 was also not served his meal in a timely manner. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 During the initial tour of the facility on 05/18/11 at 12:00 p.m., this resident was observed eating her lunch in her bed. Her tray was sitting on a plastic cart with wheels, which was located on the left side of her bed. This was noted to be her isolation cart with supplies in it required for maintaining contact isolation precautions. Resident #228 was feeding herself with her right hand, and her left arm was just lying on the bed. She was reaching over and getting chili on her spoon and was having difficulty getting it to her mouth without spilling it on her gown and bed linens. She said she could do it, but she just had to do a little bit at a time. When questioned about the cart her tray was sitting on, she stated she guessed that was all they had. She stated she ate on it earlier that morning. She stated someone fixed that up for her or she probably wouldn't have had anything to sit her tray on. She said, It doesn't look like much, but at least it works. She verified she could not use her left arm because she had a stroke and she was having a difficult time reaching over that side to get to her tray. Employee #67 (housekeeping aide) was passing by the room at 12:15 p.m., and this surveyor ask him if he knew why Resident #228 did not have a bedside table. He stated he was not sure why she did not have one, but he would get her one. He obtained an overbed table for this resident, and she stated this was much better. -- b) Resident #70 Random observations were made of lunch service on the second floor on 05/24/11. These observations began within one (1) hour of entrance into the building to begin the Medicare / Medicaid certification resurvey. At 12:02 p.m., Resident #70 was sitting in a wheelchair in her semi-private room between the two (2) beds. Her roommate (Resident #175), who was sitting up in bed, had been served and was eating her lunch. When Resident #70 was asked whether she was hungry, she nodded in the affirmative. At 12:16 p.m., Employee #118 (nursing assistant) entered the room. She said, You don't have a bib, and went to find one. She returned and put a bath towel across the resident's chest and around her neck. Resident #70 was not served until 12:37 p.m. - more than thirty-five (35) minutes after her roommate had been served. Additionally, Resident #70 was not provided with the adaptive utensils as identified on her tray slip. When asked about this, she spelled on her communication board, They probably forgot. The resident's dignity was not enhanced as follows: - She sat for at least thirty-five (35) minutes after her roommate was served; - The staff member called the clothing protector a bib, which is most commonly associated with infants; - A towel was used rather than adult clothing protector; and - She was not provided with the special utensils, which had the potential to make her feel unimportant / forgotten. -- c) Resident #87 At 12:00 p.m. on 05/24/11, Resident #40 was observed eating lunch in his room. His roommate (Resident #87) had not been served. When asked whether he had had his lunch for long, Resident #40 said, About five (5) minutes. It was noted he had already consumed approximately half of his meal. At 12:14 p.m., Resident #40 had finished his meal, but Resident #87 had yet to be served. At 12:23, Employee #131 (nursing assistant) was asked about the meal service. She said residents who could feed themselves were served first, then the residents who had to be fed were served. At approximately 12:40 p.m., Employee #118 (nursing assistant) passed by the resident's room and was heard to comment, (Resident #87's first name) basically feeds himself. Resident #87 was not served his lunch until 12:52 p.m., when Employee #92 (nursing assistant) sat down to feed him. (During subsequent observations, the resident was noted to feed himself.) A red napkin was noted on the resident's tray. At 12:56 p.m., Employee #69 (nursing assistant) was asked what the red napkin meant. She said it was to alert staff to let the residents try to feed themselves but to keep checking on them and feed the residents if necessary. Resident #87 was not served for nearly an hour after his roommate (Resident #40) had been served his lunch.	2016-01-01
9199	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	246	D	0	1	MZQB11	Based on observation, record review, resident interview, and staff interview, the facility failed to make reasonable accommodations to meet the individual needs of residents. The facility failed to ensure staff answered call lights within a reasonable period of time for two (2) of thirty-eight (38) residents on the Stage II sample and one (1) randomly observed resident. During a period of approximately one (1) hour, three (3) call lights were observed to be on for thirteen (13) to twenty-two (22) minutes without staff responding for more than ten (10) minutes. Additionally, Resident #228 was not provided with a bedside table for use during meals and was, instead, provided a small plastic isolation cart with wheels; the height of the isolation cart was not adjustable, and the resident spilled food on her gown and bed linens as she attempted to feed herself. Resident identifiers #60, #85, #155, and #228. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Residents #60, #85, and #155 1. On 06/08/11, while reviewing some information at the second floor nurses' station, it was noted at approximately 8:00 a.m., call lights were remaining on for extended periods of time. The display panel, the telephone display, staff in the halls, and the rooms were observed for staff's responses to the call lights. During this time, the following were noted on C hall: - Resident #60's call light rang for seventeen (17) minutes, - Resident #85's call light rang for twenty-two (22) minutes, and - Resident #155's call light rang for thirteen (13) minutes. Employee #58 (licensed practical nurse - LPN) was passing medication on the unit. Several nursing assistants (including, but not limited to, Employees #122 and #127) were also observed on C hall. No one answered the call lights in a timely manner. 2. Resident Council Meeting minutes Review of the Resident Council meeting minutes, dated 05/16/11, found under Nursing for Any requests (completion of form) the individual recording the minutes had written Timely call lights in the section for new business. -- b) Resident #228 During the initial tour of the facility on 05/18/11 at 12:00 p.m., this resident was observed eating her lunch in her bed. Her tray was sitting on a plastic cart with wheels, which was located on the left side of her bed. This was noted to be her isolation cart with supplies in it required for maintaining contact isolation precautions. Resident #228 was feeding herself with her right hand, and her left arm was just lying on the bed. She was reaching over and getting chili on her spoon and was having difficulty getting it to her mouth without spilling it on her gown and bed linens. She said she could do it, but she just had to do a little bit at a time. When questioned about the cart her tray was sitting on, she stated she guessed that was all they had. She stated she ate on it earlier that morning. She stated someone fixed that up for her or she probably wouldn't have had anything to sit her tray on. She said, It doesn't look like much, but at least it works. She verified she could not use her left arm because she had a stroke and she was having a difficult time reaching over that side to get to her tray. Employee #67 (housekeeping aide) was passing by the room at 12:15 p.m., and this surveyor asked him if he knew why Resident #228 did not have a bedside table. He stated he was not sure why she did not have one, but he would get her one. He obtained an overbed table for this resident, and she stated this was much better.	2016-01-01
9200	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	250	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide medically-related social services to one (1) of thirty-eight (38) Stage II sample residents who was approved for short-term placement at the facility, by failing to assess the resident's goals with respect to discharge and develop an appropriate discharge plan to accomplish those goals. Resident identifier: #148. Facility census: 144. Findings include: a) Resident #148 Medical record review revealed this [AGE] year old female was originally admitted to the facility on [DATE], and was discharged to home on 08/31/10. The resident was readmitted to the facility on [DATE] after she suffered a fracture of the right femur. Her current active [DIAGNOSES REDACTED]. Further record review revealed a social work assessment and history, dated 03/29/11. The sections addressing the resident's expected length of stay, anticipated discharge potential, anticipated discharge destination, and community resources potentially needed after discharge were not completed. Review of the resident's pre-admission screening (form PAS-2000) revealed the physician expected her to be able to return home in less than three (3) months. The PAS-2000 was signed by the physician on 03/21/11. Review of her minimum data set assessment (MDS 3.0), with an assessment reference date (ARD) of 04/01/11, found in Section Q0400 (Discharge Plan) that a determination for discharge had not been made. Employee #25 (physical therapy assistant), when interviewed on 06/02/11 at 11:05 a.m., stated he had treated the resident around this time last year and she was able to return home. He stated her son and husband had been very active in her treatment on her last admission, but he had not seen them this time around. He stated he was not sure what had happened. Employee #34 (licensed social worker), when interviewed on 06/02/11 at 10:35 a.m., stated she thought the resident was going to be a long term placement, but she was not sure. She was unable to produce any documentation of discharge plans having been discussed with the resident or her family. The social work assessment stated the resident had . 3 sons for support and to make decisions regarding her care while at (name of nursing home).	2016-01-01
9201	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	272	E	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident interview, and staff interview, the facility's interdisciplinary team failed to complete assessments to accurately reflect each resident's health status / condition for six (6) of thirty-eight (38) Stage II sample residents. Complete and accurate assessments were not conducted for Resident #223's pressure ulcer, Resident #129's indwelling catheter, Residents #116 and #199's bladder continence, Resident #155's dental status, and Resident #125's complaints of a sore toe. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #223 During a review of Resident #223's initial Medicare 5-Day minimum data set assessment (MDS), with an assessment reference date of 04/14/11, found this resident had a pressure ulcer measuring 2.5 cm x 3.4 cm. This pressure ulcer, which was noted to have been present on admission to the facility, was identified on the MDS as being unstageable due to the presence of slough or eschar. Further review of the MDS found in Section V that the care area of Pressure Ulcer was then triggered and addressed in the care plan. The assessor noted that the further information for this care area could be found in a worksheet dated 04/18/11. The Care Area Assessment (CAA) worksheet dated 04/18/11, when reviewed, found in the analysis of this ulcer that this represented a potential problem. The nature of the problem was stated: At risk for pressure ulcers. The end note stated: (Resident #223) could be at risk for a pressure ulcer related to impaired mobility and incontinent. See the plan of care documentation for 4/11/2011. The staff will continue to assist her as needed for frequent position changes as well as prompt incontinence care. Any concerns with her skin will be reported to the MD promptly. Will proceed to care plan. This CAA did not reflect the resident's actual condition or evaluate the causative factors or the care needs for the pressure area that was already present. It addressed only the potential for developing pressure sore, when the medical record and skin assessments indicated she had actual skin breakdown. During an interview with Employee #173 (registered nurse (RN) - case mix consultant) at 3:15 p.m. on 06/06/11, she was questioned about the CAA note not providing additional information about the pressure ulcer. She stated that they sometimes write the CAA notes in a manner not to repeat what is already specified in the MDS assessment; for example, since the wound measurements were already there, they would not write them again. She verified the CAA note addressed this ulcer as a potential problem and did not identify that the resident had an actual pressure ulcer at the time this assessment was completed. -- b) Resident #129 Record review revealed Resident #129 was admitted to the facility on [DATE] with an order for [REDACTED]. Resident #129's admission MDS, with an ARD of 03/11/11, revealed this resident had an indwelling urinary catheter. This triggered the care area Urinary Incontinence and Indwelling Catheter in Section V of the MDS, where the assessor recorded that the location and date of the CAA could be found in the worksheet dated 03/16/11. The resident's CAA worksheet for Urinary Incontinence and Indwelling Catheter, when reviewed, stated that there was a potential problem. When describing the nature of the problem / condition, the assessor noted the resident had a Foley indwelling urinary catheter in place and needed assistance with toileting. There was no discussion of why the catheter was needed. In the section for discussing the summary and care plan considerations, the assessor recorded: Resident has a Foley catheter in place as evidenced by the order dated 3/5/11. This could place her at risk for problems such as altered urinary output, pain etc. She needs assistance with toileting as evidenced by the documentation in the POC (plan of care). Staff will continue to assist her with toileting and catheter care to help minimize the risk of problems. Any problems noted or reported will be addressed with the MD. Will continue to care plan. There was no information in this resident's medical record discussing why she had this indwelling catheter, when it had been inserted, or whether there was any consideration to remove the catheter. During an interview on the afternoon of 06/04/11, Employee #88 (RN - assistant director of nursing) verified the reason for this catheter was excoriation, which was present on admission. This excoriation was resolved on 04/04/11, and there was no evidence of an assessment to determine whether a continued need for this indwelling catheter existed. -- c) Resident #116 The resident's annual MDS, with an ARD of 02/01/11, indicated the resident was always continent of urine. The quarterly assessment, with an ARD of 04/20/11, indicated she was occasionally incontinent of urine. Neither assessment was coded to indicate the resident was on a urinary toileting program. A physician's progress note, dated 05/19/11, stated the resident . C/O (complained of) new onset incontinence - sudden, no urge or control 'I don't know what's wrong.' The physician also noted the resident was alert and oriented. A urinalysis and a urine culture and sensitivity were ordered on [DATE]. These were completed on 05/20/11. An antibiotic was ordered for the identified urinary tract infection. No evidence was found in the nurses' notes of any complaints having been made by the resident of any urinary elimination problems. There was no evidence of monitoring to determine the effectiveness of the antibiotic in relieving the resident's complaints of urgency and loss of bladder control. On 06/03/11 at 9:30 a.m., the resident was interviewed regarding her bladder function. She stated, Sometimes I need to go when I need to go and Sometimes I can't make it. The resident stated there had been some improvement since she was given the antibiotic, but she still had times when she needed to go right away. On 06/03/11 at 10:34 a.m., Employee #95 (RN), when asked about the resident's urinary continence status, said the staff had talked about possibly seeing if the resident would wear an incontinence brief at night. He was unable to find any evaluation of the change in her continence status. Employee #69 (nursing assistant), when asked about the resident's urinary continence in mid-morning on 06/07/11, said she had been reporting the resident's incontinence for about four (4) weeks. She demonstrated how the nursing assistants could put issues in the care tracker to alert the nurse. She said she had asked about whether the resident could have an incontinence brief at night. The nursing assistant also said it had been discussed whether the perimeter mattress kept the resident from getting out of bed at night. On the afternoon of 06/07/11, the director of nursing (DON - Employee #12) was asked whether there was any evidence of an evaluation of the resident's continence status. On the morning of 06/08/11, she reported she had not found anything. There was no evidence the decline from always continent to occasionally incontinent of urine had been assessed in an attempt to identify any contributing / causal factors, in an effort to restore or to prevent further decline in her urinary continence. -- d) Resident #199 The resident's admission MDS, with an ARD of 02/11/11, indicated the resident was frequently incontinent of urine. He was noted to remain frequently incontinent of urine on the quarterly MDS with an ARD of 04/29/11. No evidence of an assessment for voiding patterns or possible causal factors for his incontinence was found. On the late afternoon of 06/07/11, the DON was asked for evidence of an assessment of his urinary continence. A significant change in status assessment (SCSA) MDS, with an ARD of 05/27/11, was reviewed. This assessment indicated he required extensive assistance for toilet use, that he could walk in his room independently, and needed supervision when walking in the hall. He was coded as being able to be understood and could understand others. On 06/08/11 at approximately 1:00 p.m., the CAA for urinary incontinence, completed for the SCSA, was reviewed. The CAA noted the resident required extensive assistance with toilet use and he was frequently incontinent. The form used by the facility for completion of the CAA included a section for identifying the type of incontinence. The choices were stress, urge, mixed, overflow, transient, and functional. None of these were checked. Under the section of the CAA for Care Plan Considerations, the assessor had checked to avoid complications, maintain current level of functioning, and to minimize risks as the overall objectives. Improvement and Slow of minimize decline were options, but neither had not been checked. The narrative for the CAA stated: Resident is frequently incontinent of urine and needs assist with toileting as evidenced by the documentation in POC. This places him at risk for problems such as skin break down and infections. Staff will continue to asist (sic) him as needed with continent (sic) care to help minimize the risk of problems. Any noted will be addressed with the MD. Will continue to care plan. His [DIAGNOSES REDACTED]. None were indicative of a condition that would prohibit an attempt to improve his urinary continence status. The CAA had a section for diseases and conditions that might affect continence, but none were checked. In an interview with the resident on 06/08/11 at 11:10 a.m., he said he usually knew when he had to void. The CAA verbiage used by the facility was the same as the CAA in Appendix C of CMS's RAI Version 3.0 Manual. The instructions in Appendix C included: Step 4: . provide supporting documentation regarding the basis or reason for checking the item, including the location and date of that information, symptoms, possible causal and contributing factor(s) for that item, etc. Step 5: Obtain and consider input from resident and/or family/resident's representative regarding the care area. Step 6: Analyze the findings in the context of their relationship to the care area. This should include a review of indicators and supporting documentation, including symptoms and causal and contributing factors, related to this care area. Draw conclusions about the causal/contributing factors and effect(s) on the functional ability of the resident, and document this information in the Analysis of Findings section. There was no evidence these steps had been taken in an attempt to assess the resident's potential to have an improvement in his urinary continence status, or to prevent further decline if improvement was not possible. -- e) Resident #155 Medical record review revealed this [AGE] year old male resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. During two (2) interviews with the resident - on 05/25/11 at 8:46 a.m. and again on 05/31/11 at 11:20 a.m., the resident stated his teeth hurt, especially when eating. He related he had about seven (7) teeth and they were rotted out. On 06/01/11 at 2:00 p.m., the DON stated she could find no evidence of a dental assessment and no evidence the resident had been evaluated by a dentist since his admission on 11/18/09. Another review of the medical record, on 06/01/11, revealed a nursing admission evaluation completed 10/08/10. Section F, regarding the resident's condition of teeth, indicated the resident had broken teeth. On 06/02/11 at 3:00 p.m., Employee #95 (RN - director of care delivery) was asked to assess the resident's dental needs. Employee #95 assessed the resident's teeth and stated, Looks like he may have a cavity in that back tooth. The resident's MDS with an ARD of 11/10/10, when reviewed, did not indicate the resident had any oral problems under Section L (L0200 - Oral / Dental Status). The response to this section was: None of the above was present. Since the resident had broken teeth the facility should have chosen the response: Obvious or likely cavity or broken natural teeth. -- f) Resident #125 During Stage I of the survey, on 05/25/11 at 2:20 p.m., this resident stated he had pain with no relief. When asked to describe, the resident said the toe beside his great toe on his right foot had a sharp nail (toenail). The resident stated the podiatrist, who trimmed his toenails, left it like that. The resident stated it hurt to walk, so he had been avoiding walking due to the pain. When asked if he had informed facility staff of this problem, he said, I let three (3) or four (4) people know. Review of the resident's medical record, during Stage II of the survey on 05/31/11, revealed no evidence the facility had assessed or addressed this resident's sore toe. An interview was conducted with Employee #58 (licensed practical nurse) at 9:00 a.m. on 06/01/11. Upon inquiry, Employee #58 stated the resident was very compliant with care and allowed staff to care for his needs. When asked about the sore toe, Employee #58 stated she had not been made aware of the resident's sore toe. At 10:45 a.m. on 06/01/11, the resident's right toe was observed with Employee #58. During the observation, the resident stated this toe had been hurting a lot. Employee #58 confirmed there was a sharp toenail on the toe beside his great toe on his right foot. At this time, the resident was asked again if he had let anyone know about this sore toe. The resident stated, I let three (3) or four (4) of them know. On 06/02/11 at 10:30 a.m., an interview was conducted with the DON. Upon describing the resident's sore toe and his statements that he told nursing staff about the problem, the DON stated the resident was competent and she felt his statements (regarding telling staff about his sore toe) were credible. At the time of the survey, the facility had not assessed the resident's sore toe to determine the extent of the problem and/or to determine the appropriate care and services needed to address the problem.	2016-01-01
9202	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	278	D	0	1	MZQB12	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure minimum data set assessments (MDSs) accurately reflected the health and functional status of two (2) of fourteen (14) sampled records. Resident identifiers: #141 and #21. Facility census: 140. Findings include: a) Resident #141 Record review revealed Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's discharge MDS, with assessment reference date (ARD) of 08/04/11, found the assessor noted the number of falls since the prior assessment (which was a quarterly MDS with an ARD of 07/13/11) as follows: - Fall with no injury - none - Fall with injury (except major) - none - Fall with major injury - 1 - A review of the incident reports, nursing notes, and the significant event reporting in the computer revealed that Resident #141 had sustained falls as follows: - On 07/20/11 at 5:00 p.m., he was found on the floor and had sustained a scratch to his right hand measuring approximately 5 cm long. - On 07/22/11 at 7:30 p.m., he slid down the side of a chair after missing the seat, and an assessment found no apparent injuries. - On 07/24/11 at 10:45 a.m., he fell , hitting his left arm and the left side of his head against a door frame; he subsequently was found to have sustained a fractured humerus and a subdural hematoma. - The above assessment was inaccurate with respect to the numbers and types of falls that had occurred since his prior MDS with an ARD of 07/13/11. -- b) Resident #21 A review of a significant change in status MDS with an ARD of 05/02/11 found the assessor indicated, in Item M0300F, that Resident #21 had one (1) unstageable pressure ulcer. In a quarterly MDS with ARD of 07/27/11, the assessor again indicated the presence of one (1) unstageable pressure ulcer (measuring 0.4 cm x 0.5 cm) in Item M0300F. - Review of the resident's nursing notes revealed an entry, at 9:50 a.m. on 06/21/11, stating: Note necrotic tissue to L (left) heel wound came off. Wound bed with slough and sm (small) area of necrotic tissue present. Another entry, at 7:41 a.m. on 07/06/11, stated: Wound to L heel 0.6 x 1 cm slough to center of wound /c (with) scant drainage . Stage III. - The instructions for Item M0300F direct the assessor to encode the number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar. - During an interview with the MDS nurse (Employee #164) and a corporate nurse consultant (Employee #192) at 2:00 p.m. on 08/23/11, the MDS nurse stated she was aware of the Stage 3 determination by the wound care nurse, but she never changes the staging on the MDS as the ulcer is healing, as that was her understanding of the RAI (resident assessment instrument) user manual. - Review of the RAI user manual for the MDS 3.0 found the following instructions: Coding Instructions for M0300F - Enter the number of pressure ulcers that are unstageable due related to slough and/or eschar. . Enter the number of unstageable pressure ulcers due related to slough and/or eschar that were first noted at the time of admission AND - for residents who are reentering the facility being readmitted after a hospital stay - that were acquired during the hospitalization . Coding Tips - Pressure ulcers that are covered with slough and/or eschar should be coded as unstageable because the true depth (and therefore stage) cannot be determined. Only until enough slough and/or eschar is removed to expose the depth of the tissue layers involved, can the stage of the wound be determined. - Stable eschar (i.e., dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heels serves as 'the body's natural (biological) cover' and should only be not be removed after careful clinical consideration including ruling out ischemia and consultation with the resident's physician, or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. - Once the pressure ulcer is debrided of slough and/or eschar such that the tissues involved can be determined, then code the ulcer for the reclassified stage. The pressure ulcer does not have to be completely debrided or free of all slough and/or eschar tissue in order for reclassification of stage to occur. After reviewing the RAI, both nurses agreed the MDS should be corrected to indicate pressure the ulcer was a Stage 3.	2016-01-01
9203	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	279	E	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, resident interview, staff interview, and family interview, the facility's interdisciplinary team failed to develop comprehensive care plans to address the care needs and to describe the services needed for residents to maintain a safe environment, prevent further condition decline, and prevent complications in their condition. The care plans were not complete and/or did not provide instructions to provide care in the areas of accidents / falls, activities of daily living, dental needs, hospitalization , nutrition, behaviors, the use of psychoactive medications, pressure ulcers, range of motion, contractures, indwelling urinary catheters, and management of urinary incontinence. The care plans did not address specific care needs for thirteen (13) of thirty-eight (38) stage II sampled residents. Resident identifiers: #228, #223, #129, #116, #199, #169, #138, #5, #148, #55, #3, #155, and #215. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 A complaint investigation was initiated at this facility at 12:00 p.m. on 05/18/11. Review of Resident #228's medical record revealed this [AGE] year old female was admitted to the facility at 8:30 p.m. on 05/17/11. According to hospital records provided on admission, this resident had dementia and a history of falls. That she had frequent falls was also noted on her physician's admission orders [REDACTED] According to the nursing notes dated 05/18/11 at 2:30 a.m., Resident #228 was found face down in the floor in her room with blood on her right hand and on the left side of her forehead; she was subsequently transferred to the hospital for evaluation due to complaints of pain in her left leg. The resident was in this facility for a total of six (6) hours prior to falling and being transferred to the hospital. She subsequently returned to the facility at 6:00 a.m. on 05/18/11. Based on record review and staff interviews, there was no evidence that direct care staff had been made aware of the resident's risk for falls when she arrived at the facility (in view of her previous history of falls), and there were no evidence to reflect safety measures were implemented by staff to address her immediate care and safety needs until a comprehensive assessment could be completed. Employee #93 (nursing assistant) was interviewed, at 1:00 p.m. on 05/18/11, about how he was made aware of the immediate needs of newly admitted residents. He stated they have a care plan sheet on which the care interventions were written for every resident. He went to the nurses' station and showed this surveyor the care plan sheet. Review of this sheet found no mention of Resident #228. Employee #93 stated they still had the name of the resident who used to be in that room on the sheet and they had not added Resident #228 to it yet. He said usually they added new people and her care needs should have been on here. During an interview with a registered nurse (RN - director of care delivery Employee #104) on 05/18/11 at 2:00 p.m., she was asked how the immediate care needs for newly admitted residents were communicated to the direct care staff. She verified that Resident #228 was not on the care plan sheet, that the sheet contained the name of the resident who previously occupied her bed, and that this had not been changed yet. At this time, eighteen (18) hours had passed since Resident #228's admission to the facility. Employee #104, when questioned how often the care plan sheet was updated, said it was printed each morning with changes. However, this resident had not been added to the form and she was admitted at 8:30 p.m. the prior evening. Employee #76 (nursing assistant) was interviewed the afternoon on 05/18/11; she was providing care to Resident #228 at that time. She was questioned about how she was made aware of the immediate care needs for newly admitted residents, including measures to promote the safety of residents at risk for falling. She stated this facility did not use alarms or side rails because it was against the state law and they just do the best they can. Employee #104 was observed, at 5:00 p.m. on 05/18/11, to be completing a care plan for this resident's immediate care needs. She verified there had been nothing written prior to this time, and she could not provide any evidence to show that staff members assigned to provide care to Resident #228 had been made aware of her risk for falls and/or the need for supervision, prior to her fall that resulted in her being sent back to the hospital. She verified that the safety interventions now in place for this resident (low bed and the bilateral landing strips on the floor beside the bed) were initiated after the fall that resulted in her emergency room visit. She also verified that there was no immediate or interim care plan or physician's orders [REDACTED]. -- b) Resident #223 During a review of Resident #223's initial Medicare 5-Day minimum data set assessment (MDS), with an assessment reference date of 04/14/11, found this resident had a pressure ulcer measuring 2.5 cm x 3.4 cm. This pressure ulcer, which was noted to have been present on admission to the facility, was identified on the MDS as being unstageable due to the presence of slough or eschar. Further review of the MDS found in Section V that the care area of Pressure Ulcer was then triggered and addressed in the care plan. The assessor noted that the further information for this care area could be found in a worksheet dated 04/18/11. The Care Area Assessment (CAA) worksheet dated 04/18/11, when reviewed, found in the analysis of this ulcer that this represented a potential problem. The nature of the problem was stated: At risk for pressure ulcers. The end note stated: (Resident #223) could be at risk for a pressure ulcer related to impaired mobility and incontinent. See the plan of care documentation for 4/11/2011. The staff will continue to assist her as needed for frequent position changes as well as prompt incontinence care. Any concerns with her skin will be reported to the MD promptly. Will proceed to care plan. This CAA did not reflect the resident's actual condition or evaluate the causative factors or the care needs for the pressure area that was already present. It addressed only the potential for developing pressure sore, when the medical record and skin assessments indicated she had actual skin breakdown. During an interview with Employee #173 (RN - case mix consultant) at 3:15 p.m. on 06/06/11, she was questioned about the CAA note not providing additional information about the pressure ulcer. She stated that they sometimes write the CAA notes in a manner not to repeat what is already specified in the MDS assessment; for example, since the wound measurements were already there, they would not write them again. She verified the CAA note addressed this ulcer as a potential problem and did not identify that the resident had an actual pressure ulcer at the time this assessment was completed. The most recent care plan for this resident had a revision date of 04/18/11. This care plan stated the resident was at risk for breaks in skin integrity / pressure ulcers related to pain, impaired mobility, diabetes, recent surgery, and incontinence. The goals for this care plan were for her skin to remain free of breakdown within limits of the disease process and to decrease / minimize skin breakdown risks. There was no evidence to reflect that a care plan had been implemented to address actual skin breakdown which had been present since her admission. -- c) Resident #129 Record review revealed Resident #129 was admitted to the facility on [DATE] with an order for [REDACTED]. Resident #129's admission MDS, with an ARD of 03/11/11, revealed this resident had an indwelling urinary catheter. This triggered the care area Urinary Incontinence and Indwelling Catheter in Section V of the MDS, where the assessor recorded that the location and date of the CAA could be found in the worksheet dated 03/16/11. The resident's CAA worksheet for Urinary Incontinence and Indwelling Catheter, when reviewed, stated that there was a potential problem. When describing the nature of the problem / condition, the assessor noted the resident had a Foley indwelling urinary catheter in place and needed assistance with toileting. There was no discussion of why the catheter was needed. In the section for discussing the summary and care plan considerations, the assessor recorded: Resident has a Foley catheter in place as evidenced by the order dated 3/5/11. This could place her at risk for problems such as altered urinary output, pain etc. She needs assistance with toileting as evidenced by the documentation in the POC (plan of care). Staff will continue to assist her with toileting and catheter care to help minimize the risk of problems. Any problems noted or reported will be addressed with the MD. Will continue to care plan. There was no information in this resident's medical record discussing why she had this indwelling catheter, when it had been inserted, or whether there was any consideration to remove the catheter. The resident's care plan, dated 03/11/11, contained the following problem statement: Use of indwelling catheter needed due to open area on coccyx. A goal associated with this problem statement was: Will have dignity r/t (related to) presence of catheter preserved. A second goal stated: Will have no acute complications of urinary catheter use. The care plan did not contain a goal to remove the catheter when it was not longer needed. During an interview on the afternoon of 06/04/11, Employee #88 (RN - assistant director of nursing) verified the reason for this catheter was excoriation, which was present on admission. She could find no evidence that any open area on the coccyx having existed as stated in the care plan dated 03/11/11, and she verified this statement must not have been correct. This excoriation was resolved on 04/04/11, and there was no evidence of an assessment to determine whether a continued need for this indwelling catheter existed. -- d) Resident #116 1. This resident triggered for review in Stage II due to falls having been identified in Stage I of the Quality Indicator Survey (QIS) process. A staff interview with Employee #45 (an RN) identified the resident had fallen in the dining room on 05/18/11. Review of the resident's medical record found the following entries: - On 01/19/11 at 1:00 p.m. - Please note resident found on floor this am (morning) by bed; lying on door side of bed, outstretched feet bare; w/c (wheelchair) behind her states 'I'm not sure, but I was coming back from bathroom'. No injury noted; assisted back to bed neuro (symbol for 'checkmark') initiated. Phys. notif; call placed to MPOA (medical power of attorney), message left. - On 01/26/11 at 2:45 a.m. - Resident found on floor per CNA (certified nursing assistant). States 'I was not trying to get up and I didn't know. Able to move all extremities, . - On 01/26/11 at 2005 (8:05 p.m.) - Into room found resident laying beside bed. Stating she fell while turning. VSS (vital signs stable) States 'My bottom hurts, hip + shoulder.' No neuro changes noted. New order to send resident to ER for evaluation. (She was noted to have returned on 01/27/11 at 0125 (1:25 a.m.) with a [DIAGNOSES REDACTED]. - On 02/25/11 (a late entry, although the author did not provide the date / time when the late entry was made) - Resident continues to have attentions seeking behaviors. Resident was sitting on the bed approx. 5 min. prior to fall /c (with) call light on. This nurse answered call light and resident asked for a pain pill. This nurse advised her that it would be a few minutes. Approx. 5 min later laundry staff walked by and advised resident was laying in the floor. Resident was helped to feet and the bed after ROM (range of motion). - On 03/30/11, Employee #117 (RN) recorded the following: reviewed falls /c IDT (interdisciplinary team). (The dx & meds were noted) Resident had 4 falls in Jan. and one fall @ the end of February. In January she c/o severe (L) side abd. pain & was sent to ER for eval. D/T recents (sic) testing it is questionable whether this caused her to have concerns about outcome of tests. Three of these fall were unwitnessed; Res. was found on floor. Resident had a psyche eval and is following up /c (name of an agency). Staff encourages her to use call light & ask for assist. Anti-rollbacks were added to W/C. Calcium /c Vit D has been added. Will modify environment to minimize risks of falls /c injury. - On 04/24/11 at 2230 (10:30 p.m.) - CNA made myself aware that resident has sit (sic) down on floor beside bed. Nursing assessment completed. No injury noted. Family notified. Dr. (name) aware. Will continue observations. - On 05/18/11 at 10:30 p.m. - Resident found on 2nd floor dining room floor. Stated she was trying to stand up. No injuries . When interviewed on 06/03/11 at 9:15 a.m., Employee #143 (a licensed practical nurse - LPN) said behaviors should be documented in the nurses' notes. She said that most of this resident's behaviors were attention-seeking - like complaints of pain that, when assessed using different assessment tools to verify she was having pain or physical complaints, she (the resident) would forget about immediately after she voiced the concerns. When interviewed further regarding the resident's attention-seeking behaviors on 06/06/11 at 8:50 a.m., Employee #143 explained the resident had been observed sitting on the side of her bed. While staff was still standing in the hall near her room, the resident was observed by other staff to be on the floor. A table had not been moved that should have moved, had the resident fallen as stated. She said they had not heard any noise when the resident fell , etc. She also said that, when there was something wrong with her roommate, Resident #116 would voice more complaints. Documentation in the nurses' notes and staff interviews identified at least some of the resident's falls were thought to be attention-seeking behaviors. Review of her care plan revealed the following goal: Minimize risk for injury r/t (related to) falls. The only behavioral interventions included were for evaluating the effectiveness and side effects of [MEDICAL CONDITION] drugs and for an outside agency to evaluate and treat as needed. The care plan did not include interventions for direct care staff to employ to address the resident's attention-seeking behaviors as a factor in the resident's falls. - 2. The resident's annual MDS, with an ARD of 02/01/11, indicated the resident was always continent of urine. The quarterly assessment, with an ARD of 04/20/11, indicated she was occasionally incontinent of urine. Neither assessment was coded to indicate the resident was on a urinary toileting program. A physician's progress note, dated 05/19/11, stated the resident . C/O (complained of) new onset incontinence - sudden, no urge or control 'I don't know what's wrong.' The physician also noted the resident was alert and oriented. A urinalysis and a urine culture and sensitivity were ordered on [DATE]. These were completed on 05/20/11. An antibiotic was ordered for the identified urinary tract infection. No evidence was found in the nurses' notes of any complaints having been made by the resident of any urinary elimination problems. There was no evidence of monitoring to determine the effectiveness of the antibiotic in relieving the resident's complaints of urgency and loss of bladder control. On 06/03/11 at approximately 9:15 a.m., observation found a large wet ring on the bottom sheet of the resident's bed. The ring extended nearly to the edges of the bed. On 06/03/11 at 9:30 a.m., the resident was interviewed regarding her bladder function. She stated, Sometimes I need to go when I need to go and Sometimes I can't make it. The resident stated there had been some improvement since she was given the antibiotic, but she still had times when she needed to go right away. According to the resident, most of her incontinence was at night. On 06/03/11 at 10:34 a.m., Employee #95 (RN), when asked about the resident's urinary continence status, said the staff had talked about possibly seeing if the resident would wear an incontinence brief at night. He was unable to find any evaluation of the change in her continence status. Employee #69 (nursing assistant), when asked about the resident's urinary continence in mid-morning on 06/07/11, said she had been reporting the resident's incontinence for about four (4) weeks. She demonstrated how the nursing assistants could put issues in the care tracker to alert the nurse. She said she had asked about whether the resident could have an incontinence brief at night. The nursing assistant also said it had been discussed whether the perimeter mattress kept the resident from getting out of bed at night. On 06/07/11 at 10:20 a.m., Employee #95 was again interviewed about the resident's incontinence. He said the resident had been admitted in 2008 on [MEDICATION NAME] 2 mg twice daily. She had been changed to [MEDICATION NAME] XL 15 mg every day in November 2010. The RN said they were going to talk to the doctor to see whether they could take her out of the scoop mattress; that staff thought the mattress might be making it harder for the resident to get up at night. He noted the resident needed help in the mornings when getting out of bed, but she could take herself to the bathroom after she was up in her wheelchair. He identified the resident was only incontinent at night and the nursing assistants felt the resident could transfer herself if the mattress was changed. According to the RN, the resident could not walk, but she was able to transfer herself. Review of the resident's care plan found no plan for continence management. Although her MDS, with an ARD of 04/20/11, indicated a decline in urinary continence, and staff interviews identified their awareness of this problem, no plan had been implemented in an attempt to restore the resident's urinary continence status. -- e) Resident #199 The resident's admission MDS, with an ARD of 02/11/11, identified the resident as being frequently incontinent. He was coded as frequently incontinent on subsequent assessments - a quarterly assessment with an ARD of 04/29/11 and a significant change in status assessment with an ARD of 05/27/11. According to his assessments, he was not able to ambulate when admitted . However, according to the quarterly assessment with an ARD of 04/29/11, he could ambulate in his room independently and in the corridor with supervision. The resident was coded on his MDSs as being able to understand and to be understood. His assessments indicated he required extensive assistance with toileting, even after his ability to ambulate improved. However, his balance for moving on and off of the toilet was coded as his being unsteady, but able to stabilize without human assistance. None of his MDS assessments indicated he was on a toileting program. During the survey, he was observed in the halls ambulating about ad lib. On 06/08/11 at 11:10 a.m., the resident was asked if he knew when he needed to void. He replied that he usually knew. His care plan indicated he was incontinent and needed care, but it did not include any plan for assisting the resident to improve his urinary continence status. -- f) Resident #169 The resident had a significant change in status assessment with an ARD of 03/15/11; this was the same date as her acceptance of hospice services. The care plan had many goals and interventions identified as being initiated on 03/05/11, which was before the ARD and before the completion of the assessment. The goals and interventions were not always reflective of the resident's assessed health and/or functional status. The resident had returned from the hospital on [DATE]. The quarterly assessment, with an ARD of 01/19/11, reflected the resident had been functioning at a higher level than she was at the time the significant change assessment was conducted. That, in and of itself would have been acceptable, but the care plan did not reflect the comprehensive assessment findings, nor her current ADL status. Another significant change assessment had been completed after the resident was discharged from hospice services. The ARD of that assessment was 05/02/11. A copy of the resident's care plan was requested. The copy was printed on 06/01/11. In an interview on 06/02/11 at 1:57 p.m., the DON stated the care plan should only have the current issues, but one with resolved issues could be printed if needed. - 1. A problem was identified as: At risk for adverse effects related to [MEDICAL CONDITION]. The goal was: Will have no adverse effects. The intervention was: Evaluate if need to administer medications for [MEDICAL CONDITION]. Review of Section I of the MDS (the section for current diagnoses), review of the list of diagnoses included in the care plan, review of the physician's orders [REDACTED]. On the late afternoon of 06/06/11, the DON was asked to see whether she could find a [DIAGNOSES REDACTED]. She reported, on 06/07/11 at approximately 4:00 p.m., that no [DIAGNOSES REDACTED]. The DON agreed this plan may have been developed because the resident was on [MEDICATION NAME] - a medication that is given to treat [MEDICAL CONDITION], but is also given for management of behavioral problems. The goal was not stated in measurable terms. The care plan was not clear, and the interventions for the goal were not well developed. Most importantly, the resident did not have a known [DIAGNOSES REDACTED]. - 2. A plan for the role of hospice was not included in the facility's care plan. The only reference to hospice was the inclusion of Hospice End of Life Care as an intervention in goals for activities of daily living and for her to accept care and medications. (Note: Hospice services had been terminated the first days of May 2011, but hospice references continued to be present in the care plan.) - 3. A problem was identified as: At risk for loss of range of motion r/t disease process (dementia). The goal was: Will exhibit no decline in ROM (range of motion) within confines of disease processes. The interventions were: OT (occupational therapy) evaluation and treatment as ordered and PT (physical therapy) evaluation and treatment as ordered. The goal was not measurable. -- g) Resident #138 Record review revealed this [AGE] year old female was admitted on [DATE] and discharged on [DATE]. The discharge summary noted a discharge [DIAGNOSES REDACTED]. The reason on the Notice of Transfer or Discharge was: The transfer or discharge is necessary for your welfare and your needs cannot be met in this facility. Also checked was: The safety of other individuals in the facility is endangered. The destination was a psychiatric unit of a local hospital. Review of the physician's orders [REDACTED]. Review of the nursing entries found she had hit at staff, been verbally aggressive with other residents and staff, had been physically combative with other residents, etc. It was noted the resident had been take to the emergency room at 2:40 p.m. on 03/12/11, and returned at 9:00 p.m., due to aggressive behavior towards staff and other residents. On 03/15/11, the nurses' notes described more behaviors, such as the resident trying to his her roommate, etc. Review of the resident's care plan found no plan had been developed to address the resident's behaviors. -- h) Resident #5 1. Observation of this resident, on 05/25/11 at 2:25 p.m., noted her legs appeared to be slightly contracted at the knees. She was able to use her hands to hold the carton of liquid nutritional supplement and to wipe her mouth. During the Stage I staff interview on 05/24/11 at 3:23 p.m., Employee #154 (LPN) identified the resident as having contracted legs. She was noted to be able to feed herself, but she was classified as needing to be fed by staff. The LPN stated the resident would hold drinks with her right hand and feed herself with her left hand. When asked Does the resident receive range of motion services or have a splint device in place? the nurse said, No. There is no restorative nursing program. Review of the medical record found the resident had been screened on 01/15/11 by PT and OT. Both disciplines noted no services were indicated at that time. Review of the care plan found a problem of: At risk for loss of range of motion r/t (related to) decreased mobility, requires assist with ADL's (sic). The goal was: Will exhibit no decline in ROM within confines of disease processes. This goal was not stated in measurable terms. The interventions were: Monitor for and report any changes in ROM noted during daily care. Notify physician. Encourage to participate in exercise activities. Nail care as needed. The goal was for the resident to prevent a decline in the resident's range of motion; however, the interventions did not offer any preventative methods for staff to routinely employ to achieve this goal. At the time of the survey, the resident was not observed to be out of bed during the day or early evening. - 2. Review of the resident's record found a care plan for the resident to have a stable weight and to consume at least 50-75% of meals and 75-100% of fluids. The interventions included: Food in bowls all meals -- No straw. Another goal was to prevent aspiration, and the interventions included elevating the head of her bed as upright as possible for meals and thirty (30) minutes afterwards. Review of the physician's orders [REDACTED]. This was also an instruction on the Patient Information Worksheet given to direct care staff. A copy of the worksheet was provided at 10:00 a.m. on 06/01/11. According to Employee #58 (LPN), the staff can carry these worksheets with them. On 05/25/11 at 2:26 p.m., the resident was observed sitting in bed with the head of the bed elevated at approximately 30 degrees. She was sipping on a carton of supplement. A straw was being used. On 05/26/11, the resident was again observed drinking her afternoon supplement. The head of her bed was elevated at approximately 30 degrees. This posed a potential for increased risk of aspiration. She was drinking the beverage through a straw. Observations, on 05/31/11 at approximately 2:00 p.m., found the resident lying in bed holding a carton of supplement with a straw in the carton. The head of her bed was elevated at approximately 30 degrees. On 06/01/11 at 11:30 a.m., the resident was observed lying in bed. A cup with a straw and a small carton of supplement with a straw were by the resident's bed. The resident's head was elevated at approximately 20 degrees. On 06/02/11 at 12:45 p.m., Employee #155 (nursing assistant) sat down to feed the resident. After giving her a bite of food, he got up and said he had to go get a straw. He took the straw to the resident's room to use for her milk. A speech therapy evaluation, dated 02/15/11, included the resident was to be in the upright position when eating or drinking. The resident was observed using a straw to drink and was not positioned to lessen the potential for aspiration. -- i) Resident #148 During the initial tour on 05/24/11 at 11:15 a.m., observation found this resident seated in a wheelchair in the hallway on C Wing. The resident had a yellow Theraband (stretchy therapy band) tied to her wheelchair and attached to her right foot. The devise was knotted in several places to shorten it, and it had a loop on the end in which to place the resident's foot. The device did not appear to be a product designed to be used in this manner; instead, it appeared to be something rigged to suit a purpose. At 11:40 a.m. on 05/24/11, an interview was conducted with Employee #8 (LPN) who stated, Therapy puts it on her foot to keep her from dropping her leg. Employee #8 looked at the resident's treatment records and stated there was nothing in those records regarding the observed device. The resident was reviewed during Stage II of the survey. At 10:45 a.m. on 06/08/11, an interview was conducted with Employee #110 (rehabilitation services manager) and Employee #200 (physical therapist). Employee #200 stated she had decided to use the device and had applied it to the resident and the wheelchair. Further interview revealed the resident had a total hip replacement. The surgery later had to be redone. Employee #200 stated, After the surgery, the whole leg was rotating, and she does not have cognitive ability to maintain hip precautions. For these reasons, Employee #200 stated she decided to use the Theraband in this fashion. When asked if this was a recommended use for a Theraband, Employee #200 stated, I have seen other therapists do it at other places. Medical record review, on 06/08/11, revealed no assessment or care plan for any device to maintain hip precautions. Employees #110 and #200 were asked if there were any therapy notes and/or orders for this device. At 10:45 on 06/08/11, Employee #110 reported there were no progress notes, physician orders, or care plans addressing the use of this device. The facility had not used the results of a comprehensive assessment to develop a care plan for this resident regarding her need to maintain hip precautions. -- j) Resident #55 Employee #120 (LPN) was interviewed at 2:55 p.m. on 05/24/11, as part of Stage I of the QIS process. Upon inquiry, Employee #120 looked at the resident's medical record and stated the resident had a contracture of the right hand. Further interview revealed the resident did not receive ROM services or have a splint / device in place. Observations of the resident, at 10:00 a.m. on 05/26/11, 3:00 p.m. on 05/31/11, and on 06/01/11 at 1:30 p.m., revealed the resident's right hand did not have a device to maintain ROM. Medical record review, on 05/31/11, revealed a care plan (last revised on 02/02/11) containing the following goal: Will exhibit no decline in ROM within confines of disease. There were no interventions regarding the contracture of the resident's right hand. -- k) Resident #3 During Stage I of the QIS process, this resident was identified with a contracture of the right hand. The resident did not have a splint / device or receive ROM services. Medical record review, on 05/31/11, revealed a care plan (last revised on 02/02/11) with the following goal: Will exhibit no decline in ROM within confines of disease. There were no interventions regarding the contracture of the resident's right hand. Medical record review, on 06/01/11, revealed no order for splints or other devices; however, the facility's current Patient Information Worksheet indicated the resident was to have hand palm protector on at all times. Observation of the resident, at 10:45 a.m. 06/01/11, revealed the resident was in bed with no hand rolls in place. The resident was obse	2016-01-01
9204	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	280	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, family interviews, and review of medical records, the facility's interdisciplinary team failed to periodically review and revise residents' care plans to address changes in their conditions and needs. One (1) resident's care plan was not updated to reflect her discharge from hospice or the change in her functional abilities. Another resident had an indwelling urinary catheter that was noted to be in place for excoriation; the care plan had not been updated to plan for removal of the catheter after resolution of the excoriation. Two (2) of thirty-eight (38) residents on the Stage II sample were affected. Resident identifiers: #116 and #129. Facility census: 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #116 A copy of the resident's current care plan was requested. The copy was noted to have a print date of 06/01/11. A second copy was provided in response to a request for information regarding another issue. The second copy had a print date of 06/07/11. The resident had been discharged from hospice early in May 2011. The actual physician's orders [REDACTED]. A significant change in status assessment (SCSA), with an assessment reference date (ARD) of 05/02/11, was signed as complete on 05/12/11. The care plan should have been updated to address the results of the comprehensive assessment within seven (7) days of the assessment completion date. 1. The care plan printed on 06/01/11 still referenced receipt of hospice care in the interventions for two (2) goals. - 2. According to the assessment, the resident was totally dependent for bed mobility, locomotion on the unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene. She required extensive assistance for transfers. The walk in room and walk in corridor items were coded as the activity having not occurred. Both of the care plans included interventions that included: Resident wonders (sic) around the facility with her baby dolls. According to the assessment, the resident was not capable of wandering by walking or by maneuvering her wheelchair. Additionally, her assessment was coded in E0900 (Wandering - Presence and Frequency) to indicate the behavior did not occur. Observations of the resident revealed she was up in a wheelchair at times, but she was transported by family members. She was not noted to maneuver the chair herself. According to a nursing assistant (Employee #69) on 06/01/11 at 2:00 p.m., the resident had been able to walk and did wander, but she had not done so for a while. According to an interview with the resident's husband on the afternoon of 06/07/11, before the resident had been so ill with diverticulitis and [MEDICAL CONDITION] (C diff), she had been able to walk about independently. He commented at one time, before she had been so sick, staff had said she was walking in the hall and throwing things, so she had to be evaluated for her medications. - 3. The care plan (printed on 06/01/11) had a goal for: Resident's infection will be resolved in 7 days without complications. The goal was initiated on 04/26/11 for a problem identified as pneumonia. It also had a goal for: Resident's infection will be resolved in 21 days without complications. This goal was initiated on 04/28/11 for [MEDICAL CONDITION] candidiasis. According to the director of nursing (DON) in an interview on 06/02/11 at 1:57 p.m., the care plan should only have the current issues. She said if needed, they could print one with resolved issues. - 4. A goal was created on 08/10/10 to: Minimize risk for injury r/t (related to) falls, and another for Minimize risk for falls was also established on that date. The interventions included providing assistance to transfer and ambulate and to monitor for and report changes in gait. As previously noted, the resident was non-ambulatory at the time of her most recent assessment and remained non-ambulatory at the time of the survey. -- b) Resident #129 Record review revealed Resident #129 was admitted to the facility on [DATE] with an order for [REDACTED]. Resident #129's admission MDS, with an ARD of 03/11/11, revealed this resident had an indwelling urinary catheter. This triggered the care area Urinary Incontinence and Indwelling Catheter in Section V of the MDS, where the assessor recorded that the location and date of the care area assessment (CAA) could be found in the worksheet dated 03/16/11. The resident's CAA worksheet for Urinary Incontinence and Indwelling Catheter, when reviewed, stated that there was a potential problem. When describing the nature of the problem / condition, the assessor noted the resident had a Foley indwelling urinary catheter in place and needed assistance with toileting. In the section for discussing the summary and care plan considerations, the assessor recorded: Resident has a Foley catheter in place as evidenced by the order dated 3/5/11. This could place her at risk for problems such as altered urinary output, pain etc. She needs assistance with toileting as evidenced by the documentation in the POC (plan of care). Staff will continue to assist her with toileting and catheter care to help minimize the risk of problems. Any problems noted or reported will be addressed with the MD. Will continue to care plan. Review of the resident's care plan (dated 03/11/11) found the following problem statement: Use of indwelling catheter needed due to open area on coccyx. A goal stated: Will have dignity r/t (related to) presence of catheter preserved. A second goal stated: Will have no acute complications of urinary catheter use. The care plan did not contain a goal to remove the catheter when it was not longer needed. During an interview on the afternoon of 06/04/11, Employee #88 (RN - assistant director of nursing) verified the reason for this catheter was excoriation, which was present on admission. This excoriation was resolved on 04/04/11, and there was no evidence of an assessment to determine whether a continued need for this indwelling catheter existed. Review of the physician's orders [REDACTED]. There was no evidence in the medical record to reflect the continued need for this indwelling catheter, and there was no evidence to reflect the care plan had been revised after the excoriation (the stated reason for the catheter) had resolved. Observation of Resident #129, on the morning of 06/03/11, found the indwelling urinary catheter was still in use.	2016-01-01
9205	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	281	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to assure staff adequately assessed the patency of a gastrostomy tube prior to administering the medications and tube feeding. The nurse did not verify the placement of the tube by aspirating for residual per physician order. The physician's orders [REDACTED]. This did not occur for one (1) of one (1) resident observed during medication administration by gastrostomy tube. Resident identifier: #76. Facility census: 144. Findings include: a) Resident #76 During medication administration on 05/31/11 at 1:30 p.m., a licensed practical nurse (LPN - Employee #100) prepared to administer a medication to Resident #76 via gastrostomy tube. Employee #100 stated it was also time to turn on the resident's tube feeding, so she would do that too as soon as she gave his medication. Employee #100 administered the resident's medication in his enteral gastrostomy tube and then turned on his feeding of [MEDICATION NAME] 1.5 at a rate of 66 ml/hour as ordered. She stated this was ordered to run until 1320 cc of the tube feeding had infused. After administering this medication and turning on the feeding, the nurse then checked the Medication Administration Record [REDACTED]. If 400 ml of residual, hold the feeding and call the MD. The nurse, when questioned about verifying placement of the tube, stated, I know I forgot to aspirate to verify placement and check the residual. She verified that this should have been checked prior to administering the medication and starting the feeding. .	2016-01-01
9206	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	282	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure implementation of established care plans for three (3) of thirty-eight (38) residents on the Stage II sample. The residents' care plans identified specific approaches direct care staff was to employ to address each identified problem, but these approaches were not consistently implemented. For example, a resident, who had a physician's orders [REDACTED]. This individual also had interventions identifying she enjoyed watching westerns on television, enjoyed listening to county music in her room, and for her glasses to be worn due to impaired vision. These interventions were not noted to be implemented until near the end of the third week of the survey. Other residents had care plans identifying hygienic needs, but these needs were not being met prior to identification of deficits by a survey team member. Resident identifiers: #5, #40, and #125. Facility census: 144. Findings include: a) Resident #5 1. Review of the resident's care plan found a problem of At risk for respiratory impairment related to risk for aspiration d/t (due to) dysphagia. Three (3) goals had been established for this problem: - Maintain patent airway - Will have no acute respiratory distress - Will exhibit no S&S (signs and symptoms) of aspiration such as coughing, fever, etc. One (1) of the interventions was: Position as upright as possible for meals and 30 minutes afterwards. The speech therapist had noted, in an evaluation dated 02/15/11, the resident needed to be in upright position. On 05/26/11, the resident was observed drinking her afternoon supplement while in bed in her room. The head of the resident's bed was elevated at only approximately 30 degrees. On 05/31/11 at approximately 2:00 p.m., observation found the resident lying in bed holding a carton of supplement. The head of her bed was elevated at only approximately 30 degrees. On 06/01/11 at 11:30 a.m., the resident was observed lying in bed. The resident was holding a cup, and her head was elevated at only 20 degrees. On 06/02/11 at 12:45 p.m., Employee #155 (nursing assistant) was observed feeding the resident. The head of the resident's bed was elevated to 80-85 degrees. The resident appeared to be comfortable in this position, thus establishing she could tolerate having the head of her bed elevated to an upright position. - 2. The physician had written an order for [REDACTED]. On page 19 of 25 of the resident's current care plan, the interventions for goals of weight stability and amount of meals to be consumed included: Food in bowls all meals -- no straw. The instruction for no straws was also on the Patient Information Worksheet given to direct care staff. A copy of this sheet was provided by Employee #58 (a licensed practice nurse - LPN) at 10:00 a.m. on 06/01/11. She stated the nursing assistants could carry these sheets with them. On 05/26/11, the resident was observed drinking her afternoon supplement in her room while in bed and unsupervised. She was drinking from a straw that was in the small carton of supplement after lunch. Subsequent observations throughout the day on 06/01/11 and 06/02/11 found she had a straw in her beverages. Observation on 05/31/11, at approximately 2:00 p.m., noted the resident lying in bed holding a carton of supplement with a straw. On 06/01/11 at 11:30 a.m., the resident was observed lying in bed. A cup with a straw and a small carton of supplement with a straw were accessible to - or in use by - the resident. On 06/02/11 at 12:45 p.m., Employee #155 got a chair and sat down to feed the resident. After giving her a bite of food, he got up and said he had to go get a straw. He brought a straw to the resident's room, where it was put into the carton of milk for the resident to drink. - 3. A goal for self-directed activities had been established. Two (2) of the interventions were: - Resident enjoys watching westerns in her room on TV. - Resident enjoys listening to country music while in h ER (sic) room.continue (sic) to invite, praise and encoruage (sic). The resident was observed on 05/24/11, 05/25/11, 05/26/11, 05/31/11, 06/01/11, 06/02/11, 06/06/11, 06/07/11, and 06/08/11. The resident was observed primarily on the day shift and early evening shift between two (2) and six (6) times a day. It was not until 06/08/11, around midday, the resident's television was noted to be on for her to watch. - 4. A problem of Impaired vision was included in the care plan. One (1) of the interventions was: Glasses will be in place when awake and in good repair. The resident was observed primarily on the day shift and early evening shift between two (2) and six (6) times a day. On 05/24/11, 05/25/11, 05/26/11, 05/31/11, 06/01/11, 06/02/11, 06/06/11, and 06/07/11, the resident was not noted to have her glasses on. On 06/08/11, at midday, a staff member was sought to find out whether the resident would wear her glasses. No staff were available in the immediate vicinity of the resident's room, so the resident was again observed. At that time, she was wearing her glasses. She was not noted to make any effort to remove them. -- b) Resident #40 During Stage I of the survey on 05/25/11 at 1:19 p.m., this resident was asked: Does staff help you as necessary to clean your teeth? The resident said staff did not. The resident further stated he had not asked them to brush his teeth. The next question asked was: How often are your teeth / mouth cleaned? The resident answered his teeth had not been brushed for a month or more, because he is no longer able to brush them due to his [MEDICAL CONDITION] (MS). He stated no one had brushed them for him. The resident said he would really like to have his teeth brushed. When asked if he had a toothbrush, the resident said, Look in that drawer and see. There was an unopened toothbrush and an unopened box of toothpaste in the drawer. At 9:00 a.m. on 06/01/11, Employee #58, when asked if this resident was compliant with the provision of care, said, Oh yes, he allows care needs to be met. He is very compliant with care. On 06/01/11, the resident's care plan was reviewed. There was a care plan (last revised on 05/11/01) with the goal: Will receive assistance necessary to meet ADL (activity of daily living) needs. There was an intervention to: Assist with daily hygiene, grooming, dressing, and oral care as needed. At 2:45 p.m. on 06/01/11, the resident was visited with the director of nursing (DON - Employee #12). Upon inquiry, the resident told the DON he was not provided a bed bath or cleaning between showers. He also told the DON his teeth had not been brushed for at least a month. He said, I guess I should have told someone. At that time, the DON told the resident staff should have checked to see if his teeth needed to be brushed and should have done so. The DON also told the resident he should not have to ask for this care, that staff should have asked him if he needed this assistance. On 06/02/11 at 8:30 a.m., another visit was made to the resident. He was asked if his teeth had been brushed yet, and he said, No. At 8:50 a.m. on 06/02/11, with the DON, a visit was made to the resident again. The DON asked the resident if he had been shaved, his teeth brushed, and his hands washed before breakfast. The resident answered no to each of the questions. At that time, observation noted the packages for the toothbrush and toothpaste were still unopened in the resident's drawer. -- c) Resident #125 General observations of this resident, at 2:28 p.m. on Wednesday 05/25/11, revealed the resident's fingernails were quite long. Upon inquiry, the resident stated his nails were too long and they needed to be trimmed. On 06/01/11 at 8:45 a.m., the resident was observed, and his nails were still long. An interview was conducted with Employee #58 at 9:00 a.m. on 06/01/11. Employee #58 stated the resident was very compliant with care, so there was no reason they (the fingernails) were not trimmed. Employee #58 further stated this should be done when the resident was showered. Further inquiry confirmed the resident never refused his scheduled showers. Review of the shower schedule revealed the resident received showers on Tuesdays and Fridays. He was showered Tuesday 05/24/11 and Tuesday 05/31/11. Each of these days was one (1) day before he was observed with long fingernails (on Wednesday 05/25/11 and Wednesday 06/01/11). The resident's care plan (last revised 03/02/11) had the following goal: Will be clean, dressed, and well groomed daily . The associated interventions included: Provide assistance as necessary with ADL care and Assist with daily hygiene, grooming, dressing, and oral care as needed. On 06/02/11 at 10:30 a.m., the DON stated her expectation would be his nails should have been trimmed during his showers.	2016-01-01
9207	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	309	G	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, resident interview, and staff interview, the facility failed to ensure residents received the services and care necessary to promote their highest level of well being. The facility failed to provide services to promote comfort and relieve pain and failed to communicate the recommendations of a consulting physician to a resident's attending physician related to lab studies for three (3) of thirty-eight (38) Stage II sample residents. The failure to provide these services caused actual harm to Resident #228, with the potential for more than minimal harm for Residents #227 and #125. Resident #228 suffered a fall with injuries and was sent to the emergency room six (6) hours after her admission to this facility. Her wound was treated, and she was sent back to the nursing home with instructions from the emergency room physician for follow up care of her injuries and measures for pain relief. This resident verbalized that she was experiencing pain at 3:15 p.m. on 05/18/11. She said she would like to have ice on her eye but they told to they did not have any. Observation found she had a hematoma, a laceration, and facial swelling around her left eye, as well as a large area of bruising. There was no evidence that any pain assessments or any pain relief interventions had been initiated for this resident since her return from the emergency room at 6:30 a.m. on 05/18/11. Resident #227 was admitted to the facility with wounds on his coccyx and was going to the wound healing center every week for treatment. On his visit to the wound center on 05/26/11, the following recommendation was communicated in writing to the facility by the wound center's physician: If he has not had a PT ([MEDICATION NAME] Time) / INR (International Normalized Ratio) recently, please check. Patient bled during assessment and cleaning. (These are blood test to assess the clotting tendency of the blood and are also used to detect bleeding disorders.) There was no evidence to reflect this recommendation from the wound center's physician was communicated to the resident's attending physician, and these test were not performed. According to the physician orders [REDACTED]. Resident #125 made the staff aware he had a sore toe. The facility failed to address this sore toe even after being made aware of it by the resident. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 This surveyor arrived at the facility and went to this resident's room at 12:00 p.m. on 05/18/11. Observation found the resident had dried blood on her laceration just above her left eye, bruising surrounding the eye, and facial swelling involving the area around the eye. She also had a hematoma on her forehead. She was very pleasant and was eating lunch at that time of this visit. When asked about her eye, she stated she fell while trying to pick up a bag of birdseed. It was later learned that this was the same thing she told the emergency room physician. This surveyor introduced herself and told the resident we could talk after she ate. - Review of the resident's nursing notes found this resident was admitted to the facility at 8:30 p.m. on 05/17/11. The next entry in her nursing notes was at 2:30 a.m. on 05/18/11; this note stated the resident was found face down in her room with blood on her right hand and the left side of her forehead. She was transferred to the emergency room at that time. At the emergency room , her injuries were assessed and her wound was cleaned and repaired. According to the nursing notes, she returned to the facility at 6:30 a.m. on 05/18/11. The resident returned with instructions from the emergency department for follow-up care. There was no evidence the staff assessed the resident's wound, pain or swelling upon her return or provided interventions as instructed by the emergency room physician. The return note, written on 05/18/11, stated (quoted as written), The resident arrived (name) hospital at 0630 (6:30 a.m.) via ambulance. Resident left eye has a hematoma cut to left eye is bleeding. Resident is talking refused to put ice on her eye for swelling. This was the last entry in the nursing notes when this surveyor reviewed the resident's medical record at 1:30 p.m. on 05/18/11. The resident's Medication Administration Record [REDACTED]. There was evidence to reflect she received treatment for [REDACTED]. - The resident was interviewed multiple times for short periods on 05/18/11. At 3:15 p.m., she stated, They have not give me any medicine since I have been here, and I need my medicine. When asked what medicines she took, she said, I do not know, but I do know that my eye and my head hurts. She was picking at the area above her eye where there was dried blood, and she had dried blood under her fingernails. When asked her if her eye was hurting, she stated, What do you think? Look at it. When asked about putting ice on the area, and she said, They have not done anything to it. She stated the man told her he did not have any ice. When questioned further about this, she did not remember who the man was, and she stated, They don't even come in here. This surveyor told her, that according to documentation in her medical record, she refused to allow ice to be placed on her eye this morning at 6:30 a.m. when she came back from the emergency room . She denied this and stated, They told me they did not have any ice. When asked (at 3:40 p.m. on 05/18/11) if she would like some ice, she said, Yes, if they have some. Maybe that would make it stop hurting. - At 3:45 p.m. on 05/18/11, the registered nurse (RN - Employee #104) was asked by the surveyor to assess the resident for pain at that time. The resident told the RN that her eye was really hurting. The RN asked her if she would like some ice on it, and she stated, Yes, but they told me they did not have any. The RN obtained an ice pack. The resident was very receptive and placed the ice pack on her eye. The resident had been back from the emergency room for more than nine (9) hours by this time. There was no evidence to reflect staff had assessed this resident, followed the instructions for the care that were provided by the emergency room , or contacted the resident's attending physician for further instructions. The RN stated they would notify the physician and see if they could get her something for pain. She also stated that, perhaps, the resident was speaking of the ambulance driver when she said they told her they did not have any ice. - Employee #104, when interviewed at 4:30 p.m. on 05/18/11, was questioned about the aftercare instructions provided by the hospital emergency department, which directed them to use Tylenol or [MEDICATION NAME] to control the resident's pain and apply an ice pack for swelling for twenty (20) minutes every one (1) to two (2) hours until the swelling goes down. Employee #104 stated they were not allowed to follow the orders given by the emergency room doctor - they had to call the resident's attending doctor at the facility to get these orders. When asked if anyone had called Resident #228's attending physician for further direction, Employee #104 stated, Not yet. When asked if there was evidence that any one had completed a pain assessment or provided any interventions for this resident since she returned from the hospital this morning at 6:30 a.m., she reported that an assessment had not yet been completed. - (NOTE: The facility's investigation report for this incident gave times that various events occurred that were different from those documented in the resident's nursing notes. According to the investigation report, the resident was admitted to the facility at 8:30 p.m. on 05/17/11, and she was found face down in the floor at 1:30 a.m. on 05/18/11, after which she was sent to the emergency room . She then returned from the emergency room at 4:45 a.m. on 05/18/11. This deficiency used the event times as recorded in the resident's nursing notes.) -- b) Resident #227 Review of Resident #227's medical record found he was admitted to this facility on 05/06/11 with multiple chronic sacral decubitus ulcers. He was going to the wound healing center weekly, and the physician at the wound clinic changed his dressings and made recommendations for his wound care. During his visit to the wound center on 05/26/11, the wound center physician stated in a report sent back to the facility: If he has not had a PT / INR recently, please check. Patient bled during assessment and cleaning. There was no evidence this recommendation from the wound center physician was communicated to the resident's attending physician at the facility. A nursing note, dated 06/06/11 at 5:00 p.m., stated (quoted as written): Resident was up in w/c (wheelchair) and when we returned him to bed his decubitus to his S/C (sacral / coccygeal) area begin to bleed profusely and it was noticed that his roommate while attempting a little earlier to exit the room ran into and caused skin tear /c (with) profusely bleeding to 3rd and 4th toe of (R) (right) foot. Both feet are very cyanotic - Wound to foot cleaned & dressed. Bandages to S/C area saturated /c blood & removed for transport to hosp. Dr. (name) notified of status advised to transport to ER (emergency room ). A physician's orders [REDACTED]. The nursing note, written at 9:30 p.m. on 06/06/11, stated the hospital was called, and they reported the resident was admitted to the intensive care unit. During an interview on 06/07/11 at 11:00 a.m., the director of nursing (DON - Employee #12) verified the facility had not completed the laboratory test (PT / INR) as recommended by the wound center physician to assess the resident's clotting time. There was no evidence this recommendation had ever been communicated to the attending physician at the facility. The resident's attending physician discussed this issue with the surveyor at 11:30 a.m. on 06/08/11. He confirmed these tests (PT / INR) were done after the resident was transferred to the hospital and the results were normal. -- c) Resident #125 During Stage I of the survey on 05/25/11 at 2:20 p.m., this resident stated he had pain with no relief. When asked to describe it, the resident said the toe beside his great toe on his right foot had a sharp nail (toenail). The resident stated the podiatrist was the person who trimmed his toenails, and he left it like that. The resident stated it hurt to walk, so he had been avoiding walking due to the pain. When asked if he had informed facility staff of this problem, he said, I let three (3) or four (4) people know. Review of the resident's medical record, during Stage II of the survey on 05/31/11, revealed no evidence the facility had assessed or addressed this resident's sore toe. An interview was conducted with Employee #58 (a licensed practical nurse - LPN) at 9:00 a.m. on 06/01/11. Upon inquiry, Employee #58 stated the resident was very compliant with care and allowed staff to care for his needs. When asked about the sore toe, Employee #58 stated she had not been made aware of the resident's sore toe. At 10:45 a.m. on 06/01/11, the resident's right toe was observed with Employee #58. During the observation, the resident stated this toe had been hurting a lot. Employee #58 confirmed there was a sharp toenail on the toe beside his great toe on his right foot. At this time, the resident was asked again if he had let anyone know about this sore toe. The resident stated, I let three (3) or four (4) of them know. On 06/02/11 at 10:30 a.m., an interview was conducted with the DON. Upon describing the resident's sore toe and statements he told nursing staff about the problem, the DON stated the resident was competent and she believed his statements (regarding telling staff about his sore toe) were credible. At the time of the survey, the facility had not assessed the resident's sore toe to determine the extent of the problem and/or to determine the appropriate care and services needed to address the problem.	2016-01-01
9208	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	312	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, observations, medical record review, and staff interview, the facility failed to provide necessary services to maintain good grooming and personal and oral hygiene for two (2) of thirty-eight Stage II sample residents. Each of these residents, who required assistance with activities of daily living (ADLs), were not provided this assistance. There were care plans to provide and/or assist the residents; however, the staff failed to implement the care plans. One (1) resident needed personal hygiene and oral care; the other resident needed assistance with grooming. Resident identifiers: #40 and #125. Facility census: 144. Findings include: a) Resident #40 During Stage I of the survey on 05/25/11 at 1:19 p.m., Resident #40 was asked, Does staff help you as necessary to clean your teeth? The resident said staff did not. The resident further stated he had not asked them to brush his teeth. The next question asked was: How often are your teeth / mouth cleaned? The resident answered his teeth had not been brushed for a month or more, because he was no longer able to brush them due to his [MEDICAL CONDITION] (MS). He stated no one had brushed them for him. The resident said he would really like to have his teeth brushed. When asked if he had a toothbrush, the resident said, Look in that drawer and see. There was an unopened toothbrush and an unopened box of toothpaste in the drawer. At 9:00 a.m. on 06/01/11, Employee #58 (licensed practical nurse - LPN), when asked if this resident was compliant with the provision of care, responded, Oh yes, he allows care needs to be met. He is very compliant with care. On 06/01/11, review of the resident's medical record revealed [REDACTED]. An intervention to assist the resident in achieving this goal was: Assist with daily hygiene, grooming, dressing, and oral care as needed. At 2:45 p.m. on 06/01/11, the resident was visited with the director of nursing (DON - Employee #12). Upon inquiry, the resident told the DON he was not provided a bed bath or cleaning between showers. He also told the DON his teeth had not been brushed for at least a month. He said, I guess I should have told someone. At that time, the DON told the resident that staff should have checked to see if his teeth needed to be brushed and should have done so. The DON also told the resident he should not have to ask for this care, that staff should have asked him if he needed this assistance. On 06/02/11 at 8:30 a.m., another visit was made to the resident. When asked if his teeth had been brushed yet, he said, No. At 8:50 a.m. on 06/02/11, another visit was made to the resident in the company of the DON. The DON asked the resident if he had been shaved, his teeth brushed, and his hands washed before breakfast. The resident answered no to each of the questions. At that time, observation found packages containing a toothbrush and toothpaste were still unopened in the resident's drawer. -- b) Resident #125 General observations of this resident, at 2:28 p.m. on Wednesday 05/25/11, found the resident's fingernails were quite long. Upon inquiry, the resident stated his nails were too long and needed trimming. When observed on 06/01/11 at 8:45 a.m., his nails were still long. In an interview conducted at 9:00 a.m. on 06/01/11, Employee #58 stated the resident was very compliant with care, so there was no reason they (the fingernails) were not trimmed. Employee #58 further stated this should be done when the resident was showered. Further inquiry confirmed the resident never refused his scheduled showers. Review of the shower schedule revealed the resident received showers on Tuesdays and Fridays. He was showered Tuesday 05/24/11 and Tuesday 05/31/11. Each of these showers occurred one (1) day before he was observed with long fingernails (on Wednesday 05/25/11 and Wednesday 06/01/11). The resident's care plan (last revised 03/02/11) contained the following goal: Will be clean, dressed, and well groomed daily . The associated interventions included: Provide assistance as necessary with ADL care and Assist with daily hygiene, grooming, dressing, and oral care as needed. On 06/02/11 at 10:30 a.m., the DON stated her expectation would be his nails should have been trimmed during his showers.	2016-01-01
9209	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	314	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to provide the necessary services to promote wound healing. This was found to be true for one (1) of thirty-eight (38) Stage II sample residents. A resident was assessed by the facility's registered dietitian (RD) on 04/11/11, at which time the RD recommended a multivitamin and Pro-Mod (a protein powder) to promote wound healing. These interventions were not initiated until 04/27/11 - sixteen (16) days after the recommendation was made. Resident identifier: #223. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #223 Review of Resident #223's closed record revealed she was admitted to the facility on [DATE] with a pressure area on her left buttock. This area was identified as an unstageable area and described as having dark necrotic tissue present. Review of the RD's assessment and progress note, dated 04/11/11, found the RD assessed the resident's nutritional needs and recommended a multivitamin (MVI) and ProMod twice daily (BID) to promote healing of the wound on the left buttock. There was no evidence to reflect these recommendations were communicated to nursing or that these supplements were ordered by the physician. On 04/19/11, the RD wrote: Previously documented resident with pressure area on left buttock. - Incorrect. Resident without pressure area. No new dietary interventions. On 04/20/11, the RD wrote: Note 4/19/11 documented resident with no pressure area - incorrect - wrong resident. Resident admitted with pressure area on coccyx which has increased in size this week. Will recommend ProMod 30 ml BID (100 kcal, 10 g pro) and MVI to promote wound healing. This was the same recommendation the RD had made on 04/11/11 but was never initiated. On 04/21/11, an interdisciplinary care plan meeting was held. The RD was present as well as all other disciplines and the family. There was no evidence the RD's dietary recommendations or the current status of the resident's pressure ulcer were discussed in that meeting. According to documentation in the medical record, the resident still was not receiving the nutritional supplements to promote healing of that pressure ulcer at that time. The resident's care plan was not revised to incorporate these nutritional interventions that had been recommended to promote wound healing. The RD evaluated the resident again on 04/26/11. Her progress note stated: Skin Note: Pressure area on left buttock with slight improvement this week. Diet liberalized due to no history of DM (Diabetes Mellitus). No orders for Pro Mod 30 ml BID or MVI. Will re-address. Continue to monitor. This note was written fifteen (15) days after her initial note on 04/11/11, when she stated that she was going to make these recommendations to promote healing of the pressure ulcers. Review of the physician's orders [REDACTED]. The director of nursing (DON - Employee #12) was questioned at 3:00 p.m. on 06/07/11 about the RD's assessment and recommendations to promote wound healing, which were not ordered until 04/27/11. The DON stated she could not find where these had been ordered prior to that date and that nursing was not aware of the dietary assessment.	2016-01-01
9210	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	315	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, observation, medical record review, and staff interview, the facility failed to assess each resident's bladder function and develop / implement measures to restore as much normal bladder function as possible. Resident #129 had an indwelling Foley urinary catheter present without a [DIAGNOSES REDACTED]. She had a catheter change followed by a urinary tract infection, and the continued need for the catheter was not re-evaluated. There was no current [DIAGNOSES REDACTED]. Residents #116 and #199 did not receive services to improve their bladder function. There was no evidence to reflect efforts by the facility to ascertain the type of urinary incontinence each was experiencing, nor did the facility implement measures in an effort to improve their urinary incontinence. This deficient practice affected three (3) of thirty-eight (38) Stage II sample residents. Resident identifiers: #129, #116, and #199. Facility census: 144. Findings include: a) Resident #129 During an interview with Resident #129 on 05/25/11 at 1:00 p.m., observation revealed she had an indwelling Foley urinary catheter. When questioned about the presence of the catheter, Resident #129 stated the catheter had been inserted at the facility where she was prior to coming here. Record review revealed Resident #129 was admitted from a hospital to the facility on [DATE] with an order for [REDACTED]. Resident #129's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 03/11/11, revealed, in Section H, this resident had an indwelling urinary catheter. This triggered the care area Urinary Incontinence and Indwelling Catheter in Section V of the MDS, where the assessor recorded that the location and date of the CAA could be found in the worksheet dated 03/16/11. In Section M of the MDS, the assessor did not identify the presence of any pressure ulcers or open areas. The resident's CAA worksheet for Urinary Incontinence and Indwelling Catheter (dated 03/16/11), when reviewed, stated that there was a potential problem. When describing the nature of the problem / condition, the assessor noted the resident had a Foley indwelling urinary catheter in place and needed assistance with toileting. In the section for discussing the summary and care plan considerations, the assessor recorded: Resident has a Foley catheter in place as evidenced by the order dated 3/5/11. This could place her at risk for problems such as altered urinary output, pain etc. She needs assistance with toileting as evidenced by the documentation in the POC (plan of care). Staff will continue to assist her with toileting and catheter care to help minimize the risk of problems. Any problems noted or reported will be addressed with the MD. Will continue to care plan. There was no discussion of why the catheter was needed and no plan to discontinue the use of this catheter or to have the physician re-evaluate its continued need. There was no information in this resident's medical record discussing why she had this indwelling catheter, when it had been inserted, or whether there was any consideration to remove the catheter. A care plan (dated 03/11/11) contained the following problem statement: Use of indwelling catheter needed due to open area on coccyx. The goals for this problem were: Will have dignity r/t (related to) presence of catheter preserved and Will have no acute complications of the urinary catheter use. The interventions focused caring for and changing of the catheter. There was no plan to discontinue the use of the catheter and no further mention of the open area to the coccyx. Further record review found an order discontinuing the treatment to the resident ' s excoriated area dated 04/04/11, noting the excoriation had resolved. There was no mention of re-evaluating the use of the catheter in view of the resolution of the underlying condition for which the catheter was inserted. On 04/28/11, the nursing notes recorded that this resident ' s catheter was leaking and a new catheter was inserted. There was no evidence there was any continued need for this catheter. On 05/29/11, the nursing notes indicated this resident was complaining of burning on urination. A new order was written for a urinalysis to be completed, and the resident was to start an antibiotic for signs of a urinary tract infection. During an interview on the afternoon of 06/04/11, Employee #88 (assistant director of nursing - ADON) verified the reason for this catheter was excoriation, which was present on admission. This excoriation was resolved on 04/04/11, and there was no evidence of an assessment to determine whether a continued need for this indwelling catheter existed. Employee #35 (a licensed practical nurse - LPN) was questioned about the catheter at 10:45 a.m. on 06/06/11. She reviewed the resident's medical record and stated the reason for the catheter was excoriation. She also verified that, according to the medical record, the excoriation was resolved by 04/04/11. Employee #88, when questioned again on 06/06/11 at 11:00 a.m., verified that she could not find any evidence that this resident ever had any skin open areas besides the excoriation. She was unable to show medical justification for the indwelling catheter. -- b) Resident #116 The resident's annual comprehensive MDS, with an ARD of 02/01/11, indicated the resident was always continent of urine. The quarterly assessment, with an ARD of 04/20/11, indicated she was occasionally incontinent of urine. The physician noted, in a 05/19/11 progress note, the resident had denied dyspnea, did not have dizziness, had no nausea, vomiting, or diarrhea, etc. The note included, C/O (complained of) new onset incontinence - sudden, no urge or control 'I don't know what's wrong (physician quoted the resident).' (The physician noted the resident was alert and oriented.) A urinalysis and culture and sensitivity were ordered. These were completed on 05/20/11. She was found to have a urinary tract infection, and an antibiotic was ordered. There was no evidence found in the nurses' notes of resident having complained for a new onset of incontinence or any other urinary problems. There was no evidence of monitoring to see whether the antibiotic affected resident's complaint of urgency and loss of control. Although the resident's quarterly assessment indicated the resident experienced a slight decline in urinary continence, there was no evidence of an assessment of possible causal factors for the decline. No care plan had been implemented in an attempt to restore her prior continence status, or to prevent further decline. - On 06/03/11 at 9:30 a.m., the resident was interviewed about her bladder function. She stated, Sometimes I need to go when I need to go and Sometimes I can't make it. She said there had been some improvement since she was given the antibiotic, but she still had times when she needed to go right away. - Shortly before the resident was interviewed, observaiton found a large wet ring on the bottom sheet on the resident's bed. The ring extended almost to the side edges of the bed with the outer edges being slightly brown, as though drying. On 06/03/11 at 10:34 a.m., the wet ring on the resident's sheet was observed with a registered nurse (RN - Employee #95). He said the staff had talked about possibly seeing if the resident would wear a brief at night. He was asked to see whether he could find any documentation regarding the resident's continence status. He later reported the resident had been on [MEDICATION NAME] since 11/2010. Before that, she had been on [MEDICATION NAME] for her bladder. - In a confidential interview, a staff member stated the ring of urine that had been observed on 06/03/11, had to be the result of several episodes of urinary incontinence - the resident did not void much urine at a single time. (This was consistent with the evidence of the light brown drying area at the outer edge of the ring.) - A nursing assistant (Employee #69) was also interviewed on 06/07/11 about the resident's urinary continence. She said she had been reporting the resident's incontinence for about four (4) weeks now. She demonstrated how issues identified by the nursing assistants could be put in the care tracker to alert the nurses. The nursing assistant stated she had asked about whether the resident could have a brief at night. She also said it had also been discussed whether the perimeter mattress kept the resident from getting out of bed at night. - On 06/07/11, the director of nursing (DON - Employee #12) was asked for evidence of an assessment regarding the resident's change in urinary continence status. On the morning of 06/08/11, the DON reported she was unable to locate any assessment for this problem. -- c) Resident #199 The resident's comprehensive admission MDS, with an ARD of 02/11/11, identified the resident was frequently incontinent of urine. He was noted to remain frequently incontinent of urine on the quarterly MDS with an ARD of 04/29/11 and the significant change in status MDS with an ARD of 05/27/11. Initially, the resident was assessed as being non-ambulatory. His quarterly assessment, with an ARD of 04/29/11, indicated he was independently ambulatory in his room, and needed supervision when walking in the halls. During the survey, the resident was observed ambulating independently in his room and in the halls. His assessments indicated he required extensive assistance with toileting, even after his ability to ambulate improved. However, his balance for moving on and off of the toilet continued to be coded as his being unsteady, but able to stabilize without human assistance. None of his MDS assessments indicated he was on a toileting program. The resident was coded as being able to understand and to be understood. His care plan indicated he was incontinent and needed incontinence care, but it did not include any plan for toileting the resident. - On 06/08/11 at 11:10 a.m., the resident was asked if he knew when he needed to void. He replied that he usually knew. - On 06/07/11, in late afternoon, the director of nursing was asked for evidence of an assessment of his urinary continence. She provided a copy of the care area assessment for the significant change in status MDS, with an ARD of 05/27/11, in late morning of 06/08/11. - On 06/08/11, at approximately 1:00 p.m., the CAA for urinary incontinence, completed for the SCSA, was reviewed. The CAA noted the resident required extensive assistance with toilet use and he was frequently incontinent. The form used by the facility for completion of the CAA included a section for the type of incontinence. The choices were stress, urge, mixed, overflow, transient, and functional. None of these were checked. Under the section of the CAA for Care Plan Considerations the assessor had checked to avoid complications, maintain current level of functioning, and to minimize risks as the overall objectives. Improvement and Slow of minimize decline were options, but had not been checked. The narrative for the CAA was Resident is frequently incontinent of urine and needs assist with toileting as evidenced by the documentation in POC. This places him at risk for problems such as skin break down and infections. Staff will continue to asist (sic) him as needed with continent (sic) care to help minimize the risk of problems. Any noted will be addressed with the MD. Will continue to care plan. His [DIAGNOSES REDACTED]. None were indicative of a condition that would prohibit an attempt to improve his urinary continence status. The CAA had a section for diseases and conditions that might affect continence, but none were checked. The CAA verbiage used by the facility was the same as the CAA in Appendix C of CMS's RAI Version 3.0 Manual. The instructions in Appendix C included: Step 4: . provide supporting documentation regarding the basis or reason for checking the item, including the location and date of that information, symptoms, possible causal and contributing factor(s) for that item, etc. Step 5: Obtain and consider input from resident and/or family/resident's representative regarding the care area. Step 6: Analyze the findings in the context of their relationship to the care area. This should include a review of indicators and supporting documentation, including symptoms and causal and contributing factors, related to this care area. Draw conclusions about the causal/contributing factors and effect(s) on the functional ability of the resident, and document this information in the Analysis of Findings section. There was no evidence these steps had been taken in an attempt to assess the resident's potential to have an improvement in his urinary continence status, or to prevent further decline if improvement was not possible. - Also on the afternoon of 06/08/11, the DON provided a copy of the facility's Bladder Patterning and Analysis Worksheet. The purpose stated on the document was: The purpose of the Bladder Patterning and Analysis Worksheet is to provide a space for documentation of a resident's usual bladder pattern and to provide suggested interventions for care plan development. The worksheet covered three (3) days, twenty-four (24) hours for each day, for staff to mark the resident's continence status. Based on the information collected during the three (3) day period, interventions listed on the form were to be reviewed and selected to develop an individualized care plan. This information was not found in the resident's medical records, nor was it provided by the director of nursing when evidence of assessment of the resident's incontinence status was requested.	2016-01-01
9211	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	318	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview, the facility failed to assure two (2) of thirty-eight (38) Stage II sample residents received treatment and services, including preventive care, to increase range of motion (ROM) and/or to prevent further decrease in ROM. The facility had no individualized plans in place for these two (2) residents, each with a limited range of motion, which assured each resident was provided services to reach and maintain his or her highest level of range of motion, or to prevent decline of range of motion. Resident identifiers: #3 and #55. Facility census: 144. Findings include: a) Resident #3 During Stage I of this survey, this resident was identified with a contracture of the right hand. The resident did not have a splint / device or receive ROM activities. Medical record review, on 06/01/11, revealed no order for splints or other devices; however, the facility's current Patient Information Worksheet indicated the resident was to have hand palm protector on at all times. Observation of the resident, at 10:45 a.m. 06/01/11, revealed the resident was in bed and had no hand rolls in place. The resident was observed again at 1:30 p.m. on 06/01/11, and no hand rolls were in place. Medical record review, on 05/31/11, revealed a care plan, last revised on 02/02/11 with the following goal: Will exhibit no decline in ROM within confines of disease. There were no interventions regarding the contracture of the resident's right hand. Interview with the rehabilitation manager (Employee #110), on 06/01/11 at 1:30 p.m., revealed the resident's last rehabilitation evaluation occurred in November 2010. According to Employee #110, at that time, a palm protector for the right hand was recommended. On 06/02/11 at 11:00 a.m., the director of nursing (DON - Employee #12) stated the resident now had an order for [REDACTED]. The DON confirmed occupational therapy had evaluated the resident's need for a device in November 2010, but the device did not get ordered until 06/01/11. At that time, the DON confirmed the palm protector should have already been in place. -- b) Resident #55 During Stage I interviews with nursing personnel, Employee #120 (licensed practical nurse - LPN) was interviewed at 2:55 p.m. on 05/24/11. Upon inquiry, Employee #120 looked at the resident's medical record and stated the resident had a contracture of the right hand. Further interview revealed the resident did not receive ROM services or have a splint / device in place. Observations of the resident at 10:00 a.m. on 05/26/11, 3:00 p.m. on 05/31/11, and at 1:30 p.m. on 06/01/11 revealed the resident's right hand did not have a device to maintain ROM. Medical record review, on 05/31/11, revealed a care plan (last revised on 02/02/11) with the following goal: Will exhibit no decline in ROM within confines of disease. There were no interventions regarding the contracture of the resident's right hand. At the time of the survey, the facility had not implemented any care and services to prevent further decrease in ROM for this resident.	2016-01-01
9212	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	323	G	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents and to promote resident safety. The facility failed to assess the immediate safety needs for Resident #228, a newly admitted resident who was identified in her admission information as having dementia and a history of falls. Failure of the facility to assess the resident upon admission for safety needs and to implement measures to prevent falls resulted in the resident falling only six (6) hours after she arrived at the facility and sustaining a head injury. She was transferred to the emergency room and treated for [REDACTED]. After safety measures were ordered upon her return to the facility (to include a low bed without side rails and mats on both sides of her bed), she was observed in her bed with a mat on only one (1) side of bed and tile floor on the other side. Resident #76, who had a [DIAGNOSES REDACTED]. He was in a low bed, and according to his treatment record, he was to have mats on both sides of the bed. Two (2) mats were stacked on top of each other on one (1) side of the bed with the tile floor on the other side. Resident #48 was observed to have Theraband used in a manner that was presented an accident hazard to this cognitively impaired resident. This band, which had been tied to the wheelchair to secure her leg secured to the chair, presented a hazard when the resident attempted to stand up from the chair without assistance. Resident #5 was observed at meal time to have straws in beverages, which were contrary to his physician's orders [REDACTED]. This was an accident hazard for this resident. Failure of the facility to assess the residents for safety needs and implement measures to prevent accidents and injuries affected three (4) of thirty-eight (38) Stage II sample residents. Resident identifiers: #228, #76, #48, and #5. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 A complaint investigation was initiated at this facility at 12:00 p.m. on 05/18/11. Observation, at this time, found Resident #228 in her room. The resident was seated on a low bed with one (1) mat on the floor on the right side of her bed by the window. She was reaching over to feed herself from her meal tray, which was sitting at bedside on a small isolation cart with rollers. There was no a mat on the floor on the left side of her bed. She had dried blood on her laceration just above her left eye, bruising surrounding the eye, and facial swelling involving the area around the eye. She also had a hematoma on her forehead. She was very pleasant and was eating lunch at that time of this visit. When asked about her eye, she stated she fell while trying to pick up a bag of birdseed. - Review of Resident #228's medical record revealed this [AGE] year old female was admitted to the facility at 8:30 p.m. on 05/17/11. According to hospital records provided on admission, this resident had dementia and a history of falls. That she had frequent falls was also noted on her physician's admission orders [REDACTED] According to the medical record, this resident was admitted to the facility at 8:30 a.m. on 05/17/11. Her admission note recorded her vital signs, weight, and height and stated the dietary department and the pharmacy were notified of her admission and her medications were ordered. The physician's orders [REDACTED]. The note stated: Will cont (continued) to monitor. There were no further entries in the resident's nursing notes, there were no assessments on file, and there was no evidence to reflect that any safety measures had been implemented. According to the nursing notes dated 05/18/11 at 2:30 a.m., Resident #228 was found face down in the floor in her room with blood on her right hand and on the left side of her forehead; she was subsequently transferred to the hospital for evaluation due to complaints of pain in her left leg. The resident was in this facility for a total of six (6) hours prior to falling and being transferred to the hospital. She subsequently returned to the facility at 6:00 a.m. on 05/18/11. The hospital emergency department notes, when reviewed, indicated the resident arrived at the hospital with signs of head trauma present. Her forehead was tender with a small abrasion. She had facial swelling present involving the area around the left eye. She had a small abrasion to the left cheek and a small abrasion to the left lower eyelid. Her left eyebrow area had a 1.0 cm laceration with controlled bleeding. The resident's wound was repaired with skin adhesive. There were not complications. She had a CAT (Computerized Axial Tomography) scan of the head. The resident was then transported back to the nursing home. The nursing notes upon her return to the facility, dated 05/18/11 at 4:45 a.m., stated: Notified POA of residents return. The next note, written on 05/18/11, stated (quoted as written), The resident arrived (name) hospital at 0630 (6:30 a.m.) via ambulance. Resident left eye has a hematoma cut to left eye is bleeding. Resident is talking refused to put ice on her eye for swelling. This was the last entry in the nursing notes when this surveyor reviewed the resident's medical record at 1:30 p.m. on 05/18/11. Based on record review and staff interviews, there was no evidence that direct care staff had been made aware of the resident's risk for falls when she arrived at the facility (in view of her previous history of falls), and there were no evidence to reflect safety measures were implemented by staff to address her immediate care and safety needs until a comprehensive assessment could be completed. Employee #93 (nursing assistant) was interviewed, at 1:00 p.m. on 05/18/11, about how he was made aware of the immediate needs of newly admitted residents. He stated they have a care plan sheet on which the care interventions were written for every resident. He went to the nurses' station and showed this surveyor the care plan sheet. Review of this sheet found no mention of Resident #228. Employee #93 stated they still had the name of the resident who used to be in that room on the sheet and they had not added Resident #228 to it yet. He said usually they added new people and her care needs should have been on here. During an interview with a registered nurse (RN - director of care delivery Employee #104) on 05/18/11 at 2:00 p.m., she was asked how the immediate care needs for newly admitted residents were communicated to the direct care staff. She verified that Resident #228 was not on the care plan sheet, that the sheet contained the name of the resident who previously occupied her bed, and that this had not been changed yet. At this time, eighteen (18) hours had passed since Resident #228's admission to the facility. Employee #104, when questioned how often the care plan sheet was updated, said it was printed each morning with changes. However, this resident had not been added to the form and she was admitted at 8:30 p.m. the prior evening. Employee #76 (nursing assistant) was interviewed the afternoon on 05/18/11; she was providing care to Resident #228 at that time. She was questioned about how she was made aware of the immediate care needs for newly admitted residents, including measures to promote the safety of residents at risk for falling. She stated this facility did not use alarms or side rails because it was against the state law and they just do the best they can. Employee #104 was observed, at 5:00 p.m. on 05/18/11, to be completing a care plan for this resident's immediate care needs. She verified there had been nothing written prior to this time, and she could not provide any evidence to show that staff members assigned to provide care to Resident #228 had been made aware of her risk for falls and/or the need for supervision, prior to her fall that resulted in her being sent back to the hospital. She verified that the safety interventions now in place for this resident (low bed and the bilateral landing strips on the floor beside the bed) were initiated after the fall that resulted in her emergency room visit. She also verified that there was no immediate or interim care plan or physician's orders [REDACTED]. When she was made aware that there was only one (1) landing strip beside the resident's bed, she obtained another one (1) for the resident's safety. -- b) Resident # 76 Observation, on 05/31/11 at 1:30 p.m., found Resident #76 in a low bed. He had a feeding tube, a below the knee amputation, and a tracheostomy. There were no side rails on his bed, and two (2) mats (landing strips) were stacked on top of each other in the floor on the resident's left side of the bed by the window. The nurse administering his medications at that time (Employee #100) was questioned about the mats being on top of each other and asked if there should be one (1) mat on each side of the bed. She stated she did not know, because she was new to this unit. She stated they (the mats) were that way this morning, and this was how she had always seen them. The nurse administered the resident's medication and did not move the mats to provide safety to this resident, nor did she check his medical record to see how these mats were to be used. She stated at that time that she would have to check on that. The medical record was reviewed, and the resident's medications were checked. At this time, it was noted that this resident's [DIAGNOSES REDACTED]. Employee #100 was questioned again about the mats at 2:30 p.m. on 05/31/11. It had been one (1) hour since the initial observation of these mats being found on only one (1) side of the resident's bed. The nurse said she forgot to check. She looked in the resident's record and stated, You are right. They should be on both sides of the bed. She then went into the resident's room at that time and moved one (1) of the mats to the resident's right side of the bed, so he would have padding on the tile floor on both sides of the bed. -- c) Resident #148 During the initial tour in Stage I of the survey on 05/24/11 at 11:15 a.m., this resident was observed seated in a wheelchair in the hallway on C-Wing. The resident had a yellow Theraband (stretchy therapy band) tied to her wheelchair and attached to her right foot. The device was knotted in several places to make it short, and had a loop on the end in which to place the resident's foot. The device did not appear to be a product designed to be used in this manner, instead it appeared to be something rigged to suit a purpose. During the observation, the resident attempted to stand several times. Fortunately, she had squirmed around in her wheelchair enough that her foot had slipped out of the Theraband before she attempted to stand. However, the resident did not have the cognitive ability to purposefully remove her foot from the device so it would not cause a fall when she attempted to stand. Since the resident made attempts to stand, the Theraband (when attached to her foot) presented an accident hazard. At 11:40 a.m. on 05/24/11, an interview was conducted with a licensed practical nurse (LPN - Employee #8), who stated, Therapy puts it on her foot to keep her from dropping her leg. Employee #8 looked at the resident's treatment records and stated there was nothing in those records regarding the use of this observed device. - The resident was reviewed during Stage II of the survey. At 10:45 a.m. on 06/08/11, an interview was conducted with Employee #110 (the rehabilitation services manager) and Employee #200 (a physical therapist). Employee #200 stated she had decided to use the device and had applied it to the resident and the wheelchair. Further interview revealed the resident had a total hip replacement. The surgery later had to be redone. Employee #200 stated, After the surgery the whole leg was rotating, and she does not have cognitive ability to maintain hip precautions. For these reasons, Employee #200 stated she decided to use the Theraband in this fashion. When asked if this was a recommended use for a Theraband, Employee #200 stated, I have seen other therapists do it at other places. At that time, Employee #200 was informed about the resident's attempts to stand on 05/24/11. Employee #200 stated she was not aware the resident was able to stand and was not aware of her attempts to do so. - Medical record review, on 06/08/11, revealed no assessment or care plan for any device to maintain hip precautions. Employees #110 and #200 were asked if there were any therapy notes and/or orders for this device. At 10:45 on 06/08/11, Employee #110 stated there were no progress notes, physician's orders [REDACTED]. - The facility had not used results of a comprehensive assessment to develop a care plan for this resident regarding her need to maintain hip precautions, and at the same time prevent avoidable accidents. The hazards and risks of using a device which restricts the movement of a foot, especially for a cognitively impaired resident, were not identified. There was the potential for an avoidable accident because the facility failed to identify this resident's individual risk of an accident. The Theraband, as used, was an accident hazard over which the facility had control. The facility failed to assess this resident's individual needs and risks regarding the use of the Theraband in this manner. -- d) Resident #5 After lunch on 05/26/11, the resident was observed lying in bed drinking her afternoon nutritional supplement. She was drinking from a straw inserted into a small carton of supplement. The head of her bed was elevated at only approximately 30 degrees. This posed a potential for increased risk of aspiration. Observation, on 05/31/11 at approximately 2:00 p.m., found the resident lying in bed holding a carton of supplement with a straw. The head of her bed was elevated at only approximately 30 degrees. On 06/01/11 at 11:30 a.m., the resident was observed lying in bed. A cup with a straw and a small carton of supplement with a straw were at her bedside. The resident was elevated at only approximately 20 degrees. Subsequent observations throughout the day on 06/01/11 and 06/02/11 found she had straws in her beverages and was not positioned in an upright position. A speech therapist had evaluated the resident on 02/15/11. The therapist had noted the resident needed to be in upright position. Review of the physician's orders [REDACTED].	2016-01-01
9213	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	325	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview, the facility failed to assure the resident received nutritional supplements as ordered by the physician after the resident experienced a 7 pound weight loss in three (3) days. The facility failed to specify how often the resident would be weighed to monitor the effectiveness of the diet ordered. This was true for one (1) of thirty-eight (38) Stage II sample residents. Resident identifier: #215. Facility census: 144. Findings include: a) Resident #215 Medical record review revealed an [AGE] year old male admitted to the facility on [DATE]. The resident's admission weight was 129.8 pounds (#). On 03/21/11, the resident's weight was 122.8#. On 03/21/11, the physician added nutritional supplements to the resident's diet in an effort to address the resident's unplanned weight loss. Review of the nutrition risk assessment completed by the registered dietitian (RD) on 03/31/11 stated, . note 3/18/11 wt. (weight) 129.8# and 3/21/11 wt. of 122.8 #. ? (symbol for 'question') accuracy of these wts. - will monitor wt. status. Review of the June 2011 recapitulation of the monthly physician's orders [REDACTED]. On 04/07/11, the physician added one (1) house supplement with lunch. In total, the resident was now to receive three (3) house supplements and three (3) cans of Ensure daily, according to the physician's orders [REDACTED]. Observation of the resident's noon meal, on 06/06/11, found the resident was served lunch without the Ensure; however, the house supplement was present on the noon tray. Employee #24 (assistant dietary manager), when interviewed at 2:15 p.m. on 06/06/11, was unaware of the orders for Ensure to be served with each meal. She produced a copy of the resident's tray ticket, which verified the dietary department would send only a house supplement with the noon meal. Employee #81 (RD), when interviewed on 06/06/11 at 2:30 p.m., stated she thought the physician's orders [REDACTED]. Employee #81 was unable to verify that Ensure had been served with the noon meals as directed by the physician. Review of the resident's care plan revealed the following problem statement written by the RD: Leaves more than 25% of most meals uneaten, dementia and dysphasia. The goal associated with this problem was: Will consume at least 75% of most meals and 75%-100% of fluids provided. An intervention was: Provide diet (with consistency adjustments) / supplements per orders. The care plan was not individualized for this resident. It failed to specify which supplements were to be provided for this resident, what department (nursing or dietary) would be responsible for providing the supplement(s), and who was responsible for monitoring and documenting the consumption of the supplements. Another approach for this care plan was: Monitor wt (weight) as indicated. The care plan failed to indicate how often the resident was to be weighed. The DON and the RD were both interviewed on the afternoon of 06/06/11, and no further information was supplied by either employee. The DON stated the physician's orders [REDACTED].	2016-01-01
9214	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	329	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview the facility failed to: (1)identify the problem or need for a medication; (2) identify the targeted behaviors for use of a psychoactive medication; (3) implement non-pharmacological interventions before administering a psychoactive medication to control a resident's behavior; (4) monitor for potential adverse side effects of a psychoactive medication; (5) monitor the resident's response to medications; and (6) act upon recommendations made by the consultant pharmacist. This was true for two (2) of thirty-eight (38) Stage II sample residents. Resident identifiers: #215 and #73. Facility census: 144. Findings include: a) Resident #215 Review of Resident #215's medical record revealed this [AGE] year old male resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed an order, handwritten by the physician on 04/07/11, for: [MEDICATION NAME] 0.125 mg PO (by mouth) PRN (as needed) every evening for anxiety and agitation (family request). Review of the April 2011 Medication Administration Record [REDACTED]. On 04/24/11, the physician gave an order for [REDACTED]. Review of the nurses' notes from 04/24/11 through 04/30/11 revealed the following entries: - On 04/24/11: Resident has been to the desk several times c/o (complaining of) different things . - On 04/28/11: Resident has been at N.S. (nurses station) several times. c/o of different things. Wanting wife returned to bed then (symbol for 'up'). (Resident #215 shared a room at the facility with his wife.) Review of the May 2011 MAR found the PRN [MEDICATION NAME] was administered on eighteen (18) occasions. Review of the nurses notes from 05/01/11 through 05/31/11 revealed resident behaviors were documented on only two (2) occasions - 05/26/11 and 05/28/11. - On 05/26/11: Out in hallway demanding in loud voice that he pays for paper towels and he does not have any. Staff offered to get him some. - On 05/28/11: Resident out in hallway wanting to know who pays for the water and who is going to call them about the water. Unsuccessful to re-direct. Further review of the MAR indicated [REDACTED]. The behavior monitor sheets where to be completed with information on the resident's specific behaviors, side effects of the medication, and the name of the drug to be administered. The monitoring sheets should also have contained documentation of each episode of type of target behavior per shift, the number of episodes that occurred, and the initials of the nurse administering the medication. The behavior monitoring sheets had not been completed for either month; they contained only the resident's name. Review of a pharmacist's consultation report, dated 05/06/11, found the following related to the [MEDICATION NAME]: Please consider additional documentation which supports the continued use of this product, including goals of therapy and the extent to which those goals have been met. It is recommended that the resident record contain documentation of continued efficacy of therapy and evaluation for the presence of adverse side effects. The director of nursing (DON), when interviewed on 06/06/11 at 4:30 p.m., was unable to provide any further information of documentation of the resident's behaviors and attempts by staff to redirect the resident using non-pharmacologic interventions prior to administering the PRN [MEDICATION NAME]. The DON agreed the behavior monitoring sheets for the PRN [MEDICATION NAME] should have been completed. On 06/08/11 at 9:15 a.m., the DON, when asked, was unable to produce documentation to reflect the pharmacist's recommendation had been acted upon by the physician. -- b) Resident #73 Medical record review, on 06/02/11, revealed a 05/06/11 consultant pharmacist recommendation to discontinue sliding scale insulin coverage because the resident's pre-breakfast blood sugars were in excellent control with his oral medications. The pharmacist also noted the facility had not monitored the resident's HgbA1c level (blood sugar indicator) since November 2010. The pharmacist's report gave explicit details relative to why the sliding scale insulin was not recommended, as well as the facility's need to assure ongoing monitoring for effectiveness and potential adverse consequences. This resident was not monitored for the continued use of insulin to assure he only received the insulin in doses and for the duration clinically indicated to treat his assessed condition. An interview was conducted with the DON at 10:30 a.m. on 06/02/11. At that time, the DON confirmed the pharmacist's recommendation for monitoring had not been implemented.	2016-01-01
9215	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	332	E	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interview, the facility failed to assure the medications were administered as ordered by the physician and that the medication error rate was not greater than five percent (5%). The medication errors included omissions, the incorrect dosage, administration of the incorrect type of vitamins, and inadequate flushing of the gastrostomy tube when administering medications. There error rate for the facility was sixteen and seven one-hundredth percent (16.07%). There were medication errors observed for six (6) of eleven (11) residents observed during medication pass. Resident identifiers: #68, #142, #76, #169, #6, and #37. Facility census: 144. Findings include: a) Resident #68 During a medication administration on 06/02/11 at 1:13 p.m., a licensed practical nurse (LPN - Employee #100) was observed preparing the medications for Resident #68. During this preparation, she was observed to prepare a tablet of Multivitamin (MVI) with Iron. The medication administration record (MAR) did not indicate this resident was to receive a MVI with Iron. Prior to going in to the resident's room to administer these medications, the nurse was questioned about the medications. She stated this was all of them. She was stopped and asked to review the MAR with the nurse surveyor, who brought to her attention there was no MVI with Iron scheduled for this resident. She stated, That is what our House Supplement is. It was noted on the MAR this resident was to receive a house supplement TID (three-times-a day). This nurse surveyor again asked Employee #100 if she was sure this was what she should give, and the LPN stated, Yes. This surveyor told the LPN at that time that she was told earlier the house supplement written on the MAR was something sent from the kitchen for the residents to drink for extra calories. Employee #100 stated, If that is what it is, no one has ever told me. The LPN then proceeded in to the resident's room. The resident had visitors, and they told the nurse that the resident was up in therapy. The nurse had prepared [MEDICATION NAME] 10 mg and [MEDICATION NAME] 20 mg, and she still had the MVI with Iron in the medication cup. The nurse made no effort to ascertain whether the resident was to receive the MVI with Iron even after the surveyor brought to her attention that this was not the same thing as the house supplement that came from the dietary department. Employee #100 came out of Resident #68's room and stated she was going to destroy those medications, since this resident was in therapy. She stated she would pull them out again when the resident came back. This nurse was instructed at that time that this surveyor would be at the nursing station desk and asked that she get the surveyor before administering these medications to Resident #68. - At 3:00 p.m., Employee #100 was questioned about the medications that were to be administered to Resident #68. She stated she was trying to finish up, but she passed it on in report that this resident had not received her medications. When asked which nurse she passed this information to, she stated it was Employee #57 - registered nurse (RN). Employee #57, when questioned at 4:30 p.m. on 06/02/11 if she administered the missed medications to Resident #68, stated she did not administer these medications, because it was not within the time frame allowed. The MAR was reviewed, and the nurse circled her initials for medications, indicating they were not given. These medications were counted as omissions, because the resident did not receive them. -- b) Resident #142 This resident was observed during medication pass at 1:20 p.m. on 06/02/11. Employee #100 reviewed the resident's MAR and poured [MEDICATION NAME] 325 mg 1 tab in a medicine cup. She then was observed to administer this medication to the resident. Employee #100 was then asked to look at the MAR again and carefully read the medication order. She verified the order stated: [MEDICATION NAME] 325 mg tablet give 2 tabs (650 mg) by mouth tid (three-times-a-day). She verified she had not administered the correct dosage. After surveyor intervention, she then administered another 325 mg tablet. Review of the resident's physician orders [REDACTED]. -- c) Resident #76 During medication administration on 06/02/11 at 1:45 p.m., Employee #100 prepared medications for Resident #76. She was taking out a breathing treatment and accidently ripped the top off, opening the treatment. She stated she had to give this anyway, so she was going to go ahead and pour it into the machine and give it after his other medications. She was observed to pour the breathing treatment into his machine at that time. The nurse then prepared his medication for his [DEVICE]. He had an order for [REDACTED]. She then obtained a second 6 oz cup of plain water and went to the resident's bedside. She checked placement of the [DEVICE] per auscultation, but she did not aspirate to check for residuals. She flushed the [DEVICE] with 1/2 of the 6 oz cup of water, then poured in half of the 6 oz cup that contained the crushed medication. She then poured remaining half cup of water into the other half cup that contained the medication ([MEDICATION NAME]) and poured it all into the [DEVICE] until it was gone. When she got to the bottom of the cup, there was still medication in the bottom that had not dissolved. She swirled it around to mix up the medication with the water and poured the final liquid into the [DEVICE]. There were still some medication particles in the bottom of the cup, and this was poured in last. This was not followed by a flush, because there was no water left in the other cup. This was counted as a medication error; the resident may not receive all of his medication, as the final flush to push the medication through the [DEVICE] was omitted. The nurse was questioned about flushing the tube after her medication administration. She stated she poured the rest of her flush in with the medication, because the medication was not dissolved yet. She said she was not aware the flush of water had to go in the tube last. The nurse was observed to leave this resident's room. She did not administer his breathing treatment of [REDACTED]. At 3:00. p.m., Employee #100 was preparing to leave for the day. When questioned about the administration of the breathing treatment, she stated, I forgot all about that. This medication was counted as an omission. -- d) Resident #169 During the observation of medication pass at 7:55 a.m. on 06/02/11, Employee #58 (an LPN) gave the resident a multivitamin with iron. Review of the physician's orders [REDACTED]. An Internet search of Tab-a-Vite preparations found one that did not include iron in the medication name on the label, and one that did include iron in the name of the medication on the label. -- e) Resident #6 On 06/02/11, during morning medication pass, Employee #58 was observed giving medications to the resident. The nurse gave a liquid multivitamin with iron. The physician's orders [REDACTED]. Vi-[MEDICATION NAME] is a liquid multivitamin, but it comes in a preparation with iron and in a preparation without iron. The physician had not ordered a preparation with iron. -- f) Resident #37 On 06/02/11 at 8:28 a.m., Employee #112 (an LPN) was observed giving medications to this resident. The nurse administered Tab-a-Vite with Iron. Reconciliation of the observations with the physician's orders [REDACTED]. A search of Tab-a-Vite preparations found one that did not include iron in the medication name on the label, and one that did include iron in the name of the medication on the label. -- g) Staff interviews about vitamins On 06/02/11 at 2:40 p.m., Employee #58 was asked to check the vitamins in the second floor A-Hall medication cart. Only Tab-a-Vite with Iron was found in the drawer, and the liquid multivitamin label also included with iron. On 06/08/11 at 10:15 a.m., Employee #112 was asked to check his medication cart. Two (2) bottles of multivitamin that did not include iron and a bottle of a multivitamin with iron (in the name of the medication) were found. Employee #112 was asked which he would give if the order was for a multivitamin - he said the one without iron. On 06/08/11 at 10:40 a.m., this was discussed with Employee #95 - registered nurse (RN) and director of care delivery. He agreed the vitamin without iron should have been used.	2016-01-01
9216	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	356	B	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, the facility failed to post the required nurse staffing information in an area readily accessible to the residents. The posting was observed in the front lobby on the office door, in an area not readily accessible to most of the residents. This practice has the potential to affect more than an isolated number of residents who may desire to view this information. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Upon entrance to the facility on [DATE] at 12:00 p.m., the nurse staffing posting was observed in the front lobby on the office door. During a tour of the facility, other areas of the facility were observed, and the front lobby was the only area where the nurse staffing posting was displayed. Access to the front lobby through double doors from the nursing unit was restricted for any resident wearing a Wanderguard bracelet. Observations were continued throughout the survey event from 05/24/11 to 06/08/11, and the front lobby was the only area in which the nurse staffing posting was displayed. According to the requirement, this posting must be in a prominent place readily accessible to residents and visitors. The front lobby area was readily accessible to visitors, but this area was not readily accessible to all residents.	2016-01-01
9217	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	369	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of medical records, resident interview, and review of a resident's dietary slip, the facility failed to ensure each residents received special utensils at meal times as indicated. A resident did not have the specialized utensils provided for two (2) of four (4) meals observed. One (1) of thirty-eight (38) Stage II sample residents was affected. Resident identifier: #70. Facility census: 144. Findings include: a) Resident #70 Record review revealed this resident's [DIAGNOSES REDACTED]. On 05/24/11, the resident was observed sitting in her wheelchair in her room at lunch time. After she was served her meal and began to eat, observation found she had some difficulty in manipulating the standard flatware. When asked whether she had ever tried using large handled or other adaptive utensils, she reached for her communication board. Using her communication board, the resident spelled out: I got some in Kitchen. She then spelled out: They probably forgot. At the bottom of her tray slip was printed RED NAPKIN, which she got, and SPECIAL, SPOON, FORK, which she did not receive. She was provided the special utensils at lunch time on 06/01/11, but she did not receive them at lunch time on 06/02/11. She had them again at lunch time on 06/06/11, at which time she demonstrated how she used her spoon with the special handle that went around her hand.	2016-01-01
9218	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	371	F	0	1	MZQB11	Based on observation, information from the ServSafe Manual (Fifth Edition), and temperature measurement, the facility did not store the emergency food supply in a manner to assure food safety. The temperature of the outdoor emergency food storage area was higher than recommended, and it was not ventilated to help keep the interior temperature and humidity constant throughout the storage area as recommended. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 144. Findings include: a) At 1:15 p.m. on 05/31/11, the outside food storage area, where emergency foods were stored, was found to have an interior temperature of 78 degrees Fahrenheit (F). In addition, the area was not well ventilated to assist in keeping the temperature and humidity constant. According to the ServSafe Manual (Fifth Edition), To keep food at its highest quality and to assure food safety, the temperature of the dry-storage area should be between 50 (degree sign) F and 70 (degree sign) F. Additionally, the ServSafe Manual discussed the need to (m)ake sure dry-storage areas are well ventilated to help keep temperature and humidity constant throughout the storage area.	2016-01-01
9219	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	412	D	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, medical record review, and staff interview, the facility failed to assess the resident's dental needs, resulting in a failure to arrange dental services. This was true for one (1) of thirty-eight (38) Stage II residents reviewed. Resident identifier: #155. Facility census: 144. Findings include: a) Resident #155 Medical record review revealed this [AGE] year old male resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. During two (2) interviews with the resident (on 05/25/11 at 8:46 a.m. and again on 05/31/11 at 11:20 a.m.), the resident stated his teeth hurt, especially when eating. He related he had about seven (7) teeth and they were rotted out. On 05/31/11 at 12:20 p.m., the director of nursing (DON) was interviewed regarding the resident's dental needs and was advised the resident had stated his teeth were hurting when he ate. On 06/01/11 at 2:00 p.m., the DON stated she could find no evidence of a dental assessment and no evidence the resident had been evaluated by a dentist since his admission on 11/18/09. She stated the facility had scheduled a dental consult for the resident. Review of the medical record, on 06/01/11, revealed a telephone order received on 05/31/11 at 6:15 p.m. for: Consult dentist due to toothache. Further review of the medical record revealed a nursing admission evaluation completed on 10/08/10. In Section F, regarding the resident's condition of teeth, the assessor indicated the resident had broken teeth. The resident's annual comprehensive minimum data set (MDS), with an assessment reference date of 11/10/10, did not indicate the resident had any oral problems in Section L (Oral / Dental Status). On 06/02/11 at 3:00 p.m., Employee #95, a registered nurse (RN), was asked to assess the resident's dental needs. Employee #95 assessed the resident's teeth and stated, Looks like he may have a cavity in that back tooth.	2016-01-01
9220	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	425	E	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, resident interview, staff interview, and a review of the facility's inservice records and procedures for ordering medications, the facility failed to assure medications were acquired timely and available for administration as ordered by the physician. Medications for newly admitted residents were not obtained in a timely manner, the emergency box was not checked to see if a medication was available when it was not found on the medication cart, and there was no evidence that staff notified the physician when medications were not administered in accordance with the orders. Review of residents' medication administration records (MARs) revealed medications were frequently not available and were not administered, with no interventions or follow-up actions evident. This practice was true for six (6) of thirty-eight (38) Stage II sample residents and one (1) resident of random opportunity. Resident identifiers: #228, #116, #112, #6, #40, #3, and #215. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #228 During a complaint investigation beginning at 12:00 p.m. on 05/18/11, a nurse surveyor found Resident #228 was admitted at 8:30 p.m. the prior evening (on 05/17/11). On admission, the physician ordered multiple medications for this resident. The orders were stamped STAT at that time, and someone had written on the orders: STAT meds (medications) please. The resident had orders to receive sixteen (16) medications on a daily basis, and she did not receive morning doses for any of these medications on 05/18/11. Her orders included six (6) medications to treat high blood pressure (Tenormin, Diovan, Lisinopril, Catapres, Apresoline, Zaroxolyn and Lasix). Her vital signs were recorded by staff at 8:00 a.m., and her blood pressure was not elevated (132/72). The resident's medication nurse - a licensed practical nurse (LPN - Employee #75) - when questioned about the medications at 12:30 p.m. on 05/18/11, stated, They have not arrived from the pharmacy. When questioned further about the medications, he stated, I reported this to my charge nurse. The LPN identified Employee #104 as the registered nurse (RN) he reported to. He confirmed he had been notified during shift report earlier that morning that Resident #228's medications were not there yet, but he had not called the pharmacy himself. During an interview with Resident #228 at 1:00 p.m., she stated, I have not had any medicine since I came here. This resident was noted to have dementia, and she was pleasantly confused, but she repeated this statement during three (3) different visits from this surveyor. She also stated, Not taking my medications right is why I was in the hospital, but I don't think I really need them anyway. Employee #104, when questioned about this resident's medications at 1:00 p.m., stated they were ordered, but the nurse did not call the pharmacy; she only faxed the orders and never called the pharmacy. This was why they did not arrive. She said, When you order medications from the pharmacy in the evening, you are supposed to call them as well as fax the orders. She verified she had re-faxed the orders and spoke with the pharmacy this morning. The facility's medical director, who was visiting the facility at this time, was made aware of the issue with Resident #228's medications not being available, and he called the pharmacy again at 1:45 p.m. He said the pharmacy assured him the resident's medications were on their way. Employee #93, a nursing assistant, checked the resident's blood pressure at 3:00 p.m., at which time the resident's blood pressure was 109/69. During an interview with Employee #104 at 3:30 p.m., she was questioned about the facility's emergency drug box. She stated they had checked it; some of these medications were available and were going to be administered from that box. She was not sure why staff had not checked the emergency drug box prior to this time. Resident #228's medications arrived from the pharmacy, and Employee #58 (an LPN) was observed at 4:30 p.m. to administer the medications to the resident. During an interview with the director of nursing (DON - Employee #12) at 5:00 p.m. an 05/18/11, she verified that staff had not followed the facility's procedures for obtaining medications from the pharmacy and assuring they were administered timely. She stated they identified having issues with medications not being available, and the facility had re-educated the nurses on this process. A review of the facility's inservice records found an inservice was conducted on 04/20/11, during which the DON reviewed with nurses the procedure for ordering medications. According to the facility's procedure, all orders received after 5:00 p.m. must be faxed and called to the pharmacy to obtain confirmation that the orders were received. If medications are not been received within four (4) hours after a STAT order has been placed, the nurse is to call the pharmacy to check on the status. Also, on new admissions that are to receive medications after 7:00 p.m., staff is to notify the physician and obtain an order to start the medications at 9:00 a.m. the next morning, so there are no missed doses. This procedure was not followed for Resident #228. -- b) Resident #116 Review of Resident #116's MAR for May 2011 found the 9:00 a.m. dose of Glimepiride 2 mg tablet (give 1 tab by mouth every morning) had been circled on 05/03/11. (This is a medication given to control blood sugar.) The nurse had documented on the back of the MAR: Glimperide (sic) 2 mg PO - N/A (not available) - Reordered. -- c) Resident #112 Review of Resident #112's MAR for May 2011 found the 4:00 a.m. dose of Percocet 10/325 1 via [DEVICE] Q4 (hour symbol) while awake was circled on 05/09/11. The nurse had noted on the reverse of the MAR: Percocet Awaiting from Pharmacy. On 05/26/11 at 12:00 a.m., the dose of medication was circled again. On the back of the MAR indicated [REDACTED]. -- d) Resident #6 Review of Resident #6's May 2011 MAR found the doses for Exelon Outer 9.5 mg / 24 hr Patch Apply one patch topically every day for Dementia were circled on 05/30/11 and 05/31/11. There was no reason provided for the dose circled on 05/30/11, but N/A (not available) was written under the 05/31/11 dose that was circled. -- e) Resident #40 Medical record review, on 06/01/11, revealed this resident was not administered Betaseron on 05/27/11. The reason given for not providing the medication was: Med never came from pharmacy. -- f) Resident #3 Medical record review, on 06/01/11, revealed this resident was not administered Levothyroxine on 05/28/11. The medication was circled on the MAR, indicating it was not given on this date. The reason the medication was not given was not documented. Additionally, this particular medication was one 1 the facility kept available in the emergency medication box. -- g) Resident #215 Review of the MAR for April 2011 revealed Resident #215 had a physician's orders [REDACTED]. Further review of the MAR indicated [REDACTED]. Documentation on the back of the MAR, for this time period, revealed the Flomax was unavailable. On two (2) occasions (04/23/11 and 04/28/11) nurses documented the pharmacy was aware. The DON, when interviewed on the afternoon of 06/06/11, verified the circling of the nurses' initials indicated the medication was not given as ordered. She was unable to explain why the medication was not available. She did state the facility had realized there was a problem with medications not being available for residents throughout the facility. She stated the facility had taken this issue to their quality assessment and assurance (QAA) committee, and she presented evidence that nurses had been inserviced as early as 04/20/11 on how to resolve the issue of medications not being available for resident use, yet the problem continued to occur after the inservicing.	2016-01-01
9221	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	428	D	0	1	MZQB11	Based on medical record review and staff interview, the facility failed to assure the pharmacist's recommendations of irregularities identified in the medication regimen were acted upon by the attending physician and the director of nursing in a timely manner. This was true for three (3) of thirty-eight (38) Stage II sample residents whose records were reviewed. Resident identifiers: #140, #5, and #73. Facility census: 144. Findings include: a) Resident #140 Review of consultation report from the pharmacist dated 02/10/11 revealed, (Name of resident) is on glimepiride / Amaryl 2 mg qd (every day) and sliding scale insulin QID (four times a day); morning fingerstick's range 78 to 103 mg/dl, excellent control; coverage seldom required as blood sugars seldom are over 150 mg/dl at any time of day. Recommendation: Please consider discontinuing use of sliding scale insulin and begin fingersticks with no coverage alternating mornings Mon, Wed, Fri and 4 p.m. Tues, Thurs, Sat. On 03/21/11, the physician responded to the recommendations from the pharmacist by documenting, Agree. On 03/10/11, the consultant pharmacist reviewed the resident's medication regimen and, again, made the same recommendation as made on the 02/10/11 visit. The resident's physician reviewed and signed this recommendation on 04/04/11. The order to discontinue the sliding scale insulin and previous fingersticks was not written until 04/04/11, after being recommended by the pharmacist on 02/10/11 and 03/10/11. The director of nursing (DON, when interviewed on 05/31/11 at 2:15 p.m., was unable to explain the delay in writing the orders in accordance with the pharmacist's recommendations. She verified the orders should have been written on 03/21/11, when the resident's physician agreed to the recommendations. -- b) Resident #5 On 05/11/11, the consultant pharmacist issued a report that included: Comment: (Resident #5's name) is on Remeron 15 mg qhs (every hour of sleep) since January 2011; due for review and documentation of continued need. This regimen may be the lowest effective dose. Recommendation: Please review. If therapy is to continue at the current dose, please provide rationale describing a dose reduction is clinically contraindicated. There was no evidence found in the resident's medical record to reflect this issue had been addressed. In an interview with the DON on 06/02/11 at 10:30 a.m., she acknowledged the pharmacist's recommendation should have been addressed already. -- c) Resident #73 Medical record review, on 06/02/11, revealed the consultant pharmacist noted an irregularity during this resident's April 2011 medication regimen review. The DON was asked to provide the consultation report. On 06/02/11 at 10:30 a.m., the DON provided the requested report. The report was for the period of April 1 - April 30, 2011. It noted a recommendation date of 05/06/11. The pharmacist made three (3) recommendations to the physician: discontinue sliding scale insulin coverage; obtain an HgbA1c level; and continue fingersticks with no coverage daily before breakfast. The pharmacist's report gave explicit details relative to why these were recommended. There was no evidence these recommendations were acted upon by the physician. The DON, on 06/02/11 at 10:30 a.m., confirmed these recommendations had not been acted upon by the physician.	2016-01-01
9222	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	431	E	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility failed to ensure drugs and biologicals are labeled in accordance with currently accepted professional principles. Eye drops used for Resident #76 were not labeled to ensure the drops were not administered to another resident, especially in view of the fact this resident had recently been treated for [REDACTED]. This practice have the potential to affect more than an isolated number of residents. Resident identifier: #76. Facility census: 144. Findings include: a) Resident #76 During medication administration on 06/02/11 at 1:45 p.m., the licensed practical nurse (LPN - Employee #100) was observed preparing Resident #76's medications, which included eye drops (Natural Balance Tears 0.4%). Employee #100 removed a box of eye drops from the medication cart; however, there was no name written on the box to ensure these eye drops were administered only to Resident #76. Employee #100 applied her gloves and proceeded to administer eye drops as ordered for this resident. The eye drop container was observed to have direct contact with the resident's eyes. This action contaminated the eye dropper, as well as contamination the resident's eyes with any organisms that may have been on the dropper. (See also citation at F441.) Review of Resident #76's medical record found he had been treated for [REDACTED]. There was a potential for these eye drops to be administered to another resident after being contaminated when used for Resident #76. Employee #100 was questioned at 1:50 p.m. 06/2/11 about the eye drop box not having a label and she said, This is our facility's stock. When asked how she knew these were Resident #76's eye drops, she stated again, They are our facility stock. When the surveyor told the nurse there was no way to assure these eye drops were to be only administered to this resident and had not been used on someone else, she asked the surveyor, Do you want me to write his name on them? This surveyor then asked her what the facility's policy was, and she stated, I guess they should have his name on them, but they were laying beside of his medicine, so I know they were his. -- b) During an inspection of medication storage at 10:00 a.m. on 05/26/11, observation found an open multidose vial of Pneumovax in the medication refrigerator in the second floor medication room. Neither the vial itself nor the box containing the vial was dated to indicate when the first dose was accessed. When interviewed at 10:00 a.m. on 05/26/11, the licensed practical nurse (LPN) supervisor (Employee #143), who was present during the observation, confirmed the expectation was that nurses were to date multidose vials when opened.	2016-01-01
9223	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	441	E	0	1	MZQB11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and record review, the facility failed to establish and maintain an effective program in which practices of the facility prevent the spread of disease and infection. During medication pass for Resident #76, the nurse contaminated a bottle of eye drops by directly touching the tip of the eye dropper to resident's the eyes (which had been treated for [REDACTED]. The nurse, who was wearing gloves, then wiped the resident's eyes with a tissue. She did not change her gloves prior to administering medications via the resident's his gastrostomy tube. The contaminated bottle of eye drops was then placed back in the medication cart, potentially contaminating other items in the cart. Staff used an isolation cart from outside of Resident #228's room in lieu of an overbed table for serving this resident her meal. Resident #228 was in contact isolation for a multi-drug resistant organism. When staff provided an overbed table for the resident to use for the remainder of the meal, the contaminated isolation cart was placed back out in the hallway. Multiple observations were made of soiled linen and contaminated linen in red bags lying on the floors of residents' rooms and bathrooms. Isolation precautions were not implemented for Resident #3 (who resided on the second floor), when staff suspected she had a condition that could be spread to others. These deficient practices had the potential to cause more than minimal harm to more than an isolated number of residents. Resident identifiers: #76, #228, and #3. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Resident #76 1. Eye Drop Technique During medication administration on 06/02/11 at 1:45 p.m., the licensed practical nurse (LPN - Employee #100) was observed preparing Resident #76's medications, which included eye drops (Natural Balance Tears 0.4%). Employee #100 removed a box of eye drops from the medication cart; however, there was no name written on the box to ensure these eye drops were administered only to Resident #76. Employee #100 applied her gloves and proceeded to administer eye drops as ordered for this resident. The eye drop container was observed to have direct contact with the resident's eyes. This action contaminated the eye dropper, as well as contamination the resident's eyes with any organisms that may have been on the dropper. Review of Resident #76's medical record found he had been treated for [REDACTED]. There was a potential for these eye drops to be administered to another resident after being contaminated when used for Resident #76. When the nurse placed the bottle of eye drops that had been contaminated back in the medication cart, the potential existed for other items in the medication cart to become contaminated if they were to come in contact with the bottle. 2. Gloves After Employee #100 administered Resident #76's eye drops, she wiped his eyes with a tissue. This resident's eyes were observed to be slightly red and have dried crusty material in the corners which she removed with her gloved hand and a tissue. She then proceeded to administer medication via his gastrostomy tube without first changing her gloves. The LPN, when questioned about this practice at 1:50 p.m. 06/02/11, stated, I guess I should have changed gloves. She agreed this was not a good infection control measure. -- b) Resident #228 Observation, at 12:00 p.m. on 05/18/11, found Resident #228 in bed in her room with her lunch tray sitting on top of a small cart with wheels and drawers beside her bed. This cart was identified as a portable isolation cart containing personal protective equipment; the cart had been outside her door, because she was in contact isolation. Employee #67 (housekeeping aide) was passing by the room at 12:15 p.m., and this surveyor asked him if he knew why Resident #228 did not have a bedside table. He stated he was not sure why she did not have one, but he would get her one. He obtained an overbed table for this resident, and she stated this was much better. Employee #67 returned to isolation cart to its previous location outside the resident's door in the corridor. A registered nurse (RN - Employee #104), when questioned about this observation 05/18/11 at 1:00 p.m., verified the cart had been outside the resident's door to hold personal protective equipment because she was in contact isolation. Employee #104 further identified this resident had [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) in her urine. Employee #104 agreed this cart was placed outside of the room so the staff has access to its contents and that it should not be used to serve the resident's meal. -- c) Soiled laundry During the initial complaint investigation beginning on 05/18/11, observation found a red plastic bag of laundry on the floor in Resident #228's bathroom at 12:00 p.m. The facility was entered again at 8:30 p.m. on 05/23/11. At this time, observation of room [ROOM NUMBER] (which was not occupied at that time) found two (2) bags of linen and one (1) red plastic bag on the floor; in the bathroom, observation found larger cloth bags of linens and two (2) red plastic bags on the floor. The director of nursing (DON), when questioned about the process for handling soiled linens and linens from isolation rooms on 05/23/11 at 9:15 p.m., stated these bags should have been transported to a soiled laundry container in the soiled utility room. She was made aware of the above observation, and she confirmed these bags should not have been placed on the floor. -- d) Resident #3 On 06/06/11, a hospice nurse asked Employee #95 (an RN) to go to the resident's room to check something she had found. After entering the room, Employee #95 donned gloves to check an area on the resident's right posterolateral side. After removing his gloves, he did not wash hands before returning to the nurses' station. The physician was contacted by the hospice nurse. [MEDICATION NAME] was ordered for possible shingles. On 06/07/11 at 1:40 p.m., Employee #95 provided a copy of Type and Duration of Precautions (cont) (from appendix A of CDC's Type and Duration of Precautions Needed for Selected Infections and Condition). He said one (1) of the listings was for those with chickenpox and one (1) for those with shingles. When asked what staff was told about the resident's condition, he said no one who was pregnant was to work with the resident. This would not ensure no susceptible visitors or staff who had not had chicken pox had contact with the resident. On 06/07/11 at 1:55 p.m., the DON, when asked what type of precautions should be a used with a resident with suspected shingles, she agreed the resident should be on contact precautions. On 06/08/11 at 2:45 p.m., no isolation cart or signage was noted near the resident's room.	2016-01-01
9224	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	513	D	0	1	MZQB12	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to obtain in a timely manner and file on the medical record the results of diagnostic services performed on one (1) of fourteen (14) sampled residents. The results of diagnostic procedures performed to evaluate Resident #33's urinary tract were not obtained and filed on the resident's medical record until thirteen (13) days after the procedures were completed. Resident identifier: #33. Facility census: 140. Findings include: a) Resident #33 Medical record review, on 08/22/11, revealed this [AGE] year old male with [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder had an indwelling Foley urinary catheter in place for a long time. He also had experienced a history of urinary tract infections and [MEDICAL CONDITION]. Resident #33 had a history of [REDACTED]. Further medical record review revealed the resident, at a local hospital on [DATE], underwent a rigid cystourethroscopy (endoscopy of the urinary bladder via the urethra, carried out with a cystoscope). The resident also had a bilateral retrograde pyelography with interpretation (a procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney). These tests revealed no evidence of hydrouretero[DIAGNOSES REDACTED] (distension of the kidney and/or ureter caused by backward pressure on the kidney when the flow of urine is obstructed). (http://www.merckmanuals.com/home/kidney_and_urinary_tract_disorders/obstruction_of_the_urinary_tract/hydro[DIAGNOSES REDACTED].html#v 1) - When asked about the results of the above mentioned diagnostic procedures on 08/22/11 at 12:00 p.m., Employee #200 (a registered nurse) reported the facility had not yet received the report. She said she had this on a list of items she needed to get. On 08/23/11 at approximately 10:00 a.m., the facility obtained a copy of the diagnostic test results. - Review of the operative report for these two (2) procedures, dated 08/10/11, revealed the following discharge instructions (quoted as typed): . He will have a followup appointment in roughly 4 weeks in the Urology Clinic to further discuss his symptoms.	2016-01-01
9225	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2011-06-08	520	E	0	1	MZQB11	Based on the findings of the current survey, staff interviews, review of documentation of inservices, and review of medical records, the facility's quality assessment and assurance (QAA) committee failed to implement fully implement its action plan to correct identified quality deficiencies with respect to the availability of medications for administration to residents in a timely manner, and failed to implement monitoring activities to ensure the quality deficiencies were corrected going forward. All residents had the potential to be affected. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Availability of medications During a complaint investigation beginning at 12:00 p.m. on 05/18/11, a nurse surveyor found Resident #228 was admitted at 8:30 p.m. the prior evening (on 05/17/11). On admission, the physician ordered multiple medications for this resident. The orders were stamped STAT at that time, and someone had written on the orders: STAT meds (medications) please. The resident had orders to receive sixteen (16) medications on a daily basis, and she did not receive morning doses for any of these medications on 05/18/11. (See citation at F425 for additional details related to Resident #228 and additional examples of other residents affected by this deficient practice.) This lack of availability of medications for administration was further investigated during the Quality Indicator Survey (QIS) conducted between 05/24/11 and 06/08/11. It was learned the facility had identified a problem with the timely and / or consistent provision of the medications. Review of the corrective actions taken to correct the problem found inservices had been provided to the facility's licensed nurses beginning in the latter part of April 2011 and continuing into May 2011. The inservice documents included copies of the various forms that were to be used to order / reorder medications, a copy of the pharmacy's presentation slides covering the pharmacy orientation packet, how to reorder using E-Refill, a document that covered what to do if the medication was not found (including documentation, notifications, etc.), and a page entitled Medication Ordering. Review of signatures on the inservice sign-in sheets found four (4) nurses received the training on 04/20/11 at 7:00 a.m. and another four (4) at 1:30 p.m.; eleven (11) nurses on 04/21/11; and three (3) on 05/04/11. A comparison of the sign-in sheets with the facility's employee roster revealed nineteen (19) nurses did not receive the training until between 05/23/11 and 05/25/11, according to the documentation, after the nurse surveyor identified the omitted doses related to Resident #228. Review of medication administration records (MARs) of residents on the Stage II sample found six (6) of thirty-eight (38) residents had medications that had not been available and / or available timely, in May 2011. The facility continued to have an issue with timely medication availability. The facility's QAA committee was aware of this quality deficiency and addressed it through the initiation of inservice training for its licensed nurses; however, the QAA committee failed to all licensed nurses received this training and failed to implement monitoring activities to ensure the quality deficiencies were corrected going forward.	2016-01-01
9226	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2013-01-08	241	E	1	0	C0IF11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interview, care plan review, and observation, the facility failed to ensure four (4) of ten (10) residents, who were dependent in activities of daily living, received the assistance needed as indicated by their physical condition. All four (4) residents had unmet grooming needs which they were unable to attend to on their own. Resident identifiers: #114, #72, #57, and #37. Facility census: 114. Findings include: a) Resident #57 An observation of Resident #57, on 01/07/13 at 1:00 p.m., revealed this resident needed his facial hair shaved. He had several days beard growth and hair was growing out of his ears. He said he would like to have a shave and a hair cut as well as the hair trimmed from his ears. He said he had not had a hair cut or a shave in a long time. At 1:30 p.m. on 01/07/13, Employee #130, a licensed practical nurse (LPN) said the resident was on the list to have a hair cut from the beautician. On 01/07/13 at 4:00 p.m. the resident had received a hair cut. On 01/08/13 at 10:50 a.m. the resident was still not shaven. Employee #130 said the resident would get shaved this morning. The resident liaison (Employee #97) said she had noticed this resident needed shaved on the morning of 01/07/13. Employee #97 said she knew the facility needed razors on the morning of 01/07/13. b) Resident #72 An observation of Resident #72, on 01/07/13 at 12:30 p.m., revealed this female resident had long hairs on her chin. She said she was not scheduled for a bed bath today and she had forgotten to mention this to the staff over the weekend. On 01/07/13 at 12:45 p.m., Employee #101, a registered nurse (RN), stated he would make sure this hygiene need was addressed. c) Resident #37 Resident #37 was observed on 01/07/13 at 11:30 a.m. This female resident had chin hair that needed removed. d) Resident #114 On 01/07/13 at 1:15 p.m., this resident was observed. He was in need of a shave. Upon inquiry, Employee #130 said the resident had returned from the hospital on [DATE]. She said the facility did not have any razors. On 01/07/13 at 1:20 p.m. Employee #130 (LPN) and Employee #101(RN) both indicated the facility did not have any razors to shave residents.	2016-01-01
9227	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2013-01-08	280	D	1	0	C0IF11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and observation, the facility failed to update the care plan in a timely manner for one (1) of six (6) sample residents. The care plan for a resident who had experienced falls was not updated at the time of the falls. Resident identifier: #73. Facility Census: 114. Finding include: a) Resident #73 Resident #73 was first observed on 01/03/13 at 11:00 a.m. She was lying on her right side, sleeping. She was wearing an immobilizer related to a [MEDICAL CONDITION] humerus. Bruising was visible on her left upper arm and her left hand was [MEDICAL CONDITION]. Employee #60, nursing assistant (NA), was seated next to the bed. She stated she was providing one-on-one supervision, because the resident had fallen. During an interview with Employee #159, a registered nurse (RN), and Employee #9, director of nursing services (DNS), on 01/03/13, at approximately 2:00 p.m., they related Resident #73 had a history of [REDACTED]. They also stated the resident had a fall with an injury on 12/12/12. The DNS stated many of the resident's falls were due to attempts to obtain gum or candy from her over-the-bed table or bedside stand. Employee #159 said the resident was on fluid restrictions, which caused her to have a dry mouth. Both the DNS and the RN indicated the dry mouth increased the resident's desire for gum or candy. Employee #159 stated several interventions had been put into place. One of the interventions was a low over-the-bed table. She indicated the purpose was to ensure the gum and candy were within the resident's reach. The resident's medical record was reviewed on 01/04/13 at 12:00 p.m. The general progress note, dated 12/12/12 at 5:32 p.m., noted . notified at this time by cna that resident was lying at foot of bed with laceration noted to forehead . resident previously was sitting in wheelchair beside bed . send to ER for evaluation. The general progress note dated 12/13/12 at 2:37 p.m. included, . sutures intact, and the note dated 12/13/12 indicated the resident had a dressing to forehead. Review of the care plan, on 01/04/13 at 12:00 p.m., revealed there was no intervention related to fall prevention until 12/26/12. Review of the care plan, on 01/04/13 at 12:00 p.m., revealed the care plan related to fall prevention was not updated in a timely manner as follows: -Falls 06/02/12 and 06/10/12 - care plan revised on 07/03/12 -Falls 08/06/12, 08/13/12, 08/31/12, 09/18/12 - care plan revised on 09/18/12 -Falls 09/19/12 and 09/22/12 - care plan revised on 09/26/12 -Fall 10/28/12 - care plan revised on 11/29/12 -Fall 12/12/12 with injury - no care plan revision until 12/26/12	2016-01-01
9228	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2013-01-08	323	D	1	0	C0IF11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and resident comments, and staff interview, the facility failed to ensure one (2) of six (6) residents who had sustained past fractures were equipped with the assistance devices and accommodations necessary to prevent further accidents. Resident identifiers: #73 and #37. Facility census: 113. Findings include: a) Resident #37 The medical record review for Resident #37, conducted on 01/05/13 at 10:00 a.m., revealed this resident sustained [REDACTED]. She had fallen out of her wheelchair and hit her face and head. On 01/05/13 at 10:45 a.m., the director of nursing (DON), Employee #9, provided a copy of the resident's care plan which contained an intervention for her fall risk. The facility had developed a plan which included the use of a scoot chair when the resident was out of bed. An observation of Resident #37, on 01/05/13 at 11:30 a.m., revealed the resident sitting in a regular wheelchair in the dining room, eating lunch. She did not have a scoot chair. On 01/07/13 at 11:00 a.m., Resident #37 sat in the dining room participating in an activity. She sat in a wheelchair, not a scoot chair. On 01/07/13 at 11:15 a.m., the occupational therapy assistant (Employee #120) confirmed the resident was not sitting in a scoot chair. On 01/07/13 at 11:30 a.m., the licensed practical nurse (LPN), Employee #130, indicated the resident had used a scoot chair before, but did not know why she currently was not using one. She located the resident's scoot chair in a storage room. On 01/07/13 at 11:45 a.m., the director of care delivery (DCD) (Employee #121) indicated the facility had cleaned the resident's scoot chair last week. After the cleaning of the chair the resident was placed in a wheelchair instead of back in her scoot chair. On 01/08/13 at 12:00 p.m., a review of the cleaning schedule revealed scoot chairs were cleaned on Monday and Friday. b) Resident #73 Resident #73 was first observed on 01/03/13 at 11:00 a.m. She was lying on her right side, sleeping. She was wearing an immobilizer related to a fracture of the left humerus. Bruising was visible on her left upper arm and her left hand was edematous. Employee #60, a nursing assistant (NA), was seated next to the bed. She stated she was providing one-on-one supervision, because the resident had fallen. During an interview with Employee #159, registered nurse (RN), and Employee #9, director of nursing services (DNS), on 01/03/13, at approximately 2:00 p.m., they related Resident #73 had a history of [REDACTED]. They also stated the resident had a fall with an injury on 12/12/12. The DNS stated many of the resident's falls were due to attempts to obtain gum or candy from her over bed table or bedside stand. Employee #159 said the resident was on fluid restrictions, which caused her to have a dry mouth. Both the DNS and the RN indicated the dry mouth increased the resident's desire for gum or candy. Employee #159 stated several interventions had been put into effect. One of these was a low over-bed table. She indicated the purpose was to ensure the gum and candy were within the resident's reach to prevent accidents. The resident was receiving one-on-one observation. The DNS related this would not be continued. Resident #73 was again observed on 01/03/13 at 2:30 p.m. Employee #60, who was in the room with the resident, stated the resident chewed gum all the time. She said the resident would ask for her chew chew. She had two (2) containers with gum and candy on a regular height over-the-bed table. It was not within Resident #73's reach. There was a low over-the-bed table in the resident's room, but it was not being used as described by the DNS. On 01/04/13 at 10:00 a.m., Resident #73 was observed lying in bed. The resident said, Honey, can I have a drink? Employee #60 responded she could not give her a drink. Then Resident #73 said, Well, if I can't have a drink, then can I have a piece of candy? The resident's gum and candy were on the regular height over-the-bed table, which was out of the resident's reach. Review of the medical record, on 01/04/12 at 12:00 p.m., revealed Resident #73 had fallen on 12/24/12 while attempting to obtain gum and/or candy. The general progress note, dated 12/24/12 at 5:15 p.m., noted the resident was found sitting in floor . with drawer open digging in for candy and gum, when asked why she was in the floor she stated she needed another chew chew. The care plan was reviewed on 01/04/12 at 12:00 p.m. It indicated the resident was to have commonly used articles, such as gum and candy, within easy reach. In addition, the positioning of the storage containers were to be evaluated for easy access of gum and candy. Another observation, on 01/07/12 at 2:30 p.m., revealed Resident #73's gum and candy were on the regular over-the-bed table, and not on the low over-the-bed table. Employee #14, nursing assistant (NA), was interviewed on 01/08/13 at 9:07 a.m. She stated the resident had multiple interventions to prevent falls. She related these included one-on-one observation at all times, bed in the lowest position with bilateral landing strips, and a scoop mattress. She stated, We used to get her up for about an hour, if she was restless. She would sit near the nurses station. She added, She doesn't like to be up much. Employee #14 stated the resident liked her gum. She opened the containers and stated, These were full yesterday. Now they are almost empty. Interview with Employee #8, licensed practical nurse (LPN), on 01/08/12, confirmed the resident liked to chew gum. She related she would chew large amounts. On 01/08/12, Employee #159 acknowledged the low over-the-bed table was not placed where the resident could reach her gum and candy.	2016-01-01
9229	EASTBROOK CENTER LLC	515089	3819 CHESTERFIELD AVENUE	CHARLESTON	WV	25304	2013-01-08	511	D	1	0	C0IF11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and observation, the facility failed to promptly notify the attending physician of x-ray results for one (1) of eight (8) sample residents. The physician was not notified of x-ray results which indicated a dislocated left femoral prosthesis. Resident identifier: #49. Facility census: 114. Findings include: a) Resident # 49 During observation of Resident #49, on 01/03/13 at 12:00 p.m., he was in bed, lying on his back. His left leg was rotated inward. He did not respond to conversation. Another observation, on 01/04/13 at 9:30 a.m., revealed he was again on his back, with his left leg rotated inward. His family was present, and upon inquiry, stated he had broken his hip. Review of the medical record, on 01/04/13 at 11:00 a.m., revealed an x-ray was obtained on 06/15/12 related to constipation. The x-ray report was received by the facility at 9:22 p.m. on 06/15/12. Significant findings on the report included, The left femoral prosthesis appears to be dislocated .Impression 2) Dislocated left hip prosthesis. Further review of the medical record, on 01/07/13, revealed a note by the physician, dated 06/21/12, which stated, Sent to ER ,[DATE] for incidental finding of (L) left hip prosthesis dislocation on (abd) abdomen xray done for constipation a few days ago, just found out about this yesterday at 4 pm. This was five (5) days after the facility received the x-ray report. There was no evidence of notification of the physician prior to 06/20/12. Interview with Employee #86 (registered nurse), on 01/08/13 at 2:30 p.m., confirmed no evidence was available to indicate the physician was notified of the dislocated prosthesis between 06/15/12 and 06/20/12.	2016-01-01
9230	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	156	C	0	1	O68G11	Based on observation and staff interview, the facility failed to prominently displayed in the facility written information on how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Additionally, information posted regarding various agencies' names and addresses contained the wrong address for the State survey agency and the wrong name of the State long-term care ombudsman. This had the potential to affect all residents and visitors. Facility census: 31. Findings include: a) Observations of information posted throughout the unit during the survey revealed a typed notice which contained the names, addresses and telephone numbers of various agencies which the residents may need to contact. On this list, the State survey agency's street address and the name of the State long-term care ombudsman were incorrect. b) Observations also found no notices of any kind which provided information regarding how to apply for Medicaid / Medicare benefits, nor was there information about how to receive refunds for previous payments covered by those benefits. c) These issues were discussed with the social worker (Employee #77) at 1:50 p.m. on 06/ 7/11. She accompanied the surveyor to observe the notices, and she verified the above findings.	2016-01-01
9231	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	167	C	0	1	O68G11	Based on observations and staff interview, the facility had failed to post a notice of the availability of the most recent survey results. This has the potential to affect all residents and visitors. Facility census: 31. Findings include: a) Observations by the surveyor, on 06/07/11 at 10:30 a.m., did not find any survey results of the most recent survey available for review by residents and visitors. When staff at the nursing station was asked where the survey results were posted, they were unaware of the location as well. At 10:40 a.m. on 06/07/11, a registered nurse (Employee #26) informed the surveyor that the information was in a notebook on a bookcase in the activity / dining room area. Subsequent observation of this area found all types of books, such as reading novels, etc., on this bookcase for resident access, including the survey results. There was no signage posted to inform residents or visitors where this information could be located for review.	2016-01-01
9232	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	241	E	0	1	O68G11	Based on observation, review of resident diet slips, and staff interview, the facility failed to provide care to eight (8) of thirty-one (31) residents in a manner and an environment that maintained or enhanced dignity and respect for residents who required assistance with eating. Facility staff and the dietary department referred to these residents as feeders both verbally in the dining room during meal service and in writing on the residents' diet slips. Resident identifiers: #26, #35, #27, #24, #16, #23, #12, and #32. Facility census: 31. Findings include: a) Residents #26, #35, #27, #24, #16, #23, #12, and #32 During random observation of the evening meal service in the main dining room on 05/31/11 at approximately 6:00 p.m., facility staff was overheard referring to residents as feeders. Review of the diet slips left on the tables by the residents' plates noted the slips were labeled with the residents' names and identified them as feeders. During an interview with the nurse manager (Employee #8), on 06/01/11 at 2:15 p.m., she provided a list of all residents with dietary slips which identified them as feeders. She stated that steps had been initiated to correct this practice.	2016-01-01
9233	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	279	D	0	1	O68G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to develop a care plan with goals and approaches addressing anxiety for two (2) of nineteen (19) Stage II sampled residents with orders for anxiolytic medications. Resident identifiers: #33 and #20. Facility census: 31. Findings include: a) Resident #33 Review of the medical record found this female resident was admitted to the facility on [DATE] with orders for [MEDICATION NAME] 0.25 mg twice-a-day (BID) for anxiety. Review of the behavioral monitoring sheets noted staff was not monitoring for signs and symptoms of anxiety. Staff was monitoring for social withdrawal and [MEDICAL CONDITION]. Review of the current care plan found the facility had not developed goals or approaches related to assisting the resident to reach her highest practicable level of functioning related to experiencing anxiety. The care plan merely addressed the dosage, side effects, and dosage reduction attempts for the use of [MEDICATION NAME]. The minimum data set (MDS) coordinator (Employee #8), when interviewed on the afternoon of 06/01/11, was unable to provide any further evidence that the facility had developed an appropriate care plan related to anxiety for this resident. -- b) Resident #20 Review of the medical record found Resident #20 was prescribed and had received [MEDICATION NAME] 10 mg BID and [MEDICATION NAME] 1 mg BID for a [DIAGNOSES REDACTED]. Review of the care plan found no care plan had been developed related to this resident experiencing anxiety.	2016-01-01
9234	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	309	D	0	1	O68G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to assure one (1) of nineteen (19) Stage II sampled residents did not receive medications beyond the date the physician determined they should be discontinued. Resident identifier: #33. Facility census: 31. Findings include: a) Resident #33 1. Review of the medical record found a physician's progress note, dated 05/25/11, which documented the resident's potassium was mildly elevated and to stop K-Dur. Review of the Medication Administration Record [REDACTED]. An interview with the unit manager (Employee #8), on 06/07/11 at 2:00 p.m., revealed the physician had overlooked writing an order to stop the potassium for this resident. -- 2. Review of the medical record found the resident received [MEDICATION NAME] (antidepressant) 20 mg daily. A physician's orders [REDACTED]. Review of the MAR found nursing staff members gave the resident both the [MEDICATION NAME] 20 mg and the [MEDICATION NAME] 60 mg on 05/06/11.	2016-01-01
9235	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	329	D	0	1	O68G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and and staff interview, the facility failed to assure the drug regimen, for one (1) of nineteen (19) Stage II sampled residents, was free from unnecessary drugs. Resident #33 was prescribed [MEDICATION NAME] 0.25 mg twice-a-day (BID) without adequate indications for its use. Resident identifier: #33. Facility census: 31. Findings include: a) Resident #33 Review of the medical record found Resident #33 was admitted to the facility on [DATE] with orders for [MEDICATION NAME] 0.25 mg BID for anxiety. Review of the behavior monitoring sheets found facility staff was not monitoring for anxiety or signs and symptoms of anxious behaviors. The behavior monitoring sheets indicated staff was monitoring for social withdrawal and [MEDICAL CONDITION]. Review of the current care plan found no goals or interventions related to the resident experiencing anxiety. Review of the 04/22/11 social worker progress note found the following documentation: . She also stated she feels that she is depressed and has been for several years. The progress note did not address nor give evidence to reflect the resident was experiencing anxiety. A subsequent social worker progress note, written on 05/05/11, contained the following language: . She usually refuses to get out of bed and come out of her room. She did indicate she has symptoms of depression and she gave them a frequency of 2 - 6 days over the past two weeks. Her daughters indicate that she has been depressed for a long time and has not been active This note was also devoid of any evidence that the resident was experiencing anxiety. An interview with the social worker (Employee #77), on 06/07/11 at 12:20 p.m., revealed that Employee #77 visited the resident regularly to encourage her to leave her room and participate in facility life and activities. Employee #77 discussed the resident's depression but could offer no indications of the resident experiencing or demonstrating signs and symptoms of anxiety. The facility failed to provide a clinical rationale for the use of an anxiolytic for this resident.	2016-01-01
9236	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	332	D	0	1	O68G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, the facility's medication delivery window policy, and medical record review, the facility failed to ensure a medication error rate less than five percent (5%). Resident identifier: #1. Facility census: 31. Findings include: a) Resident #1 During observation of the facility's medication passes on 06/06/11 and 06/07/11, a licensed practical nurse (LPN - Employee #5) failed to administer Resident #1's medication in a timely manner. Resident #1 had an order for [REDACTED]. On 06/07/11 at 1:13 p.m., Employee #5 again administered Resident #1'[MEDICATION NAME] 24 after the prescribed time. When interviewed on 06/07/11 at 1:30 p.m., the unit manager (Employee #8) could offer no explanation for the error, but she provided a copy of the facility's medication delivery window policy. Review of the medication delivery window identified medications will be delivered to the resident within a window of one (1) hour prior to or one (1) hour after the assigned delivery time.	2016-01-01
9237	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	354	F	0	1	O68G11	Based on review of facility information, observation, and staff interview, the facility failed to designate a registered nurse (RN) to serve as of the director of nursing (DON) on a full time basis. This deficient practice had the potential to affect all thirty-one (31) residents currently residing in the facility. Facility census: 31. Findings include: a) Review of the entrance information, provided by the facility on 05/31/11, found that Employee #000 was identified as the DON. Observations made throughout this two-week survey noted this individual was not present on the unit. An interview was conducted with Employee #000 at 10:51 a.m. on 06/07/11. She stated she did not work on the long term care unit, nor did she direct the provision of nursing care for the residents residing there. She stated the unit manager provides her with monthly reports related to budgetary and administrative concerns.	2016-01-01
9238	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	371	F	0	1	O68G11	Based on observation and staff interview, the facility failed to store food items in a manner that maintained sanitary conditions. Containers of food times were not dated when opened, and one (1) freezer unit was not equipped with a thermometer to ensure foods were being stored at the correct temperature. This practice has the potential to affect all residents who consume food by oral means as all residents are served from this location. Facility census: 31. Findings include: a) During a tour of the nourishment kitchen for the skilled unit at 1:05 p.m. on 06/07/11 with the unit manager (Employee #8), the following sanitation issues were noted: a plastic container of honey thickened water and two (2) plastic containers of nectar thickened products (one (1) filled with water and one (1) filled with cranberry juice) were found opened but not labeled with a date when they were opened. A specific label for recording the open date was attached to one (1) container, but it was blank. b) During this same time period, observation found a freezer unit did not have an internal thermometer nor any temperature device on the outside of the equipment. This freezer was located in the nourishment area where food was served from that room directly to the dining room. c) These issues were found with Employee #8, who accompanied the surveyor at the time of observations.	2016-01-01
9239	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	425	D	0	1	O68G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medication administration records (MARs) and staff interview, the facility failed to assure medications ordered for residents were available for administration in a timely manner. Two (2) of nineteen (19) Stage II sampled residents did not receive their 5:00 a.m. medications. Resident identifiers: #1 and #12. Facility census: 31. Findings include: a) Resident #1 Review of the resident's MAR, on 06/07/11 at 10:30 a.m., found Resident #1 was ordered Sinemet 25/250 for a [DIAGNOSES REDACTED]. Review of the MAR indicated [REDACTED]. The medication had been circled, and on the reverse side of the MAR, the nurse documented: Sinemet not available. During an interview on 06/07/11 at 10:45 a.m., the unit manager (Employee #8) confirmed the Seroquel 25/250 was available via the hospital pharmacy. Employee #8 could offer no explanation why the medication was not obtained and given to Resident #1 as ordered. -- b) Resident #12 Review of the resident's MAR, on 06/07/11 at 10:30 a.m., found Resident #12 was ordered Seroquel 50 mg to be given twice a day. The morning dose was circled, and the nurse documented: Seroquel not given - not available. At 06/07/11 at 10:45 a.m., Employee #8 confirmed Seroquel was available via the hospital pharmacy. She further stated, The nurse would just need to request the medication from the hospital pharmacy, and it could be obtained.	2016-01-01
9240	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	428	D	0	1	O68G11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to assure the consultant pharmacist reported irregularities related to the drug regimen for one (1) of nineteen (19) facility residents. Residents #33 received an anxiolytic drug without adequate indications for its use, which was not identified by the pharmacist and reported to the attending physician and director of nursing (DON) as required. Resident identifier: #33. Facility census: 31. Findings include: a) Resident #33 Review of the medical record found this female resident was admitted to the facility on [DATE] with orders for Xanax 0.25 mg twice-a-day (BID). The record contained [DIAGNOSES REDACTED]. Review of the behavior monitoring sheets for April 2011 and May 2011 found the facility was monitoring the resident for social withdrawal and insomnia. The behavior monitoring sheets contained no evidence that nursing staff was monitoring for signs and symptoms of anxiety. An interview with the social services director (Employee #77), on 06/07/11 at 12:20 p.m., revealed Employee #77 was concerned that the resident did not come out of her room, she expressed no interest in out-of-room activities, and she exhibited no desire for conversation. Employee #77 stated the resident appeared very depressed. Employee #77 gave no examples of the resident displaying signs and/or symptoms of anxiety. The consultant pharmacist conducted a drug regimen review on 05/02/11 with documentation of .medications & labs reviewed. The drug regimen report contained no evidence the consultant pharmacist identified the absence of a clinical rationale for use of the Xanax to be communicated to the attending physician and DON.	2016-01-01
9241	ROANE GENERAL HOSPITAL, D/P	515099	200 HOSPITAL DRIVE	SPENCER	WV	25276	2011-06-08	431	F	0	1	O68G11	Based on observation and facility staff interview, the facility failed to store drugs in locked compartments which could be accessed only by authorized personnel. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 31. Findings include: a) An inspection of the facility's medication storage, conducted on the morning of 06/09/11, found the facility maintained an unlocked emergency drug box in an unlocked cabinet at the nursing station. The drug box was accessible to all employees, unsupervised residents, and/or visitors. An interview with the unit manager (Employee #8), at 9:30 a.m. on 06/08/11, elicited the facility kept a list of medications stored in the emergency drug box. Review of this list found the following potentially hazardous medications listed: Digoxin, Geodon, Haloperidol, Nitroglycerin, and Warfarin. -- b) Random observations, conducted on the afternoon of 06/07/11, noted a pharmacy employee and nurse stocking medications in the nursing station. The employees were removing medications from three (3) large blue duffel bags. Further observations, during the medication storage inspection conducted the following day on 06/08/11 at 9:30 a.m., noted three (3) large blue duffel bags stacked in the nursing station in clear view from the dining room and resident hallway. With the assistance of a licensed practical nurse (LPN - Employee #27), an inspection of the three (3) large blue duffel bags revealed the zippers of duffel bags were secured by the use of a luggage-type tab which was merely threaded through the rubber loops to hold the bags closed. This tab was easily removed. An inspection of the contents of all three (3) duffel bags found numerous medications intended for return to the pharmacy. Employee #27 confirmed the three (3) duffel bags containing medications had been present at the nursing station as of the afternoon of 06/07/11. The unit manager placed the duffel bags in her office until pick up by the pharmacy.	2016-01-01
9242	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	246	D	0	1	UNLT11	Based on resident interview, observation and staff interview, the facility failed to ensure a resident's right to receive services with reasonable accommodation of individual needs. One (1) of twelve (12) Stage II sample residents did not have access to her call bell when she needed to be assisted to the bathroom. Resident identifier: #121. Facility census: 61. Findings include: a) Resident #121 On 05/11/11 at 9:07 a.m., during a conversation with the resident, she said she needed to go to the bathroom. She was seated in her wheelchair approximately two and one-half (2 -1/2) feet to the right of her bed. Her call bell was on the floor under her bed. It was also noted the resident had a cast on her right lower arm. While retrieving the resident's call bell for her, this surveyor inadvertently set off the resident's bed alarm. A nursing assistant (Employee #53) responded to the sound of the alarm in approximately two (2) minutes; at that time, he was informed of the resident's request to be taken to the bathroom. After assisting the resident out of the bathroom, Employee #53 asked whether the resident had used her call bell. He said they had been working with her to use her call bell when she needed to go to the bathroom. It was explained to him the call bell had been under the bed and the resident had been unable to reach the call bell.	2016-01-01
9243	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	274	D	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to complete a significant change assessment when indicated. One (1) of twelve (12) Stage II sample residents had experienced declines and improvements during the three (3) months between her admission assessment and the following quarterly assessment. These changes had the potential to affect her care needs. A comprehensive assessment was needed to determine possible causal factors for the declines and to determine what interventions might be implemented to reverse, or prevent further, declines. Resident identifier: #90. Facility census: 61. Findings include: a) Resident #90 Review of the resident's admission assessment with an assessment reference date (ARD) of 12/22/10, and her quarterly assessment with an ARD of 03/22/11, found she had experienced declines and improvements in a number of areas. The following changes were noted: 1. Her ability to understand and to be understood declined from usually to sometimes. 2. The score on her Brief Interview of Mental Status (BIMS) score declined from 11 to 3 (with a maximum score of 15). 3. In the section for signs and symptoms of [MEDICAL CONDITION], she had been coded as having none on the admission assessment, while the quarterly assessment indicated she had inattention and disorganized thinking. 4. Her quarterly assessment was coded as her having problems sleeping and feeling tired or having low energy, which had not been present on the admission assessment. 5. She did not have problems concentrating according to her admission assessment. Her quarterly assessment indicated she had problems in this area nearly every day. 6. Her admission assessment indicated she did not have physical behaviors or reject care, but the quarterly assessment indicated both of these were present one (1) to three (3) days a week. 7. She had wandered one (1) to three (3) days according to the admission assessment, but the quarterly assessment indicated she no longer wandered. 8. The admission assessment indicated she had required limited assistance with eating. The quarterly assessment indicated she needed extensive assistance. 9. For functional range of motion of the upper extremities, she was coded as having no limitations on the admission assessment, but on the quarterly assessment she was coded as having impairment on both sides. 10. Her admission assessment indicated she was frequently incontinent of urine. The quarterly assessment was coded as always incontinent. 11. She declined from being always continent of bowel on her admission assessment to being frequently incontinent on her quarterly assessment. 12. She had also had a progressive weight loss. In an interview with Employee #52 (an registered nurse assessment coordinator) at approximately 2:30 p.m. on 05/18/11, the resident's progressive weight loss, decreased use of upper extremities, decrease in BIMS score, disorganized thinking, eating abilities decline from limited to extensive assistance in eating, decline in urinary continence from frequent to always incontinent, decline in bowel continence, etc., were discussed. She showed this surveyor what the software had identified as changes. After discussing the changes this resident had experienced according to comparison of the assessments, she agreed a significant change assessment should have been completed.	2016-01-01
9244	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	279	D	0	1	UNLT11	Based on medical record review, staff interview, and observation, the facility failed to develop care plans for two (2) of twelve (12) Stage II sampled residents to address care and services required to meet each resident's medical and nursing needs. Resident identifiers: #90 and #121. Facility census: 61. Findings include: a) Resident #90 Review of the resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/22/10, and her quarterly assessment with an ARD of 03/22/11, found she had experienced declines in continence. Her admission assessment indicated she was frequently incontinent of urine. The quarterly assessment was coded as always incontinent. She was also assessed as having declined from being always continent of bowel on her admission assessment to being frequently incontinent on her quarterly assessment. No care plan had been developed to address the declines in bowel and bladder continence in an attempt to restore her to prior levels of continence or to prevent further decline in these areas. -- c) Resident #121 Review of this resident's care plan found it was identified the resident had a cast on her right arm. However, it was not identified the resident's right side was her dominant side. The care plan did not identify what accommodations / adaptations needed to be implemented to assist the resident in maintaining as much independence as possible. For example, her call bell was on the floor to her right on 05/11/11. If the call bell had been on the bed, it still would have been difficult for the resident to access with her right hand. At lunch time on 05/18/11, observation found the cast on her right arm had been replaced with a splint. She continued to eat with her left hand. She was able to eat, but an adaptive device (such as a scoop plate, a plate guard, or a plate with a raised edge) would have been of benefit in making it easier for her to get food on her fork.	2016-01-01
9245	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	280	D	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, record review, and staff interview, the facility failed to review / revise the care plans of two (2) of twelve (12) Stage II sample residents when changes were indicated in their care and treatment. Resident identifiers: #14 and #30. Facility census: 61. Findings include: a) Resident #14 While standing in the corridor outside of Resident #14's room on 05/11/11 at 9:15 a.m., this nurse surveyor observed Resident #14 in his bed slumped toward the right with his head on the siderail. After entering his room, observation found an overbed table placed across his abdominal area with his breakfast tray on top. His head, right arm, and right shoulder were pressed against the siderail of his bed, two (2) pillows were noted on the left side of the resident, and the call bell was wedged under his right side between the air mattress and siderail. The resident had a lift pad beneath him, which did not offer resistance to sliding when in contact with the surface of the air mattress. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. A nursing assistant (NA - Employee #70) responded to a request for assistance. She assisted the resident to move away from the siderail and retrieved the call bell from between the siderail and the air mattress. After repositioning Resident #14, Employee #70 brushed back his hair with her hand, revealing a rectangular reddened area in the shape of the top of the siderail above the resident's right ear. When asked, Employee #70 stated she would report this reddened area to his nurse. She stated the resident chokes easily but had refused to get up that morning. -- An interview with the licensed practical nurse (LPN) responsible for the resident (Employee #27) was conducted at 9:22 a.m. on 05/11/11. She stated the resident had choked earlier, and she and another NA had assisted him to reposition in the bed. She stated she stayed with him until the resident cleared his throat, and then she left to continue her medication pass. Review of information collected by the facility on 05/11/11 found that Employee #1 was identified as the NA who assisted Employee #27 that morning. Review of the facility's documentation found the NA had delivered the resident's breakfast tray to his room at approximately 8:30 a.m. on 05/11/11. The NA returned to the resident's room approximately five (5) minutes later after hearing the resident cough. The resident was leaning to the left, so she pulled him to the middle of the bed and got Employee #27 to assist. -- Record review revealed the following nursing note, entered two (2) hours after Resident #14's second choking episode by a corporate nurse consultant at 11:30 a.m. on 05/11/11 (quoted as typed), Resident was assessed following a choking episode during morning meal. No signs of distress. No reddened area to (r) side of head as indicated by the surveyor observation. -- Record review revealed this [AGE] year old male was most recently readmitted from the hospital to the facility on [DATE] where he had been treated for [REDACTED]. His active [DIAGNOSES REDACTED]. Review of Resident #14's most recent assessment, a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/06/11, found in Section G that he required the extensive physical assistance of two (2) or more persons for bed mobility, was totally dependent on two (2) or more persons for transferring, required the extensive physical assistance of one (1) person with eating, required human assistance to stabilize when transferring between surfaces, and had impaired functional limitation in range of motion of his upper extremity on one (1) side. Review of Section K found the resident displayed coughing or choking during meals or when swallowing medications. Review of his previous two (2) MDSs, a Medicare 5-Day MDS with an ARD of 03/21/11 and a Medicare 14-Day MDS with an ARD of 03/26/11, revealed in Section G that he required the extensive physical assistance of two (2) or more persons for bed mobility, was totally dependent on two (2) or more persons for transferring, required the extensive physical assistance of one (1) person with eating, required human assistance to stabilize when transferring between surfaces and when moving on and off the toilet, and had impaired functional limitation in range of motion of his upper and lower extremities on one (1) side. Review of Section K found the resident displayed coughing or choking during meals or when swallowing medications. -- Review of Page 3 of 24 of the current care plan found the following problem statement (Date Initiated: 11/12/10; Revision on: 04/13/11) (quoted as typed): restorative program for up in w/c (wheelchair) for all meals per program plan. The goal associated with this problem statement was (quoted as typed): Follow OOB (out of bed) schedule to be up in w/c for meals. The interventions developed to assist the resident in achieving this goal were (quoted as typed): Assist patient in sitting upright in w/c for all meals. Explain task to resident prior to activity. Provide supervision with meals. Review of Page 16 of 24 of the current care plan found the following problem statement (Date Initiated: 08/16/08; Revision on: 04/13/11) (quoted as typed): Resident has impaired swallowing due to dysphagia and is edentulous - Resident is at risk for aspiration, chokes easily. The goal associated with this problem statement was (quoted as typed): The resident will be free from signs and symptoms of possible aspiration thru next review. The interventions developed to assist the resident in achieving this goal were (quoted as typed): Honor food preferences within meal plan. Provide diet as ordered (family aware of choking,waiver was signed). Provide thickened consistency liquids as ordered. Place resident in 90 (symbol for 'degree') upright position / out of bed when swallowing food or drink. Encourage resident to take small sips / bites. Observe for signs / symptoms of aspiration. Place call light within reach at all times. Supervise / cue / assist as needed with meals. Elsewhere in the care plan, the following interventions were found in association with other problem statements: - On Page 2 of 24 - Observer (sic) resident safety, his diet and watch for choking. - On Page 5 of 24 - Provide supervision with meals after set up. Assist as needed. The care plan did not address how staff was to ensure Resident #14 maintained an upright position at 90 degrees while consuming food / fluids in bed, nor did it provide guidance as to how much supervision to provide the resident when consuming food / fluids. -- An interview was conducted on 05/11/11 at 10:10 a.m. with the registered nurse (RN - Employee #43) who authored the care plan. She stated the resident was in the restorative program to be up in his wheelchair for all meals so he could be supervised while eating. She conveyed that the resident refused to get up / out of bed for meals at times. When asked if a care plan had been developed to assure the resident's safety while eating in bed, she stated that no such plan had been developed. -- An interview with the individual identified by the facility as the occupational therapist (OT - Employee #91) was conducted at 10:48 a.m. on 05/11/11. Employee #91 stated the resident was really a high aspiration risk and the plan was for him to be supervised in the dining room for all his meals. -- Review of the 04/27/11 care plan meeting note written at 1:52 p.m. found the following: .The resident continues to be very high risk for aspiration. At times, he refuses to get out of bed for meals. He expresses understanding of the importance of getting out of bed for meals, and he understands how he needs to be up to reduce the risk for aspiration. He still refuses at times to get up. He is to be supervised with eating / drinking. Review of the physician determination of capacity form in the medical record found that the attending physician determined, on 02/21/11, that Resident #14 lacked sufficient mental or physical capacity to appreciate the nature and implications of health care decisions. -- Further review of the medical record found an evaluation by the speech language pathologist (SLP) for the treatment period from 12/28/10 through 01/26/11. The SLP identified [DIAGNOSES REDACTED]. Her assessment found the resident demonstrated impairment in the following areas: dry swallow, reflexive cough, reflexive throat clear, volitional throat clear, volitional cough, and gag reflex. The assessment recommended distant supervision during consumption of food / fluids for safety. Additionally, a progress note recorded by a SLP on 12/31/10 stated (quoted as typed): . Swallowing Therapy ( ) to assess and modify positioning to enhance swallow function including repositioning the patient in bed, with head of bed elevation and pillow positioning under right sid eof body to increase ability to sustain midline position. (Note: The SLP who recorded this progress note was not the same SLP who also served as the therapy program manager.) -- An interview was conducted with the therapy program manager / SLP (Employee #85) at 9:10 a.m. on 05/12/11, in the presence of two (2) other nurse surveyors. She stated Resident #14 was a chronic aspirator, his aspiration was significant, and he can aspirate on his own saliva. She stated the resident has a very large, weak tongue which affects his swallowing, and it was a significant danger to him to consume an oral diet, but the family refused PEG tube placement. She stated she tried to make the best out of a really difficult situation. She recommended safe swallowing strategies and education for the NAs. She stated occupational therapy (OT) had a long-standing restorative program to encourage him to get up for meals. He frequently refused meals and frequently refused to get up out of bed for meals. She stated she tried to make the best out of a really difficult situation. She relayed that, when taking staffing concerns into consideration, she recommended he be sitting upright at 90 degrees with distant supervision. When asked what her recommendation would have been if she did not have to take staffing levels into consideration, she stated she would have recommended he be kept under close supervision which would have required him to be within eyesight of staff members at all times while consuming an oral diet or liquids. When asked, she stated that evidence of choking included obvious signs of distress during eating, such as coughing. -- Review of witness statements from staff, obtained by the facility after Resident #14's second choking incident on the morning of 05/11/11, found the following: Statement from Employee #1, obtained during a telephone interview conducted by the director of nursing (DON) at 3:45 p.m. on 05/11/11 and signed by the employee on 05/12/11 (quoted as written): . (Employee #1) stated at about 8:30 a.m., she went in and set up residents tray for him. She asked him if that was OK and he said yes. States his call light was in his lap when she left. Approximately 5 minutes later she heard him cough & went back in to check on him. He was leaning to the left so she pulled him to the middle of the bed. She then got the nurse (Employee #27), LPN to help pull him up higher in the bed & put a pillow behind his head. H.O.B. (head of bed) was adjusted as high as it would go. Asked him again if he was OK and he nodded yes. His call light was in his reach when she left. She was unaware resident should have constant supervision. Statement written by Employee #27, signed and dated on 05/11/11 (quoted as written): In hallway passing meds when CNA (certified nursing assistant) called for assist to pull resident further up in bed. BKF (breakfast) tray was on bedside table - resident was eating prior to entering room, coughing episode was in progress when I entered the room. CNA & I pulled resident to head of bed placed a pillow behind his back to sit him more forward to eat. Resident was able to clear his throat on his own while CNA & I were in the room. When resident was OK, CNA pulled BKF tray to resident. I asked resident 'Are you OK' resident nodded his head yes. CNA & myself left the room. I returned to hallway to do med pass, did not hear resident cough while on 300 hall. Call light within reach. Based on the above statements, there was no evidence Employees #1 and #27 were aware of the need to place pillows under the resident's right side to assist the resident in maintaining a midline position when sitting upright in bed. -- Staff was aware that Resident #14 was at high risk for choking / aspirating food and fluids and that he would frequently refuse to get out of bed and sit in an upright position in a wheelchair for meals. The interdisciplinary team failed to develop interventions for staff to follow when Resident #14 refused to get out of bed for meals (to eliminate safety hazards over which the facility had control to prevent choking while the resident consumed food / fluids in bed), to include the application of pillow positioning under the right side to increase the resident's ability to sustain a midline position when sitting upright in bed. -- b) Resident #30 Review of Resident #30's medical record found the current care plan with a target date of 06/05/11 instructed staff members to utilize a gait belt and the assistance of two (2) staff members for transfers. Further review found a lift-transfer-repositioning evaluation, completed on 04/15/11, which assessed the resident as requiring a total mechanical lift for transfers. In an interview with the registered nurse (Employee #83) on 05/19/11 at 11:47 a.m., when shown the care plan and the transfer assessment, she agreed the care plan should have been revised to reflect the change in transfer status for the resident.	2016-01-01
9246	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	309	E	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and review of the facility's bowel protocol, the facility failed to institute the bowel protocol for five (5) of ten (10) residents experiencing constipation. Review of the residents' activities of daily living (ADL) flow sheets, medication administration records (MARs), and the facility's standing orders revealed these residents experienced constipation for more than three (3) days before the facility intervened. Resident identifiers: #44, #12, #54, #90, and #27. Facility census: 61. Findings include: a) Residents #44, #12, #54, #90, and #27 1. Resident #44 Review of the resident's April 2011 MAR, on 05/17/11, revealed Resident #44 had no bowel movement (BM) for four (4) days, for which the facility failed to initiate the bowel protocol. On 04/06/11, Resident #44 was given a [MEDICATION NAME] suppository after not having a bowel movement for four (4) days. On 04/07/11, Resident #44 was given a fleets enema. Further review of the MAR found, on 04/20/11 Resident #44, was again given a [MEDICATION NAME] rectal suppository for no bowel movement after four (4) days. According to the bowel protocol (which is described below), staff should have administered a 30 cc dose of milk of magnesia (MOM) for a resident who had no BM after three (3) days. -- 2. Resident #12 Review, on 05/17/11, of Resident #12's April 2011 ADL flow sheet identified this resident had no BM from 04/03/11 through 04/06/11 (four (4) days). On 04/06/11, a [MEDICATION NAME] rectal suppository was given. Further review revealed Resident #12 also went from 04/15/11 through 04/20/11 without a BM. The MAR indicated [REDACTED]. According to the May 2011 ADL flow sheet, on 05/12/11, Resident #12 did not have a BM from 05/12/11 through 05/15/11 (four (4) days). A dose of MOM was given on 05/15/11. -- 3. Resident #54 Review, on 05/17/11, of Resident #54's April 2011 ADL flow sheet revealed this resident had no BM for eight (8) days, from 04/10/11 through 04/17/11. According to the April 2011 MAR, nothing was given to treat this constipation as per the facility's standing orders. -- 4. Resident #90 Review, on 05/17/11, of Resident #90's May 2011 ADL flow sheet identified the resident had no BM from 05/05/11 through 05/08/11, and no BM from 05/12/11 through 05/15/11. On 05/15/11, the MAR indicated [REDACTED]. -- 5. Resident #27 Review, on 05/17/11, of Resident #27's April 2011 ADL flow sheet identified the resident had no BM from 04/17/11 through 04/23/11. The resident's April 2011 MAR found no evidence the facility's bowel protocol was initiated for Resident #27. The resident's May 2011 ADL flow sheet revealed the resident had no BM from 05/09/11 through 05/14/11 (six (6) days). Review of the May 2011 MAR found a dose of MOM was given on 05/15/11 (after Day 6). -- b) On 05/17/11 at 2:50 p.m., the director of nursing (DON - employee #40) confirmed the bowel protocol had not been started for these residents. She further stated, We identified that we had a problem in March and the standing orders were changed on 03/31/11. -- c) Review of the facility's new standing orders, dated 03/31/11, revealed the following instructions (quoted as typed): - If no BM (bowel movement) on day 3, give MOM (milk of magnesia) 30 ml PO (by mouth) x 1 dose in AM - If no BM within next shift, give [MEDICATION NAME] suppository PR (per rectum) x 1 - If no BM by nest day Fleets enema - If no results from Fleets enema, call physician for further order Review of the facility's new standing orders identified the only change made to the previous protocol was related to giving the Fleets enema.	2016-01-01
9247	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	323	J	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident interview, medical record review, and staff interview, the facility failed to assure that one (1) of twelve (12) Stage II sample residents received the necessary supervision and positioning to prevent choking / aspiration during oral consumption. Resident #14, a [AGE] year old male with [DIAGNOSES REDACTED]. The resident was discovered slumped sideways in his bed at 9:15 a.m. on 05/11/11, with his breakfast tray on an overbed table above his abdomen. His head, right arm, and right shoulder were pressed against the siderail of his bed, with the call bell wedged under his right side between the mattress and siderail. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. Interviews with staff members revealed the resident had experienced an episode of choking earlier the same morning, with staff intervening and repositioning him in the bed. The resident was left unsupervised to continue to eat until discovered by this nurse surveyor. review of the resident's medical record revealed [REDACTED]. Staff was aware he would frequently refuse to get out of bed for meals, and he was evaluated by a speech language pathologist (SLP) to see what could be done to promote safe eating and drinking while in bed. A recommendation was made to have him sitting in an upright position in bed with pillow positioning under his right side to assist him in maintaining this upright position, but this recommendation was not incorporated into the resident's care plan. In fact, his care plan was not revised at all to address his frequent refusals to get out of bed for meals. With regard to the amount of supervision Resident #14 was to receive during meals, the SLP's recommendation for distant supervision was made based on the need to consider the availability of nursing staff. When asked what kind of supervision the SLP would have recommended if nursing staffing was not a consideration, the SLP stated she would have recommended Resident #14 be kept under close supervision which would have required him to be within eyesight of staff members at all times while consuming an oral diet or liquids. The administrator was informed at 10:45 a.m. on 05/11/11 that failing to provide for appropriate positioning and necessary supervision when the resident was eating in bed placed Resident #14 in immediate jeopardy of harm or death from choking / aspiration. The immediate jeopardy was removed at 12:20 p.m. on 05/11/11, following an assessment of the resident's condition and implementation of a plan to assure appropriate positioning and supervision during consumption of food or fluids by Resident #14. There was no deficient practice identified following the implementation of the facility's interventions to assure resident safety during oral consumption. Resident identifier: #14. Facility census: 61. Findings include: a) Resident #14 While standing in the corridor outside of Resident #14's room on 05/11/11 at 9:15 a.m., this nurse surveyor observed Resident #14 in his bed slumped toward the right with his head on the siderail. After entering his room, observation found an overbed table placed across his abdominal area with his breakfast tray on top. His head, right arm, and right shoulder were pressed against the siderail of his bed, two (2) pillows were noted on the left side of the resident, and the call bell was wedged under his right side between the air mattress and siderail. The resident had a lift pad beneath him, which did not offer resistance to sliding when in contact with the surface of the air mattress. The resident was noted to have partially masticated eggs on his chin and on the front of his shirt. He complained of having choked on his eggs. The resident was unable to reposition himself away from the siderail when cued. A nursing assistant (NA - Employee #70) responded to a request for assistance. She assisted the resident to move away from the siderail and retrieved the call bell from between the siderail and the air mattress. After repositioning Resident #14, Employee #70 brushed back his hair with her hand, revealing a rectangular reddened area in the shape of the top of the siderail above the resident's right ear. When asked, Employee #70 stated she would report this reddened area to his nurse. She stated the resident chokes easily but had refused to get up that morning. -- An interview with the licensed practical nurse (LPN) responsible for the resident (Employee #27) was conducted at 9:22 a.m. on 05/11/11. She stated the resident had choked earlier, and she and another NA had assisted him to reposition in the bed. She stated she stayed with him until the resident cleared his throat, and then she left to continue her medication pass. Review of information collected by the facility on 05/11/11 found that Employee #1 was identified as the NA who assisted Employee #27 that morning. Review of the facility's documentation found the NA had delivered the resident's breakfast tray to his room at approximately 8:30 a.m. on 05/11/11. The NA returned to the resident's room approximately five (5) minutes later after hearing the resident cough. The resident was leaning to the left, so she pulled him to the middle of the bed and got Employee #27 to assist. -- Record review revealed the following nursing note, entered two (2) hours after Resident #14's second choking episode by a corporate nurse consultant at 11:30 a.m. on 05/11/11 (quoted as typed), Resident was assessed following a choking episode during morning meal. No signs of distress. No reddened area to (r) side of head as indicated by the surveyor observation. -- Record review revealed this [AGE] year old male was most recently readmitted from the hospital to the facility on [DATE] where he had been treated for [REDACTED]. His active [DIAGNOSES REDACTED]. Review of Resident #14's most recent assessment, a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/06/11, found in Section G that he required the extensive physical assistance of two (2) or more persons for bed mobility, was totally dependent on two (2) or more persons for transferring, required the extensive physical assistance of one (1) person with eating, required human assistance to stabilize when transferring between surfaces, and had impaired functional limitation in range of motion of his upper extremity on one (1) side. Review of Section K found the resident displayed coughing or choking during meals or when swallowing medications. Review of his previous two (2) MDSs, a Medicare 5-Day MDS with an ARD of 03/21/11 and a Medicare 14-Day MDS with an ARD of 03/26/11, revealed in Section G that he required the extensive physical assistance of two (2) or more persons for bed mobility, was totally dependent on two (2) or more persons for transferring, required the extensive physical assistance of one (1) person with eating, required human assistance to stabilize when transferring between surfaces and when moving on and off the toilet, and had impaired functional limitation in range of motion of his upper and lower extremities on one (1) side. Review of Section K found the resident displayed coughing or choking during meals or when swallowing medications. -- Review of Page 3 of 24 of the current care plan found the following problem statement (Date Initiated: 11/12/10; Revision on: 04/13/11) (quoted as typed): restorative program for up in w/c (wheelchair) for all meals per program plan. The goal associated with this problem statement was (quoted as typed): Follow OOB (out of bed) schedule to be up in w/c for meals. The interventions developed to assist the resident in achieving this goal were (quoted as typed): Assist patient in sitting upright in w/c for all meals. Explain task to resident prior to activity. Provide supervision with meals. Review of Page 16 of 24 of the current care plan found the following problem statement (Date Initiated: 08/16/08; Revision on: 04/13/11) (quoted as typed): Resident has impaired swallowing due to dysphagia and is edentulous - Resident is at risk for aspiration, chokes easily. The goal associated with this problem statement was (quoted as typed): The resident will be free from signs and symptoms of possible aspiration thru next review. The interventions developed to assist the resident in achieving this goal were (quoted as typed): Honor food preferences within meal plan. Provide diet as ordered (family aware of choking,waiver was signed). Provide thickened consistency liquids as ordered. Place resident in 90 (symbol for 'degree') upright position / out of bed when swallowing food or drink. Encourage resident to take small sips / bites. Observe for signs / symptoms of aspiration. Place call light within reach at all times. Supervise / cue / assist as needed with meals. Elsewhere in the care plan, the following interventions were found in association with other problem statements: - On Page 2 of 24 - Observer (sic) resident safety, his diet and watch for choking. - On Page 5 of 24 - Provide supervision with meals after set up. Assist as needed. The care plan did not address how staff was to ensure Resident #14 maintained an upright position at 90 degrees while consuming food / fluids in bed, nor did it provide guidance as to how much supervision to provide the resident when consuming food / fluids. -- An interview was conducted on 05/11/11 at 10:10 a.m. with the registered nurse (RN - Employee #43) who authored the care plan. She stated the resident was in the restorative program to be up in his wheelchair for all meals so he could be supervised while eating. She conveyed that the resident refused to get up / out of bed for meals at times. When asked if a care plan had been developed to assure the resident's safety while eating in bed, she stated that no such plan had been developed. -- An interview with the individual identified by the facility as the occupational therapist (OT - Employee #91) was conducted at 10:48 a.m. on 05/11/11. Employee #91 stated the resident was really a high aspiration risk and the plan was for him to be supervised in the dining room for all his meals. -- Review of the 04/27/11 care plan meeting note written at 1:52 p.m. found the following: .The resident continues to be very high risk for aspiration. At times, he refuses to get out of bed for meals. He expresses understanding of the importance of getting out of bed for meals, and he understands how he needs to be up to reduce the risk for aspiration. He still refuses at times to get up. He is to be supervised with eating / drinking. Review of the physician determination of capacity form in the medical record found that the attending physician determined, on 02/21/11, that Resident #14 lacked sufficient mental or physical capacity to appreciate the nature and implications of health care decisions. -- Further review of the medical record found an evaluation by the speech language pathologist (SLP) for the treatment period from 12/28/10 through 01/26/11. The SLP identified [DIAGNOSES REDACTED]. Her assessment found the resident demonstrated impairment in the following areas: dry swallow, reflexive cough, reflexive throat clear, volitional throat clear, volitional cough, and gag reflex. The assessment recommended distant supervision during consumption of food / fluids for safety. Additionally, a progress note recorded by a SLP on 12/31/10 stated (quoted as typed): . Swallowing Therapy ( ) to assess and modify positioning to enhance swallow function including repositioning the patient in bed, with head of bed elevation and pillow positioning under right sid eof body to increase ability to sustain midline position. (Note: The SLP who recorded this progress note was not the same SLP who also served as the therapy program manager.) -- An interview was conducted with the therapy program manager / SLP (Employee #85) at 9:10 a.m. on 05/12/11, in the presence of two (2) other nurse surveyors. She stated Resident #14 was a chronic aspirator, his aspiration was significant, and he can aspirate on his own saliva. She stated the resident has a very large, weak tongue which affects his swallowing, and it was a significant danger to him to consume an oral diet, but the family refused PEG tube placement. She stated she tried to make the best out of a really difficult situation. She recommended safe swallowing strategies and education for the NAs. She stated occupational therapy (OT) had a long-standing restorative program to encourage him to get up for meals. He frequently refused meals and frequently refused to get up out of bed for meals. She stated she tried to make the best out of a really difficult situation. She relayed that, when taking staffing concerns into consideration, she recommended he be sitting upright at 90 degrees with distant supervision. When asked what her recommendation would have been if she did not have to take staffing levels into consideration, she stated she would have recommended he be kept under close supervision which would have required him to be within eyesight of staff members at all times while consuming an oral diet or liquids. When asked, she stated that evidence of choking included obvious signs of distress during eating, such as coughing. -- Review of witness statements from staff, obtained by the facility after Resident #14's second choking incident on the morning of 05/11/11, found the following: Statement from Employee #1, obtained during a telephone interview conducted by the director of nursing (DON) at 3:45 p.m. on 05/11/11 and signed by the employee on 05/12/11 (quoted as written): . (Employee #1) stated at about 8:30 a.m., she went in and set up residents tray for him. She asked him if that was OK and he said yes. States his call light was in his lap when she left. Approximately 5 minutes later she heard him cough & went back in to check on him. He was leaning to the left so she pulled him to the middle of the bed. She then got the nurse (Employee #27), LPN to help pull him up higher in the bed & put a pillow behind his head. H.O.B. (head of bed) was adjusted as high as it would go. Asked him again if he was OK and he nodded yes. His call light was in his reach when she left. She was unaware resident should have constant supervision. Statement written by Employee #27, signed and dated on 05/11/11 (quoted as written): In hallway passing meds when CNA (certified nursing assistant) called for assist to pull resident further up in bed. BKF (breakfast) tray was on bedside table - resident was eating prior to entering room, coughing episode was in progress when I entered the room. CNA & I pulled resident to head of bed placed a pillow behind his back to sit him more forward to eat. Resident was able to clear his throat on his own while CNA & I were in the room. When resident was OK, CNA pulled BKF tray to resident. I asked resident 'Are you OK' resident nodded his head yes. CNA & myself left the room. I returned to hallway to do med pass, did not hear resident cough while on 300 hall. Call light within reach. Based on the above statements, there was no evidence Employees #1 and #27 were aware of the need to place pillows under the resident's right side to assist the resident in maintaining a midline position when sitting upright in bed. -- Staff was aware that Resident #14 was at high risk for choking / aspirating food and fluids and that he would frequently refuse to get out of bed and sit in an upright position in a wheelchair for meals. The interdisciplinary team failed to develop interventions for staff to follow when Resident #14 refused to get out of bed for meals (to eliminate safety hazards over which the facility had control to prevent choking while the resident consumed food / fluids in bed), to include the application of pillow positioning under the right side to increase the resident's ability to sustain a midline position when sitting upright in bed. Staff left Resident #14 unsupervised following an episode of the resident sliding in the bed and choking / coughing during his morning meal. The failure to assure the resident remained in an upright position with staff supervision during the remainder of the morning meal on 05/11/11 placed this resident at risk of harm or death from aspiration.	2016-01-01
9248	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	328	D	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and pulse oximeter reading, the facility failed to assure one (1) of twelve (12) Stage II sampled residents received continuous oxygen as ordered by the attending physician. Resident identifier: #30. Facility census: 61. Findings include: a) Resident #30 During random observations of the resident environment on 05/19/11 at 10:15 a.m., Resident #30 was seated in her wheelchair in the middle of the 100 hallway. The resident was noted to have her head tilted back and appeared to be sleeping. Closer observation found the resident displayed an indentation extending from her nares, across her cheek, to her right ear. This type of mark is frequently observed with residents who utilize oxygen via a nasal cannula. No oxygen tank was observed on the back of her wheelchair, nor was any oxygen tubing observed. Review of the resident's medical record found the attending physician ordered the resident to receive oxygen at a rate of 2 liters / minute via nasal cannula continuously for a [DIAGNOSES REDACTED]. This active order was dated 09/13/10. A request was made of the director of nursing (DON - Employee #40 to check the resident's oxygen saturation at 10:18 a.m. on 05/19/11. The DON then asked a licensed practical nurse (LPN - Employee #67) to check the resident's oxygen saturation. Employee #67 obtained a pulse oximeter and checked the resident's oxygen level while the resident was in the dining room. The initial reading on the pulse oximeter was 89%. As the resident was stimulated with conversation, her reading increased to 92%.	2016-01-01
9249	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	360	E	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, the facility failed to assure seven (7) of sixty (60) residents receiving an oral diet containing an adequate amount of protein for the evening meal; the dietary staff failed to prepare pureed turkey in a manner to assure residents on a pureed diet received 2 ounces of turkey as required by the planned menu. Additionally, the facility failed to assure one (1) of twelve (12) Stage II sample residents was provided the ordered amount of nutritional supplement. Resident identifiers: #29, #44, #46, #55, #63, #66, #83, #90, and #7. Facility census: 61. Findings include: a) Residents #29, #44, #46, #55, #63, #66, #83, and #90 During observations of the evening meal service on 05/16/11, the cook (Employee #61) was observed portioning pureed turkey with a 2 ounce scoop. Review of the menu found residents were to receive a turkey sandwich for dinner. Employee #61 was not observed to serve pureed bread with the pureed diets. When asked why residents did not receive pureed bread, Employee #61 stated he had pureed the turkey and bread together. The dietary manager (Employee #5) was asked, at 4:50 p.m., how much protein residents on pureed diets were to receive. She stated the residents on pureed diets were to receive 2 ounces of pureed turkey. When asked how Employee #61 was providing 2 ounces of turkey when he had pureed turkey and bread together and was utilizing a 2 ounce scoop to serve the combined food items, she agreed the residents were not receiving 2 ounces of turkey and gave Employee #61 a 3 ounce scoop to utilize for service of the pureed turkey / bread mixture to residents on a pureed diet. -- b) Resident #7 During morning medication pass on 05/17/11, the nurse said the resident was to receive 4 ounces of Hi-Cal (a nutritional supplement) as she poured the liquid into a small plastic cup. She poured up to the lowest decorative line on the cup. The same type of cup used during the medication pass was later compared to a graduated medication cup, revealing the resident had only received 1 ounce of the supplement. Four (4) ounces filled the cup used by the nurse. According to the physician's orders [REDACTED].	2016-01-01
9250	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	371	F	0	1	UNLT11	Based on observation and staff interview, the facility failed to assure dietary personnel prepared and distributed food in a sanitary manner. This deficient practice had the potential to affect sixty (60) of sixty-one (61) residents who consumed an oral diet. Facility census: 61. Findings include: a) During the evening meal service on 05/16/11 at 4:20 p.m., observation found a small food bar set-up in the resident dining room. Residents and staff referred to this arrangement as the cafe. Staff members obtained individual plates of food and bowls of soup from the cook for delivery to the residents seated in the dining room. This created a restaurant-like atmosphere. Observation further noted that dietary slips were arranged on a table in front of the food bar. Numerous staff members in the dining room handled the dietary slips with their bare hands. During the service, staff members handed the cook the dietary slips, who would place them on top of the eating surface of a clean plate. The cook would then place food on these contaminated plates for service to the residents in the dining room. Prior to beginning the food service, the cook was observed at 4:20 p.m. on 05/16/11 to enter the cafe area from the resident hallway. Without washing his hands, the cook donned gloves in preparation to begin assembling turkey sandwiches. When asked where he had come from, the cook (Employee #61) stated he had been fixing the handrail in the resident hallway. After this prompting, Employee #61 removed the gloves and washed his hands. Observations of the meal service noted Employee #61 would repeatedly use his gloved hands to pull up the back of his pants and touch other parts of his clothing. He would then use the contaminated gloves to touch white bread, tomato, lettuce, and slices of turkey to assemble the turkey sandwiches being served for the regular consistency diets. When this practice was brought to the attention of the dietary manager (Employee #5), she stated Employee #61 tended to fidget when nervous. -- b) Initial dining observation In the main dining room during the evening meal on 05/09/11, two (2) dietary staff (Employees #61 and #72) were observed preparing the meals for the residents at a table in the dining room. Two (2) skillets were being used to prepare grilled cheese sandwiches. Employee #61 was observed handling the grilled cheese with gloved hands. At one point, Resident #58 said she wanted chicken soup, not the tomato soup that was being served. This was communicated to a staff member when she served. The staff member informed Employees #61 and #72 of Resident #58's request. Employee #72 reached under the table with his gloved hand and removed a can of chicken noodle soup. He then handled a grilled cheese sandwich before opening the can of soup. After putting the soup in a bowl and putting it into the microwave behind the table, he returned to the table. He proceeded to handle another grilled cheese sandwich and added Tater Tots to a plate. Both items were handled with the same gloves worn when the soup was opened and microwaved. A few minutes later, Employee #61 was observed wiping his gloved hands on the front of his visibly soiled apron and placing his gloved hands behind his body when he adjusted his apron. He then resumed serving meals with the same gloves. -- c) In the main dining room at approximately 5:45 p.m. on 05/09/11, Employee #72 was observed washing his hands at a sink. He applied soap to his hands, then turned on the water. After washing his hands and rinsing them, he turned the faucet off with his bare hands.	2016-01-01
9251	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	425	D	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to obtain medications in a timely manner for administration to two (2) of twelve (12) Stage II sample residents. The facility failed to assure Resident #67 received Ativan 2 mg as prescribed by the attending physician, for treatment of [REDACTED].#7 in a timely manner. Resident identifiers: #67 and #7. Facility census: 61. Findings include: a) Resident #67 Review of Resident #67's medical record found an order by the attending physician written on 05/01/11 for Ativan 2 mg at bedtime for treatment of [REDACTED]. During an interview with a registered nurse (Employee #84) on 05/17/11 at 1:22 p.m., she was asked why the resident missed two (2) doses of Ativan 2 mg after it was ordered by the physician. Employee #84 relayed they did not have a prescription to send to the pharmacy. When asked why the medication was not obtained from the emergency drug box, she stated nursing staff should have contacted the physician and requested they call the pharmacy to provide an access code which would allow the nursing staff to remove this controlled medication from the emergency drug box. -- b) Resident #7 On 05/17/11 at 8:30 a.m., a licensed practical nurse (LPN - Employee #27) was observed administering medications to this resident. During reconciliation of medication pass to this resident on 05/17/11 at approximately 10:50 a.m., it was noted the resident had not received the medication Prilosec that morning. The MAR, when checked to ascertain the time it was scheduled to be given, indicated the medication should have been given during the morning medication pass. At 11:18 a.m., Employee #27 was asked about the Prilosec. She said the resident was out of the medication. She was asked to verify this by checking the medication cart. There was an empty box in the drawer of the medication cart for this resident. Review of the medications available in the emergency medication box found Prilosec was available and could have been given.	2016-01-01
9252	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	431	F	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on inspection of medication storage rooms, the facility had failed to ensure medications and supplies were stored in a safe and orderly manner. Expired medications, improperly stored medications, expired ancillary items, and expired non-medication items were found stored in a disarrayed fashion. This had the potential to affect all residents receiving medications. Facility census: 61. Findings include: a) Medication storage rooms On 05/19/11 at approximately 4:00 p.m., inspection of the medication storage rooms found the following (this list is not all inclusive): -- A gastrostomy tube that was labeled as having been sterile stamped by the manufacturer as Use by [DATE] -- 2 ml Monoject safety syringes that expired 02/2011 -- An open 10 ml vial of bacteriostatic sodium chloride with less than half of the solution remaining was not labeled to indicate when it had been opened -- Two (2) tabs of Lipitor 40 mg were found loose in a drawer -- One (1) bag of mixed meds including Amoxicillin, Cephalexin,Warfarin of various strengths, Cipro 500, Lisinopril 40, Coreg, Bactrim, Lasix- various strengths , Levaquin, Nexium, Chlorpromazine, Clindamycin, etc. There were over fifty (50) pills in the bag. -- A book of Bible Puzzles for Kids -- Four (4) Vacutainers for urine that had an expiration date of 04/2007 -- An IV connecter that expired 11/2009 -- A Micro-tainer that had expired December 1999 -- Seven (7) Vacutainers (purple top) that had passed their expiration dates -- Applicators that had expired 10/10 , 10/08, 12/06 -- An IV start kit that had expired 10/10 -- A contaminated Foley catheter -- IV supplies and urinary catheters were found stored in drawers in a haphazard manner -- Three (3) vials of Influenza Virus Vaccine that were open, with no date to indicate when they were opened. Additionally they were stamped by the manufacturer as expiring 03/31/11 -- One (1) vial of Influenza Virus Vaccine that was opened and dated 11/14/10, that had expired 03/31/11 -- Four (4) unopened vials of Influenza Virus Vaccine that expired 03/31/11 -- A vial of purified protein derivative that was open, but was not dated to indicate when it was opened -- IV fluids with Amoxicillin and Clavulanate 400 mg / 57 mg per 5 ml that had expired 05/05/11 -- Two (2) - 200 ml bags of Vancomycin injection one (1) expired 03/18/11 and one (1) expired 03/23/11 and two (2) more expired 03/20/11 all for one (1) resident -- Ceftriaxone 500 mg expired in 24 hours after mixing - prepared 05/03/11 -- Two (2) bags of Ceftriaxone 500 mg expired twenty-four (24) hours after mixing - expired 05/23/11 -- Foley catheters whose packaging had yellowed with age	2016-01-01
9253	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	441	F	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, review of facility surveillance data, review of hand hygiene guidelines from the Centers for Disease Control and Prevention (CDC), and review of facility policies and procedures, the facility failed develop and implement an infection control program to prevent the development and spread of disease. Surveillance data was not analyzed to determined whether there were trends and / or patterns of infection, employees did not perform handwashing using accepted guidelines, clean gloves were not handled in a manner to prevent contamination before use, the scoop for [MEDICATION NAME] was not stored to prevent contamination of the product, and the tip of the dropper bottle for eye drops was contaminated during medication administration. All residents had the potential to be affected by these practices. Facility census: 61. Findings include: a) Initial dining observation In the main dining room during the evening meal on 05/09/11, two (2) dietary staff (Employees #61 and #72) were observed preparing the meals for the residents at a table in the dining room. Two (2) skillets were being used to prepare grilled cheese sandwiches. Employee #61 was observed handling the grilled cheese with gloved hands. At one point, Resident #58 said she wanted chicken soup, not the tomato soup that was being served. This was communicated to a staff member when she served. The staff member informed Employees #61 and #72 of Resident #58's request. Employee #72 reached under the table with his gloved hand and removed a can of chicken noodle soup. He then handled a grilled cheese sandwich before opening the can of soup. After putting the soup in a bowl and putting it into the microwave behind the table, he returned to the table. He proceeded to handle another grilled cheese sandwich and added Tater Tots to a plate. Both items were handled with the same gloves worn when the soup was opened and microwaved. A few minutes later, Employee #61 was observed wiping his gloved hands on the front of his visibly soiled apron and placing his gloved hands behind his body when he adjusted his apron. He then resumed serving meals with the same gloves. -- b) In the main dining room at approximately 5:45 p.m. on 05/09/11, Employee #72 was observed washing his hands at a sink. He applied soap to his hands, then turned on the water. After washing his hands and rinsing them, he turned the faucet off with his bare hands. -- c) Resident #7 During morning medication pass on 05/17/11, a licensed practical nurse (LPN - Employee #27) put the opened [MEDICATION NAME] and a box containing a bottle of eye drops in her pocket to take into the resident's room. After giving the resident her oral meds, the LPN washed her hands at the sink. She returned holding clean gloves in her left hand and retrieved the patch from her pocket with her right hand. She applied the patch to the resident's left clavicular area. This entailed moving the resident's clothing. The LPN then administered the resident's inhaler and returned to the sink to wash her hands. She put the gloves she had been holding wadded in her hand into her pocket while she washed her hands. The handwashing procedure was less than three (3) seconds. The LPN returned to the bedside, removed the gloves from her pocket and donned them, and instilled the eye drops after lowering the head of the resident's bed. During the instillation of the drops, the tip of the eye drop bottle came in contact with the lashes of the resident's left eye. The LPN again washed her hands for approximately three (3) seconds. Review of the facility's hand hygiene policy and procedure found handwashing was to be done for fifteen (15) seconds. This is in keeping with the CDC guidelines. Placing items in one's pockets creates a potential for contamination of gloves and other items. Pockets are considered contaminated as they are accessed numerous times a day without first performing handwashing. Wadding gloves up in one's hand creates a potential for transfer of microorganisms from the hands to the gloves, rendering them unclean. Contact with the resident's eyelashes creates a potential for contamination of the medication. -- d) Resident #39 During the observation of morning medication pass on 05/18/11, an LPN (Employee #67) prepared [MEDICATION NAME] for this resident. She retrieved the scoop out of the container with her bare hand and, after preparing the dose, dropped the scoop back into the container. No measures were taken to ensure the handle of the scoop did not come into contact with the product. The LPN repeated this process when the resident asked it be placed in orange juice rather than water. In both instances, the LPN had contact with various environmental objects prior to handling the scoop. -- e) Surveillance data Review of the line listing for December 2010, through the time of the survey in May 2011, found no apparent analysis of the collected data other causative analysis of urinary tract infections (UTIs). The analysis looked at various factors relative to UTIs but only included the unit, not the geographical proximity of rooms. There was no analysis of trends and patterns for other types of infections. This was discussed with Employee #84, a registered nurse (RN) and the facility's infection control nurse. She said the only analysis was the tracking of the UTIs. She also said the documents provided were the ones given to the Infection Control / QA Committee.	2016-01-01
9254	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	492	D	0	1	UNLT12	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and a review of the West Virginia Board of Pharmacy, West Virginia Code of State Rules, the facility failed to comply with the rules set forth by the board of pharmacy related to labeling of medication for one (1) of eight (8) sampled residents. Resident identifier: #21. Facility census: 58. Findings include: a) Resident #21 On 07/21/11 at approximately 2:00 p.m., the medical record for Resident #21 revealed a physician's orders [REDACTED].) The order, written at 10:00 p.m. on 07/15/11, stated: (symbol for 'change') [MEDICATION NAME] to 66 ml BID (twice per day). The Medication Administration Record [REDACTED]. On 07/22/11 at approximately 3:00 p.m., Employee #76 (registered nurse / nurse practice educator) and Employee #77 (a corporate registered nurse) provided a copy of the label attached to the bottle of [MEDICATION NAME]. The label contained the resident's name as well as the date 07/14/11. The label indicated the following dosage instructions: 22.5 ml by mouth every eight (8) hours. The bottle also identified the contents of the medication as [MEDICATION NAME] 10 gm/15 ml solution. The West Virginia Board of Pharmacy, West Virginia Code of State Rules, states: 19.13.2. To dispense, deliver, or distribute a prescription drug order accurately as prescribed. For the purposes of this paragraph 'accurately as prescribed' means a. To the correct patient (or agent of the patient) for whom the drug or devise was prescribed; b. with the correct drug in the correct strength, quantity, and dosage from ordered by the practitioner; a pharmacist may substitute a generic drug pursuant to W.Va. Code? 30-5-12b; and c. With correct labeling (including directions for use) as ordered by the practitioner. On 07/22/11 at approximately 3:30 p.m., Employees #76 and #77 confirmed the label on the bottle of [MEDICATION NAME] did not accurately reflect the current order by the prescribing practitioner.	2016-01-01
9255	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	502	D	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure an ordered laboratory test was completed timely. One (1) of twelve (12) Stage II sample residents did not have a metabolic panel completed as ordered after she was found to have a critically low serum potassium level. Resident identifier: #27. Facility census: 61. Findings include: a) Resident #27 A basic metabolic panel (BMP) was ordered on [DATE] to be done in three (3) days. The results of the complete metabolic panel (CMP), completed on 04/18/11, showed the resident had a potassium of 2.4, which was noted to be a critical level (normal 3.5 - 5.2 according to the lab printout). The physician ordered the resident's [MEDICATION NAME] be reduced from 80 mg TID (three (3) times a day) to 80 mg BID (two (2) times a day) and her potassium chloride be increased from 20 mEq in the morning and 40 mEq at night to 40 mEq BID. Review of the medical record, on the mid-afternoon of 05/18/11, did not find the results of the BMP that should have been completed on 04/22/11. Employees #25 (the ward clerk) and #83 (a registered nurse) looked in the physicians' notebooks, reports that needed to be filed, the resident's medical record, and elsewhere. The results could not be located. Employee #83 found the treatment book, where it was indicated the day the BMP was scheduled and the nurse had written REF. The nurse said this meant the resident had refused the test. The nursing entries were reviewed, but there was no mention of the resident's refusal of the lab study. There was no indication the physician had been made aware of the resident's refusal. There was no evidence further attempts were made to collect the needed specimen.	2016-01-01
9256	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	508	D	0	1	UNLT11	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to obtain an ordered chest x-ray for one (1) of twelve (12) Stage II sample residents in a timely manner when ordered by the attending physician. An x-ray that was ordered by the physician to be obtained on 03/25/11 was not obtained until 03/29/11. Resident identifier: #14. Facility census: 61. Findings include: a) Resident #14 Review of the medical record found that, on 03/24/11, the attending physician ordered the facility to obtain a chest x-ray on 03/25/11. The physician also ordered, on 03/24/11, the antibiotic medication [MEDICATION NAME] 500 mg every day for seven (7) days. Review of the Medication Administration Record [REDACTED]. The medical record did not contain evidence of the chest x-ray results which was ordered to be obtained on 03/25/11. On the morning of 05/19/11, the director of nursing (DON) was asked for the results from the chest x-ray ordered by the attending physician (which was to have been obtained on 03/25/11). She provided a report which evidenced that the facility did not obtain the chest x-ray until 03/29/11, six (6) days after the resident began receiving antibiotics. An interview was conducted on 05/19/11 at 10:40 a.m. with the ward clerk, Employee #25. She stated she was responsible for scheduling the tests ordered by physicians. When asked why Resident #14 did not receive the ordered chest x-ray until 03/29/11, she relayed that she works Monday through Friday. She stated that she called their contracted mobile x-ray company on 03/25/11 to request the chest x-ray. She then returned on Monday, 03/28/11 and noted that the x-ray had not been done. She stated that she called them again and they did not come until 03/29/11. The DON, who was present in the nursing station during the interview with Employee #25, stated the facility can obtain ordered x-rays 24/7 (twenty-four hours a day / seven days a week). She relayed that, if needed, residents can be sent out to obtain an ordered x-ray. She could provide no evidence the facility attempted to obtain the ordered chest x-ray for Resident #14 in this manner.	2016-01-01
9257	WHITE SULPHUR SPRINGS CENTER	515100	ROUTE 92, PO BOX 249	WHITE SULPHUR SPRING	WV	24986	2011-05-19	514	E	0	1	UNLT11	Based on medical record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices. Review of activities of daily living (ADL) flow sheets for nine (9) of twelve (12) Stage II sample residents found staff failed to follow accepted practices for correcting errors in entries. The section of each ADL flow sheet related to frequency of bowel movements contained entries that had been written over. Resident identifiers: #44, #110, #121, #67, #12, #82, #54, #39, and #27. Facility census: 61. Findings include: a) Residents #44, #110, #121, #67, #12, #82, #54, #39, and #27 Review, on 05/17/11, of the facility's records of ADL flow sheets found the record of Residents #44, #110, #121, #67, #12, #82, #54, #39, and #27 to have incorrect documentation of bowel movements. Resident records for 04/01/11 through 05/17/11 were reviewed. The nursing assistants document the frequency of bowel movements for each of these residents on the ADL flow sheets. Review of these records identified inaccurate correction of errors. The nursing assistants had written in zeros (0), identifying the residents to not having a bowel movement. These zeros (0) were written over identifying entries indicating the residents did have bowel movements. Interview with the director of nursing (DON - Employee #40), at 2:50 p.m. on 05/17/11, identified the facility had inserviced staff on proper correction of documentation errors in August 2010. She further stated, They know not to do this. Review, on 05/17/11, of the ADL flow sheets identified a designated area for errors to be corrected. During an interview with the MDS nurse (Employee #52) on 05/18/11 at 2:00 p.m., she reported having inserviced the nursing staff on this in August 2010.	2016-01-01
9258	PARKERSBURG CENTER	515102	1716 GIHON ROAD	PARKERSBURG	WV	26101	2013-01-30	309	G	1	0	7W2211	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental and psychosocial well-being for one (1) of seven (7) sampled residents. The facility failed to assess, monitor, and provide interventions to potentially prevent hospitalization of a resident with a urinary tract infection, [MEDICAL CONDITIONS], and mental status changes. Resident identifier: #63. Facility census: 61. Findings include: a) Resident #63 Review of the medical record, on 01/28/13 at 2:30 p.m., revealed an interdisciplinary note completed on 12/24/12 at 10:00 p.m. It noted the resident's temperature was 101.3 degrees Fahrenheit. Tylenol was administered for the fever. On 12/25/12 at 6:35 a.m., according to a nursing entry, the resident's temperature was 101.8 and his apical heart rate was 109. He was suctioned for copious amount of sputum . MD (physician) faxed. On 12/25/12 at 7:10 a.m., a nurse noted rales scattered throughout bilateral lungs, oxygen saturation was 77-82%. His oxygen was applied at 4 lpm (liters per minute) and his sat (oxygen saturation) increased to 86%. The physician was notified at 7:20 a.m., and the resident was transferred to the hospital. A physician's orders [REDACTED]. Another order, dated 12/22/12, indicated a urinalysis with culture and sensitivity (U/A C&S) was to be obtained on 12/23/12 Further review of the medical record, revealed a hospital discharge summary, dated 01/10/13. It verified Resident #63 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Additionally, a hospital progress note, dated 12/26/12, noted altered mental status due to infection, dehydration, underlying dementia, and [MEDICAL CONDITION]. A hospital history and physical visit note, dated 12/27/12, noted the chief complaint on admission was altered mental status and shortness of breath . while at the nursing home the resident was found to have altered mental status compared to his baseline, as well as a low oxygen saturation, and low grade fevers . On arrival to the emergency department, the patient was significantly obtunded as well as being significantly tachypneic with gurgling respiration . was significantly hyperglycemic . The patient had a corrected sodium value 168 with estimated free water deficit of 7.4 liters. The patient appeared to be severely dehydrated, and per patient's family had significantly decreased p.o. intake over the past several weeks . The patient was volume resuscitated with two liters of [MEDICATION NAME] ringers with some improvement in blood pressure. The patient remained significantly obtunded. The hospital case management assessment note, completed on 12/28/12, also indicated Resident #63 was admitted with dehydration and urinary tract infection [MEDICAL CONDITION]. Lab results completed at the hospital on the day of admission, 12/25/12, included a blood urea nitrogen (BUN) of 36, Serum Creatinine (Cr) of 1.5, and Serum Sodium (Na) of 161. On 01/08/13, after intravenous fluids, the hospital lab report indicated the BUN was 13, Cr was 1.00 and Na was 147. Review of a nursing facility resident encounter sheet, completed by the nurse practitioner on 12/05/12 (prior to the onset of symptoms), noted lab results of a BUN of 13, Cr of 1.00, and the Na of 138 on A monthly summary, completed on 12/23/12 by a nurse at the long term care facility, described Resident #63's skin turgor as fair. A dietary note, completed on 11/07/12, by the registered dietitian (RD), revealed the resident should be consuming 1700-2040 mls daily. The following is a list of mls consumed each day from 12/08/12 through 12/24/12 as reported on the resident's functional performance record: 12/24 1440 ml 12/23 1260 ml 12/22 1440 ml 12/21 720 ml 12/20 1200 ml 12/19 1160 ml 12/18 1800 ml 12/17 1320 ml 12/16 1440 ml 12/15 1680 ml 12/14 960 ml 12/13 1080 ml 12/12 1440 ml 12/11 1320 ml 12/10 840 ml 12/09 840 ml 12/08 1680 ml During an interview with Employee #42, the director of nursing (DNS), on 01/29/13 at 10:30 a.m., she related the resident also received fluids during snack pass. She was unable to provide evidence fluids were provided and consumed. She stated no other record was utilized related to fluid intake. An interview with the registered dietitian, Employee #77, on 01/29/13 at 11:30 a.m., indicated fluids were provided via nourishment - up to 800 mls per day. Insensible fluid loss was not considered, related to fluid intake of Resident #63. The care plan, dated 10/22/12, identified a risk for altered nutritional status. Staff were to observe for signs and symptoms of dehydration and aspiration. A swallowing evaluation was completed on 12/28/13. This noted the resident was admitted to the hospital with [REDACTED]. Mucosal quality was noted as, bruising present; cracked, dry. A hospital consultation visit note of 01/03/13 indicated the resident was evaluated for PEG (percutaneous endoscopic gastrostomy or feeding tube) tube placement. The family is agreeable to a PEG tube after apparently failing a swallowing evaluation. The hospital nutrition assessment revealed a feeding tube placed on 01/05/13. She also noted the resident was confused and unable to remain upright in bed. It noted Resident #63 had a history of [REDACTED]. Pharyngeal phase: penetration occurred during and after swallow . residue in the pharynx of all consistencies post swallow is noted . significant risk of aspiration is observed. During an interview with Employee #68 (licensed practical nurse), on 01/30/13 at 9:30 a.m., she stated lung sounds were documented per physicians order. She related when a resident was skilled, a head to toe evaluation was completed daily and documented in the nurses' notes. She said breath sounds were documented on the medication administration record (MAR). She also related staff was to document daily on areas related to skilled services or change in condition. Additionally, oxygen saturations were to be monitored per physician order. Review of the December 2012 MAR, on 01/29/13, found no evidence lung sounds were monitored. The schedule for [MEDICATION NAME]-[MEDICATION NAME] inhalation to be administered as needed, was blank. The December 2012 treatment administration record (TAR), revealed Resident #63 was not using his oxygen prior to discharge to the hospital. The schedule for oxygen administration was blank and the schedule for oxygen tubing and humidifier changes was noted as not using. The care plan, dated 10/22/12, was reviewed on 01/28/13 at 4:00 p.m. It indicated staff were to monitor the resident for signs and symptoms an of upper respiratory infection and aspiration. The urinalysis, dated 12/25/12, described the urine as, turbid in clarity. Employee #35 (nursing assistant) was interviewed on 01/29/13 at 2:10 p.m. She noted signs and symptoms of a UTI to be odor, pain, and complaints of hurting when they pee. She stated, I can not think of anything else. Employee #50 (nursing assistant) was interviewed at 3:30 p.m., on 01/29/13. She related behavior changes, they get mean and their urine smells. Review of the behavior monthly flow sheet, dated December 2012, revealed behavior episodes documented as zero (0) from 12/01/12 through 12/16/12. Behaviors were documented as observed daily from 12/17/12 through 12/24/12 (immediately prior to the resident's hospitalization ). The care plan, dated 10/22/12, indicated staff were to monitor for a urinary tract infection. Staff were to report changes in amount, frequency, color or odor of urine. An entry in the interdisciplinary notes, dated 12/22/12 at 5:00 a.m., noted the resident was guarding peri area and grimace when urinating. An order was received at 5:00 p.m. on 12/22/12 for a straight cath urinalysis and culture and sensitivity. No further notation was found concerning the urinary tract infection. An interview with the director on nurses, on 01/30/13, confirmed no evidence of further assessment, monitoring, or implementation of care of the UTI was completed. The hospital physician note, dated 12/27/12, noted Resident #63 was significantly hyperglycemic on arrival to the emergency room (ER) on 12/25/12. The long term care facility medication administration record (MAR), dated December 2012, was reviewed on 01/28/13. It revealed the resident was to have fingerstick blood sugars (FSBS) at 7:00 a.m. and 4:00 p.m., weekly. According to the MAR, the resident had refused the FSBS at 4:00 p.m. on 12/11/12 and 7:00 a.m. and 4:00 p.m. on 12/18/12. No evidence was provided to indicate other attempts were made to monitor his blood sugar until 12/25/12. During an interview with the DNS, on 01/30/13, she reviewed the chart and verified a lack of evidence related to assessment, monitoring and implementation of care. She stated her expectation for prudent care would be an assessment related to comorbidities to be completed daily. Additionally, the Physician order [REDACTED]. It revealed the resident was to receive care which included medical treatment, IV (intravenous) fluids, cardiac monitoring, antibiotics, and a feeding tube for a defined trial period.	2016-01-01
9259	PARKERSBURG CENTER	515102	1716 GIHON ROAD	PARKERSBURG	WV	26101	2013-01-30	327	G	1	0	7W2211	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and medical record review, the facility failed to ensure a resident received sufficient fluid intake to maintain proper hydration and health. One of seven (7) sample residents was transferred to the hospital and admitted with the [DIAGNOSES REDACTED].#63. Facility census: 61. Findings include: a) Resident #63 Review of the medical record, on 01/28/13 at 2:30 p.m., included a review of a hospital discharge summary. It verified Resident #63 was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Lab results included a blood urea nitrogen (BUN) of 36, Serum Creatinine (Cr) of 1.5, and Serum Sodium (Na) of 161 on the date of admission. On 01/08/13, the hospital lab report indicated the resident ' s BUN was 13, Cr was 1.00 and Na was 147. Upon admission to the hospital the urine was noted as, turbid in clarity. A hospital history and physical visit note, dated 12/27/12, described the chief complaint on admission was altered mental status and shortness of breath. . while at the nursing home the resident was found to have altered mental status compared to his baseline as well as a low oxygen saturation and low grade fevers . On arrival to the emergency department, the patient was significantly obtunded (mentally dulled) as well as being significantly tachypneic (rapid respirations) with gurgling respiration . was significantly hyperglycemic (high blood sugar) . The patient had a corrected sodium value 168 with estimated free water deficit of 7.4 liters. The patient appeared to be severely dehydrated, and per patient's family had significantly decreased p.o. (oral) intake over the past several weeks . The patient was volume resuscitated with two liters of [MEDICATION NAME] ringers with some improvement in blood pressure. The patient remained significantly obtunded. On 12/28/12, an interdisciplinary note, completed by the licensed social worker, noted . Fluid intake reviewed for month of December with adequate intake noted. Nursing to obtain order for regular hydration periods. However, a dietary note, completed on 11/07/12, by Employee #77, the registered dietitian revealed the resident should be consuming 1700-2040 ml daily. The following is a list of amount of fluids consumed each day from 12/08/12 through 12/24/12, as reported on the resident's functional performance record: 12/24 1440 ml 12/23 1260 ml 12/22 1440 ml 12/21 720 ml 12/20 1200 ml 12/19 1160 ml 12/18 1800 ml 12/17 1320 ml 12/16 1440 ml 12/15 1680 ml 12/14 960 ml 12/13 1080 ml 12/12 1440 ml 12/11 1320 ml 12/10 840 ml 12/09 840 ml 12/08 1680 ml During an interview with Employee #42, the director of nursing (DNS), on 01/29/13 at 10:30 a.m., she related the resident also received fluids during snack pass. She was unable to provide evidence fluids were provided and consumed. She stated no other record was utilized, related to fluid intake. An interview with the registered dietitian, Employee #77, on 01/29/13 at 11:30 a.m., indicated fluids were provided via nourishment - up to 800 ml per day. Insensible fluid loss was not considered, related to fluid intake and output for Resident #63. The care plan, dated 10/22/12, identified a risk for altered nutritional status. staff were to observe for signs and symptoms of dehydration and aspiration. During an interview, on 01/30/13 at 9:30 a.m., with the unit manager, Employee #25, and Employee #68 (licensed practical nurse), they stated hydration was tracked in the resident functional performance record. They also stated the record was reviewed during care plan meetings. Otherwise, the nursing assistants notified licensed staff of declines. Employee #68 stated the nurses do not monitor fluid intake. The Physician order [REDACTED]. It revealed the resident was to receive care which included medical treatment, IV (intravenous) fluids, cardiac monitoring, antibiotics, and a feeding tube for a defined trial period. .	2016-01-01
9260	CAMERON NURSING AND REHABILITATION CENTER, LLC	515125	ROUTE 4, BOX 20	CAMERON	WV	26033	2011-10-05	159	D	0	1	JZU011	Based on record review and staff interview, the facility failed to obtain written authorization for the management of personal funds from the legal representative of one (1) of five (5) sampled residents. Resident identifier: #40. Facility census: 55. Findings include: a) Resident #40 Review of the financial records of five (5) sampled residents for whom the facility managed personal funds found an account was being managed by the facility for Resident #40. Further review found no evidence the resident or a legal representative with the authority to make financial decisions on the resident's behalf had provided written authorization permitting the facility to manage the resident's personal funds. This was verified by Employee #47 ( who was assisting with the review) at 2:00 p.m. on 10/04/11, and acknowledged by the director of nurses and the administrator at 2:30 p.m. on 10/04/11, after they had reviewed the records.	2016-01-01
9261	CAMERON NURSING AND REHABILITATION CENTER, LLC	515125	ROUTE 4, BOX 20	CAMERON	WV	26033	2011-10-05	225	D	0	1	JZU011	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility record review, policy review, and staff interview, the facility failed to immediately report an incident involving possible neglect to the appropriate State officials and/or to investigate the incident which involved a fall resulting in a resident sustaining a fracture. This affected one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #42. Facility census: 55. Findings include: a) Resident #55 Medical record review revealed Resident #42 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident had been determined to lack capacity to form her own medical decisions and had a court-appointed guardian for several years. A review of the physician's orders [REDACTED]. The following was added on 12/28/10: Transfer order: transfer with two assist and gait belt, wheelchair for mobility w/i (within) facility. A new order was written on 07/26/11, stating: Transfer order: transfer with two assist and sit to stand lift. The ambulation order was discontinued except for physical therapy, and she was to be turned every two (2) hours. The resident's physical status had deteriorated, and the physical therapy record stated that, during the treatment period from 07/25/11 through 08/11/11, the resident had poor balance and was unable to stand at all on several occasions during this treatment period. The notes attributed this to weakness caused by a recent bout of pneumonia. At the time of her fall on 08/11/11, she had met none of her therapy goals. A review of the quarterly minimum data set assessment (MDS) with an assessment reference date of 07/21/11 found the assessor indicated the resident required physical assistance from 2 + persons for transfers, she was not steady getting on and off the toilet, and she could only stabilize with assistance. The resident sustained [REDACTED]. The incident report completed by the licensed practical nurse (LPN - Employee #7) read: Resident climbed out of bed insisting that she needed to walk to the bathroom with her walker, tried to encourage not to walk and use stand up lift but she became very agitated and angry so staff proceeded to walk her to the bathroom. After toileting tried to stand up and pivot into w/c (wheelchair) she yells 'I am too weak and I can't stand' and just let herself fall to the floor with knees underneath her taking all the weight and a 'popping' sound was heard and resident started screaming out 'my knee my knee' 'I broke my kneecap'. The occurrence note by the same LPN stated: fell on to floor in bathroom when trying to transfer off of toilet in w/c with walker. The resident was transferred to the hospital via ambulance and found to have a [MEDICAL CONDITION] tibia. She was readmitted to the facility on [DATE], with a knee immobilizer to the right leg. The resident was assisted out of bed to the bathroom without the use of the sit-to-stand lift, although the ADL (activities of daily living) records revealed the resident had not ambulated since 06/30/11. This was in violation of the physician's orders [REDACTED]. During an interview with the administrator and the director of nursing (DON - Employee #74) at 10:30 a.m. on 10/04/11, they were asked why this incident had not been reported as an allegation of neglect, to which they responded that it was because the resident had insisted on transferring / ambulating without a mechanical lift. They both admitted they were aware she was weak and had not been ambulating. The DON stated she had investigated the incident and the LPN involved had been counseled. During a follow-up interview with the administrator at 11:05 a.m. on 10/05/11, he stated he would report the incident and the LPN, although there was no evidence that an investigation had taken place.	2016-01-01
9262	CAMERON NURSING AND REHABILITATION CENTER, LLC	515125	ROUTE 4, BOX 20	CAMERON	WV	26033	2011-10-05	226	D	0	1	JZU011	Based on record review and staff interview, staff did not follow the Reporting / Response section of the facility's policy for reporting allegations of abuse or neglect by not indicating in their Five Day Follow-Up - Nursing Home Program either the outcome of the investigation or the complete corrective action taken by the facility for one (1) of three (3) reports reviewed. Resident identifier: #29. Facility census: 55. Findings include: a) Resident #29 Review of the facility's self-reported allegations of abuse / neglect found that, on 05/17/11, the daughter of Resident #29 reported the following, which was recorded on a grievance / concern report form (quoted as written): daughter stated that while resident was out to appointment 'that girl lifted my mom into the seat of the van without a gait belt. I don't think she knows how bad my mom's arms are. If she whines tonight that her arms hurt that is why.' On 05/18/11, the facility submitted the following allegation to the State survey agency on a form titled Immediate Fax Reporting of Allegations - Nursing Home Program: While transferring patient from wheelchair to facility van sent nurse did not use gait belt as ordered by physician. Patient complained of Left arm pain on 5/18/11. On 05/18/11, the facility submitted a form titled Five Day Follow-Up - Nursing Home Program stating the following under the heading Outcome / Results of Investigation (quoted as written): X-rays of Left arm were negative for any fracture or dislocation. Heat wrap applied to left shoulder. Under the heading titled Corrective Action By Facility was written: Nurse reeducated to use of gait belt and following physician orders. In an incident summary, the reporter noted the alleged perpetrator stated (quoted as typed) . she wrapped she did not pull or move patient's arms during the transfer . she wrapped her arms around patient's waist and with patient's help completed the transfer. She stated that during transport resident was complaining of seatbelt strap was hurting her arm. The facility's investigation verified the nurse had not used a gait belt during this transfer, but there was no documentation on the Five Day Follow-up form indicating the allegation had been substantiated. Additionally, although documentation on the form stated that education had been provided to the nurse, there was no mention of whether or not the nurse had been reported to the appropriate licensing board. During an interview with the administrator at 11:05 a.m. on 10/04/11, he acknowledged the facility's policy required this missing information be included in the report, and he stated he would file an amended report.	2016-01-01
9263	CAMERON NURSING AND REHABILITATION CENTER, LLC	515125	ROUTE 4, BOX 20	CAMERON	WV	26033	2011-10-05	280	D	0	1	JZU011	NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interview, the facility failed to review and revise the care plan for one (1) of thirty-two (32) Stage II sample residents, who sustained multiple falls since her admission to the facility on [DATE], including falls with injuries, in an effort to promote resident safety. Resident identifier: #66. Facility census: 55. Findings include: a) Resident #66 1. A review of the clinical record revealed Resident #66 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was assessed on admission as being at high risk for falls due to wandering and altered safety awareness. - 2. Review of the resident's comprehensive admission minimum data set (MDS) with an assessment reference date (ARD) of 02/18/11 found these responses to the following questions related to falls (J1700 and J1800): - Did the resident have a fall any time in the last month prior to admission? - No - Did the resident have a fall any time in the last 2-6 months prior to admission? - No - Did the resident have any fractures related to a fall in the 6 months prior to admission? - No - Has the resident had any falls since admission or the prior assessment , whichever is more recent? - Yes According to the assessor, the resident one (1) fall since admission or the prior assessment, for which no injury was sustained. - Review of the results of the brief interview for mental status (BIMS) completed as part of the 02/18/11 MDS found the resident scored 04 out of 15, indicating the resident's cognitive status was severely impaired (C0500). As part of the BIMS, the resident was asked to recall three (3) words that had been said to her earlier in the interview (C0400); she was unable to recall two (2) of the words and was only able to recall the third word with cuing. (Review of the resident's most recent quarterly MDS with an ARD of 07/28/11 found her BIMS score was 06 out of 15, again indicating her cognitive status was severely impaired (C0500). As part of this BIMS, she was able to recall one (1) word with no cuing and one (1) word with cuing and was not able to recall the third word.) - Review of the assessment of her functional status completed as part of the 02/18/11 MDS found her balance (G0300) when moving from a seated position to a standing position was not steady and she was only able to stabilize with human assistance; her balance while walking and while turning around and facing the opposite direction while walking was not steady but she was able to stabilize without human assistance. - 3. Her comprehensive admission care plan included the following problem statement: (Resident #66) is High risk for falls r/t wandering. (initiated on 02/14/11) Interventions to promote Resident #66's safety with respect to her risk of falling (all of which were initiated on 02/14/11) included (quoted as typed): HIGH FALL RISK: Anticipate and meet patient's needs. Provide a safe environment for the patient by observing the condition of his/her room every shift and correcting any identified issues. PT (physical therapy) evaluate and treat prn (as needed). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate patient / family / IDT (interdisciplinary team) as to cause. (These were the same routine interventions found on all the records records reviewed for falls during the survey, and there were no interventions that reflected the unique needs of the individual residents.) - Additional problem statements (P) and their associated interventions (I) included (quoted as typed): P - (Resident #66) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Dementia / occassional aggressive behaviors. (initiated on 02/14/11) I - 1/2 side rails up on both sides of bed to enhance bed mobility and transfer ability TRANSFER: Independent. DRESSING: Assist of 1. Wears Glasses. TOILET USE: Independent. TOILETING SCHEDULE: . PERSONAL HYGIENE/ORAL CARE: Assist of 1. BATHING: Assist of 1. (all initiated 02/17/11) P - Patient is at risk for elopement due to Hx (history) of elopements from home, increased confusion. (initiated on 02/09/11) I - Secure Care Alarm to right ankle at all times. Check alarm device every shift to ensure functionality. Allow patient to wander freely within safe and secure environment. Involve patient in 1:1 (one-on-one) recreational activities. Encourage socialization with other appropriate residents. Encourage family support / involvement. (all initiated on 02/09/11) - 4. Her admission orders [REDACTED]. Following her admission to the facility on [DATE], Resident #66 sustained falls on the following dates, as documented in her progress notes (quoted as typed): - 02/13/11 at 7:20 p.m. - Resident was found sitting beside of foot of bed on buttocks. - 02/20/11 at 8:20 a.m. - found sitting on floor beside bed in room (number), merriwalker in hallway . - 02/24/11 at 3:27 p.m. - fall, found on the floor beside merry-walker sitting, leaning up against the . - 02/27/11 at 2:00 p.m. - resident observed sitting on buttocks beside of bed . - 03/02/11 at 9:09 p.m. resident sat down on floor from merry walker . - 03/06/11 at 11:47 a.m. - resident was found on floor in room (number) on buttocks in front of merry walker. - 04/08/11 at 7:50 p.m. - Nursing assistants reports to me resident was on floor beside of bed . - 07/29/11 at 3:45 p.m. - CNA (certified nursing assistant) walking down B hall, observed resident sitting on floor beside bed . Hematoma 6cm x 6cm x 3cm protrusion observed to left forehead . - 07/29/11 at 10:39 p.m. - Fall out of bed with no apparent injury. - 08/27/11 at 3:58 a.m. - . Resident found lying on back on floor.Denies hitting head. - 10/02/11 at 7:10 a.m. - patient found on floor lying on rt (right) side in front of lt (left) side of bed, 1cm laceration and 2cm laceration rt side of rt eyebrow and 3cm hematoma under lacerations. - 10/03/11 at 12:52 a.m. - Fall this morning . The resident sustained [REDACTED]. [REDACTED]. - 5. The resident was observed at 2:30 p.m. on 09/26/11, walking aimlessly in the hallway, asking staff members if they would help her find her cane. A nurse (Employee #56) led her back to her room and got her quad cane for her. The resident was observed again on 09/27/11, 09/28/11, and 09/29/11, walking about either with or without her cane. She would ask about it, and staff would get it for her. Sometimes she would carry the cane with her while she walked, and sometimes she would use it for support. - 6. Although the initial (and still active) care plan stated that all falls were to be reviewed and evaluated to identify root cause(s) with resulting changes made to the care plan, there was no evidence in the record (nursing notes, progress notes, incident reports, CAA Worksheets, care plans, etc.) to reflect this was being done. The care plan for falls remained, on 10/05/11, exactly as it was at its initiation. There had been no revisions to the care plan (to include use of the quad cane) and/or any evidence that additional / different interventions had been attempted in an effort to promote the resident's safety even after she sustained falls with injuries requiring medical intervention. - 7. The director of nurses (DON - Employee #74), when asked at 11:00 a.m. on 10/04/11 if the resident's falls were being reviewed, stated they always talked about them, but she acknowledged, after reviewing Resident #66's medical record, that there had been no revisions to the care plan and no documentation reflecting an effort to identify causal or contributing factors to the falls. She had no answer when asked when and why the use of the cane was started. - 8. A review of the physical therapy (PT) evaluation and notes from 02/10/11 through her discharge from PT services on 04/08/11 found that, although she had improved and had less ataxia with her gait, she did not meet her rehabilitation goals. She continued a second course of therapy from 04/09/11 through 04/22/11, and at discharge was noted to have less unsteadiness. A review of subsequent therapy screens dated 07/15/11, 08/01/11, and 08/30/11 failed to find any proposed interventions or comments except for recommending the use of a bed alarm on 08/30/11, which was not adopted. There was also no evidence that therapy staff had assessed the resident for or instructed her in the use of a quad cane. This was verified by the physical therapist (Employee #76) at 9:30 a.m. on 10/05/11. - 9. During an interview with Employee #75 (the nurse who was responsible for developing the care plans) at 11:15 a.m. on 10/05/11, she acknowledged there had been no entries into the care plan regarding the use of the quad cane and no revisions to the care plan interventions after any of the falls. When asked about the lack of individuality in the care plan addressing Resident #66's falls, she stated that, usually after they know the resident better, they address individual needs, but she acknowledged this had not occurred for Resident #66.	2016-01-01

CMS-Nursing-Home-Full-Deficiencies

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