rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
131,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,356,B,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the nurse staff posting contained the correct date. This practice had the potential to effect more than a limited number of residents and or family members wishing to view the posting. Facility census: 180. Findings include: a) Staff posting Upon entrance to the facility for the initial tour, at 11:14 a.m. on 08/28/18, observation found the staff nursing posting was dated 08/27/17. Employee #104, the [MEDICAL CONDITION] program manager, confirmed the date on the posting was incorrect. Employee #111, a Licensed Practice Nurse (LPN) said she put the incorrect date in error because she had been working all night. The staff posting was corrected immediately. At 1:26 p.m. on 09/06/17, the administrator was advised of the above findings. The administrator provided no comment.",2020-09-01
828,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,282,B,0,1,ZQ9211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to implement the care plan as directed for two (2) residents reviewed. For Resident #113, staff failed to follow physician's orders [REDACTED]. The facility failed to ensure Resident #91 received a therapeutic diet as directed. Failure to follow the care plan placed residents at risk not to receive the care they were assessed to require. Resident identifiers: #113 and #91. Facility census: 85. Findings include: a) Resident #113 Review of the resident's care plan, on 03/21/17 at 2:32 p.m., revealed a care plan, last revised on 03/14/17, that identified the resident was an insulin dependent diabetic. A listed intervention was for nursing staff to administer insulin as ordered. Physician orders, reviewed on 03/21/17 at 1:35 p.m., revealed an order for [REDACTED]. --Blood sugar of 0 - 150 = 0 units of insulin --Blood sugar of 151 - 200 = 2 units of insulin --Blood sugar of 201 - 250 = 4 units of insulin --Blood sugar of 251 - 300 = 6 units of insulin --Blood sugar of 301 - 350 = 8 units of insulin The (MONTH) (YEAR) Medication Administration Record (MAR), reviewed on 03/22/17 at 9:15 a.m., revealed staff administered an inaccurate dose of insulin on the following dates: -On 02/13/17 at 6:00 a.m., blood sugar was 201 and 2 units of insulin were given instead of the 4 units ordered; --On 02/04/17 at 4:30 p.m., blood sugar was 172 and it appeared staff documented administering 4 units of insulin (the handwriting made it difficult to decipher) instead of the 2 units ordered; and --On 02/14/17 at 4:30 p.m., blood sugar was 374 and staff administered 6 units instead of the 10 units ordered. In an interview, on 03/22/17 at 9:26 a.m., Assistant Director of Nursing (ADON) #79 reviewed the MAR and verified errors occurred in administering physician order [REDACTED]. b) Resident #91 The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/17 indicated Resident #91 required supervision for meals and received [MEDICAL TREATMENT] treatment. The most recent care plan initiated on 01/11/17 was reviewed on 03/22/17 at 1:05 p.m. The care plan indicated the resident had a nutritional concern related to the [DIAGNOSES REDACTED]. On 02/02/17, the care plan was revised to include the following intervention: Provide liberalized renal diet as ordered: No potatoes, beans or bananas, double meat portions with all meals. On 03/22/17 at 12:52 p.m., the resident was observed in the dining room eating lunch. The resident was eating a hamburger sandwich with one patty. The Director of Nursing (DON) #3 stated the resident did not receive double meats. On 03/22/17 at 2:23 p.m., interview with DON #3 stated dietary received the physician order [REDACTED].#58 he stated it was in his notes, but the double meats did not print on the diet card, so the resident did not receive them according to physician's orders [REDACTED]. In an interview, on 03/22/17 at 2:26 p.m., Resident #91 stated she couldn't remember getting double meats on her tray. .",2020-09-01
884,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-07-24,514,B,1,0,2NJ511,"> Based on resident interview, and record review, the facility failed to ensure resident records were complete and accurate for two (2) of eleven (11) residents. The facility failed to ensure residents' refusals of baths were documented. This failed practice had the potential to affect an isolated number of resident. Resident identifiers: #63 and #11. Facility census: 113. Findings include: a) Resident #63 During an interview with Nurse Aide (NA) #26, the NA stated Resident #63 was scheduled to receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. NA #26 stated that most residents received showers twice a week, but residents' personal preferences were also taken into consideration. Review of the shower schedule confirmed that Resident #63 was scheduled to receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. On 07/20/2017 at 12:05 p.m., Registered Nurse #60 stated Resident #63 frequently refused showers. On 07/20/2017 at 12:00 p.m., RN #89 stated Resident #63 refused showers at times because she was would be watching a favorite television program, and did want to be interrupted. RN #150 stated on 07/20/2017 at 2:00 p.m. Resident #63 frequently refuses showers. Review of the bathing section of the Activities of Daily Living (ADL) Records for Resident #63 revealed the following documentation: --05/05/17 - R (refusal of bathing) --05/11/17 - R (refusal of bathing) --05/15/17 - S (shower) --05/31/17 - S (shower) --06/01/17 - S (shower) --06/15/17 - S (shower) --07/05/17 - B (bed bath) --06/06/17 - R (refusal of bathing) --07/13/17 - S (shower) -07/17/17 - R (refusal of bathing) The remainder of the dates on the ADL Records for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), had no documentation of bathing. The Director of Nursing (DON) stated during an interview on 07/20/17 at 11:45 p.m. R means refusal, B means bed bath, and S means shower. Review of medical records revealed a General Nursing Progress note written 01/04/17, that stated, Spoke with resident. She refused shower on Monday evening due to not feeling well. On 07/24/17 at 11:25 a.m., the DON stated Resident #63 had refused showers when they were offered. The DON reviewed ADL Reports for Resident #63 for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). On 07/25/17 at 11:40 a.m. the DON stated the ADL reports did not document that showers were refused on dates other than those listed above. The DoN said the ADL reports should reflect whether or not a resident refused bathing. b) Resident #11 A review of Resident #11's Activities of Daily Living Record (ADLs) for (MONTH) (YEAR) revealed the facility had documented the resident consumed 50% of the breakfast meal on 07/19/17. During an interview with the Director of Nursing (DON) on 07/20/17 at 11:00 a.m., she was asked how the facility calculated meal percentages. She was informed of the resident not eating any breakfast on 07/19/17 and having a 50% of meal consumption recorded on the ADL sheet for the breakfast meal on 07/19/17. At 12:00 p.m., the DON said she had contacted Nurse Aide (NA) #123 because she was the NA assigned to Resident #11 on 07/19/17. NA #123 stated she did not know how much the resident ate for breakfast because she just wrote anything down. Further review of the ADL record for (MONTH) (YEAR) revealed the facility had documented one (1) bed bath between 07/01/17 and 07/19/17. The bed bath was given on 07/08/17. During an interview with the DON on 07/24/17 at 11:40 a.m., the DON confirmed that staff needed to do a better job documenting refusals when someone refused to be bathed/showered.",2020-09-01
1579,WHITE SULPHUR SPRINGS CENTER,515100,345 POCAHONTAS TRAIL,WHITE SULPHUR SPRING,WV,24986,2016-12-15,356,B,0,1,32NE11,"Based on observation, record review, and staff interview, the facility failed to post accurate nurse staffing data that reflected the number of registered nurses (RN) and licensed practical nurses (LPN) who were responsible for providing direct care to residents. This had the potential to affect more than a limited number of residents and visitors who would access the staffing information. Facility census: 63. Findings include: a) Nurse Staffing Information During the initial tour of the facility on 12/05/16 at 12:30 p.m., the staffing and census form displayed near the front door of the building listed direct care licensed nurses currently on duty as two (2) RNs and two (2) LPNs. During an interview with Licensed Practical Nurse #11 on 12/05/16 at 12:52 p.m., she said the staffing sheet currently on display was incorrect because there were call ins that morning. As a result, three (3) RNs and one (1) LPN were actually on duty. On 12/05/16 at 1:00 p.m., during interview, Scheduler #68 stated the staffing sheet was updated as changes occurred. She agreed the current staffing sheet was not accurate. She said there had been call ins and she had not put the correct information on the sheet.",2020-09-01
2189,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2017-03-31,159,B,0,1,YOOX11,"Based on staff interview and record review, the facility failed to offer a petty cash fund for residents to have ready access to monies when needed such as on weekends. This has the potential to affect the forty-six (46) residents who currently have the facility handle their funds. Facility census: 58. Findings include: a) Interview with Accounts Payable Employee #50, on 03/28/17 at 3:00 p.m., revealed the facility does not have a petty cash procedure to ensure residents have access to their funds when wanted or needed. Review of the admission policy information at the same time showed new residents are informed about how the facility will handle money for them, but does not explain how the process is for them to get money at different times such as when the business office is not open. There was also nothing posted to direct residents how to obtain money when the business office is closed.",2020-09-01
2190,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2017-03-31,161,B,0,1,YOOX11,"Based on review of the surety bond, bank statements from the resident trust fund account and staff interview, the facility failed to ensure a surety bond was in place to cover the highest daily balance of the resident trust fund account. This failed practice has the potential to affect at least forty-six (46) residents who allow the facility to handle funds for them. Facility census: 58 Findings include: a) Interview with the Accounts Payable Employee #50, on 03/28/17 at 3:00 p m., revealed the surety bond was in the amount of $30,000. Bank statements from the resident trust fund account for the most recent quarter showed the highest daily balance from the account on (MONTH) 13, (YEAR) was for $30,343.05 which was above the surety bond amount. This was discussed with the Administrator, on 03/28/17 at 3:45 p.m. She was not aware the bond had not been sufficient and would check with financial services division of the facility to see if it had been increased. She returned shortly afterward and stated there had been no increase in the surety bond amount above $30,000 and verified the bond was not enough to cover that highest daily balance.",2020-09-01
2218,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2017-08-10,167,B,1,0,PUVN11,"> Based on random observation and staff interview, the facility failed to post and/or have readily accessible, the results of the most recent survey. This had the potential to affect any resident or visitor who desired to examine the most recent survey results. Facility census: 57. Findings include: a) Observation on 08/09/17 at 2:00 p.m. found the facility's survey results were kept inside a binder, and stored inside a wall-mounted container which was located on a wall in the main corridor leading to the residents' rooms. Upon inspection, it was found that the facility's most recent quality indicator survey, which concluded on 03/31/17, was not included in the survey book. On 08/09/17 at 2:15 p.m., an interview was completed with the administrator. She checked, then agreed that the most recent annual quality indicator survey result was not in the facility's survey book. The administrator said a resident once took the survey book and put it in a trash can. She said she found it by watching video surveillance tapes of the hallways to see who took it and its final location. She said she thought that the most recent annual quality indicator survey result had been filed inside the survey book. She then obtained a copy of that survey, with survey end date of 03/31/17, and placed it inside the facility's survey book.",2020-09-01
2557,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2018-08-16,578,B,0,1,WFEZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform and provide written information concerning the right to formulate an advanced directive. This affected three out of five sampled residents reviewed for advanced directives. Resident identifiers: #56, #17, #15. Facility census: 98. Findings included: a) Resident #56 Review of the clinical record, on 08/14/18 at 10:15 AM, for Resident #56 revealed an admission history form with an original admission date of [DATE] and a re-admission date of [DATE]. The quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which represented minimal memory impairment. A Physician Determination for Capacity form dated 02/03/17 documented that Resident #56 lacked the capacity to make health care decisions due to [MEDICAL CONDITION] and that a surrogate had been named to make health care decisions. There was no evidence of information in the clinical record to document that the surrogate decision maker and/or the resident was provided with information about the right to formulate an advanced directive. b) Resident #17 Review of the clinical record, for Resident #17 on 08/14/18 at 10:25 AM, revealed an admission history form with an original admission date of [DATE] and a re-admission date of [DATE]. The significant change of condition minimum data set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which represented no memory impairment. A Physician Determination for Capacity form, dated 10/31/14, documented that Resident #17 had the capacity to make health care decisions. There was no evidence of information in the clinical record to document that the resident was provided with information about the right to formulate an advanced directive. c) Resident #15 Review of the clinical record, for Resident #15 on 08/13/18 at 3:30 PM, revealed an admission history form with an original admission date of [DATE] and a re-admission date of [DATE]. The quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score too low to score which represented significant memory impairment. A Physician Determination for Capacity form, dated 01/21/16, documented that Resident #15 lacked the capacity to make health care decisions and that a surrogate had been named. There was no evidence of information in the clinical record to document that the surrogate decision maker and/or the resident was provided with information about the right to formulate an advanced directive. Review of the Health Care Decision Making Policy, dated 06/01/93 and revised on 01/01/13, revealed under the section titled Process Advanced Directive: 2. Upon admission, the Center Admissions designee will review the Admissions Agreement with the patient/responsible party informing them of the rights under state law regarding health care decision making, including the right to prepare and advanced directive. 2.1 Advance directive information will be available and provided to patients/responsible party by the Center Admissions Designee as part of the admission process. 2.3 A signed acknowledgment that such information had been received by the patient/family is required. On 08/15/18 at 9:45 AM Employee #106 and Employee #136 were interviewed about the process to provide written information concerning the right to formulate an advanced directive. Employee #136 stated that as long a power of attorney was designated then that was all she thought she needed to complete. On 08/15/18 at 12:05 PM Employee #100 was interviewed. He stated that the nursing home could not provide any acknowledgement that they had educated the patients/responsible parties on Advanced Directives.",2020-09-01
2578,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-22,812,B,0,1,CMRU11,"Based on observation and staff interview, the facility failed to ensure food preparation equipment was clean and sanitary. The inside of microwave in the A hallway nourishment pantry had food debris. This had the potential to affect more than a limited number of residents. Facility census: 101. Findings included: a) Facility task - kitchen On 08/19/19 at 11:30 AM, a tour of the unit nutritional pantries was performed, accompanied by the Dietary Manager. The microwave in the A Hallway nutritional pantry was noted to have debris on the inside. The inside of the door was noted to have a white substance on it. The inside walls and inside top appeared to have dried food debris. The Dietary Manager stated he would have the microwave sanitized. On 08/19/19 at 12:21 PM, the Administrator was informed of the above-mentioned situation. No further information was provided through the completion of the survey.",2020-09-01
2886,LINCOLN NURSING AND REHABILITATION CENTER,515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2019-01-17,732,B,0,1,VF3611,"Based on facility records and staff interview, the facility failed to ensure staff postings were complete and had the census number for each shift. This was evident for the postings that were in place for (MONTH) (YEAR) and (MONTH) (YEAR). This had the potential to affect all residents and public who wished to have access to this information. Facility census: 59. Findings included: a). Staff posting Documents of nurse staffing that was posted previously was received from the administrator on 01/16/19 at 3:14 p.m. This review revealed the forms did not cotain complete information regarding the census for each shift. This would indicate if the census of the facilty had changed and needed adjusted. The days with the incomplete information was 11/05/18, 11/17/18, 11/18/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18, 11/26/18, 11/29/18, and 11/30/18. For (MONTH) the missing information was on: 12/03/18, 12/04/18, 12/05/18 , 12/10/18, 12/11/18, 12/12/18, 12/16/18, 12,1/187, 12/18/18, and 12/19/18. Spoke with the administrator on 1/16/19 at 3:45 p.m. regarding the blanks on the staff forms. There were some days for the months of (MONTH) and (MONTH) of (YEAR) that did not show the census for some shifts. He verified the forms did contain blanks in the census section.",2020-09-01
3282,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,356,B,0,1,UXFJ11,"Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date; the current resident census; the total number and actual hours worked by registered nurses, licensed nurses, and nurse aides per shift. This had the potential to affect more than an isolated number of residents and/or visitors residing or visiting the facility. Facility census: 58. Findings include: a) Observation of the staff posting on the 2nd floor, during the initial tour of the facility, at 10:34 a.m. on 02/06/17, found the facility staff posting was dated 02/02/17. An interview with the director of nursing, at 10:35 a.m. on 02/06/17, confirmed the facility had not displayed the staff posting information for 02/03/17 through 02/06/17. .",2020-09-01
3473,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,252,B,0,1,ITHZ11,"Based on observation and staff interview, the facility failed to that six (6) of 32 rooms observed during Stage 1 of the Quality Indicator Survey was home like. Each of the sic (6) bathrooms had the following on the floor just inside the bathroom door, SV2. It appeared this was spray painted. Also the carpet in hallway of the 300 hall was stained and discolored which was not home like. Room Identifiers: 110, 111, 112, 301, 303, 304. Facility Census: 83. Findings Include: a) Room 110 Observations of Room 110 at 8:54 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. The maintenance supervisor indicated that the contractors when they built the building spray painted the letters SV2 on the concrete to let the men laying the floor know what type of flooring to put down. She indicated in some of the rooms these spray painted letter have bleed through and are now visible on the bathroom floors. b) Room 111 Observations of Room 111 at 8:47 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. c) Room 112 Observations of Room 112 at 11:06 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. d) [RM #]1 Observations of [RM #]1 at 9:59 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. e) [RM #]3 Observations of [RM #]3 at 10:11 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. f) [RM #]4 Observations of [RM #]4 at 10:07 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. A tour with the Nursing Home Administrator (NHA) beginning at 1:52 p.m. on 09/19/17 confirmed that the letters visible in each of the bathrooms was a result of the contractors spray painting the letters on the concrete and now those spray painted letter are coming up thru the flooring and is now visible. He stated that the flooring would have to be replaced. g) 300 hallway Observations during Stage 1 of the QIS survey found the carpet in the 300 hall way was stained and discolored in multiple areas. A tour with the NHA at 11:09 a.m. on 09/21/17, confirmed the carpet was stained and discolored in multiple areas. He indicated that they clean the carpet every Monday but some of the stains will just not come up. He indicated the discolored areas were just something with the carpet and no matter what they do the discolorations never improve. He indicated they would have to replace the carpet.",2020-09-01
3944,STONE PEAR PAVILION,515130,125 FOX LANE,CHESTER,WV,26034,2017-01-19,514,B,0,1,E2UQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure complete and accurately documented clinical records. The facility transcribed a medication dosage incorrectly onto the physician's orders [REDACTED]. Nursing staff documented they administered this incorrectly transcribed physician's orders [REDACTED]. Resident identifier: #84. Facility census: 52. Findings include: a) Resident #84 Review of the medical record on 01/18/17 found physician's orders [REDACTED]. The medication ordered was [MEDICATION NAME] 30 milligrams (mg) per 0.3 milliliter (ml). [MEDICATION NAME] is a blood thinner used to aid in the prevention of [MEDICAL CONDITION] (blood clots), and [MEDICAL CONDITION] embolism. The physician's orders [REDACTED]. subcutaneously once daily for [MEDICAL CONDITION], until the resident was consistently ambulating. This dose amounted to one-thirtieth of three (3) tenths of a milliliter, which is so minuscule it could not be measured accurately in a syringe. Review of the MAR found that nursing staff initialed that they gave that dosage as written on seven (7) consecutive days at 8:00 a.m. on 11/26/16, 11/27/16, 11/28/16, 11/29/16, 11/30/16, 12/01/16, and 12/02/16, without seeking clarification of the order. Further review of the medical record found the order was changed on the afternoon of 12/02/16 to inject 0.3 ml. one time daily of a 30 mg/0.3 ml solution. An interview was conducted with licensed practical nurse #114 on 01/18/17 at 9:25 a.m. He said [MEDICATION NAME] comes from the pharmacy in a prepackaged syringe. He said one (1) mg. of [MEDICATION NAME] could not possibly be correct, and that the order should have been clarified right from the start. He said that on 12/03/16 he gave the full 0.3 mg. dose of [MEDICATION NAME] as the new order specified. He said he did not recall how this order became corrected. An interview was completed with the director of nursing (DON) on 01/18/17 at 9:35 a.m. She said the syringes of [MEDICATION NAME] are pre-filled from the pharmacy at 30 mg. per 0.3 ml. She said the error was caught by the administrative nursing staff and corrected on 12/02/16. She stated her belief that nursing staff gave the correct dosages, although the physician's orders [REDACTED].",2020-04-01
3992,NELLA'S INC,51A010,499 FERGUSON ROAD,ELKINS,WV,26241,2016-05-12,371,B,0,1,GBXO11,"Based on observation and staff interview it was determined facility dietary staff did not ensure the equipment used to prepare food was kept clean and in a sanitary manner. This practice has the potential to affect residents who are served food from this central location. Census: 86. Findings include: a) During the kitchen tour after entrance at 11:15 a.m. on 05/02/16, observation revealed the drip pan under the range top had an accumulation of food debris and was in need of cleaning. This was discussed with the dietary management staff who was present at the time of the observation.",2020-04-01
4028,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2016-10-17,203,B,0,1,353M11,"Based on review of the facility's notification of transfer/discharge form and staff interview, the facility failed to ensure the notice provided complete and correct information regarding the current professional person who reviews transfer/discharge appeals at the Inspector General's office Board of Review. and contained no telephone number. This had the potential to affect more than a limited number of residents. Facility census: 91. Findings include: a) On 10/13/16 at 4:30 p.m., review of the notification of transfer/discharge form provided by the facility found it included the name of the former professional person who reviewed transfer/discharge appeals at the Inspector General's Board of Review office and it's address. The name of the professional person who reviews transfer/discharge appeals in the Inspector General's Board of Review Office was incorrect. The current professional person assumed that position approximately one and one-half year's ago, and the facility's uniform notice was not revised to reflect this. The uniform transfer/discharge form did not contain the telephone number for the office of the Inspector General's Board of Review. During interview with the DON and the administrator on 10/13/16 at 4:30 p.m., they said they were unaware of those inaccuracies.",2020-02-01
4036,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2016-10-17,516,B,0,1,353M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure the privacy of residents' personal information. A random observation found personal information including names, birth dates, admitted s, and [DIAGNOSES REDACTED]. The former residents affected were Residents #123, #124, and #125. Facility census: 91. Findings include: a) During the initial tour of the facility on 10/04/16 at approximately 10:00 a.m., observation of a large bulletin board on the wall across from the North hall nurses' station found it contained Patient Overview Reports for three (3) former residents. The residents' names, dates of birth, and medical record numbers were darkened with a black marker, but still legible. No attempt was made to block their diagnoses, payers, admitted s, or discharge destinations. 1. Resident #123 - Her name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained her admitted and discharge location. The payer source was Managed Care RU[NAME] [DIAGNOSES REDACTED]. The report showed her range of motion scores upon admission and discharge, and her bathing/showering scores upon admission and discharge. 2. Resident #124 - Her name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained her admitted and discharge location. The payer source was Medicare Part [NAME] [DIAGNOSES REDACTED]. It noted her range of motion scores for gait and transfers upon admission and discharge, and her bathing/showering scores. 3. Resident #125 - His name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained his admitted and discharge location. The payer source was the Veteran's Administration. [DIAGNOSES REDACTED]. His range of motion scores for gait and transfers were shown for admission and discharge. His bathing/showering and dressing scores were shown for admission and discharge. b) The director of nursing agreed the former resident's names, birthdates, diagnoses, functional status, payer source, and medical record numbers should not have been discernible to the public, as it was sharing identifiable personal and health information with the general public. She ensured that the patient identifiable data was covered and illegible before returning the three (3) reports to the bulletin board across from the nurse's desk.",2020-02-01
4225,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,371,B,0,1,1GMW11,"Based on observations and staff interview it was revealed the dietary staff had not ensured foods were stored in accordance with acceptable sanitation practices. Refrigeration storage areas had containers of items which were not labeled or dated as required. This practice has the potential to affect more than a limited number of residents as all residents who consume foods by oral means are served from this central location. Facility census: 84. Findings include a) The kitchen tour was completed shortly after entrance, on 08/08/16 at 11:15 a.m. The tour was completed with the assistant dietary manager. The following items were noted in the walk-in refrigerator during the observations: --Two (2) large containers of sweet BBQ (barbeque) sauce were not labeled or dated of when they were opened. --A sheet pan containing saucers which had desserts on them were not labeled nor dated indicating when they were prepared or to be used. --Four (4) plastic containers were not labeled and dated identifying what the content inside was or when it was opened. These were identified with assistant dietary manager and the dietary manager at the time of the observations and the items were immediately removed from the unit.",2020-02-01
4243,GRANT REHABILITATION AND CARE CENTER,515151,127 EARLY AVENUE,PETERSBURG,WV,26847,2015-07-30,356,B,0,1,DRSJ11,"Based on posted document observation and staff interview, the facility failed to post accurate nurse staffing data on a daily basis. This practice had the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) Upon entry to the facility at 10:45 a.m. on 07/27/15, an observation of the daily staffing sheet, posted on the wall inside the entrance door dated 07/27/15, revealed two (2) registered nurses (RN) were responsible for resident direct care. Review of staff performing direct care upon entering the facility revealed only one (1) RN responsible for direct care. At 11:15 a.m. on 07/27/15, the facility administrator reported the staffing sheet was incorrectly completed. One (1) of the two (2) RNs called off work. The staff member completing the daily staffing posting was not aware of the call off.",2020-02-01
4265,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,467,B,0,1,310011,"Based on observation and staff interview, the ventilation system for the facility's one common shower room, used by all facility residents, was not operational. This had the potential to affect all residents provided bathing care in the common shower area. Facility census 69. Findings include: During an observation of the shower area on 10/04/16 at 4:00 p.m. with the shower aide/nurse aide (NA) #74, the room was noted very humid and air movement could not be detected. A follow-up observation was conducted with the Maintenance Director #19 on 10/04/16 at 4:30 p.m. Maintenance Director #19 then went to the building roof to check on the status of the system and reported back that the air exchange system in the shower room was not working. He stated that during his inspection last month it had been working correctly and he had been unaware that the ventilation was not currently working. He explained that he would order a replacement motor later in the day on 10/04/16 with the expectation that it would be delivered on 10/06/16 and would be installed on 10/06/16. There was a window observed in the shower room that could be opened for ventilation; however, it was not observed open on 10/04/16 or 10/05/16.",2020-02-01
4371,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2016-11-11,514,B,1,0,UGKB11,"> Based on medical record review and staff interviews, the facility failed to accurately maintain medical record for meal intake percentage and/or bedtime snack acceptance for five (5) of eight (8) residents. Resident Identifiers: #1, #2, #4, #7 and #8. Facility census 93. Findings include: a) Resident #2 A review of Resident #2's activity daily living (ADL) flow record on 11/09/16 at 5:50 p.m., found in (MONTH) (YEAR), (2) breakfast, (3) lunch, and one (1) dinner meal had no percentage of Resident #2's meal intake. One (1) bedtime snack in (MONTH) (YEAR) had no evidence the resident accepted her bed time snack. In (MONTH) (YEAR), there was one (1) dinner meal had no percentage of the resident's meal intake, and no evidence for one (1) bedtime snack the resident accepted her bed time snack. The assistant director of nursing (ADON ) #98 were interviewed on 11/09/16 at 5:58 p.m., and she confirmed the meal percentage and/or bedtime snack acceptances were not completed on the ADL flow record. b) Resident #1 A review of Resident #1's ADL flow record on 11/09/16 at 6:10 p.m., revealed in (MONTH) (YEAR), three (3) times for breakfast, two (2) times for lunch, and six (6) times for dinner the ADL flow record had no evidence of the percentage Resident #1 had consumed during her meals. Ten (10) times in (MONTH) (YEAR), there was no evidence the resident accepted her bed time snack. In (MONTH) (YEAR), there is no evidence of Resident #1's meal intake for five (5) dinner meals. There were Nine (9) bedtime snack in (MONTH) (YEAR) had no evidence the resident had accepted her snack. In (MONTH) (YEAR), there is no evidence for one (1) breakfast and one (1) lunch meal intake percentages. In an interview and review of Resident #1's ADL flow record on 11/09/16 at 6:18 p.m., with the ADON #91. She reviewed the meal percentage and the acceptance for the bedtime snacks for August, (MONTH) and (MONTH) (YEAR). The ADON confirmed the staff had left the area blank. Employee #91 said after every meal, we put the meal ticket in the in the staff assignment book, and then the Nurse - aide (NA) who is responsible for that resident documents the meal percentages on their activity daily flow. The ADON also said the NA is responsible for putting whether the resident accepts her bedtime snack. c) Resident #4 Review of the activities of daily living (ADL) flow sheets for this resident found the following incomplete documentation of the percentages of meals and/or bedtime snack intake: --09/04/16, 09/09/16, 09/10/16, 09/12/16, 09/14/16 had no percentages recorded for the dinner meals --09/09/16, 09/10/16, 09/11/16, 09/12/16, had no documentation of a snack offered to the resident. An interview was conducted with the director of nursing on 11/11/16 at 11:00 a.m. She agreed that staff is supposed to record meal percentages every meal, and staff know to do so. She acknowledged the missing data. She said she has been working with staff on maintaining accurate record keeping of the meal and snack intakes. d) Resident #7 Review of the ADL records for the past three months, on 11/10/16 at 2:28 p.m., revealed gaps in the records. Review of (MONTH) (YEAR) ADL record (11/01/16 through 11/10/16) revealed there were no entries missing for the percentage of any meals or any snacks. Review of (MONTH) (YEAR) ADL record revealed an entry missing for meal percentages for dinner on 10/29/16 and a missing entry for meal percentage for snacks on 10/15/16 and 10/17/16. Review of (MONTH) (YEAR) ADL record revealed no entry for meal percentages for dinner on 09/29/16. There were missing entries for meal percentage for lunch on 09/30/16 and 09/31/16. There were missing entries for meal percentage for breakfast on 09/29/16 and 09/31/16. e) Resident #8 Review of ADL Records for last three (3) months revealed no missing entries for the percentage of meals or snacks for the month of (MONTH) (YEAR) or (MONTH) (YEAR) (11/01/16 through 11/10/16). In the month of (MONTH) (YEAR) there were two (2) missing meal percentages. On 09/12/16 and 09/14/16 there were no entries for the percentage of dinner eaten.",2019-11-01
4437,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2016-02-03,514,B,0,1,47S511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a complete, accurately documented clinical record for one (1) of five (5) sampled residents reviewed for unnecessary medications. A resident receiving opiate pain medication several times daily had no documented bowel movements throughout an eight (8) day period. During this period, the clinical record lacked numerous nurse aide flow records, which should have reflected the resident's bowel movements, or lack thereof. Resident identifier: #8. Facility census: 83. Findings include: a) Resident #78 Review of the medical record on 01/28/16 at 9:00 a.m., found this resident received an opioid pain medication, [MEDICATION NAME] 5 milligrams (mg), three (3) times daily. (Opioid medications have the potential to cause constipation, sometimes to the point of fecal impaction.) The resident's [DIAGNOSES REDACTED]. Review of both the electronic aide flow records and the paper records for the month of (MONTH) (YEAR), revealed the records were silent for evidence of bowel movements (BMs) in the eight (8) day period between 01/11/16 and 01/19/16. During an interview with the director of nursing (DON) on 01/28/16 at 4:30 p.m., she said she was unable to find evidence of any bowel movements for this resident between 01/11/16 and 01/19/16. She said she believed the lapse in recorded BMs from the 11th to the 19th of (MONTH) (YEAR), were documentation errors of not recording them. A review of the computerized nurse aide flow records at 3:00 p.m. on 02/02/16, found the following dates and shifts had no nurse aide flow records for Resident #78: -- Day shift - on 01/12/16, 01/14/16, 01/15/16, and 01/17/16. -- Evening shift - 01/17/16 and 01/18/16. -- Night shift - 01/14/16, 01/17/16, and 01/18/16. No further information was provided prior to exit.",2019-11-01
4608,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2016-02-29,514,B,0,1,7MOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, policy review, and staff interview, the facility failed to maintain accurate clinical records for four (4) of nineteen (19) residents whose medical records were reviewed during Stage 2 of the Quality Indicator Survey (QIS). The facility failed to document conversations with Resident #102 and #97 relating to care planning, failed to document conversation with Resident #97 relating to a room change, failed to document an oral pain assessment and the reason for refusal of medications for Resident #37, and failed to document intake on an activity of daily living (ADLs) flow sheet for Resident #36. Resident identifiers: #102, #97, #37, and #36. Facility census: 64. Findings include: a) Resident #102 During Stage 1 of the Quality Indicator Survey (QIS) on 02/23/16 at 11:04 a.m., Resident #102 responded to the question, Do staff include you in decisions about your medicine, therapy, or other treatments, by stating, I cant think when they did. b) Resident #97 During Stage 1 of the QIS Resident #97 responded the the question; Do staff include you in decisions about your medicine, therapy, or other treatments, by stating, no they don't. c) On 02/23/16 review of medical records for Residents #102 and #97, found numerous social service notes in which information concerning the residents' care was reported to their respective medical power of attorney with no mention of discussing the same information with the resident. On 02/24/16 at 3:23 p.m., the facility's licensed social worker explained that she speaks to both the residents almost daily, but they do not attend the care plan meetings. She stated the medical power of attorney for each of these residents had requested the resident not attend the care plan meetings due to their inability to accept they cannot go home at this time. The social worker went on to state that in general, residents without medical capacity were not invited to the care plan meetings. She also stated she did discuss care and care planning with the residents, but she did not document this discussion. The medical records revealed no evidence the social worker discussed individualized care with these resident. d) Resident #97 On 02/11/16 at 1:28 p.m., during Stage 1 of the Quality Indicator Survey (QIS), when asked if a notice had been given before a room change, Resident #97 stated No. In an interview on 02/24/16 at 3:32 p.m., when asked to assist in finding any evidence this resident was notified regarding a room change, the Social Worker (SW) reviewed the resident's electronic medical record (EMR). After her review, she stated, I guess I didn't make a note in the chart regarding this room move. She further stated she remembered talking with family members of Resident #97, but failed to complete the facility transfer record. She agreed she should have noted the request for transfer in the medical record. e) Resident #37 On 02/24/16 at 2:08 p.m., a review of the physician orders [REDACTED]. A concurrent review of the Medication Administration Record [REDACTED]. No evidence was found on the MAR indicated [REDACTED]. The director of nursing (DON) was asked to provide the facility policy and procedure regarding the refusal of medication by a resident on 02/29/16 at 2:20 p.m On 02/29/16 at 2:30 p.m., a review of the policy and procedure titled Medication Administration: General revealed in section 8.3 For medication refused by patient, circle your initials in the date and time space where that medication is ordered, and document patient's refusal of medication on the back of the MAR. An interview with Licensed Practical Nurse (LPN) #55 on 02/29/16 at 1:40 p.m., revealed she was aware of the policy regarding documentation of refusal of medication by a resident. She stated they (staff) were to document the reason for the refusal on the back of the MAR, . but we are not very good about doing this. f) Resident #36 Medical record review on 02/25/16 at 9:00 a.m., found this [AGE] year old resident had [DIAGNOSES REDACTED]. Review of the activities of daily living (ADL) record found the meals and liquids were recorded together as an overall percentage of intake. Her overall intake was poor to fair in (MONTH) and (MONTH) (YEAR). There were numerous blank spaces where staff failed to record any percentage of the meal or snack intake. These omissions were: -- 01/10/16 for all three (3) meals, -- 01/21/16, 01/22/16, 01/23/16, 01/24/16, for breakfast and lunch, and -- 01/25/16 for all three (3) meals. Staff did not record bedtime snacks on ten (10) of thirty-one (31) days in (MONTH) (YEAR). In (MONTH) (YEAR), staff did not record: -- breakfast intake on three (3) of twenty-four (24) days; -- lunch intake on four (4) of twenty-four (24) days; -- dinner intake on four (4) of twenty-four (24) days. Staff did not record bedtime snack intake on four (4) of twenty-four (24) days. The current ADL book contained an in-service education form dated 01/11/16, as presented by the speech therapist. It directed staff to allow 30-45 minutes per meal with multiple rest breaks when they fed the resident. If the resident's intake was less than twenty-five percent (25%), staff must offer a milkshake with ice cream and nectar thick milk. Observation of the noon meal on 02/25/16 at 12:00 p.m. found a nurse aide sitting on a chair by the bed as she assisted the resident with the meal. The resident could sip liquids through a straw, but she was unable to reach for the cup, or hold the cup by herself. In an interview with Director of Dietary Services #65, on 02/25/16 at 12:42 p.m., she acknowledged the many blanks on the ADL meal intake record for (MONTH) and (MONTH) (YEAR). She said the dietary kitchen daily sends a 10:00 a.m., 2:00 p.m. and a bedtime snack for this resident. By reviewing the ADL record, she was unable to determine the amount of fluids the resident consumed each day in (MONTH) or (MONTH) (YEAR).",2019-09-01
4782,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2016-01-14,372,B,0,1,D0ID11,"Based on observations of the dumpsters, it was determined the hinged dumpster was not consistently closed, thereby allowing trash to blow out of the container and collect in the area behind the facility along the railroad tracks and the river wall. This had the potential to affect all residents. Facility census: 159. Findings include: a) Observations of the dumpster on 01/11/16 at 8:15 a.m. and 2:00 p.m., on 11/12/16 at 11:30 a.m., on 11/13/16 at 3:30 p.m., and on 01/14/16 at 2:00 p.m., found the hinged lid on the dumpster left open on each of the four (4) days of the survey. Adjacent to the hinge-lidded dumpster was a trash compactor. The door to the compactor was consistently observed to be closed. Observations on 01/11/16 at 8:15 a.m., noted the contents of the dumpster were bagged; however, there was trash blowing around the area. The trash included numerous cigarette butts, napkins, drink lids, bread wrappers, a green bell pepper, empty soda cans and bottles, a large blue plastic bag, straws, pepper packet wrappers, candy wrappers, a portion of a broken fluorescent light bulb, and Pride butter packets. During observation and interview with Dietary Manager #70 on 01/11/16 at 8:15 a.m., he stated kitchen staff utilized the compacter, and housekeeping utilized the dumpster. The back area of the facility butted up against a railroad track and the river wall. The facility grounds ended at the top of the raised area between the curb and the railroad tracks. The majority of the trash was on the railroad tracks and near the wall, not the facility's property. During an interview with Maintenance Director #16, on 01/13/16 at 3:00 p.m., he stated that since the railroad track was not their property, they did not pick up trash on that property. He believed that the majority of the trash observed fell out of the trash truck during their daily pick up at the facility. He stated that the trash service was responsible for getting out of their truck and picking up what they spilled.",2019-07-01
4999,STONE PEAR PAVILION,515130,125 FOX LANE,CHESTER,WV,26034,2015-10-01,241,B,0,1,GCQW11,"Based on observation, record review, resident interview, and staff interview, the facility failed to provide care to residents in a manner that enhanced each resident's dignity. The facility failed to administer morning medications in a dignified and respectful manner that recognized each resident's individuality. Random observations were made of residents lined-up in wheelchairs at the medication cart waiting for morning medications. This had the potential to affect more than a limited number of residents. Facility census: 55. Findings include: a) Medication Pass Random observations, on 09/28/15 at 7:48 a.m., revealed seven (7) residents on the East hallway seated in wheelchairs waiting in line for medications from the nurse. A nurse was standing at the medication cart located in the East hallway outside the nursing station. Interview with a resident waiting in line revealed, We wait in line for medications then go to the dining room for breakfast. Observations on 09/29/15 at 8:32 a.m., revealed three (3) residents seated in wheelchairs in a line in front of the medication cart on the West hallway. Residents were waiting in line to have Licensed Practical Nurse (LPN) #14 administer their medications. Interview with Registered Nurse (RN) #4, on 09/30/15 at 10:50 a.m., verified the residents were lined up in the hallway at the medication cart. She stated during the six (6) years of her employment, medications had always been administered in the hallway. She stated residents have the right to receive medications in the hallway. When told residents expressed they had to wait in line for their medications before breakfast, RN #4 stated residents could bypass the medication cart and go directly to breakfast, if they choose. She stated if residents wanted their medications administered in their rooms, they were accommodated. Interview with NA #23, on 09/30/15 at 11:07 a.m., revealed she wheeled residents down to the medication cart. If there was a long line, she would ask the nurse the wait time. She said she lined the residents up if the wait was short. She stated some residents bypass the medication cart and went directly to breakfast. Interview with LPN #10, on 09/30/2015 at 11:45 a.m., verified she passes medications in the hallway. She stated eye drops and injections were administered in the resident's room. She confirmed the NAs brought residents to the medication cart and lined them up for their medications. She stated residents wait in line for their medications before going to breakfast. Furthermore, she stated medication administration had always been done like that, with the residents waiting in line in the hallway.",2019-04-01
5073,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2015-09-14,278,B,0,1,HR8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to complete an assessment to accurately reflect the resident's status. Resident #77 had experienced a significant weight loss. This weight loss was incorrectly assessed on three (3) of three (3) Minimum Data Set (MDS) assessments. Resident identifier: #77. Facility census: 88. Findings include: a) Resident #77 A medical record review for Resident #77, on 09/14/15 at 12:00 p.m., revealed Resident #77 was admitted on [DATE] with diagnoses, including [MEDICAL CONDITION] end of right tibia, dislocation of unspecified ankle joint, gastro-[MEDICAL CONDITION] reflux disease without esophagitis, and periapical (encompassing or surrounding the tip of the root of a tooth) abscess without sinus. Her admission weight on 05/29/15 was 238.8 pounds using a mechanical lift. Her weight on 06/10/15 was 221.6 pounds, and this weight was used on the 14-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/12/15. However, the assessment question at item (K0300) Loss of 5% or more in the last month or loss of 10% or more in last 6 months was answered 0. No or unknown. The general progress note completed by the Dietary Manager #12, on 06/12/15, the same day she completed the MDS stated, Resident has had a 7% wt. (weight) loss since admission. The registered dietician confirmed this in her 06/19/15 note which stated Review for wt (weight) loss: Resident has experienced a 7.2% wt decline The next MDS completed was a 30-day assessment dated with ARD of 06/26/15. The most current weight used for this assessment is still the 221.6 weight from 06/10/15. Again, the question K0300 Loss of 5% or more in the last month or loss of 10% or more in last 6 months was answered 0. No or unknown. A 60 day MDS assessment was completed with an ARD of 07/24/15 and the most recent weight of 213, obtained 07/15/15, was used. Again, the question at item (K0300) Loss of 5% or more in the last month or loss of 10% or more in the last 6 months was answered 0. No or unknown. This weight of 213 was documented by the Dietary Manager #12 as a 10.8% weight loss x 3 months in her 9/18/15 progress note. The registered dietician documented on 08/25/15 in her general note Resident has experienced a 10.8% wt decline The appropriate weights were used when completing the MDS. The dietary department documented the significant weight loss. The care plan included the significant weight loss. The MDS did not reflect the significant weight loss on any of the three (3) assessments listed above. This matter was discussed with the administrator and director of nursing 09/14/15 at 12:30 p.m. They acknowledged the pattern of errors for this resident. The dietary manager was not available for an interview.",2019-03-01
5188,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2016-03-03,329,B,1,0,MTOL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for unnecessary medications during a complaint survey did not receive an atypical antipsychotic without adequate indications for the use of the drug. Resident identifier: #5. Facility census: 125. Findings include: a) Resident #5 Review of Resident's #5's medical records on 03/03/16 beginning at 9:00 a.m., revealed a physician's orders [REDACTED]. A nursing note, dated 07/19/15, revealed the facility called the residents son ., to see if he wanted [MEDICATION NAME] (same as [MEDICATION NAME]) started. He stated that he would read up on it at home and sign it if he wanted to start the medications when he is in to visit again. I told him I would place the psychotic medication informed consent in her chart for him to sign if he decided to have his mother take it. The medical record review found there were no behaviors, or evidence the resident was at risk of harming herself or others, for at least 24 hours prior to the medication being initiated. The record was silent for evidence she was exhibiting behaviors on (MONTH) 19, (YEAR), (MONTH) 20, (YEAR), or (MONTH) 21, (YEAR). The Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. An additional physician order [REDACTED]. [MEDICATION NAME] was administered to Resident #5 on three (3) occasions after the resident's son verbally indicated he wanted the antipsychotic medication held until further notice. On 03/03/16 at 2:20 p.m., the director of nursing stated the mediation was given, held, and discontinued according to physician orders.",2019-03-01
5219,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2015-09-16,156,B,0,1,5JCO11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 81 Findings include: a) Observation of the facility, on 09/14/15 at 11:45 a.m., revealed there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview with the Nursing Home Administrator, on 09/16/15 at 10:20 a.m., verified the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits.",2019-02-01
5229,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,156,B,0,1,76WG11,"Based on observation, staff interview, and resident interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits, or how to contact the State Ombudsman. The facility did not prominently display the written information regarding these benefits or the Ombudsman contact information. This had the potential to affect more than an isolated number of residents. Facility census: 160 Findings include: a) On 07/22/15 at 1:35 p.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform residents or responsible parties about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview with the Nursing Home Administrator on 07/22/15 at 3:07 p.m., revealed she was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. b) Ombudsman Information On 07/20/15 at 1:00 p.m., during an interview with the resident council president, the president did not know if the facility had the Ombudsman contact information posted. At 1:20 p.m. on 07/20/15, Director of Nursing #205 and Assistant Administrator #235 toured the facility and confirmed the facility did not have the Ombudsman contact information posted.",2019-02-01
5230,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,167,B,0,1,76WG11,"Based on observation and staff interview, the facility failed to ensure a notice of the results of the most recent survey and any plans of correction were in a place readily accessible to residents. The survey results book was located on the wall at a height not accessible to residents in wheelchairs. This practice had the potential to affect more than an isolated number of residents. Facility census: 160. Findings include: a) An observation on 07/22/15 at 1:35 p.m., revealed the survey results book was located in a plastic holder that hung against a wall in the front lobby. The book was too high for residents in a wheelchair to reach. On 07/22/15 at 3:07 p.m., the Nursing Home Administrator agreed the survey book was not located at a height accessible to a resident in a wheelchair. She stated the survey book would be moved to a location accessible to residents in wheelchairs.",2019-02-01
5257,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-09-30,278,B,0,1,C8H511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each individual completing Minimum Data Set (MDS) assessments completed the assessments to accurately reflect the resident's condition. Resident #83's assessment did not identify weight loss. Resident #9's MDS did not indicate the resident received Hospice services. Resident #34's assessment did not include the resident's active [DIAGNOSES REDACTED].#62's assessment did not identify the use of antianxiety medication. Assessment coding errors were found for four (4) of sixteen (16) sample residents. Resident identifiers: #83, #9, #34, and #62. Facility Census: 58. Findings include: a) Resident #83 This resident's 14-day MDS assessment, with an assessment reference date (ARD) of 06/26/15, listed the resident's weight as 165 pounds (#). The next MDS, with an ARD of 07/21/15, indicated the resident's weight was 139#, but was not identified as a weight decline of 5% or more in the last month in item K0300. On 09/30/15 at 10:30 a.m., the MDS coordinator verified the 07/21/15 assessment should have been coded showing the weight loss. b) Resident #9 Review of the resident's quarterly MDS with an ARD of 07/30/15, found the assessment failed to show the resident was receiving hospice services during the look back period for the assessment. A significant change MDS with an ARD of 05/16/15, had identified the resident received Hospice services. Hospice services had begun at that time and were identified on the MDS. It was not carried over onto the 07/30/15 assessment. Discussion with the MDS coordinator on 09/29/15 at 10:25 a.m. revealed the assessment was coded in error and should have indicated the resident continued to receive hospice services. c) Resident #34 A review of the medical record for Resident #34, on 09/29/15 1:35 p.m., revealed the quarterly MDS assessment with an assessment reference date (ARD) of 08/20/15, did not accurately reflect a [DIAGNOSES REDACTED]. The current physician's orders [REDACTED].#34 had a current order for [MEDICATION NAME] 200 milligrams (mg) at bedtime for [MEDICAL CONDITION] disorder. Review of the Medication Administration Record [REDACTED]. An interview on 09/29/15 at 2:35 p.m., with the MDS Coordinator, verified Section I Active [DIAGNOSES REDACTED].#34. d) Resident #62 Review of medical records found a quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/18/15, identified the resident received an antipsychotic, a diuretic, an anticoagulant, and antibiotic on each of the 7 days in the look back period in Section N, Item N0410 - Medication Received. On 09/29/15 at 10:55 a.m., review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of physician orders [REDACTED]. On 09/30/15 at 9:46 a.m., the DON verified the antianxiety medication should have been indicated on the MDS with an ARD of 09/18/15 for the [MEDICATION NAME] Resident #62 was taking for anxiety.",2019-02-01
5259,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-09-30,371,B,0,1,C8H511,"Based on staff interview and observation, the facility did not ensure food was stored in a sanitary manner. Food items in the dry food storage area and the walk-in refrigerator were found to not be labeled with the name of the item or the date it was opened. This practice had the potential to affect more than a limited number of residents as all residents were fed from this central location. Facility census: 58. Findings include: a) During the initial tour of the dietary department at 11:15 a.m. on 09/27/15, the following items were observed: 1. In the dry food storage area a package of elbow macaroni was on the shelf not labeled or dated of when it was opened. 2. The walk-in refrigerator had a plastic bag that contained lettuce which was not dated of when it was opened. 3. The walk-in freezer storage area had a plastic bag which had broccoli and cauliflower in it and the package did not contain a date of when the product was opened. This practice did not allow the dietary staff to determine how long the product has been opened and if it was still safe for consumption. b) These items were brought to the attention of the cook at the time and then was discussed with the administrator and consultant dietitian on 09/29/15 prior to lunch.",2019-02-01
5343,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2015-01-28,156,B,0,1,11X211,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 64 Findings include: a) On 01/20/15 at 11:45 a.m., during an observation of the facility, observation revealed there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. During an interview on 01/27/15 at 9:30 a.m. the Nursing Home Administer was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits.",2019-01-01
5344,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2015-01-28,167,B,0,1,11X211,"Based on observation and staff interview, the facility failed to post the annual survey results in a prominent and readily available area where residents and families may access without asking for assistance. This practice had the potential to affect more than an isolated number of residents. Facility census: 64 Finding include: a) Observation on 01/20/15 at 3:30 p.m. revealed the results of the past annual survey were located on the wall at the nursing station. They were located high on the wall, behind a tall medication cart. b) An observation and interview with Employee #78, on 01/28/15 at 3:30 p.m., indicated a resident in a wheelchair would not be able to reach the annual survey results without difficulty. Facility personal moved the survey results to a more accessible location for residents.",2019-01-01
5369,MEADOW GARDEN,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2015-06-25,167,B,0,1,1EZS11,"Based on observation and staff interview, the facility failed to ensure a notice of the results of the most recent survey and any plans of correction were in a place readily accessible to residents. The survey results book was located on a wall at a height that was not accessible to residents in wheelchairs. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) An observation on 06/24/15 at 9:00 a.m., revealed the survey results book was located on the wall in front of the nurse's station. The book was placed in a plastic holder that was too high for residents in wheelchairs to reach. On 06/25/15 at 1:33 p.m., a second observation of the survey results book revealed it was still located at a height that was not accessible to residents in wheelchairs. At 1:45 p.m. on 06/25/15, Director of Nursing #68 agreed the survey book was located at a height that was not accessible to residents in wheelchairs. She said she could move the survey book to a lower level which would make it easier to view if someone was in a wheelchair.",2019-01-01
5442,SUMMERS NURSING AND REHABILITATION CENTER,515170,198 JOHN COOK NURSING HOME ROAD,HINTON,WV,25951,2015-07-09,278,B,0,1,R3IE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0 (RAI Manual), and staff interview, the facility failed to ensure three (3) quarterly assessments and one (1) discharge return anticipated assessment, accurately reflected the residents' status for three (3) of sixteen (16) residents whose minimum data set (MDS) assessments were reviewed during Stage 2 of the survey. Resident #26 was inaccurately assessed as taking a hypnotic medication when she was not. Resident #34 was inaccurately assessed as taking a diuretic medication when she was not. Resident #68 had two (2) quarterly assessments which were not coded to reflect the [DIAGNOSES REDACTED]. Resident identifiers: #26, #34, and #68. Facility census: 109. Findings Include: a) Resident #26 A review of Resident #26's medical record at 9:30 a.m. on 07/08/15, revealed a discharge return anticipated minimum date set (MDS) assessment, with an assessment reference date (ARD) of 02/14/15. Item N0410 D. Hypnotic was coded with a six (6). This indicated Resident #26 received a Hypnotic medication six (6) of the seven (7) days during the look back period. Review of Resident #26's Medication Administration Records (MARs) for the month of (MONTH) (YEAR), found Resident #26 did not receive any hypnotic medications during the seven (7) day look back period. The instructions in the RAI Manual for coding Item N0410 are: Indicate the number of days the resident received the following medications during the last 7 (seven) days or since admission/entry or reentry if less than 7 (seven) days. Enter 0 (zero) if medication was not received by the resident during the last 7 (seven) days. An interview with Registered Nurse Assessment Coordinator (RNAC) #43 at 2:30 p.m. on 07/08/15, confirmed Resident #26 did not receive a hypnotic medication during the seven (7) day look back period. She stated, I must have counted the [MEDICATION NAME] because she receives it for [MEDICAL CONDITION]. RNAC #43 then confirmed that [MEDICATION NAME] was not a hypnotic and the MDS was inaccurately coded. b) Resident #34 A review of Resident #34's medical record at 2:06 p.m. on 07/08/15, found the quarterly MDS with an ARD of 11/26/14 coded with a 7 for item N0410 G. Diuretic. This indicated Resident #34 received a diuretic medication seven (7) of the seven (7) days during the look back period. Review of Resident #34's Medication Administration Records (MARs) for the month of (MONTH) 2014 found Resident #34 did not receive any diuretic medications during the seven (7) day look back period. The instructions for coding Item N0410 in the RAI Manual are: Indicate the number of days the resident received the following medications during the last 7 (seven) days or since admission/entry or reentry if less than 7 (seven) days. Enter 0 (zero) if medication was not received by the resident during the last 7 (seven) days. An interview with Director of Nursing (DON) #42 at 4:10 p.m. on 07/08/15, confirmed Resident #34 did not receive a diuretic medication during the seven (7) day look back period. She indicated they must have counted the resident's [MEDICATION NAME] (an antihypertensive) as a diuretic, but confirmed that was inaccurate and the MDS would need to be corrected. c) Resident #68 Review of the medical record on 07/07/15 at 1:30 p.m., found a physician's progress note dated 11/08/14, which addressed the resident's bladder obstruction and the need for an indwelling urinary catheter. According to the quarterly minimum data set (MDS), with and assessment reference date (ARD) of 02/15/15, this resident had an indwelling urinary catheter. Item I1650 was coded as not having a [DIAGNOSES REDACTED]. Review of the quarterly MDS, with an ARD of 05/08/15, found this resident continued to have an indwelling urinary catheter. Item I1650 again was not coded as the resident having a [DIAGNOSES REDACTED]. During an interview with an MDS coordinator, Registered Nurse #44, on 07/07/15 at 3:55 p.m., she said both the 02/15/15 and the 05/08/15 quarterly MDSs were incorrectly coded for Item I1650. She said the [DIAGNOSES REDACTED]. She said it would be coded correctly on the next MDS.",2019-01-01
5477,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2015-09-24,156,B,0,1,HNWB11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 65. Findings include: a) On 09/21/15 at 11:45 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview on 09/24/15 at 10:20 a.m., the Nursing Home Administrator, agreed the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits.",2019-01-01
5478,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2015-09-24,253,B,0,1,HNWB11,"Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior. Observations during Stage 1 and Stage 2 of the Quality Indicator Survey (QIS) found fourteen (14) rooms on the 100 hallway, and two (2) rooms on the 200 hallway, had window dressings detached from the rods, causing the drapes to hang unevenly. This was found in Rooms 100, 101, 102, 103, 104, 105, 107, 108, 109, 110, 111, 112, 113, 114, 213, and 215. Facility census: 65 Findings include a) Window dressings on 100 hallway Observations on 09/22/15 at 8:51 a.m., revealed rooms 100, 101, 102, 103, 104, 105, 107, 108, 109, 110, 111, 112, 113 and 114, had drapes detached from the rods causing the drapes to hang unevenly. b) Window dressings on 200 hallway Observation on 09/22/15 at 9:40 a.m., discovered rooms 213 and 215 had curtains separated from the rods causing the curtains to hang unevenly. c) Tour with the Nursing Home Administrator A tour with the Nursing Home Administrator (NHA), beginning at 10:00 a.m. on 09/24/15, confirmed these cosmetic imperfections. He verified the drapes in the residents' rooms on the 100 and 200 hallways needed to be repaired.",2019-01-01
5482,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2015-07-30,272,B,0,1,ZCVH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it was determined the facility had not conducted an accurate assessment of each resident's condition in the area of medical prognosis and uncessary medications for four (4) of 13 minimum data set (MDS) assessments reviewed. Resident identifiers: #73, #20, #68, and #6. Facility census: 56. Findings include: a) Resident #73 This resident was admitted on [DATE] and had orders for comfort measures only. He was offered Hospice services but declined. According to the medical record, reviewed on the afternoon of [DATE], the resident expired at the facility on [DATE]. The admission MDS with an assessment review date (ARD) of [DATE] did not indicate the resident had a condition or terminal illness which would result in a life expectancy of less than six (6) months. Orders showed the resident had comfort care, which began [DATE], and [MEDICATION NAME] for pain ordered on [DATE]. The most recent care plan contained a problem listed as palliative care due to terminal illness. Nursing notes, dated [DATE], revealed the resident was offered hospice services but declined. On [DATE] and [DATE] there were orders to not provide intravenous (IV) medications, tube feedings, or do lab sticks. b) Resident #20 Review of Resident #20's medical record, on [DATE] at 3:10 p.m., found a history and physical (H&P) dated [DATE]. The H&P revealed the resident was offered Hospice services. The resident denied these services. Nursing notes dated [DATE] reflected the resident as being in the dying process, and taking [MEDICATION NAME] for increasing pain. The resident did expire later on [DATE]. Resident #20 was admitted on [DATE] with a Do Not Resuscitate (DNR) order as well as orders for [MEDICATION NAME] and [MEDICATION NAME]. A physician's orders [REDACTED]. The admission MDS with an assessment reference date of [DATE] did not have yes marked under the prognosis in Section J. This section reflected whether or not he resident had a condition or terminal illness which would lead to a life expectancy of six (6) months or less. Interview with Registered Nurse/Minimum Data Set (RN/MDS) Nurse #32, on [DATE] at 3:10 p.m., verified the resident assessments should have been coded as yes for a prognosis of terminal illness with six (6) months to live under Section J of the MDS assessment.RN/MDS #32 confirmed pain and comfort measures only were in place, plus the offer to provide Hospice were factors associated with an illness leading to a life expectancy of six (6) months or less. c) Resident #68A review of Resident #68's medical record, completed on [DATE] at 2:00 p.m., revealed an admission date of [DATE]. On [DATE] the attending physician completed a History and Physical (H&P) for Resident #68. The assessment and plan read, Metastasis [MEDICAL CONDITION] Comfort end of life care in the dying process. Additionally, a progress note, date [DATE] by the physician read, . Poor prognosis .The medical record contained an admission MDS with an assessment reference date (ARD) of [DATE]. This MDS, under section (J1400 Prognosis), was coded to reflect Resident #68 did not have a condition or chronic disease that may result in a life expectancy of less than six (6) months. Review of the Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument User's Manual Version 3.0 dated (MONTH) 2013 (RAI Manual), on [DATE] at 2:30 p.m., revealed: on page J-24 of the RAI manual, the following was written in regards to (section J1400) of the MDS, Code 1, Yes: If the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. During an interview, on [DATE] at 3:30 p.m., the MDS Coordinator/registered nurse (MDSRN) #49 stated she did not code Resident #68's MDS as yes because the family had refused hospice services and she thought the resident had to be under the care of hospice services. When the physician's H&P and progress notes were reviewed with Employee #49, she then agreed she had not coded Section J1400 accurately. d) Resident #6 A review Resident #6's medical record at 8:41 a.m. on [DATE], found an admission physician order [REDACTED]. The Medication Administration Record [REDACTED]. Further review of the medical record found an admission minimum data set (MDS) revelaed an assessment reference date (ARD) of ,[DATE]//15. Review of this MDS revealed Section N0410. Medication Received E. Anticoagulant, marked with a zero (0) indicating resident #6 did not receive an anticoagulant in the seven (7) day look back period from [DATE]. Section N0410 contained directions to, Indicate the number of days the resident received the following medications during the last 7 (seven) days or since admission/entry or reentry if less than 7 (seven) days. Enter 0 (zero) if medication was not received by the resident during the last 7 (seven) days. Review of Mosby's (YEAR) Nursing Drug Reference book, found Xarelto listed on page 1,028. The functional class of Xarelto was listed as an anticoagulant. An interview with the RN/MDS Nurse #32 at 9:45 a.m. on [DATE], confirmed Resident #6 was administered Xarelto seven (7) of the seven (7) days during the look back period. She stated she did not count this medication as an anticoagulant because it is not monitored with laboratory testing as most anticoagulant therapies. She indicated this is why she recorded a zero (0) on section N0410 E. Anticoagulant for this MDS. She stated she was not aware it should be counted as an anticoagulant for MDS purposes.",2019-01-01
5507,MINNIE HAMILTON HEALTH CARE,51A013,186 HOSPITAL DRIVE,GRANTSVILLE,WV,26147,2015-10-07,156,B,0,1,WP4G11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 22 Findings include: a) On 10/05/15 at 11:45 a.m., an observation of the facility revealed there was no written information posted in the facility to inform a resident how to apply for and use Medicare benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview, on 10/06/15 at 9:45 a.m., the Director of Social Services agreed the information was not posted prominently to inform residents on how to apply for and use Medicare benefits.",2019-01-01
5932,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2015-01-16,356,B,0,1,947511,"Based on observation and staff interview the facility failed to post nurse staffing data that reflected the current date and the facility's census. The facility staff posting on 01/13/15, the first day of the Quality Indicator Survey was for the week of 12/07/14 through 12/13/14. Additionally, when the facility provided the accurate posting for the week of 01/11/15 through 01/17/15 the census for 01/11/15 and 01/12/15 was not contained on the form. This had the potential to affect more than an isolated of residents currently residing in the facility. Facility census: 38 Findings include: The staff posting was observed, at 2:30 p.m. on 01/13/15, during the initial tour of the second floor. The posting was for the week of 12/07/14 through 12/13/14. It did not contain the census for any of the seven (7) days during that week. An interview with the director of nursing (DON), at 3:58 p.m. on 01/13/15, confirmed the staff posting is always there and accurate. She stated she would have to try to find out where it was and why it was not posted. She confirmed the staff posting, which was posted, was for the week of 12/07/14 through 12/13/14. At 4:15 p.m., on 01/13/15, the human resources director presented the staff posting for the week of 01/11/15 to 01/17/15. The dates of 01/11/15, 01/12/15 and for the 7-3 shift of 01/13/15 was completed on the form, but the census was not filled out for those dates. When asked why it was not posted in a prominent place at the time of the initial tour she stated, I came and got it to make sure it was updated and forgot to put it back up. When asked if the census was included on the staff posting she stated, It's not on these, should it be?",2018-05-01
6047,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,356,B,0,1,R3PM11,The facility failed to ensure the posted nurse staffing data was completed and available for viewing by the residents and/or visitors. The total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were not posted for day shift in Building 1. This had the potential to affect more than a limited number of residents and/or visitors. Facility census: 135. Findings include: a) The completion of the initial tour of building one (1) of the facility took place on 03/17/14 at 12:15 p.m. Observations at and near the nurses' station revealed the facility had not posted the staffing numbers for day shift on 03/17/14. An interview with Employee #119 (nursing supervisor) and Employee #25 (assistant director of nursing) revealed the facility had not posted the required staff posting for 03/17/14 day shift. They said the employee who normally completed the posting was not working on 03/17/14. The nurses went on to say that no other employee had completed this posting on 03/17/14.,2018-05-01
6122,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,356,B,0,1,L8JN11,"Based on observation and staff interview, the facility failed to ensure the residents and/or public were informed on a daily basis of the nurse staffing data as required by 42 CFR 483.30(e). The facility failed to include the actual hours worked by the direct care staff on the posting. This had the potential to affect more than a limited number of residents. Facility census: 111. Findings include: a) On 05/15/14 at 1:30 p.m., the nurse staffing data posted daily was reviewed. The actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care each shift was not included in the postings. The form in use did not require inclusion of the hours worked for registered nurses, licensed practical nurses, and nurse aides. This was pointed out to the Administrator at 3:00 p.m. on 05/15/14. He stated he would have this corrected.",2018-05-01
6174,MILETREE CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2014-09-23,167,B,0,1,577211,"Based on observation, resident interview, and staff interview, the facility failed to make survey results of Federal and State surveys readily accessible to residents. The facility posted the survey too high for a person sitting in a wheelchair to reach This had the potential to affect more than a limited number of residents. Facility census: 62. Findings include: a) Upon initial entry into the facility, on 09/14/14 at 4:15 p.m., the survey results were observed attached to the wall at a height too high to be accessible to a person sitting in a wheelchair. On 09/17/14 at 2:25 p.m., a resident who was sitting in a wheelchair was asked to attempt to reach the survey results. The resident was unable to obtain the survey results. At 3:45 p.m., on this same date, the Administrator was made aware the survey results were not accessible to all residents. The next day the survey results were placed on the wall within reach of all residents.",2018-05-01
6182,MILETREE CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2014-09-23,356,B,0,1,577211,"Based on observation and staff interview, the facility failed to ensure the nursing staffing data was posted in a timely manner for each shift. This had the potential to affect more than an isolated number of residents. Facility census: 62. Findings Include: a) Upon entry of the facility, on 09/14/14 at 4:15 p.m., observation revealed the daily nursing staffing posting was not completed for the current shift, which began at 2:00 p.m. Licensed practical nurse, Employee #73, confirmed the staffing information for the evening shift was not posted. At 5:20 p.m., the nurse staff posting, in accordance with the number of staff working at the time, was observed completed and posted.",2018-05-01
6185,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,156,B,0,1,O60P11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 55 Findings include: a) On 09/17/14 at 10:10 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview was conducted on 09/17/14 at 1:20 p.m., with the Nursing Home Administrator. She was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits.",2018-05-01
6305,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2014-02-28,356,B,0,1,WS1J11,"Based on observation, staff interview, and review of staff postings, it was determined the facility failed to post the required nurse staffing data in a prominent place in the facility that was readily accessible to residents and visitors. This had the potential to affect more than a limited number. Facility census: 54. Findings include: a) An attempt to locate the required nurse staffing data posting during the initial tour of the facility on 02/24/14 at 12:30 p.m., revealed it was not posted. During an interview with the director of nursing (DON), Employee #12, on 02/24/14 at 12:37 p.m., she verified there was no posting of the current staffing data in the facility. On 02/26/14 at 4:30 p.m., the staffing sheet was found on a clip board at the nurses' desk with the day shift posting only. Registered Nurse (RN), Employee #4, verified the staff posting was not completed for evening shift and stated she would inform the DON. The staffing was posted for the evening shift at 4:50 p.m.",2018-04-01
6326,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2014-07-23,356,B,0,1,5EN111,"Based on Review of the POS [REDACTED]. This practice had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Review of the facility's posted nursing staffing information, on 07/11/14 , indicated three (3) registered nurses were working the day shift. Review of the staff schedule indicated only one (1) registered nurse was scheduled for direct care on 07/11/14. This information was reviewed with Employee # 76, the director of nursing (DON), on 07/23/14 at 11:00 a.m. She stated, The nurse who filled this out must have counted me and the other nurse. The other nurse was identified as the minimum data set assessment nurse. The DON confirmed she and the MDS nurse were not performing direct care that day, and should not have been counted on the posting.",2018-04-01
6614,HAMPSHIRE MEMORIAL HOSPITAL,515080,363 SUNRISE BLVD,ROMNEY,WV,26757,2014-04-04,170,B,0,1,EI1111,"Based on resident interview and staff interview, the facility failed to ensure residents received mail on Saturdays when mail delivery was scheduled and available through the postal service. This had the potential to affect all thirty (30) residents residing at the facility. Facility census: 30. Findings include: a) An interview was conducted on 04/03/14 at 8:30 a.m. with the resident council president, Resident #13. During this interview, the resident stated she did not think residents received mail on Saturdays. b) The activity director, Employee #42, was interviewed at 8:48 a.m. on 04/03/14. Employee #42 confirmed residents do not receive mail on Saturdays. She stated, Mail does not run on Saturdays. c) On 04/03/14 at 1:15 p.m., the administrator was interviewed. She stated the facility does not receive mail on Saturdays. d) At 1:52 p.m. on 04/03/14, the administrator contacted the postmaster of the local post office, who stated mail could be delivered to the facility on Saturdays, but was not because the facility had requested the mail not be delivered on Saturdays. The administrator stated she asked the postmaster to deliver the mail on Saturdays.",2017-12-01
6640,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2014-08-20,334,B,0,1,R6QV11,". Based on staff interview, the facility failed to develop policies and procedures which addressed when influenza and pneumococcal vaccines would be offered, what education would be provided to the resident or the resident's responsible party, the resident's right to refuse vaccinations, and what documentation needed to be completed. This practice had the potential to affect more than an isolated number of residents. Facility Census: 34. Findings Include: a) When the facility's policy and procedure for the administration of influenza and pneumococcal vaccines was requested, it was learned the facility did not have a written policy regarding the vaccines. The director of nursing (Employee #27) provided an information sheet, on 08/18/14 at 2:00 p.m., titled Vaccine Information Statement. She stated this information sheet was provided to everyone and was what the Center for Disease Control and Prevention recommended. She verified there was no written policy which addressed when influenza and pneumococcal vaccines would be offered, what education would be provided to the resident or the resident's responsible party, the resident's right to refuse vaccinations, and what documentation needed to be completed. b) Review of five (5) residents found that all five (5) had the appropriate vaccinations offered and administered; however, none of the five (5) was provided all parts of the information required by this regulation.",2017-12-01
6732,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2013-11-13,156,B,0,1,IQK011,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 107. Findings include: a) On 11/12/13 at 2:15 p.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of these benefits. An interview was conducted, on 11/12/13 at 2:45 p.m., with the Nursing Home Administrator. He was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits.",2017-11-01
6777,WILLOWS CENTER,515085,723 SUMMERS STREET,PARKERSBURG,WV,26101,2014-02-18,497,B,0,1,1K7S11,"Based on personnel record review and staff interview, the facility failed to complete annual performance reviews for one (1) of four (4) nursing assistants (NAs) whose records were reviewed. This had the potential to affect more than an isolated number of residents. Employee identifier: #53. Facility census: 94. Findings include: a) Employee records were reviewed on 02/12/14 at 10:00 a.m. The personnel file for Employee #53, a nursing assistant, lacked an evaluation of her work performance. During an interview with the administrator, Employee #100, on 02/12/14 at 2:00 p.m., he confirmed the personnel record for Employee #53 lacked an annual evaluation of her work performance. He reported the facility had recently discovered annual employee evaluations had not been completed by the previous director of nursing. He said the facility managers were in the process of completing reviews on all employees.",2017-11-01
6798,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2014-08-08,356,B,0,1,6TWN11,"Based on observation and staff interview, the facility failed to post, in a prominent place and in a clear and readable format, the information regarding the total number of staff and the actual hours worked by licensed and unlicensed staff directly responsible for resident care each shift. This had the potential to affect all residents and/or visitors. Facility census: 11. Findings include: a) Observations on 08/04/2014 at 11:30 a.m. did not find the posting of staff members for this date. At 11:45 a.m., Employee #20, a licensed practical nurse (LPN), was asked where the staff posting might be located. The LPN pulled the posting off of a cabinet to which it had been taped. The cabinet was behind the desk of the nursing station where it could not easily be seen by residents or families. Additionally, the posting did include the total number of hours worked by each category of staff. b) Interview with Employee #1, Registered Nurse (RN) Manager, at 12:05 p.m. on 08/04/14, revealed the posting should be on the wall across from the nursing station in plain view. c) Further observations did not find the posting on 08/04/2014 at 3:00 p.m. or on 08/05/2014 at 08:30 a.m., 10:30 a.m., or 3:30 p.m. d) Observation on 08/06/2014 at 8:30 a.m., found the posting in place with the correct information regarding the number of licensed staff members, hours worked, and the facility census. At 8:40 a.m. on 08/06/14, Employee #1 confirmed the required information had not been posted on 08/04/14 or 08/05/14.",2017-11-01
6819,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2014-02-20,356,B,0,1,SDOD11,"Based on document review and staff interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. This practice had a potential to affect more than a limited residents. Facility census: 85. Findings include: a) Posting of nursing staffing data Upon entry to the facility, at 4:45 p.m. on 02/09/14, observation found the Daily Staffing Sheet posted on the wall in the main hall found was dated 02/07/14. The initial tour found no postings of the current nursing staffing data. In a discussion with the Administrator, at 7:00 p.m. on 02/09/14, she acknowledged the information was not for the current date.",2017-11-01
6835,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2013-10-31,287,B,0,1,PWUW11,"Based on a review of residents minimum data sets (MDS) and staff interview, the facility failed to enter and submit any subsets of items upon a resident's entry, transfer, reentry, or discharge into the computer as required by the Centers for Medicare and Medicaid Services (CMS). A review of the MDS information for three (3) of thirty (30) admission sample residents revealed no admission-entry tracking, reentry tracking, discharge assessment-return anticipated, and/or discharge assessment-return not anticipated, had been completed and entered into the computer as required by CMS. Resident identifiers: Resident #23, #59, and #81. Facility census: 97. Findings include: a) Resident #23 On 10/22/13 at 9:45 a.m., a review of the MDS submissions revealed an Omnibus Budget Reconciliation Act (OBRA) fourteen (14) day admission assessment was completed on 05/20/13, with no prior entry tracking record completed and entered into the computer. On 07/23/13, a significant change readmit tracking record was completed. No discharge and re-entry tracking records were submitted prior to the significant change assessment. On 09/30/13, a death in facility tracking record was completed with no prior discharge-return not anticipated record being submitted. b) Resident #59 A review of Resident #59's MDS was conducted on 10/22/13 at 9:55 a.m An Admission/Medicare - 5 day assessment was completed on 06/18/13. No entry record was submitted prior to the Medicare assessment. On 09/06/13 a death in facility report was submitted and the required discharge - return not anticipated report was not submitted. c) Resident #81 On 10/22/13 at 10:15 a.m., a review of Resident #81's MDS was conducted. A death in facility tracking report was submitted on 10/04/13. The required discharge - return not anticipated report was not submitted. d) An interview was conducted on 10/22/13 at 10:30 a.m., with the MDS coordinator and the DON. They were informed of the findings and were asked if there was any evidence the reports had been completed. The MDS coordinator stated she had no explanation as to why the reports had not been submitted. At 4:00 p.m., the MDS coordinator provided a copy of an MDS correction form which had been submitted for Resident #23.",2017-11-01
6887,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2013-05-22,514,B,0,1,M57P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical record was accurate and complete for two (2) of twenty-two (22) sampled residents reviewed. Resident #3's medical record contained an altered physician's orders [REDACTED]. Resident #88's medication adminsitration records were unclear and inaccurate. Resident identifiers: #3 and #88. Facility census: 62. Findings include: a) Resident #3 A review of the resident's medical record, on 05/15/13, at 3:20 p.m., revealed physician's orders [REDACTED]. This medication was originally ordered to be given as needed (PRN) at bedtime. Further review of the medical record identified on the April 2013 physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR for February 2013, and March 2013, was altered with a line drawn through the at bedtime. An interview with Employee #27, a licensed practical nurse (LPN), at 3:22 p.m. on 05/15/13, revealed Resident #3 was receiving [MEDICATION NAME] ointment in both eyes as needed. She did not state the ointment was to only be given at bed time as needed as indicated on the original physician's orders [REDACTED].>Further interview with Employee #27, LPN, confirmed she did not know why the at bedtime was crossed out on the original physician's orders [REDACTED].#27 was unable to provide verification the physician had consented to this change. Interview with Employee #47, the assistant director of nursing (ADON) and Employee #21, the director of nursing (DON), on 05/15/13 at 3:32 p.m., further confirmed they did not why the at bedtime had been removed from the physician's orders [REDACTED].#21, the director of nursing, on the morning of 05/15/13, revealed she was unable to provide any evidence of a physician order [REDACTED]. She confirmed the resident received the medication whenever needed, not just at bedtime. b) Resident #88 Medication administration records were reviewed with the DON.[MEDICATION NAME](a medication to promote sleep) 5 mg po (by mouth) was noted as given at 11:20 a.m. on 11/14/13. Employee #29 (LPN), and the DON said the (entry) order was rewritten because the medication actually administered, was [MEDICATION NAME] 30 mg by mouth, which was noted above the (entry) order for the Ambien. Additionally, only a note at the top of the right side of the page indicated the [MEDICATION NAME] was rewritten. No indication was provided to indicate [MEDICATION NAME] was noted twice. Further review of the MAR indicated [REDACTED]. The entry on page 2 of 7 noted [MEDICATION NAME] 100 mcg patch, administer two (2) every three days, beginning on 03/11/13. This entry was not discontinued or removed from the MAR. The only indication of a second order was a note on the left side of the page, between the entry [MEDICATION NAME] order and the [MEDICATION NAME] order, which read see 1st page. The second entry order was noted for [MEDICATION NAME] 200 mcg/hr, to be applied every 72 hours, and was on a different change schedule than the initial entry. Employee #39 (RN) confirmed the medication in the medication cart was 100 mcg /hr. The physician's orders [REDACTED]. Employee #39 and the DON agreed the medication sheets were confusing. While reviewing the narcotic record, two (2) doses of Oxy IR liquid were noted as given. The DON said the 11:00 a.m. entry on 05/14/13, was incorrectly documented as liquid, and when actually a tablet was administered. The other dose of medication had not been entered into the narcotic log as given. The dose documented as given was not on the administration log, and the DON, confirmed it should have been.",2017-11-01
6917,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2014-10-08,153,B,1,0,KVTV11,"Based on review of the facility's policies and procedures, the facility failed to ensure the policies established for accessing medical records was in compliance with this regulation. The current facility policy had the potential to result in residents and/or the legal representative being denied access to medical records within 24 hours (excluding weekends and holidays) as required. This practice had the potential to affect any resident/responsible party who exercised the right to access clinical records. Facility Census: 81. Findings include: a) Review of the facility's policy titled Request for Medical Records, last reviewed 2013, revealed in section 6, . the documents should be produced within five (5) days of receipt of the notification that the request for a medical record is valid.",2017-10-01
6919,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2014-10-08,356,B,1,0,KVTV11,"Based on Review of the POS [REDACTED]. The posting was the number of personnel scheduled, and not the number who were actually available and working. This had the potential to affect all residents, families, and /or visitors wishing to review the number of staff providing care to the residents in the facility. Facility Census: 81 . Findings include: a) Confidential staff and family interviews, conducted 10/07/14 to 10/09/14, identified the daily posting of facility staff was frequently incorrect and did not accurately reflect the actual number of direct care staff in the facility providing direct resident care. It was expressed the posting reflected the staff scheduled, and not the actual staff working. b) On 10/08/14 at 3:00 p.m. the facility posting of staff for a period of thirty (30) days was reviewed. The staffing was requested for 08/01/14 to 08/15/14 and also for the period of 09/16/14 to 09/30/14. The schedules, assignment sheets, and time sheets were also reviewed for random days for these time frames. Review of this information identified nineteen (19) of thirty (30) days of posted information reflected incorrect numbers of direct care staff who were working in the facility at that time. Between 08/01/14 and 08/15/14, incorrect staffing information was posted on August 1, 2, 3, 4, 5, 7, 9, 11, 14, and 15. Between 09/16/14 and 09/30/14 incorrect staffing information was posted on September 21, 22, 23, 24, 26, 27, 29, and 30. c) The administrator (Employee #59) was interviewed, on 09/09/14 at 11:00 a.m., concerning the posting of staff. Employee #59 confirmed the numbers of staff were incorrectly posted and the information did not reflect the actual number of direct care staff in the facility providing care at the specified times.",2017-10-01
6921,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2014-10-08,493,B,1,0,KVTV11,"Based on review of the facility's policies and procedures and staff interview, the facility failed to ensure the policies established for obtaining copies of medical records was in compliance with State regulations. The current facility policy had the potential to result in the medical record not being produced timely and for excessive charges when obtaining copies of the record. This practice had the potential to affect any resident/responsible party who exercised the right to obtain copies of the medical record. Facility Census: 81. Findings include: a) Review of the facility's policy titled Request for Medical Records, last reviewed 2013, revealed in section 6, . the documents should be produced within five (5) days of receipt of the notification that the request for a medical record is valid. Section 7 provided instructions for the steps of this process. It specified in 7.b In WV, the cost of production of the medical record is as follows: $10.00 search fee plus reasonable expenses, provided that the total charge does not exceed $0.75 per page for copying of records already reduced to written form. The Legislative Rules West Virginia Division of Health Title 64, Series 13 Nursing Home Licensure Rule specifies: -- Regulation 4.4.c: A resident may purchase, at a cost not to exceed twenty-five cents ($0.25) per page, photocopies of the records or any portions of them, upon oral or written request to the nursing home. -- Regulation 4.4.c.1: The nursing home will provide the photocopies materials to the resident within two (2) working days of the request. The administrator (Employee #59) was interviewed on 10/08/14 at 3:00 p.m. Employee #59 verified the policy and procedure of this facility was not in compliance with the state regulations specified in the Nursing Home Licensure Rule.",2017-10-01
6960,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,496,B,0,1,WVZU11,"Based on record review and staff interview, the facility failed to obtain registry verification for one (1) of fourteen (14) employees indicating she was a registered long term care nursing assistant before allowing her to serve as a nurse aide. Employee identifier: #116. Census: 59. Findings include: a) Employee #116 Personnel records for fourteen (14) employees were requested and reviewed on 06/19/13 and 06/24/13. The file of a nursing assistant, Employee #116, contained no evidence she was a registered long term care nursing assistant. During an interview, on 06/20/13 at 11:00 a.m., nursing home administrative consultant, Employee #176, confirmed the required checks were not available. She provided a verification of active registration for NA #116 that had been obtained by the facility on 06/20/13 at 7:48 a.m. About an hour later, a certificate stating that NA #116 had successfully passed the West Virginia Nursing Assistant Written and Skills Performance Examination on 04/14/12 was provided. Employee #176 acknowledged that this documentation had not been maintained as part of the official personnel file.",2017-09-01
6971,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2014-09-05,241,B,1,0,SG0I11,"Based on observation and staff interview, the facility failed to promote care for a resident in a manner that maintained the resident's dignity and respect. While one (1) resident was being pushed forward, another resident was pulled backwards to the dining room. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #58 and #15. Facility census: 88. Findings included: a) Resident #58 On 09/04/14 at 5:20 p.m., observed a nursing assistant (NA#104) pushing Resident #15 and pulling Resident #58 backwards down the hall. The nursing home administrator ((NHA) was notified at 5:40 p.m. of this event and said she would investigate. On 09/05/14 at approximately 10:00 a.m., a review of the hallway security tapes with the NHA, revealed NA #104 did pull Resident #58 down the hallway backwards. The NHA stated the NA involved, as well the other facility NAs, would be inserviced regarding treating residents with dignity and respect.",2017-09-01
7026,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2013-08-29,514,B,0,1,30TC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of clinical records for one (1) of twenty (20) residents reviewed in Stage 2 of the survey. A physician's response to a pharmacy recommendation was not transcribed to the medical record. Resident identifier: #99. Facility census: 73 Findings include: a) Resident #99 On 08/21/13 at 9:00 a.m., a medical record review was conducted for Resident #99. Review of the Pharmacy consultation report, dated 04/04/13, revealed a recommendation to clarify order to read [MEDICATION NAME] for depression. The attending Physician documented and signed the record on 04/10/13 writing, ok to be for depression. A review of the Medication Administration Records (MAR), dated June, July and August 2013, revealed the MAR indicated [REDACTED]. Employee #13, the Administrator (NHA), provided the requested copies of the attending physician's orders [REDACTED].#99's [DIAGNOSES REDACTED]. Also, the MARs for April and May 2013 had the [DIAGNOSES REDACTED]. At 11:20 a.m. on 08/21/13, an interview was conducted with the NHA. She confirmed an order for [REDACTED]. On 08/21/13 at 11:40 a.m., an interview was conducted with Employee #23, the Director of Nursing (DON). She stated the procedure the facility was supposed to follow regarding pharmacy recommendations was to give the recommendation to the doctor on his visit to the facility. After his signature was obtained, it was to be signed by the DON or the nurse on duty. A physician's orders [REDACTED]. The pharmacy recommendation sheet was then to be placed in the medical record for the pharmacist to review on the next monthly visit. Employee #23 stated, There is not a written policy or procedure regarding this, it was like this when I came here and it has continued.",2017-09-01
7027,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2013-08-14,156,B,0,1,66WU11,"Based on record review, policy review, and staff interview the facility failed to ensure the information communicated to the residents when there was a change in their skilled status was complete. The liability notices did not identify the services being discontinued and/or the reason for the action for three (3) of six (6) sampled residents who had medicare covered services discontinued. Resident identifiers: #87, #78, and #112. Facility census 68. Findings include: a) Residents # 87, 78, and 112 A review of the Notice of Medicare Provider Non-Coverage document which was provided to the residents and/or their responsible parties revealed the following verbiage: The Effective Date Coverage of Your Current: SKILLED NURSING Services Will End (date). The document did not, in a language the resident can understand, identify all skilled services that were being received by the residents which were being discontinued. The document also did not explain why the service was being discontinued. A review of the medical records of Residents #87, #56, and #86 revealed that they were also receiving Skilled Therapy services. The residents were being asked to make an appeal decision without this information. During an interview with Employee #97 (Physical Therapy Aid) at 8:30 a.m. on 08/07/13, she confirmed Residents #87, #56, and #86 were receiving Physical Therapy services which were discontinued on the date stated in the Medicare Non-Coverage notice. After reviewing the liability notices with the Administrator at 8:45 a.m. on 08/13/13, he acknowledged the notices did not contain what services were being discontinued or why they were being discontinued. During an interview with the Social Worker (Employee #68) at 1:45 p.m. on 08/13/13, she stated she knew the resident or his responsible party should be informed of all services and the reason for discontinuing them. She stated she was not the person who filled out the notices, although she did sign them indicating she issued the notice to Resident #112.",2017-09-01
7048,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,160,B,0,1,GJXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's accounting records and staff interview, the facility failed to convey the personal funds for two (2) deceased residents,and provide a final accounting of the funds to the individual or probate jurisdiction administering the individual's estate within 30 days as provided by State law. This was found for two (2) of 21 account holders. Resident identifiers: #18 and #68. Findings include: a) Resident #18 A review of the accounting records dated [DATE] on [DATE], revealed Resident #18, who expired on [DATE], continued to show a balance in a personal account of $1123.96. This was acknowledged by Employee #58 (Business office manager) in an interview at 4:25 p.m. on [DATE]. She stated they had notified the family and were waiting for them to contact the facility with instructions. There was no evidence of this in the record. b) Resident #68 A review of the accounting records dated [DATE] on [DATE], revealed Resident #68, who expired on [DATE], continued to show a balance in a personal account of $245.82. During an interview with Employee #58 at 4:25 p.m. on [DATE], she acknowledged the funds had been there until yesterday, [DATE], when she contacted the family and was directed to issue a check made out to the executer of the estate and forward it to the funeral home.",2017-09-01
7049,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,167,B,0,1,GJXP11,"Based on observation and staff interview, the facility failed to ensure survey results and the approved plans of correction were available to residents without having to ask a staff person. An observation revealed residents in a wheelchair were not able to review the survey results without asking staff for assistance. This had the potential to affect more than a minimal number of residents. Facility census: 61. Findings include: a) On 09/12/13 at 3:15 p.m., an observation of the survey results book revealed it was located at a height of approximately five (5) feet. Any resident who could not stand or was confined to a wheelchair could not reach the book without having to ask staff to retrieve the survey results book. On this same day, the administrator was informed of this finding and agreed the survey results book was located at a height which made the survey results inaccessible to residents who could not stand or were confined to wheelchair without asking the staff for assistance. The survey results book was relocated to above the handrail in the administrative hallway prior to exiting the facility on 09/13/13 making it accessible to any resident without asking for staff assistance.",2017-09-01
7066,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2014-07-14,170,B,0,1,U25211,"Based on staff interviews and resident interviews, the facility failed to ensure personal mail was delivered to the residents within 24 hours of delivery to the facility by the postal service. This had the potential to affect more than an isolated number of residents. Facility census: 64. Findings include: a) During an interview with the resident council president (Resident #13) on 07/09/14 at 9:00 a.m., the president said the facility did not deliver residents' mail on Saturdays. On 07/09/14 at 9:40 a.m., Employee #25 (business office) said the facility delivered the mail from Saturday on Monday morning. On 07/09/14 at 9:30 a.m., the activity director (Employee #59) said she worked three (3) Saturday's a month and would be glad to distribute the mail on those days.",2017-09-01
7083,MONTGOMERY GENERAL HOSPITAL,515081,401 6TH AVENUE,MONTGOMERY,WV,25136,2013-11-21,156,B,0,1,DACE11,"Based on observation and staff interview, the facility failed to ensure it had prominently displayed written information about how to apply for and use Medicare and Medicaid benefits. This practice had the potential to affect any residents and/or residents' responsible parties who might need access to this information. Facility census: 36. Findings include: a) During the initial tour of the facility on 11/18/13, at approximately 11:45 a.m., observations found the posting of how to apply for and use Medicare and Medicaid benefits was not present. On 11/21/13 at 11:30 a.m. the director of nursing and the social worker, Employee #35, confirmed the information was not posted in the facility. Employee #35 stated the building had recently been painted and she thought the painters must have removed the information.",2017-08-01
7165,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2014-07-29,203,B,1,0,EYNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were provided the required information at discharge. There was no evidence seven (7) of eight (8) residents and/or the responsible party were notified of the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident was transferred, the right of appeal, or how to notify the ombudsman and the appropriate protection and advocacy agency, with the addresses and telephone numbers as required. The facility had no process to ensure this information was completed and provided at the time of discharge. Resident identifiers: #113, #10, #115, #79, #76, #114, and #95. Facility Census: 112. Findings include: a) Residents #113, #10, #115, #79, #76, #114, and #95 Review of the medical records for these residents, who had been transferred from the facility, found no evidence the information provided at discharge included the reason for transfer or discharge, effective date of transfer or discharge, location, right to appeal, or how to notify the ombudsman and the appropriate protection and advocacy agencies with the addresses and telephone numbers for these agencies as required. The following residents were transferred from the facility without evidence they were provided this required information: 1. Resident #113 - transferred to the hospital on [DATE] 2. Resident #10 - transferred to the hospital on [DATE] 3. Resident #115 - transferred to the hospital on [DATE] 4. Resident #79 - transferred to the hospital on [DATE] 5. Resident #76 - transferred to the hospital on [DATE] 6. Resident #114 - transferred to the hospital on [DATE] 7. Resident #95 - transferred to the hospital on [DATE] An interview was conducted with the director of nursing (DON), Employee #97, on 07/29/2014 at 2:40 p.m. She stated the facility did not keep copies of the transfer information provided residents. The DON stated nurses were instructed to provide this notice when a resident was transferred or discharged . She said sometimes the fact the information was sent was recorded in the narrative notes, but sometimes the nurses did not record it. The DON said she was unable to provide evidence the form contained the appropriate information or that it was actually completed and put in the transfer packet, since the facility did not keep a copy. She stated in the past, before the computer system they use, a copy was kept with the records, but they did not do this anymore. The DON verified there was no way to provide evidence each of these residents was provided this information. .",2017-07-01
7166,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2014-07-29,205,B,1,0,EYNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure written information, regarding the facility's bed-hold policy was provided to the residents or a legal representative, at the time of transfer of the residents from the facility. This was found for seven (7) of eight (8) sample residents who had been transferred from the facility. Resident identifiers: #113, #10, #115, #79, #76, #114, and #95. Facility Census: 112. Findings include: a) Residents #113, #10, #115, #79, #76, #114, and #95 Review of the medical records for these residents, who had been transferred from the facility, revealed no evidence information regarding the facility's bed-hold policy was provided at the time of transfer to another facility. The following residents were transferred from the facility without evidence they were provided bed-hold information: 1. Resident #113 - transferred to the hospital on [DATE] 2. Resident #10 - transferred to the hospital on [DATE] 3. Resident #115 - transferred to the hospital on [DATE] 4. Resident #79 - transferred to the hospital on [DATE] 5. Resident #76 - transferred to the hospital on [DATE] 6. Resident #114 - transferred to the hospital on [DATE] 7. Resident #95 - transferred to the hospital on [DATE] An interview was conducted with the director of nursing (DON), Employee #97, on 07/29/2014 at 2:40 p.m. She stated the bed-hold policy and re-admission rights information were on the same form as the transfer/discharge information provided residents upon discharge. The DON stated nurses were instructed to provide this information when a resident was transferred or discharged . She said sometimes the fact the information was sent was recorded in the narrative notes, but sometimes the nurses did not record it. The DON said she was unable to provide evidence the information was provided these residents, or that it was actually put in the transfer packet, since the facility did not keep a copy. She stated in the past, before the computer system they use, a copy was kept with the records, but they did not do this anymore.",2017-07-01
7275,COLUMBIA ST. FRANCIS HOSPITAL,515110,333 LAIDLEY STREET,CHARLESTON,WV,25322,2014-05-15,156,B,0,1,SERN11,"Based on observation and staff interview, the facility failed to ensure it had prominently displayed written information about how to apply for and use Medicaid benefits. This practice had the potential to affect any residents and/or residents' responsible parties who might need access to this information. Facility census: 15. Findings include: a) During the initial tour of the facility on 05/12/14 at 10:50 a.m., observations found the posting of how to apply for and use Medicaid benefits was not present. On 11/14/14 at 11:15 a.m., Employee #1, the registered nurse clinical coordinator supervisor (RN, CCS) and Employee #20, the social worker, confirmed the facility had not posted the information in the facility.",2017-06-01
7312,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2013-08-22,161,B,0,1,E42711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, communication with the state agency office, and review of the surety bond information, it was determined the facility does not have a currently approved surety bond to cover resident funds being held by the facility. This practice has the potential to affect each of the twenty-eight (28) residents who have funds managed by the facility. Facility census: 54. Findings include: a) Interview with Employee #71, the office manager, on [DATE] at 10:00 a.m., revealed the facility had a continuation certification letter from the insurance company who issued the surety bond for the facility. Review of the letter indicated the bond, for a specified amount, was in effect from [DATE] until [DATE]. This continuation notice did not contain a seal or letter from as required from the necessary state agencies to indicate it was approved and effective. Contact with the state survey agency office revealed the most current information on file showed the facility's bond expired in 2012. No other surety bond or evidence of a continuation had been submitted and approved by the state agency or the attorney general's office. Further discussion with Employee #71 indicated the facility had not submitted the most recent continuation certificate letter to the necessary agencies for proper approval.",2017-06-01
7358,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-07-22,156,B,0,1,MT7G11,"Based on observation and staff interview, the facility failed to post contact information of pertinent State client advocacy groups in a manner which was accessible to wheelchair bound residents. This had the potential to affect more than a limited number of residents. Facility census: 104. Findings include: a) During a random observation on 07/22/13, a copy of residents' rights with a listing of telephone numbers was observed posted in the lobby of the facility. The bottom of the form was about eye level, if standing. Upon inquiry, on 07/22/13 at 8:15 a.m., Employee #131 (social services), confirmed the information was not posted in another area accessible to residents. She also acknowledged the posted information, containing residents rights and contact information for pertinent State client advocacy groups, would be difficult to read from a seated position, such as a wheelchair, and was therefore not accessible to all residents.",2017-05-01
7395,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2013-08-15,492,B,0,1,PDFH11,"Based on staff interview, record review, and review of the county's food handler policy, the facility failed to ensure compliance with the county health department's requirements and regulations regarding food handler's cards for dietary employees. The facility had two (2) newly employed dietary staff employees who had not obtained a temporary food handler's card prior to being allowed to work in the kitchen area. Employee identifiers: #93 and #94. Facility census: 62. Findings included: a) Employees #93 and #94 On 08/12/13 at 1:30 p.m., Employee #73 the Dietary Manager (DM) provided requested copies of the food handler's permits for dietary staff. At 1:35 p.m. on 08/12/13, Employee #73 was asked about two (2) of the permits as none had been provided for Employees #93 and #94. Employee #73 stated they were just hired last week, and were scheduled to take the food handlers' class on 08/26/13. Upon further inquiry, he stated he would provide their temporary food handler's card. Employee #73 also stated the two (2) employees had been working within the kitchen to assist in preparing and serving food since they were employed. 1) At 9:45 a.m. on 08/13/13, a copy of Employee #93's Temporary Food Handler's Permit was received from Employee #33, the administrator. Review of the permit found it was dated as being obtained from the County Health Department on 08/13/13, and would expire on 08/26/13. On 08/13/13 at 11:30 a.m., an interview was conducted with Employee #93. She stated she had been employed at the facility since last week and was scheduled to take the food handler's class at the end of the month. This was verified, on 08/14/13 at 2:00 p.m., by a review of the dietary staffing schedule for August 2013. Employee #93 was employed and worked at the facility in the dietary department since 08/05/13. Her temporary food handler's permit was not obtained until 08/13/13. 2) A copy of a temporary food handler's permit for Employee #94 was received on 08/14/13 at 12:20 p.m. A review of this document revealed it was dated as being obtained on 08/12/13 from the local County Health Department, and would expire on 08/26/13. Review of the staffing schedule for the dietary staff on 08/14/13 revealed Employee #94 was employed and began work at the facility as a dietary staff member on 08/06/13. b) On 08/14/13 at 7:50 a.m., a review of the County Health Department Food Handler's Card Policy, revealed a Food handler's card must be possessed by all persons handling, preparing and or serving food in the county. The documentation also stated, If any employee is newly hired they are required to come to the local county Health department to receive a temporary food handler's card and attend the next scheduled food handler's class.",2017-05-01
7414,CAREHAVEN OF PLEASANTS,515191,506 RIVERVIEW ROAD,BELMONT,WV,26134,2013-08-29,225,B,0,1,2QIM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's complaint files, and staff interview, the facility failed to ensure all allegations of abuse/neglect were immediately reported to the appropriate State agencies. Allegations of neglect were made in a letter provided to the facility which expressed concerns regarding the lack of services provided to residents. This letter alleged neglect had occurred for three (3) residents. The alleged neglect issues (lack of care for a medical condition for Resident #5, ineffective pain control for Resident #30, and lack of treatment for [REDACTED].#84) were investigated by the facility, but the facility failed to report these allegations to the required State agencies. This was true for three (3) of twenty-five (25 ) residents who were reviewed in Stage 2 of the survey. Resident identifiers: #5, #30, and #84. Facility Census: 60. Findings include: a) Resident #5 It was identified during a review of the facility's abuse and neglect files, a letter, dated 08/21/13, had been written to the facility alleging this resident had suffered from lack of care from a medical condition ([MEDICAL CONDITION]) that was not being treated. It was identified in the medical record and in the facility's investigation, this resident had received multiple treatments since his admission and prior to his admission for his condition. The physician had visited and examined this resident two (2) times each month. The reasons for the decision to not provide treatments were explained in the medical record and this resident was alert and oriented and chose what treatments he would and would not have done. There was no evidence this allegation of neglect, exemplified by a lack of treatment, was reported to the required State agencies. b) Resident #30 It was identified in a letter received by the facility, dated 08/21/13, Resident #30 was dying and experiencing a lot of pain. It was alleged that her pain control was not effective and she often yelled out in agony. Observations were made of this resident multiple times from 08/26/13 to 08/29/13. She was not observed yelling or exhibiting any signs of discomfort. The medical record was reviewed and it was identified that Hospice had been offered and refused. The resident received her pain medication as scheduled and also had as needed (PRN) medication for pain. The resident's pain was always reassessed and the pain mediation was recorded as being effective. The facility's complaint investigation files indicated the issue of this resident's pain control not being effective was investigated and was not substantiated. There was no evidence the allegation regarding this resident's inadequate pain control was reported as an allegation of neglect to the required State agencies. c) Resident # 84 It was brought to the attention of the facility, in a letter dated 08/21/13, Resident #84's physician had been contacted and orders obtained for a urinalysis. The letter stated the resident had been exhibiting a change in orientation and increased behaviors. An allegation was made the facility did not get this urinalysis during day shift when it was ordered, but instead passed it on to the midnight shift nurse, and this resulted in a delay in treatment for [REDACTED]. A review of the medical record, and a review of the facility's investigation records, revealed a urinalysis was done for this resident on 08/14/13. This test came back negative and indicated she did not have a urinary tract infection and there was no treatment indicated or provided. The allegation the facility did not promptly treat infections was investigated by the facility, but was not reported to the State agencies as an allegation of neglect. d) The Administrator (Employee # 89) and the Director of Nursing (Employee # 88) were interviewed together on 08/27/13 at 11:00 a.m. regarding these allegations. They verified they were aware of the allegations and provided the investigation conducted by the facility. The Director of Nursing stated she did not feel these had to be reported to the State agencies because the nurse had indicated in the letter she sent she had reported these issues to the State.",2017-05-01
7415,CAREHAVEN OF PLEASANTS,515191,506 RIVERVIEW ROAD,BELMONT,WV,26134,2013-08-29,226,B,0,1,2QIM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's complaint files, staff interview, and policy review, the facility failed to ensure its policy regarding reporting of abuse and neglect was implemented. The facility received a letter in which allegations of neglect were made. An allegation was made that Resident #5 did not receive care for a medical condition. Resident #30 was alleged to not have received effective pain control. The letter also alleged a urinalysis was delayed for Resident #84 resulting in a delay of treatment. The facility failed to report these allegations immediately to the required State agencies as specified in their abuse prohibition policy (revised 9/00). This policy was not implemented for three (3) of twenty-five (25) Stage 2 sampled residents. Resident identifiers: #5, #30, and #84. Facility Census: 60. Findings include: a) Resident #5 It was identified during a complaint investigation a letter had been written to the facility, dated 08/21/13, alleging this resident had suffered from a lack of care from a medical condition ([MEDICAL CONDITION]) that was not being treated. There was no evidence this allegation of neglect due to a lack of treatment was reported to the required State agencies. b) Resident #30 It was identified in a letter written to the facility, dated 08/21/13, that Resident #30 was dying and experiencing a lot of pain. It was alleged that her pain control was not effective and she often yelled out in agony. There was no evidence this allegation of neglect regarding the resident's ineffective pain control was reported to the required State agencies. c) Resident # 84 It was brought to the attention of the facility in a letter dated 08/21/13, that Resident #84's physician had been contacted and orders obtained for a urinalysis. The letter stated the resident had been exhibiting a change in orientation and increased behaviors. The letter alleged the facility did not get this urinalysis during day shift when it was ordered, but instead passed it on to the midnight shift nurse, resulting in a delay in treatment for [REDACTED]. The allegation that the facility did not promptly treat infections was investigated by the facility but was not reported to the State agency. d) The Administrator (Employee # 89) and the Director of Nursing (Employee # 88) were interviewed together on 08/27/13 at 11:00 a.m. regarding these allegations of neglect. They verified they were aware of the allegations and provided the investigations conducted by the facility. The Director of Nursing stated that she did not feel these had to be reported to the State agency because the nurse had indicated in the letter that someone else had reported these issues. The facility's investigation into these allegations was dated 08/22/13. They recorded the results of the investigation, but there was no evidence these results were reported to the State agencies as required. The facility's policy titled Abuse Prohibition Policy last revised 9/00, indicated under the area of Reporting on page four (4), reporting requirements included reporting both the alleged violations and the results of the investigations to the State survey agency. The policy stated to report all alleged violations and all substantiated incidents to the State agency and Adult Protective Services.",2017-05-01
7455,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2013-06-13,158,B,0,1,TA7B11,"Based on resident interview and staff interview, the facility failed to ensure personal funds are available at all times. The facility does not provide access to resident funds in the evenings or on the weekends. This practice has the potential to affect more than a limited number of residents. Facility census: 113. Findings include: a) On 06/03/13 at 1:47 p.m., Resident #24 stated during a Stage 1 interview she did not have access to her personal funds on the weekends. On 06/11/13 at 4:00 p.m., during an interview with the Administrator, Employee #162, a Consultant, Employee #159, and the Director of Nursing Services, Employee #11, it was revealed resident funds are not available at all times. The Administrator verified resident funds are not available in the evenings or on the weekends unless there is a manager on duty in the facility.",2017-04-01
7473,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2013-06-13,492,B,0,1,TA7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interview the facility failed to comply with WV State Regulations pertaining to the following personnel requirements at Title 64 Legislative Rules, West Virginia Division of Health,Series 13, Nursing Home Licensure Rule: -11.6 Personnel Records. A nursing home shall maintain a confidential personnel record for each employee containing the following information: -11.6.c Results indicating a satisfactory health status for the employees' current job assignment as required in Subsection 8.19 of this rule. -11.6.i A job description signed by the employee. - 8.20.c.3 Employee restrictions. A nursing home shall prohibit employees with a communicable disease or infected [MEDICAL CONDITION] from direct contact with residents or their food, if direct contact will transmit the disease. Findings include. a) Employee #2 On 06/06/13 at 1:30 p.m., a review of Employee #2's personnel file was conducted. This employee was hired on 05/20/13. There was no evidence this employee had a pre-employment physical. b) Employee #52 On 06/06/13 at 1:30 p.m., a review of Employee #52's personnel file was conducted. This employee was hired on 05/20/13. There was no evidence this employee had a pre-employment physical. In an interview, with the human resources director, on 06/06/13 at 2:00 p.m., she could find no evidence of a pre-employment physical in the personnel files of Employee #2 or Employee #52. She stated the facility had recently changed the procedure for employees to have a pre-employment physical and agreed Employee #2 and Employee #52 did not have a pre-employment physical. c) Employee # 148 Review of personnel records for Employee # 148, on 06/11/13 at 2:00 p.m., revealed no evidence of a job description for this employee's position: appointment scheduler/transporter for residents. This was confirmed by Employee #124, human resource director, HR on 06/11/13 at 3:15 p.m. d) The facility failed to ensure residents were not exposed to a potentially communicable disease by failing to secure baseline testing for [MEDICAL CONDITION] for one (1) of ten (10) sampled employees prior to them preforming direct resident care. A review of the personnel and employee health records, at 09:00 a.m. on 06/06/13, revealed no evidence of the baseline testing for [MEDICAL CONDITION] as required by the facility's Employee Health policy, for Employee #153, who was a professional nurse hired on 10/17/12. Employee #153 had been providing direct resident care since that date. The above information was reviewed with Employee #124 (Human Resource Director) at 11:00 a.m. on 06/06/13. In a follow-up interview with Employee #124 at 12:00 p.m. on 06/06/13, she stated that she had been unable to confirm that the testing had been done.",2017-04-01
7637,MONTGOMERY GENERAL ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2013-04-25,170,B,0,1,BHXG11,"Based on an interview with the president of the resident council (Resident #3) and staff interview, the facility failed to afford residents with the right to promptly receive mail. The facility did not distribute resident mail on Saturdays, although mail was available for delivery on this day of the week. This had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) During an interview, on 04/23/13 at 3:30 p.m., the resident council president (Resident #3), stated residents do not receive mail on Saturdays. The activity director, Employee #25, was interviewed at 4:04 p.m. on 04/23/13. She stated the mail comes to the storage department at the hospital and We don't deliver the mail on Saturdays. The administrator, Employee #5, was interviewed on 04/23/13 at 4:22 p.m. She stated the facility shares a post office box at the post office with the hospital next door, who also owns the nursing facility. The mail is picked up and sorted by hospital personnel on Monday through Friday and no one from the hospital picks up the mail on Saturdays.",2017-03-01
7686,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2013-03-22,170,B,0,1,B0M411,"Based on interviews and policy review, the facility failed to deliver mail to residents on Saturdays. This had the potential to affect all residents who received mail at the facility. Findings include: On 3/18/13 at 2:10 P.M. the Resident Council President #11 was interviewed. During the interview the Resident Council President stated she was not sure if mail was delivered to residents on Saturdays or not. She stated in the past the residents did get mail on Saturdays. At 2:20 P.M. the Activity Director (AD) #44 was interviewed. The AD stated she only works two Saturdays a month and she does not deliver mail on Saturdays when she works. At 2:30 P.M. the Director of Nursing (DON) #73 was interviewed. She stated there was no staff on the weekend to go get the mail from the post office on Saturdays to deliver to the residents and verified residents did not receive mail on Saturday. At 3:05 P.M. the Assistant Administrator #79 was interviewed. The Assistant Administrator verified the facility used to pick up the mail on Saturday and deliver it to the residents, but not anymore. She stated the mail is picked up from the post office daily Monday through Friday and there was no mail delivery to residents on Saturday. If residents did receive mail delivery on Saturdays it was not delivered to them by facility staff until Monday. The policy and procedure for mail delivery was reviewed. The policy indicated each resident has the right to send and receive mail promptly and delivered to the resident within 24 hours.",2017-02-01
7712,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,159,B,0,1,Q01G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to provide a statement of account balances for 1 of 1 residents (Resident #89) with concerns related to personal fund account statements out of 20 residents interviewed. Findings include: Resident #89 was admitted on [DATE]. During an interview on 1/08/2013, Resident #89 reported that he was not given a statement of his facility managed trust fund account. On 1/10/2013 at 5:10 PM, an interview was completed with Bookkeeper #85. Bookkeeper #85 said that trust fund statements go out quarterly. Resident #89 has an account. I don't have have a statement for him for June or October. He did have one for the quarter ending in March (2012). If he didn't sign it and give it back, it won't be in the file. If they don't return the signed sheet, there isn't any way to show they got the statement, but everyone gets one. We provide the envelope with the statement in the daily mail. The residents bring them back up to me.",2017-02-01
7715,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,167,B,0,1,Q01G11,"Based on observations and staff interviews, the facility failed to make previous survey results available for review. Findings include: During a tour of the facility on 1/11/2013 at 9:15 AM with Maintenance Supervisor #65, survey results could not be located. Maintenance Supervisor #65 asked the facility Administrator where the results were posted. The Administrator went to a place on the wall where she said the survey results were supposed to be inside an open storage bracket mounted on the wall in the main hallway. She also noted that the notebook had a chain attached securing it to the wall. The Administrator said, I don't know where they are. I saw them there yesterday. You see the holes where they were attached. I will find them. No bracket or chain was observed. There were 4 holes noted in the wall. On 1/13/2013 at 9:20 AM, the survey results notebook was located inside the mail room inside the administrative offices.",2017-02-01
7716,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,172,B,0,1,Q01G11,"Based on record review and staff and resident interviews, the facility failed to make residents aware of the ombudsman. Findings include: A review of Resident Council minutes from July through December 2012 revealed no mention of the ombudsman. An interview was completed with Resident #18 on 1/09/2013 at 7:15 PM. Resident #18 stated that she regularly attended Resident Council meetings. Resident #18 said that she did not know the Ombudsman and said she didn't know the term. She also said that she did not recognize the name of the ombudsman. On 1/10/2013 at 9:10 AM, an interview was completed with Activity Director #55 (AD#55) AD #55 said, The Ombudsman shows up once in a while. She probably hasn't been to one (Resident Council meeting) in six months. She calls and asks when they are, but she says she can't always make it. I've told them (Resident Council) what the Ombudsman is and they can ask her to come to the meetings if they want. They know they can get her number if they need it. If someone has a problem that isn't resolved, I tell them we can call the Ombudsman. Every once in a while, I mention it during the meetings. I guess I didn't write it in the minutes. An interview was completed with Social Worker #49 (SW#49) on 1/10/2013 at 9:27 AM. SW #49 said, I have been to most of the Resident Council meeting since June. The Ombudsman hasn't been to any of the meeting that I've gone. Her information is posted on the wall. When she is here she meets with some residents. My opinion is that the residents that she visits would probably be the only ones that know who she is. I haven't even met her yet. On 1/10/2013 9:45 AM, an interview was completed with Resident #35. Resident #35 stated that he frequently attended Resident Council meetings. Resident #35 said that he was not familiar with the term ombudsman or the ombudsman's name. I go to every meeting. I go door to door and invite everyone to the meetings.",2017-02-01
7736,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,156,B,0,1,H1U811,"Based on review of liability notices and staff interview, the facility failed to provide specific written information to three (3) of three (3) residents whose Medicare covered skilled services were discontinued. The liability notices provided these residents did not indicate the reason the services would no longer be covered. Resident identifiers: #9, #53, and #51. Facility census: 44. Findings include: a) Residents #9, #53, and #51 A review of the Notice of Medicare Provider Non-Coverage document which was provided to residents and/or their responsible parties included the following statement: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END (followed by the date). The document did not identify which service was being discontinued and did not explain why the service was being discontinued. The resident was being asked to make an appeal decision without this information. During an interview with the administrator, at 9:45 a.m. on 04/24/13, he acknowledged the form did not indicate which skilled service was being discontinued or the reason for the discontinuation.",2017-02-01
7741,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,356,B,0,1,H1U811,"Based on record review and staff interview the facility failed to post accurate nurse staffing information on a daily basis. The numbers of licensed and unlicensed staff posted did not represent the actual number of staff available for direct resident care for each shift. This practice had the potential to affect more than a limited number of residents. Facility census: 44. Findings include: a) On 04/24/13, a review of staffing information postings dated 04/01/13 through 04/07/13 was conducted. The postings were compared with the facility's staffing worksheet. There was a discrepancy in the number of direct care staff listed. Four (4) of seven (7) actual staffing postings revealed one (1) less direct care staff member on duty, than the information posted for that day. During an interview with the administrator, on 04/24/13 at 2:15 p.m., it was revealed Employee #79 begins the the shift after the day shift staffing is posted. He stated the staffing posted is not updated upon arrival of Employee #79. The administrator presented an individual employee time card for Employee #79 which paralleled the noted inconsistency. The facility did not update the number of available licensed and unlicensed staff when the number of staff members changed.",2017-02-01
7742,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,364,B,0,1,H1U811,"Based on observation and resident interview, the facility failed to ensure hot foods were served at preferable temperatures as discerned by the resident and customary practice. Two (2) residents expressed concerns with the temperature of hot foods. The facility did not implement practices to ensure foods were hot enough when received by the residents. This affected two (2) residents, but had the potential to affect more than an isolated number of residents. Resident identifiers: #6 and #29. Facility census: 44. Findings include: a) Residents #29 and #6 During a Stage 1 interview, on 04/22/13 at 1:31 p.m., Resident #29 stated hot foods were not hot enough upon receipt. Resident #6, during a Stage 1 interview on 04/22/13 at 1:56 p.m., said The hot food is just barely warm. b) The meal tray line was observed, on 04/24/13 during the lunch meal. The meal service was observed from the beginning of the meal, until the last trays were served. The first trays were prepared, placed on carts, and sent to the units. The dining room, which was adjacent to the kitchen, was served last. At 12:12 p.m., prior to serving the last trays, Employee #74, a dietary assistant, was requested to obtain the temperatures of the pureed chicken and the chicken patties. The temperature of the chicken patties was 110 degrees Fahrenheit (F) and the temperature of the pureed chicken was 124 degrees F. At these temperatures, the chicken patties (which were 110 degrees) could not be received by the residents at the customary temperature of 120 degrees for hot foods. In addition, the pureed chicken (which was 124 degrees) was very likely to have fallen below 120 degrees F by the time of receipt by the residents.",2017-02-01
7761,CLAY HEALTH CARE CENTER,515142,1053 CLINIC DRIVE,IVYDALE,WV,25113,2013-04-16,514,B,0,1,KUG911,"Based on medical record review and staff interview, the facility failed to maintain an accurate, complete and systemically organized medical record for nine (9) of thirty-four (34) medical records reviewed during Stage 2 of the survey. The medical record of each resident contained forms which were not fully completed with dates and/or signatures. Records were requested for Resident #12, and the facility was unable to locate the records. In addition, information regarding the consultant pharmacist's monthly medication regimen review was not in each resident's medical record. Resident Identifiers: #12, #34, #50, #63, #57, #2, #30, #27, and #64. Facility census: 57. Findings Include: a) Resident #12 At 3:30 p.m. on 04/03/13, the resident's restorative documentation for the months of January 2013 through March 2013 was requested from the director of nursing (DON). At 11:30 a.m. on 04/04/13, the DON reported they could not locate the requested restorative records. She reported they would continue to look for them. At the time of exit, at 4:30 p.m. on 04/16/13, the facility was unable to provide the requested records for Resident #12. b) Resident #34 A medical record review was conducted at 12:54 p.m. on 04/15/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of February 2013 and March 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on either form. c) Resident #50 A medical record review was completed at 10:00 a.m. on 04/11/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, March 2013 and April 2013. These form contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. d) Resident #63 A medical record review was completed at 11:30 a.m. on 04/11/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, March 2013 and April 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. e) Resident #57 A medical record review was completed at 11:15 a.m. on 04/15/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of February 2013, and March 2013. This form contains a box which was labeled nurses signature (in accordance with state law). This box was not signed nor dated on the forms. f) Resident #2 A medical record review was completed at 2:00 p.m. on 04/15/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, and March 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms, with the exception of the February form which was dated, but not signed. g) Resident #30 A medical record review was completed at 10:00 a.m. on 04/10/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, March 2013 and April 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. h) Resident #27 A medical record review was completed at 10:00 a.m. on 04/11/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of February 2013, March 2013 and April 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. i) Resident #64 Medical record review, on 04/11/13 at 9:45 a.m., revealed the resident was admitted to restorative nursing services on 01/23/13 for ambulation and transfers. Further review of the medical record on 04/15/13 revealed the resident's restorative care plan was not signed by a nurse for the months of February 2013, March 2013, and April 2013. The restorative nursing participation logs for the months of January 2013, February 2013, March 2013, and April 2013 were reviewed. The months of February 2013, March 2013, and April 2013 were all incomplete, as nursing staff failed to provide an explanation for why services were not provided on the days the resident had no participation recorded. An interview with the nursing home administrator (NHA), at 2:34 p.m. on 04/15/13, confirmed the forms were not signed or dated by the nurse. j) Residents #64, #53, #12, #23, #36, #38, #9, #14 Review of these residents' medical records, which contained the registered pharmacist consultant reviews, revealed the consultant pharmacist did not indicate if there were or were not irregularities. The facility's policy regarding documentation for monthly consultant pharmacist medication regimen reports was reviewed. A statement on page 105 included. If no irregularities are found, consultant pharmacist also documents this and signs and dates such documentation. Additionally, the medical records contained no recommendations from the pharmacist and/or responses from the physician, regarding identified irregularities. Upon inquiry, it was discovered this information was only made available to the director of nursing and the administrator. It was also revealed this information was not placed on each resident's active record. Review of the facility's policies and procedures, regarding monthly medication regimen reviews (llA1), revealed the findings of the medication reviews were to be provided .to the director of nursing or designee and documented and stored with the other consultant pharmacist recommendations in the resident's active record.",2017-02-01
7828,MEADOW GARDEN,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2012-08-23,253,B,0,1,1T2X11,"Based on observation and staff interview, it was found the facility had not ensured the environment in resident rooms was kept in a manner that was sanitary and orderly. Doors to resident bathrooms and furniture, such as nightstands, had scuff marks and scratches that made them unsightly and not easily cleanable. This was evident for four (4) of twenty-eight (28) resident rooms in the facility. Room identifiers: A8, A9, B1 and B12. Facility census: 56. Findings include: a) Rooms A8, A9, B1 and B12 During the initial tour of the facility, and throughout the survey process, it was observed that doors to the bathrooms in these resident rooms, and some of the night stands, had scratches and scuffed marks on the finishes of the items. This made the items unsightly, and not easily cleanable. This was discussed with the maintenance director, Employee #61, on the afternoon of 08/16/12. He was aware of these issues being a concern.",2017-01-01
7948,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2012-08-20,170,B,0,1,HTLJ11,"Based on resident and staff interviews, the facility failed to ensure privacy for each resident who receives mail in the facility. The facility failed to ensure that mail was unopened upon delivery to the residents. Findings include: An interview was conducted on 8/14/2012 at 3:00 PM with a member of the resident council (Resident # 60). The resident stated that the residents do not always receive their mail unopened. She stated that she has even received her mail unopened. The resident stated that the type of mail opened usually has to do with health benefits or benefit cards. The resident shared that she prefers to open her own mail and has not signed any document permitting the facility to open her mail. The resident council member stated that the activity director (#79) gives the mail to another resident, who is also a resident council member and that resident delivers the mail. An interview was conducted with the activity director on 8/14/2012 at 5:25 PM. The activity director stated that the activity staff sorts the mail, and we only open the mail for those who cannot. The activity director stated that the mail is open when she receives it from the business office staff. The activity director stated further, The only mail that is opened is their health care cards for Medicaid. Usually something from Medicare or Medicaid. The activity director stated that no one ever questioned the mail being opened. She voiced that she could not remember how many resident's mail would be already open when she received it from the business office. An interview was conducted with the business office manager (#17) on 8/17/2012 at 8:45 AM. She voiced that the facility does open all residents' mail that contains Medicaid information. The business office manager shared that the mail is opened and they take out what they need, make copies and then deliver the mail to the residents. When asked why the business office staff opened resident mail without allowing the resident to first open their own mail, the business office manager replied, Because we can't see what's in it without opening it first. Additionally, the business office manager stated that they do not permit the residents to open their own mail first, because We would never get it. The business office manager stated that the facility does not have a policy requiring that resident mailed be opened before delivering it to the residents. She also conveyed that the facility has not requested consent from any resident to open their mail. Based on the findings, the facility failed to ensure that Medicaid residents receive mail that is un-opened.",2016-12-01
8037,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,156,B,0,1,8KXK11,"Based on record review and staff interview, the facility failed to identify the services being discontinued and/or the reason for the action on the liability notices. This affected three (3) of three (3) sampled residents who had Medicare covered services discontinued. Resident identifiers: #228, #21, and #215. Facility census: 127. Findings include: Residents #228, #21, and #215 A review of the Notice of Medicare Provider Non-Coverage document, which was provided to the residents and/or their responsible parties, found the following verbiage: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END: (followed by the date) The document did not, in a language the resident could understand, identify the service that was being discontinued, nor did it explain why the service was being discontinued. The resident was being asked to decide whether to make an appeal of the decision without this information. During an interview with the Social Worker on the skilled unit, at 11:00 a.m. on 08/22/12, it was revealed that Residents #228 and #21 had met their goals and were either discharged to home or another health care facility. During an interview with the Administrator and the Director of Nurses, at 11:30 a.m. on 08/22/12, the Administrator acknowledged that the name of the service and reason for discontinuing it were not being added to the form, although it was a CMS approved form.",2016-10-01
8120,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-10-24,225,B,1,0,0LWM11,"Based on a review of the abuse/neglect reportable allegations, the abuse/neglect reporting policy, staff interview, and review of complaint files, the facility failed to ensure seven (7) of ten (10) complaints were identified as allegations of abuse and/or neglect and reported to the appropriate outside agencies in accordance with state law. The facility investigated the complaints, but did not recognize them as allegations of abuse/neglect which required reporting to outside agencies. Resident identifiers: #59, #21, #84, #66, #37 #6, and #83. Facility census: 77. Findings include: a) Resident # 59 On 06/10/13, a complaint/concern/grievance/request form for Resident #59 stated, Daughter (name) complained that resident does not receive toileting assistance quickly enough. Stated that mom will proceed to the toilet on her own. Also complained that mother is not being offered continental breakfast. Concerned about inadequate staffing. b) Resident #21 A complaint/concern/grievance/request form for Resident #21, dated 08/06/13, stated 1.) Daughter complained that bed/mattress was noticeably dirty with dried food and also smelled of urine. 2.) Daughter also voiced concern about nursing unit being out of basic supplies like wipes, gloves, and disposable briefs. c) Resident #84 On 09/05/13, Resident #84 complained that her p.m. (night) medicines were given at 11:30 p.m., after her son had to call the facility. d) Resident #66 Resident #66 complained of not receiving baths as scheduled; being told by staff too busy. e) Resident #37 The resident's sister complained that Resident #37 is not warm enough in bed, and has told her she gets cold. The resident's sister believes this is because staff will leave Resident #37 in a thin gown instead of putting pants on her every day in bed as requested. She also believes staff does on provide Resident #37 with the use of a bedpan. The facility received the complaint on 10/02/13. f) Resident #6 Resident #6 complained that aides were not changing her at night every two (2) hours and nurses were not giving her anything for her headaches. She made the complaint on 08/13/13. g) Resident #83 On 08/26/13, the resident's wife stated a nurse aide with dark curly hair who took care of the resident on Saturday and Sunday 08/24/13 and 08/25/13 was too touchy - feely with him; calling him baby and getting in his face. She feels this frustrated and angered her husband. The nurse aide was identified as (name). h) On 10/24/13 at 1:00 p.m., the administrator (Employee #95) confirmed the facility did not report the above allegations to the required outside agencies. She said the facility did not recognize the above issues as allegations of abuse/neglect. She said they investigated these issues as complaints. i) A review of the facility's abuse, neglect, and exploitation policy, with an effective date of 05/01/12, revealed the policy contained criteria to help identify victims of abuse, but did not give criteria to identify victims of neglect.",2016-10-01
8173,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-09-20,356,B,1,0,F3O611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation of the posting of direct care staffing and staff interview, the facility failed to ensure the required information was posted daily at the beginning of each shift. The staffing information sheet on [MEDICATION NAME] Lane was not completed for of 09/16/ 13. This information is to be posted so families and residents will be aware of how many direct care staff members are in the facility at any given time providing care. This had the potential to affect more than an isolated number of residents/families who may want to review this information on each shift. [MEDICATION NAME] Lane Census: 35. Facility Census: 79. Findings Include: a) [MEDICATION NAME] Lane During the initial tour of the facility on 09/16/13 at 7:00 p.m., the staffing available in the facility at that time was checked on each of the facility's three (3) units. The posted form for staffing was observed to be complete for the Lifesteps unit and the Lighthouse unit, but on the [MEDICATION NAME] Lane unit, the form had not been completed. The form posted on [MEDICATION NAME] Lane was blank. At the time of the observation, on 09/16/13, at approximately 7:15 p.m., the form should have been completed for 7-3 shift and 3-11 shift. The Administrator (Employee #116) was made aware of the posting being incomplete on [MEDICATION NAME] Lane on 09/16/13 at 8:30 p.m. She verified the form should be completed at the beginning of each shift.",2016-09-01
8186,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,156,B,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate liability notices to one (resident #277) out of four sampled residents reviewed for liability notices and beneficiary appeal rights. Findings Include: Resident #277 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident was notified by the facility that skilled nursing services would end on May 12, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident on May 10, 2012. Resident remained in the facility and was not discharged following the end of covered services. However, the resident was not issued the Skilled Nursing Facility Advance Beneficiary Notice (CMS Form ). An interview with employee #76 was conducted on May 16, 2012. Employee #76 stated that she issued the CMS Form and not the CMS Form . A subsequent interview was conducted with employee #76 on May 17, 2012. Employee #76 stated that she misunderstood the training she received regarding the requirements for issuing liability notices.",2016-07-01
8292,COLUMBIA ST. FRANCIS HOSPITAL,515110,333 LAIDLEY STREET,CHARLESTON,WV,25322,2013-02-01,356,B,0,1,BSMW11,"Based on observation of facility postings and staff interview, it was determined the nurse staffing numbers for the day shift were inaccurate at 3:30 p.m. on 01/28/13. This had the potential to affect all residents and the public, who are to have access to this information. Facility census: 17. Findings include: a) Observation of the staff posting on 01/28/13 at 3:30 p.m., found the facility had two (2) nursing assistants on duty for day shift and the two (2) employees were working a total of sixteen (16) hours. An interview with the director of nursing, Employee #133, at 11:20 a.m. on 01/30/13, confirmed a third nursing assistant had been assigned to the unit at 11:00 a.m. on 01/28/13, and would be working from 11:00 a.m. until 7:00 p.m. She agreed the nurse staffing posting should have been updated to include the third nursing assistant, and the the total number of hours should have been changed from 16 hours to 20 hours.",2016-07-01
8354,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2012-11-07,167,B,0,1,CDQ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, the facility failed to ensure that survey results were accessible to all residents without having to ask. Findings include: Observations were conducted on November 5, 6, and 7, 2012, of a binder labeled Survey Results, located on a wall near the front entrance of the facility. The survey results were contained within a plastic holder, attached to the wall, approximately 5 and a half feet high. It did not appear that residents in wheelchairs would be able to reach the survey results without having to ask for assistance. Resident #20 was admitted on [DATE], with [DIAGNOSES REDACTED]. An interview was conducted with resident #20 on November 7, 2012. During the interview, the resident stated he was not aware of where the survey results were located and that he would have to ask staff. Resident #55 was admitted on [DATE], with [DIAGNOSES REDACTED]. An interview was conducted with resident #55 on November 7, 2012. During the interview, the resident stated that the survey results were too high for her to reach while in her wheelchair and that she would have to stand to access the survey results which she stated she was not able to do. An interview with the Recreational Director, staff #73, was conducted on November 7, 2012. Staff #73 stated that residents could ask the receptionist for assistance to access the survey results and agreed that residents in wheelchairs would not be able to reach the binder independently because they were located too high upon the wall.",2016-07-01
8500,MAIN STREET CARE,5.1e+155,"PO BOX 7, 1500 TERRACE STREET, SUITE 300",HINTON,WV,25951,2012-12-05,253,B,0,1,MNTR11,"Based on observation and staff interview, it was determined the facility had not ensured a sanitary, orderly, and comfortable interior. The doors of the resident rooms, ancillary rooms, the physician exam room, and the storage room had scratches and scuff marks observed. These conditions rendered the doors unable to be easily cleaned and sanitized. This was evident for twelve (12) of thirty-seven (37) resident rooms and two (2) ancillary rooms. Room identifiers: #345, #346, #348, #349, #351, #352, #354, #356, #343, #341, #340, and #338. Facility census: 1. Findings include: a) Rooms #345, #346, #348, #349, #351, #352, #354, #356, #343, #341, #340, and #338 While doing rounds, with the administrator, Employee #15, for environmental observations, on 12/03/12 at 3:15 p.m.,it was noted the hallway doors to twelve (12) resident rooms had scratches and scuff marks that made them unsightly and not easily cleanable. b) Observation of the physician exam room and the storage room door found these doors were scratched and scuffed. c) When the condition of the doors was discussed with the administrator, on 12/03/12 at 3:15 p.m., he verified the doors were in need of repair. He said it was part of a remodeling plan for the doors to be redone with stainless steel panels.",2016-06-01
8550,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2012-03-15,167,B,0,1,17TQ11,"Based on the resident council president interview, observation, and staff interview, it was found the facility failed to post their survey results in a place readily accessible to residents, and failed to post a notice of their availability. The survey results were in a bookcase in the lobby, blending in with several books. This practice had the potential to affect any resident or family member wishing to examine the survey results without asking a staff member where they were located. Facility census: 66. Findings include: a) An interview conducted with the resident council president, on 03/13/12 at 9:30 a.m., revealed the resident council president did not know the location of the state survey results. The survey results were not found during an observation of the front lobby, on 03/13/12, at approximately 2:00 p.m., after the interview with the council president. During an interview with the interim Nursing Home Administrator (NHA), Employee #97, on 03/14/12 at 12:00 p.m., the location of the survey results was requested. The NHA located the survey results in the front lobby in a bookcase that contained many books and survey results book blended in with other books. There was also no notice posted of their availability. The NHA agreed the survey results were not posted in an area that was readily available to residents and families without asking staff for their location.",2016-05-01
8574,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2012-05-21,356,B,0,1,ZPPW11,"Based on observation and staff interview, it was determined the facility failed to post the required nurse staffing data in a prominent place in the facility that was readily accessible to residents and visitors. This information was posted on an inside wall at the entrance to the nurse's station, and not on a wall which would be easily viewed by visitors and residents. This practice had the potential to affect all residents and visitors who were interested in viewing the daily staffing in the facility. Facility census: 54. Findings include: a) An attempt to locate the required nurse staffing data posting, on 05/15/12, revealed it was not posted with the other required postings or in a prominent location convenient for viewing by visitors and residents. During an interview with a random staff member, on 05/15/12 at 11:15 a.m., it was revealed the nurse staffing was located at the nurse's station. Observations found the posting was located just inside the nurse's station on a side wall. The posting was not readily accessible or visible to visitors and residents who was interested in the daily nurse staffing information. On 05/17/12 at 11:45 a.m., an interview was conduced with the administrator (NHA), Employee # 42. The NHA was informed the posting was not located in an area that was easily viewed by visitors and residents. The NHA stated the nurse staff posting was located at the nurse's station so nursing staff could easily update the posting at each shift. This regulation requires the nurse staff posting be in a prominent place which is readily accessible to visitors and residents, not posted in an area for staff convenience.",2016-05-01
8583,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2013-05-02,514,B,1,0,SKGC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, nursing staff failed to document a time on the Physician/Prescriber order sheets when a verbal or telephone order was written. One (1) of eight (8) records reviewed was found to have orders without the time the order had been obtained noted. Resident identifier: #98. Census: 97. Findings include: a) Resident #98 On 05/02/13 at 12:30 p.m., record review for Resident #98 found five (5) of the Physician/Prescriber order sheets were not timed when the verbal or telephone order had been written. On 05/02/13 at 12:55 p.m., Employee #2, the director of nursign, was interviewed. She said she had conducted mandatory inservices with the staff regarding telephone and verbal orders on 04/12/13 and 04/26/13. She provided copies of the inservice records, but the timing of orders was not listed on the agenda or inservice sheets. The DON stated orders were timed when they were put in the computer, but sometimes the nurses did not time the physician orders [REDACTED]. Upon further questioning of timing the orders when written, Employee #2, the DON again stated they are timed when the nurse enters them in the computer.",2016-05-01
8662,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,160,B,0,1,46GB11,"Based on review of residents' personal funds and staff interview, the facility failed to convey residents' funds, and to provide a final accounting of those funds, to the individual or probate jurisdiction administering the residents' estates. Instead, the facility paid the residents' funds to the funeral home and did not provide a final accounting of the residents' funds to a legally authorized individual or probate jurisdiction administering the estate. This practice affected three (3) of three (3) sampled residents. Resident identifiers: #2, #9, and #100. Facility census: 76. Findings include: a) Residents #2, #9, and #100 Review of the facility's personal funds accounting records found these three (3) residents' final accounts were paid directly to a funeral home. During an interview, on the afternoon of 01/11/12, a business office manager, Employee #63, confirmed when a resident passed away the facility did provide a final accounting of the residents' funds, and did not send the funds to the individual or probate jurisdiction administering the resident's estate. Employee #63 stated, All funds go directly to the funeral home.",2016-04-01
8672,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,356,B,0,1,46GB11,"Based on observations, review of the nurse staff posting and staff interview, the facility failed to ensure they were in compliance with the requirements set forth by the Center for Medicare and Medicaid Services (CMS) in relation to nurse staffing information. The facility was completing the staff posting in advance, rather than at the beginning of each shift as required. This practice had the potential to affect more than an isolated number of both residents and other interested individuals such as family members or visitors. Facility census: 76. Findings include: a) On 01/03/12, at approximately 4:30 p.m., an observation of the daily staffing sheet revealed the facility had the number of licensed practical nurses and registered nurses for night shift already filled in and counted. On 01/09/12, at approximately 11:00 a.m., a second observation of the daily staffing sheet revealed it had the wrong date listed and had the number of licensed and registered nurses had been filled in for day, evening, and night shifts. On 01/09/12, at approximately 12:00 p.m., the director of nursing (Employee #55) said Employee #89 (licensed practical nurse) took care of the daily staffing post and would answer any questions related to the issue. On 01/09/12, at approximately 1:00 p.m., Employee #89 confirmed she was responsible for the daily staffing posting. She stated she assigned another staff member to fill in the number and hours scheduled for licensed and registered nurses each day. Employee #89 indicated she would discontinue having staff fill out the sheet for the entire day, and instead, fill in the numbers at the beginning of each shift. b) The posting of staff was observed on 01/10/12. Noted on the bottom of this posting was Required staffing is 2.25 hours. This statement was misleading to the public because this is not the required staffing level, but the minimal staffing level required by the State licensure rule. The required staffing is the amount of staff necessary to meet the needs of the residents as described in their plan of care. The administrator was made aware of this statement, at 4:30 p.m. on 01/11/12. It was later verified this erroneous statement was removed from the posting.",2016-04-01
8687,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2012-04-26,253,B,0,1,S35H11,"Based on observation and staff interview, it was determined maintenance and housekeeping services had not ensured doors to resident bathrooms were free from scratches and gouges, walls were not marred and scuffed, and doorframes did not have chipped paint. This affected nine (9) resident rooms in the facility. Room numbers: 99, 110, 111, 112, 113, 221, 224, 226 and 227. Census: 64. Findings include: a) Resident room #s 99, 110, 111, 112, 113, 221, 224, 226 and 227 Observations of the facility, during Stage I of the quality indicator survey process, revealed doors and walls that were scratched, marred, and/or scuffed. Door frames to bathrooms and to the hallways had paint chipped off of the door frames. This was discussed with the maintenance director, Employee #63, as part of the environmental component of the survey process. It was also made known to the administrator, Employee #55, on the afternoon of 04/25/12.",2016-04-01
8700,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,170,B,0,1,S3DJ11,"Based on resident council representative interview and staff interview, the facility failed to ensure residents received prompt delivery of mail. The facility elected not to have mail delivered on Saturdays. Therefore, residents had to wait until Monday to receive mail when the postal service would normally deliver mail to persons living in the community on Saturdays. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) During an interview on 11/02/11 at approximately 9:00 a.m., Resident #29 (who represents the resident council as president) reported that residents at this facility did not receive mail on Saturdays. When interviewed on 11/02/11 at approximately 9:30 a.m., Employee #60 (administrative assistant) acknowledged the facility had the mail delivery stopped on Saturday due to the mail box being broken into and mail being stolen. On 11/03/11 at approximately 1:00 p.m., the director of nursing (DON) reported an activity assistant would start getting the mail out of the box after the facility resumed Saturday delivery. According to the guidance to surveyors for determining a nursing facility's compliance with this requirement: 'Promptly' means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service.",2016-04-01
8734,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2012-04-12,371,B,0,1,QOYO11,"Based on observation and staff interview, it was found the facility was using coffee cups which had some of the finish worn off. Additionally, a residue was found inside of cups which could be scratched off with a fingernail. This had the potential to affect more than a limited number of residents who might be served coffee in these cups. Census: 54. Findings include: a) On the morning of 4/10/12, coffee cups were found to have the finish worn off of the insides of the cups. A residue was also noted in the bottom of the cups that could be scratched with ones fingernail. Further observations in the kitchen found other cups that were ready to be used to serve residents in the same condition. This was discussed with the consultant dietitian, Employee #85, in the afternoon on 04/11/12. She stated she usually discarded the cups when they were found to be in that condition and had them replaced by the food equipment company.",2016-04-01
8829,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2011-08-31,160,B,0,1,5Y7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document reviews, staff interviews, and review of the facility's policy, the facility failed to convey personal funds within thirty (30) days after death for seven (7) deceased residents. Resident identifiers: #19, #22, #70, #66, #91, #96, and #97. Facility census: 100. Findings include: a) Residents #19, #22, #70, #66, #91, #96, and #97 Review of facility documentation. on [DATE] at 2:00 p.m., revealed that the facility failed to convey residents' personal funds within thirty (30) days of death. The documentation contained the following information: - Resident #19 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - one hundred-five (105) days after death. - Resident #22 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - seventy-nine (79) days after death. - Resident #66 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - fifty-two (52) days after death. - Resident #70 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - one hundred fifty-seven (157) days after death. - Resident #91 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - sixty-nine (69) days after death. - Resident #96 - date of death recorded as [DATE] and conveyance of funds by check not sent as of [DATE] - thirty-nine (39) days after death. - Resident #97 - date of death recorded as [DATE] and conveyance of funds by check not sent as of [DATE] - fifty (50) days after death. - During an interview on [DATE] at 2:15 p.m., the bookkeeper (Employee #83) stated she was new to the position since [DATE] and did not realize the facility was not in compliance with conveyance of resident personal funds within thirty (30) days of death, until a few days ago. During an interview on [DATE] at 9:00 a.m., Employee #120 (the interim director of nursing) and Employee #119 (the interim administrator) indicated they were aware of the facility's non-compliance with conveyance of funds and that Employee #83 was new to the position. - Review of the facility policy titled Distributions / Refunds and dated [DATE] indicates in the Procedure section, the following: discharged or deceased residents must be issued refund checks from the 'Trust Fund'. The Business Office Manager must ensure compliance with these regulations by quickly processing the request so that a check is issued according to state guidelines, but no longer than 30 days after discharge or death.",2016-03-01
8853,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2012-03-15,159,B,0,1,8YB611,"Based on interviews with six (6) residents in Stage I of the Quality Indicator Survey (QIS) and staff interview, the facility failed to ensure residents had access to personal funds after normal business hours. This was true for six (6) of thirty-two (32) Stage II sample residents. Resident identifiers: #22, #16, #29, #21, #4, and #26. Facility census: 59. Findings include: a) Residents #22, #16, #29, #21, #4, and #26 During stage I of the survey, these residents were interviewed and were asked, Can you get money when you need it, including on the weekends. Each of the residents stated money was not available when the business office was closed. Review of the resident funds accounts found all six (6) residents had a personal account at the facility. Employee #34, a licensed practical nurse, was interviewed, at approximately 10:00 a.m., on 03/14/12. Employee #34 stated money was not available after the business office was closed. Employee #36, a register nurse, was interviewed, at approximately 10:15 a.m., on 03/14/12. This employee stated if residents needed money after the business office closed, she would call the office staff and they could come into the facility and unlock the safe to get money.",2016-03-01
8871,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-02-01,514,B,0,1,RZ6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, five (5) of forty-nine (49) Stage II clinical records were not accurate and / or maintained in a systematically organized manner. Medical information from specific resident medical records were found in the wrong residents' medical records for four (4) residents. Additionally, information was inaccurate in one (1) resident's medical record. Resident identifiers: #32, #94, #61, #118, and #43. Findings include: a) Resident #118 While reviewing the closed medical record of Resident #118, it was found that other residents' medical record information was misfiled in this individual's record. Occupational therapy (OT), speech therapy (ST) and physical therapy (PT) progress notes and plans of care were mixed in with Resident #118's documentation. b) Resident #61 OT progress notes, dated 01/02/12, and plan of care notes, effective 12/19/11 to 02/12/12, were filed in another resident's medical record. c) Resident #94 The resident's PT plan of care notes (effective from 12/22/11 to 02/15/12), PT therapist progress report dated 01/17/12, OT progress report dated 01/04/12, and OT plan of care dated effective 12/22/11 to 02/15/12 was located in another resident's medical record. d) Resident #32 ST progress notes of 12/28/11, ST plan of care effective from 12/28/11 to 01/24/12, OT progress report dated 01/10/12, OT plan of care effective from 12/28/11 to 02/07/12, PT plan of care effective 12/28/11 to 02/21/12, PT progress note dated 01/09/12 and progress note dated 01/16/12 were misfiled in Resident #118's closed medical record. This was discussed with Employee #92, a corporate nurse, and the misfiled documentation was provided Employee #92 at 3:40 p.m. on 01/25/12. e) Resident #43 Review of the medical record for this resident revealed there were physician orders [REDACTED]. According to this order, staff was also to check the placement of the steri-strip on the resident's left forearm and leave it until it fell off. There was also an order [REDACTED]. This was inaccurate, as there was only a skin tear that required treatment on the right forearm. Discussion with the director of nursing, on 01/31/12, at midmorning confirmed the error. During the afternoon of 01/31/12 documentation showing the clarification of these orders was provided.",2016-03-01
8897,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2012-03-29,167,B,0,1,EEP611,"Based on observation and staff interview, the facility failed to ensure the results of the most recent surveys were available for examination. The facility's survey results book did not contain the results of the last annual survey and subsequent complaint investigations which were completed after the last annual survey. This issue had the potential to affect more than an isolated number of residents. Facility census: 60. Findings include: a) On 03/28/12, observation of the facility's survey results book revealed the results of a revisit to a complaint investigation completed in August 2011. According to the Centers for Medicare and Medicaid Services (CMS), results of the most recent survey means the statement of deficiencies (HCFA-2567) and the statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys and any deficiencies from any subsequent complaint investigation(s). On 03/19/12 at 9:00 a.m., the executive director (Employee #72) said she had taken out the last resurvey results and other complaints and agreed the only thing in the book was the result of the 08/16/11 complaint revisit.",2016-03-01
8902,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2011-12-14,253,B,0,1,WGCM11,"Based on observations and staff interview, it was found housekeeping services had not ensured bedroom and bathroom doors, as well as dining room furniture, were in good repair and therefore easy to clean and keep sanitary. This was evident for eight (8) resident rooms (202, 204, 205, 206, 207, 208, 209, 210) and several chairs in the main dining room. Census: 60. Findings include: a) During the Stage I observation portion of the survey process, the main doors and / or bathroom doors in rooms 202, 204, 205, 206, 207, 208, 209, and 210 were found to have deep scratches and / or damaged areas which prevented them from being easily cleaned and sanitized. b) Environmental rounds were conducted with Employee #1 (administrator) and Employee #13 (maintenance supervisor), on the morning of 12/14/11. It was found that the wooden legs on many of the chairs in the dining room were scarred and scratched. This made them unsightly and not easily cleanable. These issues were discussed with Employee #1 at the time.",2016-03-01
8968,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,167,B,0,1,VDMM11,"Based on observation and staff interview, the facility failed to ensure all survey results were available for examination, and posted in a place readily accessible to residents. The survey book was in a container on a wall in the dining room that was not accessible to residents in wheelchairs who were unable to stand. In addition, the book did not contain the results of the three (3) most recent complaint investigations. This had the potential to affect more than a limited number of residents. Facility census: 42. Findings include: a) On 04/23/14 at 1:00 p.m., the survey book was reviewed. The annual recertification survey, dated 09/27/12, was the most recent survey filed in the survey book. The reports for the three (3) complaint investigation surveys (abbreviated surveys) conducted since 09/27/12, were not filed in the survey book for residents and/or visitors review. All three (3) of the complaint investigations had deficient practices cited. On 04/23/14 at 1:40 p.m., the administrator acknowledged the complaint investigations completed since the annual recertification survey were not filed in the survey book. She located copies of the three (3) complaint investigation surveys, dated 11/30/12, 10/17/13, and 01/16/14, and filed them in the survey book. b) Observations, on 04/24/14 at 1:00 p.m., found the survey results were located in the dining room. The book containing the results was in a file holder attached to the wall. The file holder was mounted above the height of a resident's head, if he/she were sitting in a wheelchair. At 1:27 p.m. on 04/24/14, the social worker (Employee #35), agreed the survey results were posted at a height too high for all residents to access. On 04/29/14 at 3:35 p.m., an interview was conducted with the director of nursing (DON). She said all surveys, which included annual surveys and complaint investigation surveys, were supposed to be made available and easily accessible for review by residents, visitors, or staff. She acknowledged the survey book, which was kept on the dining room wall, was too high for residents in wheelchairs to reach.",2016-03-01
8969,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,203,B,0,1,VDMM11,"Based on medical record review, review of the facility's uniform notification of transfer/discharge form, and staff interview, the facility failed to provide all necessary information for residents transferred or discharged from the facility. The transfer/discharge information provided to residents who were transferred to another facility did not contain all necessary components for the transfer/discharge. The form did not contain a written reason for the resident's transfer/discharge, or a statement informing the resident or responsible party of his/her right to appeal the action to the state. This affected one (1) resident, but had the potential to affect all residents discharged or transferred from the facility. Resident identifier: #51. Facility census: 42 Findings include: a) Resident #51 A closed record reviewed for transfer/discharge requirements, on 04/30/14 at 3:00 p.m., revealed the transfer/discharge form used by the facility did not contain the reason for the resident's transfer to another facility or inform the resident or medical power of attorney (MPOA) of the resident's right to appeal the discharge from the facility. On 04/30/14 at 3:15 p.m., an interview was conducted with the licensed social worker (Employee #35). She acknowledged she was in charge of completing transfer and discharge notices, and did so for Resident #51's discharge to another facility. The social worker provided a copy of Resident #51's transfer/discharge report, dated 04/10/14. She said she was unaware of the need to give appeals notice information to a resident and/or MPOA at the time of discharge. She said she was also unaware the reason for the discharge or transfer from the facility was supposed to be included with the discharge/transfer notice.",2016-03-01
8986,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,514,B,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical records for one (1) of twenty-three (23) residents reviewed in Stage 2 of the survey. The medical record for a resident, who had a gastrostomy tube ([DEVICE]) and a physician's orders [REDACTED]. Resident identifier: #52. Facility census: 42. Findings include: a) Resident #52 On 04/30/14 8:05 a.m., a review of the medical record for Resident #52 revealed the form titled CNA (certified nursing assistant) - ADL (activities of daily living) tracking form. The director of nursing (DON) stated the form was only used for contract nursing assistant (NA) documentation. This form was dated 04/2014. It contained a section titled Eating Fluids Offered - Indicate Number Offered and ml's. The form showed Resident #52 received oral fluids on 04/03/14, 04/04/14, 04/06/14, 04/07/14, 04/09/14, 04/11/14, 04/13/14, 04/16/14, and 04/17/14. According to the medical record, Resident #52 was NPO and received nourishment via a [DEVICE]. This resident was evaluated by a speech therapist (ST) on 03/17/14. The ST gave the resident only small amounts of ice chips and pureed food. In an interview, with the DON on 04/29/14 at 2:30 p.m., the DON reviewed the documentation. She stated the documentation related to oral fluids was not accurate because the resident was NPO. The DON stated this documentation was habitual documentation. An interview was conducted at this time, with the NA (Employee #56) who documented she gave fluids to Resident #52. When the DON asked what type of diet and fluids Resident #52 received, the NA stated the resident was NPO and did not receive fluids or foods. Employee #56 offered no explanation as to why she documented she had given Resident #52 fluids when she had not.",2016-03-01
9024,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,356,B,0,1,EZVZ11,"Based on observation and staff interview, the facility failed to post staffing data as required by the regulations. During the initial tour of the facility, the information was not posted for public view. Facility census: 70. Findings include: a) During the initial tour of the facility, on 01/23/12, it was discovered the facility had not posted the required staffing information. Further review of the past staff postings found incomplete staffing information. The staff posting failed to identify the total number of hours worked, the category numbers of staff working, and some shifts were missing all of the required information. This finding was presented and verified by the director of nursing (Employee #17) at 11:00 a.m. on 01/30/12.",2016-02-01
9025,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,360,B,0,1,EZVZ11,"Based on a review of the facility's disaster menu and staff interview, the facility failed to ensure they had prepared a menu that provided each resident with a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of each resident. Twelve (12) of seventy (70) residents received a pureed diet. The facility's emergency menu had food items that did not meet the needs of resident's who received a pureed diet. Resident identifiers: #80, #70, #48, #18, #10, #24, #30, #32, #22, #26, #49, and #26. Facility census: 70. Findings include: a) On 01/26/12, at approximately 10:00 a.m., the dietary manager (Employee #92) assisted in the review of the facility's emergency menu. The menu called for the following items at dinner: - Day one: Vegetable juice, peanut butter, jelly, corn, tortilla chips, cookies, milk, salt, pepper, and sugar -Day two: Tomato juice, canned pork/ham, baked beans, potato chips, vanilla wafers, hard candy, milk, salt, pepper, and sugar -Day three: Vegetable juice, tuna, mayonnaise, carrots, tortilla chips, graham crackers, jelly beans, milk, salt, pepper, and sugar The menu indicated the facility had the following pureed items: Chicken, pork or ham, fish, jar baby cereal, carrots, green beans, peas, peaches, pears, and apricots. The dietary manger indicated her consultant dietitian had reviewed the menu and approved of the selections. The menu indicated hard candy and jelly beans would be omitted based on individual tolerance for those on ground and pureed diets. On 01/26/12, at approximately 12:00 p.m., the dietary manager said the staff would provide mashed potatoes in place of potato chips or tortilla chips for those on pureed diets. She said the facility could offer Jell-O in place of the hard candy / jelly beans. On 01/30/12, at approximately 10:00 a.m., the dietary manager indicated she had spoken with the registered dietitian and had come up with some adjustments to the emergency menu. She provided a copy of the new menu. The bottom of the menu stated substitute pureed foods or nutritional supplement. Omit jelly beans on individual tolerance. Substitute instant mashed potatoes for tortilla chips and potato chips. On 01/30/12, at approximately 1:00 p.m., the facility's diet orders were reviewed. The following residents received pureed diets: Resident #80, #70, #48, #18, #10, #24, #30, #32, #22, #26, and #49. The dietary manager agreed the previous menu did not give the staff a food item of equal nutritive value with which they could replace the tortilla and potato chips should they need to utilize the emergency menu.",2016-02-01
9117,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,170,B,0,1,REFP11,"Based on an interview with the president of the resident council (Resident #1) and staff interview, the facility failed to afford residents with the right to promptly receive mail. The facility did not distribute resident mail on Saturdays, although mail was available for delivery to the facility on this day of the week. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 50. Findings include: a) An interview with the president of the resident council (Resident #1), on the afternoon of 09/14/11, elicited that the residents did not receive mail on Saturdays. An interview with the facility's bookkeeper (Employee #22), on the morning of 09/15/11, confirmed the facility does not distribute mail to residents on Saturdays. Employee #22 stated they have the post office hold the mail until Monday, in case the mail contains any money. According to Employee #22, the facility has both delivery at the facility and a post office box, and they do not check the post office box for mail on Saturdays. Mail is delivered to the front office, sorted, and given to the activity director to distribute to the residents. An interview with the activities director (Employee #38), at 9:25 a.m. on 09/15/11, revealed she does not go to the post office on Saturdays and mail is not delivered to the facility due to no one being in the front office to receive it. She agreed she did not check the post office box on Saturdays.",2016-02-01
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
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
9322,CRESTVIEW MANOR NURSING & REHABILITATION,515160,199 COURT STREET,JANE LEW,WV,26378,2011-09-20,160,B,0,1,GVDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of financial records and staff interview, the facility failed to convey the resident's funds and/or a final accounting of those funds within 30 days after the death of the resident for two (2) of eighteen (18) sampled residents with personal funds as required by State law. Resident identifiers: #3 and #150. Facility census: 62. Findings include: a) Residents #3 and #150 A review of the facility's financial records showing the balances in the resident trust accounts at the end of [DATE] revealed accounts for two (2) residents who had expired over thirty (30) days prior. During an interview with Employee #26 at 11:50 a.m. on [DATE], she stated Resident #3 had expired on [DATE], and a check for the balance of his account ($606.17) had been issued to the facility for payment of outstanding room charges on [DATE]. There was no evidence to reflect the resident's power of attorney (POA) had been issued a final accounting of the resident's personal funds. In a follow-up interview with Employee #26 with Employee #1 (the facility's office manager) at 3:00 p.m. on [DATE], they stated Resident #150 had expired on [DATE], and a check for the balance of his personal fund account ($414.61) had been issued to the facility for payment of outstanding room charges on [DATE]. There was no evidence this resident's POA had been issued a final accounting of the resident's personal funds.",2015-12-01
9400,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,156,B,0,1,85AT11,"Based on record review and staff interview, the facility failed to assure one (1) of one (1) applicable resident / responsible party was informed of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. This practice had the potential to affect any resident who was discontinued from Medicare-covered skilled services. Resident identifier: #60. Facility census: 97. Findings include: a) Resident #60 On 04/07/10 at 3:30 p.m., a review was conducted, with the facility's business office manager, of residents whose Medicare-covered skilled services had been discontinued by the facility. Three (3) of four (4) residents reviewed had met their rehabilitation potential and were discharged home. One (1) resident (Resident #60) was discontinued from Medicare-covered services but remained in the facility. He had not exhausted his allowable one hundred (100) Medicare days, but facility staff believed he had met his rehabilitation potential. Because of this, he should have been offered the opportunity to request a demand bill. Review of the notice provided to the resident revealed the form did not contain an option for the resident / responsible party to request a demand bill. There was a space to indicate no regarding submission of a demand bill, but no space to indicate yes requesting the facility to submit a demand bill. In an interview conducted with the social worker (Employee #103) at 4:00 p.m. on 04/07/10, Employee #103 stated she had no idea how this situation had happened but confirmed the form did not contain the required information to allow a resident / responsible party to request the facility submit a demand bill in the resident's behalf.",2015-11-01
9416,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-11-07,514,B,1,0,I0U011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document percentages or acceptance of supplement intake. This was evident for three (3) of ten (10) sampled residents. Resident identifiers: #35, #66, and #11. Facility census: 102. Findings include: a) Resident #35 Review of the physician's orders [REDACTED].#35 was to receive a house supplement three (3) times daily. Review of the snack, nourishment, supplements and pantry stock policy (3.14) on 11/07/12 found the nourishment list was printed from the tray tracker and used as a guide for delivery of supplements to residents and to record acceptance. Nourishment list records were reviewed for a sample of fourteen (14) days. The dates reviewed were 10/24/12 through 11/06/12. This afforded forty-two (42) opportunities for the resident to receive a supplement. An interview with Employee #102, the director of nurses, Employee # 92, the director of food services, and Employee #37, the assistant food director, revealed no evidence was available to indicate the resident had been offered the supplement on six (6) of fourteen (14) days. A nourishment list was not available for the dates of 11/03/12, 11/02/12, 10/30/12, 10/28/12, 10/27/12, and 10/25/12. The nourishment forms for this resident were blank for five (5) of forty-two (42) opportunities reviewed. These dates included 11/04/12, 11/01/12 and 10/29/12. Acceptance only, with no percentage of consumption noted, occurred on two (2) occasions. Additionally, consumption was unable to be identified on one (1) occasion due to the report indicated both acceptance and refusal of the same date and time of distribution. b) Resident #11 Review of the medical record indicated this resident had an order to receive a house supplement twice daily. This afforded twenty-eight (28) opportunities for consumption during the fourteen (14) days reviewed. The dates reviewed were 10/24/12 through 11/06/12. Review of the snack, nourishment, supplements and pantry stock policy (3.14) on 11/07/12 indicated the nourishment list was printed from the tray tracker and used as a guide for delivery of supplements to residents and to record acceptance. Employee #102, the director of nurses; Employee # 92, director of food services and Employee #37, assistant food director, were interviewed on 11/07/12. A nourishment list (1) was not provided for the dates of 11/03/12, 10/30/12, 10/28/12, 10/27/12, and 10/25/12. Review of the nourishment record for the dates of 11/04/12, 11/01/12, 10/29/12, and 10/26/12 found no evidence the supplement had been offered. The form was not completed on four (4) occasions. On 10/26/12 the nourishment record indicated the supplement was not sent up. No evidence was provided to indicate a supplement was obtained, offered, or consumed. Staff documented acceptance for the date of 11/05/12, but the percentage of consumption was not recorded. c) Resident #66 The medical record was reviewed on 11/07/12. It revealed this resident had an order to receive a house supplement once daily at bedtime. Review of the snack, nourishment, supplements and pantry stock policy (3.14) on 11/07/12 indicated the nourishment list was printed from the tray tracker and used as a guide for delivery of supplements to residents and to record acceptance. Nourishment records were reviewed for a sample of fourteen (14) days. The dates reviewed were 10/24/12 through 11/06/12. Review of the nourishment list on 11/07/12 revealed no evidence the supplement had been offered or consumed on six (6) dates. The nourishment list was not provided for 11/03/12, 11/02/12, 10/30/12, 10/29/12, 10/28/12 and 10/26/12. No further evidence was provided by the nursing or dietary department to substantiate distribution of the supplement. Additionally, review of the nourishment list on 11/07/12 revealed the percentage intake was not completed on five (5) occasions. These dates include: 11/04/12, 11/01/12, 10/31/12, 10/27/12 and 10/25/12. This information was shared with Employee #102, the director of nurses, and Employee # 92, the director of food services and Employee #37, the assistant food director, on 11/07/12. No further information was provided.",2015-11-01
9468,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2011-02-02,161,B,0,1,U0V411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's continuation certificate and staff interview, the facility failed to provide evidence that the facility's surety bond had been reviewed (for sufficiency of form and amount) and approved by the Attorney General's Office for the funds of eleven (11) residents that were being managed by the facility. Review of the continuation certificate found it had not been submitted for review and approval by the Attorney General's Office; therefore, this facility was managing residents' personal funds without an approved surety bond. Facility census: 63. Findings include: a) Review of the facility's surety bond continuation certificate revealed a lack of evidence that it had been reviewed, for sufficiency of form and amount, by the West Virginia Attorney General's Office. Review of the facility's surety bond, held by the Office of Health Facility Licensure and Certification (OHFLAC), found the last surety bond that had been approved through the Attorney General's Office (#B 895) had expired on [DATE]. During a telephone interview on [DATE] at 2:00 p.m., the facility's office manager (Employee #31) confirmed the facility had not submitted the continuation certificate to OHFLAC for review and approval by the Attorney General's Office. Facility records revealed the facility managed funds for eleven (11) residents, and their current high balance for the month of January, 2011 was $1,300.00. Review of the continuation certificate noted the amount of the bond was for $20,000.00.",2015-11-01
9602,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-10-05,356,B,1,0,D8F011,"Based on observation and staff interview, the facility failed ensure the nurse staff posting was completed at the beginning of the shift and contained the total number and the actual hours worked for licensed and unlicensed nursing staff for the day shift of 10/01/12. This had the potential to affect more than an isolated number of residents and visitors. Facility census: 89. Findings include: a) During the initial tour of the facility, on 10/01/12 at 12:35 p.m., observation of the nurse staff posting found the number of licensed and unlicensed nursing staff for the day shift of 10/01/12 had not been completed. The nurse staffing posting was observed with the director of nursing (DON) on 10/01/12 at 12:35 p.m. The DON confirmed the information had not been completed.",2015-10-01
9635,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,492,B,0,1,SWBO11,"Based on a review of personnel files and staff interview, the facility failed to assure four (4) of five (5) sampled nursing assistants were provided with the West Virginia State Rule 69CSR6-8.1 regarding the WV Nurse Aide Registry as required by State law. Employee identifiers: #37, #172, #173, and #99. Facility census: 111. Findings include: a) Employees #37, #172, #173, and #99 A review of the personnel files for Employees #37, #172, #173, and #99, on 05/20/10 at 11:20 a.m., revealed they were hired as nursing assistants, but there was no evidence to reflect they were provided with a copy of the West Virginia State Rule 69CSR6-8.1 regarding the WV Nurse Aide Registry, as required by State law. When interviewed on 05/20/10 at 11:50 a.m., the human resources director (Employee #141) confirmed there was no evidence that the required information was provided to these four (4) nursing assistants. According to 69CSR6-8. Facility Notice and Record Keeping: 8.1. Facilities shall provide a copy of this rule to each Nurse Aide on their staff and to each Nurse Aide at the time of hiring and keep signed proof that each Nurse Aide has received a copy of the rule.",2015-10-01
9659,GRANT COUNTY NURSING HOME,515151,127 EARLY AVENUE,PETERSBURG,WV,26847,2010-08-24,167,B,0,1,GDQ711,"Based on resident interview, observation, and staff interview, the facility failed to make readily accessible to all residents wishing to review the results of the most recent survey of the facility conducted by State surveyor and any plan of correction in effect. The survey results were kept out of reach of residents who were wheelchair-dependent, with no posting to direct residents to their current location in the facility. Facility census: 110. Findings include: a) Interview with Resident #9, on 08/16/10 at 1:50 p.m., found she did not know where the survey results were kept. Observations, made on 08/24/10 at 1:00 p.m., failed to find the survey results that were supposed to be located at the front nurse's station. Interview at this time with the social services secretary (Employee #93) found the results were usually kept on the top of a file cabinet located just to the left of the nurse's station, but they were not there. At 2:00 p.m., the person-in-charge (Employee #132) said the survey results were usually kept on an end table beside of a chair by the nursing station, but some of the residents who were on the hallway just off of the nursing station picked them up, so they were moved to the top of the filing cabinet. Residents who were in wheelchairs and could not stand would not be able to access the survey results without asking for assistance.",2015-10-01
9668,GRANT COUNTY NURSING HOME,515151,127 EARLY AVENUE,PETERSBURG,WV,26847,2010-08-24,514,B,0,1,GDQ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the completeness and accuracy of the medical record, by failing to transcribe a hospital discharge order for an indwelling urinary catheter to the facility admission orders [REDACTED]. Resident identifier: #101. Facility census: 110. Findings include: a) Resident #101 A review of the medical record revealed Resident #101 was an [AGE] year old female who was initially admitted to the facility on [DATE], and was readmitted on [DATE], after a hospitalization and surgery to repair a [MEDICAL CONDITION]. The resident was readmitted to the nursing home with an indwelling Foley urinary catheter in place, as documented in the nursing notes by a nurse (Employee #52) at 9:30 p.m. on 06/04/10, even though there was no physician's order for the catheter. Her incontinence assessment, dated 06/04/10, also documented the resident was readmitted with a urinary catheter in place. During an interview with the person-in-charge (Employee #132) at 11:00 a.m. on 08/24/10, she produced the discharge instructions from the hospital which included an order for [REDACTED].>",2015-10-01
9693,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,203,B,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form and staff interview, the facility failed to correctly communicate to all residents and responsible parties the contact information of the appropriate state agencies for residents with developmental disabilities or those who are mentally ill. This error in the uniform notice has the potential to lead a resident/responsible party to contact the wrong agency to provide assistance, and may interfere in the resident's ability to exercise his or her right to contact. The uniform discharge notice provided incorrect information regarding the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility with developmental disabilities or mental illness. Facility census: 72. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: This was followed by the names and contact information for West Virginia Advocates Local Mental Health and Medicaid Fraud. This uniform notification form contained the following errors: - The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc, not West Virginia Advocates Local Mental Health. - Medicaid Fraud does not provide protection and advocacy services to persons with mental [MEDICAL CONDITION] and/or mental illness.",2015-10-01
9724,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,156,B,0,1,U9W011,"Based on observations and staff interviews, the facility failed to ensure the name of the State long-term care ombudsman was posted, and failed to ensure residents had ready access to information regarding Medicare and Medicaid. This had the potential to affect more than a limited number of residents. Facility census: 60. Findings include: a) State long-term care ombudsman On 10/05/10 at approximately 10:00 a.m., the posting of required information was reviewed as a part of the CMS- Environment observations, triggered by findings in Stage 1. The name of the State long term care ombudsman did not appear on any of the postings, just the address and telephone number. The posting requirement is: A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, . -- b) Medicare & Medicaid information On 10/05/10 at approximately 10:00 a.m., the Medicare information (a publication entitled Medicare at a Glance - from CMS) and Medicaid information (Your Guide to Medicaid - from WVDHHR) were observed posted in the entrance hall in a locked glass-covered display case. These contents of these multi-page documents would not be readily accessible to residents wishing to review them. This was discussed with the administrator and social worker during the mid-afternoon on 10/06/10. The administrator stated the social worker had copies and would provide / discuss them with residents / responsible parties and that the nurses had keys to the enclosed display case should a copy be needed. However, it was pointed out that the requirement was for the information to be posted.",2015-10-01
9750,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2010-09-15,253,B,0,1,5OCP11,"Based on observations and staff interviews, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for the residents. Doors and walls were found to have scuffs and scrapes that made them unsightly and not easily cleanable. This was found for seven (7) rooms on the 800 and 900 hallways. (Three (3) on 800 hall and four (4) on 900 hall.) Room numbers: #804, #805, #806, #901, #902, #903, #904, #905, and #907. (Some rooms shared toilet rooms, making seven (7) rooms involved.) Facility census: 90. Findings include: a) Rooms #804, #805, #806, #901, #902, #903, #904, #905, and #907 Observations of above identified resident rooms, during Stage I of the survey on 09/08/10, found bathroom doors and/or corridor doors that were scraped, scratched, had gouges or other unsightly marks and bangs on them. This did not give the facility an orderly appearance in the environment or make them easily cleanable. This was discussed with the administrator (Employee #108) on 09/15/10 at 12:56 p.m., at which time she mentioned there were plans for renovations, and the renovations would include doors and furnishings.",2015-10-01
9870,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-11-07,465,B,1,0,XBKB12,". Based on observation and staff interview, the facility failed to provide a safe and sanitary environment for the residents, staff, and the public in the long term care area located on the second floor of the main hospital building, by failing to keep the perimeters of the floors in the diet kitchen, the hallways, and the elevators clean and free of debris. This had the potential to affect all who came to this area. Facility census: 66. Findings include: a) During a follow-up tour of NCF II (Nursing Care Facility II is the unit located on the second floor of the main hospital building), at 12:45 p.m. on 11/05/07, the floor of the diet kitchen was observed to be dirty overall and grime around baseboards and pipes (near the ice machine). There were papers and debris, including a wash basin on the floor under the cabinets. The floors along the edges, near the baseboards, both in rooms and hallways were unclean. The thresholds of each room were also in need of cleaning. In the soiled utility room, the metal cabinet under the sink was rusted (completely through in spots). While there were no sterile supplies or supplies for direct resident care, there were new red (infectious waste) bags and other supplies stored there. The elevator tracks were dirty and filled with debris. Employee #67 (RN) was present in the diet kitchen at 1:00 p.m. on 11/06/12, and agreed the floor needed cleaned. The DON was informed shortly after and visited the area on her own. During an interview with the head of housekeeping (Employee #64), at 2:08 p.m. the same day, Employee #64 first stated they had a new employee working on this floor, but had no answer when it was pointed out to her the areas described had grime that was not of recent origin. She stated she would schedule these floors to be stripped and cleaned. .",2015-08-01
9871,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-11-07,253,B,1,0,XBKB12,". Based on observation and staff interview, the facility failed to provide adequate housekeeping to ensure a clean and orderly environment by failing to keep the outer perimeters of the floors, both in the residents' rooms and in the hallways of the nursing unit located on the second floor of the main hospital, clean. This had the potential to affect all residents (24) residing in this location. Facility census: 66. Findings include: a) During the initial tour of NCF II (Nursing Care Facility II is the unit located on the second floor of the main hospital building), at 12:15 p.m. on 11/05/07, the floors along the edges, near the baseboards, both in rooms and hallways were noted to be in need of cleaning. The thresholds of each room were also unclean in appearance. A revisit to NCF II, at 12:45 p.m. on 11/06/12, revealed the floors were still grimy at the edges in both rooms and hallways. These observations were reported to the DON at 1:00 p.m. on 11/06/12, and discussed with the head of housekeeping (Employee #64) at 2:08 p.m. the same day. Employee #64 first stated they had a new employee working on this floor, but had no answer when it was pointed out to her that the areas described had grime that were not of recent origin. She stated she would schedule these floors to be stripped and cleaned. .",2015-08-01
9873,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-12-01,244,B,0,1,ENOI11,". Based upon review of facility documentation, resident interview, and staff interview, the facility did not notify and/or discuss a proposed change in dining services with residents prior to implementing the change, and did not adequately address grievances that were expressed following the implementation of the change. This had the potential to affect more than an isolated number of residents. Facility census: 85. Findings include: a) Prior to entry for the survey, the regional ombudsman had advised the survey team that there had been concerns expressed over the facility stopping the practice of providing soda for residents. Resident #14, the vice president of resident council, and the resident who led the last three (3) council meetings of 9/30/11, 10/21/11, and 11/18/11, was interviewed on 11/28/11 at 10:45 a.m. She was asked about any resident council concerns regarding the facility providing soda to residents in recent months. She replied that the facility had stopped providing soda, and now they only got soda during some activities, or had to buy it from the machine. She said several residents were upset by this. She was asked for permission to review the minutes of recent resident council meetings, which she granted. b) Resident council meeting minutes for 8/26/11, 9/30/11, 10/2/11, and 11/18/11 were reviewed on 11/29/11 at 9:00 a.m. The minutes for the 11/30/11 meeting had concerns noted for the dietary department, including (typed as written): ""Suppose to have lemonade to replace soda"" and ""Don't like having the soda taken away."" The facility grievance file was reviewed on 11/29/11 at 9:30 a.m. A complaint was found from 10/4/11, which stated: (typed as written): ""Resident requested soda, staff informed resident that facility no longer provides soda. POA (power of attorney) stated back to employee, 'Don't you think it is awful to pay $7,200.00 per month and can't get a soda.'"" The resolution as documented was that ""activity dept. is to provide soda during room visits."" No other documentation was found that clarified what change in practice had been made concerning soda. c) Resident #14 was again interviewed on 11/29/11 at 10:30 a.m. She was asked if there had been any discussion with resident council regarding soda before the changes were made. She replied that she did not think that there was. She was asked if the facility had responded to the concerns voiced by the resident council on 9/30/11. She stated that the only thing that happened was that they sometimes got soda during activities, but there had been no other response. d) The facility social worker, Employee #25, was interviewed on 11/30/11 at 4:20 p.m. She was asked about the concerns documented in the resident council meeting minutes of 9/30/11 and the complaint filed on 10/4/11. She explained that the facility had maintained the practice of providing soda with meal trays for years. Sometime in September, 2011, the decision was made to remove the soda from the meal trays and have a selection of other items including milk, coffee, tea, and punch. She felt this was done in order to provide more healthy alternatives to soda, and was also part of a larger effort to initiate a fine dining program at the facility. She was asked how the residents and families were told about the upcoming change. She replied that she was not sure, but felt that it may have been discussed in resident council prior to implementation. e) The facility activities director, Employee #18, was interviewed on 11/30/11 at 4:45 p.m. The activities director facilitates the resident council meetings. She was asked if the decision not to provide soda with meal trays any more was discussed with resident council prior to stopping this long term practice, She replied that it was not discussed until the council raised the complaints noted in the minutes of 9/30/11. She said that council had met on 8/26/11, prior to the change, and had not met again until 9/30/11, after the change, which had happened earlier in the month. She acknowledged that the council's concern had not been addressed by the dietary department, but that activities had tried to come up with a way to let them have it sometimes. f) Three (3) facility nursing assistants (NAs), who requested anonymity, were interviewed on 11/30/11 at 10:00 a.m. They confirmed that the soda had been removed from the residents' trays. One (1) NA said that ""It wasn't pretty."" They recalled that the residents were really upset. g) The facility administrator,Employee #3, was interviewed on 12/1/11 at 9:15 a.m. She was asked about the decision to stop the practice of providing soda to the residents on their meal trays. She confirmed that the decision had been made in September, 2011, and was based on the desire to provide a healthier alternative to soda for hydration. She stated that the facility had been routinely placing soda on resident's trays at mealtimes, even at breakfast. She was advised that there was no documentation found at that point to indicate that there had been any discussion with residents regarding the proposed change and the rationale for it before it was implemented, and that there was no documentation found at that point to indicate any response being provided to the resident council when they voiced opposition to the change on 9/30/11. She stated that she had discussed the idea with many residents individually prior to the implementation, and that any additional documentation located would be provided before the survey exit. Upon exit, no additional documentation had been presented. .",2015-08-01
9905,WHITE SULPHUR SPRINGS CENTER,515100,"ROUTE 92, PO BOX 249",WHITE SULPHUR SPRING,WV,24986,2012-07-26,514,B,1,0,U0Q511,". Based on observation, review of documentation of shower/bath administration forms, interviews with residents, and interviews with staff, it was determined staff had not completed ADL (activity of daily living) flow sheets to show that baths/showers were consistently given. There were many blanks and incomplete documentation on these forms for residents on two (2) of four (4) hallways. Hallways involved: 200 and 300. Census: 62. Findings include: a) A review of bath and shower records on the morning of 07/26/12 revealed there were many records that contained numerous blanks and inconsistent documentation on whether baths/showers were given or not. Discussion with the director of nursing, Employee #72, at the time indicated, verified better documentation should be implemented that would verify the baths were given as needed. A short while later, Employee #72 returned and explained that after further review, the problem with documentation of baths for residents was on the 200 and 300 hallways. By observations of residents, staff interviews, and resident interviews, it was determined that baths were being given and it was a documentation issue as opposed to the baths not being provided. Residents expressed they received their baths on time. Staff interviews revealed that they were able to get the showers done for the residents on their assignment as required. No odors or grooming issues were noted when doing observations of residents. .",2015-08-01
9929,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-06-01,356,B,1,0,J5IV11,". Based on observation and staff interview, the facility failed to ensure the required staff posting contained an accurate resident census. This had the potential to affect more than an isolated number of residents and visitors. Facility census: 78. Findings include: a) During the initial tour of the facility, on 05/29/12 at 3:50 p.m., it was noted the required nursing staff posting contained an inaccurate resident census. The facility census was 78, while the posting stated the facility had 49 residents. The discrepancy was brought to the attention of the administrator. He agreed the resident census was not correct on the posting. .",2015-08-01
10064,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2012-01-19,514,B,0,1,ZNLH11,". Based on medical record review and staff interview, the facility failed to ensure clinical records were accurate and kept in a systematically organized fashion for two (2) of forty-nine (49) Stage II sampled residents. A resident's therapy records were found in another resident's medical record. Resident identifiers: #137 and #34. Facility census: 118. Findings include: a) Residents #137 and #34 Review of the medical records found therapy notes for Resident #34 had been placed in Resident #137's record. This finding was reported to Employee #12 (medical records) at 2:24 p.m. on 01/18/12. .",2015-07-01
10157,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2009-10-08,279,B,0,1,SM0211,"Based on record review and staff interview, the facility failed to develop care plans for two (2) female residents to address refusal of staff assistance with grooming. Resident identifiers: #41 and #55. Facility census: 66. Findings include: a) Residents #41 and #55 On 10/08/09 at approximately 9:30 a.m., two (2) female residents (#41 and #55) were observed to have long facial hair. When the administrator was questioned about the residents, he indicated these two (2) residents would not allow staff to trim their facial hair. Record review revealed these two residents' current care plans did not reflect their refusal of this care. The administrator agreed this needed to have been included in their care plans. .",2015-06-01
10303,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,431,B,0,1,MM9U11,". Based on observation and staff interview, the facility failed to assure the safe storage of drugs and biologicals, by retaining a vial of immunization past the manufacturer's expiration date and storing it in a refrigeration rather than in the freezer as recommended. This practice had the potential to affect any resident with orders for this medication. Facility census: 34. Findings include: a) On 05/11/10 at 9:20 a.m., observation of the facility's medication storage room, including the medication storage refrigerator used to store all medications requiring refrigeration for facility residents, found a boxed ampul with a label reading ""Varicella Virus Vaccine"". The labeled box also stated the medication should be stored at an average temperature of 5 degrees Fahrenheit (F), and the noted expiration date of the medication was 19 March 2010. The refrigerator temperature at that time was 46 degrees F. Two (2) licensed practical nurses (LPNs - Employees #21 and #22) were present at the time ,and although neither of the nurses had any idea why the medication was there or who it was for, they both confirmed the medication was beyond the expiration date and was not stored as recommended on the label. .",2015-05-01
10338,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,167,B,1,0,VNEB11,". Based on observation and staff interview, the facility failed to ensure the results of all surveys were readily accessible for resident or visitor viewing. Review of the survey book, located in the lobby of the facility, found the absence of the two (2) most recent complaint investigation surveys. Findings include: a) On 01/12/12, review of the survey book, located in the lobby at the entrance of the facility, revealed the most recent survey result posted was a complaint investigation survey completed in February 2011. During an interview with the director of nursing (DON), on 01/12/12 at 8:45 a.m., she stated she thought there was a complaint survey in December 2011. She was uncertain whether there were any others between February and December 2011. The DON stated the administrator would have copies of any surveys in his office. Interview with the administrator, on 01/12/12 at 9:00 a.m., revealed he had two (2) complaint surveys with deficiencies in his office that were not posted in the survey book in the lobby. One (1) missing complaint survey with citations was conducted in April 2011, and the other missing complaint survey with citations was conducted in October 2011. .",2015-05-01
10353,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,285,B,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the mental health status of a new resident had been evaluated under the Pre-Admission Screening and Resident Review (PASRR) program prior to the resident being admitted into the facility for three (3) of fifteen (15) sampled residents. Resident identifiers: #60, #36, and #49. Facility census: 58. Findings include: a) Resident #60 Review of Resident #60's medical record, on 10/07/09, revealed he was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 06/19/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. b) Resident #36 Review of Resident #36's medical record, on 10/06/09, revealed she was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 07/27/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. c) Resident #49 A review of the clinical record revealed Resident #49 was admitted to the facility on [DATE]. However, the Level II determination was not made, as indicated by the dated signature in Section V of the PASRR, until 07/15/09. During an interview with the administrator and the social worker at 10:15 on 10/08/09, they acknowledged the dates noted above were correct. .",2015-05-01
10409,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2009-08-27,156,B,0,1,Y5MX11,"Based on observation and staff interview, the facility failed to prominently display written information on how to apply for and use Medicare and Medicaid benefits. The facility also failed to include information on how residents / families could receive refunds for previous payments covered by Medicare and Medicaid benefits. This practice has the potential to affect more than an isolated number of residents at the facility. Facility census: 76. Findings include: a) On 08/27/09 at approximately 11:00 a.m., a tour of the facility revealed no posting describing how residents and their families could make application for and use Medicaid or Medicare benefits. The facility had information posted regarding how to file complaints and also advocacy information such as the name / address of the ombudsman; however, Medicare / Medicaid information was not on display. At approximately 11:30 a.m., the administrator agreed this information was not posted. He then made arrangements to have it posted for public display in the facility's main hallway. .",2015-04-01
10421,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2009-09-23,364,B,0,1,JZ9F11,"Based on observation and staff interview, the facility failed to ensure residents who were ordered a pureed / mechanical soft diet were served attractive and colorful meals. Fifteen (15) residents received pureed or mechanically altered diets. Resident identifiers: #3 #4, #5, #7, #10, #11, #15, #18, #30, #35, #48, #51, #54, #61, and #64. Facility census: 65. Findings include: a) Residents #3 #4, #5, #7, #10, #11, #15, #18, #30, #35, #48, #51, #54, #61, and #64 On 09/22/09 at approximately 6:00 p.m., residents were observed eating their evening meal in both the dining room and their individual rooms. A nurse aide assisting Resident #15 indicated she could not identify the main entree on the resident's plate. Other residents also could not definitively identify the main entree. Staff members in the dining room indicated they thought the entree was fish but were not sure. The menu revealed the mechanical soft and puree diets received lemon baked fish, two (2) slices of white bread, mashed potatoes, and a mayonnaise packet. All of these food items were bland in color. The dietary manager said she realized the food lacked color but did not know what to do, because those were the items listed on the menu. .",2015-04-01
10452,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,156,B,0,1,924C11,"Based on observation and staff interview, the facility failed to post contact information for all pertinent State client advocacy groups in a location accessible to all residents. This practice has the potential to affect more than an isolated number of residents who could benefit from this information. Facility census: 153. Findings include: a) Observation, on the morning of 08/13/09, found the names, addresses, and telephone numbers for State advocacy groups were posted on a bulletin board located between two (2) sets of double doors as one enters the facility. Many residents do not go near this location and would not easily access the information on these postings. When brought to the attention of the administrator on the early afternoon of 08/13/09, he verified the information would be more easily accessible at another location and stated he would move them to a new area which was frequented more often by residents. .",2015-03-01
10602,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2009-05-22,514,B,0,1,5BYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 1: oxygen tubing treatment sheets not complete Based on observation, medical record review, and staff interview, the facility failed to each resident's clinical record was accurate and complete. Staff failed to document weekly oxygen tubing changes ordered by the physician. Resident identifiers: #2188 and #3439 on the 400 Hall, and Residents #3163 and #1889 on the 100 Hall. Facility census : 95. Findings include: a) Residents #2188, #3439, #3163, and #1889 During random observations during tour on 05/19/09 and during resident interviews on the day of entry, four (4) residents were observed to have no dates on their oxygen tubings to indicate when they had most recently been changed. Also, there was no documentation on the residents' treatment records to reflect the tubing had been changed weekly as the physician had ordered. 1. Residents #2188 and #3439 On the 400 Hall on 05/19/09 at 9:30 a.m., Residents #2188 and #3439 were noted to have oxygen concentrators in use with no dates to show when the tubing had been changed. The filters on both concentrators were dirty. On 05/20/09 at 9:55 a.m., interview with the charge nurse (Employee #26) revealed the facility did not have a separate respiratory therapy department. Rather, a nurse came to the facility twice weekly, and she changed all the oxygen tubing in the facility on Fridays. Employee #26 also reported they had aides change the tubing if the nurse is not there. The charge nurse and surveyor checked the residents' treatment records and found Resident #2188's tubing change was not recorded for 05/08/09, and Resident #3439's tubing change was not recorded for 05/08/09 or 05/15/09. Both residents had orders for oxygen tubing to be changed weekly. The director of nursing (DON), who was present at this time, stated oxygen tubing was changed weekly in the facility and, when told of the above findings, said they would take care of it right away. 2. Residents #3163 and #1889 On the 100 Hall on 05/19/09 at 4:30 p.m., Residents #3163 and #1889 were noted to have oxygen concentrators with no dates on their tubings to indicate then they had last been changed. Also, Resident #3163's humidifier bottle contained about one-half inch of water, and Resident #3163's humidifier bottle had less than one-half inch of water. Review of the residents' treatment records revealed blank spaces where oxygen tubing changes were to have been recorded. Neither resident's record had been written on or initialed in the month of May 2009. Physician orders [REDACTED]. On 05/20/09 at 5:00 p.m., the nurse (Employee #15) said Resident #3163 receives nebulizer treatment four (4) times daily and wears her oxygen about two days weekly, and Resident #1889 wears oxygen two (2) to three (3) days per week. This surveyor observed both residents wearing oxygen for intervals on every day of the survey. 3. On 05/22/09 at 11:00 a.m., this surveyor asked the administrator for the facility's policy on changing oxygen tubing. She said they had no written policy, but staff changed the tubings weekly and recorded the changes on the residents' treatment records. This surveyor then gave her the names and room numbers of the above four (4) residents who had no documentation of weekly tubing changes as ordered by the physician.",2015-01-01
10622,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,159,B,0,1,GCMN11,". Based on resident and staff interview, the facility failed to assure residents had access to their funds on weekends and/or at other times the business office was closed. This practice had the potential to affect all residents for whom the facility managed funds. At the time of the survey, the facility maintained a trust fund for sixty-nine (69) residents. Facility census: 83. Findings include: a) During Stage I confidential resident interviews on 11/29/10 and 11/30/10, four (4) residents described that their personal funds were not available on weekends and/or at other times the business office was not open. On 12/08/10 at 2:00 p.m., an interview was conducted with the business office staff member who assists in resident funds. At that time, this staff member described that, prior to 11/30/10, residents had not been able to get funds except during business office hours. This person stated that, on that date, resident funds became available to residents at times the business office was closed, by means of a small amount of money provided to nursing personnel for this purpose. .",2015-01-01
10716,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,285,B,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of a new resident were evaluated prior to admission through the State-mandated pre-admission screening tool, the form PAS-2000. This was evident for two (2) of twenty-four (24) residents on the sample. Resident identifiers: #33 and #140. Facility census: 138. Findings include: a) Resident #33 Clinical record review disclosed the resident was admitted on [DATE], but the determination as to whether a Level II evaluation was required was not made until 03/17/09, as indicated by the dated signature in Section V of the form PAS-2000. b) Resident #140 Clinical record review disclosed the resident was admitted on [DATE], but the determination as to whether a Level II evaluation was required was not made until 07/08/09, as indicated by the dated signature in Section V of the form PAS-2000. c) In an interview at 2:40 p.m. on 08/19/09, the facility's three (3) social workers acknowledged the Level II determinations occurred after admission for both residents. .",2014-12-01
10726,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,156,B,0,1,H9I611,". Based on a review of the facility's Medicare demand bill records and staff interview, the facility failed to provide the appropriate beneficiary liability and appeal notices for three (3) of three (3) residents who had recently had their Medicare-covered services terminated. There was no evidence that the facility notified the beneficiary of his/her potential liability for payment and standard appeal rights. This practice affected Resident #40 and had the potential to effect more than an isolated number of residents who received Medicare-covered services. Facility census: 49. Findings include: a) Resident #40 Record review of residents who had received Medicare-covered services in the last three (3) months revealed one (1) demand bill had been requested. This was for Resident #40. The letter used to notify the resident / responsible party that services would no longer be covered by Medicare was a letter designed by the facility which did not contained all required elements found in Form CMS- or one (1) of the five (5) uniform denial letters found in the CMS Skilled Nursing Manual. The letter sent by the facility did not notify the legal representative of the beneficiary's potential liability for payment of the non-covered services. An interview with the staff member responsible for patient accounts (Employee #130) confirmed the facility was not utilizing the CMS forms to notify residents / responsible parties of Medicare non-coverage and of their right to request demand bills, which contained all of the required information for notification to the beneficiary. .",2014-12-01
10765,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-11-18,514,B,0,1,667113,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to utilize the correct reporting forms for submitting initial and five (5) day follow-up reports for allegations of resident abuse / neglect to the State survey agency's Nursing Home Program; failed to incorporate all necessary data onto one easy-to-read form for infection control tracking; and failed to ensure a transcription error did not occur for one (1) of forty-three (43) observed medication administrations. Facility census: 73. Findings include: a) Review of the facility's abuse policy, on 11/17/09, revealed, on page 3 Item #5 ""Investigation and Reporting"", the facility's plan to send immediate fax reportings of allegations and five (5) day follow-up reports to the State survey agency's Nurse Aide Abuse Registry. Review of all the self-reported allegations and their respective investigations for September, October, and November 2009 revealed several were submitted using the Nurse Aide Abuse Registry's reporting forms for instances where a nursing assistant was not involved in the alleged event and the Nursing Home Program's reporting forms (which is a separate program within the same State survey agency) should have been used, as follows: 09/13/09 involving Resident #34; 09/20/09 involving Resident #69; 09/24/09 involving Resident #34; 09/25/09 involving Resident #2; 09/29/09 involving Resident #67; and 10/04/09 involving Resident #25. Five (5) of the above events were related to unknown perpetrators, and one (1) event (dated 09/13/09) was related to a licensed practical nurse. In all of the cases, no allegations of abuse or neglect were substantiated. During interview with the director of nursing on 11/18/09 at 9:00 a.m., the above findings were discussed, and she received a copy of the two-page Table 1 - Abuse / Neglect Reporting Requirements for WV Nursing Homes and Nursing Facilities revised August 2009. She stated the social worker completes and faxes the five (5) day follow-up reports for the facility. During interview with the social worker on the afternoon of 11/18/09, he stated he used the Nurse Aide Abuse Registry forms for submitting all reportable sent to the State survey agency (regardless of which program is responsible for reviewing and/or investigating the allegations); on the fax cover sheet, he would differentiate whether the report is to be sent to the Nursing Home Program or the Nurse Aide Abuse Registry, as they have the same fax numbers. These findings were again discussed at exit. As a result, the assistant director of nursing changed the policy at page 3 ""Investigation and Reporting"", to differentiate the reporting of allegations pertaining to only nursing assistants (to the nurse aide registry) from allegations that should be faxed to the State survey agency's long term care division. Also, the assistant director of nursing spoke her awareness now of the website where both programs' reporting forms can be located and downloaded for use. The director of nursing stated, at exit, that each nursing unit and the social worker now had the August 2009 revision for [MEDICATION NAME] on site for future reference. Correction of this component of the deficient practice was completed prior to exit. b) Review, on 11/17/09, of the infection control policies and procedures and of the Infection Control Tracking Form for logging resident infections for September, October and November 2009 revealed the Infection Control Tracking Form had a place for the room numbers, but no room numbers were written on the form. There was no place on the form to document the date for the re-cultures. Additionally, the form had a place for recording the results of the re-cultures, but the results were not always recorded. Interview with the infection control nurse, on 11/17/09 at 10:15 a.m., revealed she had a Daily Culture / Re-culture Monitoring form on the computer and was able to track and give answers for every question asked about the data on the current Infection Control Tracking Form (ICTF). Each Infection Control Tracking Form was differentiated by hall divisions (100, 200, 300, 400 halls), but she agreed that filling in the room numbers on the ICTF would be a good idea for tracking purposes, in the event residents changed rooms during the process. She spoke of plans to alter the form to include the re-culture dates and spoke agreement that completing the re-culture results (or recording why they did not require re-cultures) on the ICTF would be helpful to keep information in one easily observed location. The above findings were discussing during interview with the director of nursing 11/18/09 at 9:00 a.m., as well as the infection control nurse's plan to revise the form. The director of nursing spoke highly of the improvements in their infection control prevention, monitoring, and trending, and noted that numerous inservices in infection control issues have taken place in recent months. During exit these findings were discussed, and the infection control nurse presented a revised ICTF that now has a separate place to record room numbers and a separate place to record re-culture dates. Correction of this component of the deficient practice was completed prior to exit. c) Medication pass was observed with all medication nurses 11/17/09 on the 7:00 a.m. to 7:00 p.m. shift. Reconciliation of the medications, on 11/17/09 at approximately 4:30 p.m., revealed Resident #43 received [MEDICATION NAME] 0.1% one (1) drop to each eye during the medication pass at 8:40 a.m. on 11/17/09. Review of the original physician's orders [REDACTED]."" Review of the November 2009 monthly recapitulation of physician orders [REDACTED]."" Verification with a pharmacist revealed that Patinol only comes in a 0.1% strength solution; there is no [MEDICATION NAME] 2% solution. The medication nurse rechecked the bottle of Patinol that was used for Resident #43 this morning and agreed that it was Patinol 0.1%. During interview with the director of nursing on 11/18/09 at 9:00 a.m., she stated the pharmacy was supposed to notify nursing if there are any concerns or discrepancies in physician orders. At this point in time, she was not sure if the pharmacy notified nursing and nursing did not correct the order or if pharmacy failed to notify them. She stated an investigation will be forthcoming. She agreed that no harm occurred to Resident #43, as she got the correct medication in the correct dose at the correct time, but there was a transcription error. Review, on 11/18/09, of physician orders [REDACTED].",2014-12-01
10868,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2009-12-11,253,B,0,1,IPRG11,"Based on observations, the facility failed to provide maintenance services to maintain an orderly interior. Walls in residents' rooms were damaged and/or had been repaired but not painted. Multiple rooms were affected. Facility census: 61. Findings include: a) During the initial tour of the facility and throughout the survey, observation found the walls in various residents' rooms were damaged. The damage appeared to have been caused by the raising and lowering of the residents' beds. Examples of the observed damages were (the list is representative, but not all inclusive): 1. Room 33 The wall behind the first bed, which faced the door to the hall, had gouges that were at least twelve (12) to eighteen (18) inches long, at least two (2) inches wide and at least one-half (1/2) inch deep. The backing of the drywall could be felt in some areas. 2. Room 30 The wall beside one (1) bed had been patched but not been painted. The patched area had new scarred areas. The other bed had gouges in the all next to the window and behind the head of the bed. .",2014-11-01
10903,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2009-09-11,201,B,0,1,OF0Z11,"Based on staff interview and review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with four (4) different agencies. This error in the uniform notice may lead a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. This had the potential to affect all residents in the facility who are transferred or discharged . Facility census: 92. Findings include: a) Review of the uniform discharge notice of transfer / discharge form provided by the facility revealed the following: ""If you disagree with this transfer/discharge or wish to appeal this transfer/discharge...:"" This was followed by the names and contact information of the State Long-Term Care Ombudsman, Medicaid Fraud, and the WV Advocates. Below the above list of names and addresses was ""For Medicaid Residents: Please include the provided self addressed stamped envelope which includes the address of the.... Inspector General"". This uniform notification form contained the following error: The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the three (3) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may lead a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Interview with the director of nursing, on 09/10/09, revealed the facility changed this form a year or more ago and they were under the impression this form in its current format was appropriate. .",2014-11-01
10942,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,159,B,0,1,HO2T11,"Based on record review and staff interview, the facility failed to obtain written authorization from the legal representatives, of five (5) of six (6) sampled residents with lack capacity, prior to holding and managing personal funds for these residents. Resident identifiers: #15, #23, #26, #39, and #41. Facility census: 61. Findings include: a) Resident #15 Medical record review revealed Resident #15 lacked capacity, and a representative from West Virginia Department of Health and Human Resources (DHHR) had been appointed as health care surrogate (HCS) to make medical decisions, because both the resident's daughter and her sister declined this responsibility. Resident #15 had $1,860.39 in a personal funds account being held and managed by the facility based on the signature of her daughter, although there was no evidence the daughter had the legally authority to either grant this permission or determine how the money would be disbursed. During an interview with the social worker at 4:00 p.m. on 06/16/09, she stated the resident's daughter had told her she was the resident's power of attorney (POA), but the daughter had never produced the documentation to verify this claim. b) Resident #23 Medical record review revealed Resident #23 lacked capacity to make medical decision, and a HCS was appointed to make these decisions for him. Resident #23 had $1700.63 in a personal funds account being held and managed by the facility based on the signature of the HCS, although there was no evidence the HCS had the legally authority to either grant this permission or determine how the money would be disbursed. (State law does not authorize a HCS to also make financial decisions on behalf of an incapacitated person.) During an interview with Employee #62, who was responsible for managing the personal funds accounts, she stated she was aware of this and that part of this money was to be paid to the funeral home for a burial plan. c) Residents #26 and #39 Residents #26 and #39, both of whom had been determined to lack capacity, had designated medical power of attorney representatives (MPOAs) to make their medical decisions for them. In both cases, the MPOAs for Residents #26 and #39 gave signed authorization for the facility to manage the residents' personal funds accounts. However, a review of the documentation failed to produce any evidence of the MPOAs had the legal authority to make financial decisions on behalf of these residents. (State law does not authorize a MPOA to also make financial decisions on behalf of an incapacitated person.) During an interview with Employee #62, she stated she was aware that neither resident had designated a power of attorney to make financial decisions on their behalf.. d) Resident #41 Resident #41 had been adjudged incompetent and had a legal guardian appointed by the court to make medical decisions. This guardian gave signature authorization for the facility to manage the resident's personal funds. Review of the legal documents found no evidence that this guardian had also been appointed to serve as conservator, which would have given the guardian legal authority to make financial decisions for the resident. During an interview with Employee #62, she stated she was aware that Resident #41's legal representative was limited to guardianship only. .",2014-11-01
10983,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-06-02,242,B,1,0,TI3G11,". Based on confidential resident interviews, review of the facility's planned cycle menus, observation, and staff interview, the facility failed to afford residents the right to choose a meal plan containing a variety of food items. The planned cycle menus for Weeks #1 and #3 were repetitious of entrees comprised of meat / tomato products and fish with breading and tartar sauce, respectively. Facility census: 109. Findings include: a) In confidential interviews, residents complained of the food items on the menu being ""all the same"", with little variety at times. Observation of the facility's current 4-week cycle menu found, in Week #1, three (3) consecutive days when the entrees included meat and tomato products in combination. On Tuesday 05/31/11 at the noon meal, the entree was Coney Chili on Bun; this was tasted by two (2) surveyors. On Wednesday 06/01/11 at the evening meal, the entree was Sloppy Joe on Bun; this was also sampled by the surveyors and was found to be very similar in taste, appearance, and texture to the Coney Chili offered the previous day at lunch. A review of the cycle menu and the recipes for both Coney Chili and Sloppy Joes, with the dietary manager (Employee #10) on the evening of 06/01/11, found the contents, flavor, and appearance of both items were similar. Further review of the menu with the dietary manager found a third meat / tomato product entree was to be served at the noon meal on Wednesday 06/02/11 - BBQ Pork on Bun. All three (3) of these items were found on the planned cycle menu for Week #1. Further review of the same cycle menu found, for Week #3, the following three (3) entrees that would be similar in content, taste, and appearance: - Sunday evening meal - Fish Sandwich with Tartar Sauce - Tuesday evening meal - Breaded Fish with Tartar Sauce - Wednesday noon meal - Crumb Topped Fish with Tartar Sauce The dietary manager acknowledged the menu did appear to include entrees that were similar to each other, and she agreed the taste and appearance of these entrees would be similar in nature. .",2014-10-01
11016,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,514,B,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate clinical records for two (2) of twenty one (21) sampled residents. Resident identifiers: #53 and #92. Facility census: 121. Findings include: a) Resident #53 Record review, on 02/04/09, revealed a doctor's progress note indicating the resident lacked the capacity to make healthcare decisions. This progress note contained no date and time. A social worker (Employee #79) provided a copy of the doctor's progress note at 2:50 p.m. on 02/04/09. The social worker was interviewed at this time, reviewed the record, and verified the note contained no date and time. b) Resident #92 A review of the medical record revealed a social services progress note, dated 10/22/08, which contained the following: ""Resident is a full-code status per POST."" Review of the Physician order [REDACTED]. These additional limitations would be contrary to a ""Full Code"". During an interview with the two (2) social workers (Employees #79 and #119) at 11:45 a.m. on 02/04/09, they reviewed the record and agreed that ""Full Code"" was an error in their notes. .",2014-09-01
11057,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,285,B,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of applicants for admission were screened, in accordance with the Pre-Admission Screening and Resident Review (PASRR) program, prior to admission to the facility for three (3) of twenty-eight (28) sampled residents. Resident identifiers: #19, #74, and #113. Facility census: 128. Findings include: a) Resident #19 A review of the clinical record revealed Resident #19 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 04/10/09, as indicated by the dated signature in Section V. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he acknowledged this determination was made after the resident's admission to the facility. b) Resident #74 A review of the clinical record revealed Resident #74 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 01/12/09, as indicated by the dated signature in Section V. During an interview with the social worker at 11:00 a.m. on 06/24/09, he acknowledged the determination was made after the resident's admission to the facility. c) Resident #113 The medical record of Resident #113, when reviewed on 06/23/09, disclosed the resident was admitted to the facility on [DATE]. Further review disclosed, at Item 42 on page 6 of the PASRR form, that a determination with respect to a Level II evaluation was not made until 03/25/09, after the resident's admission to the facility. .",2014-09-01
11138,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2009-08-06,252,B,0,1,R1DI11,"Based on observations, the facility failed to ensure window curtains were in good repair. Holes were observed in the curtains in five (5) rooms on the 200 hall. This had the potential to affect the residents living in those rooms. Facility census: 58. Findings include: a) During the initial tour of the facility on 08/04/09, holes were observed in the window curtains in rooms #200, #202, #206, #210, and #212. .",2014-08-01
11149,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,159,B,0,1,OCKG11,"Based on a review of the resident trust account information and staff interview, the facility failed to ensure quarterly account balances / statements were being sent only to persons with the legal authority to access this information. The facility sent quarterly account balances / statements to unauthorized third parties for four (4) residents. Resident identifiers: #11, #36, #30, and #33. Facility census: 50. Findings include: a) Residents #11, #36, #30, and #33 Record review for Residents #11, #30, #33, and #36 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal fund records, with the business office manager on 08/12/09 at 10:00 a.m., found quarterly financial statements were being sent to unauthorized representatives for all four (4) residents, two (2) of whom were alert and oriented and were entitled to this information themselves. .",2014-08-01
11301,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2010-06-10,281,B,1,0,4NN912,". Based on observation, medical record review, and staff interview, the facility failed to assure physician's orders to change the humidifier bottles on the oxygen concentrators were followed for four (4) of twenty (20) residents receiving oxygen therapy. Resident identifiers: #83, #33, #14, and #23. Facility census: 87. Findings include: a) Residents #83, #33, #14, and #23 Observations, conducted on the afternoon of 06/09/10, found the above residents were receiving oxygen therapy. Inspection of the humidifier bottles noted a date of ""05/27/10"" was written on the front of the bottles. Review of the resident's medical records found physicians' orders to change the humidifier bottles each week. Review of the treatment administration records (TARs) found the humidifier bottles for the above residents were scheduled to be changed on 06/03/10. An interview with a licensed practical nurse (LPN - Employee #4) verified the humidifier bottle on Resident #23's bottle was dated 05/27/10. No resident appeared to be in distress from this failure to follow physicians' orders. .",2014-07-01
11302,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2010-06-10,514,B,1,0,4NN912,". Based on observation, medical record review, and staff interview, the facility failed to assure the clinical record for each resident was accurately documented in accordance with accepted professional standards. This deficient practice affected four (4) of twenty (20) residents receiving oxygen therapy. Resident identifiers: #83, #33, #14, and #23. Facility census: 87. Findings include: a) Residents #83, #33, #14, and #23 Observations, conducted on the afternoon of 06/09/10, found the above residents were receiving oxygen therapy. Inspection of the humidifier bottles noted a date of ""05/27/10"" was written on the front of the bottles. Review of the resident's medical records found physicians' orders to change the humidifier bottles each week. Review of the treatment administration records (TARs) found the humidifier bottles for the above residents were scheduled to be changed on 06/03/10 and contained nursing documentation that the bottles had been changed on that date. The director of nursing (DON), when informed of the above observations at 9: 45 a.m. on 06/10/10 at 9:45 a.m., agreed the records were not accurately documented.",2014-07-01
11323,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2009-02-12,364,B,0,1,IH3P11,"Based on observation and staff interview, the facility failed to provide food that was attractive in appearance for the evening meal on 02/09/09. The food items served during evening meal provided only white, brown, and yellow as colors on the resident trays. This had the potential to affect all residents who chose the main entree for dinner on 02/09/09. Facility census: 106. Findings include: a) Observation of the dinner meal, on 02/09/09 at 5:00 p.m., found the meal consisted of chicken nuggets, cauliflower, and hashbrown casserole, which were brown and white in color. Pineapple was the dessert and was yellow in color. The appearance of the items on the residents' plates offered no variety in color and texture. An interview with the dietary manager ,and a review of the menus on the late morning of 02/12/09, found that fruit ambrosia was supposed to have been on the menu for that day. .",2014-06-01
11365,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2009-07-02,240,B,,,MWZ111,"Based on resident interview, observation, and staff interview, the facility failed to ensure residents received fresh ice and water every shift. This was evident for four (4) of four (4) sampled residents, three (3) of whom were located on the same hall. Resident identifiers: #57, #108, #6, and #31. Facility census: 102. Findings include: a) Resident #31 During an interview on 06/30/09, Resident #31 voiced a complaint of not having ice for his pitcher. He said he could not stand to drink the water that was not cold and elaborated that he will awaken from sleep and crave a cold drink, but many times there was no ice in his pitcher. He said he had not voiced complaints about this to anyone. He felt the facility should know to provide ice water to people who cannot easily get their own. He said there have been many times he had to get cold water from the bathroom in order to have a cold drink, and this may happen by day or by night. At 8:55 a.m. on 07/01/09, observation of his water pitcher found it contained only water, no ice. His pitcher was checked for ice again at 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., and no ice was present on any of these observations. Observations of every water pitcher on the same hall found none of the residents on that hall had ice in their pitchers. During an interview on 07/01/09 at 4:30 p.m., a nurse (Employee #139) stated ice was supplied to residents every shift. When informed that sampled residents had received no ice in their pitchers on day shift today, and currently none of the residents on the hall in question had ice, she stated she would take care of it immediately. b) Resident #6 Record review revealed Resident #6 was dependent on staff for all activities of daily living (ADLs) except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. c) Resident #108 Record review revealed Resident #108 was dependent on staff for all ADLs except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. d) Resident #57 Record review revealed Resident #57 was dependent on staff for all ADLs. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. The water pitcher contained the same amount of liquid, nearly empty, at each check. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. .",2014-04-01
11479,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,278,B,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for four (4) of twenty (20) sampled residents. Resident identifiers: #65, #3, #4, and #81. Facility census: 113. Findings include: a) Resident #65 Record review (on 01/06/09) revealed the resident had a Stage II pressure ulcer to the coccyx which was recorded as being healed on 12/02/08. This information was noted on the December 2008 treatment administration record and a nurse's note dated 12/02/08. A skin assessment, dated 12/20/08, recorded no pressure ulcer(s) present at that time. Review of the resident's MDS, with an assessment reference date (ARD) of 12/24/08, found the assessor recorded in Section M1 the resident had one (1) Stage II ulcer. The MDS nurse (Employee #23) was interviewed on 01/07/09 about the information coded in Section M1 of the MDS. After reviewing the issue, she verified the MDS was coded incorrectly. On 01/08/09 at 11:05 a.m., the MDS nurse provided a copy of a corrected MDS, with an ARD of 12/24/08. In Section M1, the assessor documented no pressure ulcer(s). b) Resident #31 Review (on 01/07/09) of the admission MDS, completed on 12/24/08, revealed the assessor indicated, in Section I2, the resident had an antibiotic-resistant infection. Interview with the director of nursing (DON - Employee #2), at about 6:00 p.m. on 01/07/09, and review of the laboratory reports confirmed that, when the resident was admitted on [DATE], the resident had a [DIAGNOSES REDACTED]. c) Resident #40 Review (on 01/06/09) of the quarterly MDS, completed on 11/12/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at 1:05 p.m., confirmed the resident was not on a toileting plan but was checked regularly for bladder incontinence. d) Resident #81 Review (on 01/06/09) of the quarterly MDS, completed on 11/23/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at about 1:00 p.m., confirmed the resident was not on a toileting plan. .",2014-02-01
11498,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2010-12-02,431,B,,,50Z112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on random observation, staff interview, and review of drug manufacturer's information, the facility failed to assure all medications were maintained in safe and secure storage. This deficient practice affected two (2) of four (4) sampled residents. Resident identifiers: #7 and #60. Facility census: 86. Findings include: a) Resident #7 Random observations of the resident environment, on 11/29/10 at 2:10 p.m., found a 4 ounce tube of Vitamin A&D ointment lying on the windowsill of the resident's room. Interview with Resident #7 found him to be alert and oriented, and he answered questions appropriately. When asked what the tube of medication was used for, he stated, ""They rub it on me,"" while making rubbing motions around his groin area. It was noted that no residents were wandering in the hallway. Following this observation, the director of nursing (DON) was informed that the ointment had been left unsecured in the resident's room. She agreed the ointment should be secured. Review of the manufacturer's insert found no indications the ointment could cause poisoning should it be accidently ingested by a confused resident. b) Resident #60 Random observations of the facility, on 11/29/10 at 2:15 p.m., found tubes of Collagenase (utilized for treatment of [REDACTED]. It was noted that no residents were wandering in the hallway. The DON was notified of the presence of the tubes of ointment in the resident's room. She removed the ointment and agreed the medication should be secured. Review of the manufacturer's information found the following, ""No systemic or local reaction attributed to overdose has been observed in clinical investigations and clinical use..."".",2014-02-01
250,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,576,C,0,1,DBDN11,"Based on resident interview and staff interview, the facility failed to ensure residents had the right to receive mail on Saturdays when delivery was available through the postal service. This had the potential to affect all residents residing at the facility. Facility census: 65. Findings included: a) Resident council meeting At 2:15 PM on 02/26/19, residents attending the council meeting were asked the question, is mail delivered unopened and on Saturdays? The residents agreed their mail was unopened, but they didn't know if mail was delivered on Saturdays. The activity director (AD) #10 attended the meeting. The AD said the facility did not get mail on Saturdays. She did not know if the mail could be delivered. On 02/27/19 at 3:46 PM, the administrator said the mail hadn't been delivered on Saturdays. The administrator contacted the postal carrier who can deliver mail on Saturdays and mail delivery has been arranged.",2020-09-01
297,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,167,C,0,1,UN5811,"Based on observations and staff interview, the facility failed to have a notice posted as to the location of the most-recent survey results during a random observation. This has the potential to affect all residents and visitors. Facility census 81. Findings include: a) Observation On 03/05/17 during an initial tour of the facility, the recent State survey results were observed in the main dining room in a box on the wall. A notice as to the location of the survey results was not observed during the survey week (03/05/17- 03/08/17). b) Interview During an interview with the Administrator, on 03/08/17 at 10:30 a.m., the Administratorwas asked where the notice was located to inform a visitor where the survey results would be located. The Administrator said we do not have a notice. She was not aware a posting was required to inform visitors of where to find the facility's survey results.",2020-09-01
306,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,356,C,0,1,UN5811,"Based on observation, and staff interview, the facilty failed to post the nurse staff posting information on 03/05/17. This was found during a random observation. This failed practice had the potential to affect all residents. Facility census: 81. Findings include: Observation on 03/05/17 at 10:20 a.m., found the nurse staff posting information up front near the main lobby. The date on the nurse staff posting form was 03/04/17. In an interview and review of the nurse staff posting form near the main lobby on 03/05/17 at 10:33 a.m., with registered nurse (RN) #29, she confirmed the posting on the wall was for 03/04/17. The NSRN stated that 03/05/17's nurse staff posting form should have been posted at 7:00 a.m. this morning.",2020-09-01
352,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,756,C,0,1,J1N911,"Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included but were not limited to, time frames for the different steps in the monthly medication regimen review process. This practice had the potential to affect all residents. Facility census: 134. Findings included: The facility policy titled Monthly Regimen Review stated under section seven (7): Timelines and responsibilities for Medication Regimen Review (MRR): --The consultant pharmacist shall schedule at least one monthly visit to the facility, and shall allow sufficient time to complete all required activities. --The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review. --If the pharmacist should identify an irregularity that requires urgent action to protect a resident, the DON (Director of Nursing) or designee is informed verbally. --For residents experiencing a change in condition and the nurse deems a MRR is necessary outside the routine visit, the facility will notify the pharmacy provider. --Facility shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The policy did not include time frames identified for physician notification following routine or urgent requests and no time frames for physician responses to pharmacy reviews. The Director of Nursing (DON) reviewed the current policy during an interview on 04/25/18, and confirmed the policy lacked specific time frames for the MRR review process, including times for physician notification and physician responses to monthly reviews and urgent requests.",2020-09-01
489,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,577,C,0,1,VZPJ11,"Based on resident interviews during the Resident Council meeting and staff interviews, the facility failed to post in a place readily accessible to residents, family members and legal representatives, the most recent state inspection survey results of the facility. This had the potential to affect all individuals wanting to review the results of survey and any plan of correction for this facility. Facility census: 16. Findings included: a) Posting survey results During the Resident Council meeting on 05/09/18 at 10:00 AM, the resident council members did not know the state inspection was to be made available for them to review, nor did they know where it was located in the facility. Explained the results of the most recent survey and any plan of correction was to be posted and readily accessible for them and their family members to review. In an interview with Employee #31, social services director on 05/09/18 at 10:25 AM, verified the state inspection survey results were not posted and readily accessible to residents, family members or visitors.",2020-09-01
1116,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2018-10-24,880,C,0,1,V96711,"Based on policy review and staff interview, the facility's Infection Prevention and Control Program (IPCP) failed to establish an infection prevention and control policy and/or program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility IPCP policy is unsigned and lacks an effective date and/or any review dates. This practice has the potential to affect all residents residing in the facility. Facility census: 33. Findings includes: Review of the facility policy titled Infection Prevention and Control Plan obtained from the Infection Control Nurse #5 on 10/24/18, revealed the policy lacks an effective date and/or a review date. In addition, there are no signatures indicating the approval by the Medical Director, the Chief Executive Officer or any other administrative staff. During an interview on 10/24/18, the Director of Nursing reported she was unaware of when the IPCP policy was received from the state. The DON acknowledged the policy lacks an effective date, an annual review date and approval signatures.",2020-09-01
1712,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2018-06-07,576,C,0,1,2KKW11,"Based on resident interview, staff interview and record review, the facility failed to ensure residents' mail was delivered on Saturdays. This had the potential to affect all residents in the facility. Facility census: 67. Findings included: a) Mail delivery on Saturday During a group meeting with seven (7) members of the facility resident council on 6/5/17 at 11:00 AM, The group said they did not receive mail on Saturdays. When asked if they had been given a reason for this, they said they had not, they just figured there was no one there on Saturdays to deliver it. The Activities Director, #40, who facilitates monthly Resident Council Meetings, was interviewed on 6/7/18 at 11:47 AM. She was asked about residents getting their mail on Saturdays. She said they did not. She said right after she had started working at the facility as Activities Director, about two (2) years ago, the former Administrator told her she had called the Post Office and canceled Saturday deliveries to the facility. Review of the Activities Calendars on 6/5/18 at 12:00 PM, it was found there was a notice on the calendars stating Mail delivered Monday thru Friday. During an interview on 6/5/18 at 3:00 PM, the Director of Nursing (DON), #77, confirmed the Saturday mail delivery had been canceled by the former Administrator about two years ago. Facility Administrator, #60 said on 6/5/18 at 4:00 PM he had contacted the Post Office and Saturday mail delivery would resume on 6/9/18.",2020-09-01
1713,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2018-06-07,583,C,0,1,2KKW11,"Based upon the resident group meeting, staff interview and review of facility documents, the facility failed to ensure the residents' right to promptly receive mail, except when there is no regularly scheduled postal delivery and pick-up service. Promptly as defined within the regulation, means: delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service. This had the potential to affect all the resident of the facility. Facility census: 67. Findings included: a) During a group meeting with seven (7) members of the facility resident council on 6/5/17 at 11:00 AM, The group said they did not receive mail on Saturdays. When asked if they had been given a reason for this, they said they had not, they just figured there was no one there on Saturdays to deliver it. b) The Activities Director, #40, who facilitates monthly Resident Council Meetings, was interviewed on 6/7/18 at 11:47 AM. She was asked about residents getting their mail on Saturdays. She said they did not. She said right after she had started working at the facility as Activities Director, about two (2) years ago, the former Administrator told her she had called the Post Office and canceled Saturday deliveries to the facility. c) Review of the Activities Calendars on 6/5/18 at 12:00 PM, it was found there was a notice on the calendars stating Mail delivered Monday thru Friday. d) During an interview on 6/5/18 at 3:00 PM, the Director of Nursing (DON), #77, confirmed the Saturday mail delivery had been canceled by the former Administrator about two years ago. e) Facility Administrator, #60 said on 6/5/18 at 4:00 PM he had contacted the Post Office and Saturday mail delivery would resume on 6/9/18.",2020-09-01
1782,COLUMBIA ST. FRANCIS HOSPITAL,515110,333 LAIDLEY STREET,CHARLESTON,WV,25322,2019-03-20,732,C,0,1,MRLP11,"Based on review of staffing documentation and by staff interview, the facility failed to ensure the complete staffing numbers for each shift is posted daily. There were days noted where the staff available for only one shift was recorded on the form and the other two shifts were blank. This was for three days out of months of (MONTH) and March. This practice has the potential to affect more than a limited number of residents and family who are to have access to this informaiton. Findings included: a) 03/19/19 at 1:20 p.m. discussion with the director of nursing (DON) verified the staff postings had not been completely filled out for the evening and night shifts This was found during a review of the staff posting sheets on file for (MONTH) and so far for the month of March. The documentation was incomplete for (MONTH) 14 and 17. Also for (MONTH) 9, 2019. This informaiton is to be posted for all the public to have access to the information.",2020-09-01
1855,GLASGOW HEALTH AND REHABILITATION CENTER,515118,"120 MELROSE DRIVE, BOX 350",GLASGOW,WV,25086,2017-02-14,356,C,0,1,JVKC11,"Based on review of posted staffing sheets, review of previous staffing sheets, and staff interview, found the form used by the facility did not contain all of the required information. The name of the facility was not included on the document. This had the potential to affect residents and families who wished to review the staffing information. Facility Census: 97. Findings include: a) Review of the POS [REDACTED]. Federal regulation requires the posted information include the name for the facility. On 02/13/17 at 11:15 a.m., Employee #79, the staff member in charge of preparing the posted staffing information confirmed the form being used did not have the name of the facility.",2020-09-01
2126,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2016-08-30,203,C,0,1,6MCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer/discharge form and staff interview, the facility failed to provide residents and responsible parties with the correct contact information of the single State agency responsible for reviewing making decisions for all transfer/discharge appeals. Additionally, the uniform discharge notice provided incorrect information regarding the agency designated in West Virginia (WV) to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. These findings had the potential to affect more than a limited number of residents. Facility census: 53. Findings include: a) Review of the facility's uniform notification of transfer/discharge form provided by the facility on 08/25/16, revealed it included, You have the right to appeal this action to: , This was followed by the names and contact information of the regional Ombudsman, State Ombudsman, Office of Heath Facility Licensure and Certification, and the Board of Review. Immediately following the list of names and contact information of appeals was Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: . This was followed by the contact information for West Virginia Advocates and for Medicaid Fraud. This uniform notification form contained the following errors: 1. The Office of the Inspector General's Board of Review is the only agency in WV which hears and makes determinations about appeals of transfer/discharge. None of the five (5) other agencies identified in the notice are responsible for this activity. This misinformation has the potential to delay a decision for an appeal should the resident/resident's representative submit the appeal to the wrong agency. 2. The single agency designated in WV to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc. Medicaid Fraud does not provide these services. On 08/30/16 at 1:25 p.m., Medical Records Employee #54 provided a copy of the facility's Notification of Transfer/Discharge form. She said that form was provided to all residents when they were discharged from the facility to a hospital, another nursing home facility, or to a private home. The administrator was interviewed at this time also. No further information was provided prior to exit.",2020-09-01
2201,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2017-03-31,356,C,0,1,YOOX11,"Based on record review and staff interview the facility failed to ensure the accuracy of the staff posting. Over a three-month period, the daily staff posting sheets were not filled out for every shift for 14 days. This practice had the potential to affect all residents as well as visitors. Facility census: 58. Findings include: a) On 03/29/17 at 12:00 p.m. Admissions Director #51 provided copies of the daily nursing staff form for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). A review of the forms revealed the following for (MONTH) (YEAR): --12/05/16 - the daily nurse staffing form did not include the number of hours and number of Registered nurses (RN), Licensed Practical Nurses (LPN), and nurse aides (NA) who worked on 3:00 p.m. -11:00 p.m. The form also did not list the number of RNs and hours worked for 11:00 p.m. - 7:00 a.m. shift. --12/06/16 - the number and hours worked for RNs, LPNs and NAs was not listed. --12/12/16 - the number of RNs, LPNs, and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. --12/13/16 - the number of RNs, LPNs and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. --12/19/16 - the number of RNs, LPNs and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. The number of RNs and hours worked was not listed for 11:00 p.m. - 7:00 a.m. shift. --12/27/16 - the number of RNs, LPNs, and NAs and hours worked was not listed for 3:00 p.m. - 11:00 p.m. shift and the number of RNs and hours worked was not listed for 11:00 p.m. - 7:00 a.m. shift. --12/30/16 - the number of RNs, LPNs, and NAs and hours worked for 7:00 a.m. - 3:00 p.m. shift was not listed. The number of RNs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. A review of the forms revealed the following for (MONTH) (YEAR): --01/01/17 - The number of RNs and hours worked for 7:00 a.m. - 3:00 p.m. shift was not listed. The number and hours worked for RNs was noted listed at 3:00 p.m. - 11:00 p.m. shift was not listed. The number and hours worked for RNs for 11:00 p.m. - 7:00 a.m. shift was not listed. --01/02/17 - The number of RNs and hours worked for 11:00 p.m. - 7:00 a.m. shift was not listed. --01/09/17 - The number of RNs, LPNs, and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. --01/11/17- The number of RNs, LPNs, and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. The number of RNs and hours worked for 11:00 p.m. - 7:00 a.m. shift was not listed. --01/22/17- The number of RNs, LPNs, and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. --01/26/17- The number of RNs, LPNs, and NAs and hours worked for 7:00 a.m. - 3:00 p.m. shift was not listed. A review of the forms revealed the following for (MONTH) (YEAR): --02/22/17 - The number of RNs and hours worked for 7:00 a.m. - 3:00 p.m. shift was not listed. The number of RNs and hours worked for 3:00 p.m. - 11:00 p.m. and 11:00 p.m. - 7:00 a.m. shift was not listed. On 03/29/17 at 3:30 p.m. Admissions Director #51 confirmed the number and hours of RNs, LPNs, and NAs should have been recorded on each day and each shift.",2020-09-01
2266,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2019-03-27,880,C,0,1,TD9H11,"Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was true for the laundry room having air flow pulling the air from the soiled side into the clean side and air drying and storing clean items in the soiled laundry room. This failed practice had the potential to have a minimal affect on the residents of the facility. Facility census 105. Findings included: During a tour and interview on 03/27/19 at 8:03 AM, Laundry Employee # 116 was asked to get the Maintenance Supervisor to come to the laundry room. She was asked about the mop heads being dried in the soiled laundry room and the personal items hanging on a clothing rack being stored in the soiled side of the laundry room uncovered. She said, that it was things that did not have names on them and when someone was missing something they would look there to see if the lost items were there. She was asked if the clothing were rewashed before returning them to the residents, and she said no. During a tour and interview on 03/27/19 at 8:07 AM, Maintenance #98 was shown that the air flow from the soiled side was being pulled into the clean side with a tissue paper, Also the suction on the door was very strong pulling the soiled air into the clean side. He alerted Maintenance Supervisor #1 and Maintenance Supervisor Assistant #75 about the problem. They stated the problem was the exhaust fan in the dryer room was pulling the air from the soiled to the clean. They stated that they would fix that immediately. During an interview on 03/27/19 at 8:17 AM, Housekeeping Supervisor #72 about the storing clean items of clothing and drying mop heads in the soiled laundry room. She voiced understanding and had the items removed. During a brief interview on 03/27/19 at 9:00AM, Maintenance Supervisor #1 stated that they have a plan in place to build another door and wall for separation for storing lost items. They are also going to install an exhaust fan on the soiled side to pull the soiled air outside. During an observation on 03/27/19 at 3:00 AM, there was construction going on in the laundry rooms and an exhaust fan was being installed in the soiled side of the laundry room.",2020-09-01
2308,MEADOWVIEW MANOR,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2019-08-07,732,C,0,1,LHAE11,"Based on observation and staff interview the facility failed to ensure the staff posting was readily available for residents and visitors to view at any given time. This has the potential to affect all residents/family members who might wish to review the posting. Facility census: 60. Findings included: a) Observation of staff posting On 08/05/19 at 11:59 AM, Nursing Scheduler, employee #19 verified the staff posting was not available. [NAME] #19 looked at the wall across from the nurses station and said, It is normally up there, I don't know where it is. On 08/05/19 at 12:03 PM, the above observation was discussed with the administrator. At 10:57 AM on 08/06/19, the administrator suggested the surveyor talk with the nurse who had just removed the staff posting to make corrections due to staff not reporting for work. On 08/19/19 at 10:59 AM, Employee #59, a Registered Nurse (RN), said she took the posting down at 7:30 AM on 08/19/19 when she entered the facility because some staff had called in. She said she was busy assisting with breakfast and never put the posting back up. RN #59 confirmed she should have made the corrections when she entered the building and should have returned the staff posting promptly after completion. The administrator was present for the interview. After the interview concluded, the administrator said she had been given the wrong information. She thought the posting had just been taken down minutes before the observation.",2020-09-01
2349,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2019-02-20,732,C,1,0,TETE11,"> Based on observation and staff interview, the facility failed to ensure the staff posting was complete and correct. This had the potential to affect all residents. Facility census: 86. Findings included: a) At 10:25 AM on 02/18/19, observation of the Daily Nurse Staffing form found information posted regarding the facility's census had not been completed. The census was blank. Registered Nurse (RN), Infection Prevention Nurse, RN #114 observed the posting and said she would get a corrected copy. At 8:35 AM on 02/20/19, the Director of Nursing said the facility prints forms for the following week every Friday. It is the nurses job to update the information each day and make sure the information is correct on every shift, every day. On 02/20/19 at 1:21 PM, Employee #52, the scheduler/payroll clerk, provided a corrected copy of what should have been posted on 02/18/19 at 10:25 AM. The corrected copy, supplied by [NAME] #52, noted the census was 65. The hours previously posted as worked for registered nurses was increased from 15 hours to 25 hours. The number of hours previously posted as worked by certified nursing assistants increased from 75 hours to 82.5 hours.",2020-09-01
2616,WILLOW TREE HEALTHCARE CENTER,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2017-08-17,371,C,0,1,OM4311,"Based on observation and staff interview, the facility failed to ensure the cook's production area was sanitary for food preparation. This had the potential to affect all residents consuming food prepared in the kitchen. The facility census was 101. Findings include: a) During initial observations in the kitchen on 08/14/17 at 8:30 a.m., the far wall of the kitchen, where the convection oven, grill, and steamer were located, was observed to have a heavy build-up of grease and grime on the floor underneath the equipment. The front of the oven/grill had greasy spills on the surface. Additionally, the entire perimeter of the kitchen had a visible area of grime near the wall. During an interview with Food Service Manager #72 and the Corporate Consultant on 08/17/17 at 2:30 p.m., the Food Service Manager stated that when she took the job at the facility on 07/03/17, there was no regular cleaning schedule in place for the dietary employees. She was in the process of developing cleaning schedules and was researching access to a power washer to deep clean the floors. Additionally, she was coordinating with facility housekeeping staff related to their ability to assist with deep cleaning of the kitchen floor on a periodic basis. These plans had not yet been finalized or implemented.",2020-09-01
2663,CRESTVIEW MANOR NURSING AND REHABILITATION,515160,199 COURT STREET,JANE LEW,WV,26378,2018-03-09,607,C,0,1,QUGB11,"Based on record review, policy review and staff interview, the facility failed to develop an abuse policy that included all required components. The policy did not address training related to dementia management and resident abuse prevention. The practice had the potential to affect all residents in the facility. Facility census: #70. Findings included: a) Policy and Procedure Review Review of the facility's Abuse and Neglect Policy and Procedure revealed staff in-service training would be conducted. The staff in-service training included the following topics: - Review facilities policy and procedures including State and Federal Rules and Regulations - Recognizing signs and symptoms of abuse - Conflict resolution and dealing with incidents - Burnout - Stress - Frustration - Appropriate behavior in a long term care setting - Resident rights and responsibilities - Reporting procedures Dementia management and resident abuse prevention was not included as a staff in-service training topic in the facility's Abuse and Neglect Policy and Procedure. Review of the in-service training of five (5) randomly selected direct patient staff revealed these staff members had completed trainings in dementia management. During an interview on 03/07/18 at 8:08 AM, the facility administrator was informed the facility's Abuse and Neglect Policy and Procedure did not include the required component of staff training related to dementia management and resident abuse prevention. The administrator stated staff received training related to dementia management and resident abuse prevention, even though the policy did not specify the training would be included for abuse prevention. The administrator stated the facility's Abuse and Neglect Policy and Procedure would be revised to include staff training related to dementia management and resident abuse prevention.",2020-09-01
2703,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2018-11-28,801,C,0,1,DZOV11,"Based on staff interviews, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility failed to employ a Dietary Services Supervisor hired after 11/28/17 that was a Certified Dietary Manager (CDM). This affected one of one kitchen in the facility. The resident census at the time of the survey was 93. Findings include: The Dietary Services Supervisor (DSS) was interviewed on 11/27/18 at 9:04 AM. He said he was currently enrolled in the CDM class. He started the class in the summer; approximately (MONTH) or July. He was enrolled once before but said he never took the test. He said they do not have a full-time dietician. They have a dietician in their corporate office and they have a consultant dietician that comes every two weeks. The DSS was interviewed on 11/28/18 at 12:57 PM. He said he did not have a degree in food service management. He only had experience as a food service manager. He said he started with the company as a DSS in 07/2017 and started at this facility in 01/2018. He again confirmed that he was enrolled in his CDM classes. He was hoping to finish and test for his CDM in the summer of 2019. He thought he had one year to complete the CDM once he was hired. He did not know that he needed to be a CDM prior to starting the position. The Nursing Home Administrator (NHA) was interviewed on 11/28/18 at 2:10 PM. She thought that the DSS had a year after hire to complete the CDM course and take the test. She did not realize that the DSS had to be a CDM by 11/28/17.",2020-09-01
2865,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2017-12-14,814,C,0,1,EBN311,"Based on observation and staff interview the facility failed to ensure that garbage was disposed of properly in a manner that would prevent the attraction of vermin. Observation revealed a dumpster overflowing with bags of garbage as well as bags of garbage on the ground beside the dumpster. This practice had the potential to affect all residents. Facility Census: 123 Findings include: On 12/14/17 at 12:45 p.m., the Dietary Manager and this surveyor observed various debris laying on the ground beside three (3) trash dumpsters. Observed on the ground outside the trash dumpsters was a smashed used plastic milk jug without the lid, various small pieces papers, an empty cigarette, and pieces of food wrappers. The Dietary Manager confirmed no trash is to be laying on the ground but inside the trash dumpsters.",2020-09-01
2938,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2019-07-02,732,C,1,0,42VZ11,"> Based on record review and staff interview, the facility failed to post complete and accurate staffing information as required by regulation. This practice had the potential to minimally affect more than a limited number of residents. Facility census: 66. Findings included: a) Staff posting During review of the daily staff posting for 05/29/19 showed there were no registered nurses working on this day. A interview with the scheduler on 07/01/19 at 2:10 p.m. revealed there were three nurses working on 05/29/19. The posting was inaccurate for the number of registered nursing working on 05/29/19. A staff posting form dated 06/13/19 indicated three registered nurses were on duty. Interview with the scheduler on 07/01/19 at 1:57 pm revealed compared to the actual schedule there were two nurses present. The staff posting was inaccurate as to the number of registered nursing working on 07/01/19.",2020-09-01
2962,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2017-09-28,226,C,0,1,BKPR11,"Based on policy review, and staff interview, the facility failed to develop an abuse policy that included all required training. The policy did not address training related to dementia management and resident abuse prevention. This failure has the potential to affect all residents residing in the facility. Facility Census: 61. Findings include: a) Policy Development Review of the facility's policy titled, Abuse Prohibition at 1:48 p.m. on 09/26/17 found the following related to training of employees (typed at written): .3. Training will be provided to all employees, through orientation and a minimum of annually, and will include: 3.1 the Genesis HealthCare Abuse Prohibition Policy; 3.2 appropriate interventions to deal with aggressive and/or catastrophic reactions of patients; 3.3 how staff should report their knowledge related to allegations without fear of reprisal; 3.4 how to recognize signs of burnout, frustration, and stress that may lead to abuse; 3.5 what constitutes abuse, neglect, misappropriation of patient property, and 3.6 prohibition of staff from using any type of equipment (e.g. cameras, smartphones, and other electronic devices) to take, keep, or distribute photographs and recordings of patients that demeaning or humiliating. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revision 168, with a revision date of 03/08/17 found the following, F226 ** (Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17) 483.12(b) The facility must develop and implement written policies and procedures that . (3) Include training as required at paragraph 483.95 . 483.95(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on- 483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12. 483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property 483.95(c)(3) Dementia management and resident abuse prevention. During an interview with the Director of Nursing (DON), and the Nursing Home Administrator (NHA) at 2:03 p.m. on 09/27/17, they confirmed the facility's Abuse Prohibition Policy did not contain training on Dementia management and resident abuse prevention.",2020-09-01
3027,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,356,C,0,1,CPO811,"Based on facility record review and staff interview, the facility failed to maintain completed copies of all daily staff postings for a minimum of 18 months. This had the potential to affect all residents residing in the facility. Facility census: 52. Findings include: a) Review of daily postings on 07/11/17 at 2:30 p.m. for the period of 04/13/17 through 07/10/17 revealed there were no postings for: -- 04/14/17, -- 05/01/17, -- 05/11/17, -- 05/13/17, -- 05/15/17, -- 05/16/17, -- 05/21/17, -- 05/26/17, -- 05/29/17, and -- 06/04/17. The Administrator acknowledged the missing staff posting forms during an interview on 07/11/17 at 4:32 p.m. The Administrator stated, That is why that person no longer works here.",2020-09-01
3331,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,838,C,0,1,KGJN11,"Based on review of the Facility Assessment and staff interview, the facility failed to ensure the assessment contained all the necessary components to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require. Information regarding staffing levels and competencies, facility resources necessary to provide for resident needs, health information technology resources, evaluation of the physical environment, and community based risk assessment were not included in the Facility Assessment. This had the potential to affect all residents residing at the facility. Facility census: 57. Findings included: a) Facility Assessment review On 04/10/19 at 12:46 PM, the administrator and the company president, Employee #88 were interviewed regarding the Facility Assessment. Information regarding the following components required for the assessment were not included in the copy provided by the facility: The staff competencies that are necessary to provide the level and types of care needed for the resident population. An evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs. A competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across these staff assignments. An evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment should also include an evaluation of what policies and procedures may be required in the provision of care and that these meet current professional standards of practice. The facility assessment must include an evaluation of the physical environment necessary to meet the needs of the residents. This must include an evaluation of how the facility needs to be equipped and maintained to protect and promote the health and safety of residents. This should also include an evaluation of building maintenance capital improvements, or structures, vehicles, or medical and non-medical equipment and supplies. All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. The facility assessment must consider health information technology resources, such as managing resident records and electronically sharing information with other organizations. For example, the assessment should address how the facility will securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility. The facility based and community-based risk assessment, utilizing an all-hazards approach must evaluate the facility's ability to maintain continuity of operations and its ability to secure required supplies and resources during an emergency or natural disaster. The facility's emergency preparedness plans as required should be integrated and compatible with the facility assessment. At 4:30 PM on 04/10/19, the administrator and Employee #88 were interviewed again regarding the facility assessment. The facility provided a single sheet of paper entitled facility resources. [NAME] #88 said this should have been included in the facility assessment. The original document provided noted the facility assessment consisted of 20 pages. The additional page provided was not numbered at the bottom as were the original 20 pages presented. At the close of the survey on 04/10/19 at 7:00 PM, no further information was provided.",2020-09-01
3411,FAIRMONT HEALTHCARE AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2019-01-31,868,C,0,1,0LCE11,"Based on facility record review and staff interview, the facility failed to ensure the Quality Assurance and Process Improvement (QAPI) Committee is composed of the required committee members. The Medical Director or his designee failed to attended the QAPI Committee meetings at least quarterly. This has the potential to affect all residents. Facility census 108. Findings include: a) The facility Administrator presented the QAPI sign in sheets for the months of September, October, November, (MONTH) (YEAR) and (MONTH) 2019, on 01/31/19. The sign in sheets were dated 09/27/19 (should have been 09/27/18), 10/25/18, 11/30/18, 12/27/18, and 01/25/19. Further review of the sign in sheets revealed the Medical Director only attended the QAPI meeting once in five months, on 10/25/18. No other physician signatures were identified. On 01/31/19 at 2:43 PM and interview with the facility Administrator confirmed she was the person responsible for the Quality Assurance and Process Improvement (QAPI) Committee. The Administrator reported the QAPI meeting is held monthly and attended by all departments. The Administrator reviewed the sign in sheets and confirmed the Medical Director had only signed the QAPI attendance record on 10/25/18. Once in five months, not quarterly.",2020-09-01
3567,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,577,C,0,1,EC8V11,"Based on observation and staff interview, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Review of posted survey results found no results from a recent complaint investigation that was conducted in (MONTH) 2019. This practice has the potential to affect all residents and visitors to the facility. Facility census: 23. Findings included: Observations at 1:00 PM on 08/27/19, found the survey results from the most recent complaint investigation completed on 01/17/19 was not in the three ring binder labeled Survey Result Posting. An interview with the Administrator at 1:23 PM on 08/27/19, confirmed the results from the complaint survey completed on 01/17/19 were not posted as required.",2020-09-01
3602,NELLA'S INC,51A010,499 FERGUSON ROAD,ELKINS,WV,26241,2019-03-15,732,C,1,0,YGIL11,"> Based on observation, staff interviews the facility failed to post the nurse staffing data on a daily basis at the beginning each shift. This had the potential to affect a minimum number of resident and visitors. Facility census 73. Findings included: a) Nurse Staff Posting Observation with Licensed Practical Nurse (LPN) #13 on 03/11/19 at 9:05 AM, revealed no staff posting for 03/11/19. The nurse staff posting that was in the clear plastic contain had the date of 03/08/19. The Nurse said probably someone is filling out the posting form. The Nurse was asked what time you come to work she said 7 AM. LPN #13 said no one has filled out the form as of yet. Observed the Director of Nursing (DON #18 on 03/11/19 at 9:15 AM, filling out the staff posting form at her desk in her office. The DON acknowledge the nurse staff posting had not been posted since 03/08/19.",2020-09-01
3741,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2019-02-08,947,C,0,1,YS5611,"Based on staff interview and record review the facility failed to show evidence of dementia training for 7 of 7 nurse aides reviewed training (HSW #38, #4, #1, #22, #25, #2, #71). This had the potential to affect all residents. Facility Census 49. The findings are: Review of facility personnel and education records revealed: --Health Service Worker #38 was hired on 09/01/2009. Her record did not contain evidence of dementia training. --Health Service Worker #4 was hired on 01/28/2014. Her record did not contain evidence of dementia training. --Health Service Worker #2 was hired on 10/01/2010. Her record did not contain evidence of dementia training. --Health Service Worker #1 was hired on 09/05/2017. Her record did not contain evidence of dementia training. --Health Service Worker #71 was hired on 11/16/16. Her record did not contain evidence of dementia training. --Agency HSW #22 was hired on 11/13/2017. Her record did not contain evidence of dementia training. --Agency HSW #25 was hired on 03/12/2018. Her record did not contain evidence of dementia training. During an interview, on 02/07/19 at 10:47 am, Staff development educator (SDC) stated she had been in the position for 15 months. SDC stated she was unable to provide any evidence that the facility or agency HSW had any dementia training in the 15 months since she had been in the position.",2020-09-01
3756,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2016-10-05,356,C,0,1,17JD11,"Based on observation and staff interview the facility failed to comply with the CMS guidelines for the daily Nursing Staff postings by failing to include all information required, by not including the actual hours worked by the direct care staff; and/or including staff outside of nursing in their direct care total. This had the potential to effect all residents. Facility census 54. Findings include: a) During the general tour of the facility at 11:20 a.m. on 10/03/16, the daily nursing staff postings were observed in various locations throughout the facility. The posting indicated the total number of RN's, LPN's, and CNA's present on each shift; but failed to include the actual hours worked. The posting incorrectly included Physical Therapy staff in the day shift total of nursing care staff. During interviews with the Director of Nurses (at 10:00 a.m. on 10/05/16) and the Administrator (at 10:15 a.m. on 10/05/16), they were informed of the requirements for the daily staff postings. The director of nurses said she remembered the hours being listed at other facilities and would research for an appropriate form. The Administrator also said they would correct the posting.",2020-09-01
3823,GRANT MEMORIAL HOSPITAL,515045,117 HOSPITAL DRIVE,PETERSBURG,WV,26847,2016-05-11,167,C,0,1,2V8S11,"Based on observation and staff interview, the facility failed to post the results of the most recent survey in a place readily accessible to residents. This practice had the potential to affect all residents residing in the facility. Facility census: 13. Findings include: a) On 05/09/16 at 2:00 p.m., an observation of the survey findings posted in a blue folder on the bulletin board in the hallway revealed the latest survey results had a date of 02/20/14. According to State records, the facility had an annual survey ending (MONTH) 24, (YEAR). During an interview with Nurse Manager #23 on 05/10/16 at 8:30 a.m., she agreed the most recent survey results were not posted. She stated, We were surveyed in (YEAR) and I never noticed the most recent survey results were not posted for examination by residents. On 05/10/16 at 8:55 a.m., Nurse Manager #23 reported, The survey results for (YEAR) are up now on the bulletin board on the unit.",2020-07-01
3874,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,520,C,0,1,DBHB11,"Based on record review and staff interview, the facility failed to ensure the medical director or his designee attended quarterly Quality Assurance and Assessment (QA&A) meetings. This practice was discovered during review of the mandatory facility task of QA&[NAME] Facility census: 62. Findings include: a) The QA&A quarterly attendance sign-in sheets were reviewed with the administrator at 9:16 a.m. on 01/19/17. Review of the attendance sign-in sheets from 01/01/16 to 01/19/17 found the medical director only signed two (2) attendance sheets - 04/28/16 and 10/27/16. The administrator was unable to verify the medical director or his designee attended quarterly QA&A meetings as required by the regulations.",2020-04-01
4039,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,272,C,0,1,WA6611,"Based on Minimum Data Set (MDS) review, review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), and staff interview, the facility failed to provide the dates of information used to complete the Care Area Assessments (CAA) for five (5) of five (5) residents reviewed during Stage 2. This affected all residents residing in the facility. Resident identifiers: #39, #26, #62, #11, and #10. Facility census: 61. Findings include: a) Resident #39 On 02/28/17 at 2:16 p.m., a review of the resident's annual MDS with an assessment reference date (ARD) of 06/16/16 revealed the CAA summary contained no dates of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record and see H&P (history and physical), but did not identify the dates of the referenced documents, interviews, or observations. b) Resident #26 A significant change MDS with an ARD of 11/25/16, contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. c) Resident #62 A significant change MDS with an ARD of 11/25/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. d) Resident #11 The resident's admission MDS with an ARD of 09/08/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained, interview/record, record, interview, interview/observation/record, Activity participation record, Medication Administration Record [REDACTED]. e) Resident #10 The annual MDS with an ARD of 03/24/16, contained no dates of the location of the CAA documentation. Areas that were triggered and marked to be care planned contained interview/record, record, interview, interview/observation/record, Activity participation record, Medication Administration Record [REDACTED]. f) In an interview with the MDS Coordinator, on 02/28/17 at 1:25 p.m., she confirmed the only information completed in the CAA Summaries were, interview/ record, record, interview, H&P, MAR, observation, but did not include the date of the location of the CAA documentation. She further explained she had a worksheet for each resident and each MDS, but this worksheet was not part of the medical record. She stated she followed this procedure for all MDSs for all residents. g) Review of the RAI Manual and instructions on the MDS form found the instructions for completing Section V include: Page V-5 For each triggered care area, indicate the date and location of the CAA documentation in the Location and Date of CAA Documentation column. Page V-5 Item Rationale Items V0200A 01 through 20 document which triggered care areas require further assessment, decision as to whether or not a triggered care area is addressed in the resident care plan, and the location and date of CAA documentation. The CAA Summary documents the interdisciplinary team's and the resident, resident's family or representative's final decision(s) on which triggered care areas will be addressed in the care plan. Page 4-7 Use the Location and Date of CAA Documentation column on the CAA Summary (Section V of the MDS 3.0) to note where the CAA information and decision making documentation can be found in the resident's record. Also indicate in the column Care Planning Decision whether the triggered care area is addressed in the care plan. The MDS form, item V0200 instructions include, 3. Indicated in the Location and Date of CAA Documentation column where information related to the CAA can be found",2020-02-01
4046,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,356,C,0,1,WA6611,"Based upon observation, staff interview, and review of staffing and payroll documentation, the facility failed to post complete and accurate staffing information. This had the potential to affect all residents and visitors. Facility census: 61. Findings include: a) On 02/13/17 at 11:10 a.m., during the initial tour of the facility, staffing sheets posted for review by residents and visitors were observed on the second floor unit, Nursing Care Facility Two (NCF2). The posting showed the facility name, the date, the shift, the census, and the total hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Nurse Aides (NA), but did not show the total number of RNs, LPNs, and NAs working the shift. b) The 02/13/17 posting for the day shift showed there were two (2) nurses and one (1) nurse aide working on the unit. When asked if there was only one (1) NA working the day shift, RN #141 said the posting was not correct, that someone had come down from the third floor to cover and there were two (2). She pulled the posting sheet off the bulletin board and began to correct it. c) Complaints about inadequate staffing on both the second floor unit (NCF2) and the basement unit (NCF1) led to a detailed review of the staff posting, the schedules, and the payroll data for the period from 01/29/17 through 02/21/17. Numerous, almost daily discrepancies were noted between the posting sheets designed to keep residents and visitors informed about how many staff were working each unit and the actual hours reflected in the payroll information provided. d) When questioned about the discrepancies on 02/20/17 at 2:20 p.m., the facility's Administrator, #114, said, Almost none of the staff postings are accurate.",2020-02-01
4081,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2016-07-19,226,C,0,1,KKFY11,"Based on policy review and staff interview, the facility failed to ensure its abuse policy addressed the reporting of allegations of neglect. This practice had the potential to affect all residents. Facility census: 105. Findings include: a) On 07/14/16 at 4:30 p.m., review of the facility's abuse prohibition policy, revised on 10/15/15, the policy stated under Process 5., Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will: 6.1 Enter allegation into the Risk Management System (RMS) 6.2 Report as follows: . This section did not mention neglect. During an interview on 07/14/16, at 4:45 p.m., when questioned about the policy not addressing neglect under the section titled Process 5, Social Worker (SW) #157 said she would review the policy. On 07/18/16 at 2:11 p.m., SW #157 said the facility felt the statement under Process 1, The administrator or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property would address the reporting of neglect. SW #157 was told that even though the statement under Process 1. did address operationalizing policies, it did not address reporting neglect. In #5, the policy addressed reporting, but did not specify the facility would report allegations of neglect. At 3:00 p.m. on 07/18/16, SW #157 said a corporate employee would add the word neglect to the facility's abuse prohibition policy under #6 regarding allegations to be reported.",2020-02-01
4097,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2016-01-08,334,C,0,1,UKTS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to educate each resident and/or their legal representative on the benefits and potential side effects of the influenza vaccine prior to administering the vaccine during the current (YEAR)-2016 flu season. This was found for five (5) of five (5) Stage 1 sampled residents reviewed during the annual Quality IndicatorSsurvey (QIS). Resident identifiers: #78, #71, #67, #76 and #6. Facility census: 95. Findings include: a) Review of medical records for Residents #78, #71, #67, #76, and #6, on 01/07/16 at 9:00 a.m., revealed all five (5) medical records lacked documentation indicating the resident and/or the resident's legal representative received education regarding the benefits and potential side effects of the influenza vaccine prior to administration during the current flu season. Residents #78, #67, #76, and #6 received the [MEDICATION NAME] flu vaccine on 10/23/15, and Resident #71 received the [MEDICATION NAME] flu vaccine on 10/28/15. Interview with the Medical Records Supervisor #21, on 01/07/16 at 9:30 a.m., confirmed the medical records did not contain consents and/or education regarding the benefits and potential side effects of the influenza vaccine during an interview. Interview with Registered Nurse (RN) #22, on 01/07/16 at 9:35 a.m., revealed she was unaware of the requirement to educate the resident and/or legal representative of the benefits and potential side effects of the current influenza vaccine prior to administering the annual flu shot. RN #22 acknowledged the facility did not hand out and/or educate the resident and/or legal representative prior to administering the annual influenza vaccine for the (YEAR)-2016 flu season. The facility vaccinations policy #4A, states under #4 of the section titled, Policy Interpretation and Implementation: Prior to the vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the influenza vaccinations. Provisions of such education shall be documented in the resident's medical record. .",2020-02-01
4151,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,520,C,0,1,JLJC11,"Based on record review and staff interview, the facility's quality assessment and assurance (QA & A) program failed to meet quarterly as required. This practice has the potential to effect all residents currently residing in the facility. Facility census: 29 Findings include: a) Meets at Least Quarterly Review of the facility's QA & A committee sign-in sheets for the previous year found the committee met on 02/10/16, 04/20/16 and 07/27/16, which did not represent a meeting every quarter. After this review, the Director of Nursing (DON) stated she was on vacation when one of the meetings was to be held in (MONTH) for the 3rd quarter of (YEAR), and that meeting was not held.",2020-02-01
4187,REYNOLDS MEMORIAL HOSPITAL,515112,800 WHEELING AVENUE,GLEN DALE,WV,26038,2016-08-04,356,C,0,1,YB6F11,"Based on observation and staff interview the facility failed to include all required nurse staffing data on the daily nurse staffing posting; or to maintain a copy of the information for the required 18 months. This had the potential to effect all residents. Facility census 13. Findings include: a) At 8:30 a.m. on 08/02/16, an observation made of the nurse staffing data posted at the nurses' station revealed the information was written on a chalk board, but the information was dated 07/31/16 and was for day shift only. The required information was present on the board, but the board was erased at the end of each shift, when it was kept correctly. Registed Nurse (RN) #11 was asked if there was a written record of the nurse staffing data; and replied there was a written record kept at the desk. A review of the form provided by RN #11 at 9:00 a.m. on 08/02/16, was reviewed. The form entitled Census Sheet For SNU (skilled nursing unit) was a record of each shift's attendance recorded on one line of a log. The data consisted of: Date, Census (residents), shift, RN (by #), LPN (#), CNA (#), and total staff. Thirteen (13) days could be recorded on each page and did not include the hours worked. This was reviewed with RN #52 (Director of Nurses) at 9:30 a.m. on 08/02/16, who said she would correct this immediately. At 3:30 p.m. on 08/02/16, RN #52 and RN #11 presented a corrected form written on paper and mounted on the chalk board for residents and/or visitors to read.",2020-02-01
4197,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2017-04-11,170,C,0,1,XDKG11,"Based on staff interview and resident interview, the facility failed to ensure residents received mail delivery on Saturdays. This practice had the potential to affect all residents at the facility. Resident identifier: #121. Facility census: 113. Findings include: a) Resident #121 At 3:00 p.m. on 04/03/17, when asked about mail delivery on Saturdays, Resident #121 (the resident council president) said she did not believe residents received mail on Saturdays. She said the activities staff delivered the mail to the residents. Activity Director (AD) #98, when interviewed at 6:40 a.m. on 04/06/17, said there was no mail delivery on Saturdays. At 04/06/17 at 7:15 a.m., the administrator confirmed there was mail delivery from the post office in the neighborhood on Saturdays. At 8:11 a.m. on 04/11/17, the administrator said he arranged for the mail carrier to deliver the mail to the facility on Saturdays. I guess he (the mail man) didn't come before because he knew there was nobody in the office on Saturdays.",2020-02-01
4210,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2017-04-11,356,C,0,1,XDKG11,"Based on observation and staff interview, the facility failed to ensure the nurse staff posting reflected staffing numbers for nigh shift. This practice had the potential to affect all residents and/or family members/visitors wishing to see how many staff were working. Facility Census: 113. Findings include: a) Upon entrance to the facility at 6:00 a.m. on 04/06/17, observation found the nurse staff posting form dated 04/05/17 contained spaces for staffing numbers for all three (3) shifts. 1. Day shift 6:30 a.m. to 2:30 p.m., 7:00 a.m. to 3:00 p.m., 9:00 a.m. to 5:00 p.m., and 10:30 a.m. to 6:30 p.m. 2. Evening Shift 2:30 p.m. to 10:30 p.m., 3:00 p.m. to 11:00 p.m., 3:00 p.m. to 3:00 a.m., 7:00 p.m. to 7:00 .a.m. 3. Night Shift: 10:30 p.m. to 6:30 a.m., 11:00 p.m. to 7:00 a.m., and 3:00 a.m. to 3:00 p.m. The day shift and evening shift staffing numbers were completed, but the night shift numbers were not filled in. An interview with Nurse Aide Supervisor (NAS) #41 confirmed the nurse staff posting was not completed for night shift. She stated, I take care of updating it before I leave in the evenings and I forgot to update it yesterday evening.",2020-02-01
4263,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,368,C,0,1,310011,"Based on observation, staff interview and review of the facility posted meal service time, the facility had routinely scheduled the evening meal and the next breakfast meal 14.5 hours apart. This had the potential to affect all residents served meals in the facility. Facility census: 69. Findings include: Observation on 10/03/16 revealed the meal times posted in the facility were: Breakfast --Hall #100 at 7:30 a.m. --Hall #200 / Private Dining Room at 7:40 a.m. --Main Dining Room at 7:45 a.m. --Hall #300 at 7:50 a.m. --Hall #400 at 8:00 a.m. Lunch Service --Hall #100 at noon --Hall #200 / Private Dining Room at 12:10 p.m. --Hall #300 at 12:15 p.m. --Hall #400 at 12:20 p.m. --Main Dining Room at 12:30 p.m. Dinner Service --Hall #100 at 5:00 p.m. --Hall #200 / Private Dining at 5:10 p.m. --Hall #300 at 5:15 p.m. --Hall #400 at 5:20 p.m. --Main Dining Room at 5:30 p.m. The posted meal schedule exceeds the 14 hour limit between the evening dinner meal and breakfast the following morning. During interview on 10/05/16 at 10 a.m., Food Service Manager #10 stated he had become the department manager in (MONTH) (YEAR) and that the current meal times were established before his arrival and had not been adjusted since his arrival. Food Service Manager #10 confirmed during the interview that the dietary department stocked nourishments to a room located near the nursing station. However, there was no plan to approach each resident and offer a nourishing snack each evening. The available floor stock nourishments were only available upon resident request.",2020-02-01
4284,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,356,C,0,1,WJYE11,"Based on observation and staff interview, the facility failed to post nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents. Facility census: 61. Findings include: a) During the initial tour of the facility at 12:45 p.m. on 03/14/16, an observation of the daily staff posting of the direct care staff was made. The posting form was located in the upper left corner of a bulletin board in the resident common lounge area. The information occupied an 8 inch x 11 inch sheet of sheet of paper in a typed form filled in with small typed font information. The form could not be easily read by residents and/or visitors and could not be read by anyone in a wheelchair. This was acknowledged by the Assistant Director of Nursing (ADON) at 12:50 p.m. on 03/14/16. On 3/15/16 at 8:30 a.m. Scheduler #28 reported she had corrected the staff posting. The posting is now located on the outer left side of the nurses station desk approximately 3 feet from the floor at the w/c residents' eye level, in dark ink, easily readable. In addition the original posting remains high up on the bulletin board in case the other posting disappears.",2020-02-01
4351,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2016-01-20,356,C,0,1,96LU11,"Based on observation and staff interview, the facility failed to post nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents. Facility census: 115. Findings include: a) During the initial tour at 8:00 a.m. on 01/18/16, an observation of the daily staff posting of the direct care staff found the posting forms on the north and south halls were located behind the nurses' stations. The postings were approximately five (5) feet off of the floor and occupied an eight (8) by eleven (11) inch sheet of paper. The typed form was filled in with faint handwritten figures. The daily posting form could not be easily read by the residents or visitors and could not be read by anyone in a wheelchair. This was acknowledged by the Director of Nursing (DON) on 01/19/16 at 2:00 p.m. A follow up observation on 01/19/16 at 2:30 p.m., found both staff postings relocated on the outside of the nurses' stations, approximately four (4) feet from the floor and written in darker ink.",2019-11-01
4406,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2016-08-04,167,C,0,1,BBQT11,"Based on Resident Council President interview, staff interview, and record review, the facility failed to ensure the results of its most recent survey were posted in a place which made them readily accessible for review by residents and/or family members. The facility had a Survey Book located in its lobby; however, the results located in the book were not from the most recent survey. This practice had the potential to affect all residents residing in the facility. Facility Census: 58 Findings Include: a) An interview with the Resident Council President at 1:50 p.m. on 08/01/16 revealed she was not aware of where the current state survey results were posted. She stated that she had never really looked for them but she did not know where to look even if she wanted to. At 2:04 p.m. on 08/01/16, the state survey results were located in a three ring binder in the main lobby labeled, Survey Results for Ohio Valley Health Care. Review of the results located in the three ring binder found it contained the results from the facility's Quality Indicator Survey (QIS) completed on 07/11/14. The results of the facility's last QIS completed on 09/24/15, were not readily accessible for review. An interview with the Director of Nursing at 2:19 p.m. on 08/01/16 confirmed the results in the lobby were from the (MONTH) 2014 survey and not the most recent survey completed on 09/24/15. She stated that she would have to get those results and put them in the survey results binder kept in the main lobby for the residents and families to review.",2019-11-01
4409,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2016-08-04,249,C,0,1,BBQT11,"Based on review personnel files and staff interview, the facility failed to employ a qualified professional to lead the activity program. This practice had the potential to affect all residents residing in the facility. Facility census: 58. Findings include: a) Activity Director On 07/27/16 at 3:00 p.m., a review of the licenses and certifications provided by the administrator found no license or certification for Activity Director (AD) #30. On 08/03/16 at 8:45 a.m., Registered Nurse (RN) #48 provided the personnel file for AD #30. The personnel file revealed AD #30 was an elementary school teacher, but did not reflect any qualifications as established by the Centers for Medicare and Medicaid Services (CMS) for the direction of an activity program. During an interview on 08/03/16 at 9:00 a.m., RN #48 said AD #30 had worked at the facility for approximately one (1) month and would be resigning her position soon. She said AD #30 had not enrolled in an activity certification program because those were offered only at select times. On 08/04/16 at 1:45 p.m., RN #48 said she felt since the facility had consultation once per quarter by an activities consultant that this relieved them of the obligation to have a certified activity director in the facility.",2019-11-01
4422,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2016-08-04,356,C,0,1,BBQT11,"Based on observation of the daily staff posting and staff interview, the facility failed to include the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care each shift. This had the potential to affect all residents and visitors at the facility who might wish to view the daily staff posting. Facility census: 58. Findings include: a) Staffing posting Observations upon entrance to the facility at 9:45 a.m. on 07/26/16 found the daily staff posting was at the nurses ' desk. An interview with the director of nursing (DON) at 9:00 a.m. on 08/04/16, confirmed the staff posting failed to include the actual number of hours licensed and unlicensed nursing staff planned to work on the day shift of 07/26/16.",2019-11-01
4549,MINNIE HAMILTON HEALTH CARE,51A013,186 HOSPITAL DRIVE,GRANTSVILLE,WV,26147,2016-12-07,520,C,0,1,CR3E11,"Based on review of quality assessment and assurance (QA&A) meeting attendance records and staff interview, the facility failed to ensure the attendance and/or participation of the facility's medical director in QA&A meetings. This had the potential to affect all of the residents in the facility. Facility census: 23. Findings include: a) During interview with the director of nursing (DON) on 12/07/16 at 10:00 a.m., she was asked to provide attendance records/sign-in sheets of all facility staff who attended quality assessment and assurance (QA&A) meetings for the most recent six (6) months. She said the QA&A meets once a month, but the medical director does not attend the QA&A meetings. Rather, nursing administration's director of QA&A /Risk e-mails the minutes of the QA&A meetings to the medical director. She said the facility's QA&A minutes are then placed on the agenda of the monthly medical staff meetings, and the medical director reviews the QA&A meeting minutes at those meetings. Upon request to provide evidence the facility's medical director does review the facility's QA&A meeting minutes as signified by his signature, or initials, or some form of communication, the DON said she would try to locate that information. ON 12/07/16 at 12:00 p.m. the DON said she found the facility's QA&A minutes are not placed on the monthly physician's staff meeting agenda for review by the medical director. Rather, the director of QA&A /risk emails the monthly QA&A meeting minutes to the medical director for his review. She said she would ask the director of QA&A /risk for a copies of the most recent six (6) months' of emails she sent to the current medical director, and to the former medical director of the facility, which contained QA&A meeting minutes. She said she would also provide some evidence of the medical directors' review of the monthly QA&A meeting minutes. On 12/07/16 at 1:00 p.m. the DON said she was unable to find evidence of the medical directors' review of any of the most recent six (6) months' QA&A meeting minutes. She said the facility changed medical directors on 11/01/16. She said that the current, and the former, medical directors did not attend QA&A meetings in the most recent six (6) months. She could provide no evidence that either of the two (2) medical directors reviewed the monthly QA&A meeting minutes.",2019-10-01
4686,GLASGOW HEALTH AND REHABILITATION CENTER,515118,"120 MELROSE DRIVE, BOX 350",GLASGOW,WV,25086,2016-08-24,356,C,1,0,2HCJ11,"> Based on observation, records review and staff interview, the facility failed to post staffing information that accurately reflected the current date, the total number and actual hours worked per shift by registered nurses, licensed nurses, nurse aides, and the current resident census. This had the potential to affect all residents and/or visitors of the facility. Facility census: 88 Findings include: a) Observation of the staff posting, during the initial tour of the facility, at 9:05 a.m. on 08/22/16, found the facility staff posting was dated 08/20/16. An interview with Registered Nurse (RN) Assessment Coordinator #9, at 9:10 a.m. on 08/22/16, confirmed the facility had not displayed the staff posting information for 08/21/06 and 08/22/16.",2019-08-01
4710,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,356,C,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to post nurse staffing data in a prominent place readily accessible to residents and visitors and in a clear and readable format. This had the potential to affect all residents and visitors. Facility census: 92. Findings include: a) During the initial tour at 8:30 a.m. on 03/24/16, an observation of the daily staff posting of the direct care staff found the posting form located outside of room [ROOM NUMBER]. This was across from the 100 hall nurses' station, approximately five (5) feet from the floor. The information occupied an 8.5 by 11 inch sheet of paper and was a typed form filled in with handwritten figures. A follow up observation with the Director of Nursing (DON) on 03/24/16 at 10:15 a.m., found the staffing sheets bent over the plastic holder and unreadable by anyone. The DON confirmed the staff posting was not easily accessible for residents and visitors to read.",2019-08-01
4732,CLARKSBURG NURSING AND REHABILITATION CENTER,515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2015-04-07,356,C,0,1,75SC11,"Based on observation and staff interview, the facility failed to post accurate nurse staffing data. This had the potential to affect more than a limited number of residents. Facility census: 95. Findings include: a) During the initial tour of the facility, at 9:30 a.m. on 04/30/15, an observation of the daily staff posting of the direct-care staff found the posting form located near the first floor nurses' station. The census was noted as 97 on the form. In an interview on 04/30/15 at 10:35 a.m., the administrator said the facility census was 95. When asked about the discrepancy between the present census and the data on the form, she stated, The nurses must not have updated it from the weekend. She then corrected the form.",2019-08-01
4767,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2016-02-12,522,C,0,1,PDOU11,"Based on staff interview and interview with the Office of Health Facility Licensure and Certification (OHFLAC), the facility failed to provide written notice to the State agency responsible for licensing the facility, when there was a change in the director of nursing. This had the potential to affect all residents at the facility. Facility census: 40. Findings include: a) Notification of a change of the Director of Nursing (DON) During investigation of the facility's extended survey on 02/12/16 at 9:30 a.m., review of the active employee roster found Registered Nurse (RN) #65 was listed as the current DON. The roster reflected RN #65 was hired on 12/14/15. At 10:00 a.m. on 02/12/16, the administrator confirmed she did not notify the State agency (OHFLAC) responsible for licensing the facility, when the new DON was hired. At 10:10 a.m. on 02/12/16, RN #65 said she assumed the DON position sometime in (MONTH) (YEAR), but she did not know the exact date of her appointment. At 12:32 p.m. on 02/12/16, the state agency (OHFLAC) confirmed the facility did not provide written notice of a change in the DON.",2019-07-01
5071,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2015-09-14,156,C,0,1,HR8011,"Based on observation, resident council president interview, and staff interview, the facility did not post the required information within the facility regarding names, addresses and telephone numbers of all pertinent State client advocacy groups. The facility failed to post the name, address, and telephone number of the Office of Health Facility Licensure and Certification (OHFLAC), and/or a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property. This practice had the potential to affect all residents at the facility. Facility census: 88. Findings include: a) Observation on 09/08/15 at 12:45 p.m. found no evidence of contact information for the State survey and certification agency posted within the corridors of the facility. At 1:00 p.m. on 09/08/15, Registered Nurse (RN) #20 and the licensed social worker looked for the required posted information. They could not locate a posting with the name, address, and telephone number of the State survey agency, including a statement that the resident may file a complaint with this agency concerning resident abuse, neglect, and misappropriate of resident property, and non-compliance with the advance directives requirements. They said there was none posted within the facility. The social worker devised and posted a temporary form, which included contact information and purpose, until she could obtain a laminated form. During an interview with Resident Council President (RCP) #4 on 09/14/15 at 11:50 a.m., RCP #4 said they did not know how to notify the State if they or other residents had complaints. RCP #4 knew the name of the Ombudsman and his contact information, but had no knowledge of the telephone number or address of the State survey and certification agency. RCP #4 stated she might find that information in the survey book, but did not recall seeing that information posted in the building.",2019-03-01
5079,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2015-09-14,356,C,0,1,HR8011,"Based on observation and staff interview, the facility did not display the daily nursing staffing posting and resident census in a prominent location where it could be viewed by residents and/or visitors. This had the potential to affect all residents/visitors in the facility. Facility census: 88. Findings include: a) Observation on 09/08/15 at 12:45 p.m. found no evidence that the daily nurse staffing and census was posted in a prominent location in the facility. During a staff interview with Registered Nurse (RN) #20 on 09/08/15 at 1:00 p.m., RN #20 said the daily census and nursing staff posting was displayed at a table by the front door, easily visible to visitors and residents in passing. Since some remodeling completion, the daily census and nursing staff information was no longer kept up front. RN #20 showed the current location of the daily census and nursing staff posting, located in an office behind a reception desk. The daily census and nurse staffing posting was not easily visible to residents or visitors, unless they had some reason to go through a doorway and enter into the inner business offices.",2019-03-01
5131,WHITE SULPHUR SPRINGS CENTER,515100,345 POCAHONTAS TRAIL,WHITE SULPHUR SPRING,WV,24986,2015-09-30,356,C,0,1,VQ8L11,"Based on observation of staff posting information and staff interview, the facility failed to ensure staffing information was posted on a daily basis at the beginning of each shift. This had the potential to affect all residents and/or visitors residing or visiting the facility. Resident census: 63. Findings include: a) Observation of the staff posting, during the initial tour of the facility at 4:33 p.m. on 09/27/15, found the facility staff posting was dated 09/25/15. Housekeeping Supervisor #67 was asked to make a copy of the current nursing staff posting. At 4:45 p.m. on 09/27/15, Registered Nurse #21 confirmed the facility had not posted the staffing information for 09/27/15.",2019-03-01
5146,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,167,C,0,1,PDA311,"Based on resident interview, observation, and staff interview, the facility failed to ensure residents and other interested persons were made aware of the location of the most recent survey results. In addition, the facility failed to ensure all persons were made aware the results were available for anyone to examine at any time. The posted sign indicating their availability required individuals to ask to see the results. This practice had the potential to affect all residents and other individuals who wished to examine the survey results. Four (4) of four (4) residents who were asked about the location of the survey results were unaware of their location. Resident identifiers: #24 #60, #55, and #40. Facility census: 55. Findings include: a) Resident #24 During an interview with the resident council president, on 06/16/15 at 4:30 p.m., the resident related she did not know the location of the survey results. b) Resident #60 An interview with Resident #60, on 06/16/15 at 7:06 p.m., revealed the resident did not know where to find the survey results. Review of the resident's most recent minimum data set (MDS) revealed a Brief Mental Status Score (BIMS) of fifteen (15), the highest possible score, which indicated the resident was cognitively intact. c) Resident #40 On 06/17/15 at 10:18 a.m., an interview revealed the resident did not know where to find the survey results. Review of the resident's most recent MDS revealed a BIMS score of fifteen (15), which indicated the resident was cognitively intact. d) Resident #55 When asked on 06/17/15 at 1:17 p.m., the resident did not know where to find the survey results. Review of the resident's most recent MDS revealed a BIMS score of fifteen (15), which indicated the resident was cognitively intact. e) An observation, on 06/18/15 at 10:21 a.m., revealed a corporate sign on the bulletin board in the front hallway, which read, This center has reports of surveys, certifications and complaint investigations for the preceding three years available for any individual to review upon request. Please see the administrator to inquire. The book containing the survey results was found on a table on the other side of the wall; however, there was no signage present which indicated its location and/or that it was accessible for review without asking staff. f) An interview with the administrator on 06/18/15 at 10:48 a.m., confirmed the signage indicated the results of the surveys could only be obtained upon request. It was not a sign which indicated the availably and location of the survey results.",2019-03-01
5165,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,509,C,0,1,PDA311,"Based on staff interview, review of facility records, and facility policy review, the facility failed to maintain a current agreement with an outside radiology service to provide radiology services for the residents. This had the potential to affect all residents. Facility census: 55. Findings include: a) The facility's diagnostic services agreement, with Radiology Company #1, was reviewed on 06/22/15 at 1:35 p.m. The agreement was initiated on 09/01/07. It was last reviewed by a former administrator in (MONTH) 2009. During an interview on 06/22/15 at 1:35 p.m., the current Administrator stated radiology services were provided by Radiology Company #2, and not by Radiology Company #1. The administrator stated the facility's agreement should be with Radiology Company #2. On 06/22/15 at 3:20 p.m., review of the facility's policy entitled Corporate Policies-General, dated as revised 10/01/14, found it stated any contracts with terms which exceeded one (1) year must be reviewed in advance by the Chief Executive Officer, Chief Operating Officer, and Chief Financial Officer. During a follow-up interview, on 06/23/15 at 8:30 a.m., the Administrator confirmed the agreement did not comply with corporate policy.",2019-03-01
5166,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,519,C,0,1,PDA311,"Based on staff interview, review of facility records and documents, and review of facility policy, the facility failed to maintain current hospital transfer agreements. This had the potential to affect all residents. Facility census: 55. Findings include: a) Review of facility records, on 06/22/15 at 1:35 p.m., revealed the hospital transfer agreements with Hospitals #1, #2, #3, #4, #5, #6, #7 and #8 were all dated 01/18/99, and were signed by a former administrator. The transfer agreements were last reviewed by the former administrator in (MONTH) 2009. None of the transfer agreements included the duration of the agreement or an automatic renewal clause. During an interview, on 06/22/15 at 1:35 p.m., the administrator stated facility procedure was to review agreements and contracts on an annual basis. The administrator confirmed the transfer agreements, reviewed during the survey on 06/22/15, were the most current agreements available to the facility. The administrator also confirmed the agreements had not been reviewed and/or updated since (MONTH) 2009. The administrator provided no explanation regarding why the agreements had not been reviewed and updated since (MONTH) 2009. On 06/22/15 at 3:20 p.m., review of the facility's policy entitled Corporate Policies-General, dated as revised 10/01/14, found it stated any contracts with terms which exceeded one (1) year must be reviewed in advance by the Chief Executive Officer, Chief Operating Officer, and Chief Financial Officer. During a follow-up interview, on 06/23/15 at 8:30 a.m., the Administrator confirmed the transfer agreements did not comply with corporate policy. .",2019-03-01
5208,NELLA'S INC,51A010,499 FERGUSON ROAD,ELKINS,WV,26241,2015-03-03,225,C,0,1,NK8711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review and staff interview, the facility failed to ensure it did not hire employees who had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was found to for five (5) of ten (10) employees whose personnel files were reviewed. This had the potential to affect more than an isolated number of residents. Employee identifiers: #70, #96, #11, #35, and #61. Facility census: 86. Findings include: a) Employees #70, #96, #11, #35, and #61 A review of personnel files on 02/26/15 at 1:30 p.m., revealed the files of five (5) employees contained no evidence the State nurse aide registry was checked to determine whether the individuals had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. The employees were: 1. Maintenance Employee #70, 2. Tech Support Person #96, 3. Tech Support Person #11, 4. Dietary Manager #35, and 5. Licensed Practice Nurse #61. Office Assistant #5 assisted with the personnel record review. Upon completion of the review, she stated she did not complete State nurse aide registry checks on these employees. On 03/02/15 at 9:30 a.m., Employee #5 presented completed State nurse aide registry checks on all employees in question. There were no reportable issues noted.",2019-03-01
5285,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2015-05-12,225,C,0,1,ORJG11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview; the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for one (1) of five (5) employee files reviewed. This had the potential to affect more than a limited number of residents. Employee identifier: #42. Facility census: 181.Findings include: a) Employee #42 On 04/27/15 at 4:21 p.m., a review of personnel files found one (1) of five (5) employees hired by the facility had no fingerprints, or criminal background checks based on fingerprinting, in their files. The file contained a criminal background check completed based on Nurse Aide #42's social security number. Employee #42 was hired on 03/16/15. In a discussion with the Administrator and director of nursing at 4:21 p.m. on 04/27/15, the administrator indicated Nurse Aide #42's fingerprinting had been scheduled and then rescheduled. On 05/12/15 at 11:00 a.m., the administrator provided evidence the nurse aide had fingerprints completed on 04/21/15. The facility received the results on 04/27/15. The administrator said Employee #42 had been scheduled to for fingerprinting prior to the hire date of 03/16/15. Employee #42 missed the appointment. The administrator and director of nursing said 04/21/15 was the earliest date the fingerprints could be rescheduled. However, the facility had no evidence that this was the earliest date the fingerprints could be rescheduled. On 05/12/15 at 2:15 p.m., the director of nursing provided timecard information that showed Nurse Aide #42 had worked 29 days from 03/16/15 through 04/26/15 prior to the facility obtaining the results of the criminal background fingerprint results 04/27/15. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police.The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID).",2019-01-01
5320,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2015-09-17,159,C,0,1,I3KW11,"Based on resident interview and staff interview, the facility failed to manage resident funds in a manner, which ensured residents had access to their funds seven (7) days per week, rather than just during normal banking hours. This had the potential to affect 19 of 19 residents whose accounts were managed by the facility. Resident identifiers: #5, and #20. Facility census: 25. Findings include: a) Resident #5 During an interview in Stage I of the Quality Indicator Survey (QIS) on 09/15/15 at 9:23 a.m., Resident #5 said residents could not get money from their accounts on weekends. b) Resident #20 During an interview in Stage I of the Quality Indicator Survey (QIS) on 09/15/15 at 4:33 p.m., Resident #20 said residents could not get money from their accounts on weekends. On 09/17/15 at 7:15 a.m., interviews conducted with Licensed Practical Nurse (LPN) #100, and Nurse I #87. Upon inquiry, both said they were unsure how residents would get money out of their accounts on weekends. They said they have no petty cash box in the medication carts or in the locked medication room. LPN #100 said, in the past six (6) years of her employment with the facility, she does not recall any resident requests for money out of their accounts on weekends. During an interview with Accounts Payable Representative #101, on 09/17/15 at 10:43 a.m., she said residents might only access their funds for cash during banking hours, Monday through Friday. She said there is no administrative staff available on weekends to obtain cash from (name of bank) on weekends. She was unsure if the (name of bank) was open on Saturdays. She acknowledged the facility does not keep cash on hand. She said if the residents wanted cash for use on the weekends, they needed to request those funds prior to bank closing on Fridays. She further explained residents must sign a check to obtain cash from his/her bank checking account, and two (2) administrative staff members must sign the check. Someone from the facility then travels to the bank to cash the check for the resident in the amount desired.",2019-01-01
5324,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2015-09-17,364,C,0,1,I3KW11,"Based on observation and staff interview the facility failed to ensure the appearance and palatability of leafy greens prepared for residents receiving pureed diets. They did not present the greens with a consistency that allowed them to maintain a firmness on the plate and not flow into the surrounding foods. This practice affected all residents who received pureed foods. Facility census: 25. Findings include: a) The noon food service, at 12:03 p.m. on 09/16/15, included a menu which consisted of kielbasa, sauerkraut, and mixed leafy greens. When the pureed form of the leafy greens was served from the steam table to the plate or bowl, they were observed to be thin and soup-like in appearance. This was mentioned to Cook/Server #81 (Cook/Server) and to Food Service Supervisor #84 (Food Service Supervisor), who were present during the service. Cook #81 acknowledged the greens would flow into the other items in the present consistency and added thickening to the greens for the remainder of the service.",2019-01-01
5402,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-06-11,520,C,0,1,3Y2511,"Based on record review and staff interview, the facility's Quality Assessment and Assurance (QA&A) Committee failed to meet quarterly to determine if a defined standard of quality was being achieved to ensure care practices were consistently applied to ensure the facility met, or exceeded, an expected standard of quality, and/or to implement principles of continuous quality improvement. In addition, the facility failed to ensure a designated physician was present at each meeting. This had the potential to affect all residents residing at the facility. Facility census: 81. Findings include: a) At 8:30 a.m. on 06/11/15, Corporate Consultant (CC) #45, a registered nurse, provided copies of the facility's employee sign-in sheets for the previous four (4) QA&A meetings. Review of the sign-in sheets revealed the QA&A committee was not meeting quarterly as required: -- On 05/09/14, a meeting entitled 1st Quarter Report was held. -- There was not another QA&A meeting for over five (5) months, on 10/20/14. -- The next meeting was held in 3.5 months, on 02/03/15. -- There was not another QA&A meeting for four (4) months, on 06/05/15. b) At 9:10 a.m. on 06/11/15, upon inquiry regarding the participation of a physician at the QA&A meetings, CC #45 confirmed she had no evidence to substantiate the attendance of a physician at the 05/09/14 meeting as required by the regulation.",2019-01-01
5462,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2015-06-22,354,C,0,1,N2E611,"Based on record review and staff interview, the facility failed to ensure sufficient qualified nursing staff were available on a daily basis to meet the nursing needs of each resident. The facility did not use the services of a registered nurse (RN) for at least eight (8) consecutive hours a day, seven (7) days a week. This practice had the potential to affect every resident currently residing in the facility. Facility Census: 62. Findings include: a) A review of the nurse staff postings for 05/31/15 through 06/13/15, at 12:30 p.m. on 06/22/15, found no RN hours recorded for 06/07/15. An interview with the Director of Nursing and the Administrator, at 12:00 p.m. on 06/22/15, found the facility did not have an RN in the building for eight (8) consecutive hours on 06/07/15.",2019-01-01
5463,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2015-06-22,356,C,0,1,N2E611,"Based on facility record review, observations, and staff interview, the facility failed to post nurse staffing data which accurately reflected the number of registered nurses (RN) working for four (4) of fifteen (15) days reviewed. This had the potential to affect all residents and/or visitors. Facility Census: 62. Findings Includes: a) At 11:00 a.m. on 06/15/15, the Daily Nurse Staffing Form was observed posted at the front entrance of the facility. The form contained the name of the facility, the date, and the total census. Under the section titled RN, the form indicated there was no RN currently working on 06/15/15. The licensed nursing schedule for 06/15/15 was reviewed. Two (2) RNs were identified as working to provide direct care on 06/15/15. Review of additional staff postings, on 06/15/15 at 11:00 a.m., found the staff posting on three (3) more days revealed no RNs were present. These days were 04/18/15, 06/05/15, and 06/06/15.The Director of Nursing (DON) was interviewed at 12:00 p.m. on 06/22/15. She reviewed the Daily Nurse Staffing Forms and reported they were not accurate. The DON said there was an RN on 04/18/15, 06/05/15, 06/06/15 and 06/15/15, even though the staffing forms indicated there were no RNs working on those days. For verification, the DON provided time cards, which indicated an RN worked each of the days in question.",2019-01-01
5539,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2015-06-04,225,C,0,1,EDOZ11,"Based on review of personnel files, review of the West Virginia Bureau for Medical Services' policy manual and memorandum (memo), and staff interview, the facility failed to conduct a criminal investigation background check every three (3) years during employment for one (1) of ten (10) employees reviewed. Employee identifier: # 6. Facility census: 97. Findings include: a) Hospitality Aide #6 A review of personnel files, at 10:30 a.m. on 06/03/15, determined Hospitality Aide #6, hired on 09/19/11, had a WV statewide criminal background check on 11/01/11, but had not been rechecked as required by the WV Bureau for Medical Services. This was pointed out to Employee #46 (person designated by the facility as responsible for Personnel Files) at 1:30 p.m. on 06/03/15. Employee #46 provided a letter with an appointment for Employee #6 to be fingerprinted and a receipt of payment for the search, but admitted she could not locate the results of a current WV statewide criminal background check. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013.",2018-10-01
5541,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2015-06-04,356,C,0,1,EDOZ11,"Based on observation and staff interview, the facility failed to post the nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents. Facility census: 97. Findings include: a) During the initial tour of the facility, at 11:50 a.m. on 06/01/15, an observation of the daily staff posting of the direct care staff was made. The posting form was located inside the main dining room approximately 5 feet off the floor. The information occupied an 8 inch x 11 inch sheet of paper and was a typed form filled in by handwritten figures. There were 24 sections of information on the form, making it difficult to understand. The form could not be easily read by residents and/or visitors and could not be read by anyone in a wheelchair. This was acknowledged by the Administrator at 2:20 p.m. on 06/04/15. She also acknowledged it was the only posting in the facility and would require the reader to enter the dining room to see the posting.",2018-10-01
5565,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2015-02-11,225,C,0,1,II7711,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Affordable Healthcare Act, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility failed to ensure the results of the fingerprint based statewide and/or federal criminal background checks were received and/or reviewed prior to employees working in the facility longer than sixty (60) days. This was true for three (3) of five (5) new hire personnel records reviewed. Employee identifiers: #69, #22, and #31. Facility Census: 65. Findings Include: a) Employee #69 A review of Employee #69's personnel record at 12:30 p.m. on 02/10/15, found Employee #69 was hired as a Laundry Aide on 10/29/14. Her sixtieth (60th) day of employment was 12/27/14. Review of her application found she had lived outside of the state of West Virginia in the previous five (5) years. Further review of the personnel record found no results of a fingerprint based federal background check. Additional review found the facility had mailed Employee #69's fingerprints to the company completing the federal criminal background check on 10/29/14. An interview with Employee #36, bookkeeper, at 12:45 p.m. on 02/10/15, revealed the facility identified Employee #69 had lived out of state and needed a fingerprint based federal background check. She indicated she mailed the fingerprints to the company completing the background check on 10/29/14. When asked if she had called to see why the results had not been returned she stated, No, because they told me it could take up to twelve (12) weeks to get the results back She said they advised her not to call until after twelve (12) weeks. Employee #36 was asked if Employee #69 was still actively working at the facility. She replied, Yes she is. Review of Employee #69's timecard on 02/11/15 at 1:25 p.m., for the previous thirty (30) days, found she had worked on 01/11/15 through 01/13/15, 01/16/15 through 01/20/15, 01/22/15, 01/23/15, 01/26/15 through 01/28/15, 01/30/15 through 02/02/15, 02/04/15 through 02/06/15, 02/09/15 through 02/11/15. Which was twenty-three (23) of thirty (30) days. b) Employee #22 A review of Employee #22's personnel record, at 12:50 p.m. on 02/10/15, found Employee #22 was hired as a Dietary Aide on 11/20/14. Her sixtieth (60th) day of employment was 01/18/15. Further review of the personnel record found no results of a fingerprint based statewide background check. Additional review found the facility had mailed Employee #22's fingerprints to the company completing the statewide criminal background check on 11/19/14. An interview with Employee #36, bookkeeper, at 1:00 p.m. on 02/10/15, revealed the she was aware the employee needed a fingerprint based statewide background check only. She indicated she mailed the fingerprints to the company completing the background check on 11/20/14. When asked if she had called to see why the results had not been returned she stated, No, because they told me it could take up to twelve (12) weeks to get the results back. When asked if Employee #22 was still actively working at the facility, she replied, Yes she is. Review of Employee #22's timecard on 02/11/15 at 1:25 p.m., from her sixtieth (60th ) day of employment, 01/18/15 to present, found she had worked on 01/19/15, 01/22/15, 01/24/15 through 01/27/15, 01/30/15 through 02/02/15, 02/05/15 through 02/09/15, which was fifteen (15) of twenty-four (24) days. c) Employee #31 A review of Employee #31's personnel record at 1:07 p.m. on 02/10/15, found Employee #31 was hired as a Registered Nurse on 08/18/14. Her sixtieth (60th) day of employment was 10/16/14. Further review of the personnel record found no results of a fingerprint based statewide background check. Additional review found the facility had mailed Employee #22's fingerprints to the company completing the statewide criminal background check on 08/29/14. An interview with Employee #36, bookkeeper, at 1:15 p.m. on 02/10/15, revealed the employee needed a fingerprint based statewide background check only. She indicated she mailed the fingerprints to the company completing the background check on 08/29/14. She further stated the company rejected Employee #31's fingerprints on 12/05/14. Employee #36 indicated the letter notifying them the fingerprints had been rejected was mailed to Employee #31 and not to the facility. Employee #36 stated Employee #31 did not bring in the rejection letter until two (2) weeks ago. Employee #36 stated she sent Employee #31 to have her fingerprints re-done today (02/10/15). Employee #36 was asked if Employee #31 was still actively working at the facility, and she replied, Yes she is. Review of Employee #31's timecard on 02/11/15 at 1:25 p.m., for the previous thirty (30) days found she had worked on 01/13/15, 01/14/15, 01/18/15, 01/21/15, 01/22/15, 01/29/15 through 01/31/15, 02/03/15, 02/04/15, 02/07/15, 02/08/15, and 02/11/15. Which was thirteen (13) of thirty (30) days. d) Review of Affordable Care Act Section 6201 Section 6201 (a)(3)(A) requires that long-term care facilities and providers obtain state and national criminal history background checks on prospective employees that utilize: a search of state-based abuse and neglect registries, state criminal history records, and national fingerprint-based criminal history record checks. Section 6201 (a)(3)(B) requires that participating states describe and test methods that reduce duplicative fingerprinting, including providing for the development of rap back capability by the State Section 6201 (a)(3)(C) requires that the background checks conducted under the nationwide program remain valid for a period of time as specified by the Secretary (not yet determined). Under section 6201 (a)(4)(A) and (B), participating states must also monitor compliance with the requirements of the nationwide program and have procedures in place to: - Conduct screening and criminal history background checks; - Monitor compliance by facilities and providers; - Provide for up to 60 days of provisional employment by the long term care facility/provider for a direct patient access employee, pending completion of the required criminal history background check or appeals process; . e) Review of Bureau of Medical Services (Medicaid) Services Manual The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). It is the responsibility of the employer to assure that the exclusion lists are checked monthly. The facility may employ an individual for a maximum of 60 days if a preliminary check is completed. The facility may choose to contract with a company that completes internet background checks use these results until the fingerprint results are received.",2018-10-01
5571,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2015-10-07,167,C,1,0,52YO11,"Based on observation and staff interview, the facility failed to ensure the results of the most recent survey were posted. In addition, the facility also did not post a notice of the availability of the survey results. This had the potential to affect all residents in the facility. Facility census: 118. Findings include: a) On 10/06/15 at 1:00 p.m., observation of the survey results book revealed the book contained survey results from 2009, 2010, and 2011. The most recent survey results were not in the survey book. The facility's most recent survey was conducted on 02/19/15. At 1:30 p.m. on 10/06/15, Registered Nurse (RN) #6 and Social Worker (SW) #152 agreed the results of the most recent survey were not posted in the survey results book. On 10/07/15 at 1:12 p.m., an observation of the survey results book revealed a blue three (3) ring binder was used as the survey results book. The book was located in a wooden rack mounted on the wall. A notice of the location of the survey results book was not posted anywhere in the facility, to let the residents or visitors know where they could locate the results. SW #152 agreed the facility did not have a notice posted identifying the location of the survey results.",2018-10-01
5610,MONTGOMERY GENERAL HOSPITAL,515081,401 6TH AVENUE,MONTGOMERY,WV,25136,2015-03-04,225,C,0,1,KF9N11,"Based on personnel record review and staff interview, the facility failed to ensure it did not employ individuals who found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for one (1) of ten (10) employees reviewed. This had the potential to affect more than an isolated number of residents. Employee identifier: #51. Facility census: 38. Findings include: a) Criminal Background Checks Review of personnel files on 03/04/15 at 1:30 p.m., found Nurse Aide (NA) #51, originally came to work at the facility in (MONTH) 2008. The facility completed a criminal background check with fingerprints at that time. NA #51 came back to work at the facility in (MONTH) 2011. The facility completed another criminal background check with fingerprints at that time as well. The employee came back to the facility to work for a third time on 12/30/14. The facility did not complete a statewide criminal background check with fingerprints at the time of the individual's rehire. On 03/04/15 at 2:15 p.m., Human Resources Employee #62 verified the facility did not complete a criminal background check with fingerprints when they rehired NA #51 on 12/30/14.",2018-09-01
5625,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2015-08-28,356,C,0,1,ZQ4I11,"Based on observation and staff interview the facility failed to post nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This has the potential to affect all residents. Facility census: 25. Findings include: a) During the initial tour, at 10:45 a.m. on 08/24/15, an observation of the daily staff posting of the direct care staff was made. The posting form was located at the nurses' station behind the charge nurse, approximately five (5) feet off of the floor. The information occupied an eight (8) by fourteen (14) inch sheet of paper and was a typed form filled in with hand-written figures. The daily posting form could not be easily read by the residents or visitors and could not be read by anyone in a wheel chair. This was acknowledged by the Director of Nursing (DON) on 08/26/15 at 2:10 p.m. The DON reported this was the only staff posting for the facility.",2018-09-01
5668,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY AVENUE,HARRISVILLE,WV,26362,2015-01-21,356,C,0,1,XRGM11,"Based on observation and staff interview, the facility failed to post the nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents. Facility census: 53. Findings include: a) During the initial tour of the facility, at 11:30 a.m. on 01/19/15, an observation of the daily staff posting of the direct care staff found the posting form was located in the secured area behind the nurses' station. This was approximately four (4) feet from access by a resident or the general public. The information occupied the top half of an 8 inch X 11 inch sheet of paper and was a typed form filled in by handwritten figures. Residents and/or visitors could not easily read the form. This was acknowledged by the Director of Nurses at 3:20 p.m. on 01/20/15. She also acknowledged it was the only posting in the facility.",2018-09-01
5714,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2014-11-19,226,C,0,1,H5V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review and staff interview, the facility failed to develop policies and procedures regarding abuse, neglect, mistreatment and misappropriation of property that were individualized to their facility as evidenced by their use of a corporation booklet which identified itself as a practice guide. This had the potential to affect all residents. Facility census: 110. Findings include: a) Upon request for the facility's policy addressing Abuse & Neglect on 11/15/14, the facility provided an (company name) booklet entitled, Patient Protection / Abuse, Neglect & Misappropriation Prevention. The initial entry in the booklet was the following: DISCLAIMER: This booklet is considered a practice guide. The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (company name) policies as well as federal and state regulations. It further stated: .The reader is encouraged to independently confirm the ongoing accuracy of the information contained in this document , and on Page 4 paragraph 4: Centers must adopt and operationalize an abuse prevention system that includes the seven components . The purpose of the 'Guide' is to assist each center in implementation of an abuse prevention system. Knowledge of the patient's co-morbid conditions and contributing factors allows staff to provide care specific to each patient. The following areas of concern were revealed in the review: The guide was not specific as to the facility's procedures for screening and did not include the Employee Restrictions set forth by the State of West Virginia Bureau of Medical Services in their Policy: Ch.514.4.1 addressing Criminal Investigation Background Checks. The guide did not provide a description of the training schedule or of the program used at the facility. A review of the inservice files at the facility indicated it was being done and the program in use for prevention and identification was acceptable. The policy did not identify the person responsible for the management and review of the program. The administrator indicated the social worker was responsible but the policy did not indicate this information. At 10:30 a.m. on 11/13/14, the Administrator stated the (company name) had changed their policy regarding the accessibility of the facility's investigations of accidents/incidents and of allegations of abuse, neglect, mistreatment of [REDACTED]. The facility now retains two (2) separate files on reportable events. The files presented for survey review contained: the Immediate Fax Reporting of Allegations (NAR-1); the Five Day Follow-up Report (NAR-2); and a (company name) investigative report generated by the social worker, who was the person identified as the contact person regarding abuse prohibition policies and procedures / complaints / grievance information. The second file which was protected as part of the Quality Assurance process was maintained separately and contained all original documentation generated during the investigation into an incident. In order for the surveyor to view the second file the surveyor was required to request each one from the Administrator/Social Worker who would contact the corporate office for permission and, if granted, they would bring the second file; stay while the information was reviewed; and then remove it. If a copy of any document was requested, the same procedure was repeated for each document. There was no facility policy addressing this practice, including the practice guide. The practice guide did not include the reporting requirements specific to the State of West Virginia, although the guide did identify there were different requirements from state to state. When interviewed about the practice guide, at 4:00 p.m. on 11/18/14, the administrator stated the facility recognized the practice guide as their written policies and procedures prohibiting abuse / neglect. The following morning she presented documentation of this signed by members of administration and the Medical Director.",2018-08-01
5737,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2015-08-21,356,C,1,0,Z9U411,"Based on record review, staff interview, and observation, the facility failed to ensure the nurse staff posting contained the total number of hours worked for registered nurses, licensed practical nurses, and certified nurse aides. This practice had the potential to affect all residents and/or visitors currently residing in the facility and/or visiting the facility. Facility Census: 117. Findings Include: a) Nurse Staff Posting An observation of the nurse staff posting at 10:00 p.m. on 08/19/15, found the posting only listed the total number of Registered Nurses, Licensed Practical Nurses, and Registered Nurse Aides working for the three (3) designated shifts and the the times their shift started and ended. The posting did not contain the total number of the actual hours worked for each of the aforementioned disciplines. Review of the daily staff postings from 07/26/15 through 08/01/15 found each posting just listed the total number of staff working for each shift and the time their shift started and ended. The postings did not list the total number of actual hours worked for each required discipline. An interview with the scheduler at 5:45 p.m. on 08/20/15, confirmed the staff posting just listed the start times and the end times of each of the shifts.",2018-08-01
5753,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2015-10-20,356,C,0,1,30IW11,"Based on record review and staff interview, the facility failed to ensure the daily posted nurse staffing data accurately reflected the facility census, the total number of registered nurses (RNs), Licensed Practical Nurses (LPNs), and/or Nurse Aides (NAs) from 09/25/15 through 10/08/15. This practice had the potential to affect all residents, families, and/or visitors. Facility Census: 117. Findings Include: a) Review of Nurse Staff Posting The nursing home administrator (NHA) was asked to complete the staffing calculation worksheet on 10/13/15 during Stage 2 of the Quality Indicator Survey (QIS). The instructions on the bottom of the staffing calculation worksheet are: Instructions: Please fill out the total numbers in the columns. Only Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides providing direct care can be counted. The form had a column designated for the date, the census, the total number of RNs, the total number of LPNs, the total number of NA's, and the number of nursing care hours per resident. The NHA was verbally instructed to complete the form for the last full pay period. The NHA returned the completed form on 10/14/15 and it was completed for the dates of 09/25/15 through 10/08/15. The daily nurse staff postings for the corresponding dates were also requested and provided. A review of the staffing calculation worksheet and the corresponding daily staff posting found the numbers did not match on the following dates: 1. 09/25/15: The nurse staff posting indicated the daily census was 113 on day shift , and 115 on evening and night shifts. The staffing calculation worksheet indicated the census on 09/25/15 was 116. 2. 09/25/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 47, with a total of 607.25 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 56 nursing staff members, with a total of 357.83 nursing hours for the 24 hour period. 3. 09/26/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 42.4 with a total of 531.50 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 54 nursing staff members with a total of 333.97 nursing hours for the 24 hour period. 4. 09/27/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 45.7 with a total of 602.75 total nursing hours for the 24 - hour period. The staffing calculation worksheet indicated there was a total of 53 nursing staff members with a total of 337.04 nursing hours for the 24-hour period. 5. 09/28/15: The daily nurse staff posting indicated the total number of nursing staff for all three(3) shifts was 42.1 with a total of 527.50 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 56 nursing staff members with a total of 350.23 nursing hours for the 24 hour period. 6. 09/29/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 46.5 with a total of 538.25 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 56 nursing staff members with a total of 365.12 nursing hours for the 24-hour period. 7. 09/30/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 40.3 with a total of 421.50 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 51 nursing staff members with a total of 328.75 nursing hours for the 24-hour period. 8. 10/01/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 37.8 with a total of 457.75 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 54 nursing staff members with a total of 350.06 nursing hours for the 24-hour period. 9. 10/02/15: The nurse staff posting indicated the daily census was 117 on day shift , and 114 on evening and night shift. The staffing calculation worksheet indicated the census on 09/25/15 was 115. 10. 10/02/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 41.4 with a total of 482 total nursing hours for the 24 - hour period. The staffing calculation worksheet indicated there was a total of 47 nursing staff members with a total of 316.67 nursing hours for the 24-hour period. 11. 10/03/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 40.3 with a total of 580.50 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 50 nursing staff members with a total of 320.23 nursing hours for the 24-hour period. 12. 10/04/15: The daily nurse staff posting indicated the total number of nursing staff for all three shifts was 43.1 with a total of 585.02 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 49 nursing staff members with a total of 316.78 nursing hours for the 24-hour period. 13. 10/05/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 46.9 with a total of 593 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 53 nursing staff members with a total of 352.25 nursing hours for the 24-hour period. 14. 10/06/15: The nurse staff posting indicated the daily census was 113 on all three (3) shifts on 10/06/15. The staffing calculation worksheet indicated the census on 10/06/15 was 114. The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 43 with a total of 493 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 54 nursing staff members with a total of 357.78 nursing hours for the 24 hour period. 15. 10/07/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 44.9 with a total of 545.5 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 56 nursing staff members with a total of 362.32 nursing hours for the 24 hour period. 16. 10/08/15: The daily nurse staff posting indicated the total number of nursing staff for all three (3) shifts was 41.7 with a total of 492.75 total nursing hours for the 24-hour period. The staffing calculation worksheet indicated there was a total of 54 nursing staff members with a total of 344.55 nursing hours for the 24 hour period. b) An interview with the NHA, at 2:32 p.m. on 10/14/15, confirmed the posted nurse staff was inaccurate every day in the last full pay period. He stated, I noticed that when I was filling out the form, but was waiting on you to ask me about it. He indicated the staffing calculation worksheet was accurate, but the staff postings generated in the computer system were inaccurate. He confirmed the inaccurate staff postings provided were the ones posted in the facility for residents and/or visitors to view.",2018-08-01
5788,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2014-10-07,167,C,0,1,U60O11,"Based on observation and staff interview, the facility failed to make the results of the most recent survey of the facility conducted by Federal or State surveyors readily accessible to residents. In addition, there was no notice of their availability. This had the potential to affect all residents and visitors. Facility census: 132. Findings include: a) During the general tour of the facility, at 10:40 a.m. on 09/29/14, there was no evidence near either of the first floor entries, of a posting which described the location of the most recent survey results. b) Manuals containing survey results were located near the nurses' stations on each unit, although none of them were up to date. Three (3) of them contained results of a complaint survey on 05/28/13, the most recent Quality Indicator Survey (QIS) completed on 06/06/13, and a life safety survey on 06/05/13. One (1) did not contain the 06/06/13 QIS survey results. c) At 4:00 p.m. on 09/29/14, a manual was located on a bookshelf in a lobby area at the first floor entry near the business office. It was labeled as 2013 Survey Results. It contained results from 06/05/13 Life Safety Survey, 05/28/13 Complaint Survey, 10/27/11 Revisit Survey, and 07/27/2011 Annual Survey and complaints. It did not contain the results of the most recent QIS survey on 06/06/13. d) None of the manuals found included the results of the previous four (4) complaint surveys dated: 07/25/14, 05/16/14, 02/20/14, or 11/06/13. During an interview with the Administrator, at 10:00 a.m. on 09/30/14, she offered a sixth manual which she said was kept in her office and contained all results except these four (4) complaints. She stated someone must have removed the missing survey results from manuals and she did not think Complaint surveys needed to be included. .",2018-07-01
5794,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2014-10-07,356,C,0,1,U60O11,"Based on observation and staff interview, the facility failed to ensure the residents and public were informed on a daily basis of the nurse staffing data as required by 42 CFR 483.30(e). The staffing posting was not in a prominent place or in a print size that enabled easy reading of the posting. This had the potential to affect all residents. Facility census: 132. Findings include: a) During the general tour of the facility, at 10:30 a.m. on 09/29/14, the nurse staffing data on the 200 unit (Garden Place) was observed on a 8 inch by 10 inch typed form with handwritten numbers placed in a clear container mounted above the desk. The form had been dropped in the container sideways, making it unreadable. During an interview with Employee #88 (RN Manager) and the Administrator, at 9:45 a.m. on 10/01/14, the Administrator explained the daily nursing staff postings were completed individually by each unit and posted at the respective nurses' stations. There was no posting of total staffing for the entire facility as required. Employee #88 accompanied the surveyor in reviewing the postings. The posting on the 300 unit (Sunny Brook) was above the desk in a frame mounted on a center post and not facing the hallway. On the 300-extended unit (Enchanted Garden) and the Alzheimer's unit (Golden Acres) the form was in a clear frame sitting on the desk at the nurses' station. The posting on the 200 unit was still in the container sideways. At 9:30 a.m. on 10/02/14, after reviewing the postings, the Administrator was notified of the locations and difficulty in reading the notices. She expressed surprise the postings were not on each desk as had been instructed. She said she would rectify that situation.",2018-07-01
5807,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2014-10-16,356,C,0,1,T8L111,"Based on facility record review, observation, and staff interview, the facility failed to ensure the nurse staffing data posted on a daily basis included the resident census as required by all nursing facilities certified for participation in Medicare and/or Medicaid. This had a potential to affect all residents. Facility census 111. Findings include: a) An observation during the general tour, at 10:30 a.m. on 10/09/14, of the Nurse Staffing information posting revealed the resident census was not included in the posting. On 10/14/14, a sample of postings (10/09/14 - 10/14/14) was provided by the Director of Nursing. Those postings also lacked the resident census, and there was no identified area for recording it. Those findings were reviewed with the Director of Nurses and the Assistant Director of Nurses at 8:30 a.m. on 10/16/14. The Director of Nurses said she had not been aware this was required, but they would make the changes to be in compliance.",2018-07-01
5821,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2014-10-21,356,C,0,1,VUH711,"Based on observation and staff interview, the facility to failed to post the nurse staffing in a prominent place for visitors and residents to view. This had the potential to affect all residents and/or their responsible parties/visitors. Facility census: 115. Findings include: a) On 10/13/14 at 11:00 a.m., an observation of the nurse staff posting revealed it was not located in a place that was visible and accessible to residents/visitors. The nurse staffing was posted on the wall at the nurses' station on the B unit (located at the back of the building). b) On 10/13/14 at 11:20 a.m., the Director of Nursing agreed the posting was not accessible to all residents/visitors.",2018-07-01
5879,HILLCREST HEALTH CARE CENTER,515117,462 KENMORE DRIVE,DANVILLE,WV,25053,2015-07-16,356,C,1,0,CEYQ11,"Based on record review and staff interview, the facility failed to ensure the nurse staff posting was in a clear and readable format. The posting on several occasions had multiple numbers haphazardly written on the form which made the posting unclear. In addition, the facility failed to maintain the posted daily nurse staffing for a minimum of 18 months. This practice had the potential to affect all residents and/or visitors currently residing in and/or visiting the building. Facility Census: 86. Findings Include: a) The facility's nurse staff postings for 06/16/15 through 9:30 a.m. on 07/13/15 were reviewed. The total number of nursing staff working and their total number of hours were unclear to the reader on seven (7) days. Some numbers had plus signs written in front of them, others did not. Boxes contained more than one (1) number. There were numbers which were circled and numbers which had lines drawn through them. The form contained no information for use to interpret the actual number of nursing staff present and/or the actual number of hours worked. 1. 06/16/15 The box containing the total number of Registered Nurses (RNs) working on the 7:00 a.m. to 3:00 p.m. shift contained numbers written haphazardly in the box: +1, 1, and +5. Additionally, scribbled out and illegible writing was in the upper right corner of the box. The box titled Hours Worked, for the RNs on the 7:00 a.m. to 3:00 p.m. shift, contained numbers written in a haphazard fashion: 10, +10, 7.5, and +40. 2. 06/17/15 The box containing the total number of RNs working on the 7:00 a.m. to 3:00 p.m. shift contained numbers written haphazardly in the box: +1, 1, 1 with a circle drawn around it, +3, and +2. The box titled Hours Worked, for the RNs who worked the 7:00 a.m. to 3:00 p.m. shift, contained numbers written in a haphazard fashion: 8 with a diagonal line through it, 7.5 with a circle drawn around it,16 hrs (hours), +10, and +24. In the box for the number of Licensed Practical Nurses (LPNs) for the 7:00 a.m. to 3:00 p.m. shift, the numbers 3 and +2 were written. In the total number of hours worked box for LPNs, the numbers written were a 30 with a diagonal line through it, +16 hrs, 23, and 22.5 with a straight line drawn through it. 3. 06/24/15 The box containing the total number of RN's working on the 7:00 a.m. to 3:00 p.m. shift contained numbers written haphazardly in the box: 2, +1, and +3. The box for hours worked, for RNs who worked the 7:00 a.m. to 3:00 p.m. shift, contained numbers written in a haphazard fashion: 16 with a diagonal line through it, 13.8, +24, and +10. 4. 06/25/15 The box containing the total number of LPNs working on the 7:00 a.m. to 3:00 p.m. shift contained numbers written haphazardly in the box: 3, 2 with a diagonal line drawn through it, +2, and +1. The box for hours worked, for LPNs who worked the 7:00 a.m. to 3:00 p.m. shift, contained numbers written in a haphazard fashion: 22.5, 16, +16 (with a single diagonal line drawn through the 16 and +16), and +10 with a diagonal line drawn through it. 5. 07/02/15 The box containing the total number of LPNs working on the 7:00 a.m. to 3:00 p.m. shift contained numbers written haphazardly in the box: 3, +2, and +1. The box for hours worked, for the LPNs who worked the 7:00 a.m. to 3:00 p.m. shift, contained numbers written in a haphazard fashion: 24, +16, and 10 hrs. 6. 07/08/15 The box containing the total number of LPNs working on the 7:00 a.m. to 3:00 p.m. shift contained numbers written haphazardly in the box: 2, +1, and +2. The box for hours worked, for the LPNs who worked the 7:00 a.m. to 3:00 p.m. shift, contained numbers written in a haphazard fashion: 16, 10, and +16. 7. 07/11/15 The box containing the total number of RNs working on the 7:00 a.m. to 3:00 p.m. shift contained numbers written haphazardly in the box: 1, +5, and +1. The box for hours worked, for the RNs who worked the 7:00 a.m. to 3:00 p.m. shift, contained numbers written in a haphazard fashion: 8, 10, and +4. b) The confusion caused by all the numbers haphazardly written on the staff postings was discussed with the Nursing Home Administrator (NHA) at 11:30 a.m. on 07/15/15. He indicated he had written some of the numbers on the postings while he was computing the staffing numbers for each day for the last full pay period of 06/16/15 to 06/30/15. He stated the other dates had the numbers written on them while posted in the facility. He confirmed, for the dates of 06/16/15 through 06/30/15 he wrote on the original staff posting, and had no way of knowing what was actually posted for visitors and/or residents on those days. He agreed the information should be presented in a clearer way.",2018-07-01
5890,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2014-11-04,522,C,0,1,WN6C11,"Based on facility record review and staff interview, the facility failed to comply with disclosure requirements. The facility failed to provide written notification to the State agency responsible for licensing, when a change occurred with the director of nursing (DON). This practice had the potential to affect all residents. Facility census: 60. Findings include: a) Director of nursing During an extended survey, an interview with the assistant director of nursing (ADON) on 11/03/14 at 3:30 p.m., revealed the facility had no evidence of written notification to the Office of Health and Facility Licensure and Certification, when the facility had a change in the director of nursing. A follow-up interview with the ADON, on 11/04/14 at 10:45 a.m., related she had spoken with the administrator, who confirmed the facility did not provide written notification with the identity of the individual. Additionally, during an interview with the DON, on 11/04/14 at 1:30 p.m., she confirmed the facility had not provided written notice to the State agency regarding the change of position with the director of nursing.",2018-07-01
5962,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,356,C,0,1,GK2611,"Based on observation and staff interview, the facility failed to ensure the daily staff posting was posted in a place that was visible to residents and visitors. This had the potential to affect all residents and/or their responsible parties. Facility census: 64. Findings include: a) On 08/04/14 at 3:00 p.m., an observation of the nurse staffing posting revealed it was not located in place that was visible and accessible to residents/visitors. The nurse staffing posting was in a clear plastic holder on the wall. The paper the posting was typed on was sitting sideways in the plastic holder. You could not read the posting without taking it out of the plastic holder. The plastic holder was not within reach of a resident who was in a wheelchair. b) At 3:15 p.m. on 08/04/14, the administrator said he would change the location of the daily staff posting.",2018-05-01
6024,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2014-08-14,356,C,0,1,K1XR11,"Based on observation and staff interview, the facility failed to ensure the residents and/or public were informed on a daily basis of the nurse staffing data as required by 42 CFR 483.30(e). The failed to include the actual hours worked by the direct care staff and failed to use a print size that enabled easy reading of the posting. This had the potential to affect all residents and/or the public. Facility census: 94 Findings include: a) At 1:30 p.m. on 05/15/14, Review of the POS [REDACTED]. The form in use did not require inclusion of the hours worked for registered nurses), licensed practical nurses, and nurse aides. The missing actual hours worked and the size of the wording on the posting making it very difficult to read, were pointed out to the Administrator and the Director of Nurses at 3:00 p.m. on 08/06/14. The Director of Nurses stated he would have this corrected.",2018-05-01
6066,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2015-06-12,167,C,1,0,J3JQ11,"Based on observation, review of the State Operations Manual (SOM), and staff interview, the facility failed to ensure a notice of the results of the most recent survey, and any plans of correction, were in a place readily accessible to residents. The facility notice of survey results was posted at level that residents in a wheelchair could not read. In addition, a request had to be made to review the results with instructions to see the Administrator. This practice had the potential to affect all residents/responsible parties/public. Facility census: 67. Findings include: a) A random observation revealed, on 06/10/12 at 11:42 a.m., a sign posted in the entrance hallway which read This center has reports of surveys, certifications and complaint investigations for the preceding three years available for any individual to review upon request. Please see the administrator to inquire. Per the Social Security Act at 42 U.S.C. (United States Code) 139r. A review of the SOM, on 06/10/15 at 12:15 a.m., revealed A resident has the right to examine the results of the most recent survey of the facility In the guidance to surveyors the SOM states the results of the most recent survey means the Statement of Deficiencies (2567) and the Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys, and any deficiencies resulting from any subsequent complaint investigation(s). In addition, the guidance states . and are available to residents without having to ask a staff person . where individuals wishing to examine survey results do not have to ask to see them. On 06/10/15 at 2:10 p.m., in an interview with the administrator and the director of nursing, both agreed the sign was posted too high for residents in a wheelchair to see and/or read. Both also agreed the survey results should be available to any one interested in reviewing the survey results without having to ask staff.",2018-05-01
6067,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2015-06-12,356,C,1,0,J3JQ11,"Based on a review of daily nurse staffing postings and staff interviews, the facility failed to post complete information regarding the current date and the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. This practice had the potential to affect all residents residing in the facility. Facility census: 67. Findings include: a) On 06/10/15 at 10:30 a.m., review of daily nurse staffing sheets from 05/01/15 until 06/08/15 revealed the following: - On May 1 there was no information completed for the 7/3 shift. - On May 4 there was no information completed for the 7/3 or 3/11 shift. - On May 9 and 10, there was no information completed for the 3/11 shift. - On May 11, there was no information completed for the 7/3 or 3/11 shift. - On May 13, there was no information completed for the 3/11 shift and no indication of the total number of staff working on the 11/7 shift. - On May 15, there was no information completed for the 7/3 shift. - On May 19, there was no information completed for the 3/11 or 11/7 shifts. - On May 20, there was no information completed for the 7/3 shift. - On May 22, there was no information completed for the 7/3 or 3/11 shifts. - On May 26. there was no information completed for the 3/11 shift or the total number of staff for the 11/7 shift. - On May 27, there was no information completed for the 7/3 or 3/11 shifts. - On May 28, there was no information completed for the 3/11 shift. - On June 6, 7, and 8 there was no 3/11 shift information. On 06/10/15 at 2:00 p.m., in an interview with the director of nursing (DON), she agreed there was a problem with the daily nursing staffing posted being completed as required. She stated she had only been in the facility a few weeks and had been working on a plan to put in place to correct the problem with the daily nurse staffing postings, but had not been able to implement the plan. She stated the problem would be corrected.",2018-05-01
6099,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,503,C,0,1,ZW4411,"Based on contract review and staff interview, the facility failed to maintain an agreement to obtain laboratory services from a laboratory that meets the applicable requirements. This practice has to potential to affect all residents. Facility census: 100. Findings include: a) On 01/23/14, during a review of contracts the facility had with outside agencies, a contract between a laboratory company and the facility was found. A former administrator had signed the contract, but it was not dated. The laboratory company portion had no signature. In an interview with the Administrator, on 01/23/14 at 10:00 a.m., she verified the facility still used that laboratory for services. She stated she did not have a signed and dated contract between the facility and the laboratory company.",2018-05-01
6181,MILETREE CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2014-09-23,353,C,0,1,577211,"Based on staff interview and a review of the staffing schedule, the facility failed to ensure sufficient qualified nursing staff was available on a daily basis to supervise resident care. The facility did not designate a licensed nurse to serve as a charge nurse on each tour of duty. This practice had the potential to affect all residents. Facility census: 62 Findings include: a) 09/17/14 at 10:00 a.m., review of the nurse staffing schedule revealed no charge nurse designation for each shift. An interview with the director of nursing (DON), at this time, revealed there was no charge nurse designated on the nurse staffing schedule. The DON stated it was understood that if a registered nurse (RN) was scheduled, the RN was the charge nurse on the designated shift. If there were no RN scheduled for that shift, a licensed practical nurse (LPN) would assume the charge nurse duties. This decision was made based on the length of employment as to which LPN would be the charge nurse. A vague it was understood for supervision does not ensure the responsibility of supervision will be undertaken. In addition, it does not ensure each nursing assistant will be aware of to whom they need to report.",2018-05-01
6300,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2014-04-15,492,C,0,1,ZU6S11,"Based on staff interview, facility record review, and interview with personnel from the local county health department, the facility failed to operate in compliance with state and local laws, regulations, and codes that apply to professionals providing services. The facility failed to ensure a dietary aide had a food handler's card. The county in which the facility was located required food handler's cards for food service personnel. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 105 Findings include: a) During a review of food handler's cards, on 04/08/14 at 3:30 p.m., no evidence of a card was present for Employee #176, a dietary aide. The food service director was interviewed at 3:45 p.m. She verified the dietary aide did not have a food handler's card. She said the employee had only worked about a month. An inquiry with the local county health department, on 04/09/14 at 8:00 a.m., confirmed a food handler's card was required for food service personnel in the county. Another interview with Employee #181, on 04/09/14 at 9:00 a.m., again confirmed the facility had not complied with the state and local laws requiring a food handler's card.",2018-04-01
6315,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2015-04-28,356,C,1,0,J5M711,"Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date, the total number and actual hours worked by registered nurses, licensed nurses, certified nurse aides per shift, and the current resident census. This had the potential to affect all residents and/or visitors residing or visiting the facility. Facility census: 86. Findings include: a) Observation of the staff posting, during the initial tour of the facility, at 11:25 a.m. on 04/22/15, found the facility staff posting was dated 04/21/15. An interview with the director of nursing, at 11:30 a.m. on 04/22/15, confirmed the facility had not displayed the staff posting information for 04/22/15.",2018-04-01
6358,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,167,C,0,1,OMIN11,". Based on observations, resident interview, and staff interview, the facility failed to post a sign informing residents of where the most recent State and Federal survey results were located. This practice had the potential to affect all residents who resided in the facility. Facility Census: 61. Findings include: a) On 05/21/14 at 4:30 p.m., Resident #3 was interviewed. Resident #3 was asked, Without having to ask, are the results of the state inspection available to read? Resident #3 replied, I guess they are. She was asked if she knew were the results were located, and she stated, I don't know. b) At 10:30 a.m. on 05/28/14, Resident #24 was asked, Without having to ask, are the results of the state inspection available to read? She replied, Well I guess they are. I have never asked. She was asked if she knew were the results were located and she replied, I don't know where they are located. c) Observation of the survey results was made on 05/23/14 at 1:00 p.m. The binder containing the survey results was positioned between the nurses' station and the dining room. They were hanging on a chain from the bulletin board. At this time, observations of the main lobby and other locations where additional resident information was posted, found no posted notice of the availability of the survey results. d) Employee #70, the administrator, was interviewed on 05/29/14 at 2:15 p.m. regarding the survey results. He stated the survey results were posted on the board beside the nursing station. He confirmed there were no notices posted in the facility about the availability of the survey results. He stated new admissions were given the information upon admission, but there were no notices posted.",2018-04-01
6395,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,334,C,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to develop and/or implement policies and procedures which ensured residents were educated on the risks of refusing influenza and/or pneumococcal immunizations. The facility also failed to ensure the reason for not receiving either immunization, whether due to contraindication or refusal, was documented in each resident's medical record. In addition, the facility failed to ensure Resident #40 was offered the pneumococcal vaccine after a refusal several years ago. This practice affected two (2) of five (5) residents reviewed; however, it had the potential to affect more than a limited number of residents. Resident identifiers: #40 and #95. Facility census: 77. Findings include: a) Review of the facility's policies for influenza and pneumococcal immunizations revealed the facility's policies did not specify educating residents/legal representatives on the risk of refusing the vaccines. The policy did state that the resident's medical record must include, at a minimum, the following: 1. Documentation that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of the influenza and/or pneumococcal immunizations; and 2. Documentation that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. b) The facility's influenza policy did not indicate the resident had the right to refuse the immunization, or that this refusal must be documented as described. c) Employee #5, the infection control nurse verified, at 4:00 p.m. on 06/26/14, the facility's policy did not include educating residents on the risk of refusing influenza and pneumococcal vaccines, or the need to document this information. d) When the director of nursing (DON) was asked what information was provided residents and families regarding the influenza vaccine, on 06/24/14 at 10:45 a.m., she provided a general information sheet. It was an excerpt from the Centers for Disease Control (CDC) titled: What You Need to Know. The DON was unable to provide evidence this sheet, or any other information, was provided each resident and/or family. e) Resident #40 review of the resident's medical record revealed [REDACTED]. As of 06/26/14 there was no evidence the resident was ever offered the pneumococcal immunization after the refusal on 04/23/10. In addition, there was no documented evidence the benefits and potential side effects of the vaccine were discussed with the resident. Upon inquiry, Employee #5, the infection control nurse, reported at 4:00 p.m. on 06/24/14, she was unable to find evidence the resident was again offered the pneumococcal immunization. f) Resident #95 review of the resident's medical record revealed [REDACTED]. There was no documented evidence the risks and benefits of the refusal were explained to the resident and/or responsible party. At 4:00 p.m. on 06/25/14, the infection control nurse confirmed there was no evidence the resident was provided the required education regarding the benefits and risks of the immunizations.",2018-04-01
6396,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,356,C,0,1,35BV11,". Based on observation and staff interview, the facility failed to ensure the daily staff posting was posted on a daily basis at the beginning of each shift. This had the potential to affect all residents, their families, and/or visitors. Facility census: 77. Findings include: a) On 06/17/14, at 4:00 p.m., observation revealed the facility staff posting was the posting information for 06/16/14, and not for 06/17/14 as required. At that time, this was brought to the attention of Employee #5 (registered nurse). She said she would have staff correct the issue.",2018-04-01
6403,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,493,C,0,1,35BV11,"Based on record review and staff interview, the governing body failed to establish policies which reflected current regulations. The admission contract contained two (2) clauses which were in direct conflict with Federal and State regulations. This had the potential to affect all residents. Facility census: 77 Findings include: a) Review of the facility's admission contract, on 06/24/14, revealed it contained clauses which were in conflict with regulation and/or the facility's actual practices. During an interview with Employee #63 (social worker) on 06/24/14 at 2:00 p.m., she confirmed this admission contract was used for all new residents. The inaccurate information included: 1. The contract stated Residents' personal laundry is not covered in the basic room charge. Should the facility be requested to do the laundry, the expense must be paid by the resident. Basic personal laundry is a covered service for Medicare/Medicaid eligible residents. An interview with the administrator, at 2:00 p.m. on 06/24/14 revealed the facility does not charge for personal laundry. She stated this clause needed removed from the contract. 2. The contract also stated if a physician ordered a special nurse or nurse aide to sit with the resident, the resident was responsible for the cost incurred. Residents eligible for Medicare/Medicaid services may not be charged for items and services that are not requested by the resident or representative. Any item or service ordered by a physician. The item or service ordered by the physician should fit in with the resident's care plan. At 3:00 p.m. on 06/24/14, the administrator said the facility had never charged a resident for physician ordered nursing services. She said the clause would be removed.",2018-04-01
6432,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,356,C,1,0,S2LQ11,"Based on observation and staff interview, the facility failed to post nurse staffing data in a clear and readable format and in a prominent place that was readily accessible to residents and visitors. This had the potential to affect all residents currently residing in the facility. Facility Census: 58. Findings Include: a) At 9:15 a.m. on 03/05/15, the Executive Director was asked where the nurse staff posting was located. She indicated she did not know, and indicated nursing staff would know. The Director of Nursing (DON) was asked where the nurse staff posting could be located at 9:20 a.m. on 03/05/15. She stated it should be posted outside of the nurses' station. At 9:25 a.m. on 03/05/15, the assistant Director of Nursing (ADON) and the Executive Director verified there was not a nurse staff posting anywhere on the health care unit.",2018-03-01
6448,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2015-03-31,497,C,1,0,O4DK11,"Based on personnel record review and staff interview, the facility failed to ensure one (1) of five (5) employees reviewed had a performance review at least once every 12 months. Nurse Aide #55 did not have a performance review for the year 2014. Employee Identifier: #55. Facility Census: 156. Findings Include: a) Nurse Aide #55 A review of Nurse Aide (NA) #55's personnel record, at 1:00 p.m. on 03/31/15, revealed a performance review dated 11/17/13. A performance review for the year 2014 could not be located in NA #55's personnel file. An interview with Nursing Home Administrator, at 3:30 p.m. on 03/31/15, confirmed NA #55 did not receive a performance review in the last 12 months.",2018-03-01
6449,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2015-03-31,498,C,1,0,O4DK11,"Based on personnel record review and staff interview, the facility failed to ensure three (3) of five (5) nurse aides reviewed were able to demonstrate competency in skills and techniques necessary for the care of all residents residing in the facility. Nurse Aides (NA) #55, #116, and #105 had not had their competency in skills and techniques necessary to care for residents evaluated in the previous twelve (12) months. Employee Identifiers: #55, #116, and #105. Facility Census: 156. Findings Include: a) Nurse Aide #55 A review of Nurse Aide (NA) #55's personnel file, at 1:00 p.m. on 03/31/15, found no evidence the facility had evaluated her competency in skills and techniques necessary to care for residents' needs within the last 12 months. b) Nurse Aide #116 A review of NA #116's personnel file, at 1:15 p.m. on 03/31/15, found no evidence the facility had evaluated his competency in skills and techniques necessary to care for residents' needs within the last 12 months. c) Nurse Aide #105 A review of NA #105's personnel file, at 1:25 p.m. on 03/31/15, found no evidence the facility had evaluated her competency in skills and techniques necessary to care for residents' needs within the last 12 months. d) An interview with the Nursing Home Administrator, at 3:30 p.m. on 03/31/15, confirmed NAs #55, #116, and #105 had not had their competency in skills and techniques evaluated within the last 12 months. He indicated the evaluation of their competency in skill and techniques needed to care for residents was combined with their performance evaluations. He stated that since NA #55 did not have her yearly performance review in 2014, she did not have her competency in skills and techniques necessary for resident care evaluated. He stated for NA #116 and NA #105, the wrong form was used to complete their performance reviews, so their competency to perform skills and techniques necessary for resident care were not evaluated.",2018-03-01
6494,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,167,C,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to make the results of the most recent survey of the facility by Federal or State surveyors, and any plan of correction in effect, available for examination. The facility also failed to post a notice of the availability of the survey results in a readily accessible place. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 123. Findings include: a) Upon initial entrance to the facility on [DATE] at 9:45 a.m., the binder containing the survey results and/or notice could not be located. Employee #42, the director of nursing (DON) was approached about the inability of the surveyor to locate the survey results and/or the notice as to the location of the survey results. The DON said the results were in a black binder located in the bookcase in the front lobby. The binder had a small white label noting Survey. When asked where the notice indicating the location of the survey results could be located, the DON found the notice was obscured in a corner of the bookcase in the front lobby.",2018-03-01
6510,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,356,C,0,1,3WT411,"Based on facility record review, observations, and staff interview, the facility failed to post nurse staffing data that accurately reflected the staffing numbers for the night shift, which began at 11:00 p.m. on 06/16/14 and ended at 7:00 a.m. on 06/17/14. This posting inaccurately reflected the number of nurse aides working that shift. This had the potential to affect all residents and/or visitors residing and/or visiting the facility. Facility Census: 123. Findings Includes: a) At 11:30 p.m. on 06/16/14, the Daily Nurse Staffing Form was observed posted at the North hall nurses' station. The form was completed with the name of the facility and date and reflected the total census was 125 residents. Under the section titled Night Shift (11:00 p.m. to 7:00 a.m.), the form indicated there were nine (9) nurse aides currently working on night shift at the facility. The nurse aide assignment sheets for the north, south, and the Transitional Care Unit (TCU) units were reviewed. A total of eight (8) nurse aides were identified with resident assignments for the night shift beginning at 11:00 p.m. on 06/16/14. Registered Nurse (RN) #125 was interviewed at 11:39 p.m. on 06/16/14. When asked how many nurse aides were currently working in the facility, she replied, There are eight (8) nurse aides currently working. She was then asked to review the Daily Nurse Staffing Form for accuracy. She reviewed the form and reported it was not accurate, because there were only eight (8) nurse aides working the night shift, and the form indicated there were nine (9) nurse aides working. The Director of Nursing (DON), was interviewed at 12:15 a.m. on 06/17/14. She reviewed the nursing schedule, the nurse aide assignment sheets for night shift, and the nurse staff posting. She stated it appeared someone had marked one (1) aide off the schedule, leaving only eight (8) nurse aides for the night shift. She indicated the posting was inaccurate because there were eight (8) aides working and the posting indicated there were nine (9) aides working the night shift.",2018-03-01
6522,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2015-02-23,356,C,1,0,BOMW11,"Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date, the total number and actual hours worked by registered nurses, licensed nurses, certified nurse aides per shift, and the current resident census. This had the potential to affect all residents and/or visitors residing or visiting the facility. Facility census: 81. Findings include: a) Observation of the staff posting during the initial tour of the facility, at 1:00 p.m. on 02/18/15, found the facility staff posting was dated 02/17/15. An interview with Employee #17, the staff development coordinator, at 1:10 p.m. on 02/18/15, confirmed the facility had not posted the staffing information for 02/18/15.",2018-02-01
6548,MAIN STREET CARE,5.1e+155,"189 SUMMERS HOSPITAL ROAD, SUITE 300",HINTON,WV,25951,2013-10-18,492,C,0,1,XUI411,"Based on record review and staff interview, the facility failed to inform ten (10) of ten (10) employees whose personal files were reviewed, about the Central Abuse Registry as required by West Virginia code 15-2c-8. Employee Identifiers: #31, #21, #14, #5, #7, #24, #28, #29, #12, and #23. Facility Census: 25. Findings Include: a) Employees #31, #21, #14, #5, #7, #24, #28, #29, #12, and #23 On 10/16/13 at 2:00 p.m., the personnel files for these employees were reviewed. None of these personnel files contained a Central Abuse Registry notice, as required by West Virginia Code 15-2c-8, which states the following: ?15-2C-8. Service provider responsibilities.All residential care facilities, day care centers, providers to adults with behavioral health needs and home care service providers authorized to operate in West Virginia shall: (1) Provide notice to current employees of the agency and other persons providing services under a contract with the agency within sixty days of the effective date of this article, and provide notice to any newly hired employee or person at the time an employment or contractual relationship is entered into, which notice shall be in the following form: 'NOTICE: All service providers in the state of West Virginia are subject to provisions of law creating a central abuse registry. Any person providing services for compensation to children or to incapacitated adults or to adults receiving behavioral health services, who is convicted of a misdemeanor or felony offense constituting abuse, neglect or misappropriation of property of a child or an incapacitated adult or an adult receiving behavioral health services, is subject to listing on the central abuse registry. The fact that a person is listed on the registry may be disclosed in specific instances provided by law. Listing on the registry may limit future employment opportunities, including opportunities for employment with residential care facilities, day care centers and home care agencies. It is the policy of (name of agency) to promptly report all suspected instances of abuse, neglect or misappropriation of property to the proper authorities and to cooperate fully in the prosecution of these offenses.''' The Director of Nursing (DON) was interviewed at 2:22 p.m. on 10/16/13. She confirmed the ten (10) personnel files reviewed did not contain a Central Abuse Registry notice. She stated they had not done this with their employees because they were not aware of this requirement.",2018-02-01
6675,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2014-10-01,167,C,0,1,KBHF11,"Based on staff interview, and observation, the facility failed to ensure that survey results were readily accessible to residents. Survey results were posted too high for residents and/or visitors in wheelchairs to access readily. This had the potential to affect all residents and visitors using a wheelchair. Facility census: 87. Findings include: During an interview on 09/24/14 at 2:00 p.m., Resident #10 stated he did not know where the State inspection results were located. The resident was observed sitting in a wheelchair at the time of the interview. On 09/24/14 at 5:00 p.m., the resident was observed propelling his wheelchair in the hallway. During a tour of the facility on 09/30/14 at 1:50 p.m., the following was observed: -- On the first floor A and B hallways and on the second floor A and B hallways, the State inspection report was contained in a plastic sleeve which was attached to a bulletin board. -- The state inspection report was approximately 5 feet from the floor. -- Residents and visitors using a wheelchair would not be able to access the State inspection report without having to ask for staff assistance. The aforementioned observations were verified at the time of discovery by Activities Supervisor #136.",2017-12-01
6750,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2014-07-15,167,C,0,1,Q9U911,"Based on observation, resident interview, staff interviews, and documentation review, the facility failed to make available for examination the most recent standard survey results. This had the potential to affect all 36 residents at the facility. Facility census: 36. Findings include: a) During an interview on 07/08/14 at 10:25 a.m., the resident council president, Resident #2, stated she did not know where the results of the most recent survey were located. She said, I have never seen them. b) The monthly minutes, from the resident council meetings, were reviewed from January 2014 to June 2014. The minutes contained no evidence residents were informed of the location or availability of the most recent survey results. c) Observation at 10:25 a.m. on 07/08/14 found a sign, posted on the bulletin board across from the nurses' station, indicating the survey results were available at the nurses' station. d) On 07/08/14 at 10:30 a.m., the assistant activity director, Employee #40, was unable to locate the survey results at the nurses' station. e) At 10:35 a.m. on 07/08/14 a registered nurse, Employee #62, stated she thought the survey results were located in the blue room. Observation found a notebook located in the blue room, entitled survey results. Further observation of the found the facility's most recent survey, dated 01/31/13, was not in the notebook. Employee #62 stated she would call the administrator to see if she know where the survey results were located. f) At 10:51 a.m. on 07/08/14 the administrator confirmed the most recent survey results were not available for examination. The administrator placed a copy of the survey results from the survey dated 01/31/13 in the notebook.",2017-11-01
6751,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2014-07-15,170,C,0,1,Q9U911,"Based on resident interview and staff interviews, the facility failed to ensure residents received mail delivery on Saturdays when regular mail delivery was scheduled and available through the postal service. This had the potential to affect all thirty - six (36) residents residing at the facility. Facility census: 36. Findings include: a) During a resident interview on 07/08/14 at 10:10 a.m., Resident #2 stated the residents did not receive mail on Saturdays. b) Employee #40, the activity assistant was interviewed at 10:19 a.m. on 07/08/14 regarding mail delivery at the facility. She stated, The mail truck does not run on Saturdays because the clinic downstairs is closed. c) At 10:55 a.m. on 07/08/14 the administrator stated the facility did not have anyone working downstairs on Saturdays so the mail was not delivered. She confirmed mail could be available to residents on Saturdays.",2017-11-01
6962,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,514,C,0,1,WVZU11,"Based on record review and staff interview, the facility failed to ensure the accuracy of the medical record by recording that weights were measured on a certain date when, in fact, there was no evidence of the exact date the resident was weighed. This was true for all thirty-two (32) residents in the Stage 1 sample. Resident identifiers: #1, #3, #5, #7, #10, #12, #14, #18, #20, #21, #23, #24, #25, #27, #28, #31, #34, #35, #38, #39, #40, #41, #42, #43, #48, #49, #53, #59, #63, #64, #65, and #66. Facility census: 59. Findings include: a) Residents #1, #3, #5, #7, #10, #12, #14, #18, #20, #21, #23, #24, #25, #27, #28, #31, #34, #35, #38, #39, #40, #41, #42, #43, #48, #49, #53, #59, #63, #64, #65, and #66. While reviewing the medical record for required resident weights, at 10:00 a.m. on 06/18/13, it was revealed that the weight books located at the nurses' station contained only the month and year, although when the medical record was accessed, an exact date was entered for the weights. The nurse on duty (Employee #125) was interviewed at 10:30 a.m. on 06/18/13. She verified that when the residents were weighed by the aides, the weights were documented in the weight book and that only the month and year were entered. She stated that all weights are done on the 1st of the month. When she was shown on the computer that there were different days indicated on different residents, she was surprised and had no answer. During an interview with Employee #162 (aide) at 10:50 a.m. on 06/18/13, she stated that residents were weighed between the 1st and the 5th of each month and verified they are not required to enter the day of the month when they record the weight. When interviewed at 9:00 a.m. on 06/20/13, the Director of Nurses (Employee #178) stated that weights were supposed to be taken during the last week of each month. After reviewing both the Weight Book and the computer record, she admitted that there was no way to tell which day the weight was taken. She had no explanation for the source of the entry date used in the computer record. In an interview with Employee #192 (dietitian) at 9:30 a.m. on 06/20/13, she affirmed that the date was important in calculating the percentage of weight gain or loss for each resident.",2017-09-01
7063,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,492,C,0,1,GJXP11,"Based on staff interviews, the facility failed to ensure their compliance with State regulations and codes which require a full-time dietary manager when the facility does not employee a full-time licensed dietitian. This had the potential to affect all residents. Facility census 61. Findings include: a) During the entrance interview with the Administrator, at 2:00 p.m. on 09/09/13, she stated the facility did not have a Certified Dietary Manager (CDM) at the present time. She stated the contracted licensed dietitian was present 1 - 2 times weekly (Tuesdays and Thursdays) and a regional corporate consultant also visited on a weekly basis. The administrator said the facility had hired a chef who had not yet started to work at the facility. This individual would be qualified to sit for the certification test when it is offered in 2014. When interviewed at 10:30 a.m. on 09/11/13, Employee #85, the contracted dietitian, verified she was at the facility weekly. She stated she could be contacted as needed. During an interview with Employee #86, a regional consultant, at 2:00 p.m. on 09/12/13, she stated she was assisting with managerial duties until a new CDM was hired.",2017-09-01
7094,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2013-09-26,156,C,0,1,1ZMG11,"Based on observation, staff interview, and resident interview, the facility failed to ensure residents were informed both orally and in writing, and in a language the resident understands, of his or her rights during the stay in the facility. The facility did not post the address for the State survey agency. This agency serves as the entity to which residents can make formal complaints about the care they are receiving. This practice had the potential to affect all residents and/or their responsible parties. Facility census: 118. Findings include: a) On 09/16/13 at 4:00 p.m., the resident council president (Resident #61) said she did not know where the posting was that had the name, address, and telephone number of the State survey agency. This agency is responsible for receiving complaints from residents regarding their care in nursing homes. At 4:30 p.m. on 09/16/13, an observation of the posting revealed the name and telephone number of the State survey and certification agency was posted; however, the posting did not contain the address for this agency. On 09/17/13 at 10:55 a.m., during an interview, the administrator (Employee #66) said he said he would update the postings so they contained this information.",2017-08-01
7096,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2013-09-26,167,C,0,1,1ZMG11,"Based on observation, staff interview, and resident interview, the facility failed to ensure residents had the right to examine the results of the most recent standard survey. The facility had not posted a copy of the results from the most recent standard survey. This practice had the potential to affect all residents and/or their responsible parties. Facility census: 118. Findings include: a) On 09/16/13 at 4:00 p.m., the resident council president (Resident #61) indicated she did not know where the facility kept the survey results. At 4:30 p.m. on 09/16/13, observation revealed the facility did not have the results of the most recent standard survey in the binder labeled survey results. The administrator (Employee #66), was interviewed on 09/16/13. He confirmed the survey results were not in the binder, and indicated he would copy the results and place them in the binder.",2017-08-01
7117,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2013-09-25,249,C,0,1,K4W611,"Based on staff interview, the facility failed to ensure the facility's activities program was directed by a qualified professional. The person currently holding the position of activities director was not licensed, registered, or eligible for certification as an activities professional. This had the potential to affect all resident's residing in the facility. Facility Census: 76. Findings include: a) On 09/25/13 at 9:28 a.m., the nursing home administrator (NHA) provided copies of the licenses/certifications of various staff. At that time, he stated the current activity director (Employee #3) was not certified. He reported she was in the process of being certified, but had not yet taken the class. The NHA said the individual was scheduled to take the class in October of 2013. He confirmed Employee #3 had been in the position for about thirty (30) days. The NHA stated the activities director position was vacant from 06/21/13 until Employee #3 had taken the position. He reported from 06/21/13, until Employee #3 was hired, the facility had activity directors filling in from other facilities. He reported since Employee #3 was hired, she had been directing the program even though she was not certified.",2017-08-01
7138,CLARKSBURG NURSING AND REHABILITATION CENTER,515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2014-08-22,356,C,1,0,JDMM11,"Based on staff interview and review of daily nursing staffing postings, the facility failed to accurately post only the nursing staff directly responsible for resident care per shift. A review of the facility Required Staffing Posting form revealed the facility included nursing administrative staff and licensed practical nurses (LPNs) working in medical records, as staff providing direct resident care. This regulation states to report only staff providing direct care to residents. This practice had the potential to affect all residents residing in the facility and/or visitors. Facility census: 94. Finding include: a) On 08/20/14 at 10:30 a.m., a review of the daily staff postings and the facility monthly staffing worksheet, revealed a discrepancy in the number of registered nurses (RNs) and LPN's who provided direct resident care. The following discrepancies were noted for the month of August 2014: Required Staff Posting Monthly Staffing Worksheet 08/01/14 RN - 6 RN - 3 08/04/14 RN - 6 RN - 3 08/05/14 RN - 5 RN - 2 08/06/14 RN - 4 RN - 2 08/07/14 RN - 4 RN - 2 These same discrepancies continued through the month of August and were consistent with the same findings in June and July 2014. In a interview with the Person in Charge (PIC), on 08/20/14 at 4:34 p.m., regarding the posting discrepancies, the PIC stated the daily staff postings included any registered nurse (RN) or licensed practical nurse (LPN) who was working and would be available to provide direct care in the event of an emergency. These nurses included administrative nurses, as well as two (2) LPNs who worked in medical records. She stated she had been told by a surveyor the facility should count any staff available to help in an emergency. After an explaining the regulation regarding the posting including only staff who were providing direct care, the PIC agreed the required staffing posting was probably not completed correctly.",2017-08-01
7278,MANSFIELD PLACE,515129,95 HEALTHCARE DRIVE,PHILIPPI,WV,26416,2013-08-27,226,C,0,1,Q4TH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review and staff interview, the facility failed to develop and implement a written policy and procedure which prohibited the mistreatment, abuse, and neglect of the residents of the facility. The facility's policy regarding injuries occurring as a result of staff defending themselves when residents were combative was conflicting. The policy indicated in one place, an injury sustained by a resident as a result of a staff member defending his/herself would be considered abuse. In another part of the policy, this same type of incident would not be considered abuse. Also, the policy was not revised when electronic submission of reports to the Office of Health Facility and Certification (OHFLAC) was suspended. This had the potential to affect all residents currently residing in the facility. Facility Census: 55. Findings Include: a) Policy Review 1) The facility's policy and procedure titled, Abuse Prevention, Reporting, and Investigation, was reviewed at 9:08 a.m. on 08/21/13. The policy's effective date was 06/01/11, with revisions on 11/13/08 and 02/24/12. The facility's Abuse Prevention, Reporting and Investigation policy contained a paragraph which indicated if a resident sustained [REDACTED]. The policy contained the following statements under the section titled: Identification of Abuse (sub section) Physical Abuse. -- Acts of physical retaliation, even in response to a physical attack, constitute abuse This section also contained the following, Note: Accidental injury due to self-defense or to prevent injury to another resident would not normally be considered abuse. An example would be a skin tear incurred when an assistant grabbed a resident's wrist to prevent the resident from striking the assistant or another resident. Employee #98, Social Worker, was interviewed at 12:47 p.m. on 08/21/13. She reported this was not correct. She reported if a nursing assistant injured a resident while acting in self-defense to protect themselves it would be considered physical abuse. She reported the note should not contain the word assistant and the policy needed revised to accurately reflect what is considered physical abuse. 2) Further review of the policy revealed the following step contained in the section titled, Steps to follow if there is alleged abuse: -- d. Complete the appropriate form and forward to OHFLAC: 1. Complete the Nursing Home Program form via internet at https://www.wvdhhr.org/ohflac/secure this is for anyone who is not a Certified Nursing Assistant (C.N.A.) This reporting option is no longer available. At this time, allegations cannot be reported via the internet. Employee #98, Social Worker confirmed during an interview at 12:47 p.m. on 08/21/13, the facility no longer used this method of reporting allegations to OHFLAC. She reported the policy needed updated to reflect the way they currently reported allegations to OHFLAC.",2017-06-01
7359,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-07-22,167,C,0,1,MT7G11,"Based on random observation and staff interview, the facility failed to post a notice of the availability of the most recent survey results. In addition, the location of the survey results was not in a place in which individuals wishing to examine them could do so without having to ask for them. This practice had the potential to affect all residents. Facility census: 104. Findings include: a) Observation on 07/18/13 found no evidence of the facility's most recent survey results. There was no evidence of any posting that would alert residents and/or visitors as to the location of the survey results. On 07/18/13 at 2:45 p.m., the receptionist produced, when asked, a black, three-ring binder that was housed in a box at the reception desk. There was no writing on the side of the binder that was visible when the binder was in its box, to give any indication of its contents. At this time, the administrator was unable to locate any posting to tell where the survey book was located. She said they once had a posted sign indicating where survey results could be found, but removed it last week.",2017-05-01
7558,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2013-06-13,167,C,0,1,UM2S11,"Based on observation of survey result postings and through staff interview, it was determined a notebook with past survey results was in a location not easily accessible by residents. Additionally, a notice of where the survey results were located was not posted in a manner in which the whole document could be seen. This practice had the potential to affect all residents as all residents are to have access to this information. Census: 88. Findings include: a) On 06/11/13 at 1:20 p.m., the survey book which had previous survey results was observed to be in a location not easily accessible by the residents. As you entered the front door there was a little entry way. The survey book was located in a plastic pocket on the wall of this entry way which was not noticeable and was very high up on the wall. Residents would not have easily noticed this book, nor been able to reach it from wheelchair height. In an enclosed glass case where information was posted and visible when going down the main hallway, there was a note that stated survey results were located in a notebook in the main lobby. All of this note was not visible to the reader. The part of the note stating where the results were located was blocked by the frame of the glass case and could not be seen. This was verified with the administrator, Employee #91, at the time.",2017-04-01
7559,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2013-06-13,226,C,0,1,UM2S11,"Based on policy review and staff interview, the facility failed to revise its policy for reporting allegations of abuse and neglect to the Office of Health Facility Licensure and Certification (OHFLAC). The facility faxed the abuse and neglect reports to OHFLAC, however their Abuse Prohibition Policy indicated they will file these reports electronically using the OHFLAC Facility and Nurse Aide Reporting Portal. This had the potential to affect any resident for which an allegation needed to be submitted. Facility Census: 88. Findings include: a) Policy Review The facility policy titled 1-0 WV Abuse Prohibition, was reviewed on 06/11/13. Under the heading titled Process, Section six (6) included: 6.1.1 OHFLAC Long Term Care Department of Health and Human Resources (DHHR) electronically via OHFLAC Facility and Nurse Aide Reporting Portal. Further policy review the following under section eight (8) under the heading Process of the policy. 8.1 The local OHFLAC Long Term Care Program, electronically via OHFLAC Facility and Nurse Aide Reporting Portal. 8.1.1 Select File a Five Day Follow Up Report. The facility's reportable incidents of abuse and/or neglect were reviewed on 06/11/13. This review revealed the facility was faxing all reports to OHFLAC. There was no indication they were reporting the allegations of abuse and/or neglect via the OHFLAC Facility and Nurse Aide Reporting Portal. Employee #46, Director of Nursing (DON) was interviewed at 3:34 p.m. on 06/11/13. She reports the allegations of abuse and/or neglect are faxed to OHFLAC when completed. She confirmed they do not report to OHFLAC using the portal. She stated both the immediate and five day follow up reports are always faxed to OHFLAC. She did confirm the policy stated they were to send the reports using the OHFLAC Facility and Nurse Aide Reporting Portal. She further stated she did not ever recall using this portal and the portal was not operational for very long and was surprised the policy indicated its use.",2017-04-01
7587,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,167,C,0,1,OKIC11,"Based on observation and staff interview, the facility did not ensure the residents had the opportunity to examine the results of the most recent survey of the facility conducted by the State surveyors. The facility had not posted the results of their most recent complaint investigation. This practice had the potential to affect all residents in the facility. Facility census: 60. Findings include: a) On 03/19/13 at 9:50 a.m., an observation of the facility's survey results book revealed the book did not contain the results of the most recent complaint investigation. The facility had a complaint investigation on 08/24/11 that resulted in four (4) D level deficiencies. The facility had not posted the statement of deficiencies associated with this complaint. On 03/19/13 at 10:00 a.m., the senior vice president (Employee #11) confirmed the survey results book did not contain the results of the 08/21/11 complaint investigation.",2017-03-01
7734,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2014-02-28,356,C,1,0,IEIO11,"Based on observation, review of the daily posted staffing sheets, and staff interview, the facility failed to post the total number and the actual hours worked by licensed and unlicensed nursing staff. In addition, the facility failed to maintain all of the daily staff postings for the required 18 months. This had the potential to affect all residents residing in the facility. Facility census: 33. Findings include: a) At 4:32 p.m. on 02/25/14, the daily staffing posting was noted posted above the time clock at the main entrance hallway on the unit. The daily staff posting did not contain the actual hours worked by the licensed staff for 02/25/14. On 02/26/14 at 9:30 a.m., an additional observation of the daily posted staffing sheet revealed the posting contained the number of licensed and unlicensed nursing staff, but did not contain the actual hours worked by the registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs). At 10:00 a.m. on 02/26/14, the director of nursing (DON) was asked for the daily staffing sheets from January 2014 until the current date (02/26/14). The DON stated the sheets were scanned into her computer and would need to be printed. At 10:33 a.m., the DON presented the scanned copies of the posted staffing sheets. She stated there were six (6) days missing from January 2014 through today 02/26/14. A review of the staffing sheets with the DON revealed the posting did not accurately reflect when staff members worked. The DON could not distinguish, when a staff member was scheduled to work four (4) hours on the 3/11 shift, if the staff member worked from 3:00 p.m. until 7:00 p.m. or from 7:00 p.m. until 11:00 p.m The DON agreed the hours actually worked were not on the posted daily staffing sheets.",2017-02-01
7781,GOLDEN LIVING CENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2012-06-08,252,C,0,1,5XH612,"Based on observation, resident interview, and staff interview, the facility failed to present a homelike appearance by failing to make beds in a timely manner and/or to provide an appropriately arranged coverlet for the beds that did not leave the mattress, pillows, and/or incontinence pads exposed at the sides. This condition was observed on every hall and in a significant number of rooms. Facility census: 87. Findings include: a) During the general tour at 1:30 p.m. on 08/06/12, two surveyors observed unmade empty beds on all halls. At 2:30 p.m. on 08/06/12, the Director of Nurses was asked if staffing was adequate on that day and she replied that it was. Beds that were made, were done so crudley with coverlets (blankets or bedspreads) that left the mattress, pillows, and/or incontinence pads exposed at the sides. The bedspreads, when used, were folded in half and simply laid atop the bed linens and pillows. This observation was repeated at 10:45 a.m. on 08/07/12, and was very similar to the previous day. At 11:05 a.m. on 08/07/12, Resident #7 was brought into the room by her daughter in a wheelchair. The resident's daughter stated they were returning from a doctor's appointment outside the facility. Resident #7's bed was closed, with a white thin bedspread folded in half and laid over the top of the sheets and pillow. At the sides an incontinence pad and a lift sheet could be seen, and the cover was not molded around the pillow. When asked if this was how the bed was usually made-up, they stated yes, although both were quick to add that they had no complaints about the care and understood it could not be like home and the resident would not have to stay there long. During an interview with the Director of Nurses, at 11:20 a.m on 08/07/12, these findings were shared with her and some of the rooms were viewed, including room 137. She stated that she would rectify the situation.",2017-01-01
7796,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2014-01-23,356,C,1,0,QEQR11,"Based on staff interviews and review of nursing staff data postings, the facility had not ensured nursing staff data was posted in a manner which could be kept on file for 18 months as required. The information was being recorded on a dry erase board and then erased daily and not kept in written form that could be kept in a file. This had the potential to affect all residents and public who were to have access to this information. Census: 91. Findings include: a) A review of nurse staffing postings, on 01/22/13, revealed the staffing information was posted in a prominent place on a dry erase board. This board was erased daily to document the new daily nurse staffing numbers. This did not allow the facility to maintain this information for the minimum of 18 months as required by regulation. The issue was discussed with the interim director of nursing on the afternoon of 01/22/14. She confirmed the staffing data was not being recorded in a hard copy format which could be kept on file. The facility staff had identified this concern last week and were in the process of developing a form which was in accordance with their staffing pattern which is based on 12 hours shifts as opposed to 8 hour shifts. The new form was finalized and shown to surveyors on 01/23/14, during the investigation. The form did not have all the information as required. It was lacking the facility name.",2017-01-01
7823,MEADOW GARDEN,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2012-08-23,156,C,0,1,1T2X11,"Based on review of information posted in the facility, review of medical records, and staff interview, it was determined the facility had not posted the names, addresses and telephone numbers for the agencies that are required to be posted to provide information to the residents and others. This practice had the potential to affect all residents who resided in the facility and should have access to this information. Additionally, the facility had not provided residents with a timely notice of their right to appeal when Medicare coverage of services was to be discontinued. The appeal notice timeliness affected two (2) of three (3) residents who were reviewed for appeal notices. Resident identifiers: #69 and #24. Census: 56. Findings include: a) Observation of informational materials posted in the facility found the name, address, and telephone number for the Medicaid Fraud Unit were not posted on the boards that contained information for the residents, their families, and the public. Additionally, there was no notice of how to file a complaint with the State survey and certification agency, nor how to apply for Medicare and Medicaid services. This was discussed with the administrator, Employee #78 and the social worker, Employee #35, on the afternoon of 08/20/12. b) Resident #69 Review of Resident #69's medical records found no evidence she was provided a forty-eight (48) hour notification of discontinuation of skilled services. Medical record review revealed, on 03/27/12, the facility had determined this resident no longer qualified for skilled services beginning 03/08/12. On 03/27/12, the resident signed section C of the form, the acknowledgement of receipt of the notice of non-coverage of services under Medicare. This was nineteen (19) days after the date services would no longer be covered. Staff interview, on 08/22/12 at 09:00 a.m., with Employee #35 (social worker) confirmed Employee #35 did not give Resident #69 a 48 hour notification as required. c) Resident # 24 Review, on 08/22/12 at 9:15 a.m., of Resident #24's medical record revealed the Notice of Medicare Provider Non-Coverage indicated skilled /rehabilitation services would end on March 13, 2012. There was no evidence the resident received notification these services would be discontinued 48 hours prior to the discontinuation of the services. Further review found a form which was signed by the resident on 04/03/12. This form indicated services would no longer be covered after 04/04/12. Resident #24's record review also revealed the notice of Medicare provider non-coverage form the resident signed had an expiration date of 07/31/11. The social worker was interviewed on 08/22/12 at 09:30 a.m. She confirmed the date (04/04/12) was incorrect on the form which indicated when skilled services for this resident would end. Employee #35 stated, I do not know why I put that date. She also acknowledged she used a notification letter which had an expiration date of 07/21/11.",2017-01-01
7836,MEADOW GARDEN,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2012-08-23,356,C,0,1,1T2X11,"Based on observation of facility postings and staff interview, it was determined the facility had not posted the nurse staffing numbers for the shift when the surveyors entered the building to begin the survey. This had the potential to affect all residents and the public who are to have access to this information. Facility census: 56. Findings include: a) Upon entering the facility at 11:30 a.m. on 08/13/12, a form was noted at the nurses' station. This was the form on which the nurse staffing hours were to be posted for the shift. The day shift section for 08/13/12 was completely blank. It is required the facility post information on a daily basis at the beginning of each shift. This posting is to include the current date and the total number of actual hours worked by licensed and unlicensed nursing staff who are directly responsible for resident care. The resident census must also be included. This was brought to the attention of the director of nursing, Employee #42 on 08/16/12 in the afternoon.",2017-01-01
7868,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,356,C,0,1,ZN3T11,"Based on observation and staff interview, the facility failed to post the nurse staffing information regarding available direct care staff daily, as required by this regulation. The data observed posted was four (4) days prior to the date of the observation. This practice had the potential to affect all residents. Facility census: 124. Findings include: a) Observation, on 01/08/13, of the nurse staffing data, which must be posted daily by the facility, found it was not current. The date on the posting was 01/04/13. 01/08/13 at 10:00 a.m., Employee #5 (director of nursing) confirmed that it was not correct and stated she would get it corrected.",2017-01-01
8000,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2012-08-03,159,C,0,1,706T11,"Based on resident interview and staff interview, the facility failed to ensure that fifteen (15) residents with personal funds being managed by the facility, had access to petty cash on an ongoing basis. This practice had the potential to affect all of the fifteen (15) residents. Facility census: 81. Findings include: a) During an interview with the Resident Council President (Resident #63) during Stage I of the survey, this resident stated the facility manages personal funds for her/him and there was no access to the funds on weekends or at night. During an interview with Employees #3 and #4, who are responsible for handling resident funds within the facility, at 9:00 a.m. on 08/02/12, they stated there was a petty cash box maintained at the facility with $150.00 and an additional $50.00 kept in the Activity Department but, they confirmed this money was only available when one of them, or the activity personnel, were present. There was no one on site with access to petty cash at night, on holidays, or on weekends.",2016-11-01
8042,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,354,C,0,1,8KXK11,"Based on observation and staff interview, the facility failed to ensure a registered nurse served as the director of nurses (DON) on a full time basis without serving as a charge nurse and supervising the provision of resident care. This had the potential to affect all residents. Employee identifier: #131. Facility census: 127. Findings include: a) Employee #131. Employee #131, who was identified to the survey team on the day of entry (08/13/12) as the director of nurses, was observed working as the 2nd floor charge nurse for the day shift on both 08/20/12 (census = 107) and 08/21/12 (census = 101). According to this requirement, The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. During an interview with the DON, at 5:45 p.m. on 08/21/12, she admitted that she was working as the charge nurse because of the absence of the employee scheduled to serve in that position. She stated that she was unaware that this was not allowed. At 5:55 p.m. on 08/21/12, the Administrator was interviewed and also stated that she was unaware that having the DON serve as the charge nurse was a deficient practice and stated this would be rectified.",2016-10-01
8049,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2012-06-06,156,C,0,1,RKJW11,"Based on observation and staff interview, the facility failed to prominently display the required written information on how to apply for Medicare and Medicaid. This had the potential to affect all facility residents. Facility census: 87. Findings include: a) On 05/29/12 at 2:20 p.m., a tour of the facility revealed no prominently displayed written information on how to apply for Medicare and Medicaid. In an interview with the administrator and social worker (Employee #24) at that time, they agreed there was no posting of the information on how to apply for Medicare and Medicaid in the building. Employee #24 stated she was not aware this was a requirement.",2016-10-01
8102,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,ROUTE 103 VENUS ROAD,GARY,WV,24836,2012-10-30,156,C,0,1,QR3O11,"Based on observation and staff interview, it was determined the facility had not posted the correct addresses for the State survey agency and the Medicaid Fraud Unit. These addresses are to be posted for all residents and the public should an individual wish to contact one of the agencies. Census: 97. Findings include: a) Review of information posted in the hallways on first floor for residents and the public noted the wrong address was listed for the Office of Health Facility Licensure and Certification. This was verified with the administrator, Employee #107, and the social worker, Employee #61, on 10/24/12 at 9:30 a.m. b) Posting of advocacy groups - Medicaid Fraud Control Unit At 10:15 a.m. on 10/25/12, a poster containing the address and telephone number of the State Medicaid Fraud Control Unit was observed on the first floor beside the elevator. An interview with the administrator, on 10/25/12 at 10:30 a.m., confirmed the address of the State Medicaid Fraud Control Unit was incorrect.",2016-10-01
8180,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2013-09-05,509,C,1,0,54LC11,"Based on review of the facility's contracts/agreements and staff interview, the facility failed to have evidence of an agreement for radiology services from a provider or supplier that was approved to provide these services under Medicare. This practice had the potential to affect more than a limited number of residents. Facility census: 91 Findings included: a) Radiological Services During a review of facility documents, on 09/03/13 at 4:00 p.m., no evidence was present to indicate the facility had an agreement with a provider for radiological services. An interview with the administrator, on 09/04/13 at 10:00 a.m., confirmed the facility did not complete diagnostic services internally. He said a company came into the facility and provided portable x rays. During another interview with the administrator, on 09/04/13 at 3:30 p.m., he confirmed he was unable to provide evidence of an agreement for radiology services.",2016-09-01
8298,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,167,C,0,1,TTVD11,"Based on family interview, observation, and staff interview, the facility failed to make survey results readily available to residents for examination, and failed to post a notice of their availability. This had the potential to affect all residents and families desiring to view this information. Facility census: 52. Findings include: a) Resident #54 During an interview with a family member of Resident #54, on 07/17/12 at 1:25 p.m., it was revealed he was unaware of the availability of the survey results and was not aware of where they were located. An observation was made of the facility, on 07/17/12 at 1:45 p.m A notice regarding the availability of the survey results was not found during this observation. On 07/17/12 at 1:50 p.m., Employee #22, the office manager, was interviewed regarding the location of the survey results. At that time, Employee #22 confirmed there was no notice of the availability of the survey results. Upon inquiry, this employee was unsure of the location of survey results, and stated they possibly are located at the nurses' station.",2016-07-01
8320,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,518,C,0,1,TTVD11,"Based on facility policy review, personnel records review, and staff interview, the facility failed to adequately train employees in emergency procedures by failing to use the current Fire Plan as the basis for the training. This had the potential to affect all residents. Facility census: 52. Findings include: a) After a review of the personnel records, at 2:00 p.m. on 07/17/12, a meeting was held with Employee #52 (Registered Nurse and Staff Development Coordinator). She explained all of the required in-services for both orientation purposes and annual in-services were completed by using a computerized video training program which was provided by the corporate office. The exception to this was the emergency, fire, and disaster training, which Employee #52 stated was provided by the Maintenance Director. A review of the Emergency Manual was done at 8:00 a.m. on 07/24/12. The manual was presented to the surveyors by Employee #58 (Director of Maintenance), who stated he was responsible for overseeing the employee training of emergency procedures and providing staff drills to ensure resident safety. There was no evidence the manual was periodically reviewed or revised as evidenced by the multiple Fire Plans it contained. 1) A Fire Plan (Number VII.2a) issued July 1998 and effective April 2001 2) An undated Fire Plan (it contained a policy entitled Heat Emergency Plan with an effective date of 10/10/1983), which was different than 1 and an it had an addendum dated 1990. 3) A third Fire Plan was provided, and it was also dated 2001. Employee #52, the staff development coordinator, was asked for the teaching aids used for the emergency procedures training. She provided a Fire Plan at 10:35 a.m. on 07/24/12. The fire plan Employee #52 stated was used in the training was not the current Fire Plan. The plan being used for training was the undated plan described in 2 above. During an interview with the Administrator, at 9:40 a.m. on 07/24/12, he had no comments about the concerns above, and expressed his thanks that the information had been brought to his attention.",2016-07-01
8370,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,156,C,0,1,X70T11,"Based on observation of posted information and staff interview, it was discovered the facility did not have the current address for the (state agency) Office of Health Facility Licensure and Certification (OHFLAC) posted as required. This practice had the potential to affect all residents and the public, who are to have access to this information. Facility census: 48. Findings include: a) While observing posted information on 11/28/12, at mid morning, it was discovered the address posted for OHFLAC was incorrect. The address listed was not the address for this agency, and had not been for more than a year. This was discussed and confirmed with the director of nursing, Employee #127, and the social worker, Employee #292, at the time of the review.",2016-07-01
8422,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2012-04-12,356,C,0,1,65PN11,"Based on observation and staff interview, the facility failed to post the nurse staffing data at the beginning of each shift. This deficient practice had the potential to prevent all residents and visitors from reviewing the staffing levels for the evening shift. Facility census: 78. Findings include: a) During random observations of the resident environment at 5:20 p.m. on 04/09/12, noted the daily staffing form posted at the nursing station did not display the staffing levels for the evening shift. An interview with registered nurse (RN), Employee #45 elicited the evening shift nursing assistants (NA) begin at 2:00 p.m. and licensed and registered nurse staff begin at 3:00 p.m. At 5:20 p.m., the administrator agreed the required information had not been posted.",2016-06-01
8498,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2012-11-20,514,C,0,1,VIG911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure the completeness and/or accuracy of resident medical records. Random review of medical records revealed White-out was used, there was scribbled out writing, and a physician's orders [REDACTED]. Resident identifiers: Residents #9, #11 and #5. Facility census: 69. Findings include: a) Resident #9 On 11/14/12, during a review of Resident #9's medical record, a form titled Social History & Initial Assessment, was observed with White-out used in the section titled Physician. In an interview with the administrator, on 11/19/12 at 3:00 p.m., the administrator was informed of the finding of White-out used in Resident #9's medical record. The administrator stated oh no, they know better than that. The administrator agreed white out was not to be used in any resident's medical record. b) Resident # 11 Review of medical records, on 11/13/12, found the consultant pharmacist progress notes form contained scribbled out writing on documentation dated 11/07/11. Employee #23, the director of nursing, was informed on 11/19/12. c) Resident #5 Review of the medical record on 11/19/12 indicated the pharmacist, on 11/05/12, recommended [MEDICATION NAME] 15 mg by mouth as needed (PRN) be discontinued related to non-use of the medication. The physician responded in agreement. The medical record did not contain an order to discontinue the [MEDICATION NAME]. On 11/20/12 at 8:15 a.m. the Medication Administration Record [REDACTED]. Employee #42 was interviewed on 11/20/12 at 8:30 a.m. She confirmed the [MEDICATION NAME] had not been discontinued as ordered.",2016-06-01
8510,"ST. JOSEPH'S HOSPITAL, D/P",515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2013-01-10,226,C,0,1,IYJG11,"Based on a review of employee personnel files, policy review, and staff interview, the facility failed to develop policies which required the screening of all potential employees to include a West Virginia (WV) statewide criminal background investigation as directed by the WV State survey agency. Five (5) of five (5) employees reviewed for this requirement did not have this screening. This practice had the potential to affect more than a limited number of residents. Employee identifiers: #3, #13, #22, #29, and #10. Facility census: 13. Findings include: a) A review of employees' personnel files, on 01/08/13, revealed the files for Employees #3 (a professional nurse); #13 and #10 (nurses aides); #22 (dietary aide) and #29 (a dietary manager) had no evidence of a statewide criminal background check for WV. During an interview with Employee #33 (Human Resources Representative) and Employee #1 (Nurse Manager for Long Term Care), at 1:45 p.m. on 01/09/13, they acknowledged the facility had ceased doing fingerprinting which had been sent to the WV State Police for a criminal background check. They stated the facility had contracted to a security company whom they assumed was providing the facility with the required information. After reviewing the files, they agreed that only a check of counties of residency, provided by the potential employee, was being done. b) A copy of the facility's Pre - Employment Investigation policy was provided. It had a requirement for a Criminal Background Check, but did not identify the check was to be a WV statewide check. After verifying the requirements with the Office of Health Facility Licensure and Certification, it was explained that a criminal background investigation through the WV State Police was required. This information was provided in a newsletter, which was distributed to all WV licensed nursing homes and Medicare/Medicaid certified nursing facilities in November 2004.",2016-05-01
8585,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,249,C,0,1,KWL711,"Based on review of requested documentation and staff interview, the facility failed to ensure the activities program was directed by a qualified professional. The facility did not have an activities director to plan, direct, or oversee an ongoing program of activities designed in accordance with the comprehensive assessments, the interests of the residents, and the physical, mental, and psychosocial well-being of the residents. The facility failed to employ a qualified professional to oversee the activities program for a period of approximately seven (7) months. This had the potential to affect all residents. Facility census: 60. Findings include: a) On the day of entry to the facility, on 04/16/12, the administrator (Employee #45) provided the requested the Key Personnel form which indicated the position of activities director was vacant. This was verified during an interview with a recreation aide (Employee #80) at 9:15 a.m. on 04/18/12. Employee #80 stated the previous activities director had gone on disability leave in either July or August 2011 and returned in March 2012, but had resigned shortly after her return. She stated the facility had acquired an interim director who had left at the first of 2012. She stated she had no knowledge of the credentials of the interim director. Employee #80 also stated she had been assembling the monthly activity calendars and presenting them to the administrator for approval. She stated Employee #68 (another recreation aide) completed the new admission assessment forms and gave them to the Clinical Reimbursement Coordinator (Employee #43). Employee #80 stated the recreation aides continued their daily duties based on previous practices. She knew of no plans for hiring an activity director. A third recreation aide, Employee #24, as well as Employee #80, had been in their positions for five (5) years each, but neither possessed the qualifications to serve as the activities director. During an interview with the administrator, at 10:30 a.m. on 04/19/12, she stated the former activity director had take a leave due to illness in August 2011. She had been replaced with an interim director who was a recent graduate of a qualifying program, but that individual left at the end of the year when she failed her licensing exam. The administrator stated the former director had returned in February 2012, but quit without notice on 02/15/12. She had not been replaced although the corporation was attempting to hire someone through an agency. She acknowledged the calendars were being prepared by Employee #80 and approved by herself. She stated, when asked, that there had been no activities consultant service hired during this time (August 2011 - present) to oversee the activities program.",2016-05-01
8591,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,425,C,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, pharmacist interview, and record review, the facility failed to properly dispose of medications after discharging residents and/or after expiration of the medication. The facility's pharmacy policy contained directives for medication disposal which were not implemented by the facility. This had the potential to affect all residents, as there was only one (1) medication preparation/storage area. Facility census 60. Findings include: a) During observation of medication storage, in the sole medication storage and preparation room, accompanied by the director of nurses (Employee #72) at 3:00 p.m. on 04/18/12, the following medications were found in the refrigerator in the shelf of the door: - One (1) opened and resealed bottle labeled Ativan intensol 2mg/ml with a name handwritten across the label. There was no date to indicate when it was opened. The previous name on the label was blackened out with a marker. Employee #72 confirmed the medication belonged to Resident #1001, who was discharged on [DATE]. - One (1) bottle of Novolin R insulin and one (1) bottle of Novolin N insulin whose labels indicated they were opened on 03/15/12. According to facility policy, these should have been disposed of on 04/11/12. They were labeled for Resident #1002 who was discharged on [DATE]. - One (1) opened bottle of Lantus insulin labeled as opened on 03/24/12. It belonged to Resident #1003, who was discharged on [DATE]. - One (1) opened bottle of Novolog insulin labeled as opened on 03/16/12. It belonged to Resident #69, a current resident. According to facility policy, this medication should have been discarded on 04/12/12. Observation revealed a sign, posted above the refrigerator in the medication storage/preparation room, which stated, OPENED VIALS TO BE DISCARDED AFTER 28 DAYS. The director of nursing (DON) was present, and verified this was facility policy. She acknowledged all these medications should have been discarded prior to the observations on 04/18/12. During a telephone interview with the facility's consultant pharmacist, at 10:15 a.m. on 04/19/12, he stated he was unaware of the label changes on the Ativan. He stated, as a controlled substance, Ativan could not be retained in the facility without a written, signed order from the physician received in the pharmacy. He further stated, No medications can be transferred in the facility. When a resident was discharged , all medications were to be pulled from the cart, stock, or refrigerator, and disposed of appropriately. The pharmacist had no answer why the medications of discharged residents and/or outdated medications had not been discovered during pharmacy inspections. He and the director of nurses both stated there had been a pharmacy review the preceding week.",2016-05-01
8593,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,431,C,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, consultant pharmacist interview, and record review, the facility failed to reconcile controlled medications and/or ensure that a controlled medication was appropriately labeled in accordance with currently accepted professional principles and facility policy. This had the potential to affect more than an isolated number of residents, as there was only one (1) medication storage room. Facility census: 60. Findings include: a) During observation of medication storage, in the sole medication storage and preparation room, accompanied by the director of nurses (Employee #72) at 3:00 p.m. on 04/18/12, an opened and resealed bottle of Ativan intensol 2 mg/ml was found in the the refrigerator on a shelf in the door. A resident's name was handwritten across the label. There was no date to indicate when the medication was opened. The previous name on the label had been blackened out with a marker. Employee #72 confirmed the medication belonged to Resident #1001, who was discharged on [DATE]. A second bottle of the same medication, unopened, and labeled by the pharmacy for Resident #1001, was also found on a shelf of the refrigerator. The DON stated the facility's practice was to mark out the resident's name on a label if the resident was discharged , and keep it a locked container inside the refrigerator, until it was needed by a resident with a new order. According to the DON, this ensured a resident with a new order had immediate access to the medication. The process eliminated waiting for a written signed order to be delivered to the pharmacy and the medication then delivered to the facility. When asked, the DON acknowledged this was not in accordance with state pharmacy guidelines. Observation revealed she discarded the opened bottle, marked out the resident's name on the unopened bottle, and placed it in the locked container in the refrigerator. During a telephone interview with the facility's consultant pharmacist, at 10:15 a.m. on 04/19/12, he stated he was unaware of the label changes on the Ativan. He stated, as a controlled substance, Ativan could not be retained in the facility without a written, signed order from the physician received in the pharmacy. He further stated, No medications can be transferred in the facility. When a resident was discharged , all medications were to be pulled from the cart, stock, or refrigerator, and disposed of appropriately. The pharmacist had no answer why the medications of discharged residents and/or outdated medications had not been discovered during pharmacy inspections. He and the director of nurses both stated there had been a pharmacy review the preceding week.",2016-05-01
8595,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,492,C,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each dietary employee had a valid food handlers permit as required by county regulations. Two (2) dietary employees did not have a current food handlers card. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 60 Findings include: a) Upon entrance, facility personnel were asked to provide evidence of food handlers permits, if the county in which the facility was located required them. On [DATE] at 11:40 a.m., a review of the food handlers permits, with the food service director (Employee #14), revealed the cooks (Employees #67 and #8) did not have valid food handlers permits. Inspection of the food handlers permits for these two (2) revealed each had expired in [DATE]. Employee #14 stated both employees had renewed their food handlers permits, but had not provided their cards. At the time of the survey, the facility had no evidence these employees had fulfilled the requirements to renew their food handlers permits. .",2016-05-01
8632,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,514,C,0,1,L97I11,"Based on record review, observation, and staff interview the facility failed to assure that a part of the medical record for all residents was readily accessable for resident care in accordance with accepted professional standards. This had the potential to effect all residents. Facility census 16. Findings include: a) During the initial interview with the Director of Nurses at 12:30 p.m. on 12/03/12, she informed this surveyor that all aspects of the record were available on the chart except the MDS which was in the computer and hard copies are no longer being produced for the chart. During a discussion of accessing the MDS on the morning of 12/05/12, with Employee #4 (Licensed Practical Nurse) she stated that she would have to request someone to do this as she did not have access to the computer. This was verified with the DON, who stated that only she, the unit clerk, and the MDS nurse have entry to the computer. When asked, she stated that they all worked day shift. She acknowledged that they had not considered the lack of access by the nursing staff caring for the resident when the decision was made not to print hard copies of the MDS for the chart.",2016-05-01
8641,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,156,C,0,1,5VE911,"Based on observation and staff interview, the facility failed to post the current address of the State survey agency. This practice has the potential to affect all residents and members of the general, public since all are to have access to this information. Facility census: 89. Findings include: a) On 08/09/11 at mid morning, observation of postings containing the contact information (addresses and telephone numbers) for various State client advocacy groups found the address for the State survey agency was not current. The agency had moved its office to a new location in July 2010, and the address in the posting had not been updated to reflect this change. This was brought to the attention of the facility's administrator (Employee #15) at the time. She verified the information was incorrect and had staff change the information to reflect the new address.",2016-04-01
8660,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,156,C,0,1,46GB11,"Based on interview and review of documentation, the facility was not using the correct Centers for Medicare and Medicaid Services (CMS) form when notifying residents of changes in the services being provided them under the plan. Residents are to be notified when they no longer are going to receive Medicare skilled services using form CMS . The facility was using a a form entitled C-4. This was evident for three (3) of three (3) residents whose records for denial of payment for services were reviewed. This practice had the potential to affect any resident who was discharged from Medicare services. Resident identifiers: #40, #26 and #70. Facility census: 76. Findings include: a) Residents #40, #26, and #70 Review of documentation given these residents, when they no longer qualified for Medicare services, revealed the facility was using a form entitled C-4. This was not the required form as specified by CMS. The form specified by CMS is form CMS . This is the form to be given at the time residents are no longer eligible for skilled services. Such reasons include: when a resident has used all their days, has reached his/her potential, and/or for any reasons, as set forth by CMS, in which Medicare services are discontinued. This was discussed, on 01/09/12 at mid-morning, with the business office manager(Employee #63) who was responsible for providing these notices. Employee #63 stated he was not aware of form CMS , and would begin using it immediately.",2016-04-01
8698,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,156,C,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to prominently display in the facility, written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. The information could not be located in the area of the facility to which residents and visitors members were directed on the facility's information board. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 57. Findings include: a) Upon initial entrance to the facility on [DATE] at approximately 10:45 a.m., a notice was observed in the entrance hallway on a board with other mandatory posting, stating survey results and information related to applying for Medicaid and Medicare could be found in the white binder in the front lobby. Employee #59 (front office personnel), when questioned, confirmed the front lobby was considered to be an area by the front door where two (2) chairs and a table were located. This area was searched, and no white binder was located. Employee #59, when subsequently approached about the inability of the surveyor to locate the binder of information, confirmed it was not in the designated location. This employee further stated residents sometimes carried the notebook off. In approximately fifteen (15) minutes, Employee #59 returned and had located the white binder. The necessary information was included, as stated in the posting on the information board.",2016-04-01
8699,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,167,C,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to make available for examination and post in a readily accessible place a notice of their availability, the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 57. Findings include: a) Upon initial entrance to the facility on [DATE] at approximately 10:45 a.m., a notice was observed in the entrance hallway on a board with other mandatory posting, stating survey results and information related to applying for Medicaid and Medicare could be found in the white binder in the front lobby. Employee #59 (front office personnel), when questioned, confirmed the front lobby was considered to be an area by the front door where two (2) chairs and a table were located. This area was searched, and no white binder was located. Employee #59, when subsequently approached about the inability of the surveyor to locate the binder of information, confirmed it was not in the designated location. This employee further stated residents sometimes carried the notebook off. In approximately fifteen (15) minutes, Employee #59 returned and had located the white binder. The necessary information was included, as stated in the posting on the information board.",2016-04-01
8757,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2012-01-11,226,C,0,1,K0ZK11,"Based on review of employee personnel files, policy review, and staff interview, the facility failed to develop policies requiring the screening of ALL potential employees to include a West Virginia (WV) statewide criminal background investigation as directed by the WV State survey agency. This affected two (2) of ten(10) employees sampled. Employee identifiers: #120 and #77. Facility census 141. Findings include: a) Employees #120 and #77 A review of the employees' personnel files, on 01/09/12, revealed there was no evidence of a statewide criminal background check for WV in the files for Employees #120 (a professional nurse) and #77 (a dietary manager). During an interview with the Human Resource Director, Employee #113, she pointed out because these employees resided in another state, a criminal background check had been done in that state only. The facility's Background Check Policy included, 1. All employees are screened either via a WV State Police . Criminal background check (for WV residents) or an FBI Criminal background check (for Ohio and Pennsylvania residents) upon offer of employment with . After verifying the requirements with the Office of Health Facility Licensure and Certification, it was explained that a criminal background investigation in WV is always required, regardless of the state of actual residence, as had been stated in a newsletter distributed to all WV licensed nursing homes and Medicare / Medicaid certified nursing facility in November 2004.",2016-03-01
8765,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2012-01-11,492,C,0,1,K0ZK11,"Based on record review and staff interview, the facility failed to ensure all dietary employees had a valid food handlers permit as required by county regulations. One (1) of seventeen (17) dietary employees did not have a valid food handlers permit. This had the potential to affect all residents receiving foods from the dietary department. Facility census: 141. Findings include: a) Employee #85 On 01/11/12, at approximately 9:00 a.m., a review of the copies of food handlers permits, provided by the facility, revealed one (1) dietary employee, Employee #85, did not have a valid food handlers permit. In an interview conducted with the assistant dietary manager, Employee #94, she stated she knew there was a copy of Employee #85's food handlers permit somewhere. The facility was not able to produce this copy prior to the exit conference. The facility was not in compliance with the county health department regulation which included, . establishment must insure that all food service workers obtain a Food Handlers Permit.",2016-03-01
8767,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2012-05-03,156,C,0,1,2ZMR11,"Based on observation and staff interview, the facility failed to ensure written information regarding how residents could apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits, was prominently displayed. This had the potential to affect more than an isolated number of residents. Facility census: 101. Findings include: a) On 05/03/12, at approximately 9:00 a.m., a tour of the facility revealed no information was displayed regarding how residents could apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. The administrator (Employee #23), who accompanied the tour of the facility, agreed there were no postings regarding how to apply for and use these benefits, or to receive refunds.",2016-03-01
8775,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2011-07-27,208,C,0,1,WXEM11,"Based on review of the facility's admission agreement, policy review, and staff interview, the facility failed to ensure persons having legal access to a resident's income or resources were not required to incur personal financial liability when providing payment from a resident's income or resources to the facility for the cost of all or part of the resident's care. This had the potential to affect all residents. Facility census: 134. Findings include: a) Review of the facility's admission agreement found an addendum to the financial agreement (dated 07/03) which stated: The patient or responsible party agrees to pay when billed and the nursing home will accept arrangement in full consideration for care and services rendered as follows: 1. Room, board, laundered linens and bedding, nursing and personal care $_____/a day. 2. When the patient is permanently discharged , the unused portion of this money will be refunded. 3. The physician will bill for any services rendered by the physician to the patient. 4. Medication ordered by the physician will be billed to the patient by the pharmacy. 5. The services for physical therapy, occupational therapy, speech therapy, oxygen, special dressing, etc. will be billed in addition to the above. 6. In the event the patient is placed on the West Virginia Medicaid Program, they are not responsible for any of the above financial agreements, with the exception of the Hold Bed Fee, if the bed is to be held. The patient or family is responsible for the fee. Either party may terminate or change this agreement on a 30 day written notice. Otherwise it will remain in effect until a different agreement is recorded. However this does not mean that the patient will be forced to remain in the nursing home against his/her will for any length of time. -- The agreement did not state that the facility must not require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility, or that the facility may require an individual who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources. -- When reviewing the admission policy with the administrator on 07/26/11 at 02:30 p.m., the administrator said the facility did not expect someone other than the resident to be personally at risk for payment to the facility, except for bed hold expenses. She agreed the admission agreement did not specify that the resident's responsible party would not be held personally liable for the resident's expenses.",2016-03-01
8827,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2011-08-31,156,C,0,1,5Y7411,"Based on observation and staff interview, the facility failed to prominently display, for residents and applicants, written information about how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by such benefits. This deficient practice had the potential to affect all residents and families desiring to view this information. Facility census: 100. Findings include: a) Observations of the facility, on 08/30/11, failed to find any prominent postings of information about how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by such benefits. The activity director (Employee #23) and the interim administrator (Employee #119) were unable to locate the posting when asked at 11:35 a.m. on 08/30/11. Employee #23 stated the information had been posted at one time but someone must have taken it down.",2016-03-01
8855,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2012-03-15,354,C,0,1,8YB611,"Based on observation and staff interview, the facility failed to provide registered nurse coverage for at least 8 consecutive hours 7 days a week. On 03/04/12, the facility did not have a registered nurse scheduled to work in the facility. This practice had the potential to affect all residents residing in the facility. Facility census: 59. Findings include: a) Review of sufficient nursing staffing revealed the facility did not have a registered nurse scheduled to work on March 4, 2012. On 03/14/12, at approximately 9:20 a.m., the director of nursing, Employee #4, confirmed the facility did not have registered nurse coverage on 03/04/12.",2016-03-01
8890,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2012-05-25,372,C,0,1,ZX7V11,"Based on observation and staff interview, the facility failed to ensure trash dumpsters were fully closed and surrounding area was clean and free of refuse. Findings Include: Observations on 05/23/12 at 8:30am revealed two dumpsters located to the right of the main entrance were open. One dumpster was for trash and one was for cardboard, both were equipped with lids. The dumpster for cardboard trash was observed with the lid hanging open and cardboard boxes overflowing from the top. Observation of the trash dumpster on 05/24/2012 at 8:30am revealed the lid was open and the cardboard boxes had spilled over to the ground into a pile several feet high. Interview on 05/24/2012 at 9:30 AM with the maintenance supervisor revealed that the cardboard trash dumpster was required to be emptied once a week on Monday. He confirmed the dumpster lid should be closed and the cardboard should not overflow onto the ground.",2016-03-01
8909,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2011-12-14,371,C,0,1,WGCM11,"Based on observation and staff interview, it was determined facility staff had not stored foods in the nourishment center refrigerator in a manner that maintained sanitary conditions. There was no thermometer in the unit to determine whether temperatures were being maintained that would ensure food safety. This practice had the potential to affect more than a limited number of residents who received foods stored in that unit. Census: 60 Findings include: a) Observations conducted with Employees #1 and #13, on the morning of 12/14/11, found the refrigerator at the nourishment center near the nursing station did not have an internal thermometer. There was no device to measure temperatures inside or outside of the refrigeration unit to ensure the staff could monitor the temperature of the unit. The employees (#1 and #13) verified there was no thermometer at that time, Employee #13 placed his thermometer in the unit to check the temperature. It did get an acceptable reading. Additionally, it could not be verified how long the unit had been without a thermometer. Dietary staff were notified and a thermometer was placed in the unit .",2016-03-01
8914,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,156,C,0,1,NP7N11,"Based on observation and staff interview, the facility failed to ensure they had prominently displayed written information about how to apply for and use Medicare and Medicaid benefits. The facility did not display information regarding how to apply for and use Medicare and Medicaid benefits on one (1) of three (3) units. This practice had the potential to affect all residents of that unit. Facility census: 90. Findings include: a) During a tour of the facility, on 12/07/11, at approximately 4:30 p.m., the postings of written information regarding how to apply for and use Medicare and Medicaid benefits were located on the second and third floor units. However, the first floor unit did not have this information posted. On 12/07/11, at approximately 4:45 p.m., the administrator (Employee #10) and the director of social services (Employee #100) both verified the first floor unit did not contain this information.",2016-03-01
8917,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,167,C,0,1,NP7N11,"Based on observation and staff interview, the facility failed to ensure the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect were accessible to residents. The failure to place the survey results in a place that made them readily accessible to residents had the potential to affect all facility residents. Facility census: 90. Findings include: a) On 12/07/11, at approximately 5:00 p.m., a tour of the facility revealed a sign on unit one (1) which stated survey results were available in the lobby. After touring the lobby area these results were not located. On 12/07/11, at approximately 5:10 p.m., Employee #128 (telephone operator) indicated the survey results were on her desk. She said they were moved there after the Christmas decorations were put up in the lobby. Employee #128 then moved the survey results (Statement of Deficiencies (HCFA-2567)) to a table where they were readily accessible to residents.",2016-03-01
8918,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,205,C,0,1,NP7N11,"Based on review of the facility's notification of admission/bed hold policy (revision date 03/24/11) and staff interview, the facility failed to ensure residents who were transferred to a hospital, or went on therapeutic leave, received correct information regarding names and addresses of who to contact if they wanted to appeal a decision made by the facility regarding admission or bed hold. This issue had the potential to affect all facility residents. Facility census: 90. Findings include: a) The facility's admission information, reviewed on 12/06/11 at approximately 9:00 a.m., revealed issues with the contact agencies and advocates listed in the notification of admission/bed hold policy. The facility provided this policy to residents who were going on therapeutic leave, or a medical leave of absence, from the facility. In this notice, the facility listed an incorrect name and address for the regional long-term care ombudsman. In addition, the facility listed the incorrect address for the state survey agency, which is the agency with which residents can file confidential complaints. On 12/06/11 at approximately 10:00 a.m., the administrator (Employee #10) was informed of the incorrect information in the admission/bed hold policy.",2016-03-01
8938,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,156,C,0,1,R8A111,"Based on observation and staff interview, the facility failed to prominently display how to apply for Medicare and Medicaid. Furthermore, the facility failed to post current contact information for the regional Ombudsman and State survey and certification agency. This practice had the potential to affect all residents residing in the facility. Facility census: 50. Findings include: a) On 09/19/12 at 4:47 p.m., a tour of the facility was conducted with the administrator. During the tour, no information was found posted regarding how residents could apply for Medicare and Medicaid. The administrator agreed this information was not posted. Also, the poster containing resident rights did not have the current address and phone number for the survey and certification agency or the name, address and phone number for the regional ombudsman. The administrator stated she would contact the social worker about this posting to see why this was an old posting. At 5:15 p.m., the social worker stated the correct posting had fallen off the wall and broke the glass. The social worker further stated the old posting had been put in its place until the frame was repaired.",2016-03-01
8947,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,281,C,0,1,R8A111,"Based on observation, staff interview, policy and procedure review, and review of a current fundamentals of nursing reference, the facility failed to comply with facility policy and procedure and professional standards of practice during medication administration. Two (2) different staff members initialed medication(s) as given prior to the resident taking the medication(s). This practice was observed by two (2) surveyors during medication administration at separate times. This practice was observed for 13 of 13 residents during medication pass. Facility census: 50 Findings include: a) During the observation of a medication pass, on 09/19/12 at 8:16 a.m., a registered nurse, Employee #1, revealed this employee initialed each medication as given prior to giving the medications to four (4) different residents. Again on 09/25/12 at 8:09 a.m., a registered nurse, Employee #4, was observed initially medications as given prior to administering the medications to five (5) different residents. The director of nursing was interviewed, on 09/25/12 at 10:30 a.m., and agreed medications were not to be initialed as given prior to the resident receiving the medication(s). A review of the facility policy titled POLICY #/TITLE: 6.0 General Dose Preparation and Medication Preparation, revealed the following: 6. After medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site . A review of professional standards for documenting the administration of medications found the following in Foundations of Basic Nursing by Lois White: Documentation of Drug Administration - Documentation is a critical element of drug administration. The standard is 'if it was not documented, it was not done.' Appropriate documentation can prevent many drug errors. The nurse administering a medication must initial the medication on the MAR for the time the drug was given . Documentation should be done after the client has received the drug.",2016-03-01
8957,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,356,C,0,1,R8A111,"Based on observation and staff interview, the facility failed to include the required information on the daily posting of available direct care staff as required by CMS (Centers for Medicare & Medicaid Services). This had the potential to affect all residents. Facility census: 50. Findings include: Observation of the nurse staffing data posted daily by the facility found it did not include the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. This was reviewed with the Administrator at 5:00 p.m. on 09/26/12, who acknowledged that the information was not supplied on the form in use.",2016-03-01
8983,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,500,C,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the provision of professional services which the facility did not provide. There was no current agreement/contract for (3) of nine (9) outside agencies whom the facility believed they had agreements/contracts to provide services. This practice had the potential to affect all residents. Facility census: 41 Findings include: a) Professional contracts Professional contracts were reviewed on 05/21/14 at 3:00 p.m. This review revealed three (3) contracts were made with the previous owner of the facility. These contracts were not updated and/or renegotiated by the current owner when they assumed ownership. Review of the certificate of registration of the trade name revealed the facility was authorized to transact business under their assumed name as of July 30, 2013. 1) The outpatient [MEDICAL TREATMENT] services agreement, policy -C-FDS-002, was noted as effective 07/01/00. Page seven (7) of the agreement, dated 04/01/05, read as follows: The authorized representatives of the parties have signed this Agreement on April 1, 2005. The agreement was between the previous owner and the [MEDICAL TREATMENT] unit. 2) The agreement with the hospital was effective January 1, 1990. The agreement was made between the hospital and a former owner. No evidence was present to indicate there was an agreement between the hospital and the current owner. 3) The ambulance service contract was dated 04/30/01. Review of the agreement revealed it was made between a former owner and the ambulance service. No evidence was present to indicate there was a contract between the ambulance service and the current owner. An interview with the administrator, on 05/22/14 at 11:00 a.m., confirmed the contracts were not updated since acquisition of the facility by the current owner.",2016-03-01
8984,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,503,C,0,1,VDMM11,"Based on record review and staff interview, the facility failed to ensure a current agreement to obtain laboratory testing for its residents. After the facility had a change in ownership, the agreement with an off-site laboratory to provide laboratory services to residents was not updated and/or renegotiated with the new ownership. This had the potential to affect all residents in the facility. Facility census: 42. Findings include: a) The director of nursing (DON) and the administrator provided a copy of the facility's written agreement with an off-site laboratory on 05/21/14 at 2:00 p.m. They said this was the laboratory the facility utilized for all of their routine laboratory testing. Review of the written agreement found it originated on 10/01/02. It was signed by a former facility administrator on 11/07/02. It was signed by a laboratory representative on 11/18/02. On 05/22/14 at 11:00 a.m. the administrator provided a copy of a nursing home license dated 07/23/10. She said the nursing home was purchased and re-licensed on 07/23/10 by new owners. Review of this document found a license was granted to the new owners to operate a 51 (fifty-one) bed nursing home under the provisions of Chapter 16, Article 5C, Section 6, Code of West Virginia, 1931. This license was signed by the director of the Office of Health Facility Licensure and Certification. Upon inquiry, the administrator said there had been no known revisions to the laboratories service agreement since 2002.",2016-03-01
8985,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,509,C,0,1,VDMM11,"Based on record review and staff interview, the facility failed to ensure a current agreement to obtain diagnostic radiology services for its residents. After the facility had a change in ownership, the agreement with an off-site mobile diagnostic company to provide diagnostic radiology services to residents was not updated and/or renegotiated with the new ownership. This had the potential to affect all residents in the facility. Facility census: 42. Findings include: a) The director of nursing (DON) and the administrator provided a copy of the facility's written agreement with an off-site diagnostic provider on 05/21/14 at 2:00 p.m. They said this was the provider the facility utilized for all of their diagnostic radiology services. Review of this written agreement found it originated in June 2010. It was signed by the president of the diagnostics provider. A space for the signature of the nursing home representative, his/her printed name, and his/her title, was left blank and unsigned. On 05/22/14 at 11:00 a.m. the administrator provided a copy of the nursing home license dated 07/23/10. She said the nursing home was purchased and re-licensed on 07/23/10 by new owners. Review of this document found a license was granted to the new owners to operate a 51 (fifty-one) bed nursing home under the provisions of Chapter 16, Article 5C, Section 6, Code of West Virginia, 1931. This license was signed by the director of the Office of Health Facility Licensure and Certification. Upon inquiry, the administrator said there have been no known revisions to the diagnostic service agreement since June 2010.",2016-03-01
9034,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2013-03-14,156,C,0,1,RKHC11,"Based on observation and staff interview, the facility failed to display instructions about how to apply for Medicare and Medicaid. Additionally, the address for reporting Medicaid fraud was incorrect. This had the potential to affect all residents residing in the facility. Facility census: 113. Findings include: a) On 03/11/13 at 2:00 p.m., a random tour of the building, with the nursing home administrator (NHA), revealed no evidence of prominently displayed information about how to apply for and use Medicare and Medicaid benefits. The NHA agreed this information was not displayed, and stated she was unaware of this. b) On 03/07/13 at 10:23 a.m., another observation of posted information revealed the address for reporting Medicaid fraud was incorrect. The posting contained an outdated address. On 03/11/13 at 2:00 p.m., this was brought to the attention of the NHA. She agreed the address was not correct, and stated she would immediately correct the address.",2016-02-01
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
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
9274,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2011-11-04,156,C,0,1,PGFX11,"Based on observation and staff interview, the facility failed to publicly post the contact information for the State survey and certification agency. This has the potential to affect all residents and visitors who may wish to have access to this information. Facility census: 55. Findings include: a) During the initial tour of the facility beginning at 8:30 a.m. on 11/01/11 and subsequent observations over the course of this survey event until 11/04/11, no posting of the telephone number and address of the State survey and certification agency could be found. On 11/04/11 at 12:30 p.m., this issue was brought to the attention of the administrator. At that time, this surveyor and administrator reviewed all publicly posted addressed and telephone numbers for pertinent State client advocacy groups, and the administrator verified that no contact information was posted for the survey agency.",2016-01-01
9287,"WEBSTER NURSING AND REHABILITATION CENTER, LLC",515165,"ERBACON ROAD, PO BOX 989",COWEN,WV,26206,2012-03-09,156,C,0,1,LL6H11,"I. Based on the liability notice and beneficiary appeal review and staff interview, the facility failed to ensure three (3) of three (3) residents selected for review had received the appropriate notice when there was a termination of Medicare Part A services. Resident identifiers: #27, #28, and #64. Facility census: 55. Findings include: a) On 03/08/12, at approximately 10:00 a.m., the liability notice and beneficiary appeal review revealed three (3) of three (3) residents discharged from a Medicare Part A skilled service in the past six (6) months did not receive the appropriate notice when there was a termination of Medicare Part A services. Resident #27 received the notice of Medicare provider non-coverage (CMS - - Generic Expedited Determination Notice Fee For Service Beneficiary) on 01/17/12. At that point the facility felt Medicare probably would not continue to pay for her therapy due to her plateau in therapy progress. The facility did not provide the resident / responsible party with the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice - CMS - ). This resident / responsible party should have received this notice to inform the resident of potential financial liability since the resident still had benefit days. Resident #28 received the notice of Medicare provider non-coverage (CMS - - Generic Expedited Determination Notice) on 01/05/11. At that time the facility determined the resident no longer met the criteria for skilled nursing services. The resident / responsible party should have also received the SNFABN (CMS - ). Resident #64 received the notice of Medicare provide non-coverage (CMS - ) on 01/04/12. At that time the resident had used all of her available Medicare Part A days. The facility did not send the Notice of Exclusions from Medicare Benefits Skilled Nursing Facility (CMS - - NEMB - SNF). This notice should have been provided for technical details. The facility did not need to send the generic notice (CMS - ) because the resident had exhausted Medicare Part A benefits. On 03/08/12, at approximately 10:30 a.m., Employee #78 (registered nurse) indicated she sent out the notices to the above three (3) residents. She indicated she normally sent the generic notice (CMS 0 - ). She said the chart she utilized may not be current. She felt that was the reason she did not send the appropriate notices. II. Based on observation of the facility's required postings and staff interview, the facility had not correctly listed the address of the state licensure and certification agency. This agency serves as the entity where residents / families and others can make complaints regarding unsatisfactory care rendered in long term care facilities. This had the potential to affect all residents residing in the facility. Facility cenus: 55. Findings include: a) Observations on 03/07/12, at approximately 2:00 p.m., of the postings on one (1) information board in the hallway toward the dining room, and on one (1) information board in the hallway as one first entered the building, found inaccuracies in the address of the Office of Health Facility Licensure and Certification (OHFLAC), the agency to which residents or families may contact to voice complaints. One information board, contained the incorrect OHFLAC address of Capitol Street in Charleston, WV. The other information board contained the incorrect OHFLAC address of Davis Street in Charleston, WV. In both cases, there was a potential for visitors, residents, or family members to communicate written grievances to the incorrect address of OHFLAC. Also, one (1) of the two (2) information boards contained conflicting information regarding the identity of the regional ombudsman for residents, family members, or other concerned entities who wished to make contact to report any concerns. In one place on the information board, both the identity and telephone number of the regional ombudsman were listed incorrectly, and on the same board the correct name, address, and telephone number of the current long-term care ombudsman was listed. During an interview with the licensed social worker (SW), on 03/07/12, at approximately 3:00 p.m., the SW acknowledged the information board contained incorrect information as written above, and made the necessary corrections.",2016-01-01
9302,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2011-10-20,156,C,0,1,EWP711,"Based on observation and staff interview, the facility failed to prominently display required information related to how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. This practice has the potential to affect all residents and visitors desiring to view this information. Facility census: 59. Findings include: a) During the initial tour of the facility at the onset of the survey on 10/17/11, this surveyor attempted to view the posting of the required information. The entire facility was toured, and there was no evidence of any posting containing information on how to apply for Medicare and Medicaid benefits. This observation was immediately reported to the administrator (Employee #1) on 10/17/11, who confirmed the information was not posted prominently.",2016-01-01
9310,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2011-10-20,492,C,0,1,EWP711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all dietary staff had current a food handlers permit as required by County ordinance. The food handler's card for one (1) of eight (8) dietary employees was expired. This practice has the potential to affect all residents who consume nutrition from the dietary department. Facility census: 59. Findings include: a) Employee # 77 Review of the dietary staff's food handlers cards found Employee #77's permit had expired on [DATE]. This was brought to the attention of the dietary manager (Employee #8), who verified this employee had been working in the dietary department on an expired permit. On [DATE], the facility provided evidence that Employee #77 had attended the required food service class after this surveyor discovered the expired permit, and her permit was now current.",2016-01-01
9329,CRESTVIEW MANOR NURSING & REHABILITATION,515160,199 COURT STREET,JANE LEW,WV,26378,2011-09-20,356,C,0,1,GVDH11,"Based on observation and staff interview, the facility did not post the required nurse staffing data on a daily basis at the beginning of each shift. This had the potential to affect all residents. Facility census: 62. Findings include: a) Observation at initial entrance to the facility, on 09/12/11 at 11:00 a.m., found the facility's nurse staffing posting on display consisted of a form that had been completed for all three (3) shifts on 09/11/11. Repeated observations of this posting were made throughout the day on 09/12/11. At 5:05 p.m., the facility's director of nursing (DON - Employee #14) confirmed the nurse staffing posting that had been on display throughout the day on 09/12/11 was from the previous day.",2015-12-01
9349,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2011-10-04,156,C,0,1,4F0I11,"Based on observation and staff interview, the facility failed to prominently display in the facility written information about how to apply for and use Medicare benefits and how to receive refunds for previous payments covered by Medicare benefits. This deficient practice had the potential to affect any resident or family member wishing to view the information. Facility census: 51. Findings include: a) On the morning of 09/29/11, observation revealed a bulletin board in the main corridor leading to the kitchen area. The bulletin board contained information on how to apply and use Medicaid benefits and how to receive refunds for previous payments covered by Medicaid, but it failed to contain the same information pertaining to Medicare benefits. On 09/29/11 at 9:20 a.m., the above deficient practice was discussed with the director of nursing, who stated the situation would be corrected.",2015-11-01
9438,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,353,C,0,1,R8P711,"Based on staffing schedule review, staff interview, and review of facility policy, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. The facility was unable to identify a designated charge nurse. This practice has the potential to affect all residents. Facility census: 55. Findings include: a) Review of the facility's nursing schedule for 03/01/11 through 03/31/11 no charge nurse was designated on the schedule. Review of the facility policy titled Unit Charge Nurse Designation revealed the A Hall unit charge nurse on all shifts shall be designated as in charge of the facility at all times. On 03/14/10, an interview with the clinical care supervisor (Employee #78) revealed it was understood by staff that, on evenings and weekends, the nurse on A, B, & D Halls was the charge nurse, and during day shift, each unit nurse manager was in charge of their unit. She further confirmed this was not designated on the schedule.",2015-11-01
9489,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,353,C,0,1,SJCY11,"Based on review of the nursing staffing schedule and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. This had the potential to affect all residents in the facility. Facility census: 84. Findings include: a) Review of the nursing staffing schedule for 02/01/11 revealed no licensed nurse had been designated to serve as charge nurse for each shift. On 02/01/11 at 9:35 a.m., interview with a registered nurse (Employee #8) revealed that each nurse was in charge of there own hallway, but we do not have one specific nurse designated as a charge nurse on the schedule each shift.",2015-11-01
9533,HOLBROOK NURSING HOME,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2011-05-24,356,C,0,1,OXPS11,"Based on observation, review of the facility's staff posting, and staff interview, the facility's nursing staff posting did not follow the acceptable format. The total number of licensed nursing personnel included nursing personnel that did not provide direct care to residents. This had the potential to affect all residents and visitors. Facility census: 103. Findings include: a) Nursing staffing information, observed as posted daily by the facility throughout the survey, included the director of nursing (DON), minimum data set (MDS) nurse, and the staff development nurse. The posting requirement is that the numbers and hours of licensed and unlicensed nursing staff directly responsible for resident care per shift be clearly posted and readily accessible to residents and visitors. The hours worked by the DON, MDS nurse, and staff development nurse should not have been included in these totals. During an interview with the DON (Employee #1) on 05/23/11 at 10:05 a.m., she confirmed that, although the hours worked by the DON, MDS nurse, and staff development nurse were not being included in the posted direct care hours, they were included in the posted total numbers of licensed staff.",2015-10-01
9540,"WEIRTON MEDICAL CENTER, D/P",515077,601 COLLIERS WAY,WEIRTON,WV,26062,2011-02-15,356,C,0,1,PL2X11,"Based on observation and staff interview, the facility failed to ensure that accurate nursing staffing information was posted for the 3-11 shift on 02/06/11, as required. This had the potential to affect any resident or visitor wishing to access nursing staffing data on the skilled nursing unit (SNU). Facility census: 27. Finding include: a) Observations, on 02/06/11 at 6:00 p.m., found the nursing staffing data sheet posted by the elevator of the SNU for the afternoon shift was blank. An interview with the unit secretary (Employee # ) at this time confirmed that the posting had not been updated.",2015-10-01
9547,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,156,C,0,1,5V2011,"Based on observation and staff interview, the facility failed to include the name, address, and telephone number of the State long-term care ombudsman together in its posting of information. This practice had the potential to affect all residents and visitors. Facility census: 157. Findings include: a) On 11/17/09, an observation of the facility's posting in the front lobby, which included names and addresses of individuals who could be contacted for questions related to long term care, revealed the facility had not listed the name of the State long term care (LTC) ombudsman. On 11/20/09 at 4:00 p.m., the administrator agreed the State ombudsman's name needed listed and agreed to change the posting to correct the issue. (NOTE: On 12/02/09, the administrator faxed to the State survey agency a copy of a posting titled Information Services located elsewhere in the facility. While it did contain the State LTC ombudsman's name and telephone number, it did not contain an address. Consequently, an individual who wanted the name, telephone number, and mailing address of the State LTC ombudsman would have had to locate and access both postings to obtain complete contact information.)",2015-10-01
9548,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,158,C,0,1,5V2011,"Based on review of resident funds, staff interview, and the confidential resident group interview, the facility failed to assure residents had access to petty cash on an ongoing basis. This practice had the potential to affect all residents for whom the facility handled funds. At the time of the survey, the facility handled funds for one hundred-twelve (112) residents. Facility census: 157. Findings include: a) On 11/19/09 at 2:30 p.m., residents' accounts were reviewed with the office manager and the staff member who handled resident funds. At that time, it was revealed residents only had access to their personal funds during the facility's regular business hours and for four (4) hours each Saturday and Sunday. This was confirmed during the confidential resident group meeting held on 11/18/09.",2015-10-01
9557,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,356,C,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Review of the POS [REDACTED]. Additionally, the nurse staffing data was not posted in a clear and readable format. These deficient practices had the potential to affect all residents and visitors to the facility. Facility census: 157. Findings include: a) Random observations of the facility entrance, on 11/17/09 at 10:30 a.m., found the facility had posted the nurse staffing data in a locked display case. Review of the POS [REDACTED]. Further review revealed the nurse staff data included three (3) registered nurses (RNs) on the day shift. An interview with the staffing and scheduling coordinator (Employee #145) was conducted at 11:00 a.m. on 11/17/09. When asked about the nature of the job duties performed by the three (3) RNs listed on the posting, she relayed one (1) of the RNs did treatments and the other two (2) were unit managers. When prompted, Employee #145 was unable to state any resident direct care provided by these two (2) RN unit managers. An interview with the unit manager of building 2 (Employee #40), on the afternoon of 11/19/09, elicited what duties the unit manager routinely performed. Employee #40 stated when she first comes on duty, she checks physician's orders [REDACTED]. She relayed that a part of her shift consisted of any intravenous sticks, flushing ports, and occasional feeding of residents at lunch and dinner. The facility posting indicated all duties performed by these two (2) RN unit manager constituted direct care, which was not the case. Further Review of the POS [REDACTED]. When interviewed at 11:00 a.m. on 11/17/09, Employee #145 identified this posting to mean seven (7) LPNs and one (1) treatment nurse. Posting Tx to represent an additional LPN would not be clear to residents and visitors without medical backgrounds. The facility failed to assure that only nurse staffing hours devoted to direct care were posted as required, and failed to assure the staffing data was posted at the beginning of each shift.",2015-10-01
9567,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-10-09,514,C,1,0,9WM911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that all physicians' telephone and/or verbal orders for lab work, and orders to initiated if the resident spiked a fever, were complete and accurately dated and transcribed. This was evident for one (1) of six (6) sampled residents. Resident identifier: #151. Facility census: 148. Findings include: a) Resident #151 Medical record review, on 10/09/12, found a telephone order obtained by nurse Employee #51 from the physician, dated 07/16/12. The physician ordered a urinalysis and culture and sensitivity for Resident #151. On the same physician's orders [REDACTED]. Another physician's telephone order, obtained by Employee #51, dated 07/16/12, directed to begin [MEDICATION NAME] (an antibiotic), 500 milligrams (mg.) daily if the temperature spiked again to 101 degrees. There was no time inscribed on the latter physician's orders [REDACTED]. Review of the July 2012 Medication Administration Record [REDACTED]. one tablet daily if the temperature spikes again to 101 degrees, for urinary tract infection [MEDICATION NAME]. There was no indication on the MAR indicated [REDACTED]. There was no directive on the MAR indicated [REDACTED]. Further review of the MAR found that no doses of [MEDICATION NAME] had ever been administered in July. Review of a history and physical examination [REDACTED]complaint of cough and decreased oxygen saturation.of 56%, and was in respiratory distress. The physician noted in this report the resident had a temperature of 101 degrees two days before the hospitalization , and that he (the physician) had started him on oral [MEDICATION NAME]. The admitting [DIAGNOSES REDACTED]. During an interview with the director of nursing (DON) and the Administrator, on 10/09/12, at approximately 3:30 p.m., the DON said there was no documentation that Resident #151 had ever had a fever in July. She stated her belief was that the nurse, Employee #51, read communication notes about Resident #151 (that were not part of the medical record), and thought he had had a fever on 07/15/12 when he did not. This had prompted her to relay erroneous information to the physician. Based in part on those non-medical record notes, the DON said she also did not believe the nurse transcribed the orders dated 07/16/12 the way the physician intended. The DON agreed the physician did sign the telephone order forms, dated 07/16/12, as the nurse had written them. She acknowledged there were no dates on the telephone physician order [REDACTED]. During a telephone interview with Employee #51, on 10/09/12 at 5:25 p.m., she said she could not recall anything about the resident's fever, what date or shift it may have spiked, or anything about the orders, as it happened too long ago.",2015-10-01
9568,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2011-07-14,156,C,0,1,L3JB11,". Based on observation and staff interview, the facility failed to provide a posting of names, addresses and telephone numbers of all pertinent state client advocacy groups; failed to display a written statement informing residents of their right to file a complaint with the State survey and certification agency concerning abuse, neglect and misappropriation of property and non-compliance with advance directives; and failed to prominently display written information about how to apply for and use Medicare and Medicaid benefits. These practices had the potential to all residents and visitors. Facility census: 114. Findings include: a) On 07/14/11 at approximately 11:42 a.m., observations of the facility's hallways and lobby failed to find postings of necessary information, such as the names, addresses, and telephone numbers of all pertinent state client advocacy groups, a written statement informing residents of their right to file a complaint with the State survey and certification agency concerning abuse, neglect and misappropriation of property and non compliance with advance directives, and written information on how to apply for and use Medicare and Medicaid benefits. At approximately 12:00 p.m., the maintenance supervisor (Employee #89) accompanied the tour of the building and could not locate the signs and postings. He reported these signs were taken down due to the facility's remodeling project. At approximately 2:45 p.m., these signs were located, and the maintenance director said he would ensure they were displayed in the facility.",2015-10-01
9569,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2011-07-14,167,C,0,1,L3JB11,"Based on observation and staff interview, the facility failed to ensure survey results were accessible and available to residents. This practice had the potential to affect all residents and visitors. Facility census: 114. Findings include: a) On 07/11/11 at approximately 11:45 a.m., observation revealed the survey results were not accessible and available for review. The maintenance supervisor (Employee #89) also verified the survey results were not available for review. Employee #89 stated he would locate the survey results book and put it out in a prominent place for residents and others to review. On 07/14/11 at approximately 10:00 a.m., a visitor to the facility had requested to view the survey results book. The book was not accessible to the visitor, and the visitor had to ask someone at the facility to locate the survey results. The administrator said he would locate the survey results for the visitor.",2015-10-01
9618,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,363,C,0,1,I2AU11,"Based on menu review, observation, and staff interview, the facility failed to assure menus were followed. The menu plan called for garnishes for chili; however, the garnishes were not served. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 55 Findings include: a) Review of the menu, for the noon meal on 03/03/10, revealed regular chili was supposed to have a cheese and onion garnish, and pureed chili was supposed to have one (1) tablespoon of cheese sauce on top. Observation of the meal revealed there were no onions on the regular chili and no cheese sauce on the pureed chili. An inquiry was made of the cook who prepared the meal, at 1:00 p.m. on 03/03/10. The cook stated she had not noticed these items on the menu. NOTE: THIS IS A REPEAT DEFICIENCY, HAVING PREVIOUSLY BEEN CITED DURING THE LAST ANNUAL SURVEY ON 01/30/09.",2015-10-01
9619,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,364,C,0,1,I2AU11,"Based on observation, the facility failed to assure cornbread was served at the proper temperature. Both regular and pureed cornbread were served cold. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 55. Findings include: a) Observation of the preparation and service of the noon meal, on 03/03/10, revealed neither the regular or pureed cornbread was held by a method to assure the product was hot upon receipt by the residents. The regular cornbread was removed from the oven, after baking, and left for more than thirty (30) minutes uncovered on an unheated stove top. It was then taken to the steam table and placed on top of a lid on the steam table. The cornbread was not held by any method to maintain a hot temperature. The pureed cornbread was observed sitting uncovered on a sink drain from 10:30 a.m. until it was taken to the steam table at 11:25 a.m. It was also placed on top of a lid on the steam table and was not held by any method to maintain a hot temperature.",2015-10-01
9638,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,203,C,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with six (6) different agencies. This error in the uniform notice may lead a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Additionally, the uniform discharge notice provided incorrect information regarding the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility. Facility census: 105. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: You have the right to appeal this action to: This was followed by the names and contact information of the Office of Inspector General Board of Review, the State Ombudsman, and the Regional Ombudsman. Immediately following the above list of names and addresses was: Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: This was followed by the names and contact information for West Virginia Advocates, Local Mental Health and Medicaid Fraud. This uniform notification form contained the following errors: 1. The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the five (5) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may lead a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc. (not Local Mental Health). Medicaid Fraud does not provide these services.",2015-10-01
9652,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2011-02-02,156,C,0,1,860Y11,"Based on observation and staff interview, the facility failed to ensure the names, addresses and phone numbers of advocacy groups remained posted and accessible at all times to residents and members of the general public. This practice had the potential to affect all residents. Facility census: 59. Findings include: a) Surveyors were unable to find the posted information related to advocacy groups as is required by regulation. Observations, made on 02/01/11, found a bulletin board where other information was located; however, there was no information regarding the names, addresses and phone numbers for all advocacy groups. The surveyor, on 02/01/11 at 10:36 a.m., then questioned the director of nursing (DON - Employee #15) and the administrator (Employee #25) as to where this information might be. After searching for the missing data, the administrator informed the surveyor that it had been found in a notebook that a confused resident (#61) had been given to put paperwork in. This resident had been known to remove posted items from bulletin boards, and staff would be unable to locate them. The facility provided her with a notebook, which would give staff some idea where to begin looking when things were missing. According to the administrator, this happened frequently, and staff would look once a week to see things were posted as necessary. If not, they would search the notebook.",2015-10-01
9782,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,156,C,0,1,2XEX11,". Based upon review of the notices of non-coverage for Medicare skilled services (denial notices) and staff interview, the facility failed to specify the service being denied and/or the reason for the denial in the letter provided by the facility to the resident and/or responsible party, when informing them of services that would no longer be covered under Medicare, for six (6) of (6) sampled notices. Resident identifiers: #97, #34, #16, #66, #161, and #96. Facility census: 57. Findings include: a) Residents #97, #34, #16, #66, #161, and #96 A review of the Notice of Medicare Non-Coverage letters, on 05/31/10, revealed that the only description of services paid for by Medicare that were no longer being covered, for Residents #97, #34, #16, #66, #161, and #96, was skilled nursing services, and none of the six (6) residents' denial notices provided any reason for the denial of Medicare coverage as required. During a discussion with the facility's administrator (Employee #63) on 05/31/10 at 2:00 p.m., she acknowledged the required information was not included. .",2015-09-01
9797,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-09-06,514,C,1,0,EM0I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of shower documentation and staff interviews, it was found that the staff had not maintained systematic records regarding shower administration. The system the facility used was confusing, creating a potential for residents to miss their showers at times. This was a system wide concern and had the potential to affect all residents residing in the facility. Census: 85. Findings include: a) Discussion with facility staff revealed that there was some confusion in how to determine whether a resident received assistance with showers and what type of bath was received (i.e.: bed bath, shower, whirlpool, etc.). Nurse aides were given an assignment sheet with the room numbers of the residents who were to receive baths that day. After completion of the shower, the aide was to fill out a skin report. If the resident refused the shower, they (the aides) were to attempt three (3)times to see if the resident would take a shower and if the resident continued to refuse, determine why. The nurse aid would then record the shower status in the computerized care tracker system. This was to be reported to the nurse who was to also check with the resident and see why the shower was refused. The documentation presented to the surveyor that was printed out from the computer system (ADL-activities of daily living assistance and support report) only showed the level of assistance needed and the amount of staff that assisted. For example, code 4/2 with 4 meaning total dependence on staff for the activity, and 2 meaning one person physical assist. It did not indicate whether it was a shower, bed bath, whirlpool, etc. Confidential interviews with nurse aides, the morning of 09/06/12, also revealed the system did not always show the correct days for the resident to have a shower, and if the resident was moved to a different room, the showers were coded according to room number, not the resident. For example, a resident in room [ROOM NUMBER] might have bath days listed as Mondays and Thursdays. If the resident was moved to room [ROOM NUMBER], the bath days might bed scheduled for Tuesdays and Fridays. This information did not change in the computer system, so if the resident moved to a different room, the shower information did not change to reflect the resident's previously scheduled days. If staff continued to utilize the resident's previous schedule, which may have reflected the resident's preferences, the information recorded in the system would not be accurate. .",2015-09-01
9816,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2012-09-26,356,C,1,0,0YC111,". Based on review of nurse staffing sheets that were posted and by interview with staff, it was determined the staffing forms had not been completed as required at the beginning of each shift. This information is to be posted at the start of each shift for public review. This practice had the potential to affect all residents and the public as this is to be prominently displayed and accessible for their review. Census: 73 Findings include: a) Review of staffing sheets for the past two (2) months revealed that on several days the sheets had been posted without the numbers of staff present for the shift being recorded on the form. Ten (10) forms were reviewed. Of the ten (10) forms reviewed, eight (8) lacked the documentation for one shift and two (2) lacked the documentation for two (2) shifts. b) This was confirmed with Employee #39, the director of nursing, in late afternoon on 09/28/12. .",2015-09-01
9858,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2012-08-10,252,C,0,1,5XH612,". Based on observation, resident interview, and staff interview, the facility failed to present a homelike appearance by failing to make beds in a timely manner and/or to provide an appropriately arranged coverlet for the beds that did not leave the mattress, pillows, and/or incontinence pads exposed at the sides. This condition was observed on every hall and in a significant number of rooms. Facility census: 87. Findings include: a) During the general tour at 1:30 p.m. on 08/06/12, two surveyors observed unmade empty beds on all halls. At 2:30 p.m. on 08/06/12, the Director of Nurses was asked if staffing was adequate on that day and she replied that it was. Beds that were made, were done so crudley with coverlets (blankets or bedspreads) that left the mattress, pillows, and/or incontinence pads exposed at the sides. The bedspreads, when used, were folded in half and simply laid atop the bed linens and pillows. This observation was repeated at 10:45 a.m. on 08/07/12, and was very similar to the previous day. At 11:05 a.m. on 08/07/12, Resident #7 was brought into the room by her daughter in a wheelchair. The resident's daughter stated they were returning from a doctor's appointment outside the facility. Resident #7's bed was closed, with a white thin bedspread folded in half and laid over the top of the sheets and pillow. At the sides an incontinence pad and a lift sheet could be seen, and the cover was not molded around the pillow. When asked if this was how the bed was usually made-up, they stated yes, although both were quick to add that they had no complaints about the care and understood it could not be ""like home"" and the resident would not have to stay there long. During an interview with the Director of Nurses, at 11:20 a.m on 08/07/12, these findings were shared with her and some of the rooms were viewed, including room 137. She stated that she would rectify the situation. .",2015-08-01
9861,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2010-12-02,356,C,0,1,NE1Z11,". Based on observation and staff interview, the facility failed to ensure the posted nurse staffing information included all of the requirements in Federal statute 42 CFR 483.30 (e), by failing to include the number of actual hours worked by nursing staff. This had the potential to affect all residents and visitors. BHJ facility census: 111. Findings include: a) During a tour of the environment at 1:00 p.m. on 12/01/10, the ""Nursing Staffing / Resident Census"" forms were observed posted on each floor. The posting included the facility's name, the current date, the resident census, and the total number of registered nurses, licensed practical nurses, and certified nurse aides. However, the number of actual hours worked by each of these categories of nursing staff were not listed on the form. During an interview with the director of nurses (DON) and the 100 hall nurse manager at 3:50 p.m. on 12/01/10, the DON expressed surprise that the hours were required and stated they had never included them in their posting. At her request, she was provided with the Federal statute 42 CFR 483.30 (e) at 9:00 a.m. on 12/02/10. .",2015-08-01
9880,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-05-09,156,C,1,0,SZNR11,". Based on record review and staff interview, the facility failed to ensure three (3) of three (3) resident's received the appropriate discharge notice, as required by the Centers for Medicare and Medicaid Services (CMS), after they were discharged from a Medicare skilled service. Resident #22, Resident #72, and Resident #39 were all discharged from Medicare Part A skilled services in April 2012. The facility did not issue one (1) of two (2) notices at the time Medicare Part A services ended. Facility census: 77. Findings include: a) Resident #22 This resident was discharged from Medicare Part A, on 04/21/12, due to no further skilled services being available for her. b) Resident #72 This resident was discharged from Medicare Part A, on 04/15/12, due to no further skilled services being available for her. c) Resident #39 This resident was discharged from Medicare Part A, on 04/26/12, due to a completion of antibiotic therapy. d) An interview with Employee #10 (business office manager), on 05/09/12 at 1:00 p.m., revealed these three (3) residents had received the Notice of Non Coverage, CMS form ( ). The generic notice (form ) simply informs the resident of their right to an expedited review of the service termination for coverage reasons. The facility must issue the skilled nursing advanced beneficiary notice to address the resident's potential liability for payment if they remain in the facility. The residents had not received the Skilled Nursing Advanced Beneficiary Notice (SNFABN). According to the business office manager, all three (3) residents remained in the facility under another payer source. The facility needed to give the three (3) residents both notices because all Medicare covered services were ending and the center intended to deliver non-covered care. The SNFABN is given because benefit days remain to inform the resident of potential financial liability. .",2015-08-01
9903,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2012-05-30,514,C,1,0,0XPG11,"Based on record review, staff interview, and policy review, the facility failed to maintain clinical records to show that residents received safe and orderly transfer from the facility, with pertinent communication to the receiving facility and to the resident. Facility policy dictated necessary items to be sent with the resident at the time of discharge, but record review found no evidence of what, if any, portions of the clinical records were sent with the resident when he or she was transferred to an acute care facility. This was evident for three (3) of six (6) sampled residents. Resident identifiers: #129, #127, #107. Facility census: 125. Findings include: a) Resident #129 Review of the ""Acute Care Transfer Document Checklist"" provided by the Director of Nursing (DON) on 05/29/12 at approximately 12:50 p.m., found that seven (7) documents should ""always"" accompany the resident when transferred. These items were the resident transfer form, face sheet, current medication list or current MAR (Medication Administration Record), advance directives, care limiting orders, out of hospital DNR (do not resuscitate), and the bed hold policy. Additionally, there was another section with directives to send other documents if indicated. This included the Nurse's Progress Note, the most recent history and physical, and any recent hospital discharge summary, recent orders related to acute condition, relevant lab results, relevant x-rays, and personal belongings sent with the resident (eyeglasses, hearing aid, dental appliance, or other items). Review of the acute care transfer document checklist form, also found there were lines beside each of the above listed items, and directives to check all that applied. During interview with the DON, on 05/30/12 at 1:00 p.m., she said they do not mark this form; rather, it is their policy of what to send, and is used a as guide. When asked if staff document in the nurses' notes what they send, or any kind of documentation of what they send, she stated probably not. She acknowledged the bed-hold policy and the transfer sheet had copies attached; the resident received the original, and the facility kept the copies on the chart. Record review found that Resident #129 was transferred to an acute care facility on 05/23/12. There was no evidence in her medical record of what, if any, items were sent with her to the acute care hospital, including record of a bed-hold notice. The DON was unable to produce the facility's copy of the bed-hold notice for this discharge. b) Resident #127 Record review found that Resident #128 was transferred to an acute care facility on 05/08/12. There was no evidence in her medical record of what, if any, items were sent with her to the acute care hospital, including the facility's copy of the bed hold notice and the transfer sheet. The DON was also unable to produce the facility's copy of the bed-hold notice or the transfer sheet for this discharge. c) Resident #107 Record review found that Resident #107 was transferred to an acute care facility on 05/02/12. There was no evidence in his medical record of what, if any, items were sent with him to the acute care hospital, including the facility's copy of the bed hold notice and the transfer sheet. The DON was also unable to produce the facility's copy of the bed-hold notice or the transfer sheet for this discharge. .",2015-08-01
9990,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2012-06-15,514,C,1,0,WQ7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to maintain complete documentation of blood sugar results, in the computerized clinical record, for three (3) of four (4) sampled residents who had [DIAGNOSES REDACTED]. In some instances the blood sugar results for sliding scale insulin was omitted entirely in the clinical record. At other times the blood sugar results, if below 201, were not recorded. In these instances, staff only documented the sliding scale insulin dose was held, or was held due to being out of range. The documentation did not denote if the blood sugar was over, below, or at the normal range. Resident identifiers: #87, #96, #95. Facility census: 96. Findings include: a) Resident #87 Record review revealed the following omissions of blood sugar results for June 2012: 1. On 06/12/12 at 5:49 a.m., the blood sugar test result was not recorded. According to documentation, insulin was held, as no coverage was needed. The results would have been somewhere between 0 and 200. 2. On 06/09/12 at 4:30 p.m., blood sugar test results were not recorded. 3. On 06/05/12 at 5:30 a.m., blood sugar test results were not recorded. b) Resident #96 Record review revealed the following omissions of blood sugar results for June 2012: 1. On 06/09/12 at 8:00 p.m., blood sugar test results were not recorded. 2. On 06/07/12 at 8:00 p.m. blood sugar test results were not recorded. According to documentation, insulin was held as no coverage was needed. The results would have been somewhere between 0 and 200. 3. On 06/05/12 at 5:30 a.m., blood sugar test results were not recorded. c) Resident #95 Record review revealed the following omissions of blood sugar results for June 2012: 1. On 06/05/12 at 5:30 a.m., blood sugar test results were not recorded. 2. On 06/03/12 at 4:30 p.m., blood sugar test results were not recorded. During an interview with the Director of Nursing (DON) on 06/14/12 at 2:45 p.m., she said the facility did not have a policy that required a nurse to input the blood sugar readings. She stated she would like to see a pop-up installed, in the computer, to prompt the nurse to enter the blood sugar results. The DON stated the facility formerly used pen and paper, and a treatment record, to document bloods sugars, including the amount of coverage. She said with the computerized documentation, there was no prompting in the program to enter blood sugar readings. .",2015-08-01
10099,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,356,C,0,1,8O9311,"Based upon observations and staff interview, the facility failed to ensure the daily nurse staffing posting contained all required information. This had the potential to affect all residents and visitors. Facility census: 179. Findings include: a) During daily observations throughout the survey, the facility's daily nurse staffing posting was observed to contain the current date and the total number of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs), but it did not the actual hours worked by RNs, LPNs, and CNAs. When interviewed on 10/29/09 at 8:15 a.m., the administrator confirmed the total hours worked by RNs, LPNs, and CNAs were not included on the staffing posting at the facility's entrance. .",2015-06-01
10103,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,490,C,0,1,8O9311,"Based on observations and staff interview, the facility failed to provide services in compliance with applicable Federal and State regulations regarding accepted professional standards and principles that apply to professionals providing services in this facility, by not ensuring the Roster / Sample Matrix (form CMS-802) was provided within one (1) hour after surveyors entered the facility, as required by the CMS Survey Protocol for Long Term Care Facilities. This practice impeded the survey process. Findings include: a) Surveyors entered this facility at 1:30 p.m. on 10/26/09. During the entrance conference, the administrator indicated the facility had been expecting the survey team. The survey team leader provided to the administrator the entrance information prior to conducting the tour and informed the administrator that a completed form CMS-802 was needed as soon as possible (but no later than one (1) hour after entrance), in order for the survey team to select the Phase I sample and begin the survey process. The survey team completed the tour of the facility, and the team leader was not provided with the CMS 802 until 5:00 p.m. During an interview with the administrator at 9:30 a.m. on 10/29/09, it was agreed the completed form CMS-802 was not provided to the survey team in a timely manner.",2015-06-01
10121,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,243,C,0,1,9ELI11,"Based on review of the facility's resident council meeting minutes, the confidential resident group interview, and staff interview, the facility failed to assure a designated staff person responded to the requests and concerns from the residents' group meetings. There was no evidence the facility seriously considered the group's recommendations, attempted to accommodate those recommendations to the extent possible, and/or communicated the decisions to the resident group. This practice had the potential to affect all facility residents. Facility census: 99. Findings include: a) Review of the facility's resident council meeting minutes, on 10/21/09, revealed no evidence the facility responded to resident concerns and/or requests. b) During the confidential resident group interview at 2:00 p.m. on 10/21/09, the residents stated they did not receive responses to their concerns and recommendations. c) At 9:05 a.m. on 10/23/09, an interview with the facility's administrator revealed the facility had no written and/or formal method of documenting and responding to concerns and suggestions from the facility's resident council. .",2015-06-01
10154,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,492,C,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of dietary employees' food handler certificates and staff interview, the facility failed to assure all of dietary employees had current food handler certificates as required by their County health department. One (1) of thirteen (13) dietary employees reviewed did not have a current certificate. This practice had the potential to affect all residents receiving on an oral diet. Employee identifier: #47. Facility census: 101. Findings include: a) Employee #47 Review of the dietary employees' food handler certificates, on [DATE], found Employee #47's food handler certificate had expired in [DATE]. The dietary manager (Employee #149), when interviewed regarding this finding, stated she was aware this employee's food handler certificate had expired. She stated she would ensure this employee attended the County health department's next available class. Employee #149 confirmed that Employee #47 worked on full-time on a regular basis. She stated they ""must have missed her"". This employee repeated the food handlers class during the survey on [DATE], and she was issued a current certificate at that time. .",2015-06-01
10235,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,492,C,0,1,5XSR11,". Based on a review of the consultant pharmacy permit and staff interview, as well as a review of Title 15 Legislative Rule West Virginia Board of Pharmacy Series I Rules and Regulations of the Board of Pharmacy, the facility failed to comply with 15CSR1-23.2.a., which requires a pharmacist providing consultation services to file an application with the Board of Pharmacy for each institution for which consultation services are provided. This practice had the potential to affect all residents in the facility. Facility census: 48. Findings include: a) On 05/25/10, the administrator of the facility provided a copy of the consultant pharmacist's application for license renewal. This application for renewal had the dates of 07/01/10 to 06/30/11. However, these dates were marked out with black ink, and the dates of 07/01/09 to 06/30/10 were replaced. The administrator produced this signed application on 05/25/10, one (1) day after the resurvey began. The consultant pharmacist had not applied for his 2009-2010 consultant pharmacist's license for this facility until 05/25/10. Review of Title 15 Legislative Rule, West Virginia Board of Pharmacy Series 1 Rules and Regulations of the Board of Pharmacy (15CSR1-23.2.a.) found, ""The consultant pharmacist shall file an application with the Board for each institution, place or person to whom consulting services are provided."" On 06/03/10 at approximately 2:00 p.m., the administrator confirmed the consultant pharmacist should have completed his renewal application in a timely manner, and the administrator agreed the facility did not have a pharmacist who held a current license to provide consultative services as required by State law. .",2015-06-01
10244,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,356,C,0,1,5XSR11,". Based on observation, record review, and staff interview, the facility failed to post nurse staffing data as required, to include the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses (RNs), licensed practical nurses (LPNs), and nurse aides. The facility also failed to post the nurse staffing data in a prominent place readily accessible to residents and visitors. This practice had the potential to affect all residents and visitors to the facility. Facility census: 48. Findings include: a) Observation, on 06/02/10, found the nurse staffing data sheet for the facility posted on a cork board located behind the nursing station. The location of this posting was not readily accessible to residents and visitors. Review of the nurse staffing data sheets for 05/30/10 through 06/02/10 found they did not contain a section to capture the total number and actual hours worked by RNs. In an interview on 06/02/10 at approximately 1:00 p.m., Employee #16 (an RN) stated she thought RNs were not included in this posting. However, she agreed to change the posting to reflect the total number and actual hours worked by RNs as well as make the posting more accessible to the public. .",2015-06-01
10250,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,203,C,0,1,FJI611,". Based on record review and staff interview, the facility failed to provide a discharged resident with the correct name and contact information should the resident wish to appeal her discharge from the facility. Instead, the form listed numerous agencies to which to appeal, none of which were correct. This information was lacking for one (1) resident who was discharged , and was found to be the standardized form that was provided for all residents who were transferred or discharged from the facility. This had the potential to affect all discharged and transferred residents in the facility. Resident identifier: #14. Facility census: 109. a) Resident #14 Record review of a discharged resident's medical record, found a Notice of Transfer or Discharge form, with revision date 11/2009. On this form, the discharged resident was informed of the right to appeal the center's decision for transfer or discharge, and listed multiple agencies with their contact information. None of the listed agencies was the correct appeals agency. During an interview with the administrator, on 09/25/12 at 10:00 a.m., she stated this was the facility's standardized form used for all transfers and discharges. She acknowledged the contact name and contact information of the agency to appeal decisions, was absent on the form. .",2015-05-01
10262,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,356,C,0,1,FJI611,"., Based on observation and staff interview the facility failed to post the number and the actual hours worked for the evening of 09/16/12. The facility did not have posted the actual hours and number of licensed and unlicensed staff directly responsible for resident care. This practice had the potential to affect all residents and visitors. Facility census: 109. Findings include: a) The facility was entered on 09/16/12 at approximately 5:30 p.m. During tour of the facility, it was discovered the facility did not have the numbers posted for licensed and unlicensed staff responsible for providing care to the residents. This finding was confirmed with Employee #99 (staffing coordinator) and Employee #46 (administrator) on 09/16/12, upon visual observation of the daily staffing sheet. .",2015-05-01
10269,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,514,C,0,1,FJI611,". Based on observation and staff interview, the facility failed to maintain complete clinical information which was readily accessible for resident care. Review of the facility's medical records found less than two (2) months of clinical information in residents' charts. This practice affected all residents on the QIS survey sample. Additionally, the facility continued to document nursing information on a resident who was discharged from the facility. Resident identifier:#12. Facility census: 109. Findings include: a) Thinning of Medical Records Observation of the medical records for residents during the entire survey beginning on 09/16/12, discovered only one (1) month and seventeen (17) days of nursing information was accessible on the residents' medical records. According to the facility's ""Active Medical Record Index With Thinning Guidelines,"" the facility was supposed to leave three (3) months of current nursing information on the chart. On 09/26/12, at approximately 1:15 p.m., Employee #83 (medical records director) stated, ""Sometimes the charts get too full and I have to thin them."" b) Resident #12 Review of the medical record found this resident was discharged to home on 08/03/12. Further review of the nurses' notes found nursing staff continued to document in this resident's medical record, after the resident no longer resided in the facility, as though the resident was in the building on 08/05/12 and 08/06/12. Both nursing notes referenced, "" ...call light within reach. "" The administrator and the director of nursing were made aware of the above situation on 09/20/12 at 10:30 a.m. No further information was provided by the facility.",2015-05-01
10304,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,492,C,0,1,MM9U11,". Based on record review and staff interview, the facility failed to provide the opportunity to request a demand bill for residents who were discontinued from Medicare-covered skilled services, as required to comply with 42CFR489.21(b). This practice affected all residents who were discontinued from Medicare-covered skilled services. Facility census: 34. Findings include: a) Review of the information provided residents who were discontinued from Medicare-covered skilled services, with the social worker (SW - Employee #30) on 05/11/10, revealed the facility was not providing the residents or their responsible parties an opportunity to request a demand bill when skilled services were discontinued. At that time, the SW provided copies of the letters sent, which did not include the information required to request a demand bill. He was unaware of any other forms required, and the facility had not been providing these notices to applicable Medicare residents. Therefore, no resident was offered the opportunity to request a demand bill. .",2015-05-01
10438,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,203,C,0,1,Z0GS11,"Based on review of the uniform notice provided to residents at the time of transfer / discharge related to their right to appeal that transfer / discharge, the facility failed to provide accurate information as stated in this requirement. Several agencies were erroneously identified in this uniform notice. This practice has the potential to affect all residents of the facility. Facility census: 93. Findings include a) Review of the facility's ""Notification of Transfer or Discharge"", which was provided by the facility to all residents upon transfer / discharge from the facility, revealed the document did not provide the correct information for a resident wishing to appeal the transfer / discharge decision. The required information, as stated in Federal regulation, includes the name, address, and telephone number of the State long-term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals. The uniform notice provided by the facility erroneously identified, as agencies to which an appeal of a transfer / discharge decision may be made, Adult Protective Services, Legal Aid Society, State Board of Regents, and the area long term care ombudsman. The last page of the information incorrectly directed that a copy of the appeal be sent to OHFLAC (Office of Health Care Licensure and Certification) and to the Office of Medical Services; there is no statutory requirement for copies of appeals to be sent to either of these offices. The sole State agency having the authority to rule on appeals of a transfer / discharge decision in West Virginia is the Board of Review within the Office of Inspector General, which was not correctly identified anywhere in the facility's uniform notice. .",2015-04-01
10454,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,167,C,0,1,924C11,"Based on staff interview and observation, the facility failed to post the most recent survey results for examination. This practice has the potential to affect all residents, their legal representatives, and members of the general public wishing to review this information. Facility census: 153. Findings include: a) Review of a binder located in the lobby area of the facility and labeled ""Survey Result: found the binder only contained the results from a recent complaint survey. The binder did not contain the results of the facility's last annual standard survey and all complaint investigations conducted from the date of the last annual survey (05/08/08) to the present. This was brought to the attention of the administrator on the early afternoon of 08/13/09, at which time he verified the results of the last annual survey were missing from the binder. He related that someone must have removed the full set of survey results and he would replace the report. .",2015-03-01
10488,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,249,C,0,1,D1B011,"Based on personnel file review and staff interview, the facility failed to employ the services of a qualified activities director. This practice has the potential to affect all residents, as this individual coordinates all activities for all the residents in the facility. Facility census: 60. Findings include: a) Personnel record review revealed the individual currently employed in the capacity of activities director did not possess any of the credential that would qualify this person to serve in that capacity. When this was discussed with the administrator at different times on 08/18/09 and 08/19/09, the administrator related the individual currently employed as the activities director would be completing an on-line course but had not started any lessons. This was also confirmed with the activities director on the early afternoon of 08/19/09, when she brought the surveyors computer printouts of what on-line course she would be taking in the future.",2015-03-01
10492,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,356,C,0,1,D1B011,"Based on observation and staff interview, the facility failed to ensure the daily posting of nursing staff was updated at the beginning of each shift. The posting was not completed for evening shift at 6:05 p.m. on 08/17/09. This posting is to allow the residents and visitors to know how many staff members are caring for the residents at any given time. Facility census: 60. Findings include: a) Review of the nurse staffing data at 6:05 p.m. on 08/17/09 found the evening shift (3:00 p.m. to 11:00 p.m.) staffing data had not been posted. The administrator, when made aware on 08/17/09 at 7:30 p.m. that this posting was blank for the evening shift, confirmed it should have been completed at the beginning of the shift. .",2015-03-01
10551,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,356,C,0,1,938011,"Based upon observation and staff interview, the facility failed to ensure the daily nurse staffing posting was posted in a clear and readable format. This has the potential to affect all residents and visitors. Facility census: 65 Findings include: a) Daily observations, throughout the survey, found the facility nurse staffing data posting lying on its side in a single pocket wall file which contained many old posting sheets behind the current copy. There was no signage to indicate what the paper was. During an interview with the facility's administrator (Employee #77) on 10/21/09 at 11:30 a.m., there was discussion about concerns expressed during resident interviews, family interviews, and the resident group meeting regarding staffing levels in the facility. It was explained that the posting should be clear, readable, and prominently located in order to make accurate staffing information accessible to residents and visitors. Subsequent observations, following the interview with the administrator and up until exit, revealed no changes were made in the manner of the nursing staffing data posting. .",2015-02-01
10623,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,167,C,0,1,GCMN11,". Based on observation and staff interview, the facility failed to assure the facility's survey results were posted in an area that was accessible to all residents. The results that were in the posting did not include the deficiencies cited during complaint investigations that were conducted since the facility's last standard annual survey. This practice had the potential to affect all residents who desire to review the facilities survey results. Facility census: 83. Findings include: a) Observation of the facility's publicly posted information, on the morning of 12/01/10, found the facility's survey results were posted between the two (2) front double doors in an area where most of the residents were not permitted. Review of the survey results that were posted found they did not contain the results of complaint investigations that had been conducted since the facility's last standard annual survey, during which the facility was cited deficiencies. The administrator was notified of this finding at 12:45 p.m. on 12/08/10. She verified the survey results that were posted were not complete and were not posted in an area that was accessible to all residents. .",2015-01-01
10637,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,356,C,0,1,GCMN11,". Based on observation and staff interview, the facility failed to assure the required information regarding nursing staffing was posted at the beginning of each shift. The census and/or the hours actually worked were not posted in a clear and readable format. Seventeen (17) days was reviewed, and there were twenty (20) shifts for which no information was available on these postings. This information is provided so residents and the public can review the facility's staffing patterns at any given time. The practice of not posting complete and accurate information has the potential to affect all residents and visitors who would like to review the staffing. Facility census: 83. Findings include: a) Observation of the facility's posting of nurse staffing data, on 12/08/10 at 10:30 a.m., found it did not contain the hours actually being worked at that time. The posting is required to be updated at the beginning of each shift; therefore, this posting should have been completed at 7:00 a.m. Further review of the facility's nurse staffing data sheets found there were twenty (20) shifts in the last seventeen (17) days that had not been posted. The staffing sheets did not record the census at the beginning of each shift and the actual hours worked by the nursing staff responsible for care per shift. The registered nurse supervisor (Employee #20) was made aware that the posting was not being completed as required. .",2015-01-01
10644,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,492,C,0,1,GCMN11,". Based on staff interview and review of individual food service workers' permits, the facility was not in full compliance with local laws regarding food handler's cards. One (1) of ten (10) dietary employees, who was currently working, had an expired food handler's card. This is a local requirement for the county in which the facility is located. This practice had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 83. Findings include: a) During the survey, each dietary employee's food handler's card was reviewed. No card was available for Employee #111. The dietary manager (Employee #68) was asked to determine if Employee #111 had a current food handler's card. Employee #68 reported that Employee #111's food handler's card was expired and that she was now scheduled to renew the card. .",2015-01-01
10651,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,356,C,0,1,W65Z11,"Based on observation and staff interview, the facility failed to assure the nursing staffing data were current and posted on a daily basis at the beginning of each shift. The posting was not complete for the evening shift at 5:30 p.m. on 08/24/09. This posting was to allow the public visitors to know how many staff members are caring for the residents at any given time. Not posting this information has the potential to affect anyone who would like to review the facility's current staffing. Facility census: 60. Findings include: a) Review of the required posting for the number of caregivers in the facility and the hours worked, at 5:30 p.m. on 08/24/09, revealed the evening shift (3:00 p.m. to 11:00 p.m.) nursing staffing data had not been posted. The nurse (Employee #10) was made aware this posting was blank for the evening shift, and she confirmed it should have been completed at the beginning of the shift. She completed the information at 5:32 p.m. .",2015-01-01
10670,CRESTVIEW MANOR NURSING & REHABILITATION,515160,P.O. BOX 967,JANE LEW,WV,26378,2010-10-04,492,C,0,1,K6RU11,". Based on review of sampled personnel records and staff interview, the facility failed to ensure employees were notified of the Central Abuse Registry in accordance with WV Code 15-2C-2 for five (5) of five (5) personnel records reviewed. Facility census: 68. Findings include: a) A review of five (5) sampled employees' personnel records, conducted with an administrative assistant (Employee #29) on the afternoon of 10/04/10, found each personnel record contained a document signed by the employee indicating they had been informed of the Central Abuse Agency. When Employee #29 was asked to provide a copy of the information given to the five (5) sampled employees, she provided a copy of the Nursing Home Licensure Rule (WV Legislative Rule 64-13), not the Central Abuse Registry notice found in WV Code 15-2C-8. .",2015-01-01
10685,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2009-07-02,356,C,0,1,DBCB11,"Based on observation and staff interview, the facility failed to ensure the daily nursing staffing posting was in compliance with the posting requirement set forth by section 941 of BIPA (benefits improvement and protection act) specified as sections 1819 (b)(8) and 1919 (b) (8) of the act. This practice has the potential to affect both residents and visitors to the facility. Facility census: 81. Findings include: a) On 07/01/09 at approximately 4:00 p.m., observation of the facility's nursing staff form, posted in the hallway of the first floor, revealed the facility had not updated the form to reflect the number of licensed / unlicensed nursing staff working on the evening shift. In addition, the facility did not have the total number of actual hours worked each day by nursing staff who were directly responsible for resident care. The director of nursing, when informed of the issue on 07/01/09 at approximately 4:30 p.m., indicated she was having a meeting the the nurse who was responsible for updating the staffing sheet on the evening shift. She reported she was unaware the form needed to reflect the total number of hours worked each day by direct care nursing staff.",2015-01-01
10688,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2009-07-02,156,C,0,1,DBCB11,"Based on observation and staff interview, the facility failed to post all complete contact information for all applicable State advocacy agencies as required by the regulation. Only the regional ombudsman's name and contact information were posted for public view. This has the potential to affect all residents as all residents and families are to have access to this information. Facility census: 81. Findings include: a) On 07/01/09 at 2:30 p.m., review of posted contact information of all pertinent State client advocacy groups, observed on the third floor of the facility, revealed only the name, address and telephone number of the regional ombudsman. Phone numbers were listed for other agencies, but not addresses. Discussions with the administrator, on the afternoon of 07/01/09 and again on the morning of 070/2/09, revealed the addresses and phone numbers of the other advocacy groups were not posted in any other locations of the facility as well. The following information was omitted from the public postings: - The contact information for the State survey and certification agency (which is also the State licensure office); - The contact information for the State long-term care ombudsman; - The contact information for the protection and advocacy network; - The contact information for the Medicaid fraud control unit; and - A statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. .",2015-01-01
10748,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2009-07-22,492,C,0,1,UHKM11,"Based on observation, facility records, and staff interview, the facility failed to post the nurse staffing as required by Section 941 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), which requires skilled nursing facilities and nursing facilities to post daily for each shift the number of registered nurses, licensed practical nurses, and unlicensed nursing staff directly responsible for resident care in the facility. This had the potential to affect all residents. Facility census: 122. Findings include: a) During the general tour at 1:00 p.m. on 07/20/09, observation revealed the nursing staffing posting contained only the number of licensed and unlicensed staff and total full-time equivalents (FTEs) for each shift. The posting failed to differentiate the categories of nursing staff by differentiating between licensed practical nurses and registered nurses. During an interview with the administrator and the director of nurses at 4:00 p.m. on 07/22/09, this lack of information was pointed out and they were given the source of the requirement.",2014-12-01
10754,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,226,C,0,1,667111,"Based on a review of the facility's policy titled ""reporting abuse"" and staff interview, the facility failed to ensure its ""reporting abuse"" policy addressed the identification, reporting, and prevention of resident neglect. This practice had the potential to affect all facility residents. Facility census: 75. Findings include: a) On 06/23/09 at approximately 10:00 a.m., the facility's policy titled ""reporting abuse"" was reviewed. The policy did not identify what constituted resident neglect, nor did it address how, when, or who would report such situations within the facility, and to what State agencies they would be reported outside of the facility. The policy also did not explain how the facility would prevent neglect from occurring. The policy basically only gave an understanding on what constituted abuse and how the facility would proceed with identifying, preventing, and reporting allegations involving abuse. The facility social worker and director of nurses both agreed the policy did not address allegations of resident neglect, including identification, reporting, and prevention. .",2014-12-01
10800,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,522,C,0,1,7F5X11,"Based on interview and e-mail correspondence with a representative of the Office of Health Facility Licensure and Certification (OHFLAC) and information learned at a sister facility, it was determined the facility had not provided written notice to the State agency responsible for licensing the facility at the time of a change of the facility's director of nursing. All residents had the potential to be affected. Facility census: 86. Findings include: a) During survey at a sister facility in the latter part of August 2009, a staff member had commented that Employee #44 was now the director of nursing (DON) at Marmet Center. Another surveyor had also heard of the change of DON at the facility. Prior to beginning the survey of this facility, an e-mail had been sent to OHFLAC to ascertain who the current administrator and DON were. The return e-mail named another individual as the DON. The office had not received notification of the change in DONs. A representative of OHFLAC contacted the facility and learned the DON was now Employee #44, but notification had not been made to OHFLAC at the time of the change as required.",2014-12-01
10811,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,364,C,0,1,7F5X11,"Based on observation, menu review, and staff interview, the facility failed to assure meals were attractive. Foods planned on the menu were all of one (1) color. In addition, no garnishes were planned for residents who required mechanically altered or pureed diets. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 86. Findings include: a) Observation during the noon meal, at 11:20 a.m. on 09/23/09, revealed the meal which was planned and served included sausages, french fries, and bean and vegetable salad. The menu called for sliced pears with gelatin sprinkles, but apples were substituted. All the foods were white to brown in color. No garnishes were used. In addition, garnishes were not planned for any meals except those of regular consistency. No garnishes were planned for mechanically altered or pureed meals. At 11:30 a.m., an interview was conducted with the dietary manager (DM), regarding the appearance of the meal. At that time, the DM confirmed the planned meal did not have variety in color. When asked about garnishes, the DM confirmed that all residents should have the benefit of an attractive meal presentation, through the use of garnishes, no matter what consistencies they might require. .",2014-12-01
10812,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,282,C,0,1,7F5X11,"Based on staff interview, the facility failed to assure nursing assistants have available information to provide individualized care and services, in accordance with each resident's care plan. This practice has the potential to affect all facility residents. Facility census: 86. Findings include: a) An interview was conducted with a nursing assistant (NA) at 9:00 a.m. on 09/22/09, regarding how the NAs know the specific care plan interventions for each resident, which they (the NAs) were to implement. The NA stated, ""The nurses tell us."" Further interview revealed the NAs had nothing in writing, such as a cardex or other type of individualized tool to which they could refer, to assure each resident was provided care and services as ordered. On 09/22/09 at 10:00 a.m., the director of nursing (DON) confirmed the facility did not have a method in place to provide the nursing assistants information regarding the individualized care for each resident. The DON stated the facility had been discussing the need to put something like this in place. During the afternoon of 09/22/09, the DON provided a description of a form the facility was considering implementing. .",2014-12-01
10833,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,156,C,0,1,L59911,"Based on observation and staff interview, the facility failed to post accurate information regarding the State licensure office. This practice had the potential to affect all facility residents. Facility census: 48. Findings include: a) Observation of facility postings, at 4:00 p.m. on 08/13/09, revealed the address for the Office of Health Facility Licensure and Certification (OHFLAC) was incorrect. Additionally the posting did not state that residents could file a complaint with OHFLAC, but stated that this was the agency to whom the residents should address ""appeal rights"". This was brought to the attention of the social worker (SW) at 4:05 p.m. on 0/13/09. The SW stated the posted information had just been revised and the wrong form must have been posted. .",2014-12-01
10847,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,492,C,0,1,ZHEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and review of individual food service workers' permits, the facility failed to fully comply with local laws regarding food handler's cards. One (1) of twenty-eight (28) current dietary employees had an expired food handler's card. This is a local requirement for the county in which the facility is located. This practice had the potential to affect all residents who received nourishment from the dietary department. Employee identifier: #178. Facility census: 95. Findings include: a) On [DATE], each current dietary employee's food handler's card was reviewed. No card was available for Employee #178. The administrator (Employee #19) was asked to determine if Employee #178 had a current food handler's card. During the afternoon of [DATE], the administrator reported Employee #178's food handler's card had expired and she would no be working in the dietary until she had obtained a new food handler's card.",2014-12-01
10875,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2009-06-17,249,C,0,1,GPSU11,"Based on staff interview and personnel file review, the facility failed to employ the services of a qualified professional to oversee the activities program. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #12. Facility census: 100. Findings include: a) Review of sampled personnel records, on 06/16/09 at approximately 10:00 a.m., revealed the facility's current activity director (Employee #12) did not have evidence to reflect she was qualified, by education or experience, to serve in this capacity. In an interview, Employee #12 reported she had completed a State approved training course which would have qualified her to perform the duties of an activity director; however, she could not locate any documents verifying course completion. The administrator indicated he was aware Employee #12 could not locate proof of her certification as an activity director. .",2014-11-01
10887,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,514,C,0,1,4I6911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure medical records were accurate and legible. This was true for four (4) of twenty (20) sampled residents. The facility's process for recording physician telephone orders failed to ensure legible writing for future review and reference. The facility's utilization of a carbon copy method to record physician telephone orders resulted in illegible orders until such time as the physician signed the original top portion and the signed orders were placed in the chart. This practice has the potential to affect all residents whose physician may phone in orders. The facility also failed to ensure physician orders [REDACTED]. Resident identifiers: #38, #63, #98, and #110. Facility census: 110. Findings include: a) Resident #38 Resident #38's medical record, when reviewed on 12/08/09 at 9:00 a.m., revealed a physician's telephone order dated 12/07/09, which was illegible. Review of the monthly recapitulation (recap) of physician orders [REDACTED]."" The December 2009 Medication Administration Record [REDACTED]. po q6hrs d/t (due to) anxiety."" In an interview on 12/08/09 at 10:45 a.m., the director of nurse (DON - Employee #118) acknowledged the physician's orders [REDACTED]. The DON stated there was a ""transcription error"" and the physician will write a new order to clarify. b) Resident #63 Resident #63's medical record, when reviewed on 12/10/09 at 9:45 a.m., revealed the physician's telephone orders for 12/02/09 and 12/07/09 were illegible. c) Resident #98 Resident #98's medical record, when reviewed on 12/10/09 at 10:00 a.m., revealed the physician's telephone order for 12/09/09 was illegible. d) Resident #110 Resident #110's medical record, when reviewed on 12/10/09 at 9:45 a.m., revealed the physician's orders [REDACTED]. e) The DON, when interviewed on 12/10/09 at 10:00 a.m., acknowledged the above physician's telephone orders were illegible and stated the facility plans to use a different form for recording them in the future.",2014-11-01
10945,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,156,C,0,1,T34S11,"Based on observation and staff interview, the facility failed to post accurate information regarding the regional ombudsman. This practice had the potential to affect all residents. Facility census: 86. Findings include: a) During the initial tour of the facility on 05/18/09 at approximately 3:45 p.m., observation revealed the signs posted in the front lobby area of the building contained the incorrect telephone number and no name listed for the regional ombudsman. Other signs containing this same type of information were posted in various locations throughout the building and did have to correct information related to the regional ombudsman. At approximately 5:00 p.m. on 05/18/09, the administrator agreed the sign in the front area of the building needed to be corrected. .",2014-11-01
11004,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-08-17,492,C,1,0,2TQ312,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the statement of deficiencies and plan of correction (CMS-2567) from the 06/09/11 complaint investigation # , staff interview, and review of WV Legislative Rule 10-2, the facility failed to report to the West Virginia State Board of Examiners for Licensed Practical Nurses when five (5) of five (5) licensed practical nurses (LPNs - Employees #74, #58, #73, #59, and #51) failed to report knowledge of abuse of facility residents. This deficient practice did affect four (4) facility residents and had the potential to affect all residents currently residing in the facility. Resident identifiers: #12, #62, #30, and #60. Facility census: 58. Findings include: a) Employee #74 Review of the CMS-2567 from the 06/09/11 complaint investigation # found that an internal investigation conducted by the facility during the month of January 2010 determined LPNs at the facility had knowledge of abuse perpetrated against residents by another LPN identified as Employee #81. In a witness statement obtained by the facility on 01/22/10, Employee #74 admitted having knowledge of Employee #81 recording the screams, curses and other noises made by Resident #12 when Employee #81 digitally removed a fecal impaction without a physician's orders [REDACTED]. Employee #74 further admitted having knowledge of Employee #81 giving residents too many laxatives and referring to the administration of 4 [MEDICATION NAME], 30 cc [MEDICATION NAME] and 30 cc Milk of Magnesia, without a physician's orders [REDACTED]. Employee #74 further admitted having knowledge of Employee #81 allowing unlicensed and untrained nursing assistants (NA) to administer insulin, do finger sticks, and administer medications. Employee #74 did not report this knowledge of abuse immediately as required. -- b) Employee #58 In a witness statement obtained by the facility on 01/22/10, Employee #58 admitted having knowledge of Employee #81 allowing unlicensed and untrained NAs administer medications and finger sticks for glucose levels. She further admitted having knowledge of Employee #81 getting some of the residents ""rowled"" up and laugh about it. -- c) Employee #73 In a witness statement obtained by the facility on 01/23/10, Employee #73 admitted having knowledge of Employee #81 recording the sounds made while having an impaction digitally removed. She admitted having knowledge of Employee #81 holding Resident #12's nose to give medications when she would not take them. Employee #73 further admitted having knowledge of Employee #81 taking a resident who was frightened of water (Resident #62) to the shower and spraying cold water into the resident's face. Employee #73 did not report this knowledge of abuse by Employee #81 as required. -- d) Employee #59 In a statement obtained by the facility on 01/23/10, Employee #59 admitted having knowledge of Employee #81 recording the sounds made by Resident #12 during the removal of an impaction and playing it for other employees. Employee #59 admitted knowledge of Employee #81 pouring cold water on Resident #59, and picking Resident #60 up and throwing her into the bed until she hit the wall. Employee #59 did not report this knowledge of resident abuse as required. -- e) Employee #51 In a statement collected by the facility on 01/23/10, Employee #51 admitted having knowledge of Employee #81 abusing facility residents. Employee #51 did not report this abuse as required. -- f) Review of the facility's abuse and neglect reporting found the five (5) LPNs who failed to report knowledge of abuse were not reported to the LPN licensing board for failing to follow established policies and procedures in the practice setting to safeguard patient care (Title 10 Legislative Rules West Virginia State Board of Examiners for Licensed Practical Nurses Series 2 Policies Regulating Licensure of the Licensed Practical Nurse, section 10-2-12.1.e12. -- g) Interviews with the director of nursing (DON) and the administrator, on the morning of 08/17/11, confirmed that the facility did not report Employees #74, #58, #73, #59, and #51 to the Board of Examiners for Licensed Practical Nurses for their failure to report their knowledge of resident abuse to prevent further abuse by Employee #81.",2014-10-01
11119,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2011-04-19,492,C,1,0,X5LS11,". Based on review of sampled employee files and staff interview, the facility failed to provide to each nurse aide in its employ a copy of WV Legislative Rule 69-6 (Nurse Aide Abuse Registry rule) as required by Section 8 of that law. This was evident in four (4) of eight (8) employee files reviewed. Employee identifiers: #70, #75, #76, and #77. Facility census: 65. Findings include: a) Employees #70, #75, #76, and #77 According to ?69-6-8. Facility Notice and Record Keeping: ""8.1. Facilities shall provide a copy of this rule to each Nurse Aide on their staff and to each Nurse Aide at the time of hiring and keep signed proof that each Nurse Aide has received a copy of the rule."" When reviewed on the morning of 04/19/11, the personnel files of four (4) of eight (8) sampled nurse aides (#70, #75, #76, and #77) did not contain evidence that copies of the Nurse Aide Abuse Registry rule as required by that law: - Employee #70 (hired 10/18/10), - Employee #75 (hired 12/23/10), - Employee #76 (hired 12/23/10), and - Employee #77 (hired 01/11/11). Other sampled employees (#16, #29, #52, and #55) did have a signed form in their personnel file stating they acknowledged receiving a copy of Nurse Aide Abuse Registry rule. These were nurse aides who had been employed by the facility prior to July 2010. Discussion with the staff development coordinator (Employee #64), at 12:10 p.m. on 04/19/11, revealed she was the individual responsible for completing new employee orientation. She stated she had not been giving that documentation since she began working in that position in August 2010. This was also discussed with the administrator (Employee #62) at 12:30 p.m. on 04/19/11. She verified the information had not been given to nurse aides as required.",2014-08-01
11159,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-03-30,356,C,1,0,JH3J11,". Based on observation and staff interview, the facility failed to post nurse staffing data on a daily basis at the beginning of each shift, as required. This practice has the potential to affect all residents and public desiring to access to this information. Facility census: 94. Findings include: a) On the morning of 03/28/11 at 8:00 a.m., the surveyor was checking for nurse staffing information that is to be posted. When questioned, the executive director (ED) escorted the surveyor to a signboard close to the entry of the East side hallway, stating this was where that information was to be located. The signboard was empty / blank of any information. The ED then proceeded to ask the nurse who was passing medications on East side (Employee #66) where the staffing information was. The nurse replied that she usually posted the information after she gets through with her medication pass. The ED asked the nurse to post it now. It was then posted at 8:08 a.m. Again on the morning of 03/30/11, the nurse staffing information had not been posted on the designated board as of 8:30 a.m. when the shift begins at 7:00 a.m. The regulation states the information regarding nurse staffing is to be posted at the beginning of each shift. .",2014-07-01
11197,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-03-17,356,C,1,0,JBHR11,". Based on observation and staff interview, the facility failed to post the nurse staffing data as required by the regulations. This practice had the potential to affect all residents / visitors at this facility wishing to view the staffing information. Facility census: 146. Findings include: a) On 3/8/11 at 10:30 p.m., the facility was entered to conduct a complaint investigation. The nurse staffing data were unable to be located for 03/08/11. When interviewed at approximately 11:15 p.m. on 03/08/11, the director of nursing (DON - Employee #13) stated the posting was on the door leading into her office. When the surveyor observed the posting with the DON, the posting was dated 03/07/11. The DON verified that a posting had not been completed for 03/08/11. .",2014-07-01
11199,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-05-19,156,C,1,0,7YYR11,". Based on observation, review of the facility's procedure for filing complaints, and staff interview, the facility failed to post the correct mailing address for contacting the State survey and certification agency and failed to provide clear and concise information to residents and the public on how to file a complaint with that agency. This practice had any residents, legal representative, or member of the general public wishing to file a complaint with the State. Facility census: 61. Findings include: a) The bulletin board posting in the front lobby of the facility gave an incorrect mailing address listed for the Office of Health Facility Licensure and Certification (OHFLAC - the State survey and certification agency). b) The same bulletin board also contained a posting of how to file complaints. This was a facility-originated form informing residents / legal representatives of the steps to follow if they wanted to report complaints. The information was unclear as to how to make a formal complaint to OHFLAC when an individual believed this action was necessary. c) In an interview with the administrator (Employee #59) and the director of nursing (DON - Employee #54) at 12:30 p.m. on 05/19/10, both agreed the posted address for OHFLAC was incorrect. Both employees also agreed the posted form for making in-house complaints did not clearly address who to contact at the State level to file a complaint. .",2014-07-01
11206,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,492,C,0,1,TDS111,"Based on record review and staff interview, the facility staff failed to accurately complete the forms CMS-672 and CMS-802 as part of the survey process. These two (2) documents, which were computer-generated based on data entered by staff into the resident assessment instruments, were found to contain conflicting information concerning the residents' care needs. This was found to be a systems problem and had the potential to affect all residents for whom minimum data set (MDS) assessments had been completed. Facility census: 116 Findings include: a) Review of the facility-generated form CMS-802 (Resident Roster) revealed care areas that were identified on this form as problems for the residents did not also appear on the form CMS-672 (Resident Census and Conditions of Residents). As the information on both forms was to pull from the same data entered by staff into the residents' MDS assessments, these data should not be in conflict with each other. Example: According to the CMS-802, two (2) residents were receiving hospice services. According to the CMS-672, five (5) residents were receiving hospice services. When the administrator brought a handwritten list of names of persons receiving hospice, it contained six (6) residents. Discussion with the MDS coordinator (Employee #22), the director of nursing, corporate staff, and the administrator, at different times throughout the survey, revealed the unit managers were to enter MDS information into the computer and update that information as needed. The nurses and MDS coordinator then were to enter the final totals into the CMS-672. Unit managers were not updating the MDS and the CMS-672 at the same time. One was being updated but not the other, which resulted in the different totals. This was found to be a systems problem, and corporate staff indicated it would be corrected with inservicing and additional training. .",2014-07-01
11220,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-03-16,253,C,1,0,81RJ11,". Based on observations and staff interview, the facility did not provide effective housekeeping services to maintain a clean environment for all residents. Facility census: 116. Findings include: a) An observation of the facility's hallways in the front of the building and on each unit, on 03/15/11 beginning at 3:00 p.m., revealed built-up debris along the cove base and in the corners of the floor on the hallways. An interview with the administrator, on 03/16/11 at 9:30 a.m., revealed the housekeeping staff had cleaned along the baseboards and in the corners of each hallway about three (3) months ago. She stated, ""These areas are very hard to keep clean."" .",2014-07-01
11238,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,203,C,0,1,Q61611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with five (5) different agencies. This error in the uniform notice may led a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Additionally, the uniform discharge notice provided incorrect information regarding the current State long-term care (LTC) ombudsman, who has held this position since May 2008, and the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility. Facility census: 55. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: ""You have the right to appeal this action to:"" This was followed by the names and contact information of the Office of Inspector General Board of Review, the State Ombudsman, and the Regional Ombudsman. Immediately following the above list of names and addresses was: ""Or, for the resident with developmental disabilities or those who are mentally ill, you may contact:"" This was followed by the names and contact information for ""West Virginia Advocates Local Mental Health"" and ""Medicaid Fraud"". This uniform notification form contained the following errors: 1. The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the four (4) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may led a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The name of the State LTC ombudsman was incorrect. The current State LTC ombudsman assumed the position in May 2008, and the facility's uniform notice was not revised to reflect this. 3. The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is ""West Virginia Advocates, Inc."" (not ""West Virginia Advocates Local Mental Health""). ""Medicaid Fraud"" does not provide these services. .",2014-07-01
11241,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,465,C,0,1,Q61611,"Based on observations and testing conducted on 08/04/09 and 08/05/09, the facility failed to provide a safe, functional environment with respect to resident room toilets. Facility census: 58. Findings include: a) Observations and testing, conducted on 08/04/09 and 08/05/09, found the facility had installed toilet seat risers to the low type toilets in an effort to accommodate the needs of the resident in each resident rest room. The seat risers were found to move and be unstable, creating a potential fall hazard for the residents. .",2014-07-01
11283,RAVENSWOOD VILLAGE,515177,200 RITCHIE AVENUE,RAVENSWOOD,WV,26164,2010-09-01,514,C,1,0,NING11,". Based on a review of activities of daily living (ADL) flow charts, medical record review, and staff interview, the facility failed to ensure each resident's medical record was complete and accurate. Four (4) of four (4) sampled residents' ADL flow charts contained incomplete documentation. Resident identifiers: #15, #39, #53, and #3. Facility census: 57. Findings include: a) Residents #15, #39, #53, and #3 On 09/01/10, the August 2010 ADL flow charts were reviewed for Residents #15, #39, #53 and #3. The section titled personal care / oral hygiene contained blanks where the nurse aides had not completed their documentation to verify that care had been rendered. - Resident #15's August 2010's ADL flow sheet had blanks in the oral hygiene section on 08/11/10, 08/14/10, and 08/27/10. - Resident #53's August 2010 ADL flow sheet had blanks in the oral hygiene section on 08/31/10. - Resident #3's August 2010 ADL flow sheet had blanks in the oral hygiene section on 08/11/10, 08/27/10, 08/29/10, and 08/30/10. - Resident #39's August 2010 ADL flow sheet had blanks in the oral hygiene section on 08/11/10, 08/14/10, 08/27/10, 08/30/10, and 08/31/10. On 09/01/10 at approximately 3:00 p.m., the director of nursing agreed these blanks needed filled in and acknowledged that, sometimes, the nurse aides forget to complete their documentation.",2014-07-01
11296,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-07-27,356,C,1,0,ONIB11,"Based on observation and staff interview, the facility failed to accurately post the actual resident census and actual numbers of licensed practical nurses (LPNs) and nursing assistants (NAs) working on the day shift on 07/26/09. Facility census: 112. Findings include: a) On 07/26/09 at 1:15 p.m., observation found a nursing staff posting form titled ""Daily Nurse Staffing Form"", dated 07/26/09, in the main dining room. The form did not specify the actual numbers of LPNs and NAs currently working in the facility on the day shift, nor did it specify the current resident census. The form reported fifteen and nine-tenths (15.9) NAs were on duty, yet observation revealed thirteen (13) NAs working on the day shift. The form also reported four and nine-tenths (4.9) LPNs were on duty, yet observation revealed four (4) LPNs working on the day shift. The day shift registered nurse supervisor (Employee #27), when interviewed on 07/26/09 at 2:00 p.m., confirmed the form was not accurate and complete. .",2014-07-01
11455,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2011-05-12,356,C,,,1I0H11,". Based on observation and staff interview, the facility failed to post nursing staffing information which contained all the elements required by this regulation. In addition, the posted information was not documented in a clear, readable format. This practice had the potential to affect all facility residents, families, and guests. Facility census: 129. Findings include: a) During tour on 05/02/11 at 3:00 p.m., observation of the posted nursing staffing information found it did not differentiate between registered nurses and licensed practical nurses. Additionally, it was not documented in a clear manner that any person reviewing it could understand. The confusion associated with reading the form was confirmed by the staff scheduler (Employee #162) during an interview at 3:45 p.m. on 05/02/11. .",2014-03-01
11464,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,257,C,,,H9I611,". Based on the results of the complaint investigation (State Complaint Reference # ), it was determined the facility failed to maintain a comfortable building temperature of at least 71 degrees Fahrenheit (F). Facility census: 51. Findings include: a) The National Weather Service (NOAA: www.weather.gov/climate/) temperature archives indicate the outside temperature in the greater Beckley area, beginning on 09/26/10 and continuing through 10/04/10 - a nine (9) day period, was no greater than 69 degrees F. The daily low temperature during this time period was no greater than 58 degrees F. The lowest daily temperature during this time period was 38 degrees F. on 10/02/10. When questioned as to when the facility heating system became functional, the facility's administrator stated an attempt to activate the heating system had failed on 10/01/10 due to a faulty valve. The valve and the heating system became functional on 10/04/10. Without a functional heating system, it would not be possible to maintain the building temperature at a minimum of 71 degrees F during this time period. .",2014-02-01
11467,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2010-10-19,356,C,,,SHO311,". Based on observation and staff interview, the facility failed to post - accurately and at the beginning of each shift - the required information to identify the staff members providing care and the census of the facility. Observation, on 10/17/10 at 3:40 p.m., found the posted nurse staffing information was dated 10/16/10, and the census information was absent. This practice has the potential to affect all residents and visitors. Facility census: 118 Findings include: a) Observation of the facility's posted nursing staffing data, on 10/17/10 at 3:40 p.m., found the posting was dated 10/16/10. The only nursing staffing data recorded on this posting was for the day shift of 10/16/10, and there was no resident census information recorded as required. An interview with the charge nurse (Employee #49), on 10/17/10 at 3:40 p.m., confirmed this information had not been updated to reflect the numbers of nursing staff or residents currently in the building.",2014-02-01
1,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-02-09,600,D,1,0,3JZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, abuse and neglect policy review, staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to provide necessary care and services to Resident #92 in preparation for scheduled appointments outside of the facility, of which the facility was aware of or should have been aware. The facility also failed to provide Resident #92 care and services in the care areas concerning baths and shaving. This was true for one (1) of six (6) sample residents dependent for care. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Scheduled appointments outside of the facility Resident #92 is a paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. He is totally dependent for all care, is legally blind, and newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of records on 02/05/18 at 2:55 PM revealed a significant change minimum data set (MDS) with an assessment reference date (ARD) 01/04/18. The resident had impaired vision (legally blind); had clear speech, was able to understand and make himself understood. The MDS revealed a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident was cognitively intact. Resident #92 needed extensive assistance with eating and was dependent for all other activities of daily living (ADL) including bed mobility, transfer, dressing, toileting, and hygiene. The resident was on scheduled and as needed pain medication and had not had a fall during the seven day look back period. Resident received speech therapy, occupational therapy, and physical therapy. Observations, on 02/05/18 at 11:55 AM., revealed Resident#92 appeared clean, without any body odors, hair stubble noted on chin, and Foley catheter was draining to drainage bag on bedside. The bed rails properly fit the bed. The resident had a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands. Blow call light was within reach of the resident and he was observed using it with staff responding timely. Resident#92 did not want to be interviewed at the time the surveyor attempted an interview, and this surveyor told the resident the surveyor would come back the next day to talk to him. The next day when this surveyor went to interview Resident #92, the resident was no longer a resident at the facility, Resident #92 was transferred to live at another facility and was unavailable for interview On 02/06/18 at 11:25 AM, review of reportable events revealed a report concerning Resident #92, dated 12/26/17, where the Veterans Administration Medical Center (VAMC) notified the facility of an incident occurring that morning that was reported to all appropriate agencies. The incident reported to the facility, alleged upon EMS (emergency management service) ambulance arriving to take the resident to scheduled appointments, the resident was not cleaned up, had no breakfast, catheter needed emptied, and call light was not in reach. The report revealed, Per VA the resident stated his head hitting side rail on bed and he was yelling. Someone came and shut the door but did not provide care. The results of the facility's reportable investigation revealed the allegations were unsubstantiated due to lack of information provided by EMS. The facility requested an extension for five day follow up from 12/31/17 to 01/05/18, due to awaiting statements from EMS. Review of the facility's five day follow up report findings, revealed EMS arrived at approximately 7:00 AM on 12/26/17, and the NA (Nurse Aid) had not cleaned the resident up yet. The NA did clean the resident and emptied his catheter, after being told by a nurse to clean him up for his appointment after the EMS ambulance crew arrived to pick up the resident. Breakfast had not been served yet. The social worker (SW#68) noted that EMS had been contacted multiple times, requesting statements concerning the description of the incidence (the facility reported they did not receive EMS statements). Social worker SW#68's written investigation statement in response to these allegations, dated 12/27/17, stated the ambulance arrived closed to 7:00 AM for a 9:00 AM appointment, breakfast was not ready at the time, puffer call light attached to bed by maintenance and cannot come off the bed. EMS must have seen roommates call light. SW #68 did not substantiate these allegations. On 02/06/18 at 1:15 PM, an interview with Staff#5, responsible for logging resident's appointments, revealed the Veterans Administration Medical Center (VAMC) has a contract with an ambulance service (name of local ambulance service) to transport all residents that are veterans, to any of their appointments. The VAMC is responsible for setting up and paying transport for any appointment no matter where it is. When asked what the process was to assure residents get to their appointments, Staff#5 explained the contact person at the VAMC calls at least once a month, and goes over all appointments residents who are veterans have, where the appointments are, and tells me what time the ambulance is to pick up the resident. Staff#5 said she writes the resident's name, date and time of the appointment, and the time the ambulance is to pick up the resident on the appointment calendar book. Staff#5 said, then the charge nurse has the appointment calendar book and lets the nurse aides know when they need to have the residents cleaned up and ready to go. Review of the appointment calendar book for the month of (MONTH) (YEAR), with Staff#5, revealed Resident #92 had appointments four (4) different days in December. The appointments noted on 12/26/17, revealed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Also, noted on the calendar was the time the ambulance was to pick up Resident #92, which was 7:00 AM on 12/26/17. Staff#5 said the VAMC always uses the same ambulance service for transports. When asked if the ambulance service ever is late or comes early, the receptionist replied, The ambulance service (the name of) is real good about being right on time. Staff#5 confirmed EMS ambulance was scheduled to arrive to pick Resident#92 up at 7:00 AM on 12/26/17. The facility investigation resulted in the allegations being unsubstantiated, however the investigation did not appear to be thorough. The facility's appointment calendar, clearly documented the ambulance was to pick the resident up at 7:00 AM to transport the resident for 7:30 AM labs, and that there was a second appointment at 9:00 AM. The facility's investigation Witness statements verified the ambulance arrived as scheduled and the resident was not cleaned up and ready to be transported. Resident #92 was cleaned and his catheter emptied, only after the NA was told by the nurse to clean him up for his appointment, after the ambulance crew arrived and waited. There was no evidence the resident needed to be fasting for his lab tests, nor any evidence that any breakfast had been offered to the resident, or any arrangements made to provide him a breakfast or snack. The resident did not get On 02/06/18 at 10:15 AM, after multiple failed attempts for observations and interview with Resident #92 due to not finding him in his room or elsewhere in the facility, an interview with the Administrator revealed Resident #92 was transferred to Veterans Administration Medical Center (VAMC) yesterday, 02/05/18. Administrator said this was a plan discharge that the resident had been on a waiting list to become a resident at the VAMC's facility, and an opening came available yesterday evening. Interview with the Coordinator of Health Information Management (HIMC Staff#73), on 02/07/16 at 10:00 AM, revealed Resident #92 had said he wanted to transfer to a facility closer to his ex-girlfriend so she could visit him. HIMC Staff#73 said the girlfriend told him there was one close to her that the Veterans Administration (VA) would pay for. HIMC Staff#73 said, the facility told him multiple times there was not one in that area the girlfriend was referring to, but he did not believe them, and would get upset about it each time. On 02/08/18 at 11:03 AM, an interview with VAMC Social Worker, VAMC SW#302 revealed she reported the situation because she is a mandatory reporter. VAMC SW#302 said, I was concerned for the resident because of his recent [DIAGNOSES REDACTED]. VAMC SW#302 said she reported to all the appropriate agencies, and spoke by phone to the facility's Director of Nursing (Nurse Executive Director) and SW #68 concerning these allegations on 12/26/17. VAMC SW#302 said she first saw the resident, on 12/26/17, after first being asked to see him, by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. The resident was alert and oriented and was asking to go to another nursing home closer to his family. The resident said the nursing home he lived at did not beat him, but they don't take care of him. The ambulance crew reported the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up. The ambulance crew said his call bell was across the room where he could not reach it. They had to ask someone to empty his catheter bag, and when it was emptied no one looked to see if anything else needed cleaned. He had not been given breakfast. The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. Review of VAMC SW#302 Notes dated 12/26/17, revealed the ambulance crew reported, (Name of facility) knew we were picking him up for a doctor appointment today. When we arrived he was not cleaned up. His call bell was across the room where he could not reach it. He had no breakfast. We had to ask someone to empty his catheter bag. When staff emptied the bag they did not look under the covers to check to see if anything else needed taken care of. Further review of records (facility and VAMC records) revealed alternate placement was discussed with the resident several times. The resident had discussed moving to a nursing home closer to his family and girlfriend. When the resident discovered there was not another nursing home the Veterans Administration was contracted to pay for in the area close to his family and girlfriend, Resident #92 did not want to personally pay and choose to return to the facility. The Ombudsman was interviewed via phone, on 02/08/18 at 2:30 PM, for concerns regarding these allegations. Interview with Ombudsman revealed during her interview at the facility with Resident #92 and facility staff, on 01/03/18, the resident said he lied about his head being stuck in the bed rails, that he lied just because he was mad. The Ombudsman said Resident #92 bragged on the care he receives at the facility, appeared [MEDICATION NAME] pleased, and had no complaints against the facility. After record review, abuse and neglect policy review, staff interview, VAMC staff interview, and review of the facility's investigation record, the evidence revealed some of the allegations were substantiated. There is not enough evidence to substantiate the allegation the resident's special blow call light was not in reach of the resident. The resident denied, in front of multiple witnesses, his head was hitting the side rail on his bed, and someone shut the door without providing any care. The resident said he falsely made these accusations because he was mad. The facility did neglect to ensure Resident #92 was; cleaned up and shaven; catheter drainage bag was emptied; and resident was ready to be transported for medical appointments via ambulance, as was scheduled on the facility's appointment calendar book for 12/26/17 at 7:00 AM. The resident did not have breakfast, and the facility did not provide or make any arrangements for the resident to have breakfast or a snack on a day the resident was scheduled to be out of the facility for medical appointments. The catheter drainage bag was emptied by a nurse aid (NA) after the ambulance crew arrived and only after a nurse had to instruct the NA to clean up the resident. b) Baths and shaving On 02/06/18 at 9:05 AM, review of grievance and concerns revealed a grievance dated 09/12/17 revealing one of the issues was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face. Resolution to the concerns were completed by 09/ 27/17 with staff being educated, Kardex being updated with the resident's preferences. The KARDEX provides specific instructions for the nursing assistants concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed it was important for resident to choose between a tub bath, shower, bed bath, or sponge bath, and under skin care it was noted as written ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. Resident #92 a legally blind paraplegic, totally dependent for all care, was to receive a shave and bed bath daily. The resident was incontinent of bowel and had a Foley catheter. Review of the ADL (activities of daily living) Record, on 02/07/18 at 4:00 PM, revealed during the month of (MONTH) (YEAR), Resident#92 had a minimum of twenty-five (25) opportunities to receive a bed bath and he only received fifteen (15) according to the ADL Record. There are thirty-one (31) days in December, and the resident was at the hospital on [DATE] until 12/04/17, on 12/11/17 until 12/13/17, and on 12/26/17 until 12/28/17, a total of six (6) days out of the facility (Note - It is possible the resident could have had or needed a bed bath on the days he went to the hospital and/or returned from the hospital. It is also possible an incontinent resident might need more than one bed bath per day). The resident received bed baths on fourteen days in December, on one day (12/05/17) he received two (2) baths. There was no evidence the resident refused any bed baths or refused being shaven. On 02/08/18 at 3:27 PM, interview with Nurse Aid (NA#40) revealed Resident #92 loved bed baths. NA#40 said, Resident #92 loved bed baths, they relaxed him and helped him sleep, he would take a two (2) hour nap after he got one. NA#40 denied ever knowing Resident #92 refusing a bed bath. Interview with NA#39, on 02/08/18 at 3:38 PM, revealed NA#39 stated, Resident #92 loved bed baths. I never knew of him refusing a bed bath. On 02/08/18 at 4:47 PM, an interview with two (2) Licensed Practical Nurse (LPN) LPN#44 and LPN#70 revealed the following information. When asked, as nurses, what their expectations of how often a totally dependent resident, incontinent of bowel should receive bed baths from nurse aides, both LPNs said at least daily, if not more depending on the resident's incontinence episodes. Both LPN#44 and LPN#70 said the nurse aides should have instruction on the resident's care plan and the Kardex for bathing and hygiene care.",2020-09-01
2,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-02-09,656,D,1,0,3JZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and Center (VAMC) staff interviews, the facility did not implement interventions in Resident #92's care plan to meet the resident's preferences and address the resident's medical, physical, mental and psychosocial needs. This pertained to the care area of activities of daily living (ADL), concerning shaving Resident #92 daily. This was true for one (1) of three (3) care plans reviewed for resident's totally dependent for ADL care. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Observations, on 02/05/18 at 11:55 AM., revealed Resident #92 appeared clean, without any body odors, Foley catheter was draining to drainage bag on bedside. The resident was lying in his bed, eyes closed with hair stubble noted on resident's chin. The resident has a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands, and it was within reach of the resident. On 02/06/18 at 9:05 AM, review of grievance and concerns revealed on 09/12/17 the resident complained . he was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face, . Resolution to these concerns were completed by 09/27/17 with staff being educated to shave resident daily, Kardex being updated with the resident's preferences. A Kardex provides specific instructions, for the nursing assistants, concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed under the skin care focus instructions written as is ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. On 02/08/18 11:03 a.m., an interview with VAMC SW#302 revealed she reported a situation concerning Resident #92 because she is a mandatory reporter and had notified the facility of the allegations. VAMC SW#302 said she first saw the resident, on 12/26/17, after being asked by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304 to see the resident. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. VAMC SW#302 described the resident was alert and oriented and the ambulance crew told VAMC SW#302, the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up. The ambulance crew told VAMC SW#302 his call bell was across the room where he could not reach it. They had to ask someone to empty his catheter bag, and when it was emptied no one looked to see if anything else needed cleaned. He had not been given breakfast. The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment.",2020-09-01
3,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-02-09,657,D,1,0,3JZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility did not revise a care plan to meet the resident's medical, physical, mental and psychosocial needs. Resident #92's care plan was not revised with resident specific interventions to address the resident's newly diagnosed fractured neck. This was true for one (1) of three (3) care plans reviewed. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Facility census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Interview with the Minimum Data Set Registered Nurse (RN#49), on 02/07/18 at 11:55 AM, revealed the resident was found to have cord compression of his cervical spine and a fracture. RN#49 said this was found after the resident was admitted to the Veterans Administration Medical Center (VAMC), on 12/11/17, due to suddenly having problems with both his arms. RN#49 said the VAMC recommended the cervical collar. When asked where the physician's orders [REDACTED]. RN#49 requested the Coordinator Health Information Management, Staff#73, to try and locate the order. The Coordinator Health Information Management Staff#73, on 01/07/18 at 12:17 PM, agreed there should have been an order for [REDACTED]. Review of Resident#92's care plan with RN#49 revealed there were no resident specific interventions to address the resident's current care needs related to the new [DIAGNOSES REDACTED]. On 02/07/18 at 12:50 PM, review of medical records revealed resident was admitted to the Veterans Administration Medical Center (VAMC) on 12/11/17 due to complaints of numbness of his arms, inability to raise his arms, and nausea. Resident returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. Review of VAMC physician progress notes [REDACTED]. Resident#92 returned to the facility with a soft cervical collar",2020-09-01
4,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-02-09,677,D,1,0,3JZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, facility staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to ensure Resident #92 received the care and services regarding an aspect of his life in the facility which was significant to the resident regarding bathing and shaving, and did not receive proper grooming when going to appointments outside the facility. This was true for one (1) of eleven (11) sample residents. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Baths and shaving On 02/06/18 at 9:05 AM, review of grievance and concerns revealed a grievance dated 09/12/17 revealing one of the issues was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face. Resolution to the concerns were completed by 09/ 27/17 with staff being educated, Kardex being updated with the resident's preferences. The KARDEX provides specific instructions for the nursing assistants concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed it was important for resident to choose between a tub bath, shower, bed bath, or sponge bath, and under skin care it was noted as written ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. Resident #92 a legally blind paraplegic, totally dependent for all care, was to receive a shave and bed bath daily. The resident was incontinent of bowel and had a Foley catheter. Review of the ADL (activities of daily living) Record, on 02/07/18 at 4:00 PM, revealed during the month of (MONTH) (YEAR), Resident#92 had a minimum of twenty-five (25) opportunities to receive a bed bath and he only received fifteen (15) according to the ADL Record. There are thirty-one (31) days in December, and the resident was at the hospital on [DATE] until 12/04/17, on 12/11/17 until 12/13/17, and on 12/26/17 until 12/28/17, a total of six (6) days out of the facility (Note - It is possible the resident could have had or needed a bed bath on the days he went to the hospital and/or returned from the hospital. It is also possible an incontinent resident might need more than one bed bath per day). The resident received bed baths on fourteen days in December, on one day (12/05/17) he received two (2) baths. There was no evidence the resident refused any bed baths or refused being shaven. On 02/08/18 at 3:27 PM, interview with Nurse Aid (NA#40) revealed Resident #92 loved bed baths. NA#40 said, Resident #92 loved bed baths, they relaxed him and helped him sleep, he would take a two (2) hour nap after he got one. NA#40 denied ever knowing Resident #92 refusing a bed bath. Interview with NA#39, on 02/08/18 at 3:38 PM, revealed NA#39 stated, Resident #92 loved bed baths. I never knew of him refusing a bed bath. On 02/08/18 at 4:47 PM, an interview with two (2) Licensed Practical Nurse (LPN) LPN#44 and LPN#70 revealed the following information. When asked, as nurses, what their expectations of how often a totally dependent resident, incontinent of bowel should receive bed baths from nurse aides, both LPNs said at least daily, if not more depending on the resident's incontinence episodes. Both LPN#44 and LPN#70 said the nurse aides should have instruction on the resident's care plan and the Kardex for bathing and hygiene care. b) Grooming for appointments outside the facility On 02/06/18 at 11:25 AM, review of reportable events revealed a report concerning Resident #92, dated 12/26/17, where the Veterans Administration Medical Center (VAMC) notified the facility of an incident occurring that morning that was reported to all appropriate agencies. The incident reported to the facility, alleged upon EMS (emergency management service) ambulance arriving to take the resident to scheduled appointments, the resident was not cleaned up, had no breakfast, catheter needed emptied, and call light was not in reach. Review of the facility's investigation findings, revealed EMS arrived at approximately 7:00 AM on 12/26/17, and the NA (Nurse Aid) had not cleaned the resident up yet. The facility did not ensure Resident #92 was; cleaned up and shaven; catheter drainage bag was emptied; and resident was ready to be transported for medical appointments via ambulance, as was scheduled on the facility's appointment calendar book for 12/26/17 at 7:00 AM. The catheter drainage bag was emptied by a nurse aid (NA) after the ambulance crew arrived and only after a nurse had to instruct the NA to clean up the resident. Social worker SW#68's written investigation statement in response to the allegations, dated 12/27/17, stated the ambulance arrived closed to 7:00 AM for a 9:00 AM appointment ., however the facility's appointment calendar book for the month of (MONTH) (YEAR) showed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Also, noted on the calendar was the time the ambulance was to pick up Resident #92, which was 7:00 AM on 12/26/17. On 02/06/18 at 1:15 PM, an interview with Staff#5, responsible for logging resident's appointments, revealed when a resident has an appointment Staff#5 writes the resident's name, date and time of the appointment, and the time the ambulance is to pick up the resident on the appointment calendar book. Staff#5 said, then the charge nurse has the appointment calendar book and lets the nurse aides know when they need to have the residents cleaned up and ready to go. Review of the appointment calendar book for the month of (MONTH) (YEAR), with Staff#5, revealed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Staff#5 confirmed EMS ambulance was scheduled to arrive to pick Resident#92 up at 7:00 AM on 12/26/17. The facility's investigation Witness statements verified the ambulance arrived as scheduled and the resident was not cleaned up and ready to be transported. Resident #92 was cleaned and his catheter emptied, only after the NA was told by the nurse to clean him up for his appointment, after the ambulance crew arrived and waited. Review of VAMC SW#302 progress note, dated 12/26/17, revealed the ambulance crew reported, (Name of facility) knew we were picking him up for a doctor appointment today. When we arrived, he was not cleaned up . We had to ask someone to empty his catheter bag. When staff emptied the bag, they did not look under the covers to check to see if anything else needed taken care of. On 02/08/18 at 11:03 AM, an interview with VAMC Social Worker, VAMC SW#302 revealed she first saw the resident (Resident#92), on 12/26/17, after first being asked to see him by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. VAMC SW#302 said, The ambulance crew reported the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up . The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment.",2020-09-01
5,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-02-09,684,D,1,0,3JZJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide a resident with the necessary care and services to maintain the highest practicable level of well-being for one (1) of three (3) sample resident reviewed for neglect during a complaint investigation. The facility failed to obtain a physician's orders [REDACTED].#92, after being diagnosed with [REDACTED]. Resident identifier: #92. Facility census: 107. Findings include: a) Resident #92 On 02/05/18 at 12:48 PM, review of records revealed Resident #92, a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder, totally dependent for all care, was admitted to the Veterans Administration Medical Center (VAMC) on 12/11/17 due to complaints of numbness of his arms, inability to raise his arms, and nausea. Resident returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of VAMC physician progress notes [REDACTED]. Resident#92 returned to the facility and with a soft cervical collar. Interview with the Minimum Data Set Registered Nurse (RN#49), on 02/07/18 at 11:55 AM, revealed the resident was found to have cord compression of his cervical spine and a fracture. RN#49 said this was found after the resident was admitted to the Veterans Administration Medical Center (VAMC), on 12/11/17, due to suddenly having problems with both his arms. RN#49 said the VAMC recommended the soft cervical collar. When asked where the physician's orders [REDACTED].#49 after reviewing the record, said she could not find an order. RN#49 agreed a follow up for orders for the resident's current care needs due to the new [DIAGNOSES REDACTED].#49 requested the Coordinator Health Information Management, Staff#73, to try and locate a order for the soft cervical collar. The Coordinator Health Information Management Staff#73, on 01/07/18 at 12:17 PM, agreed there should have been an order for [REDACTED].",2020-09-01
6,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,164,D,0,1,ELSQ11,"Based on random observation and staff interview the facility failed to ensure the personal privacy and confidentiality of a resident's medication records. Resident identifier: #82. Facility census: 116. Findings include: a) Resident #82 On 05/18/17 at 6:30 a.m., Licensed Practical Nurse (LPN) #55 left Resident #82's medication record open in a way the information could be read by a person other than the nurse passing the medications. The LPN entered the resident's room and returned to the cart on at least two (2) occasions and continued to leave the medication information exposed. At 6:33 a.m. on 05/18/17, LPN #55 agreed the information was exposed.",2020-09-01
9,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,278,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an accurate quarterly minimum data set (MDS) assessment to reflect the resident's pain medication regimen. This was true for one (1) of thirty-two (32) residents reviewed. Resident identifier: #100. Facility census: 116. Findings include: a) Resident #100 Review of Resident #100's medical records revealed a physician's orders [REDACTED]. Record review revealed Resident #100 continued to receive this medication through the month of (MONTH) (YEAR). Review of a quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/05/17, revealed Resident #100 did not receive scheduled pain medication. On 06/01/17 at 5:46 p.m., the MDS coordinator, Registered Nurse (RN) #108, agreed the quarterly MDS with an ARD of 05/05/17 should have been coded to identify Resident #100 received scheduled pain medication.",2020-09-01
11,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,280,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to review and/or revise care plans timely related to an arteriovenous (AV) graft (#159), restorative ambulation (#141), and an actual falls (#115). This practice affected three (3) of thirty-two (32) Stage 2 residents. Facility census: 116. Resident identifiers: #159, #141, and #115. Findings include: a) Resident #159 Medical record review revealed a physician's orders [REDACTED]. Upon inquiry, Health Information Management Coordinator (HIMC) #50, interviewed on 05/30/17 at 4:03 p.m., provided information noting the AV graft had been placed when the resident went to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the medical record revealed the resident had discharge on 03/11/17 and re-entered the facility on 03/13/17. The care plan was not revised until after completion of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/11/17. The care plan noted a revision date of 04/17/17 to reflect Resident #159 had an arteriovenous graft. MDS Coordinator #108, interviewed on 05/24/17, verbalized it was the nursing staff's responsibility to update and/or revise the care plan with a change in condition. b) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. Medical record review revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. The intervention, dated 09/22/16, indicated Resident #141 would ambulate 200 feet twice a day, six (6) days a week. During an interview on 05/24/17 at 2:36 p.m., Nurse Aide (NA) #23 reviewed the restorative records and said Resident #141 walked 150 feet two (2) times a day. Additionally, the physician's orders [REDACTED]. An interview with the director of nursing, immediately following the interview with NA #23, confirmed the care plan intervention had not been revised to reflect the physician's orders [REDACTED].> c) Resident #115 Medical record review on 05/30/17 found this resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. According to the medical record, she experienced actual falls on 04/30/17, 05/03/17, and 05/12/17. On the first and second occurrence she was found lying on the floor by the bed. On the latter occurrence, she slipped out of the wheelchair and onto the floor. Review of the current care plan found this resident was care planned as at risk for falls. The care plan was silent for any revisions showing the resident was not only at risk for falls, but that she had sustained actual falls since coming to the facility. In an interview with minimum data set (MDS) Registered Nurse #68 on 05/31/17 at 10:39 a.m., she reviewed the care plan and said they did not revise care plans to include the actual falls a resident experiences. When interviewed on 05/31/17 at 10:50 a.m., the administrator acknowledged that the care plan was not revised to include that she had sustained actual falls since admission to the facility. She said they typically update new interventions they may have added after a fall, but they do not revise the care plan to include either that the resident had sustained actual falls, or the dates of the falls.",2020-09-01
14,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,312,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to provide necessary services to maintain good grooming for two (2) of thirty-two (32) sampled residents. Resident #117 had unshaven facial hair. Resident #76 had long unkempt hair, was unshaven, and wore the same clothing on successive days. Resident identifiers: #117 and #76. Facility census: 116. Findings include: a) Resident #117 Observation on 05/16/17 at 2:16 p.m. found this [AGE] year old resident had numerous long white hairs on her chin and lower jaw area. On 05/23/17, review of the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 04/13/17, found her Brief Interview for Mental Status (BIMS) score was three (3), indicating severe cognitive impairment. She required limited assistance with personal hygiene. Review of the resident's care plan found a focus statement identifying she was at risk for decreased ability to perform activities of daily living (ADL) functions due to generalized weakness, fluctuation in cognition/dementia with behaviors, and multiple other disease processes. Interventions included to provide assistance as needed, as the ADLs might fluctuate. Observation on 05/23/17 at 12:45 p.m. found she still had long white hairs on her chin and lower jaw area. When asked about the resident's chin whiskers, Nurse Aide (NA) #59 replied that just this morning he commented that the resident's beard was longer than his. He said he would shave her right away, and he did. During an interview on 05/23/17 at 4:20 p.m., the administrator said this resident's ADL abilities fluctuated due to her behaviors and dementia. No further information was provided about the resident's facial hair. b) Resident #76 A Stage 1 observation on 05/15/17 at 1:47 p.m., revealed Resident #76 was unshaven, and his hair was long, uncombed and unclean. Another observation on 05/16/17 at 8:30 a.m., revealed his beard growth remained unshaved. On 05/17/17 at 3:24 p.m., the resident's hair remained long and disheveled, but he had been shaved. The nurse said the hospice aide had provided care. An observation on 05/23/2017 at 9:09 a.m., found Resident #76 in bed awake, watching a game show on his roommate's television. The fingernails on his right hand had dark brown debris beneath them. His hair was uncombed, and he had not been shaved. When asked how often he would like to be shaved, he replied he would like shaved right now. The resident voiced he preferred to be shaved daily. At 11:56 a.m., the resident had been shaved, and his hair combed. Another observation at 2:25 p.m. revealed his nails had been clipped and cleaned. Nurse Aide (NA) #135, on 05/23/17 at 2:28 p.m., said the resident had gotten weak and now staff did most of his care. She verbalized the hospice aide had provided his care this date. The minimum data set (MDS) with an assessment reference date (ARD) of 05/15/15 indicated Resident #76 required extensive assistance with dressing, eating, toilet use and personal hygiene. The assessment indicated the resident had impairment on both sides of his upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. The care plan, revised on 05/10/17, noted Resident #76 required assistance with activities of daily living (ADLs) with a goal to improve current level of ADL functions by next review. A hospice nurse aide (NA) provided care two (2) times a week. Licensed Practical Nurse (LPN) #62, interviewed on 05/24/17 at 1:26 p.m., said the resident was very noncompliant, but most of the time would let staff provide care if asked. She said the nurse would re-direct him if he refused for the nurse aides. An observation with the interim clinical nurse educator (CNE) on 05/24/17 at 4:10 p.m., revealed Resident #76 was still wearing the same clothing placed on him by the hospice NA on 05/23/17. During an observation on 06/01/17 at 11:27 a.m., Resident #76 was sitting in the dining room for lunch. His hair had been cut and he was clean shaven. The resident said he preferred his hair cut short. During a discussion with the CNE on 06/01/17 at 6:30 p.m., she said the facility was responsible to care for the resident on the days the hospice aide did not come to the facility. She voiced the resident had a decline, was dependent upon staff for care, and the resident should have been shaved by the facility nurse aides on the days a hospice staff member was not in the building.",2020-09-01
15,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,315,D,0,1,ELSQ11,"Based on a random observation and staff interview, the facility failed to provide care in a manner to prevent urinary tract infections. A staff member placed washcloths in the bathroom sink basin in preparation for incontinence care, creating a potential for introducing potential pathogens into the resident's urinary tract. This practice affected one (1) resident for whom incontinence care was observed. Facility census: 116. Resident identifier: #163. Findings include: a) Resident #163 During a wound care observation on 05/18/17 at 10:21 a.m., Licensed Practical Nurse unfastened the resident's brief revealing the resident had had an incontinence episode. Nurse Aide (NA) #102 obtained a stack of washcloths, placed them in the bathroom sink basin, and turned on the water. The NA wrung the washcloths and laid them on the left side of the sink near the faucet handle. NA #102 dried her hands, picked up the washcloths and gave them to Licensed Practical Nurse (LPN) #72 who utilized them to perform peri-care.",2020-09-01
16,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,318,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) residents reviewed for range of motion received services to help prevent further decline. Resident #43 had contractures of the right hand, wrist, elbow, and shoulder, but had no range of motion or orthotics ordered to help prevent further decline or other negative outcomes. Resident identifier: #43. Facility census: 116. Findings include: a) Resident #43 Review of the resident's medical record on [DATE] found the resident's [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of [DATE], found she came to the facility with contractures of the right hand, wrist, elbow, and shoulder. Review of the most recent comprehensive assessment with an ARD of [DATE], found she was assessed with [REDACTED]. The facility assessed her as having received no therapy services, no restorative nursing services, and no hand or wrist splint/orthotic device during the look back period. Her Brief Interview for Mental Status (BIMS) score was eleven (11), indicating moderately impaired cognitive functioning. On [DATE] at 4:45 p.m., the administrator provided a copy of the resident's current care plan. Review of the care plan found a focus statement related to the right side extremities being weaker than the left, and contractures of the right shoulder, elbow, wrist, and hand. However, there was no goal related to what the facility hoped to achieve related to contracture maintenance, and no interventions on how the facility planned to ensure no worsening of the contractures, or no negative outcomes related to the contractures. During an interview on [DATE] at 4:01 p.m., Director of Rehabilitation Services #52 said this resident first began therapy services [DATE] through [DATE]. Their old record keeping was done on paper and they had transferred to electronic documentation sometime in (YEAR). She reviewed the numerous times this resident had physical therapy (PT) and/or occupational therapy (OT) services in (YEAR) and found the following: - She was on PT and OT caseload [DATE] through [DATE]. - She received PT and OT services [DATE] through [DATE]. - She again received PT and OT services [DATE] through [DATE]. - She was on PT caseload [DATE] through [DATE]. Director of Rehabilitation Services #52 said she assumed the resident had a hospitalization in there somewhere. - She received OT services [DATE] through [DATE]. - She received PT and OT services [DATE] through [DATE]. Director of Rehabilitation Services #52 said they screened every patient in the facility at least every three (3) months at the time their quarterly assessments were due, and on patients after they sustained a fall. She said they also have a HEY program whereby they keep referral sheets at every nursing station. She said if any employee within the facility had a concern about a resident's functioning, they could communicate their concerns to therapy by utilizing the referral sheets. Director of Rehabilitation Services #52 said they screened this resident on [DATE] after she was readmitted to the facility following a psychiatric inpatient admission. They found that she was able to propel in a wheelchair around the facility and there was no change in functional transfers. Upon inquiry, she said the last time OT had her on case load was (MONTH) (YEAR). At that time, OT had goals for passive and active range of motion (ROM) to the right upper extremities, ten (10) repetitions for three (3) sets daily to establish a contracture management program. OT also had goals for her to tolerate a right hand orthotic for two (2) hours initially, with the goal to tolerate it long-term for four (4) hours. The final long-term OT goals were to discharge the resident to the restorative program with 100% staff training for the contracture management program. She said the director of nursing (DON) was the head of the restorative program. In an interview on [DATE] at 4:15 p.m., the DON said therapy did not say to pick her back up for restorative when they did her screening upon her return to the facility following that (MONTH) psychiatric hospitalization . Upon inquiry, she said this resident had not received restorative services since her return to the facility on or around [DATE]. On [DATE] at 4:22 p.m., during a joint interview with the DON and Director of Rehabilitation Services #52, the DON said the resident used to have a Posey roll. She said the resident also used to receive restorative services with the restorative aides. The DON said that formerly this resident had physician orders [REDACTED]. The DON said the old orders expired, and there were no new admission orders [REDACTED]. She said PT completed a screening upon her return to the facility from the hospital, and did not order restorative services or the Posey hand roll. She said that in all likelihood this may have fallen through the cracks. The DON said she felt that nursing assistants did enough range of motion during the activities of daily living to make it count for range of motion. The DON and Director of Rehabilitation Services #52 said they would check with therapy the next day to see if they want her picked back up again for restorative services. On [DATE], interviews with Nurse Aides (NA) #64 and #38, at 5:30 p.m. and at 5:35 p.m., respectively, revealed they were trained in nurse aide classes to exercise limbs of residents who had paralysis. NA #38 said she was assigned to provide care for this resident that day. She said she knew to exercise the affected limb. She said she has had no instructions to apply any type of splint, orthotic, carrot, or Posey roll to the affected hand. During an interview with the resident on [DATE] at 9:41 a.m., she demonstrated that she could use her left hand to try to stretch out the fingers on her right hand. The little finger and the thumb of the right hand were not contracted. The three (3) middles fingers on the right hand were contracted and she could not stretch them out. The three fingers were bent downward, and then pointed back toward the wrist. The fingernails that could be visualized were trim. There was no odor noted. During an another interview with Director of Rehabilitation Services #52 on [DATE] at 1:20 p.m., she said that OT looked at the resident and determined that she had not sustained any decline in functionality. She said they picked her back up on caseload. On [DATE] at 8:15 a.m., during an interview with OT #11, a box with a Posey hand splint inside was noted on her desk that had the resident's name written in black marker on the outside of the box. OT #11 said she assessed the resident yesterday and saw no decline in the functionality of the resident's right hand. She said the functionality of the resident's hand was the same as it was during the time she had most recently received therapy services. When asked what would happen if the resident did not wear the Posey hand splint, she said the palm of the resident's hand would become macerated, and her contracted fingertips could intrude into the palm. When asked if she would always need to wear a device of that type, she replied in the affirmative. She said the contracture would not correct itself at any time in the future, so it would be a lifetime need for the device. When asked whether the restorative service aides or the regular aides on the floor would apply the Posey when she was discharged from OT, she said only the restorative aides would apply it. She said the regular aides on the floor did not apply orthotics, and would not do so unless the policy changed sometime in the future to allow the aides to do so. She agreed that upon her return from the hospital in March, that she should have been picked up again for restorative and for the orthotic, and she was not.",2020-09-01
17,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,329,D,0,1,ELSQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident remained free of unnecessary drugs. The physician ordered a reduction of Resident #9's [MEDICATION NAME] more than two (2) months after the pharmacist recommended the reduction. Two (2) days after the ordered reduction, the medication was increased without any evidence the increase was needed. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #9. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report with a date of 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of [MEDICATION NAME] at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was sixty-four (64) day after the initial recommendation. On 04/13/17 the physician ordered a reduction to 0.25 mg at bedtime for one (1) week and then discontinue the [MEDICATION NAME]. On 04/15/17 the physician discontinued [MEDICATION NAME] 0.25 mg at bedtime and restarted [MEDICATION NAME] 0.5 mg at bedtime. Review of the behavioral flow sheet for (MONTH) of (YEAR) did not reveal behaviors related to anxiety. Review of nursing notes between 04/13/17 and 04/15/17 did not reveal documentation of the resident experiencing anxiety. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the records did not reveal any indication of a need for increasing the [MEDICATION NAME].",2020-09-01
20,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2017-06-02,428,D,0,1,ELSQ11,"Based on record review and staff interview, the facility failed to act upon a pharmacist's recommendation in a timely manner. This was true for two (2) of five (5) residents reviewed for unnecessary medications. The physician did not respond to a pharmacist's recommendation for Resident #9 for over two (2) months. For Resident #45, the resident continued to receive the medication Reglan nearly three (3) months after it should have been discontinued. Resident identifiers: #9 and #45. Facility census: 116. Findings include: a) Resident #9 Review of a pharmacist's consultation report dated 02/09/17 revealed a recommendation to the physician to re-evaluate the continued use of Clonazepam (a psychoactive medication) at the current dose of 0.5 mg (milligrams) at bedtime. The physician responded to this recommendation on 04/13/17, which was 64 days from the initial recommendation. On 05/31/17 at 1:36 p.m., the director of nursing (DON) agreed the physician's response to the pharmacist's recommendation was not timely. b) Resident #45 A pharmacist review dated 02/09/17 identified Resident #45 received Reglan 5 mg every 8 hours and was also taking Protonix 40 mg daily with both medications being for gastroesophageal reflux disease (GERD). The pharmacist's recommendation was to consider tapering the Reglan while continuing the Protonix. The physician accepted the recommendation with a modification of discontinuing the Reglan on 02/25/17. Review of the Medication Administration Record [REDACTED]. On 05/31/17 at 1:36 p.m., the DON agreed the resident continued to receive Reglan after the physician noted to discontinue the medication on 02/25/17.",2020-09-01
24,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,558,D,0,1,8Y4111,"Based on observation, resident interview and staff interview, the facility failed to provide appropriate accommodation of needs regarding storage and accessibility of Resident #23's personal items. This was evident for one (1) randomly observed resident. Resident identifier: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser drawer was found to be in disrepair and not functionable. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The broken drawer was hanging in such a way that it also blocked access to the bottom dresser drawer. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her personal items in the middle or bottom dresser drawers due to the front of the middle drawer falling apart and hanging in the way. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get what ever supplies he will need to fix it today.",2020-09-01
25,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,580,D,0,1,8Y4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and policy review, the facility failed to promptly notify the physician when a resident experienced a change in condition. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). Resident (R#33) refused physician ordered wound dressing for multiple days without the physician being notified. This practice had the potential to effeect a limited number of residents. Resident identifier: R#33. Facility census: 111. Findings included: During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound drainage and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19. The wound care and dry dressing was applied daily from 04/04/19 until 04/10/19 when it was documented refused and applied again daily on 04/11/19 until 04/14/19 when it was documented as refused. The wound care treatment and dry dressing was applied daily again on 04/15/19 until 04/18/19 when it was documented refused. The wound care treatment and dry dressing was applied on 04/19/19, 04/20/19, 04/21/19, 04/24/19, 04/27/19, and 04/28/19. On 04/22/19, 04/23/19, 04/25/19, 04/29/19, and 04/30/19 it was documented refused, and on 04/26/19 there was no documentation either way as to refusal or provision of wound care treatment and the dry dressing, the TAR entry was blank. In the month of (MONTH) 2019 the resident had twenty seven (27) opportunities to have wound care treatment and a dressing applied daily and had the ordered treatment randomly eighteen (18) times. There was no wound care treatment provided at all during the month of May. According to the TAR, R#33 refused wound care treatment and daily dressings twenty-nine (29) days in the month of May, and two (2) days there was no documentation either way as to refusal or application of wound care or the dry dressing, the TAR was blank on those two days. According to the TAR, R#33 refused treatment on (MONTH) first, second, third, and fourth; and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to refusals. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment as ordered and it was documented treatment was provided as ordered on only eighteen (18) days, and three (3) days there was no documentation either way as to refusal or provision. There was no documented evidence the physician was notified of the resident's refusals until 06/05/19, when the order was discontinued. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. R#33 said he did not want a dressing on it now. R#33 said, I had training myself and if I wanted a dressing I'd ask for it, but it doesn't need one. When asked where he had training and what kind of training he had, the resident did not answer but informed this surveyor he was done talking about it. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Notify physician of the refusal of treatment. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's noncompliance with wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to R#33 medical record revealed non-compliance and refusal of care in other areas other than wound treatment.",2020-09-01
26,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,584,D,0,1,8Y4111,". Based on policy review, resident interview, staff interview and record review, the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment. Through a random opportunity for discovery, it was found Resident #23 had a busted up air conditioning unit that was in disrepair. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #23. Facility census: 111. Findings included: a) Resident #23 During initial screening process on 06/02/19 at 2:30 PM, Resident #23's dresser and HVAC (centralized heating ventilation and air conditioning system) unit in her room were found to be in disrepair and maintained in an unsafe manner. The front of the middle wooden dresser drawer was observed to be busted out, loosely hanging off the base of the drawer only to be attached by one nail in the left-hand corner. The Resident's HVAC unit in her room was found to be in poor condition with the plastic framing that enclosed the heating busted in several places, along the top and sides. The HVAC unit was loose and had came unattached from the right-hand side of the heating unit sliding down over the temperature control knob, causing the temperature control knob to be very difficult to turn. On 06/02/19 at 2:33 PM, Resident #23 stated that she could not access her dresser drawers due to the front of the middle drawer falling apart. Resident stated, I told maintenance a while back, and he said he would have to go to into town and get some wood glue to fix the drawer, but he has never come back to fix it. The Resident also stated she had not been able to fully utilize her dresser for quite some time due to the broken dresser drawer, and she was unable to adjust the heat on the HVAC unit due to the broken plastic frame, so she just left it on one setting (high heat) and had gotten used to hot temperature. At 9:05 AM on 06/05/19 during an interview, the Administrator agreed the Resident's dresser drawer was in disrepair and inaccessible to Resident, and it needed repaired immediately. The facility's Administrator stated, I will get with our maintenance guy and have him get whatever supplies he will need to fix it today. In regard to the broken plastic framing around the HVAC unit, the Administrator stated, I will have our maintenance guy go to storage right now and see if we have another HVAC unit that we can use to replace this immediately, this is not acceptable.",2020-09-01
27,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,585,D,0,1,8Y4111,"Based on policy review, Resident interview, staff interview and record review the facility failed to make prompt efforts by the facility to resolve grievances the resident may have. This was true for two (2) of four (4) reviewed in the care area of personal property. Identified Resident's #115 and #82. The facility census was111. Findings included: a) Facility policy Facility Grievance/Concern Policy with a revision date of 03/01/18 stated: --The purpose for grievance /concern reporting is ensure that any patient/patient representative has the right to express a grievance/concern without fear of restraint, interference, coercion, discrimination, or reprisal in any form. --To assure prompt receipt and resolution of the grievance/concern. --Notify the person filling the grievance/concern of resolution within 72 hours. b) Resident #115 During an interview on 06/04/19 at 12:51 PM, Resident #115 stated, that while at the hospital her TV and google home was reported to be missing when she returned, but nothing has been done about it. A review of the Grievance/Concerns reports revealed that there was not a form filled out about the missing items. During an interview on 06/06/19 at 11:30 AM, Administrator was asked about a Grievance/Concern report on this missing TV and Google home. He stated that an employee that is no longer here spoke to Resident # 115, about her missing items, but for whatever reason there was not a form completed. During an interview on 06/10/19 at 9:11 AM, Administrator provided a completed Grievance/ Concern form, dated 06/06/19, he stated that he did look for Resident # 115 missing items and they could not be located. He stated, that the facility will have to replace them. b) Resident #82 During an interview on 06/03/19 at 1:45 PM, Resident #82 stated, that her red satin [NAME]et with a white strip has been missing for a while and that she did tell the Administrator, but nothing has been done. She went on to say, that some of the staff said, that they have looked for it, but all they did was put things in her closet that does not belong to her. During an interview on 06/06/19 at 11:15 AM, Administrator asked Resident #82 about her missing [NAME]et. He said to her that he thought they had found and returned her red [NAME]et. Resident #82 applied to him, that they put a man's tan [NAME]et in her closet, and that was not hers and it is not even red. Administrator looked though her closet with her consent and presents, no red satin [NAME]et was found. On 06/10/19 at 9:11 AM, Administrator provided a Grievance/ Concern form dated; 06/06/19 concerning the red [NAME]et. It stated, that a search for the [NAME]et was done, the item was not located and will be replaced with a like item.",2020-09-01
28,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,656,D,0,1,8Y4111,"Based on observation record review and staff interview, the facility failed to develop a care plan for discharge planning. This was true for one (1) of one (1) reviewed in for the care area of discharge planning. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #117. Facility Census: 111. Findings included: b) Resident #117 A review of the medical record on 06/05/19 for Resident #117 revealed the comprehensive care plan had not been developed to include discharge planning. In an interview on 06/05/19 at 3:22 PM, Social Services Specialist (SSS) #101 verified the care plan for Resident #117 was not developed to include discharge planning.",2020-09-01
29,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,657,D,0,1,8Y4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan related to refusal of care and non-compliance. This was true of one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory). This practice had the potential to effect more than a limited number. Resident identifier: #33. Facility census: 111. Findings include: a) Resident #33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for the requested documentation, while she finished the interview with this surveyor. LPN#84 said she was aware there was still some occasional drainage from the wound site. LPN#84 agreed the physician should have been notified concerning the resident's refusal of daily wound care and dressings. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment. LPN#61 said there was documentation concerning refusing care and non-compliance in other areas, but nothing concerning wound care. The facility was unable to provide any documentation or evidence that patient education was provided to the resident or any documentation that showed the physician was notified of the resident's refusals of wound care treatment. Review of care plan, on 06/10/19 at 11:23 AM, revealed a focus area related to the potential for further skin breakdown due to history of abscess to right side s/p (status [REDACTED]. An intervention added to this focus area on 06/05/19 by the wound nurse LPN#84 was Resident frequently refuses to come back from room from outside smoking for treatments to be completed A revision noted to the focus area potential for further skin breakdown on 06/06/19 now includes Resident noncompliant with wound treatments at times. The care plan was not revised timely to address resident's ongoing noncompliance with daily wound care treatments. The care plan was not revised to reflect any interventions addressing non-compliance and refusal of care in other areas that LPN#61 confirmed was documented in the resident's medical record. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed staff should have notified the physician sooner than 06/05/19, more than forty days after the resident consistently refused wound care treatment. The physician should have been notified when the resident continued refusing daily wound care treatment, so that the physician could order an alternative treatment if they chose to. The CNE confirmed R#33's care plan should have been revised with interventions concerning refusal of treatment and non-compliance prior to 06/05/19, due to the ongoing refusal of daily wound care treatment. The CNE also confirmed based on R#33 medical record showing non-compliance and refusal of care in other areas the care plan should have been revised to address refusal of care in those areas as well.",2020-09-01
30,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,676,D,0,1,8Y4111,"Based on resident interview, staff interview, observation and record review, the facility failed to ensure care and services for the following activities of daily living; Hygiene, bathing, dressing, grooming, and oral care for Resident #33 and #78. This was true for two (2) of two (2) reviewed in the care area of ADLS. Also, the facility failed to provide a communication board for Resident #105. This was true for one (1) of one (1) in the care area of communication. Resident identifiers: #33 and #78. Facility census: 111. Findings included: a) Resident #33 During an interview on 06/03/19 at 10:56 AM, Resident #33 said, that it is hard to get the aides to help him with a shower, they seem to pass him to another aide, and they take a lot of smoke brakes. He stated, that he must give himself a bed bath. When asked how long it had been since his last shower, he stated, that he did not know only that it has been too long. A review of the of the ADL records revealed that Resident #33 is scheduled to get a shower on Wednesdays and Saturdays, and he had no showers or baths for the month of April, and one (1) shower in the month of May. There was 15 days between his last shower until the shower he received on 06/06/19. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL recorded and agreed that Resident #33 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff members. b) Resident #78 During an interview on 06/03/19 at 12:14 PM, Resident #78 complained that it was hard to get a shower, and it had been ever since the one shower has been broken. He stated that the shower had been for down for months. He had below the shoulder length hair that appeared oily. A review of the ADL record revealed Resident #78 was scheduled to have showers on Tuesdays and Fridays. Review of ADL records revealed Resident # 78 in the month of (MONTH) he went 20 days without a shower or bath, and from (MONTH) 24th to (MONTH) the 6th that was 12 days without a shower or bath. During an interview on 06/06/19 at 2:35 PM, Unit Manager #61 reviewed the ADL records and agreed that Resident # 78 did not get his showers as scheduled and she stated, that she had already re-educated three of her staff. c) R105 During an observation with R105 on 06/04/19 at 9:14 AM it was discovered the word/letter board she used as a communication system was found in very poor condition, with food particles, water stains and frayed edges. The regulation requires any communication devices used by residents to be in good repair. In an interview with E84, Licensed Practical Nurse (LPN) on 06/05/19 at 8:44 AM, verified the communication board was in very poor repair and needed to be replaced.",2020-09-01
31,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,684,D,0,1,8Y4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, and policy review, the facility failed to ensure and provide needed care and services in accordance with professional standards of practice for two residents reviewed during the annual LTCSP (Long Term Care Survey Process). This was true for one (1) of one (1) sample residents reviewed for infections (not UTI or Respiratory) who was not provided education on wound care and infection control. This was true for one (1) of five (5) sample residents reviewed for falls that was not provided neuro checks appropriately after a fall. This practice had the potential to affect a limited number. Resident identifier: R#33 and R#60. Facility census: 111. Findings included: a) R#33 During the initial tour of the annual Long-Term Care Survey Process, on 06/03/19 at 11:15 AM, Surveyor# observed Resident (R#33) with dried crusted drainage around a small open circular wound site located on the resident's upper abdominal right side. This was identified as a concern for further investigation by Surveyor# due to the open wound draining and not being covered with a dressing. Review of records, on 06/10/19 at 11:01 AM, revealed R#33's brief interview for mental status (BIMs) score is fourteen (14) indicating the resident is cognitively intact. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to the facility after having incision and drainage (I&D) of abscesses, which developed after having lower-back spinal surgery and after having a cholecystectomy. A cholecystectomy is the surgical procedure to remove a gallbladder. After gallbladder surgery the resident had a drainage tube at the surgical site, on his right upper abdomen, to prevent the build-up of bile, blood, and/or infection. The resident developed an abscess on his right side and another incision and drainage procedure was performed and a drainage tube was again placed to facilitate healing. On 04/04/19, after the drainage tube was removed a new order was given to clean surgical incision to right side with wound cleanser, pat dry, and apply dry dressing every day. Review of the treatment administration record (TAR) revealed daily wound care treatment including a dry dressing was ordered and started on 04/04/19 and on 06/05/19 the wound nurse obtained an order to discontinue treatment due to resident refusing treatment. From the time of the order until the order was discontinued there were sixty-two (62) opportunities to provide daily wound care treatment and it was documented treatment was provided randomly only in the month of April. R#33 received wound care treatment eighteen (18) days due to resident refusing care on the other days, and three (3) times out of the sixty-two (62) opportunities to provide daily wound care treatment there was no documentation either way as to refusal or provision. An interview with the wound nurse, Licensed Practical Nurse (LPN#84), on 06/10/19 at 11:44 AM, revealed LPN#84 said she kept trying to get R#33 to allow her to provide the wound treatment but he always refused. LPN#84 said the resident would let her clean and measure the wound weekly but not provide treatment and place a dry dressing on it daily as it was ordered. This surveyor requested evidence or documentation showing the resident refused wound care treatment, the physician was notified about the refusals of treatment, and R#33 was provided education concerning the importance of wound care and infection control. LPN#84 asked the nurse unit manager (LPN#61), to help review R#33's medical records for any of the requested documentation, while she finished the interview with this surveyor. LPN#84 said she did not document notifying the physician about the refusal of treatment or any education concerning wound care or infection control. LPN#84 said she was aware there was still some occasional minimal drainage from the wound site. LPN#84 said she thought she contacted the physician sometime during the middle of (MONTH) and told the physician about the resident's refusal of treatment, however she said she did not document the conversation as she should have. When asked what instructions the physician gave her, LPN#84 said, I was to keep encouraging the resident to allow dressing changes. LPN#84 was asked by this surveyor if any other nursing staff tried to get the resident to comply with the ordered wound care treatment, such as the Center Nurse Executive (CNE), formerly known as the Director of Nursing or the Nurse Practitioner (NP). A Nurse Practitioner works in the facility three to four days a week and was available to see the resident. The wound nurse said she did not speak with the CNE or the NP or any other staff concerning R#33's refusals of wound care treatment. LPN#84 said she did not ask anyone else to see or speak to the resident to see if they might get R#33 to comply with the wound care treatment and/or to educate the resident on the importance of proper wound care and/or to ensure the resident understood. After review of the resident's medical records the nurse unit manager (LPN#61) stated she could find no documentation concerning refusal or non-compliance with the wound care treatment or any documentation or evidence that patient education was provided to the resident concerning wound care, disease processes, or infection control. On 06/10/19 at 01:10 PM, interview with the resident revealed the wound still has some occasional drainage, but not as much as it did. When asked if anyone had explained to him the importance of wound care and applying a dry dressing to cover and catch any drainage; the resident stated no one at the facility had talked to him about infections or the proper way to care for the wound. Review of Refusal of Treatment policy, on 06/10/19 at 03:55 PM, revealed if the patient refuses treatment staff will determine what the patient is refusing and why. Staff will try to address the patient's concerns and consult his/her supervisor. Staff will determine and document what the patient is refusing; assess the reasons for refusal; advise patient of consequences of refusal; and offer alternative treatments. Document discussions with the patient/health care decision maker, physician, and other involved persons. The wound nurse did not follow the facility's policy on Refusal of Treatment, particularly advising or educating the resident of consequences of refusal. An interview with the Center Nurse Executive (CNE), on 06/10/19 at 2:30 PM, confirmed the resident should have been provided education by staff regarding wound care, infection control, and disease processes that influence healing, and was not. b) Resident #60 On 06/10/19 at 09:55 AM, medical record review revealed Resident #60 had endured an un-witnessed fall on 05/22/19 at 3:00 PM while transferring from wheelchair to bed. Licensed Practical Nurse (LPN) #110 documented that the Resident stated (typed as written), I hit head but not hurting. At that time, LPN #110 implemented neurological assessments (screening tool used post fall for monitoring and detection of head injury) with a start time of 3:00 PM. The neurological assessments were completed for the following dates and time: --05/22/19 at 3:00 PM --05/22/19 at 3:30 PM --05/22/19 at 4:00 PM --05/22/19 at 4:30 PM --05/22/19 at 5:30 PM --05/22/19 at 6:30 PM --05/22/19 at 7:30 PM --05/22/19 at 8:30 PM --05/23/19 at 12:30 AM --05/23/19 at 4:30 AM The neurological assessment flow sheet was found to be incomplete with no data in all the following categories: level of consciousness, pupil response, hand grasps, movement of extremities, and pain response for nine (9) of the ten (10) assessments completed. The first neurological assessment completed on 05/22/19 at 3:00 PM was the only neurological assessment found to be completed in its entirety. Review of the facility's Neurological policy on 06/10/19 at 11:20 AM revealed the following guidelines for completion of neuroglial assessments (after an unwitnessed fall) to be done at the following frequency: --Every 30 Minutes x 2 hours, then --Every 1 hour x four hours, then --Every four hours x 24 hours. Further review of the neurological assessment sheet revealed the neurological assessments were discontinued without completion for the frequency as indicated. The last neurological assessment was completed on 05/23/19 at 4:30 AM, for a total of ten (10) assessments. In order to complete the neurological assessments for the correct number of times as indicated in the facility's Neurological policy, fourteen (14) assessments should have been done with an end time and date of 05/23/19 at 8:30 PM. During an interview on 06/10/19 at 11:28 AM the Director of Nursing (DON) agreed that the neurological assessments for the Resident was not completed correctly. The DON stated the expectation is for nursing staff to complete all information on the Neurological Assessment Flow sheet, and nothing should ever be left blank. The DON also stated, Yes we stopped the neurological assessments too soon, we did not complete the 24-hour frequency. At 1:10 PM on 06/10/19 during an interview, LPN #110 verified the portion of the Neurological Assessment Flow Sheet that she completed, and agreed the assessments were not completed correctly and should not have been left blank for level of consciousness, pupil response, motor response, and pain response. LPN #110 stated, It just gets so busy around here, and it's hard to get everything done because it's so hectic, I should have done better.",2020-09-01
32,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,689,D,0,1,8Y4111,"Based on observation, staff interview, and Policy review the facility failed to ensure an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifier: #53. Facility census 111. Findings included: a) Resident #53 1. Policy review Facility Waste Management policy directed personnel to: --Discard contaminated sharps immediately be disposed in a sharp's container. --Not discard sharps in routine trash. 2. Observation During an interview on 06/04/19 at 9:40 AM, with the Resident #53's roommate, this surveyor observed Resident #53 in her wheelchair at the sink with the water running. Resident #53 then moved herself over to the window. Licensed Practical Nurse (LPN) #85 entered the room and asked if she could turn off the water. She turned off the water and picked up a blue razor from the sink and threw it in the trash can under the sink. Resident #53 wheeled herself to the sink and removed the razor from the trash can. With the razor on her lap she wheeled herself back in front of her window and began the shave her left leg. Upon closer observation it was noted that her left ankle was bleeding. 3. Interviews This surveyor asked a passing employee get a nurse and distracted the resident with conversation. LPN #85 returned to the room and looked at Resident #53's left. LPN #85 left the room to retrieve supplies to treat the cuts to Resident #53's legs. There were seven (7) cuts on her left leg from the razor. On 06/04/19 at 10:00 AM, LPN #85 and Nurse Unit Manager (NUM) #61 returned to the room with supplies to treat the wounds. LPN #85 was asked how it Resident #53 had access to a razor. She said she uses the razor for the hairs on her chin, but she does it for her. Resident # 53 stated, that she does not remember where she got the razor from. During an interview with Administrator on 06/06/19 at 11:30 AM, was asked where the razors where kept. He stated they were stored in the clean utility room that had a coded lock on the door, inside the room they were stored in a drawer. He stated, that he does not understand how Resident #53 got a razor. During an interview on 06/10/19 at 10:00 AM, Director of Nursing (DoN) stated, that she has removed all razors from the utility rooms and put them in the medication rooms that are locked and only the nurses have access to and the NA have to sign the razors out and back in with a nurse for disposal. She agreed this was an avoidable accident.",2020-09-01
33,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,690,D,0,1,8Y4111,"Based on observation, staff interview, and policy review the facility failed to ensure a resident's Foley Catheter drainage tubing was securely anchored. This was true of one (1) of three (3) sample residents reviewed for catheter care. This practice had the potential to effect more than a limited number. Resident identifier: R#68. Facility census: 111. Findings include: Observations of Licensed Practical Nurse (LPN#84) providing catheter care to Resident (R#68), on 06/05/19 at 04:13 PM, revealed the Foley catheter drainage tubing was not secured or anchored in anyway. LPN#84 first provided pressure ulcer wound care to R#68 for three (3) different areas on the resident's buttocks prior to providing catheter care. During the provision of care the resident was assisted to turn multiple times from side to side. The Foley catheter drainage tube was not secured to the resident's leg. Observations, during the repositioning of the resident to expose the areas being cared for, revealed strong tension, pulling, and stretching of the drainage tubing was occurring at times. The Foley catheter drainage tube's taut tension, pulling, and stretching had the potential to cause injury to the resident's urethra and urinary meatus. After LPN#84 stated she was finished doing catheter care, this surveyor asked what method the facility used to secure the Foley catheter drainage tube. LPN#84 then acknowledged the resident did not have an anchor device on and should have, and that she also forgot to anchor and secure the tubing when she did the catheter care. LPN#84 confirmed the catheter drainage tubing was supposed to be secured so it did not pull. Review of the facility's Catheter: Indwelling Urinary - Insertion policy revealed #25 stated Ensure the catheter tubing is secured with catheter tube holder or leg strap. Keep the drainage bag below the level of the patient's bladder and off the floor.",2020-09-01
34,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2019-06-10,695,D,0,1,8Y4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to provide necessary respiratory care and services. This was true for one (1) of two (2) residents reviewed for respiratory services during the investigation phase of the survey process. It was observed R28 was not receiving her oxygen therapy at the prescribed flow rate. Resident identifier: #28. Facility census: 111. Findings included: a) Resident #28 A medical record review for Resident #28 on 06/04/19 revealed a physician's orders [REDACTED]. During an observation on 06/04/19 at 7:56 AM, it was discovered the oxygen concentrator for R28 was administering one and a half (1.5) liters of oxygen via nasal cannula and not the prescribed two (2) liters. Licensed Practical Nurse (LPN) #110 on 06/04/19 at 7:59 AM verified the oxygen concentrator for R28 was set on (1.5) liters and not the prescribed two (2) liters.",2020-09-01
36,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-07-19,684,D,0,1,KVZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview, the facility failed to provide appropriate treatment and care in accordance with physician orders [REDACTED]. This affected one (#160) of one sampled resident reviewed as a new admission. The facility census was 113. Findings included: Resident #160 was observed sitting up in bed on 07/16/18 at 10:15 AM. At the time of the observation, Resident #160 was interviewed. He stated he had not received his pain medication when he was admitted to the facility. Resident #160 also stated he did not get all his routine medications in a timely manner. He stated his sister brought in his medications from home and he took those. The medical record review for Resident #160 was completed on 07/19/18 at 5:30 PM. The census tab of the electronic record documented Resident #160 was admitted on [DATE] at 8:13 PM with [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The Medication Administration Record [REDACTED]. The documentation revealed Resident #160 did not receive the aspirin until one day after admission on 07/15/18 at 10:00 PM. The [MEDICATION NAME] was administered three days after admission on 07/18/18 at 6:00 AM. The [MEDICATION NAME] bisulfate was administered two days after admission on 07/16/18 at 9:00 AM. The [MEDICATION NAME] was administered four days after admission on 07/18/18 at 9:00 AM. the Tylenol administered two days after admission on 07/16/18 at 12:15 AM. Review of the weights and vitals summary on 07/19/18 at 5:30 PM revealed Resident #160 had vital signs documented approximately 5 hours after admission on 07/15/18 at 1:12 AM. The second set of vital signs was dated four days later at 07/18/18 at 7:32 PM. There was no documentation of any vital signs taken upon admission. An interview was conducted with the unit manager, Registered Nurse (RN) #23 on 07/18/18 at 6:10 PM. She stated according to the electronic record, Resident #160 was admitted on [DATE] at 8:13 PM. She verified the progress notes did not indicate the date and time Resident #160 was admitted . RN #23 verified Resident #160 did not receive his medications as ordered by the physician according to the Medication Administration Record [REDACTED]. An interview with RN #23 on 07/19/18 at 10:45 AM revealed the expectation of the facility was newly admitted residents received their medications within 24 hours. An interview on 07/19/18 at 12:00 PM with the pharmaceutical technician from the pharmaceutical company revealed Resident #160's medications were delivered within 24 hours on 07/15/18 at 5:34 PM.",2020-09-01
37,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2018-07-19,801,D,0,1,KVZF11,"Based on staff interviews, the facility failed to employ a full-time Dietary Manager that met the qualifications to manage the food and nutrition services. The facility census was 113. Findings included: On 07/18/18 at 5:00 PM, Food Service Director #121 was interviewed. Food Service Director #121 stated he was not a certified dietary manager. He stated he took the position of Food Service Director one week ago. He was not currently enrolled in a program for certification. Food Service Director #121 stated he was told he was going to be enrolled in the training program but did not know when. Food Service Director #121 verified he did not have any nutrition schooling or a college degree in nutrition. He verified he was not a certified food service manager and did not have a national certification for food service management and safety from a national certifying entity. On 07/19/18 at 1:27 PM, Regional Vice President #144 was interviewed. He verified Food Service Director #121 did not meet the qualifications for food service management and was not currently enrolled in a program for certification.",2020-09-01
39,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,157,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based resident, staff and physician interviews and clinical record review, the facility failed to notify the physician timely of a resident incident for one resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifiers: #260. Facility census 145. Findings include: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #260 until today. The DON expected the staff to have made documentation in the clinical record on the evening shift and reported the incident immediately to the charge nurse, physician and family. The DON stated she was starting an investigation of the incident. During a phone interview, on 02/27/17 at 1:14 p.m., the surgeon stated he expected an immediate assessment of any injury sustained by this resident, and staff would have notified him. The surgeon stated was concerned the resident may have a rupture at the insertion site repair. During an interview, on 02/27/17 at 4:06 p.m., LPN #46 stated she took care of Resident #260 on the evening shift on 02/22/17. LPN #46 stated NA #81 reported to her the resident's foot touched the bathroom floor and did not mention the resident had any pain. LPN #46 stated she did not give the resident any medication for pain, and she did not assess the resident's foot. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During an interview, on 02/28/17 at 10:40 a.m., the DON and Administrator confirmed the lack of timely notification of the physician of a resident incident.",2020-09-01
41,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,272,D,0,1,TKXD11,"Based on staff interview, record review, resident interview, and observation, the facility failed to complete an accurate comprehensive assessment for one (1) of eighteen (18) sample residents. The dental status assessment of one (1) resident was inaccurate on the comprehensive minimum data set (MDS). Resident identifier: #33. Facility census: 145. Findings include: a) Resident #33 During the stage 1 observation and interview of Resident #33 conducted on 02/22/17 at 1:00 p.m., she said she had a broken front tooth and used to wear a partial denture. Her mouth had several teeth in various states of wear and decay, with missing teeth evident. During the medical record review performed on 02/28/17, there were dental consultation notes with the following information: --08/09/16 Exam: Generalized Decay; Generalized Periodontal Disease The attached treatment plan included options for replacing missing teeth, specifically dental implants and partial dentures. --08/30/16 Presents for exam and x ray with extractions Further interview with Resident #33 on 02/28/17 at 10:13 a.m. revealed she was looking into getting a new partial and was awaiting an appointment. On 02/28/17 at 12:30 p.m. a review of the most recent comprehensive (annual) MDS with an assessment reference date (ARD) of 09/24/16 found section L Oral/Dental Status with the following assessment: B. No natural teeth or tooth fragment(s) (edentulous). Registered Nurse Assessment Coordinator #102 was interviewed on 02/28/17 at 1:00 p.m. and said the oral assessment in section L was an error. She provided evidence that a correction was made to the MDS prior to the survey exit.",2020-09-01
42,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,280,D,0,1,TKXD11,"Based on resident interview, medical record review and staff interview, the facility failed to revise a care plan for one (1) of eighteen (18) stage 2 sample residents. The facility did not revise a Brief Interview for Mental Status (BIMS) score. Resident identifier: #12. Facility census 145. Findings include: a) Resident #12 Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 12/02/16 revealed a BIMS score of fifteen (15) which indicates the resident is cognitively intact. The residents most recent care plan indicated a BIMS score of five (5) which indicates severely cognitive impaired. On 02/21/17 at 1:00 p.m., Resident #12 was able to answer stage one interview questions without difficulty. During interview on 02/28/17 at 3:45 p.m., registered nurse (RN) #17 stated the BIMS score on the care plan had not been updated from the residents admission and should have been updated to the current BIMS score of 15.",2020-09-01
43,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,323,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record reviews and review of safety data sheets, the facility failed to prevent accidents by failing to use proper transfer technique for 1 of 1 residents reviewed for accidents, resulting in pain. (Resident #260.) The facility failed to prevent accident hazards by storing chemicals safely (Resident #177.)and storing medications safely. Census 145. The findings are: a.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--Norco 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and Norco. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/23/17 at 1:58 p.m., LPN #64 stated he was unaware Resident #260 had hurt her foot yesterday evening. LPN #64 stated he would immediately notify the physician about the incident. During an interview, on 02/23/17 at 2:52 p.m., the Director of Nursing (DON) stated she was unaware of the incident regarding Resident #260 until today. The DON expected the staff to have made documentation in the clinical record on the evening shift and reported the incident immediately to the charge nurse, physician and family. The DON stated she was starting an investigation of the incident. During a phone interview, on 02/27/17 at 1:14 p.m., the surgeon stated he expected an immediate assessment of any injury sustained by this resident, and staff would have notified him. The surgeon stated was concerned the resident may have a rupture at the insertion site repair. During an interview, on 02/27/17 at 4:06 p.m., LPN #46 stated she took care of Resident #260 on the evening shift on 02/22/17. LPN #46 stated NA #81 reported to her the resident's foot touched the bathroom floor and did not mention the resident had any pain. LPN #46 stated she did not give the resident any medication for pain, and she did not assess the resident's foot. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During an interview, on 02/28/17 at 7:07 a.m., NA #81 stated she assisted the resident to the bathroom about 8:30 to 9:30 p.m. NA #81 stated the resident got unsteady when getting off the toilet. NA #81 stated, I grabbed her by the waist and sat her back into the wheelchair. The resident hit her foot on the floor. NA #81 stated the resident asked for pain medication because her foot hurt. NA #81 stated she was supposed to use a gait belt to transfer the resident but did not use it. NA #81 stated some resident's just don't like them. During a phone interview, on 02/28/17 at 10:24 a.m., RN #121 stated she worked the night shift on 02/22/17 at 11:00 p.m. until 02/23/17 at 7:00 a.m. RN #121 stated she was unaware of any incident occurring with Resident #260 on the evening shift. RN #121 stated the resident request pain medication at 1:30 a.m. and she gave the resident Norco for her pain. RN #121 stated she did not document the medication administration in the clinical record. RN #121 stated she just got busy and forgot to document the administration of the administration of the administration. During an interview, on 02/28/17 at 10:40 a.m., the Director of Nursing and Administrator confirmed the lack of timely notification of the physician of a resident incident, the lack of timely assessment of resident injury and administration of medication for pain, the lack of following physician orders [REDACTED]. b.) Resident #177 After completion of a dressing change, on 02/23/17 at 12:00 p.m., RN #137 placed an open bottle of 0.25% acetic acid on the resident's window sill above the resident's heater. During an interview, on 02/23/17 at 1:03 p.m., RN #137 stated she left the acetic acid on the window sill, so other staff could have access to it. I didn't want to put it back in the treatment cart. I thought that would be more of an issue. After the interview, RN #137 removed the acetic acid from the window sill and put it in the locked treatment cart. Review of safety data sheet for acetic acid stated solution is corrosive, Causes severe skin burns, eye damage, may be harmful if swallowed, is flammable and to keep away from heat/sparks/open flames/hot surfaces. c) Medications A random observation of the 200 Hall on 02/23/17 at 7:50 a.m., revealed medications on the counter of the nurses's station unattended and accessible to anyone from 7:50 a.m. to 8:00 a.m. The following Resident's medications were observed on the nurses's station counter: --Resident #15 - Ipratropium/Albuterol (3 packs) --Resident #92 - Phenytoin EX 100 mg (56 capsules) --Resident #184 - Clonidine HCL 0.1 mg (56 tablets) --Resident #187 - Celecoxib 200 mg (56 capsules) An interview with Licensed Practical Nurse (LPN) #64 on 02/23/17 at 8:00 a.m. revealed the night shift nurse must have left the medications at the nurse's station. The LPN stated his shift began at 7:00 a.m. The LPN stated the medications should have been locked upon acceptance from the pharmacy. A random observation of the 800 Hall on 02/23/17 at 8:05 a.m. revealed the medication cart was unlocked at the nurses station. The cart was unlocked, unattended, and out of sight of any staff from 8:05 a.m. until 8:12 a.m. The cart contained the medications for all the 800 Hall residents. An interview with Registered Nurse-Nurse Manager (RN-NM) #21 on 02/23/17 at 8:12 a.m. revealed the medication cart should always be locked when not in sight of the nurse.",2020-09-01
46,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,441,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow proper hand hygiene techniques during medication administration for one (1) of twenty six (26) opportunities observed. In addition, the facility failed to perform proper cleaning technique on reusable equipment during one (1) of three (3) dressing change observations. This failed practice affected an isolated number of residents who received medications administered by the facility and of those who had pressure ulcers. Resident identifiers: #126 and #177. Facility census: 145. Findings include: a) Resident #126 An observation of medication administration on 02/28/17 at 08:24 a.m., revealed Licensed Practical Nurse (LPN) #44 attempted to pop a [MEDICATION NAME] 25 milligram (mg) tablet out of the packaging into a medicine cup for Resident #126. The pill missed the cup and fell to the floor. LPN #44 picked up the pill with her bare hands and discarded it. She then popped out a second [MEDICATION NAME] 25 mg tablet into the medication cup and continued with her medication administration for Resident #126 without washing or sanitizing her hands. On 02/28/17 at 10:59 a.m. this matter was discussed with Employee #4, who was responsible for infection control. She agreed that it was an infection control issue. She provided the facility policy titled Handwashing/Hand Hygiene last revised (MONTH) (YEAR). This policy stated to use alcohol-based hand rub or soap and water Before preparing or handling medications. b.) Resident #177 During a dressing change, on 02/23/17 at 12:00 p.m., RN #137 removed scissors from her uniform pocket and cut kling soaked with acetic acid which LPN #64 was using to pack resident #177 coccyx stage IV wound. RN #137 did not clean the scissors prior to use. At the end of the dressing change procedure, RN #137 placed the scissors back into her uniform pocket without cleaning them when she left the room. During an interview, on 2/23/17 at 1:08 pm, RN #137 stated she probably should have cleaned her scissors prior to use and after use. During an interview, on 2/23/17 at 3:03 pm, the Director of Nursing confirmed RN #137 should have cleaned the scissors before and after use during the dressing change.",2020-09-01
47,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2017-03-01,514,D,0,1,TKXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately for two (2) of eighteen (18) sample residents. Behavior monitoring and bowel pattern tracking was not consistently and/or accurately documented for one (1) resident and a second resident had incomplete medication administration records. Resident identifiers: #258 and #260. Facility census: 145. Findings include: a) Resident #258 1. Behavior sheets A medical record review for Resident #258 on 02/27/17 revealed she had physician's orders [REDACTED]. This medication was first administered on 02/03/17 at 8:00 p.m. She also had an order for [REDACTED]. Although the orders were initiated on 02/03/17, the Behavior/Intervention Monthly Flow Sheet were not documented until night shift of 02/04/17 for both [MEDICATION NAME] and [MEDICATION NAME]. In addition, there were multiple blanks holes on both sheets. The director of nursing (DON) was interviewed on 02/27/17 at 4:39 p.m. and she acknowledged the holes on the sheets were where nursing had not completed the forms. 2. Bowel patterns During the medical record review for Resident #258 on 02/27/17, there were several missing entries in the nurse aide documentation for Bowel Patterns. In addition, the documentation reflected no record of the resident having a bowel movement from night shift on 02/17/17 until evening shift on 02/23/17, as the nurse aides had documented 0 meaning No Bowel Movement. Nurse manager #21 was interviewed on 02/28/17 at 3:05 p.m. and she said that the documentation was inaccurate. She also agreed that the holes in the record resulted in the record being incomplete. c.) Resident #260 Clinical record review, conducted on 02/23/17 at 2:00 p.m., revealed Resident #260 was admitted to the facility on [DATE] after right Achilles tendon repair. The 02/21/17 physician order [REDACTED]. The admission physician orders [REDACTED].>--[MEDICATION NAME] 5-325 milligrams (mg) every six (6) hours as needed for pain --Tylenol 325 mg, 2 tablets every four (4) hours as needed for mild pain. The 02/20/17 admission nursing assessment revealed the resident was not steady moving on and off the toilet and with surface to surface transfer, only able to stabilize with staff assistance. The clinical record was silent regarding any incident involving the resident on 02/22/17 or any administration of as needed pain medication. The record contained no notification of the physician of the incident. During an interview, on 02/23/17 at 12:45 p.m., Resident #260 stated she had an incident in the bathroom the previous evening. The resident stated the nurse aide was in a hurry and did not have the wheelchair close and when she went to get off the toilet. Resident #260 further said, I hit my right foot on the floor. It hurt me. I had to get pain medication for it. I had to have Tylenol and [MEDICATION NAME]. I didn't need it since my first day here. The resident stated her foot was still hurting now. During an interview, on 02/27/17 at 4:36: p.m., LPN #36 stated she gave Resident #260 two (2) Tylenol about 11:30 p.m. on 02/22/17. LPN #36 verified she did not document she administered the medication. LPN #36 stated she did not assess the resident's foot since it was covered with a sheet. LPN #36 stated the resident reported to her she had hit her right foot on the bathroom floor on the evening shift. During a phone interview, on 02/28/17 at 10:24 a.m., RN #121 stated she worked the night shift on 02/22/17 from 11:00 p.m. until 02/23/17 at 7:00 a.m. RN #121 stated she was unaware of any incident occurring with Resident #260 on the evening shift. RN #121 stated the resident request pain medication at 1:30 am and she gave the resident [MEDICATION NAME] for her pain. RN #121 stated she did not document the medication administration in the clinical record. RN #121 stated she just got busy and forgot to document the administration of the medication. During an interview, on 02/28/17 at 10:40 a.m., the Director of Nursing and Administrator confirmed the lack of complete and accurate documentation in the clinical record.",2020-09-01
48,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,561,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promote one resident's right to make choices about aspects of their life. Specifically, the facility failed to provide a shower to resident #305 as requested. This failed practice had the potential to affect a limited number of residents. Resident identifier: #305. Facility census: 142. Findings included: a) Resident #305 According to the 5/18 physician's orders [REDACTED]. According to the admission progress note, dated 4/28/18, the resident was oriented to person, place, and time and was able to make her needs known. In an interview on 4/30/18 at 4:12 PM, Resident #305 said she had just admitted that past Saturday. She said the hospital never showered her so she really wanted a shower. She wanted to feel clean and thought she would feel much better after she received a shower. She said she had been asking for a shower since she admitted to the facilty. She asked her aide taking care of her that day if she could get a shower and the aide told her she would see what she could do. The resident was tearful during the interview. In an interview on 5/1/18 at 5:03 PM, Resident #305's hair was visibly wet and she was brushing it. She said she had just received a shower, her first since admission, and she felt much better. The resident's 5/18 physician's orders [REDACTED]. An order dated 4/28/18 directed Transfer assist of 2 with gait belt. An order dated 4/30/18 directed Cont (continue) with transfer assist of 2 and gait belt. Pt (patient) non-ambulatory on wing. Shower documentation and progress notes were reviewed on 5/2/18 at 4:50 PM. The shower records revealed an entry on 5/1/18 that documented not applicable, indicating a shower was not provided. Review of the progress notes revealed there was no documentation that a shower was given. The skilled progress note on 4/29/18 indicated the resident required assistance of two with transfers and bed mobility. In an interview on 5/2/18 at 4:31 PM, Licensed Practical Nurse (LPN) #34 said she was the one who admitted the resident after dinner on Saturday night. On admission the resident expressed that the hospital had not showered her in four days or changed her gown, so they had discussed getting her a shower. On Saturday night, staff provided her a bed bath and got her cleaned up. The resident was supposed to receive a shower on Sunday if she still expressed the desire to receive one. LPN #34 said the shower schedule was pre-set based on room numbers. The resident's shower days were Tuesdays and Fridays. She said no showers were scheduled on Sundays, but staff should have provided one, if needed. In an interview on 5/2/18 at 5:10 PM, CNA #121 said she had only worked at the facility for a few weeks and had worked that past Sunday. She said Resident #305 had requested a shower on Sunday, but she did not provide her with one. She explained she thought therapy had to evaluate a new resident before staff could assist the resident in any transfers. She said the resident stayed in bed all day on Sunday as she would not get residents up until therapy evaluated them. She stated she provided the resident with a shower 5/1/18, Tuesday. The Assistant Director of Nursing was present during the interview with CNA #121. She said the resident could have received a shower on Sunday as she requested. She said the facility's protocol was that all new admissions could be transferred with two staff and a gait belt until therapy could evaluate them, or if orders indicated otherwise. In an interview on 5/3/18 at 11:45 AM, the Director of Nursing (DON) said the CNA should have spoken to the nurse about the resident's transfer status. The nurse could have called the doctor to obtain orders, if they were unclear. She said most new admissions were a two assist with a gait belt unless they were walking as they entered the facility or they had non-weight bearing orders. She said residents could receive showers whenever they requested them. There was a shower schedule but if a resident requested a shower, then the staff should provide one.",2020-09-01
50,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,657,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to include the resident in the care planning process. Specifically, the facility failed to keep one resident (#108) reviewed for Discharge informed of his progress towards discharge. This failed practice had the potential to affect a limited number of residents. Resident identifier: #108. Facility census: 142. Findings included: a) Facility policy The care planning policy, revised 09/2013, was reviewed on 5/3/18 at 9:15 AM. The policy indicated in pertinent part: .The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . Every effort will be made to schedule care plan meeting at the best time of the day for the resident and family .' b) Resident #108 Resident #108 admitted to the facility on [DATE] and discharged to the community on 4/30/18. According to admission physician's orders [REDACTED]. Review of the 3/22/18 Minimum Data Set (MDS) assessment on 5/2/18 at 11:35 AM. According to the MDS, the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. The MDS assessed he required extensive assistance with all activities of daily living (ADLs). In an interview on 4/30/18 at 1:13 PM, the resident stated he was scheduled to be discharged around 3:00 PM that day. He complained that there was a lack of communication between the facility and himself. He stated he received therapy under his insurance and that staff never discussed his progress with him or discussed when discharge may occur. He said, all of a sudden they came and spoke with him and said they were discharging him in a couple days. He said he appealed the discharge and won, but he did not want to stay at the facility due to the lack of communication. He said they had a meeting with him when he first arrived back in March, but no other meetings since then. He said the staff had an internal meeting every week to discuss residents, but no one ever came and spoke to him about what was talked about in that meeting regarding his care or progress. The resident's record was reviewed on 5/2/18 at 1:15 PM. The discharge care plan, initiated on 3/15/18, identified the resident expressed his wish to discharge home with family. Interventions included reviewing progress towards discharge during scheduled meetings. Review of progress notes revealed no documented conversations with the resident regarding his progress or plans towards discharge. There was no evidence of care conferences that took place during his stay. A Social Services note, dated 3/15/18, revealed the Social Service staff met with the resident, completed the admission packet with him and spoke with his family member by phone. They discussed options in case the resident would be unable to return home. The plan was for the resident to return home with family. Social Services made them aware of their services and assistance. Social Services documented the internal Medicare meeting that occurred each week. The Medicare meeting note dated 4/25/18 revealed the resident's last covered day would be 5/4/18 with long term care being recommended. There was no documentation after the meeting indicating the resident was informed of the upcoming end of therapy. On 4/27/18, Staff #70 documented in the record that she issued the notice of Medicare non coverage to the resident. The notice was discussed with the resident's family member via phone. She discussed the appeal process with both of them. There was no explanation for the 2 day delay between when the facility determined the resident's therapy would end and when the resident was notified. On 4/30/18, Social Services documented the resident was discharging from the facility and which services would be provided at home. A note from the nurse practitioner on 4/30/18 documented in pertinent part, .At this time patient feels he is being thrown out. Discussed situation and insurance and he would continue therapy at home . The Physical Therapy and Occupational Therapy daily progress notes were reviewed on 5/3/18 at 11:20 AM. Review of the notes revealed there was no documentation from therapy discussing the resident's progress with the resident or progress towards discharge. On 4/27/18, the same date the resident was notified his therapy was ending, Physical Therapy documented, Therapist met with patient and spouse and discussed patients D/C (discharge) planning. Educated patient on his progress with therapy to this point and discussed patients future progress and plans. In an interview on 5/2/18 at 1:27 PM, Social Services #51 explained one of the two Social Service staff met with residents within 48 hours of admission. They provided the resident with a packet of information, discussed their history and goals, and the discharge planning process. She said they had an open door policy so if any one wanted to speak to them, they were able to. Social services helped arrange for home services and placements. She said she met with residents regularly to complete MDS assessments. She said the facility had internal Medicare meetings every Wednesday morning. She tried to meet with the residents after that meeting, but mostly met with those that had upcoming discharge date s or that were going to need increased services. She said she always tried to document in the record whenever she had a conversation with a resident or family member. She remembered speaking with Resident #108's family member more than the resident. She stated the family member called every couple weeks to find out what the resident was going to need when he returned home. She further explained when she met with a resident upon admission she told them that they could have a care conference any time they wanted to. She said the short-term residents did not have a set care conference schedule and that the resident, family, or therapy were the ones to typically initiate the scheduling of a care conference. She said the facility did not complete an admission care conference. In an interview on 5/2/18 at 5:33 PM Case Manager #70 said she was the case manager for the residents that had managed care. She helped with discharge planning along with social services. She remembered having a conversation with the resident when she issued his notice of Medicare non-coverage. She explained that he was being discharged by his insurance. She said it was hard to let the resident know when they may be discharged because insurance could cut them off at any time. The interim therapy director was interviewed on 5/3/18 at 10:34 AM. She said therapy discussed progress on a daily basis with residents during their sessions. Those conversations would be documented in their progress notes. She said therapy did not attend care conferences unless they were the ones to request the care conference. Normally a care conference was suggested when the discharge was questionable, which would be if the resident needed placement instead of returning home. She stated she worked directly with Resident #108 and remembered having conversations with the resident about his progress. She remembered speaking with the resident's family member a couple of times as well. She said she was not sure why no care conference was held, but the resident got mad at therapy because they were discharging him. In an interview on 5/3/18 at 11:40 AM, the interim therapy director reviewed the weekly progress notes. She confirmed there was no documentation to indicate the resident was spoken to about his progress towards discharge. She was certain that conversations occurred but could not find any evidence of the conversations. In an interview on 5/3/18 at 12:35 PM the Administrator said the facility met internally every week to discuss short term stay residents. Social Services communicates with the residents and gets the discharge information from the resident, such as their prior level of function and home setting upon admission. Therapy speaks to residents from the beginning as well about discharge planning and how the process worked. She said care conferences should be completed prior to the resident being discharged and therapy would be at that meeting.",2020-09-01
51,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,689,D,1,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide adequate supervision in accordance with the resident's plan of care to prevent accidents. Specifically, two (2) residents reviewed for Accidents, the facility failed to follow aspiration precautions when each was allowed to use a straw despite physician's orders [REDACTED]. Resident identifiers: #93 and #8. Facility census: 142. Findings included: a) Resident #93 Review of the care plan, dated 3/5/18, revealed Resident #93 had nutritional risks based, in part, on a recent [DIAGNOSES REDACTED]. Review of the current Kardex (care directives provided for and used by Certified Nurse Aides - CNA) revealed Diet: ST (speech therapy) Orders: no straw protocol w/ liquids. The physician's orders [REDACTED]. Observation on 5/2/18 at 8:43 AM revealed CNA #110 place a breakfast tray in front of Resident #93. The CNA set up the resident's meal, including opening the resident's milk carton, placed it in front of him, and left. A straw was observed on the tray. Resident #93 picked up the straw, removed the paper wrap and placed it in the milk carton. He then began to drink using the straw. CNA #105 and #110 both passed by in the next few minutes, but did not intervene. There was no nurse on the unit during this observation. The meal card on the resident's tray did not identify the resident was not to have straws. In an interview on 5/2/18 at 8:52 AM CNA #110 stated she was not aware the resident was not supposed to have a straw. She said she did not think it was identified on the Kardex. At 9:01 AM CNA #105 stated she did not know Resident #93 was not supposed to have a straw. In an interview on 5/2/18 at 10:41 AM Nurses #3 and #82 explained there were three nurses splitting Unit 5 today. They explained there were extended periods of time they would each be on their other respective units, and so no nurse would be present on Unit 5. Both stated they were not aware Resident #93 should not have a straw, however they were able to locate the physician's orders [REDACTED]. In an interview on 5/02/18 at 11:02 AM, Speech Therapist #158 stated Resident #93 should not have straws as she did not believe his swallow reflex was fast enough to compensate if he had issues. She stated she had not been notified of any coughing or choking that might be related to the resident's use of straws and did not believe he had experienced any ill effects, however she stated he should not be provided one or allowed to use them. b) Resident #8 Observation on 5/02/18 at 5:01 PM revealed Resident #8 propel his wheelchair out of his room. He stated loudly, They took my straws! He explained he had straws in his room that he used daily, I have to drink a lot of water . I had straws but someone came in while I was out of my room and took them. He stated he had been using straws for months. CNA #65 stated she had heard there were issues with residents using straws and she remembered Resident #8's care plan directed he should not have any so she took them. She verified the resident had straws in his room that he used daily, She did not know how long he had been using them, but stated, awhile. According to the 1/24/18 quarterly Minimum Data Set, the resident had a Brief Interview for Mental Status score of 15, indicative of no cognitive loss. The MDS (Section K) revealed the resident exhibited no signs or symptoms of a swallowing disorder. According to the 12/20/16 Modified [MEDICATION NAME] Swallowing Study, located in the resident's record, strategies identified to address the resident's swallowing difficulties included no straws. A physician's orders [REDACTED]. NO STRAW. CUE PT TO USE CHIN TUCK. Review of the most current Kardex revealed thin/regular liquids. Cup only, no straw, cue pt (patient) to use chin tuck. According to the Alteration in Nutrition Care Plan, updated 2/12/18, Resident #8 had a [DIAGNOSES REDACTED]. Interventions included Regular Diet, regular texture, thin/regular liquids. Cup only, no straw, cue pt to use chin tuck; Encourage 6 to 8 glasses of water per day; Suction cup to be provided at all meals. In an interview on 5/03/18 at 9:35 AM, the Administrator and Director of Nursing (DON) stated staff should follow the care plans. They verified Resident #8 should not have had straws according to his most current orders. In an interview on 05/03/18 at 11:13 AM, Therapist #139 reviewed Resident #8's therapy notes. She stated Resident #8 should not have straws. She verified that order was current and based on his last skilled speech therapy services. In an interview on 5/3/18 at 12:50 PM, the Assistant DON #88, stated there had been no observed swallowing issues for Resident #8 since his diet had been upgraded. She stated staff are expected to follow physician's orders [REDACTED].",2020-09-01
52,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,698,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate care with the [MEDICAL TREATMENT] Center for Resident #126, one of one residents reviewed for [MEDICAL TREATMENT]. The facility failed to ensure communication from the [MEDICAL TREATMENT] Center following the resident's treatment was reviewed and recorded. This failed practice had the potential to affect a limited number of residents. Resident identifier: #126. Facility census: 142. Findings included: a) Resident #126 Review of the resident's record revealed Resident #126 was admitted to the hospital 4/16-21/18. She readmitted to the facility 4/21/18. Review of physician's orders [REDACTED]. The record revealed the resident refused [MEDICAL TREATMENT] on 4/24/18, but went on 4/28/18 and 5/1/18. physician's orders [REDACTED]. Staff were directed, in the order, to put results in computer. Review of the electronic record revealed one weight for 4/28/18 and no weights for 5/1/18. In addition, a dietary progress note, dated 5/2/18 indicated .Current [MEDICAL TREATMENT] labs are unavailable to me here at this time. The [MEDICAL TREATMENT] labs were recommended to be obtained by our facility at today's morning/clinical meeting. In an interview on 5/2/18 at 1:34 PM, Licensed Nurse #82 was asked how the [MEDICAL TREATMENT] center and the facility communicate. She explained she did not work the floor very often, but had been pulled to do so that day. She stated they used to have a little form, with pre and post weights. Vital signs. She looked through the resident's record but was unable to locate any communication. In an interview on 5/2/18 at 1:37 PM, the Assistant Director of Nursing #88, stated We have a little form, with weights, treatment changes. Might be in her packet. Probably downstairs with (Receptionist). Let me go check. At 5/2/18 at 1:51 PM Staff #33 provided a blank copy of the [MEDICAL TREATMENT] Patient Data Sheet. It goes in the envelope and the van driver takes it to [MEDICAL TREATMENT], then they fill it out, bring it back. I don't know what happens then, I guess the nurse puts it in the computer? This resident went to the hospital. I wonder if we didn't make her a packet (to send to [MEDICAL TREATMENT]) when she got back? I will go do that. At 5/2/18 at 2:00 PM, ADON #88 stated she asked the transportation driver what he did with the papers he brought back from the [MEDICAL TREATMENT] Center. She said he left the envelope in the resident's room after each appointment. ADON #88 located the 4/28 and 5/1/18 [MEDICAL TREATMENT] Patient Data Sheets in the resident's room. She stated the nurse should have obtained and reviewed them and put them in the chart. She explained if medication orders changed or something significant occurred at [MEDICAL TREATMENT], the center would usually call and notify the facility. However, the [MEDICAL TREATMENT] Center recorded vital signs, weights, lab results and other communication on the forms and the facility should still be obtaining these.",2020-09-01
55,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,812,D,0,1,X20F11,"Based on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety in one of one kitchens. Specifically, the facility failed to ensure staff conducted proper hand hygiene and transported clean utensils in a sanitary manner. This failed practice had the potential to affect a limited number of residents. Facility census: 142. Findings included: a) Facility policy The Safety and Sanitation policy, revised 12/14/17, was provided by the Director of Nursing on 5/3/18 at 1:20 PM. The policy directed, in pertinent part: VII. Hand washing . 1. When to wash: i. After working with or cleaning dirty equipment or utensils . l. Between glove changes . q. Between any dirty to clean task . VII. Glove use . 1. Single use gloves: c. Wash hands thoroughly before and after wearing or changing gloves. Bacteria will build up under gloves and should be washed away after wearing gloves . 3. Cloth gloves: a. (MONTH) not be used in direct contact with food . b) Observations On 4/30/18 at 8:40 AM, during the initial tour, two trash cans were observed close to the handwashing sink. One trash can had a foot pedal that opened the top. The other trash can had a lid on top that had to be manually opened. Multiple observations were made on 5/1/18 from 11:10 AM to 12:25 PM. At 11:30 AM, Cook #119 was observed to mix cabbage and noodles togethers. During this process, the food mixture touched her oven mitt that was holding onto the pan. At 11:37 AM, Cook #119 was observed to gather the serving utensils to serve from the steam table. While transporting the utensils to the steam table, she held the ladle for the gravy up next to her chest, touching her shirt. Her shirt was visibly dirty with food debris. At 11:45 AM, Dietary Staff #89 was observed spreading butter on slices of bread, while wearing gloves. When she was finished with the butter, she covered it with plastic wrap and pulled a pen out of her shirt to write the date. Wearing the same gloves, she proceeded to place the buttered bread in a pan and grab slices of cheese to make grilled cheeses. Cook #119 served the lunch meal from the steam table. Multiple observations were made during the lunch service from 11:54 AM to 12:25 PM. While Cook #119 served, she was observed to place two to three plates along the steam table. She then leaned across the plates to get food from the back of the steam table. As she did this, her shirt touched the plates. This process was observed several times. From 11:10 AM to 12:25 PM, multiple observations were made of staff changing their gloves without washing their hands between glove changes. Food preparation was observed on 5/2/18 from 10:00 AM to 10:30 AM. At 10:02 AM, Cook #119 was observed to leave the kitchen with a measuring cup full of butter. She was observed to use the microwave in the staff break room. She came back into the kitchen at 10:05 AM and the butter was melted. She did not wash her hands when she returned to the kitchen. She proceeded to prepare the pureed foods and used the butter for the vegetables. At 10:09 AM, after Cook #119 made a batch of pureed vegetables in the food processor, the blade fell out as she poured the mixture into the pan. She touched the blade, rinsed it off under some water, and then placed it back into the processor. She proceeded to make other portions of pureed vegetables. At 10:18 AM, Cook #119 was observed to dry off her hands and place the paper towel in the trash can with the manual lid on top of it. She had to touch the trash can lid to place the paper towel inside. Cook #119 stated that the trash can with the manual lid was the trash can they used for everything, including after they washed their hands. She said the trash can with the pedal was used for salad preparation. At 10:24 AM, Cook #119 grabbed the food processor pieces and spatula that had been sanitized in the three-compartment sink. While transporting the food processor pieces and spatula to the preparation area, she held the pieces up against her shirt. Her shirt was visibly soiled with food debris. From 10:00 AM to 10:30 PM, multiple observations were made of staff changing their gloves without washing their hands between glove changes. c) Interviews In an interview on 5/3/18 at 10:08 AM the Dietary Manager stated every time a staff member changed gloves, they were supposed to wash their hands. Staff were also supposed to wash their hands each time they entered the kitchen. If they left to go to the breakroom, then they needed to wash their hands when they returned. She stated she did not know why there was not a microwave in the kitchen but said staff should not have to go to the break room to use the microwave for food preparation. She said when transporting clean utensils, they should be carried away from the body. If the utensils touched the body, such as a shirt, then that was unsanitary. Clothing was not supposed to touch plates as meals were being served from the steam table.",2020-09-01
56,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,842,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately transcribe, in the medical record, the correct amount of nutritional supplement ordered for one of five residents reviewed for nutritional weight loss. Resident identifier: #98. Facility census: 142. Findings included: a) Resident #98 The medical record was reviewed on 5/2/18 at 11:45 AM. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the resident had verbal behaviors, received diuretics and had depression and anxiety. The Plan of Care dated 3/26/18 for Nutritional Status as evidenced by significant weight loss revealed the goal for the resident to consume appropriate amounts of food and fluids to maintain nutritional status. The plan of care revealed interventions to maintain weight through the next review that included the following: assist as needed to consume foods and/or supplements and fluids offered at and between meals, provide supplements per orders: Med Pass 2.0 (Dietary Supplement) 3 ounces, 4 times per day. On 5/2/18 at 1:54 PM the Medication Administration Records (MAR) for (MONTH) and (MONTH) (YEAR) were reviewed. The MARs for (MONTH) (YEAR) and up to 4/21/18 revealed the resident received Med Pass 2.0, 3 ounces, 4 times per day. On 4/21/18 at 11:30 AM, according to the MAR, the resident started receiving Med Pass 2.0, 2 ounces, 4 times per day. On 5/2/18 at 2:13 PM, a Dietary Communication form dated 4/20/18 by Registered Dietician (RD) #120 was reviewed. The dietary request directed: 1. Prosource Plus (Dietary Supplement) 1 ounce twice a day. 2. Please document the percentage of Med Pass 2.0 and magic cups that are already ordered in the MAR. The physician's orders [REDACTED]. The original order dated 12/10/15 directed Med Pass 2.0 before meals and at bedtime 3 ounces (4 times a day). A physician's orders [REDACTED]. On 5/3/18 at 11:52 AM the nutritional notes were reviewed. A nutritional note dated 5/3/18 indicated Please clarify the order for Med Pass 2.0 to be 3 ounces, 4 times per day. Document the percentage consumed in the MAR. Discontinue the order for Med pass 2.0, 2 ounces, 4 times per day as previously ordered. On 5/3/18 at 12:00 PM RD #120 was interviewed. RD #120 reviewed the documentation in the medical record regarding the recommendation he made on 4/20/18. He stated in (MONTH) (YEAR) when dietary recommendations were made the nurse must have put the wrong amount of the Med Pass 2.0 into the computer. RD #120 stated the order was for Med Pass 2.0 3 ounces four times a day, but the documentation revealed the nurses were giving only 2 ounces four times a day. In an interview on 5/3/18 at 12:04 PM, Registered Nurse (RN) #41 verified the nurse entered the incorrect amount of supplement into the computer, causing the resident to miss 4 ounces of the supplement daily. RN #41 stated at the beginning of each month the nurses do a recapitulation to ensure that physician's orders [REDACTED]. RN #41 verified the nurse missed this error, as there was no new physician order [REDACTED].",2020-09-01
57,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2018-05-03,880,D,0,1,X20F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an infection prevention program designed to help prevent the development and transmission of diseases and infections. Specifically, the facility failed to keep Resident #301's [MEDICAL CONDITION] tubing off of the floor. This failed practice had the potential to affect a limited number of residents. Resident identifier: #301. Facility census: 142. Findings included: a) Resident #301 Resident #301 admitted to the facility on [DATE]. According to the 5/18 physician orders, [DIAGNOSES REDACTED]. The resident had orders for a [MEDICAL CONDITION]. Review of the 4/24/18 Minimum Data Set (MDS) assessment, on 5/2/18 at 9:05 AM revealed Resident #301 was in a vegetative state with no discernible consciousness. He required total care for all activities of daily living (ADL). He was identified as receiving [MEDICAL CONDITION] care, suctioning, and oxygen. Multiple observations were made of the resident throughout the day from 4/30/18 to 5/3/18. During each of these observations, the resident's [MEDICAL CONDITION] tubing was observed to be very long, with the tubing laying on the floor touching multiple objects next to the resident's bed. Specific observations included the following: On 4/30/18 at 10:57 AM, 5/1/18 at 4:51 PM, 5/2/18 at 12:01 PM, 5/2/18 at 4:58 PM and 5/3/18 at 8:49 AM, the resident's [MEDICAL CONDITION] tubing was observed laying on the floor touching multiple objects next to the resident's bed. On 5/2/18 from 7:53 AM to 8:11 AM, [MEDICAL CONDITION] care was observed to be given by Licensed Practical Nurse (LPN) #4. She suctioned the resident, cleaned around the [MEDICAL CONDITION], and changed the soiled gauze around the [MEDICAL CONDITION]. The [MEDICAL CONDITION] tubing was observed to be laying on the ground the entire time the treatment occurred. In an interview on 5/3/18 at 8:55 AM, LPN #4 observed the resident's [MEDICAL CONDITION] tubing. She acknowledged the tubing was laying directly on the floor. She said the tubing should not be on the floor because of bacteria and for the draining of the humidity. There was a bag on the tubing that caught the excess liquid/humidity. She said it was supposed to be tied to the bed but the tie had broken. She said the resident had not had any infections and was doing well. She proceeded to get new tubing and change it. After she changed the tubing, the tubing was tied to the bed and off of the floor. In an interview on 5/3/18 at 9:16 AM, the Assistant Director of Nursing said [MEDICAL CONDITION] tubing should never touch the floor. Anything that touches the floor has the potential for infection. She said the tubing should be tied to the bed, so it was off the floor. In an interview on 5/3/18 at 10:44 AM, the Director of Nursing said [MEDICAL CONDITION] tubing should never be laying on the floor. She explained bacteria could potentially get in the [MEDICAL CONDITION] area.",2020-09-01
59,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,558,D,0,1,WJ7O11,"Based on observation, record review, staff interview and policy review, the facility failed to provide reasonable accommodations to a resident. The facility failed to ensure resident's call light was within reach. This failed practice affected two (2) of 31 residents. Resident identifier: #130 and #111. Facility census: 140. Findings included: a) Resident #130 An observation, on 07/29/19 at 11:49 AM, revealed Resident #130's sheets and call light was laying on the floor by the foot of the bed. Resident #130 was in bed and unable to reach call light. An interview with Licensed Practical Nurse (LPN) #122, on 07/29/19 at 11:54 AM, confirmed call light was on floor and out of reach of Resident #130. LPN stated, I will go pick up her call light and change her sheets since hers are on the floor. A policy review Answering the Call Light with Revised date (MONTH) 2010. Policy stated, Step four (4) When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. b) Resident #111 An observation of the Resident, on 07/30/19 at 08:39 AM, revealed she was in bed. The call light was hanging off the side of the bed and was not within reach of the Resident. An interview with the Resident, on 07/30/19 at 8:40 AM, revealed she did not know where her call light was. An interview with Nurse Aide (NA) #100, on 07/30/19 at 8:45 AM, revealed all call lights should be within reach while residents are in bed. The NA placed the call light within reach.",2020-09-01
61,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,602,D,1,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the resident's medications were not diverted to an unlicensed person for administration. A nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of facility for an appointment. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. a) Resident #239 Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Resident #239's (MONTH) 2019 Medication Administration Record [REDACTED]. A new order with a start date of 02/13/19 is to give [MEDICATION NAME] 15 mg every four (4) hours as needed for pain. The first dose of this order was given on 02/13/19 at 7:54 PM. On 02/14/19 the MAR indicated [REDACTED]. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/19. 3. A note written by SS #111 in which Resident #239 stated she did not feel like it was not right for the van driver to give her [MEDICATION NAME]. 4. A note written by RN #136, with a date of 02/14/19 reveals, Van driver was given [MEDICATION NAME] tab to hand to this resident. He did not administer the med. Upon review of MARS, only dose documented was at 1 am on 2/14. Nursing supervisor said she was given [MEDICATION NAME] again around 4:35 am, but this dose was not documented on her MARS. Resident left for appointment @ 7:15 am. Med sent to appointment was given per resident from the van driver approximately at 8:30 am. Not documented on MARS upon return to facility same day. Appointment at 9 am. Resident returned around 11:15 am. Information given to Dir of Nurs to investigate by gathering witness statements and determining if resident right were violated. Email sent to Dir of Nurs on 2/25/as a follow up in regarding to resolving this grievance., On 07/31/19 at 4:00 PM the director of nursing expressed the incident was not reported to OHFLAC. A self-medication administration evaluation on 02/15/19, occurred after the incident. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate.",2020-09-01
62,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,609,D,1,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to identify and report an allegation of abuse/neglect related to a threat to discharge Resident #239, if she refused to go to an appointment and an allegation the nursing staff gave [MEDICATION NAME] to the van driver to dispense to Resident #239, while out of the facility. This is true for one (1) of two (2) complaint concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: Review of a complaint/concern with a date of 02/14/19 revealed Resident #239 reported to Social Services (SS) #111 on 02/14/19 a threat was made by facility staff that she would be discharged if she did not go to an appointment scheduled for this same day. She also reported the van driver was given [MEDICATION NAME] to dispense to her while on the trip. Further review found no evidence a Reportable was completed and sent to the Office of Health Facility Licensure and Certification (OHFLAC) concerning the allegations. On 07/31/19 at 4:00 PM the director of nursing expressed the incident was not reported to OHFLAC. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate.",2020-09-01
63,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,610,D,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to thoroughly investigate an allegation of abuse/neglect related to a threat to discharge Resident #239, if she refused to go to an appointment and an allegation the nursing staff gave [MEDICATION NAME] to the van driver to dispense to Resident #239, while out of the facility. This is true for one (1) of two (2) complaint concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: a) Resident #239 Resident #239 filed a grievance with Social Services, (SS) #111, on 02/14/19 concerning a threat made by facility staff that she would be discharged if she did not go to an appointment scheduled for this same day. In addition, Resident #239 complained she did not believe the nursing staff should give [MEDICATION NAME] to the van driver to dispense to her, while out of the facility. On 02/14/19 the complaint/grievance form was signed by SS #111, and the risk manager registered nurse (RN), #136. The DON signed the resolution section of the complaint/grievance on 02/15/19 documenting the grievance was resolved and the complainant is satisfied. There no evidence the facility thoroughly investigated these allegations. On 02/25/19 RN #136, sent an e-mail to the DON an information statement regarding completing an investigation, by gathering witness statements and determining if Resident #239's rights were violated. On 07/31/19 at 4:00 PM the director of nursing expressed a thorough investigation did not occur related to the allegation of threatening to discharge Resident #239, and to medication being sent with the van driver. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate.",2020-09-01
64,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,623,D,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the Ombudsman of resident transfers to an acute care setting. This was found for two (2) of two (2) residents reviewed for hospitalization s. Resident identifiers: #133 and #130. Facility census: 140. Findings included: a) Resident #133 Review of the medical record on 07/31/19, revealed Resident (R) #133 was admitted to the facility on [DATE] and discharged to the hospital after a fall on 05/29/19. The medical record is silent in regard to the Ombudsman being notified of the unplanned transfer and admission to the hospital. During an interview on 07/31/19 at 1:20 PM, social workers (SW) #134 and #111, acknowledged the Ombudsman was not notified. SW #134 stated, We just started notifying the Ombudsman on 07/01/19, after the new Administrator identified the issue. b) Resident #130 During a medical record review on 07/31/19 at 1:19 PM, found no evidence of a bed hold or ombudsman notification for hospitalization s on 04/28/19, 05/31/19 and 06/30/19. Employee #111 and Employee #134 reported on 07/31/19 at 1:20 PM, the facility just started notifying the ombudsman on 7/1/19. On 07/31/19 at 1:30 PM, Employee #40 and Employee #147 explained she (Resident #130) is on Medicaid so it is automatically a twelve (12) day bed hold. Upon further inquiry Employee #40 stated, We just heard that we need to notify the ombudsman for hospitalization s. Employee #40 and Employee #147 verified the medical record did not contain any notification for hospitalization s on 04/28/19, 05/31/19 and 06/30/19.",2020-09-01
65,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,625,D,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the resident and/or family with a copy of the Bed-Hold notification on admission and/or at the time of transfer. This was found for one (1) of two (2) residents reviewed for hospitalization . Resident identifier: #133. Facility census: 140. Findings included: a) Review of the medical record on 07/31/19, revealed Resident (R) #133 was admitted to the facility on [DATE] and discharged to the hospital after a fall on 05/29/19. The medical record is silent regarding the resident and/or Medical Power of Attorney receiving information related to the facility's bed-hold policy on admission or at the time of the unplanned transfer to the hospital. Social Worker (SW) #111 reported the business office staff review the bed-hold policy with the resident and/or family on admission. SW #111 reviewed the electronic medical record and confirmed it lacked any information related to this policy. At 11:42 AM on 07/31/19, the Business office Manager (BOM) acknowledged she reviews the bed-hold policy with the resident and/or family on admission and a signed copy is placed in the medical record. The BOM reported the nurse is to complete a second bed-hold notification when the resident is transferred to the hospital. On 07/31/19 at 12:30 PM, SW #134, verified R#133's medical record lacks any information indicating the bed-hold policy was reviewed and/or given to the resident and/or family during admission or at the time of the hospital transfer.",2020-09-01
66,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,640,D,0,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to transmit a resident assessment within 14 days after completion. This was true for one (1) of 31 residents reviewed. Resident identifier: #1. Facility census: 140. Findings included: a) Review of the medical record on 07/31/19, revealed Resident (R) #1 was admitted to the facility on [DATE] and discharged to home 02/26/19. The status section of the electronic minimum data set (MDS) assessment for the five (5) day admission assessment dated [DATE], the 14-day assessment dated [DATE] and the discharge return not anticipated assessment dated [DATE], all state assessment was never added to batch. The status section of R #1's MDS assessments was reviewed by corporate consultant (CC) #152 and Registered Nurse Assessment Coordinator (RNAC) #33, during an interview on 07/31/19 at 3:45 PM. CC#152 acknowledged the status was marked incorrectly and the discharge assessment was never submitted. CC #152 corrected the discharge assessment and submitted it during this interview.",2020-09-01
67,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,641,D,0,1,WJ7O11,"Based on record review, staff interview and Minimum Data Set (MDS) Resident Assessment Instrument (RAI) version 3.0 manual, the facility failed to ensure the accuracy of a MDS for a resident receiving Hospice services. This practice was found for one (1) of one (1) residents reviewed for Hospice services. Resident identifier: #130. Facility census: 140. Findings included: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19. Review of the significant change MDS with assessment reference date (ARD) of 07/21/19 discovered the following: Section J, titled Health Conditions, J1400 Prognosis, coded as: NO. MDS RAI version 3.0 manual coding instructions for J1400 Prognosis (typed as written): . --Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. After review of the significant change MDS with ARD of 07/21/19 on 07/31/19 at 11:55, Employee #152 stated, Yes, the manual states it should be coded yes because the resident is on Hospice. But the coordinator was waiting on physician documentation. Yes, if you follow the manual which they are supposed to, it is coded wrong.",2020-09-01
68,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,656,D,0,1,WJ7O11,"Based on record review, hospice contract review and staff interview, the facility failed to implement and/or develop a comprehensive person-centered care plan. A resident's call light was not within reach as directed by their care plan and a resident receiving hospice services did not have a care plan that included a detailed description of the services being provided. These practices affected two (2) of thirty-one (31) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #111 and #130. Facility census: 140. Findings included: a) Resident #111 An observation of the Resident, on 07/30/19 at 08:39 AM, revealed she was in bed. The call light was hanging off the side of the bed and was not within reach of the Resident. An interview with the Resident, on 07/30/19 at 8:40 AM, revealed she did not know where her call light was. An interview with Nurse Aide (NA) #100, on 07/30/19 at 8:45 AM, revealed all call lights should be within reach while residents are in bed. The NA placed the call light within reach. A review of the Resident's Care Plan, on 07/30/19 at 10:15 AM, revealed the focus History of falls with the intervention keep call light within reach. The Care Plan was initiated on 3/31/2017. b) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19. Review of the care plan revealed an intervention created on 07/19/19 stating (typed as written): . Hospice staff to visit to provide care, assistance and/or evaluation . The care plan lacked a goal related to Hospice care and/or services. After review of the care plan on 07/31/19 at 12:35 PM, the Director of Nursing (DON) agreed the care plan was not individualized with measurable goals and interventions. She further agreed the care plan did not specify what Hospice staff would visit and when the visits would occur.",2020-09-01
69,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,657,D,0,1,WJ7O11,"Based on resident interview, record review and staff interview the facility failed to ensure a resident was invited to a care plan meeting. The facility failed to ensure a resident had the right to participate in choosing treatment options and was given the opportunity to participate in the development, review and revision of the care plan. The failed practice affected one (1) of 31 residents. Resident identifier: Resident #7. Facility census: 140. Findings included: a) Resident #7 A resident interview, on 07/29/19 at 1:00 PM, Resident #7 revealed questions about medication orders and administration. Resident #7 stated, I have tried to ask the nurses and doctors about my meds but they are always too busy, I would like to know what medications I am taking and why I need to take them. A record review, on 07/31/19 at 10:00 AM, revealed a social service note dated for 07/24/19 that stated, SW talked with brother (name of brother), MPOA, and updated him on IDT review. He is not interested in having a quarterly review meeting. He visits regularly and is aware of (resident's name) condition and daily routine. (Resident's name) continues attending activities of choice and interacts well with other residents. He is aware to contact SW with questions/concerns. A second social service note found dated for 05/24/18, stated, SW talked with brother (brother;s name) by phone and updated him on IDT review of treatment plan and asked if he would like to schedule a meeting. (Brother's name) visits regularly and is aware of (resident's name) condition and daily routine. He was not interested in having a meeting. (Resident's name) attends activities of choice and interacts well with staff, residents and visitors. He is well adjusted to long term care and aware to contact SW with questions/concerns. Further record review, on 07/31/19, revealed Resident #7 has a current Brief Interview for Mental Status (BIMS) of 15. An interview with Social Worker (SW) #134, on 07/31/19 at 11:08 AM, revealed no documentation that Resident # 7 was ever invited to a care plan meeting. SW #7 stated, I always talk to Resident #7's Medical Power of Attorney (MPOA) with Resident #7 present about the Care Plan Meetings after meeting is held. SW #134 confirmed the facility completes Care Plan Meetings and then updates the MPOA and Resident #7 after meeting occurred.",2020-09-01
71,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,684,D,1,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, Hospice service contract and staff interview, the facility failed to ensure prescribed Hospice services were provided to a resident in accordance with professional standards of practice. This practice was found for one (1) of one (1) Hospice resident reviewed during the survey. In addition the facility failed to ensure staff followed physician orders [REDACTED]. This practice was found for one (1) of thirty-one (31) residents reviewed during the survey. Resident identifiers: #130 and #233. Facility census: 140. Findings include: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19 for a terminal health condition. Continued review of the medical record found no evidence of documentation of further Hospice care visits following her admission to Hospice services. Review of the Hospice care plan created on admission was silent for the identification of services to be provided. After reviewing the medical record on 07/31/19 at 12:35 PM, the Director of Nursing (DON) was unable to locate documentation of Hospice visits following Resident #130's initial admission to Hospice services. The DON stated, I am sure that they have been here to visit, but there is nothing to prove it. I agree their care plan does not even tell who is going to visit and when. Review of the facility agreement/contract with the contracted Hospice services provided by the DON revealed the following (typed as written): .III Services provided by Hospice: .C. Hospice shall develop the Plan of care to be provided to the Home specifying information pertinent to the resident's treatment. The Plan will be updated bi-weekly by the hospice team . M. Documentation of all visits by Hospice staff shall be placed on the Home chart at the time of the visit . b) Resident #233 Review of medical records for Resident #233, found an order with a start date of 07/26/19 to give Meropenem Solution one (1) gram intravenously (IV), to treat an infection. On 07/30/19 at 11:16 AM a bag of Meropenem Solution hanging on a pole contained liquid which was approximately one (1) inch from the bottom of the bag, that had not been delivered to the resident intravenously. At this time registered nurse (RN) #97 agreed she had disconnected the IV medication and agreed all of the medications was not delivered to the resident and stated I could have run it all. Registered nurse #97 then removed the IV medication from the pole.",2020-09-01
72,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,689,D,0,1,WJ7O11,"Based on observation and staff interview, the facility failed to provide an environment free of accident hazards over which it had control. The facility failed to secure hot liquids from resident's access. The 700 Hall Nourishment Room contained a coffee maker that was left unattended and brewing with hot coffee in the pitcher. The room, which is located on the resident hallway, had no door and was accessible to anyone. There was a resident observed seated in a wheelchair at the entrance of the Nourishment Room. No staff was in sight of the Nourishment Room at the time of the observation. The coffee inside the pitcher was tested to be 184.6 degrees Fahrenheit by the facility's Maintenance Director. An observation of the first floor lobby, on 07/29/19 at 4:30 PM, revealed three (3) male residents sitting in the lobby. Resident #121 was observed independently pouring a cup of coffee from a coffee maker that was on a counter in the lobby. The coffee maker, which was unsupervised at the time of the observation, had coffee readily available. The coffee was then poured into a cup and tested at 161 degrees Fahrenheit. The facility also failed to secure chemicals and sharp objects and to keep resident area floor's dry. All the deficient practices had the potential to affect more than a limited number of residents residing in the facility. Room identifiers: 700 Hall Nourishment Room, First Floor Lobby, 600 Hall Soiled Utility Room, and 100 Hall Shower Room. Facility census: 140. Findings included: a) 700 Hall Nourishment Room An observation of the 700 Hall Nourishment Room, on 07/29/19 at 11:30 AM, revealed a coffee maker noted to be brewing with six (6) ounces of coffee in the pot. The coffee was situated on the countertop approximately three (3) inches from the edge of the counter. There was no separation or door to the Nourishment Room from the resident hallway. Residents were observed walking by as well as one resident seated in a wheelchair at the entrance of the Nourishment Room. An interview with Licensed Practical Nurse (LPN) #1, on 07/29/19 at 11:30 AM, revealed the coffee was for staff and not the residents. The LPN verified that any mobile Residents in the facility had access to the coffee maker. A temperature test conducted by the facility's Maintenance Director, on 07/29/19 at 11:50 AM, revealed the coffee was 184.6 Degrees Fahrenheit. An interview with the Maintenance Director, on 07/29/19 at 11:50 AM, revealed the Maintenance Director stated that's pretty hot, I did not know this coffee maker was here. Further observations, on 07/29/19 at 12:00 PM, revealed six (6) other Nourishment Rooms within the facility had coffee makers on their counters with brewing capacity and supplies. An interview with the Administrator, on 07/29/19 at 12:26 PM, revealed he had been notified of the coffee on the 700 Hall and its temperature of 184.6 degrees Fahrenheit. The Administrator stated he had taken care of it. b) First Floor Lobby An observation of the First Floor Lobby, on 07/29/19 at 4:30 PM, revealed a self-service coffee maker. Three residents were noted to be seated in wheelchairs, in close proximity to the coffee maker. Resident #121 was serving himself coffee from the coffee maker unsupervised. A temperature test of the coffee maker, on 07/29/19 at 04:30 PM, revealed the coffee was 161 Degrees Fahrenheit. The temperature was verified by the Assistant Director of Nursing (ADON). The ADON stated I will take care of that right now. An interview with the Administrator, on 07/29/19 at 05:15 PM, revealed he was aware of the self-service coffee maker in the First Floor Lobby. c) 600 Hall Soiled Utility Room An observation of the 600 Hall, on 07/30/19 at 10:00 AM, revealed the room labeled Soiled Utility Room was unlocked. No staff were in sight of the room at the time of the observation. The room contained the following items in an unlocked cabinet: One (1) bottle of Peroxide Multi-Surface Cleaner and Disinfectant with the warning Keep out of reach of children. Ten (10) capped shaving razors Two (2) unsecured razor blades Fifteen (15) tacks Four (4) large glass vases An interview with Registered Nurse (RN) #105, on 07/30/19 at 10:10 AM, revealed the room should have never been unlocked. The RN stated she would ensure the room was locked. d) Wing one (1) Shower Room A resident interview, on 07/31/19 at 9:00 AM, revealed a concern in the shower room. Resident #21 stated, when I go into the shower the water overflows onto the floor. Resident #21 stated, with all the water on the floor someone is going to fall and get hurt. An observation of Wing one (1) Shower Room, on 07/31/19 at 12:05 PM, revealed a shower that water flowed out the sides of the shower stall onto the bathroom floor. An immediate staff interview with Certified Nursing Assistant (CNA) #6, on 07/31/19 at 12:05 PM, revealed, The shower water flows out on the floor a lot. CNA #6 stated, if you hold the handheld shower head it doesn't flow over into the floor as bad.",2020-09-01
73,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,692,D,0,1,WJ7O11,"Based on family interview, record review, staff interview, the facility failed to ensure a resident maintained an acceptable parameter of nutritional status. A resident who was admitted under weight, was not weighed after a decline in status. This is true for one (1) of nine (9) residents reviewed for nutrition. Resident identifier: #126. Facility census: 140. Findings included: a) Resident #126 On 07/29/19 at 12:25 PM Resident #126's wife expressed she did not think the facility was weighting her husband, she requested his weight be obtained, and she is concerned about how very thin he is. Review of medical records found the admit weight on 06/21/19 to be one-hundred and thirteen (113) pounds. Additional weights on 07/07/19, 07/05/19, remained at (113) pounds. On 07/12/19 the residents weight was one-hundred and twelve (112) pounds. On 07/31/19 the surveyor requested the facility weight the resident. The residents weight was one-hundred and seven (107) pounds which represents a five (5) percent weight loss between 07/12/19 and 07/31/19. Observation of the resident during the survey found the resident to appear very weak, and with very low energy. The facility followed the weight admission orders [REDACTED].",2020-09-01
74,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,741,D,1,1,WJ7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility to failed to provide competent staffing for the care and services delivered to maintain resident safety and attain the highest practicable physical mental and psychosocial well-being of each resident. The facility failed to thoroughly investigate an allegation of neglect related to threatening a resident with discharge and an incident in which a nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of the facility. This is true for one (1) of two (2) compliant/concerns reviewed. Resident #239. Facility census. 140. Findings included: a) Resident #239 Review of medical records revealed a physician order [REDACTED]. The first dose of this order was given on 02/13/19 at 7:54 PM. The previous order with a start date of 01/23/19 was [MEDICATION NAME] 15 mg every six (6) hours as needed for pain. Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver by nursing staff. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/19. 3. A note written by SS #111 in which Resident #239 stated she did not feel like it was not right for the van driver to give her [MEDICATION NAME]. 4. A note written by RN #136, with a date of 02/14/19 reveals, Van driver was given [MEDICATION NAME] tab to hand to this resident. He did not administer the med. Upon review of MARS, only dose documented was at 1 am on 2/14. Nursing supervisor said she was given [MEDICATION NAME] again around 4:35 am, but this dose was not documented on her MARS. Resident left for appointment @ 7:15 am. Med sent to appointment was given per resident from the van driver approximately at 8:30 am. Not documented on MARS upon return to facility same day. Appointment at 9 am. Resident returned around 11:15 am. Information given to Dir of Nurs to investigate by gathering witness statements and determining if resident right were violated. Email sent to Dir of Nurs on 2/25/as a follow up in regarding to resolving this grievance., On 0805/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate.",2020-09-01
82,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,849,D,0,1,WJ7O11,"Based on medical record review, Hospice service contract and staff interview, the facility failed to ensure in accordance with the agreement/contract prescribed Hospice services were provided to a resident. This practice was found for one (1) of one (1) Hospice resident reviewed during the survey. Resident identifier: #130. Facility census: 140. Findings included: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19 for a terminal health condition. Continued review of the medical record found no evidence of documentation of further Hospice care visits following her admission to Hospice services. Review of the Hospice care plan created on admission was silent for the identification of services to be provided. Review of the facility agreement/contract with the contracted Hospice services provided by the Director of Nursing (DON) revealed the following (typed as written): --Hospice shall develop the Plan of care to be provided to the Home specifying information pertinent to the resident's treatment. The Plan will be updated bi-weekly by the hospice team . --Documentation of all visits by Hospice staff shall be placed on the Home chart at the time of the visit . After reviewing the medical record on 07/31/19 at 12:35 PM, the DON was unable to locate documentation of Hospice visits following Resident #130's initial admission to Hospice services. The DON stated, I am sure that they have been here to visit, but there is nothing to prove it. I agree their care plan does not even tell who is going to visit and when. In addition the DON agreed the Hospice services company did not adhere to their contract regarding the care plan and documentation.",2020-09-01
86,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2019-08-06,947,D,0,1,WJ7O11,"Based on employee records and staff interview the facility failed to ensure continuing competence of nurse aides (CNA) included dementia management and abuse prevention training. Two (2) CNA's lacked dementia care and one (1) CNA lacked abuse prevention training as required. The failed practice affected two (2) of five (5) CNA's employed by the facility. Employee identifiers: #1 and #4. Facility census: 140. Findings included: a) Employee #1 An employee record review, on 08/06/19 at 8:39 AM, of CNA's in-service trainings was conducted. Employee #1 lacked training in the areas of Dementia Management and Abuse Prevention courses as required. An interview with ADoN, on 08/06/19 at 8:39 AM, revealed no other documentation availability for Employees #1 regarding in-service completion. ADoN stated, that is all the information for training we could find. b) Employee #4 An employee record review, on 08/06/19 at 8:39 AM, of CNA's in-service trainings was conducted. Employee #4 lacked training in the area of Dementia Management as required. An interview with ADoN, on 08/06/19 at 8:39 AM, revealed no other documentation availability for Employees #4 regarding in-service completion. ADoN stated, that is all the information for training we could find.",2020-09-01
89,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-03-13,580,D,1,0,6GC411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and policy and procedure review, the facility failed to promptly notify a resident's physician and responsible party when there was an accident involving injury, a significant change in the resident's condition including a need to alter treatment significantly for one (1) of five (5) residents reviewed. The facility failed to immediately notify a resident's representative when there were new orders involving care and treatment upon return from the hospital. Resident identifier:: R1 The findings included: a) Resident #1 (R1) Record review on 3/11/19, noted R1 had sustained a fall on 01/26/19, at 12:10, resulting in a laceration to the face. R1 was taken to the hospital for care and further treatment. R1 was released back to the nursing facility on 01/26/19, with the following change in orders: --[MEDICATION NAME] Suspension Reconstituted 250 milligrams {mg} / 5 milliliters {ml}. Give 10 ml by mouth four times a day for periorbital laceration status [REDACTED]. --Neuro checks per facility policy times 72 hours --Therapy to evaluate wheelchair status [REDACTED].>Further review of the medical record on 3/12/19, revealed no evidence the resident's responsible party had been notified of the orders upon return from the hospital. A review of the policy and procedure, Changes in Resident Condition, revision date, (MONTH) (YEAR), noted under Guideline 2. prompt notification is required when there is a need to alter treatment significantly. An interview with the Director of Nursing (DON), on 03/12/19, at 01:26 PM, revealed there was no documentation of the medical power of attorney (MPOA) for R1 being notified of the new orders for Cepahalexin suspension , the neuro checks or therapy evaluation when R1 had returned from the hospital. The DON further stated I did not see where the MPOA was notified and agreed notification was not done in accordance with facility policy.",2020-09-01
90,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-03-13,656,D,1,0,6GC411,"> Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the implementation of individualized care plan interventions related to high fall risks. Call lights were not within reach for residents as directed by their care plans. This practice affected two (2) of five (5) residents reviewed for high fall risks. Resident identifiers: #3 and #4. Facility census. 182. Findings include: a) Resident #3 An observation of the Resident, on 03/12/19 at 10:05 AM, revealed the Resident was in bed. The Resident's call light was under the bed and out of reach of the resident. An interview with Licensed Practical Nurse (LPN) #100, on 03/12/19 at 10:10 AM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/12/19 at 11:15 AM. The Care Plan dated 01/21/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b) Resident #4 An observation of the Resident, on 03/12/19 at 10:30 AM, revealed the Resident was up in his wheelchair in his room watching television. The Resident's call light was under the opposite side of the bed where he was sitting and out of reach of the resident. An interview with the Resident, on 03/12/19 at 10:32 AM, revealed the Resident did not know where his call light was. The Resident stated I do not see it anywhere. An interview with Nurse Aide (NA) #101, on 03/12/19 at 10:35 AM, revealed the Resident does not need his call light near him because he is more mobile than most other residents. A review of the Care Plan was conducted on 03/12/19 at 11:30 AM. The Care Plan dated 02/25/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.",2020-09-01
91,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-03-13,689,D,1,0,6GC411,"> Based on observation, record review, resident interview, and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. Call lights were not within reach for high fall risk residents as directed by their care plans. This practice affected two (2) of five (5) residents reviewed for high fall risks. Resident identifiers: #3 and #4. Facility census. 182. Findings included: a) Resident #3 An observation of the Resident, on 03/12/19 at 10:05 AM, revealed the Resident was in bed. The Resident's call light was under the bed and out of reach of the resident. An interview with Licensed Practical Nurse (LPN) #100, on 03/12/19 at 10:10 AM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/12/19 at 11:15 AM. The Care Plan dated 01/21/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b) Resident #4 An observation of the Resident, on 03/12/19 at 10:30 AM, revealed the Resident was up in his wheelchair in his room watching television. The Resident's call light was under the opposite side of the bed where he was sitting and out of reach of the resident. An interview with the Resident, on 03/12/19 at 10:32 AM, revealed the Resident did not know where his call light was. The Resident stated I do not see it anywhere. An interview with Nurse Aide (NA) #101, on 03/12/19 at 10:35 AM, revealed the Resident does not need his call light near him because he is more mobile than most other residents. A review of the Care Plan was conducted on 03/12/19 at 11:30 AM. The Care Plan dated 02/25/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.",2020-09-01
93,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-04-17,558,D,1,0,R6BQ11,"> Based on observation, resident interview, and staff interview, the facility failed to provide services with reasonable accommodation for residents. A resident's over the bed light cord was not long enough to be easily reached and a resident could not access his bathroom due to the door being locked. This practice affected two (2) of eleven (11) residents observed. Resident identifiers: #10 and #11. Facility census: 178. Findings included: a) Resident #10 An observation of the Resident, on 04/16/18 at 11:10 AM, revealed the Resident's over the bed light cord was approximately 6 inches long. An interview with the District Director of Clinical Services (DDCS), on 04/16/18 at 11:15 AM, revealed the Resident could not easily reach the over the bed light cord without having to get up out of bed. b) Resident #11 An observation of the Resident's room, on 04/16/18 at 11:25 AM, revealed the Resident's bathroom door was locked. The bathroom was not occupied at the time of the observation. An interview Resident #11, on 04/16/18 at 11:27 AM, revealed the door to the bathroom is locked almost daily. The Resident stated he has to go to room next door to enter his bathroom. The Resident stated whoever uses the bathroom in that room keeps the door locked preventing him from getting in. An interview with the DDCS, on 04/16/18 at 11:30 AM, revealed she had no idea Resident #11 was being locked out of his bathroom. The DDCS stated she would take care of the issue.",2020-09-01
100,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,679,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, observations and review of policy and procedure for activities, the facility failed to invite and provide activities of interests for two of three residents reviewed for activities. Resident identifiers: #74 and #80. Facility census: 176. Findings included: a) Resident #74 1. Resident #74's medical record was reviewed on 08/22/18 at 09:46 AM. The resident was admitted on [DATE]. The Admission Minimum Data Set (MDS) assessment Section I revealed the resident had [DIAGNOSES REDACTED]. Section G0110, required extensive assistance of two with transfers. Section F0500, Interview for Activity Preferences, responses from the resident were reviewed and revealed that is was very important to have books, newspaper or magazines to read, music, news, group activities, favorite activities, religion and fresh air. The resident's activities care plan, dated 05/15/18, was reviewed on 08/22/18 at 10:18 AM. The care plan revealed the resident had an anticipated short stay and had interventions that included the following: ensure that the activities the resident attend are compatible with known interests, invite the resident to activities, provide a program of activities that is of interest, provide activity calendars, review resident activation needs, staff will informally visit on a regular basis to ensure leisure needs are being met, the resident needs assistance/escort to activity functions, attending church services, when resident chooses not to participate in organized activities, the resident prefers to spend time in room listening to music or reading. Observations were made of the resident on 08/20/18 at 03:35 PM of the resident in bed and awake. The television that was in front of the bed was not on. On 08/21/18 at 12:12 PM the resident was observed lying in bed asleep. On 08/22/18 at 08:57 AM the resident was observed in bed and had just finished breakfast, at 10:58 AM the resident was asleep in bed. On 08/23/18 at 9:24 AM the resident was observed in bed in room awake, the television was not on and there was no music on. On 08/22/18 at 10:34 AM the Individual Activity Participation Records for May, June, (MONTH) and (MONTH) (YEAR) were reviewed. The documentation revealed in the past four months that Resident #74 only participated in music one time, cards/other games one time and received mail twice. The resident refused glamour nails once. There were no other refusals documented on the participation records. On 08/22/18 at 11:00 AM, Activity Assistant (AA)#21 was interviewed. AA #21 stated that she used to be the Activity Director but stepped down and was an Activity Assistant. AA #21 was asked if she invited Resident #74 to the group activities and she stated she had not invited the resident any this month. She stated she did not invite her to come to activities, realized she should and that was a mistake. She stated she made informal visits to Resident #74's room, but nothing specific based on her activity preferences. On 08/23/18 at 11:06 AM, Activity Assistant (AA) #22 was interviewed. AA #22 stated she provided activities on the unit. AA #22 stated she did not invite Resident #74 to come to activities when the resident was in bed. On 08/23/18 at 11:07 AM, Activity Director (AD) #80 was interviewed regarding Resident #74. AD #80 verified the staff did not provide invitations for the resident to attend scheduled activities based on the resident's individual activity preferences and should have. b) Resident #80 2. Resident #80's record review was reviewed on 08/21/18 at 03:51 PM. The Annual Minimum Data Set (MDS), dated [DATE], Section I had [DIAGNOSES REDACTED]. Section G0110 revealed the resident required extensive assistance of two for transfers and revealed in Section F0500, Interview for Activity Preferences, responses from the resident were as follows: very important to have music, news, pets, group activities, fresh air, favorite activities and religious activities. The Resident #80's care plan, dated 7/31/18, was reviewed on 08/21/18 at 04:03 PM. The care plan revealed the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. The care plan interventions included: ensure that the activities the resident attend are compatible with known interests and preferences, compatible with individual needs and abilities, introduce the resident to residents with similar background and interests, invite the resident to scheduled activities, provide a program of activities that is of interest, provide activity calendars, resident needs assistance/escort to activity functions, when resident chooses not to participate in organized activities the resident prefers to sit up in wheelchair in hall and socialize among peers, watch television for social and sensory stimulation. Observations were made on 08/20/18 at 03:27 PM of the resident lying in bed awake. There was no television on the wall in front of the resident's bed. Only a television wall mount was there and no radio or music was playing. Observations were made on 08/21/18 at 12:11 PM of the resident lying in bed awake. There was no television on the wall mount and there was no radio or music playing. On 08/21/18 at 04:08 PM the Individual Activity Participation Records for June, (MONTH) and (MONTH) (YEAR) were reviewed. The documentation recorded on Individual Activity Participation Records revealed that Resident #80 attended cards/other games and a religious activity one time in (MONTH) (YEAR). Further review of the Individual Activity Participation Records dated June, (MONTH) and (MONTH) (YEAR) revealed documentation that the resident was provided television and visits with family or friends every day in June, (MONTH) and (MONTH) (YEAR). On 08/21/18 at 02:09 PM, Activity Assistant (AA) #160 was interviewed. AA #160 stated she had not invited the resident to any group activities. AA #160 verified the Individual Activity Participation Record for (MONTH) (YEAR) revealed television was provided to the resident every day. AA #160 stated the resident was independent with television and watched it in her room. AA#160 walked with this writer to the resident's room and verified the resident did not have a television in front of her bed that she could operate independently. Observations were made of the resident's roommate with a television, but the cubicle curtain was observed closed. AA #160 stated she didn't invite the resident to activities because she was in bed. AA #160 provided the resident's care plan and stated she goes by the care plan to provide activities to the resident but verified she didn't follow it. On 08/21/18 at 02:20 PM Resident Care Specialist (RCS) #91 was interviewed. RCS #91 stated the activity staff invite the resident to activities. RCS #91 stated Resident #80 couldn't get out of bed on her own and required assistance of two staff to get out of bed. RCS #91 stated the nursing staff or activity staff could assist to take the resident to the activity if the resident wanted to go. On 08/21/18 at 02:50 PM Activity Director (AD) #80 was interviewed. AD #80 verified on the Individual Activity Participation Records for the past three months the resident received visits with family or friends every day and was independent in watching television every day. AD #80 verified there was no television in the Resident #80's room. AD #80 verified there had been no radio in the resident's room until today and that music was listed as a preference of the resident on the care plan. AD #80 was not aware the resident had no visitors and had a caseworker listed as a primary contact person. On 08/21/18 at 03:32 PM Licensed Practical Nurse (LPN) #41 was interviewed. LPN #41 stated had not seen any family or friends visit and the resident's contact person was a caseworker that she had to call if there were concerns regarding the resident. On 08/23/18 at 11:06 AM Activity Assistant (AA) #22 was interviewed. AA #22 stated she provided activities on the unit but does not invite residents to come to group activities when the residents are still in bed. AA #22 verified she did not invite Resident #80 to join the scheduled activities on the unit per the care plan. On 08/23/18 at 11:07 AM, Activity Director (AD) #80 was interviewed regarding both Resident #74 and Resident #80. AD #80 verified that the activity staff failed to invite the resident to scheduled activities, failed to provide a television or music based on individual preferences of the resident. AD #80 also verified for both Resident #74 and #80 that if the residents were not up and out of bed, the Activity Assistants should still ask the resident if they wanted to come to activities. If the residents wanted to come, the Activity Assistants should inform the nursing staff to assist with getting the residents up so they could attend the activity. AD #80 verified if the nursing staff did not get the resident up out of bed when asked, it should be reported to her or nursing staff. AD #80 verified that if the resident did not want to get out of bed to attend a group activity, the activity assistants should provide things to do in their room based on the Individual Activity Preferences on the care plan. If the resident refused, it should be documented on the Individual Activity Participation Records as a refusal. AD #80 verified the staff did not follow the care plan to invite the residents to scheduled activities. AD #80 provided the Policy on Activities Program on 08/23/18 at 11:08 AM. The policy was reviewed and revealed that activities are provided to meet the assessment and interests of each resident. The resident's interests are assessed upon admission and according to the Resident Assessment Instrument (RAI) manual with MDS reference periods and a comprehensive care plan is developed and reviewed and revised as needed. AD #80 verified the policy wasn't followed to provide activities to Residents #74 and #80.",2020-09-01
101,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,695,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that one resident's oxygen therapy was monitored for the need and effectiveness of oxygen therapy and failed to document respiratory signs and symptoms, changes in oxygen administration, and/or results of oxygen therapy. This affected one of one resident reviewed for oxygen therapy in the sample of 28. Resident identifier: #92. Facility census: 176. Findings included: a) Resident #92 Resident #92's medical record was reviewed on 08/22/18 at 02:17 PM. Resident #92 is severely cognitively impaired according to the Minimum Data Assessment, dated 05/24/18. Resident #92 had [DIAGNOSES REDACTED]. Resident #92 had a physician's orders [REDACTED]. The order further stated that the oxygen should be titrated to keep oxygen levels above 92%. There were no oxygen saturation levels documented in the medical record. There were no progress notes regarding the resident's respiratory signs and symptoms, the time or reason oxygen was administered, or the result of oxygen therapy. Resident #92's care plan, target date 08/21/18, listed interventions to observe for signs and symptoms of acute respiratory insufficiency such as anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, and somnolence. Resident #92 was observed in bed receiving oxygen therapy via nasal canula on 08/20/18 at 11:35 AM, 08/21/18 at 01:39 PM, 08/21/18 at 5:45 PM, and 08/22/18 at 10:10 AM at 2 L/M. On 08/22/18 at 02:49 PM Resident #92 was observed receiving oxygen at 3.5 L/M via the nasal canula. On 08/22/18 at 02:49 the Unit Coordinator/Licensed Practical Nurse (LPN) #55 confirmed that Resident #92's oxygen level was set at 3.5 L/M. LPN #55 stated that the order is for 2 L/M as needed, but that the oxygen can be titrated up to keep saturation levels greater than 92% per the physician's orders [REDACTED]. LPN #55 said, There should be oxygen saturation levels for her. LPN #55 obtained Resident #92's oxygen saturation level and reported it was 95 - 96%. On 08/22/18 at 03:01 PM LPN #75 was interviewed. LPN #75 confirmed that she was the nurse caring for Resident #92 on that day. LPN #75 said she checked Resident #92's oxygen concentrator a couple hours ago and it was on 2 L/M. LPN #75 said she checked Resident #92's oxygen saturation level at that time and it was 97%. LPN #75 said she did not record the result in the medical record. On 08/22/18 at 03:14 PM the Director of Nursing (DON) was interviewed. The DON said that oxygen saturation levels should be checked as needed depending on what symptoms the resident is displaying. The DON said, They should not put oxygen on her unless she is displaying signs and symptoms, or her saturation levels are below 92%. The facility's Oxygen Administration Policy, revised (MONTH) 2010, was reviewed on 08/22/18 at 03:30 PM. The policy stated in part, D[NAME]UMENTATION: In the Nurse's notes and Treatment Administration Record (TAR) and/or Medication Administration Record [REDACTED].",2020-09-01
102,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,698,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain effective communication with the [MEDICAL TREATMENT] center and failed to follow-up on communication related to the resident's blood pressure dropping during [MEDICAL TREATMENT]. This affected one of one resident reviewed for [MEDICAL TREATMENT] care in the sample of 28. Resident identifier: #32. Facility census: 176. Findings included: a) Resident #32 On 08/20/18 at 10:39 AM Resident #32 was interviewed in his room. Resident #32 stated that sometimes his blood pressure is low during [MEDICAL TREATMENT] and that he was instructed by the [MEDICAL TREATMENT] clinic not to take his morning blood pressure medication before [MEDICAL TREATMENT]. Resident #32 said he leaves for [MEDICAL TREATMENT] around 06:00 AM and he takes his morning medications before he leaves, but was under the impression that he was not getting his blood pressure medication before he goes to [MEDICAL TREATMENT]. On 08/21/18 at 03:55 PM Resident #32's medical record was reviewed. Resident #32 has intact cognition according to the Minimum Data Sets (MDS), dated [DATE]. Resident #32 had [DIAGNOSES REDACTED]. Resident #32 received [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday, according to the current [MEDICAL TREATMENT] care plan, initiated 05/24/18. The care plan intervention stated, [MEDICAL TREATMENT] Communication Record is sent to the [MEDICAL TREATMENT] center with each appointment and return of form is ensured after appointment is completed. Resident #32 had physician's orders [REDACTED]. [REDACTED]. Resident #32 was scheduled to receive his first doses of [MEDICATION NAME] and [MEDICATION NAME] ER at 0600 (06:00 AM) according to the Medication Administration Record (MAR), dated 08/01/2018 - 08/31/18. Resident #32's progress note, dated 08/5/18, 06:29 read, RES STATED THAT [MEDICAL TREATMENT] NURSE STATES HIS BP IS DROPPING TOO LOW AND NOT TO TAKE HIS BP MEDS PRIOR TO [MEDICAL TREATMENT]. HELD BP MEDS, INFORMED SUPERVISOR AND SIALYSIS PER PROGRESS NOTE. SENT ORDER SHEET W/RES TO [MEDICAL TREATMENT] FOR ORDERS TO BE WRITTEN REGARDING BP MEDS. The progress note was signed by Licensed Practical Nurse (LPN) #70. Resident #32's corresponding [MEDICAL TREATMENT] Communication Record form (Briggs), dated 08/05/18, and completed by LPN #70 read, Res stated that you wanted his blood pressure meds held prior to [MEDICAL TREATMENT]. [MEDICATION NAME] and [MEDICATION NAME] held today. We can change time of BP meds if needed. Pls respond below. There was no response documented from the [MEDICAL TREATMENT] center on the 08/05/18 [MEDICAL TREATMENT] Communication form. The only information completed on the form by the [MEDICAL TREATMENT] center was the resident's pre- and post-[MEDICAL TREATMENT] weights. The following sections where left blank: [MEDICAL TREATMENT] completed without incident?; Problem with access graft/catheter?; Lab work completed?; Medications given at [MEDICAL TREATMENT]; Recommendations/Follow-up. Resident #32's MAR and progress notes were reviewed on 08/23/18 at 10:00 AM. There was no follow-up regarding whether Resident #32's blood pressure medication should be held prior to [MEDICAL TREATMENT] according to review of the progress notes dated 08/05 - 08/23/18 in the medical record. Resident #32's pre-[MEDICAL TREATMENT] blood pressure medications, [MEDICATION NAME] and [MEDICATION NAME] ER, were held on 08/05/18 due to the resident self-report of his blood pressure dropping during [MEDICAL TREATMENT], per documentation in the MAR and progress note dated 08/05/18. Resident #32's blood pressure medications were also held on 08/09/18 and 08/11/18 due to the resident's refusal per documentation in the MAR. Resident #32 received his blood pressure medications on all other pre-[MEDICAL TREATMENT] days including 08/07, 08/14, 08/16, 08/18, 08/21, and 08/23/18 per the MAR. On 08/23/18 at 10:05 AM Registered Nurse (RN) #34 confirmed there was no follow-up documented regarding the 08/05/18 communication to the [MEDICAL TREATMENT] center about the resident's blood pressure medication. RN #34 said Resident #32 continued to receive his blood pressure medications prior to [MEDICAL TREATMENT]. There were no [MEDICAL TREATMENT] Communication Record forms for Resident #32's [MEDICAL TREATMENT] visits of 08/11/18, 08/14/18, and 08/16/18. Resident #32's [MEDICAL TREATMENT] Communication Record forms dated 08/02/18 and 08/21/18 were also incomplete in the section to be completed by the [MEDICAL TREATMENT] center. An interview was conducted with the Director of Nursing (DON) on 08/21/18 at 04:09 PM. The DON stated the nurse should verify that the [MEDICAL TREATMENT] Communication form is completed upon the resident's return to the facility. The DON said if it's not completed they should fax it back to the [MEDICAL TREATMENT] center and request that it be completed. The DON also stated that if the [MEDICAL TREATMENT] center does not send back the [MEDICAL TREATMENT] Communication form the nurse should call the [MEDICAL TREATMENT] center and request the form. The DON confirmed that the [MEDICAL TREATMENT] Communication Record forms for 08/11/18, 08/14/18 and 08/16/18 were not in the record or in the facility. The facility policy titled [MEDICAL TREATMENT], Care of Residents, revised (MONTH) (YEAR), stated in part, 3. A [MEDICAL TREATMENT] Communication Record (Briggs) is initiated and sent to the [MEDICAL TREATMENT] center for each appointment. Ensure it is received upon return.",2020-09-01
103,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,756,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and Consultant Pharmacist interviews, the facility failed to ensure that the consulting pharmacist identified drug irregularities related to laboratory (lab) testing levels for one of seven sampled who were reviewed for unnecessary medications. Resident identifier: #84. Facility census: 176. Findings included: a) Resident #84 A review of the admission record for Resident #84 was conducted on 08/22/18 at approximately 4:52 PM. The admission record revealed that Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's policy and procedure entitled Monthly Drug Regimen Review, dated (MONTH) (YEAR), was reviewed on 08/24/18 at approximately 10:45 AM. The policy read in part, The facility contracts with a pharmacist to perform a monthly review of each resident's drug regimen to ensure the necessity and safety of each prescribed medication. Under the section entitled procedure the following entries were noted in part: --The pharmacist reviews resident charts monthly and submits a written report of the irregularities to the attending physician, the Director of Nursing and the facility Medical Director. --The pharmacist's report includes resident' names, relevant drug(s) and identified irregularity(ies). A review of the physician's orders [REDACTED]. The order summary note indicated that Resident #84 was scheduled to have a HgbA1C (a measure of average blood sugar over the past 3 months) every 3 three months d/t (due to) DM (Diabetes Mellitus) - Due (MONTH) (YEAR). Upon further review it was determined that the HgbA1C lab results were not found in the clinical record. An interview was conducted with nurse #28 on 08/22/18 at approximately 4:52 PM regarding the missing HgbA1C level for the month of (MONTH) (YEAR). Nurse #28 stated, It's not in the lab book and the lab doesn't have it in their records either. Nurse #28 shared that she had looked in the both the clinical record and well as the South unit's lab (laboratory) book. She explained that the lab book maintains labs that need to be drawn daily. Nurse #28 stated that she had called the lab to see if they had the lab results in their database, but there was no record of the HgbA1C. A review of the admission MDS (Minimum Data Set) assessment was conducted on 08/22/18 at 4:59 PM. The MDS assessment was dated 04/27/18 and had the resident coded as having a [DIAGNOSES REDACTED]. The MDS assessment also indicated that the resident had received insulin injections on 6 occasions within the last 7 days. An interview was conducted with the DON (Director of Nursing) regarding the missing HgbA1C level on 8/22/18 at 5:07 PM. The DON said she would follow-up on the missing HgbA1C level. An interview was conducted with the Consultant Pharmacist (#167) via telephone call on 08/23/18 at 10:32 AM. The DON was present for the call. The Consultant Pharmacist was asked about the monthly drug regimen review for the month of (MONTH) (YEAR) which failed to note the missing HgbA1C that was ordered for the month of (MONTH) (YEAR). The Consultant Pharmacist stated that she was driving at the time of the call and did not have immediate access to her records. The pharmacist went on to explain her process stating that if a lab were missing, she would give the nurses a piece of paper with what she needed to see if it was something they could find immediately. This writer informed the Consultant Pharmacist that the medication regimen review form completed by her for the months of (MONTH) and (MONTH) (YEAR) both indicated that there were no irregularities as evidenced by an X which was placed in the box indicating no irregularities. The box on the same form next to See report for any noted irregularities and or recommendations was left blank. The Consultant Pharmacist #167 stated that she would not necessarily have written a recommendation at that point. She went on to say that when she reviewed the chart again in (MONTH) of (YEAR) and the lab was still missing she would make a written recommendation at that point. As the Consultant Pharmacist was driving at the time of this interview, this writer encouraged her to call back to the facility on ce she had an opportunity to review her records. No further follow-up was provided by the Consultant Pharmacist. The concern regarding the HgbA1C was shared with the administrator on 08/23/18 at approximately 11:10 AM. The administrator acknowledged being aware of the drug irregularity.",2020-09-01
104,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,760,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident and staff interviews, the facility failed to prevent a significant medication error from occurring for one of 12 sampled residents (Resident #120) who was reviewed for medication administration. Resident #120 was administered long acting insulin that was prescribed for another resident. Resident identifier: #120. Facility census: 176. Findings included: a) Resident #120 An interview was conducted with Resident #120 on 08/20/18 at 11:05 AM. Resident #120 stated that a male nurse (Nurse #4), who she referred to as the medicine man had administered insulin to her in her belly (abdomen) although she is not diabetic. She repeated this again stating that, He gave me an insulin needle in my belly. She also stated that Nurse #4 had administered the insulin injection on the day prior to this interview which was Sunday, 08/19/18. Resident #120 went on to say that she had specifically asked Nurse #4 why was she receiving the insulin injection as she was not diabetic. Resident #120 reported that Nurse #4 gave her the insulin injection anyway and stated, Well, you're supposed to get it. Resident #120 also stated that Nurse #4 checked her blood sugar level after he had administered the insulin injection. She said he told her that the blood sugar reading was 108 and showed it to her on the blood sugar monitor. Resident #120 said that Nurse #4 told her it was fine. Resident #120 stated that Nurse #4 did not check her blood sugar level before administering the insulin injection. Additionally, Resident #120 voiced that she did not report the insulin administration incident to any other facility staff but said she did call her family member and informed him of the incident on the same day that the incident occurred, Sunday, 08/19/18. A review of the clinical record was conducted for Resident #120 on 08/20/18 at approximately 12:05 PM. The admission record, which listed the resident's diagnoses, indicated that Resident #120 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Neither the admission record nor any other part of the clinical record indicated that Resident #120 had a [DIAGNOSES REDACTED].#120 and failed to indicate that Resident #120 had a physician's orders [REDACTED]. A review of the admission MDS (Minimum Data Set) assessment was conducted on 08/20/18 at approximately 12:35 AM. The MDS, dated [DATE], had the resident coded as having a BIMS (Brief Interview for Mental Status) summary score of 15 indicating the resident's cognition was intact. Resident #120 was also coded as being oriented to year, month and date as well. Resident #120 was not coded as having a [DIAGNOSES REDACTED]. An interview was conducted with the Unit Manager, Nurse (#34) on 08/20/18 at approximately 12:50 PM. Nurse #34 stated that she was aware of the allegation involving the insulin error as Resident #120's family member came in earlier that morning before lunch and brought it to her attention. Nurse #34 confirmed that Resident #120 did not have a physician's orders [REDACTED]. Nurse #34 also reviewed the daily staffing report with this writer and confirmed that Nurse #4 was on duty the previous day when Resident #120 alleged having received an insulin injection. Nurse #34 also conveyed that Nurse #4 is a PRN (works as necessary) nurse and worked from 7AM -7PM on 08/19/18. Nurse #34 stated that another nurse, Nurse #113 was the unit manager that was on duty at the time of the insulin administration error and that Nurse #113 typically worked a double shift on the weekends from 7AM-11:30 PM. Initial attempts to call Nurse #4 and Nurse #113 were unsuccessful. Voicemail messages were left for each of these nurses. An interview was later conducted with Nurse #4 on 08/20/18 at 3:21 PM. Nurse #4 stated that he came back to the facility at the request of the Director of Nursing (DON). Nurse #4 stated, If you're asking about the insulin, yes, I made a mistake. I'll own up to it. I was supposed to give it to a resident across the hall. This is only the second time that I worked down there (referring to the hallway where Resident #120 resides.) I only have the computer to go by. I don't really know the people. I just made a mistake. Nurse #4 stated, As soon as I gave it to her (Resident#120) she said, But I'm not a diabetic. Why am I getting insulin? Nurse #4 stated that he had administered 30 units of [MEDICATION NAME]to Resident #120. Nurse #4 stated, I went by the name and the picture on the MAR (Medication Administration Record) when asked which identifiers were used to correctly identify Resident #120 as the correct resident to receive the 30 units of [MEDICATION NAME] insulin. Nurse #4 also stated, They are very similar referring to the appearance of Resident #120 and the other resident across the hall who he said was supposed to receive the insulin. Nurse #4 stated, I'm sick to death over it. I've never done anything like this before. During the same interview with Nurse #4 he stated that he knew right away that he had made a mistake and immediately reported the incident to his unit manager (Nurse #113). Nurse #4 shared that he did not call the physician after the incident, but that his unit manager, Nurse #113, had done so. He also stated that Nurse #113 gave him instructions to check Resident #120's blood sugar level three more times as ordered by the physician. Nurse #4 stated that he checked Resident #120's blood sugar levels at least three more times after administering the insulin. Nurse #4 recalled checking Resident #120's blood sugar immediately after administering the insulin and received 108. He acknowledged showing the blood sugar monitor result to Resident #120. He also reported checking the resident's blood sugar level again after lunch which was 103, before dinner, which was 93 and again after dinner around 5:30 PM. At 5:30 PM he stated that the resident's blood sugar level was 91. Nurse #4 voiced that he had written an incident report and pinned it up on the incident board before leaving work. He also recalled reporting the incident to the oncoming nurse that worked the 7PM-7AM shift. An interview was conducted with Nurse #113 on 08/20/18 at approximately 3:38 PM who confirmed that she was on duty at the time of the alleged insulin incident. She stated she worked from 7 AM - 2 AM on Sunday, 08/19/18. Nurse #113 recalled that Nurse #4 came to the desk and informed her that he had administered 30 units of [MEDICATION NAME]to the wrong resident. Nurse #113 also recalled Nurse #4 having notified Resident #120 that he had mistakenly given her insulin that was meant for another resident. Nurse #113 confirmed that she called the physician and notified the physician of the medication error that had occurred with Resident #120. She said she informed the physician that Resident #120 received 30 units of [MEDICATION NAME]and that Resident #120 was not diabetic. Nurse #113 also stated that the physician gave her an order to monitor Resident #120's blood sugar level three more times. Nurse #113 shared with this writer that the peak time for [MEDICATION NAME]was eight hours and Resident #120's blood sugar level never dropped below 91. Nurse #113 also stated that she went down to the room of Resident #120 after the incident had occurred and that Resident #120 reiterated the same story to her that Nurse #4 had previously communicated to her about the insulin error. Nurse #113 also stated that Nurse #4 had apologized to Resident #120. Nurse #113 stated that both she and Nurse #4 were very open with Resident #120 about the incident and that Resident #120 was aware of the incident and what had occurred. Nurse #113 also stated that Resident #120 had eaten all her meals that day and that she was fine (without symptoms of a low blood sugar reaction). Nurse #113 conveyed that nurses are supposed identify residents by checking the name on door check their arm bands and using the pictures on the MAR. Nurse #113 stated, Had Nurse #4 done that, yes, he should have known that it wasn't the right resident. Resident #120 was re-interviewed on 08/20/18 at approximately 4:22 PM to clarify if Nurse # 4 had checked her blood sugar before he administered the insulin. Resident #120 was quite certain that Nurse #4 did not check her blood sugar before giving her the insulin injection. The incident/accident report was reviewed on 08/22/18 at approximately 4:45 PM. The report conveyed that [MEDICATION NAME] 30 units was given in error on 08/19/18. The report also indicated that the physician was notified. Under the section entitled action the report indicated that the blood sugar level was checked immediately, and that snacks were also offered. The incident report also listed blood sugar checks that were conducted at the following times on 08/19/18: 10:00 AM-BS=108 11:00 AM -BS =103 1:30 PM -BS =93 5:00 PM- BS =91 The incident report was signed by Nurse#4 as having prepared the report and was also signed by the DON. The incident report indicated that the physician, unit manager (Nurse #113) and Resident #120 were each notified that [MEDICATION NAME] 30 units was given in error. The medication variance report was also reviewed on 08/22/18 at approximately 4:58 PM. The variance report indicated that [MEDICATION NAME] 30 units SQ (subcutaneous) was given in error and the error type was listed as wrong resident. An interview was conducted with the DON on 08/20/18 at approximately 4:30 PM. The DON stated that she was aware of the medication error involving both Resident #120 and Nurse #4. The DON shared that the incident report was completed before she arrived to work on the morning of 08/20/18. She conveyed that someone slid the incident report and the medication variance report under the door to her office over the weekend. The DON also stated that it was her expectation that the nursing staff use two resident identifiers to correctly identify their residents during medication pass. A review of the facility's policy regarding safe medication practices was reviewed and was dated (MONTH) 17, (YEAR). The policy indicated the following: To promote a culture of safety and prevent medication errors, nurses must adhere to the rights of medication administration: --Identify the right resident by using at least two resident identifiers. --Select the right medication --Give the right dose --Give the right medication at the right time --Give the medication by the right route --Provide the right documentation Under the section entitled Implementation the policy also indicated in part, confirm the resident's identity using as least two resident identifiers.",2020-09-01
105,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,773,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two of seven residents reviewed for unnecessary medications obtained laboratory services as ordered by the physician. Resident identifiers: #84 and #93. Facility census: 176. Findings included: a) Resident #93 Resident #93 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission physician's orders dated 01/23/18, was conducted on 08/22/18 at 2:30 PM and revealed an order for [REDACTED].#93 to have his vitamin D level monitored every 6 months. The physician's orders documented the vitamin D level was to be performed in (MONTH) (YEAR). Further review of the clinical record revealed there was no evidence Resident 93's laboratory test for a vitamin D level was obtained in (MONTH) (YEAR). Interview with Licensed Practical Nurse (LPN) #170 on 08/22/18 at 2:18 PM revealed they were not able to find the physician ordered Vitamin D laboratory test results from (MONTH) (YEAR). A call was made to the laboratory responsible for conducting the test and the facility was informed the Vitamin D laboratory test for Resident #93's had never been completed. Staff #170 stated they were unsure of why Resident #93 failed to have the ordered laboratory testing to monitor his vitamin D level. During an interview with LPN Staff #170 again on 08/23/18 at 8:48 AM at the 400 nurses station revealed they had done more research but were still not able to determine why the vitamin D level was not obtained for Resident #93. Staff #170 stated the process for obtaining laboratory tests is the order for the test is obtained and the information is relayed to the laboratory for them to collect the blood sample. He verified Resident #93 was admitted to the facility with an order for [REDACTED]. During an interview with the Director of Nursing and the Administrator on 08/23/18 at 10:35 AM, they both verified Resident #93 failed to have his vitamin D laboratory test completed according to his current physician orders. Review of the facility policy for Diagnostic Testing on 08/23/18 at 10:30 AM revealed the policy was dated 11/17. The policy documented laboratory services provided must be both accurate and timely. Timely means that the tests are completed, and results are provided to the facility within timeframe's normal for appropriate intervention. The facility is responsible for quality and timely services whether services are provided by the facility or an outside agency. b) Resident #84 A review of the admission record for resident #84 was conducted on 08/22/18 at approximately 4:52 PM. The admission record revealed that Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders for Resident #84 was conducted on 08/22/18 at approximately 4:52 PM. The order summary noted that Resident #84 was scheduled to have a HgbA1C (a measure of average blood sugar over the past 3 months) every three months d/t (due to) DM (Diabetes Mellitus)-Due (MONTH) (YEAR). Upon further review, it was determined that the HgbA1C laboratory (lab) results were not located in the clinical record. An interview was conducted with nurse #28 on 08/22/18 at approximately 4:52 PM regarding the missing HgbA1C level for the month of (MONTH) (YEAR). Nurse #28 stated, It's not in the lab book and the lab doesn't have it in their records either. Nurse #28 shared that she had looked in the both the clinical record and well as the South unit's lab book. She explained that the lab book maintains labs that need to be drawn daily. Nurse #28 stated that she had also called the lab to see if they had the lab in their database, but there was no record of the HgbA1C. A review of the MDS (Minimum Data Set) assessment was conducted on 08/22/18 at 4:59 PM. The MDS assessment, dated 04/27/18, had the resident coded as having a [DIAGNOSES REDACTED]. The MDS assessment also indicated that the resident had received insulin injections on six occasions within the last seven days. An interview was conducted with the Director of Nursing (DON) regarding the missing HgbA1C level on 08/22/18 at 5:07 PM. The DON said she would follow-up on the missing HgbA1C level. A review of the facility's policy entitled Diagnostic Services Management, dated (MONTH) (YEAR), was reviewed on 08/24/18 at approximately 10:30 AM. The policy read in in part, Residents requiring laboratory, radiology or other diagnostic services will receive accurate and timely testing services from certified diagnostic facilities in accordance with Federal regulations to support [DIAGNOSES REDACTED]. The facility is responsible for quality and timely services whether services are provided by the facility or an outside agency.",2020-09-01
106,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2018-08-23,880,D,0,1,TKSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed ensure that staff properly changed gloves and performed hand hygiene during personal care to maintain good infection control practices and failed to ensure the urine drainage bag was positioned properly so that it did not touch the floor. This affected one of two residents reviewed for urinary catheter in the sample of 28 residents. Resident identifier: #92. Facility census: 176. Findings included: a) Resident #92 Resident #92's medical record was reviewed on 08/22/18 at 02:17 PM. Resident #92 is severely cognitively impaired according to the Minimum Data Assessment, dated 05/24/18. Resident #92 has multiple [DIAGNOSES REDACTED]. Resident #92 had a physician's orders [REDACTED]. On 8/22/18 at 10:10 AM Certified Nursing Assistant (CNA) #44 was observed providing peri care to Resident #92. After gathering the care supplies, CNA #44 washed her hands and applied gloves prior to starting peri care. As CNA #44 was cleansing the peri area, she removed a small amount of feces using the washcloth. Each time she cleansed the peri area, which was four times, she touched the feces soiled washcloth with gloved hands. After completing peri care CNA #44 did not change her gloves. CNA #44 then touched the resident's gown, arms, legs, hands, pillows, back of the resident's head, and bed control mechanism while still wearing the same feces contaminated gloves. CNA #44 was interviewed afterwards and said that she should have changed her gloves after the peri care was complete. On 08/20/18 at 11:34 AM, 03:57 PM, on 08/21/18 at 01:38 PM and on 08/22/18 at 08:44 AM, the Resident #92's urine catheter bag was in contact with the floor. Resident #92's bed was in the low position and the catheter bag was hooked to the bed frame. The bottom of the urine catheter bag was in direct contact with the floor. On 08/22/18 at 08:44 AM Unit Manager/Licensed Practical Nurse (LPN) #55 confirmed that the urine catheter bag was in contact with the floor. LPN #55 said the bag should not be touching the floor. The facility policy titled Indwelling urinary catheter (Foley) care and management, revised 11/17/17, stated in part, Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder .However, don't place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI (Catheter Acquired Urinary Tract Infection). The facility policy titled Hand Hygiene, revised 05/18/18, stated in part, The hands are the conduits for almost every transfer of potential pathogens form on patient to another, form a contaminated object to a patient, and from a staff member to a patient. Hand hygiene, therefore, is the single most important procedure in preventing infection.",2020-09-01
107,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,152,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility staff failed to identify the appointed Health Care Surrogate (HCS) for Resident #84, as designated by the attending physician on 06/05/17. Thus, the designated HCS was unable to exercise the resident rights to the extent provided by state law. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 Review of Resident #84's medical records, on 08/30/17 at 11:15 a.m., found the resident was admitted to the facility on [DATE] following a hospitalization . Admission paperwork was completed by the resident's daughter. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision maker on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17. On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided.",2020-09-01
110,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,160,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of personal funds during Stage 2 of the Quality Indicator Survey (QIS), had her/his personal funds conveyed within 30 days of death to the individual or probate jurisdiction administering the resident's estate. Resident identifier: # 382. Facility census: 180. Findings include: a) Resident #382. Medical records found Resident # 382 expired on [DATE]. On [DATE], a check for the amount of $1,144.03 dollars was made out to Resident #382 and mailed to the family. At 9:20 a.m., on [DATE]. Business Office Manager (BOM) confirmed the personal funds of Resident #382 was not conveyed to the proper individual or probate jurisdiction administering the residents' estate after her death. On [DATE] at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided.",2020-09-01
115,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,246,D,0,1,QLZ111,"Based on observation, resident interview and staff interview the facility failed to ensure once (1) resident received grooming tools to ensure she could perform activities of daily living. During this random opportunity for discovery the resident was observed having long hair on her chin. Resident identifier: #35. Facility census: 180. Findings include: a) Resident #35 On 08/29/17 at 9:12 a.m. an observation of Resident #35 revealed Resident #35 had long chin hairs. Resident #35 said, I'm growing a beard, I use to get them waxed when I went to the beauty shop. They will give you a razor but you have to ask. On 08/30/17 at 9:00 a.m. Resident Care Specialist (RCS) #145 indicated she had been assigned to work with Resident #35. RCS #145 was asked to go to Resident #35's room. Once in the room Resident #35 asked RCS #145 for a razor and RCS #145 said she would get one for her. Upon leaving the room RCS #145 agreed the resident had long hair on her chin and said the resident had never asked her for a razor. On 08/31/17 at 12:55 p.m. Resident #35 said the facility had given her a razor a few months ago but she had broken it and did not want to ask for another one. She said, they should have noticed because I was starting to look like a goat.",2020-09-01
116,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,247,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review and staff interview, the facility failed to ensure notice was provided to one (1) of four (4) residents reviewed during Stage 2 of the Quality Indicator survey (QIS) who voiced concerns regarding room moves without notification. Resident identifier: #30. Facility census: 180. Findings include: a) Resident #30 At 4:17 p.m. on 08/28/17, the resident's responsible party said the resident had been moved on several occasions and notification prior to room moves was not always provided. Review of resident census found the following dates the resident was moved to other rooms in the facility: --On 12/21/16, the resident was admitted to the facility and was placed in room [ROOM NUMBER] B on the first floor. --On 03/01/17, the resident moved from first room floor 35 B to room [ROOM NUMBER] B also on the first floor. --On 04/05/17, the resident was moved from room [ROOM NUMBER]B on the first floor to third floor, room [ROOM NUMBER] B. --On 05/09/17, the resident was moved from room [ROOM NUMBER] B to fourth floor, room [ROOM NUMBER]. --On 06/02/17, the resident was moved from fourth floor, room [ROOM NUMBER] to third floor, room [ROOM NUMBER]. --On 06/16/17, the resident was moved from room [ROOM NUMBER] to first floor, room [ROOM NUMBER]. --On 06/27/17, the resident was moved to third floor, room [ROOM NUMBER]. --On 07/10/17 the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on the third floor. Record review found the facility provided written forms, entitled, Notification Of Room Change, for the room moves occurring on 04/05/17, 06/02/17, 06/27/17, 07/10/17. The notification was provided to the responsible party. Review of the medical record with the director of nursing (DON) at 10:08 a.m. on 09/06/17, found the facility had no documentation the responsible party/resident was notified of the room moves occurring on 03/01/17, 05/09/17, and 06/16/17. The DON confirmed the responsible party should have been notified of the room changes as the resident does not have capacity to make health care decisions.",2020-09-01
117,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,272,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate minimum data set (MDS) for one (1) of twenty-nine (29) residents whose MDS's were reviewed during Stage 2 of the Quality Indicator survey (QIS). Resident #19's MDS was incorrect in the area of diagnosis. Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 Review of the current residents Medication Administration Record [REDACTED]. On 04/20/17, the pharmacist advised the physician to please consider either documenting more appropriate justification for use of the [MEDICATION NAME] or titrate off this agent until justification is apparent or it is possible to discontinue the agent. At 2:55 p.m. on 08/30/17, the Director of Nursing (DON) provided a physician's progress visit note, completed by Employee #178, the Advanced Practice Registered Nurse. The visit was signed by E #178 on 05/02/17. Documentation noted the resident had a [DIAGNOSES REDACTED]. At 12:12 p.m. on 09/05/17, two (2) Advanced Nurse Practioners, #177 and #178 who visit the resident at the facility, said the resident has always had mental illness. Employees #117 and #178 provided a copy of a visit by a third Advanced Practice Registered Nurse indicating the resident had mental illness on 11/04/16. This visit noted the resident had a [DIAGNOSES REDACTED].#178 said she had spoken to the family members of the resident and she believed the son also told her about the mental illness. E#178 said the third Advanced Nurse Practioner specialized in psychiatric illness. [NAME] #178 did not explain why the [DIAGNOSES REDACTED]. One annual minimum data set (MDS) with an assessment reference date (ARD) of 03/12/17 was completed after the [DIAGNOSES REDACTED]. Section I, of the MDS provides boxes to check for a [DIAGNOSES REDACTED]. and [MEDICAL CONDITION]. The MDS did not reflect the resident had a [DIAGNOSES REDACTED]. The Registered Nurse (RN), Resident Care Manager, RN #3, said she coded the MDS's but did not know the medication was being given for a mental illness during her interview at 1:18 p.m. on 09/05/17. If that's what they are giving it for, then they should say so.",2020-09-01
119,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,279,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to identify and develop a comprehensive care plan for significant weight loss for one (1) of twenty-nine (29) residents reviewed during Stage 2 of the Quality Indicatior Survey. Resident Identifier: #320. Facility Census: 180 Findings include: a) Resident #320 Resident #320 lost 10.8% (percent) of his body weight, from 04/22/17 to 05/05/17, which represented a severe weight loss. Additionally, Resident #320 lost 13.1% of his body weight from 04/22/17 to 06/04/17, which again represented a severe weight loss. There was no evidence the facility identified these weight losses nor assessed causes and/or provided interventions to prevent additional weight loss. A record review on 09/05/17 at 12:08 p.m., revealed the Nursing Initial Plan of Care completed on 04/22/17, Section E. Nutrition, 1. Focus, 2. Goal, 3. Interventions, and 4. Responsible Disciplines had no responses. It was signed by Employee #87. The Nursing Care Plan completed on 06/06/17, which was the current care plan at the time of this review, stated, Focus: (First name of resident #320) has nutritional problem or potential nutritional problem (skin breakdown) r/t Obesity (weight 277, BMI/IBW 34.6/196-206). Date Initiated: 04/28/2017. Revision on: 04/28/2017. Goal: (First name of resident #320) will have gradual weight loss (1-2 lbs per month) through review date. Date Initiated: 04/28/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. (Resident #320's last name) will maintain adequate nutritional status as evidenced by maintaining weight within (10)% of (196), no s/sx of malnutrition, and consuming at least (50)% of at least (2) meals daily through review date. Date Initiated: 04/28/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. (First name of resident #320) will not develop complications related to obesity, includng skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired moblity through review date. Date Initiated: 04/28/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. Interventions: (included) Develop an activity program that includes exercise, mobility. Offer activities of choice to help divert attention from food. Date Initiated: 04/28/2017. Observe/record/ report to MD PRN s/sx of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss. Date Initiated: 04/28/2017. RD to evaluate and make diet change recommendations PRN. Date Initiated: 04/28/2017. Weigh at same time of day and record each month. Date Initiated: 04/28/2017 Revision on 04/28/2017. A record review on 08/30/17 at 8:28 a.m., revealed the folllowing weights for Resident #320: -- 04/22/17: 277.0 pounds -- 05/05/17: 247.0 pounds (-10.8%, -30.0 pounds) -- 06/04/17: 240.8 pounds (-13.1%, -36.2 pounds) The resident's percentage of weight loss from 04/22/17 to 05/05/17 and from 04/22/17 to 06/06/17 were calculated using the following formula % of weight loss = (usual weight - actual weight) / (usual weight) x 100. -- From 04/22/17 to 05/05/17, the resident lost 10.8% of his body weight. -- From 04/22/17 to 06/04/17, the resident lost 13.1% of his body weight. Review of resident #320 physician's orders [REDACTED]. Dietary supervisor clarified this order as Controlled Carbohydrate Diet, No Added Salt Diet, Regular Texture, Regular Consistency. From 4/22/17 to 5/19/17, two (2) Nutrition Data Collection had been completed. The first note, description admitted d 4/22/17 at 12:00 p.m., signed and locked 4/28/17 at 2:17 p.m The most recent weight was noted in Section A: 277.0 Lbs on 4/22/17 at 1:54 p.m. The Diet/Supplement/Snack/Fortified Foods was noted in Section I, 2 Regular Diet and the Average meal intake percentage/day was noted in Section A: 1,3 50-75%. The Summary/Plan/Progress Note was noted in Section K,2, which included, Resident evaluated for initial admission nutritional status. Current diet is NAS with average intake of 75-100%, which is adequate to meet needs. Weight is 277/34.6, and indicates overweight/obesity status. Current diet order is adequate and appropriate. Will follow prn. The second Nutrition Data Collection dated 5/19/17 at 10:45 a.m., signed and locked 5/30/17 at 09:24 a.m. by Employee #182. The most recent weight was noted in Section A: 249.6 on 5/10/17 at 09:39. Section B, Weight Status, 1. Is there a change in weight? Response: a. No Change. In 3. Weight Loss =/> 5% in 30 days, 7.5% in 90 days, or 10% in 180 days?; however, there was No Response noted in this section. In 4. Please select concerning =/> 5% weight loss; however there was No Response noted in this section. In Section I, 2,Diet/Supplement/Snack/Fortified Foods: CCD/NAS/REG texture. Section I. 3 Average meal intake percentage/day: 100%. In Section K Summary/Plan/Progress Note: Pt with history of GERD/T2DM/Unsteady Gait/Pt is post home-invasion with facial trauma. No problems with eating. Glucose is running elevated. He has a history low H&H and depressed [MEDICATION NAME]. Per pt he has no problems. The Nutrition RD assessment dated [DATE] at 09:03 a.m., signed and locked 5/3/17 at 09:06. Section A: Nutrient Estimated Needs, 1. Calories: 20-25/kg ABW of 98kg=1965-2450. 2. Protein: 1-1.1g/kg ABW=98-108. 3. Fluid: 1mL/kcal= 1965-2450. Section B : Nutrition Diagnosis, 1d. Predicted excessive energy intake NI-1.5. Section C: Problem/Etiology/Signs/Symptoms Statement, 3. Nutrition Goals: Maintain/improve nutritional status. Slow, gradual wt. loss of 3-5 # per month. Avg intake >50%. The Nutrition Status Review dated 7/22/15 at 12:00 p.m, signed and locked 7/29/17 at 5:40 p.m Section B: Weight Status, 3 Weight Loss =/> 5% in 30 days, 7.55 in 90 days, or 10% in 180 days?: No Response. In 4. Please select concerning =/>5% weight loss: No Response. The Nursing Monthly Summary for Resident #320, dated 6/23/17 at 2:00 p.m., signed and locked 6/23/17 at 3:09 p.m., noted Eating 4h: Usual Appetite: b. Fair. Interview was conducted with Resident #320 on 9/5/17 from 1:45 PM-2:30 p.m. The resident explained the events that led up to his admission in April, as well as the therapy received initially. He stated that his appetite when first admitted to the facility was I don't remember much when I first came here. I guess I ate pretty good. I don't really know. I don't have any problem eating now, though. When asked if he was aware he had lost weight after his admission, he replied, No, I really don't. They keep record of it I guess, so I guess they took care of it. Resident #320 said, I don't have any problems eating now. When asked if the staff ever offer him something else to eat, if he doesn't eat and/or like what has been served, he replied, No, I guess they would if I'd ask. Interview was conducted with Employee #40 on 9/7/17 at 9:17 a.m. regarding Resident #320's noted weight loss for April, (MONTH) and (MONTH) (YEAR). She reviewed the Weight Summary report and noted the weight loss for this time period and stated I'll have to talk with (First name of Employee #180) and check if there were interventions for his weight loss. No other information was provided during the survey.",2020-09-01
121,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,282,D,1,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to implement the care plan for two (2) of twenty-nine (29) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #19 did not receive restorative services according to the care plan. Resident #320's care plan was not implemented for bladder incontinence. Resident identifiers: #19 and #320. Facility census: 180. Findings include: a) Resident #19 Review of the resident's current care plan found the following problem: Resident has limited physical mobility related to disease process dementia, [MEDICAL CONDITION], weakness, revised on 08/24/17. The goal associated with the problem: Resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date, revised on 08/24/17. Interventions included; Nursing Rehabilitation/Restorative: Active range of motion, revised on 08/24/17. On 08/22/17, the physical therapist referred the resident to the facility's restorative program. On 08/24/17, the resident began the following restorative program: The goal for restorative therapy was: Maintain strength and functional mobility level Activities to be performed for restorative: 1. Stretching to Bilateral hamstrings and bilateral gastrocnemius muscles 30-45 second hold. (MONTH) do in seated or supine position. 2. Therapeutic exercises for bilateral lower extremities ankle pumps, heel slides straight leg raises, hip abduction/adduction and hip flexions long arc quads, 2 sets of 10 reps; may do in seated or supine. 3. Wheel chair mobility 50-100 feet Bilateral upper extremities and bilateral lower extremities for propulsion, min Assistance to SBA (stand by assistance); instruct patient on safe turning of wheel chair, safe negotiation of obstacles and correct upper extremity and lower extremity placement. At 2:19 p.m. on 08/30/17, the unit manager, Registered Nurse (RN) #116 said the restorative aides keep paper documentation of restorative services provided to residents. RN #116 said the resident had not received any therapy and she did not know why. RN #116 called Restorative Aide (RA) #33 to review the restorative therapy services. RA #33 said the resident had not had any therapy because a second aide who normally works this floor had not been working due to an injury. RA #33 said she had not been on this floor since last Thursday because she had been pulled to the floor to work as a nursing assistant. At 12:50 p.m. on 09/05/17, RN #116 was asked if the second restorative aide had returned to work. She said the RA was in the dining room today. An interview with the second RA #42 at 1:05 p.m. on 09/05/17, found he was in the dining room assisting with lunch. RA #42 said he was on light duty so he would not be able to work with Resident #19. At 1:10 p.m. RA #33 said she worked the floor yesterday so she did not get to see the resident. She stated, I last saw her on 08/31/17 and she refused her therapy. The resident was seen only one (1) time between 08/24/17 and 08/31/17. The resident had not received restorative therapy during the month of September, according to RA #33. The DON confirmed Resident #19 was not receiving her restorative therapy as ordered upon interview on 09/05/17 at 4:17 p.m., after review of the Rehabilitation/Restorative Service Delivery Record. At 4:17 p.m. on 09/05/17, the administrator confirmed RA #42 was injured on the job, sometime last week. At 9:49 a.m. on 09/07/17, the Registered Nurse, Resident Care Management Director, (RN) #3 reviewed the restorative services delivery record and confirmed the Resident's care plan addressing the resident's limited physical mobility was not implemented. b) Resident #320 A record review on 09/05/17 at 12:08 p.m., revealed the Nursing Care Plan completed on 06/06/17, read as follows, Focus: (Resident #320's first name) has bowel incontinence r/t Decreased Activity, Weakness. Date Initiated: 05/03/2017 Revision on: 05/03/2017 Goal: (Resident #320's first name) will have less than two episodes of incontinence per day through the review date. Date Initiated: 05/03/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. Interventions: (included) Check resident every two hours and assist with toileting as needed. Date Initiated: 05/03/2017 Provide bedpan/bedside commode. Date Initiated: 05/03/2017 Provide loose fitting, easy to remove clothing. Date Initiated: 05/03/2017 Provide peri care after each incontinent episode. Date Initiated: 05/03/2017 Resident #320 also had a Nursing Care Plan completed on 07/06/2017, which read as follows: Focus: (Resident #320's first name) has bladder incontinence r/t Weakness, Decreased Activity, DM. Date Initiated: 05/03/2017 Revision on: 05/03/2017. Goal: (Resident #320's first name) will remain free from skin breakdown due to incontinence and brief use through the review date. Date Initiated: 05/03/2017. Revision on: 05/03/2017. Target Date: 08/02/2017. Interventions: (included) Clean peri-area with each incontinence episode. Date Initiated: 05/03/2017 Have call light within easy reach. Date Initiated: 05/03/2017 Incontinent: Check EVERY TWO HOURS AND PRN for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Date Initiated: 05/03/2017 Revision on 05/03/2017 Interview was conducted with Resident #320 on 9/5/17 at 1:45 PM. The resident explained the events that led up to admission in April, as well as the therapy received initially. He explained that he isn't able to walk, and transfers in his wheelchair. The resident stated he is not on a scheduled toileting program. He stated, No, they come and change me twice a day, every morning and every evening. They used to change me only one time a day, and they recently increased changing me two times a day. At this time, a male Nurse Aide entered the room, carrying supplies, and stated he was there to check the resident. Surveyor stepped out into the hall until he was finished. Approximately five (5) minutes passed, and the male Nurse Aide came out of the resident's room, pulled the door closed, and stated, I have to get some help Approximately five (5) minutes later, the male staff came back to Resident #320s room, along with a female assistant, who was pushing a Hoyer Lift. I asked the female staff what type of lift it was, and she replied, It's a special one that enables us to stand a resident up. Both assistants left the room in approximately 10 minutes. Interview with the male Nurse Aide and asked him how often do they check and/or assist the resident, and he replied, We do it with every round. I asked the male assistant how frequently to they make rounds, and he replied, It always depends on what all we've got going on. This surveyor re-entered Resident #320 room to resume my interview, I asked resident if anyone had instructed him how to use his call-light, and he replied, Yes, ma'am. Upon further interview he was asked if anyone at the facilty had instructed him to turn on his call-light every time he needs to go to the restroom, and he replied, No, I just wait until they come in to change me. When asked if the staff get a wash basin with water and soap to wash him after they remove the soiled brief. Resident smiled, and replied, No, they use those wet-ones, you know, that come in a pack. Resident added, I'm unable to stand up, so they bring a lift-thing that they use to stand me up. When asked if he had any sore or raw areas on his bottom, or between his legs and private area, and he replied, No. I asked him if the Nurse Aides or anyone applies any type of ointment, cream &/or powder on him during his care, and he replied, No.",2020-09-01
123,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,311,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide restorative therapy as ordered by the physician for one (1) of three (3) resident's reviewed for the care area of activities of daily living (ADL's) during Stage 2 of the Quality Indicator Survey. Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 On 08/22/17, the physical therapist referred the resident to the facility's restorative program. On 08/24/17, the resident began the following restorative program: The goal for restorative therapy was: Maintain strength and functional mobility level Activities to be performed for restorative: 1. Stretching to Bilateral hamstrings and bilateral gastrocnemius muscles 30-45 second hold. (MONTH) do in seated or supine position 2. Therapeutic exercises for bilateral lower extremities ankle pumps, heel slides straight leg raises, hip abduction/adduction and hip flexions long arc quads, 2 sets of 10 reps; may do in seated or supine. 3. Wheel chair mobility 50-100 feet Bilateral upper extremities and bilateral lower extremities for propulsion, min Assistance to SBA (stand by assistance); instruct patient on safe turning of wheel chair, safe negotiation of obstacles and correct upper extremity and lower extremity placement. At 2:19 p.m. on 08/30/17, the unit manager, Registered Nurse (RN) #116 said the restorative aides keep paper documentation of restorative services provided to residents. RN #116 said the resident had not received any therapy and she did not know why. RN #116 called Restorative Aide (RA) #33 to review the restorative therapy services. RA #33 said the resident had not had any therapy because a second aide who normally works this floor had not been working due to an injury. RA #33 said she had not been on this floor since last Thursday because she had been pulled to the floor to work as a nursing assistant. At 12:50 p.m. on 09/05/17, RN #116 was asked if the second restorative aide had returned to work. She said the RA was in the dining room today. An interview with the second RA #42 at 1:05 p.m. on 09/05/17, found he was in the dining room assisting with lunch. RA #42 said he was on light duty so he would not be able to work with Resident #19. At 1:10 p.m. RA #33 said she worked the floor yesterday so she did not get to see the resident. She stated, I last saw her on 08/31/17 and she refused her therapy. The resident was seen only one (1) time between 08/24/17 and 08/31/17. The resident had not received restorative therapy during the month of September, according to RA #33. The DON confirmed, Resident #19 was not receiving her restorative therapy as ordered on [DATE] at 4:17 p.m. after review of the Rehabilitation/Restorative Service Delivery Record. At 4:17 p.m. on 09/05/17, the administrator confirmed RA #42 was injured on the job, sometime last week.",2020-09-01
124,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,312,D,1,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident interview, record review, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of activities of daily living (ADL's) was provided care for oral hygiene. The facility was unaware Resident #90, who had resided at the facility since 02/12/15, had a upper partial. Resident identifier: #90. Facility census: 180. Findings include: a) Resident #90 Observation of the resident's oral cavity at 10:41 a.m. on 08/29/17, found the resident had what appeared to be her own teeth. Some were missing, discolored and were covered with a white, chalky substance that appeared to be plaque. Observation of the resident's oral cavity with the Registered Nurse (RN) unit manager, at 12:57 p.m. on 09/05/17, found RN #116 discovered the resident had an upper partial and, What looks like a cavity on the lower back tooth. The resident said she had a partial. She stated, I am not going to show it to you because you might steal it. Three (3) nursing assistants (NA's) #47, #5 and #58, (all working on the resident's unit) and RN #116 denied knowing the resident had a partial at 1:21 p.m. on 09/05/17. All denied removing the partial for cleaning. RN #116 was asked if she could find any evidence the facility was ever aware the resident had a partial or any documentation the partial had been removed for cleaning. Record review found the resident was admitted to the facility on [DATE]. The most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 06/29/17 notes the resident requires extensive assistance of 1 staff member for personal hygiene, which includes brushing teeth. Review of the last 3 nursing monthly assessments, dated 06/12/17, 07/12/17, and 08/12/17 noted the resident has her own teeth under the section entitled, Dentition. The form also allowed the nurse completing the assessment to note the resident had a Partial(s) Bridge(s). This section was not completed, indicating the resident did not have a partial. At approximately 3:00 p.m. on 09/05/17, the Registered Nurse (RN), Resident Care Manager, #3, provided a progress note from a local dentist. She said the family had requested a dental appointment during the resident's care plan meeting. She said the resident did not cooperate and a follow up appointment was going to be scheduled when the family could attend. She said this was the only dental consult she could find for the resident. The dental consult, dated 08/02/17 noted: Patient barely opened mouth for exam. Patient states she does wear a partial on the MX (maxillary) however was unable to have her remove it. There was gross amount of plaque present. Patient will require [MEDICATION NAME] and a more comprehensive exam. Review of the resident's MDS Kardex Report for the nursing assistants found documentation an upper partial had been added to the Kardex on 09/05/17. At 4:16 p.m. on 09/05/17, the Director of Nursing confirmed she had no further information to present regarding the resident's oral status.",2020-09-01
125,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,315,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #141 and Resident #320 received the services and assistance necessary to maintain their bladder continence status. Resident #141 and Resident #320 both suffered a decline in bladder continence status since their admission to the facility. The facility failed to consistently provide services to these residents to help them to maintain their bladder continence status. This practice affected two (2) of four (4) residents reviewed for the care area of urinary incontinence during Stage Two (2) of the Quality Indicator Survey (QIS). Resident Identifiers: #141 and #320. Facility Census: 180. Findings Include: a) Resident #141 During a Stage 1 interview with Resident #141 at 11:12 a.m. on 08/29/17, when asked if she received enough fluids between meals Resident #141 replied, they bring me plenty to drink but I watch what I drink because I wet on myself now and I never used to do that and I don't like it so I try not to drink to much. A review of Resident #141's medical record beginning at 8:02 a.m. on 09/07/17, found Resident #141 was admitted to the facility on [DATE] at which time she had an indwelling urinary catheter. Resident #141 continued to have a catheter until 01/27/17 at which time it was removed. A review of the nurse aides documentation pertaining to urinary continence was completed beginning with (MONTH) (YEAR) through 09/07/17. This review found the following ( the review was not started until (MONTH) due to the use of the catheter until 01/27/17): In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 16.25 percent (%) of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 16.48 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 5.19 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 79.57 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 83.70 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 73.91 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 78.49 % of the time. In (MONTH) (YEAR) Resident #141 was incontinent of her bladder 78.95 % of the time. Further review of the record found a physician order [REDACTED]. This order was added after the resident had a fall as an intervention to prevent further falls. This toileting plan was not initiated due to Resident #141's decline in continence status. Review of Resident #141's Minimum Data Sets (MDS) found the following: An admission MDS with an Assessment Reference Date (ARD) of 12/13/17 found the resident had an Indwelling Catheter and was occasionally incontinent of urine and was not in a toileting program. A quarterly MDS with an ARD of 03/13/17 found the resident was occasionally incontinent or urine and was not currently in a toileting program. A quarterly MDS with an ARD of 06/02/17 found the resident was frequently incontinent of urine and was not currently in a toileting program. (Please note this MDS was completed after the toileting plan was ordered on [DATE].) Further review of the record found Resident #141 had the following bowel and bladder evaluations completed. Each bowel and bladder evaluation contained these directions for completion If resident is continent of both bowel and bladder evaluation complete. If resident is Incontinent of either bowel and/or bladder continue with the evaluation: -- Evaluation Dated 12/06/17 indicated Resident #141 was incontinent of urine. (Please note at the time this evaluation was completed Resident #141 had an indwelling catheter and her continent status could not be determined as incontinent due to the catheter.) -- Evaluation Dated 03/06/17 indicated Resident #141 was continent of urine. The remainder of the evaluation was not completed because she was marked as continent of bowel and bladder therefore the evaluation was complete. -- Evaluation Dated 06/06/17 indicated Resident #141 was incontinent of bladder. The remainder of this evaluation was not complete even though it should have been completed because Resident #141 was marked as incontinent of bowel and bladder. The Director of Nursing was interviewed at 8:45 a.m. on 09/07/17 she was asked to show evidence the toileting plan initiated on 05/15/17 was being implemented by the Nurse Aides. She referred to the treatment administration record (TAR). Review of the TAR for 05/2017 through 09/07/17 found the nurses initialed the toileting plan as being completed three times daily at 7:00 a.m., 3:00 p.m., and 11:00 p.m. Further review of the TARs found on the following dates and times the nurses failed to initial the toileting plan was completed: -- 05/16/17 at 3:00 p.m. -- 05/17/17 at 7:00 a.m. -- 05/19/17 at 7:00 a.m. -- 06/08/17 at 7:00 a.m. -- 06/09/17 at 7:00 a.m. -- 07/14/17 at 3:00 p.m. -- 07/19/17 at 3:00 p.m. and 11:00 p.m. -- 07/20/17 at 3:00 p.m. -- 07/25/17 at 7:00 a.m. -- 07/26/17 at 3:00 p.m. -- 07/29/17 at 7:00 a.m. -- 09/05/17 at 3:00 p.m. The DON was then asked if the nurse aides document anywhere to indicate the resident is on a toileting program. She pulled up a follow up question report, in the electronic medical record, for Resident #141. The question which the nurse aides were asked to answer on every shift was, Is the resident on a toileting or bladder retraining program? A review of the nurse aides answers were reviewed for the time period of 05/15/17 through 09/07/17 and found the nurse aides only answered yes to this question on 05/31/17 at 8:30 a.m., 06/30/17 at 2:58 p.m., 07/21/17 at 8:39 a.m., 08/08/17 at 6:38 p.m., 08/12/17 at 9:33 a.m., 08/13/17 at 9:36 a.m., 08/17/17 at 7:35 a.m., 08/21/17 at 7:58 a.m., and 08/27/17 at 4:31 p.m. On all other days three times daily the Nurse Aides answered no to this question. The DON agreed the Nurse Aides are responsible for toileting the resident on the majority of occasions. She stated, The nurses are supposed to make sure it is done. The DON was also asked why the remainder of the bowel and bladder evaluation dated 06/06/17 was not completed. She agreed the remainder of the evaluation should have been completed because the resident was marked as incontinent of her bowel and bladder. She indicated she did not know why the evaluation was not complete and stated, It should not have let them sign it as complete with it remaining blank. A final interview was completed with the DON, the District Director of Clinical Services and the Nursing Home Administrator, at 12:20 p.m. on 09/07/17. At which time they asserted the resident's fluid intake with her meals had not decreased, but they had no way of measuring the amount of fluids which the resident took in between meals which was the subject of the Stage 1 question posed to Resident #141. They also asserted that nursing will at times toilet the resident which is likely true, but they agreed the majority of the toileting program implementation was the responsibility of the Nurse Aides who were documenting that Resident #141 was not on a toileting program. No other information was provided. b.) Resident #320 Review of Resident #320's medical record at 8/30/17 at 12:25 p.m., found: MDS Findings: Section H' Bladder and Bowel 4/29/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 5/8/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 5/22/17: H0300. Urinary Continence: 3. Always Incontinent (no episodes of continent voiding) 6/17/17: H0300. Urinary Continence: *2. Frequently Incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent-voiding) 7/22/17: H0300. Urinary Continence: 3. Always Incontinent (no episodes of continent voiding) Review of Braden Scale for Predicting Pressure Sore Risk: 04/22/2017 at 2:18 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. (3 pts.) 04/25/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. (1 pt.) 05/02/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 2. Very Moist: Skin is often, but not always moist. Linen must be changed at least once a shift. (2 pts.) 05/09/2017 at 4:24 p.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, reqiring an extra linen change approximately once a day. (3 pts.) 06/16/2017 at 9:43 a.m. 2. Moisture: Degree to which skin is exposed to moisture: 3. Occasionally Moist: Skin is occasionally moist, reqiring an extra linen change approximately once a day. (3 pts.) A Verbal physician's orders [REDACTED]. Confirmed by Employee #1. The above order was discontinued by telephone on 05/05/2017 at 3:08 p.m. Confirmed by Employee #81. A Telephone physician's orders [REDACTED].#81. Review of Treatment Administration Record 05/01/2017-05/31/2017 included the following: Cleanse bilateral buttocks, coccyx, and sacrum with warm soapy water, rinse, pat dry, apply [MEDICATION NAME] cream topically and prn every shift for increased risk for skin break down. -Order Date 04/25/2017 at 4:33 p.m. -D/C Date 05/05/2017 at 2:55 p.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Wash coccyx with warm, soapy water, rinse, pat dry, apply [MEDICATION NAME] q shift and prn every shift for prevention. -Order Date 04/22/2017 at 6:59 p.m. -D/C Date 05/05/2017 at 3:08 p.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Review of Treatment Administration Record 06/01/2017-06/30/2017 included the following: Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Review of Treatment Administration Record 07/01/2017-07/31/2017 included the following: Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry-apply [MEDICATION NAME] cream topically every shift. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically every shift. -Order Date 07/10/2017 at 8:18 p.m. Cleanse scrotum with warm soapy water, rinse, pat dry, and apply [MEDICATION NAME] every shift. -Order Date 07/01/2017 at 5:03 a.m. -D/C Date 07/10/2017 at 8:17 a.m. Cleanse bilateral buttocks, coccyx and sacrum with warm soapy water. Rinse and pat dry -apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 05/05/2017 at 2:55 p.m. -D/C Date 07/10/2017 at 8:18 a.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 07/10/2017 at 8:18 p.m. Review of Treatment Administration Record 08/01/2017-08/31/2017 included the following: Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically every shift. -Order Date 07/10/2017 at 8:18 p.m. Cleanse bilateral buttocks, coccyx, scrotum, and sacrum with warm soapy water. Rinse and pat dry- apply [MEDICATION NAME] cream topically as needed for increased risk for skin breakdown. -Order Date 07/10/2017 at 8:18 p.m. Review of the Nursing Daily Skilled Charting-V 1: (4/22/17, 4/24/17, 4/25/17, 4/26/17, 4/27/17, 4/28/17, 4/29/17, 4/30/17, 5/1/17, 5/2/17, 5/3/17, 5/4/17, 5/5/17, 5/6/17, 5/7/17, 5/8/17, 5/9/17, 5/10/17, 5/11/17, 5/12/17 and 5/27/17) F. GU/BLADDER: 1 b. Bladder Continence: b. INCONTINENT (Total 21 Days) Review of the Nursing Daily Skilled Charting-V 1: (5/13/17, 5/14/17, 5/15/17, 5/16/17, 5/17/17, 5/18/17, 5/19/17, 5/21/17, 5/22/17, 5/23/17, 5/24/17, 5/25/17, 5/26/17, 5/29/17, 5/30/17 and 5/31/17) F. GU/BLADDER: 1 b. Bladder Continence: a. CONTINENT (Total 16 Days) Review of the Nursing Daily Skilled Charting-V 1: (6/9/17,6/12/17, 6/13/17, 6/26/17 and 6/27/17) F. GU/BLADDER: 1 b. Bladder Continence: b. INCONTINENT (Total 5 Days) Review of the Nursing Daily Skilled Charting-V 1: (6/1/17, 6/2/17, 6/4/17, 6/5/17, 6/6/17, 6/7/17, 6/8/17, 6/10/17, 6/11/17, 6/14/17, 6/15/17, 6/17/17, 6/18/17, 6/19/17, 6/20/17, 6/21/17, 6/22/17, 6/23/17, 6/24/17, 6/25/17, 6/28/18, 6/29/17 and 6/30/17) F. GU/BLADDER: 1 b. Bladder Continence: a. CONTINENT (Total 23 Days) Review of the Nursing Daily Skilled Charting-V 1: (7/2/17, 7/3/17, 7/4/17, 7/10/17, 7/17/17, 7/18/17, 7/19/17, 7/20/17, 7/21/17, 7/22/17, 7/23/17, 7/24/17, 7/25/17, 7/26/17, 7/27/17, 7/28/17, 7/29/17, 7/30/17, 7/31/17, 8/1/17, 8/2/17 and 8/15/17 ) F. GU/BLADDER: 1 b. Bladder Continence: b. INCONTINENT (Total 22 Days) Review of the Nursing Daily Skilled Charting-V 1: (7/1/17, 7/5/17, 7/6/17, 7/7/17, 7/8/17, 7/9/17, 7/11/17, 7/12/17, 7/13/17, 7/14/17, 7/15/17 and 7/16/17) F. GU/BLADDER: 1 b. Bladder Continence: a. CONTINENT (Total 12 Days) Review of the Nursing Monthly Summary dated 6/23/2017, Section [NAME] GU/Bladder, 1. What is resident's bladder status? a. Continent 2. Scheduled Toileting Plan 2a. Is resident on a Scheduled Toileting Plan? b. No Review of the Nursing Monthly Summary dated 7/23/2017, Section [NAME] GU/Bladder, 1. What is resident's bladder status? a. Continent 2. Scheduled Toileting Plan 2a. Is resident on a Scheduled Toileting Plan? b. No Review of the Nursing Monthly Summary dated 8/23/2017, Section [NAME] GU/Bladder, 1. What is resident's bladder status? b. Incontinent 2. Scheduled Toileting Plan 2a. Is resident on a Scheduled Toileting Plan? a. Yes Interview conducted with Resident #320 on 9/5/17 at 1:45 PM. He explained the events that led up to his admission in April, as well as the therapy he received initially. He explained that he isn't able to walk, and transfers in his wheelchair. When asked if the facility had him on a scheduled toileting program, and he replied, No. Observation found his call-light was within his reach. When asked if he turns on the call-light when he needs to go to the restroom. Resident stated, No, they come and change me twice a day, every morning and every evening. They used to change me only one time a day, and they recently increased changing me two times a day. At this time, a male Nurse Aide entered the room, carrying supplies, and stated he was there to check the resident. Approximately five (5) minutes passed, and the male Nurse Aide came out of the resident's room, pulled the door closed, and stated, I have to get some help. Approximately five (5) minutes later, the male Nurse Aide came back to Resident #320s room, along with a female Nurse Aide, who was pushing a Hoyer Lift. I asked the female staff what type of lift it was, and she replied, It's a special one that enables us to stand a resident up. Both Nurse Aides left the room in approximately 10 minutes. During an nterview with the male Nurse Aide he was asked him how often do they check and/or assist the resident, and he replied, We do it with every round. When asked how frequently do they make rounds, and he replied, It always depends on what all we've got going on. Upon re-entering Resident #320 room to resume the resident interview, he was asked if anyone had instructed him how to use his call-light, and he replied, Yes, ma'am.When asked if they had instructed him to turn on his call-light every time he needs to go to the restroom, he replied, No, I just wait until they come in to change me. When asked if the staff get a wash basin with water and soap to wash him after they remove the soiled brief. Resident smiled, and replied, No, they use those wet-ones, you know, that come in a pack. Resident added, I'm unable to stand up, so they bring a lift-thing that they use to stand me up. When asked if he had any sore or raw areas on his bottom, or between his legs and private area, and he replied, No. When asked him if the Nurse Aide or anyone applies any type of ointment, cream &/or powder on him during his care, and he replied, No. Interview conducted with Employee #40 on 9/7/17 at 9:17 a.m. regarding Resident #320's noted incontinence for April, (MONTH) and (MONTH) (YEAR), and asked if Resident #320 was on a toileting plan. She replied, I'll have to talk with (First name of Employee #180) and check if there is a toileting plan in place for this resident. No one provided this Surveyor with any additional and/or follow-up information.",2020-09-01
126,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,323,D,1,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure the resident's environment, over which the facility had control, was free from accidents. Resident #350's over the bed table was sitting on a fall mat. Resident #214's grab bars in the bathroom were loose. This was true for one of three residents reviewed for the care area of accidents during Stage 2 of The Quality Indicator survey (QIS) and one random observation. Resident identifiers: #350 and #214. Facility census: 180. Findings include: a) Resident #350 Record review found the resident was admitted to the facility on [DATE]. The resident's current care plan, included a problem for: Being at risk of falls related to CVA (cerebral vascular accident) with aphasia, incontinence, muscle weakness, impaired balance, impaired cognition, history of falls. The goal associated with the problem is: Resident will not sustain serious injury through the review date Interventions included: Low bed with bilateral floor mats per MD (physician) order The resident needs a safe environment with (even floor free from spills and or clutter, etc.) Record review found the resident had seven (7) falls since his admission: --06/09/17 - Resident up in wheelchair in room attempted to stand and fell in floor no injuries noted. --06/13/17 - Resident seen by nurse sliding off edge of bed onto the floor on his knees. --06/20/17 - Resident found lying on his left side on the floor mat beside his bed. --06/22/17 - at 5:30 a.m., Resident noted sitting in floor on mat beside his bed --06/22/17 - at 1:15 a.m., Resident observed sitting in the floor next to his bed --08/21/17 - Resident found lying in front of his wheelchair in the day room. --08/27/17 - Resident found sitting on the left side of his bed on floor mat, obtained a skin tear to the upper part of the back of his right and left arm. Five (5) of the falls occurred when the resident fell from bed. On 06/28/17, the physical ordered a low bed with bilateral floor mats at all times while in bed-verify position and placement. At 4:28 p.m. on 08/30/17, the resident was in bed sleeping. The over the bed table was observed sitting on the fall mat on the right side of the resident's bed. The Registered Nurse (RN) unit manager, Employee #116, was asked if the over the bed table should be on top of the fall mat and could the table pose a risk if the resident fell from bed. RN #116 said she would move the over the bed table. Observation of the resident at 2:56 p.m. on 09/05/17, found he was again in bed with the over the bed table on top of the right fall mat. The Registered Nurse (RN), Resident Care Manager, RN #3, was asked if the over the bed table should be parked on top of the fall mat. She said she would move the table. The Director of Nursing (DON) was advised of the above observations on 09/05/17 at 4:13 p.m. She confirmed the over the bed table should not be sitting on the resident's floor mats. b) Resident #214 Observation of the resident's bathroom at 10:36 a.m. on 08/29/17, found two grab bars in the bathroom, located beside the commode, were loose. A second observation of the resident's bathroom with the maintenance supervisor at 12:55 p.m. on 09/06/17, found the grab bar to the right side of the toilet was easily moved with the touch of a hand. A second grab bar, on the wall behind the commode, was protruding outward from the wall. The screw that held the bar to the wall could be seen between the space between the bar and the wall. The maintenance supervisor confirmed the bars were loose and said he would fix them immediately.",2020-09-01
127,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,325,D,1,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview and staff interview, the facility failed to identify and address a severe weight loss for one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 Quality Indicator Survey. Resident #320 lost 10.8% (percent) of his body weight, from 04/22/17 to 05/05/17, which represented a severe weight loss. Additionally, Resident #320 lost 13.1% of his body weight from 04/22/17 to 06/ , which again represented a severe weight loss. There was no evidence the facility identified these weight losses nor assessed causes and/or provided interventions to prevent additional weight losses. As no interventions had been implemented, the weight loss could not be determined to be unavoidable. This represents actual harm to resident #320. Resident Identifier: #320. Facility Census: 180 Findings Include: a) Resident #320 A record review on 08/30/17 at 8:28 a.m., revealed the following weights for Resident #320: -- 04/22/17: 277.0 pounds -- 05/05/17: 247.0 pounds (-10.8%, -30.0 pounds) -- 06/04/17: 240.8 pounds (-13.1%, -36.2 pounds) The resident's percentage of weight loss from 04/22/17 to 05/05/17 and from 04/22/17 to 06/06/17 were calculated using the following formula % of weight loss = (usual weight - actual weight) / (usual weight) x 100. -- From 04/22/17 to 05/05/17, the resident lost 10.8% of his body weight. -- From 04/22/17 to 06/04/17, the resident lost 13.1% of his body weight. Review of resident #320 physician's orders [REDACTED]. Dietary supervisor clarified this order as Controlled Carbohydrate Diet, No Added Salt Diet, Regular Texture, Regular Consistency. Review of resident #320 medical record found a Minimum data set (MDS) with an assessment reference date of 06/17/17. Section K of this MDS Swallowing/Nutritional Status K0300: Weight Loss of the MDS, indicated Resident #320 had not had a Loss of 5% or more in the last month or loss of 10% or more in last 6 months. Further review of the medical record found a 7/22/17: MDS Modified & Accepted; however, it was noted there were not any changes in Section K: Weight Loss: (Loss of 5% or more in the last month or loss of 10%in last 6 months): 0 NO or UNKNOWN From 4/22/17 to 5/19/17, two (2) Nutrition Data Collection had been completed. The first note, description admitted d 4/22/17 at 12:00 p.m., signed and locked 4/28/17 at 2:17 p.m The most recent weight was noted in Section A: 277.0 Lbs on 4/22/17 at 1:54 p.m. The Diet/Supplement/Snack/Fortified Foods was noted in Section I, 2 Regular Diet and the Average meal intake percentage/day was noted in Section A: 1,3 50-75%. The Summary/Plan/Progress Note was noted in Section K,2, which included, Resident evaluated for initial admission nutritional status. Current diet is NAS with average intake of 75-100%, which is adequate to meet needs. Weight is 277/34.6, and indicates overweight/obesity status. Current diet order is adequate and appropriate. Will follow prn. The second Nutrition Data Collection dated 5/19/17 at 10:45 a.m., signed and locked 5/30/17 at 09:24 a.m. by Employee #182. The most recent weight was noted in Section A: 249.6 on 5/10/17 at 09:39. Section B, Weight Status, 1. Is there a change in weight? Response: a. No Change. In 3. Weight Loss =/> 5% in 30 days, 7.5% in 90 days, or 10% in 180 days?; however, there was No Response noted in this section. In 4. Please select concerning =/> 5% weight loss; however there was No Response noted in this section. In Section I, 2,Diet/Supplement/Snack/Fortified Foods: CCD/NAS/REG texture. Section I. 3 Average meal intake percentage/day: 100%. In Section K Summary/Plan/Progress Note: Pt with history of GERD/DM/Unsteady Gait/Pt is post home-invasion with facial trauma. No problems with eating. Glucose is running elevated. He has a history low H&H and depressed [MEDICATION NAME]. Per pt he has no problems. The Nutrition RD assessment dated [DATE] at 09:03 a.m., signed and locked 5/3/17 at 09:06. Section A: Nutrient Estimated Needs, 1. Calories: 20-25/kg ABW of 98kg=1965-2450. 2. Protein: 1-1.1g/kg ABW=98-108. 3. Fluid: 1mL/kcal= 1965-2450. Section B : Nutrition Diagnosis, 1d.Predicticted excessive energy intake NI-1.5. Section C: Problem/Etiology/Signs/Symptoms Statement, 3. Nutrition Goals: Maintain/improve nutritional status. Slow, gradual wt. loss of 3-5 # per month. Avg intake >50%. The Nutrition Status Review dated 7/22/15 at 12:00 p.m, signed and locked 7/29/17 at 5:40 p.m Section B: Weight Status, 3 Weight Loss =/> 5% in 30 days, 7.55 in 90 days, or 10% in 180 days?: No Response. In 4. Please select concerning =/>5% weight loss: No Response. The Nursing Monthly Summary for Resident #320, dated 6/23/17 at 2:00 p.m., signed and locked 6/23/17 at 3:09 p.m., noted Eating 4h: Usual Appetite: b. Fair. The Quarterly MDS Review dated 6/17/17, 2. GO110-H Eating: Independent. 3. KO300. Weight: 258 lbs Weight Loss: (Loss of 5% or more in the last month or loss of 10%in last 6 months): 0 NO or UNKNOWN. The Modified & Accepted MDS dated [DATE] was reviewed, and there were not any noted changes in Section K. Weight Loss: (Loss of 5% or more in the last month or loss of 10%in last 6 months): 0 NO or UNKNOWN. Record review of the Resident #320's Monthly Meal Consumption documentation for April, (MONTH) and (MONTH) (YEAR), revealed the following findings: APRIL (YEAR): Total Meals Documented: 26 Percentage Guide 0 0-25% 0 1 26%-50% 5 2 51%-75% 14 3 76%-100% 7 MAY (YEAR): Total Meals Documented: 91 Percentage Guide Missed Documentation 2 0 0-25% 0 1 26%-50% 4 2 51%-75% 53 3 76%-100% 34 JUNE (YEAR): Total Meals Documented: 90 Percentage Guide Missed Documentation 0 0 0-25% 0 1 26%-50% 1 2 51%-75% 33 3 76%-100% 56 Review of Facility's Food Consumption Chart reference tool for staff reference, which gives the specific examples of 0%, 25%, 50%, 75% and 100%; however, the Facility failed to have a Food Consumption Chart reference tool for staff reference for examples of the percentage guide they currently use, which is 0 0-25%, 1 26%-50%, 2 51%-75%, and 3 76%-100%. During an interview conducted with Resident #320 on 9/5/17 beginning at 1:45 p.m., he explained to me the events that led up to his admission in April, as well as the therapy he received initially. I asked him how his appetite was when he was first admitted to the Facility, and he replied, I don't remember much when I first came here. I guess I ate pretty good. I don't really know. I don't have any problem eating now, though. I asked him if he was aware he had lost weight after his admission, and he replied, No, I really don't. They keep record of it I guess, so I guess they took care of it. Resident #320 smiled and said, I don't have any problems eating now. I asked if the staff ever offer him something else to eat, if he doesn't eat and/or like what has been served. He replied, No, I guess they would if I'd ask. During an interview conducted with Employee #40 on 9/7/17 at 9:17 a.m. regarding Resident #320's noted weight loss for April, (MONTH) and (MONTH) (YEAR). Employee #40 reviewed the Weight Summary report, and noted the weight loss for this time period, and stated, I'll have to talk with (First name of Employee #180) and check if there were interventions for his weight loss. No one provided this Surveyor with any additional and/or follow-up information. Resident #320 lost 10.8% (percent) of his body weight, from 04/22/17 to 05/05/17, which represented a severe weight loss. Additionally, Resident #320 lost 13.1% of his body weight from 04/22/17 to 06/ , which again represented a severe weight loss. There was no evidence the facility identified these weight losses nor assessed causes and/or provided interventions to prevent additional weight losses. As no interventions had been implemented, the weight loss could not be determined to be unavoidable. This represents actual harm to resident #320.",2020-09-01
129,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,334,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the staff failed to obtain a consent prior to administering the [MEDICAL CONDITION] vaccine in (YEAR) for three (3) of five (5) residents reviewed. Resident identifiers: #19, #95, and #190. Facility census: 180. Findings include: a) Resident #19 According to the Medication Administration Record, [REDACTED]. However, no informed consent was obtained before the [MEDICAL CONDITION] vaccine injection on 10/27/16. b) Resident #95 According to the Medication Administration Record, [REDACTED]. On 09/07/17 at 1:35 p.m., Unit Manager (UM) #87 was unable to locate any documentation that consent for the [MEDICAL CONDITION] vaccine had been obtained from Resident #95 or his representative at any time. c) Resident #190 According to the Medication Administration Record, [REDACTED]. On 09/07/17 at 1:35 p.m., Unit Manager (UM) #87 was unable to locate any documentation that consent for the [MEDICAL CONDITION] vaccine had been obtained from Resident #190 or her representative at any time. According to the facility's policy and procedure entitled Immunizations: Influenza (Flu) Vaccination of Residents, Staff, and Volunteers, Informed consent in the form of a discussion regarding risks and benefits of vaccination will occur prior to vaccination. According to the facility's policy and procedure entitled Standing Orders for Administering Influenza Vaccine to Adults, Provide all patients with a copy of the most current federal Vaccine Information Statement (VIS). You must document in the patient's medical record or office log, the publication date of the VIS and the date it was given to the patient. UM #22 and UM #87 were interviewed on 09/07/17 at 1:35 p.m. UM #22 stated verbal consent was obtained from the resident or the resident's representative prior to administration of the [MEDICAL CONDITION] vaccine. UM #87 stated that written consent is obtained. The Director of Nursing (DoN) was also interviewed on 09/07/17 at 1:35 p.m. The DoN stated consents for the [MEDICAL CONDITION] vaccine are not obtained annually. She stated once consent had been obtained, the vaccine was administered yearly based on this consent.",2020-09-01
133,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,412,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, and record review, the facility failed to provide a medicaid resident routine dental services when the resident lost her dentures. This was true for one (1) of three (3) residents reviewed for dental care during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #19. Facility census: 180. Findings include: a) Resident #19 During a telephone interview with the resident's responsible party at 9:56 a.m. on 08/29/17, the responsible party expressed concern because the resident's bottom dentures were missing. The responsible party said she was unsure how long the dentures had been missing. The responsible party stated she could not afford to replace the dentures and the facility did not offer to assist with replacing the dentures. At 10:27 a.m. on 08/29/17 the resident was observed in her room without any upper or lower dentures and no natural teeth. At 12:10 p.m. on 08/30/17, Employee #15, the social services manager, said she was unaware the resident's bottom denture was missing. She stated the admission agreement specifies the facility does not replace lost or missing items. At 12:20 p.m. on 08/30/17, the resident was observed to be up in her wheelchair sitting at the nurses station. She had no lower or upper dentures. At 2:23 p.m. on 08/30/17, the unit charge nurse, Registered Nurse (RN) #116 was asked if the resident had dentures. She stated, I knew she had uppers and apparently they are missing now. I just found out, we are looking for them. An interview with the resident's nursing assistant, (NA) # ///, at 2:29 p.m. on 08/30/17 found she knew the resident had upper dentures. I don't know how long they have been missing, I don't remember the last time I saw them. At 2:35 p.m. on 08/30/17 an interview with [NAME] #15 found she was unaware the residents upper dentures were now missing. When asked if the facility arranges for financial assistance to replace the dentures, she stated, We haven't in the past. She verified she was unaware of any appointments made in the past to explore replacing the lower dentures. Review of the resident's personal inventory sheet, completed upon her admission to the facility on [DATE], noted the resident was admitted with both upper and lower dentures. A second personal inventory sheet, completed on 05/21/15, noted the resident only had upper dentures. At 11:28 a.m. on 09/05/17, the Director of nursing was asked if the facility had located the resident's upper dentures. The DON stated the upper dentures had not been located at 4:22 p.m. on 09/05/17. At the same time, the administrator stated if the dentures were affecting her ability to eat she could be sent to see a dentist.",2020-09-01
135,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,428,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities during the monthly medication regimen review for one (1) of six (6) residents reviewed for unnecessary medications. The pharmacist did not identify Resident #350's insulin was not administered according to physician's orders [REDACTED].#350. Facility census: 180. Findings include: a) Resident #350 The resident was admitted to the facility on [DATE]. Review of the resident's (MONTH) Medication Administration Record [REDACTED] Novolog Flex Pen Solution Pen-injector 100 units (ML (insulin Aspart). Inject 10 units subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia, hold for Blood sugar (BS) less than 150. Order date 08/03/17. On 08/22/17 the order was changed to Novolog Flex pen Solution Pen-Injector 100 unit/ML (insulin Aspart). Inject 5 units subcutaneously before meals related to Type 2 Diabetes Mellitus with Hyperglycemia, hold for blood sugar less than 150. Novolog was administered on the following ten (10) dates and times when the resident's blood sugar (BS) was less than 150: --08/05/17, at 5:00 p.m., BS was 148. --08/07/17, at 7:00 a.m. BS was 122 --08/09/17, at 7:00 a.m. BS was 130 --08/13/17, at 7:00 p.m. BS 147 --08/14/17, at 7:00 a.m. BS was 127 --08/17/17, at 7:00 a.m. BS was 112 --08/19/17, at 11:00 a.m. BS was 146 --08/20/17, at 11:00 a.m. BS was 144 --08/23/17, at 7:00 a.m. BS was 124 --08/29/17, at 7:00 a.m. BS was 127 At 9:47 a.m. on 08/31/17, the DON, compared the recorded blood sugars to the MAR. The DON verified the insulin was administered on the above dates and times, when the insulin should have been held. The DON said a performance improvement plan was started on 07/07/17 to correct the above issue. She said, I thought the problem had been corrected but I guess not. On 08/16/17, the pharmacist completed a monthly medication regimen review and reported no irregularities. The resident's insulin was administered incorrectly on five (5) occasions before the monthly medication review. At 4:14 p.m. on 09/05/17, the DON verified the pharmacist failed to identify this irregularity during his 08/16/17 review of the resident's medications.",2020-09-01
137,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,463,D,0,1,QLZ111,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure one (1) of 40 residents had a functioning call light system. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 08/29/17 at 11:51 a.m. Resident #84's call light was observed not functioning. It did not light up above the resident's door when the button was pushed. Resident #84 did have the ability to use the call light. Nurse Aide #134 verified this light was not working. Resident #84's brief interview for mental status (BIMS) completed on the admission minimum data set ((MDS) dated [DATE] revealed the resident's BIMS score as 15. A score of 15 indicated the resident was cognitively intact.,2020-09-01
138,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,465,D,0,1,QLZ111,"Based on observation and staff interview the facility failed to ensure the heating and air conditioning unit in one (1) of 38 rooms observed during Stage 1 of the quality indicator survey (QIS) was in good repair. The heating/air condition unit in Room #409 had broken vents in the top of the unit. Room number: #409. Facility census: 180. Findings include: a) Room #409 On 08/29/17 at 2:39 p.m. an observation of the heat/air unit in Room #409 revealed the unit had broken vents in the top. The entire section of the top of the unit where the heat/air unit was missing. During an observation with Maintenance Supervisor #34, on 08/30/17 at 10:24 a.m., he agreed the unit needed replaced.",2020-09-01
139,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,497,D,0,1,QLZ111,"Based on staff interview, observation, and review of employee personnel records, the facility failed to ensure a performance review was completed every twelve (12) months for two (2) of five (5) nurse aides reviewed during the extended survey. Employee identifiers: #74 and #126. Facility census: 180. Findings include: a) Review of personnel files At 10:58 a.m. on 09/07/17, the Director of Nursing (DON) and the Human Resources Director, #183, confirmed Nurse Aides (NA's) #74 and #126 did not have a performance review completed within the past twelve (12) months.",2020-09-01
141,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,502,D,0,1,QLZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain a physician ordered laboratory test for Resident #235. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey. Resident Identifiers: #235. Facility Census: 180. Findings Include: a) Resident #235 A review of Resident #235's medical record at 9:24 a.m. on 09/06/17 found the following physician progress notes [REDACTED]. Plan: For Pneumonia- completed [MEDICATION NAME] 2 days ago. Cough and Congestion have improved. Will Continue [MEDICATION NAME] for 5 more days and monitor. EXG - NSR, [MEDICAL CONDITION] resolved at this time but will continue to monitor heart rate. Will Check CBC (complete blood count) and CMP in the AM. The Interim Director of Nursing (DON) shortly after this review was asked to provide the results of the CBC and CMP which should have been obtained on 06/23/17. At 11:46 a.m. on 09/06/17 the interim DON reported she did not have the requested lab results. She stated, there was never an order put in for it and they never obtained it.",2020-09-01
142,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2017-09-07,514,D,0,1,QLZ111,"Based on record review and staff interview, the facility failed to ensure the resident's medical record was correct in the area of Health Care Surrogate (HCS) and whom to notify when Resident #84 experienced a change which would require notification of the appropriate responsible party. The facility had conflicting contact information on Resident #84's face sheet concerning responsible party. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 Review of Resident #84's face sheet, on 09/06/17 at 9:00 a.m, found under section titled, Contacts , the residents daughter was listed as the first contact and it was indicated she was the Power of Attorney (POA) and his son was listed as secondary contact. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Additionally, the daughter is not his PO[NAME] Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided this surveyor with a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision make on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17 and Resident #84 does not have a power of attorney.",2020-09-01
146,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,584,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. Resident #9 had an order for [REDACTED]. Resident identifier: #9. Facility census: 182. Findings included: a) Resident #9 On 10/07/19 at 4:13 PM, during an observation of Resident #9's room, the fall mat located near the bathroom, was noted to have fluid underneath the entire length of the fall mat. Moreover, the fall mat located on the right side of Resident #9's bed had debris underneath the fall mat. The fall mat on the left side of Resident #9's bed had fluid underneath the fall mat, spanning the length of the mat. The floor underneath the fall mat was white, and discolored. On 10/07/19 at 4:15 PM, Employee #81, Unit Manger, entered Resident #9's room and observed the fluid underneath two fall mats and the debris underneath the third fall mat. Employee #81 stated that she would notify housekeeping. On 10/07/19 at 4:24 PM, the Director of Nursing (DON) and the District Director of Clinical Services were informed of the findings. On 10/09/19 at 2:06 PM, the findings were discussed with the Administrator and the DON and no further information was provided",2020-09-01
147,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,605,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all residents were free from chemical restraint for purposes of discipline or staff convenience for 2 out of 35 sampled residents. This failed practice had the potential to affect a limited number of residents. Identified Resident identifiers: #161, and #9. Facility census 182. Findings included: a) Resident #161 During a review of medical records for Resident #161 on 10/08/19 at 12:30 PM, revealed his care plan had the following intervention: --Resident #161 receives antipsychotic medication-- [MEDICATION NAME]-- for refusal of care/mood changes. This was initiated on 03/20/18. During an interview on 10/10/19 at 9:45 AM, Director of Nursing agreed, he should not be given a medication for refusal of care, and that it was his right to refuse showering/bathing. b) Resident #9 Review of the medical record revealed a current order, dated 08/05/19 for [MEDICATION NAME] 200 mg given at bedtime for refusal of care related to [MEDICAL CONDITION] disorder, recurrent, and unspecified. Review of the care plan found the resident refuses to wear his identification bracelet. The care plan also noted that the resident would refuse incontinent care. The care plan referenced the use of an anti-anxiety medication and said the resident refused care related to anxiety but the specific care refused was not documented. On 10/10/19 at 11:26 AM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided to indicated what type of care the resident refused, prior to the survey conclusion. There was no evidence provided to verify the resident refused any type of care.",2020-09-01
148,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,623,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to notify the Ombudsman when Residents #94, #119, and #95 were transferred to a local hospital. This was true for two (2) of three (3) residents reviewed for hospital transfers and one (1) random opportunity for discovery. Resident identifiers: #94, #119, and #95. Facility census 182. Findings included: a) Resident #94 Record review on 10/07/19 at 8:19 PM, revealed the resident was discharged to the hospital on [DATE] at 11:13 AM, due to abnormal labs. b) Resident #119 Record review on 10/07/19 at 8:19 PM, revealed the resident was discharged to the hospital on [DATE] at 6:45 PM, due to abnormal and critical lab work. c) Resident #95 Record review on 10/08/19 at 9:04 AM, revealed the resident was discharged to the hospital on [DATE] at 7:25 PM, per resident and family request. d) Interviews On 10/08/19 at 1:20 PM, the Administrator stated the Social Worker completes the notifications to the Ombudsman regarding facility-initiated discharges. During an interview on 10/08/19 at 1:21 PM, Employee #126, Social Services Manager, stated the facility sends the discharge notifications to the Ombudsman every time a resident leaves the facility. Employee #126 was asked to provide the Ombudsman notification for Resident #94, #119, and #95 when each resident was transferred to a local hospital. Employee #126 stated that the facility does not notify the Ombudsman when a resident is discharged to the hospital. The facility only notifies the Ombudsman when the resident discharges to home or is transferred to another facility. On 10/09/19 at 8:22 AM, the findings were discussed with the Administrator and the Director of Nursing (DON).",2020-09-01
149,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,625,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to provide the resident/resident representative notice of the bed hold policy when Resident #95 was transferred to a local hospital. This was true for one (1) of three (3) residents reviewed for hospital transfers. Resident identifier: #95. Facility census 182. Findings include: a) Resident #95 During a medical record review, on 10/08/19, it was discovered that Resident #95 was transferred to a local hospital on [DATE] at 7:25 PM. There was no evidence the resident or the residents representative received a copy of the bed hold policy at the time of transfer. In addition there was no documentation in the medical record of contacting the resident / resident representative regarding the bed hold policy. During a record review on 10/08/19 at 1:47 PM, a copy of the bed hold notice could not be located on Resident #95's chart on the unit or in the thinned medical record. On 10/08/19 at 3:57 PM, the chart was given to the Director of Nursing (DON) for review to see if the bed hold notice could be located. The DON was unable to locate the bed hold notice. During an interview with the DON on 10/08/19 at 4:11 PM, the DON stated that she could not find the transfer form with the stamp that indicated that the notice of bed hold policy was provided upon discharge. The findings were discussed with the DON and Administrator on 10/09/19 at 8:22 AM and no further information was provided.",2020-09-01
150,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,641,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure accurately completed assessment for Resident #151 reflecting urinary catheterization for 1 of 35 sampled residents. This practice had the potential to affect a limited number of residents. Resident identifiers: R#151 Facility census: 181. Findings included: a) Resident #151 Review of records, on 10/08/19 at 12:28 PM, revealed Resident (R#151) was admitted on [DATE]. Review of the 5-day minimum data set (MDS) with an assessment reference date (ARD) 09/17/19 revealed the MDS was marked indicating an indwelling catheter and intermittent catheterization. Review of orders revealed an order Straight Cath resident if greater than 300 ml (milliliter) residual leave catheter in and follow up with provider . Physician was notified R#151 had 500 ml of output when catheter was initially inserted, an order was given to leave as an indwelling catheter. According to the National Library of Medicine, 'intermittent catheterization' is the insertion and removal of a catheter several times a day to empty the bladder. This type of catheterization is used to drain urine from a bladder that is not emptying adequately. Intermittent catheters are only used at certain times and they are removed right after the urine is drained. On 10/09/19 at 09:54 AM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing MDSs, revealed R#151's 5-day MDS was in error. RCMD#165 verified R#151's 5-day MDS should only have been marked indwelling catheter. Indwelling catheter due to when intermittent catheterization was first attempted the resident had 500 cc of urine drained and the catheter was not removed but remained indwelling and was attached to a closed drainage system as ordered.",2020-09-01
151,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,657,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to revise care plans regarding falls, behaviors, and Total [MEDICATION NAME] Nutrition (TPN). This was true for two (2) out of thirty-five (35) resident's care plans reviewed. This failed practice had the potential to affect a limited number of residents. Resident identifiers: R#116 and R#94. Facility census: 181. Findings included: a) Resident (R#116) 1. Falls Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. The resident did not have any behaviors during the 7 day look back period. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily. The resident has history of falls and currently participates in occupational therapy services. Review of records, on 10/08/19 at 04:23 PM, revealed the resident had an unwitnessed fall in the courtyard on 08/19/19. The resident fell out of his wheelchair bending forward to retrieve an item off the ground. The resident suffered an abrasion above the right eye on 08/19/19. Approximately a month later, on 09/12/19, the resident again fell out of wheelchair in courtyard reaching forward to pick something up off the ground, causing an abrasion to the back of his left hand's knuckle area. Both times the injured areas were appropriately cleaned and treated; vital signs and neuro checks were completed; and proper notifications were made. On 10/09/19 at 10:29 AM, an interview with Registered Nurse (RN#96) revealed at every morning meeting a post fall review from the day before is completed. If a fall is unwitnessed or if the resident hits their head, then a physical therapy referral is made for an evaluation and neuro checks are done for 3 days after the fall. Records showed an interdisciplinary team (IDT) meeting note dated 8/20/19, was held to discuss the fall occurring on 8/19/19. The note included the following Intervention: hey therapy (physical therapy referral), neuro-checks, skin treatment/first aid, provider eval with an order for [REDACTED]. Review of R#116's care plan, on 10/09/19 at 10:56 AM, revealed only one revision concerning the fall was made to the care plan after the 1st fall out of the wheelchair. The revision was made on 08/22/19. The revision stated, to have reacher at bedside. A reacher is a reaching extension tool used for grasping items in hard-to-reach places without having to bend over. An interview with RN#96, on 10/09/19 at 11:08 AM, revealed RN#96 confirmed the care plan was not revised appropriately. RN#96 said, The resident did not fall out of the bed, but both times out of his wheelchair, reaching for things on the ground. The care plan should not have limited the reacher to be only at bedside, so it would be available when or where he needed it. On 10/09/19 at 01:12 PM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing resident's MDS and care plans, revealed R#116 care plan was not revised as it should have been, to address the issue of the resident falling out of his wheel chair due to reaching for items on the ground. Also, the care plan was not revised with any new or different interventions when the resident fell out of the wheelchair the second time while reaching for items on the ground. 2. Resident (R#116) Behavioral needs Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. The resident did not have any behaviors during the 7 day look back period. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily and was admitted to the facility on [DATE]. Review of records showed an order for [REDACTED].#116 refused care. Review of the care plan revealed a care area receives antipsychotic medication [MEDICATION NAME] d/t refusal of care r/t [MEDICAL CONDITION]. The care plan did not reveal a care focus area concerning refusing care or any other interventions to address refusing care, such as encouraging, prompting, cueing, or redirecting. Review of the (MONTH) and (MONTH) 2019 medication administration records (MARs) revealed Observation: Antipsychotic Med: Observe for behavior: refusal of care & doc. #of episodes (and document number of episodes). Observe for side effects: (listed side effects) Document 'Y' if resident is free of side effects. 'N' if the resident is not free of side effects. If 'N' document SE (side effects)in the progress notes every shift. Neither month documented the resident refused care. The MAR indicated [REDACTED]. Observations made by Surveyor # and Surveyor # during the initial dining tour revealed R#116 eating his lunch with his face down in his plate using his mouth to eat out of his plate without the use of any eating utensils or his fingers. On 10/09/19 at 10: 44 AM, an interview with Registered Nurse (RN#96) revealed R#116 has behaviors and has a [DIAGNOSES REDACTED].#96 described the resident has verbal outburst; is easily agitated; and has unusual mannerisms like the way he eats with his mouth in his plate. When asked where staff monitors and documents these behaviors, RN#96 said on the MAR (medication administration record) with the [MEDICAL CONDITION] medication. RN#96 denied there was any other behavior monitoring sheet to track identified behaviors other than the MAR. On 10/09/19 at 12:53 PM resident was observed in dining room without participating in lunch. The resident stated he was going to wait until dinner and did not want lunch now. Nursing Assistant Mentor (NA#54) was monitoring the dining room. An interview with Nursing Assistant Mentor (NA#54), who helps train newly hired NAs, revealed she often observes R#116 using unusual eating habits at meals. NA#54 stated she has worked at the facility a few years prior to R#116 being admitted to the facility. NA#54 said since R#116 has been at the facility, she has often seen R#116 placing his face in his plate when eating, she said, He usually does. NA#54 stated, It's like, he likes to sleep in it. If anyone tries to correct him, he will go off. This surveyor asked if R#116 had ever fallen asleep in his food, NA#54 denied ever seeing him sleeping in his plate, but said, It just looks like it sometimes. When asked, How would a newly employeed NA know about his specific behaviors and how they should handle them? NA#54 said grinning, If they try to correct him, they will get an ear full. They should follow the Kardex, it comes from the care plan. This surveyor asked, Is his eating behavior and other behaviors addressed in the care plan? NA#54 replied, I would like to think so. It should be addressed in it. When asked what NAs are trained to do if the resident has an outburst or is agitated, NA#54 replied, They should redirect him and use a calming voice. They should just follow the care plan. On 10/09/19 at 01:12 PM, an interview and review of records with Resident Care Management Director (RCMD#165) responsible for developing MDSs and care plans, revealed R#116 care plan was not revised to monitor or address his unusual eating habit or different behaviors unique to R#116. Review of care plan revealed a focus area, (Resident's name) is verbally aggressive at times and will curse and yell. The 3 interventions noted in the care plan were Administer medications as ordered. Observe/document for side effects and effectiveness.; Give the resident as many choices as possible about care and activities.; and Psychiatric/Psychogeriatric consult as indicated. There was no guidance to staff on individualized specific strategies that R#116 responds to or works well for the resident. RCMD#165 agreed the care plan needed to be revised to include more individualized and person-centered strategies to address the resident's specific behaviors. b) Resident #94 During a record review, Resident #94's care plan noted the resident received total paranteral nutrition (TPN). TPN is an intravenous (IV) fluid that attempts to provide all the body's need for nutrition without using the gastrointestinal (GI) tract. Review of Residents #94's care plan found a focus/problem: [NAME] will self disconnect TPN from catheter. The goal associated with this problem: [NAME] will have fewer episodes of listed behaviors by review date. Interventions included: -- Allow choices within individual's decision making abilities. -- Anticipate and meet the resident's needs. Focus/problem: [NAME] has a potential fluid deficit r/t (related to) need for TPN. The goal associated with this problem: [NAME] will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions included: -- Ensure the resident has access to fluids of choice whenever possible. During an interview on 10/09/19 at 10:48 AM, Employee #165, Care Management Minimum Data Set (MDS) Director, confirmed the resident no longers receives TPN. Employee #165 stated that the care plan had not been updated since the TPN had been discontinued. On 10/09/19 at 11:06 AM, the findings were discussed with the Administrator, the Director of Nursing (DON), and the District Director of Clinical Services.",2020-09-01
153,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,689,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. This was true for 1 of 5 residents reviewed for care area of accidents. This practice had the potential to affect a limited number of residents. Resident identifiers: R#116. Facility census: 181 Findings included: a) Resident #116 Review of resident (R#116)'s recent annual minimum data set (MDS) with an assessment reference date (ARD) 09/06/19, on 10/08/19 at 03:53 PM, revealed the following. The resident's Brief Interview for Mental Status (BIMS) score is 3 indicating the resident has a severe cognitive impairment. R#116 needs extensive assistance with all activities of daily living and has range of motion impairments on both sides of his upper and lower extremities. The resident has an indwelling catheter and is continent of bowels. Some pertinent [DIAGNOSES REDACTED]. The resident takes Antipsychotic medication daily. The resident has history of falls and currently participates in occupational therapy services. Review of records, on 10/08/19 at 04:23 PM, revealed the resident had an unwitnessed fall in the courtyard on 08/19/19. The resident fell out of his wheelchair bending forward to retrieve an item off the ground. The resident suffered an abrasion above the right eye on 08/19/19. Approximately a month later, on 09/12/19, the resident again fell out of wheelchair in courtyard reaching forward to pick something up off the ground, causing an abrasion to the back of his left hand's knuckle area. On 10/09/19 at 10:29 AM, an interview with Registered Nurse (RN#96) revealed at every morning meeting a post fall review from the day before is completed. If a fall is unwitnessed or if the resident hits their head, then a physical therapy referral is made for an evaluation and neuro checks are done for 3 days after the fall. Records showed an interdisciplinary team (IDT) meeting note dated 8/20/19, was held to discuss the fall occurring on 8/19/19. The note included the following Intervention: hey therapy (physical therapy referral), neuro-checks, skin treatment/first aid, provider eval with an order for [REDACTED]. Review of records showed a revision was made to R#116's care plan after the first fall but no revisions were made the second time the resident had a similar fall. R#116's care plan, on 10/09/19 at 10:56 AM, revealed the facility's intervention was to provide the resident with a reacher at bedside. A reacher is a reaching extension tool used for grasping items in hard-to-reach places without having to bend over. This intervention would be helpful to the resident with picking up items without the resident stretching out and toppling forward, however the resident was not toppling forward out of his bed, but out of his wheelchair. There was no evidence the facility assessed or reevaluated the effectiveness of the intervention of a reacher bedside after the resident had the second similar fall. There was no evidence the facility monitored or encouraged the resident to use the reacher. An interview with RN#96, on 10/09/19 at 11:08 AM, revealed RN#96 confirmed there was no evidence the facility assessed or reevaluated the effectiveness of the intervention of a reacher bedside. RN#96 said, The resident did not fall out of the bed, but both times out of his wheelchair, reaching for things on the ground. RN#96 reviewed records and confirmed there was no evidence the facility monitored or encouraged the resident to use the reacher, nor were there any other different interventions put into place after the second fall.",2020-09-01
154,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,698,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Bsed on record review and staff interview, the facility failed to ensure the [MEDICAL TREATMENT] Communication Record post [MEDICAL TREATMENT] section was completed for Resident #151 each time he went to [MEDICAL TREATMENT]. The facility failed to follow up with the [MEDICAL TREATMENT] center regarding pre and post weights, and failed to follow the medication recommendations from the [MEDICAL TREATMENT] center. This practice had the potential to affect a limited number of residents. Resident identifiers: R#151. Facility census: 181 Findings included: a) Resident #151 Resident (R#151) was transferred and admitted to the facility on [DATE], after the resident had a failed kidney transplant. Some pertinent [DIAGNOSES REDACTED]. The resident was admitted to current [MEDICAL TREATMENT] services on 09/04/19. Interview with Licensed Practical Nurse (LPN#84), on 10/09/19 at 01:55 PM, revealed the facility maintains a communication record with the [MEDICAL TREATMENT] center in a [MEDICAL TREATMENT] communication book. The facility keeps forms in the book that requires pertinent information to be recorded by [MEDICAL TREATMENT] staff and facility nursing staff. Review of the resident's [MEDICAL TREATMENT] communications book with LPN#84 revealed the post [MEDICAL TREATMENT] section for R#151 was not completed by [MEDICAL TREATMENT] staff each time R#151 went to [MEDICAL TREATMENT]. The facility staff failed to follow up and obtain the pre and post weights from the [MEDICAL TREATMENT] center on 09/06/19, and post weights on 09/11/19. The facility staff failed to follow up or discontinue medications the [MEDICAL TREATMENT] center identified on 09/06/19 and requested the resident stop taking. ` The [MEDICAL TREATMENT] communication sheet dated 09/06/19 revealed no pre or post [MEDICAL TREATMENT] weights were recorded. In the 'Recommendation/Follow-up' section of the communication sheet dated 09/06/19 where orders from the [MEDICAL TREATMENT] center are written, the [MEDICAL TREATMENT] center specified Stop Calcium Acetate, Stop [MEDICATION NAME], and Please continue [MEDICATION NAME]. Review of records showed, since R#151's admission to the facility, the resident was not taking [MEDICATION NAME] or [MEDICATION NAME]. The resident was taking [MEDICATION NAME] suspension related to kidney transplant status, which is a [MEDICATION NAME] for organ rejection. The resident was taking Calcium Acetate 1334 mg daily and continued to take it until surveyor intervention. LPN#84 confirmed staff should have contacted the [MEDICAL TREATMENT] center and obtained weights, followed the [MEDICAL TREATMENT] center recommendations, and clarified the resident's medications. Review of orders revealed Calcium Acetate Capsule 667 mg (milligrams). Give 2 capsule by mouth with meals every Mon, Wed, Fri related to End Stage [MEDICAL CONDITION] (Time on [MEDICAL TREATMENT] days) 2 capsules to equal 1334 mg; and Calcium Acetate Capsule 667 mg. Give 2 capsule by mouth with meals every Tue, Thu, Sat, Sun related to End Stage [MEDICAL CONDITION] (Timed for non-[MEDICAL TREATMENT] days) 2 capsules to equal 1334 mg. Review of R#151's Medication Administration Record [REDACTED]. The resident received Calcium Acetate (a base binder) for thirty-three (33) more days after it should have been discontinued. On 10/10/19 at 11:53 AM, a phone interview with the [MEDICAL TREATMENT] Center Clinic Manager revealed R#151 was admitted to [MEDICAL TREATMENT] service on 09/04/19 and labs were taken at that time showing the resident's calcium was high and phosphorus level was low. Calcium and phosphorus are essential minerals found in the bone, blood and soft tissue of the body and have a role in numerous body functions. The [MEDICAL TREATMENT] Center Clinic Manager stated their doctor does not like to use a calcium base binder (binds to phosphorus to remove phosphorus from the body) and since the resident's phosphorus was already low. The [MEDICAL TREATMENT] Center Clinic Manager voiced concern that by R#151 continuing to take the binder it could make R#151's phosphorus levels even lower. The [MEDICAL TREATMENT] Center Clinic Manager said the facility had contacted them yesterday and notified them the resident had continued to receive the Calcium Acetate, so labs were drawn, and they were awaiting the results. (Surveyor was notified by the [MEDICAL TREATMENT] Center Clinic Manager the last lab results were within normal limits.)",2020-09-01
160,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2019-10-10,760,D,0,1,RPKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #139 was free from significant medication error. This failed practice had the potential to affect a limited number of residents residing at the facility. Resident identifier: #139. Facility census: 182. Findings included: a) Resident #139 Medical record review for Resident #139, revealed he was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident is unresponsive and requires a gastrostomy feeding tube for all nutritional needs and [MEDICAL CONDITION] in place secondary to [MEDICAL CONDITION]. Resident #139 is to receive nothing by mouth (po) secondary to dysphagia and aspiration. Further review of Resident #139's medical records found an order for [REDACTED]. Review of the Controlled Medication Utilization Record for 09/29/19 at 1:00 am through 10/01/19 at 5:00 pm, found Resident #139 received [MEDICATION NAME] 20 mg per 1ml; which equals 20 mgs by mouth (po) every hour. Resident #139 received fifty-one (51) doses of 20mgs of [MEDICATION NAME] instead of the 4mgs and the resident received the [MEDICATION NAME] po instead of SL as ordered. Interview with attending physician on 10/09/19 at 5:00 pm revealed the [MEDICATION NAME] should be given SL not po and the dosage should be 20mg per 1 ml - give 0.25 ml which equals 4 mg every hour as needed for pain. Clarification orders was noted by the attending physician to give SL not po due to aspiration. Interview on 10/10/19 at 10:00 am with the Director of Nursing (DON), found the resident received the wrong dosage of [MEDICATION NAME] on the above dates. Additionally, she confirmed the [MEDICATION NAME] was to be given SL but was documented it was administered po.",2020-09-01
166,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2017-06-20,225,D,1,0,HCKF11,"> Based on review of reported allegations, staff interview, family interview, and policy review, the facility failed to report timely and/or investigate an allegation of abuse for one (1) of five (5) allegations reviewed. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., said the LPN's role was to tell the director of nursing (DON), and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. NA#79, interviewed via telephone on 06/20/17 at 12:10 p.m. verbalized she usually worked dayshift, but had worked over that day. The nurse aide said the resident was toileted on the bedside commode and when done was put in the wheelchair (w/c). The NA said the resident asked what time dinner was served and was told about 5:30 p.m. NA#79 stated Resident #1 asked to be put back to bed because it was only 4:00 p.m. The nurse aide alleged NA#22 told the resident they were not playing these f-----g games and don't (do not) care what your daughter says. You are not being babied. NA#79 verbalized she notified LPN #63, who was passing medications. The LPN then ensured the resident was placed back in bed. NA #79 verbalized during the interview, that she went back into the room and apologized for what had happened. The nurse aide said Resident #1 did not exhibit behaviors, was a very sweet person. The NA said the resident's routine was to toilet and lay down. The resident would get up fifteen (15) minutes before meals. The NA voiced she thought the family member had talked to the facility about it. Resident #1, interviewed on 06/20/17 at about 12:30 p.m. ,was in bed, lying on left side, awake and alert. The resident verbalized that staff sometimes puts her down too hard when putting her back in bed. Resident #1 said when she had a concern she told her daughter and the daughter talked to the facility. Family Member (FM) #1, interviewed at 12:48 p.m., verbalized she had not made a formal complaint because her mother was confused as to dates and times. FM #1 said the resident informed her that someone said, Well, that was totally unnecessary to another staff person when they were providing care. The family member said she informed RN #73 last week about Resident #1's concerns, but did not file a formal complaint with the facility, because she did not know if it was true. The minimum data set (MDS) with an assessment reference date (ARD) of 04/28/17 indicated Resident #1 had a brief interview for mental status (BIMS) score of 08 which indicated moderate cognitive impairment. During an interview with the assistant administrator, at 1:10 p.m., she voiced the LPN should have started the investigative process, filled out forms, notified the charge nurse, and called the social worker so there was no lag time. The administrator verbalized that she, the director of nursing, and the social worker were out of the building last week. When asked who was in charge, she said Administrator #10, whatever charge nurse, and RN #71. RN #71, interviewed at 1:17 p.m., voiced FM #1 had spoken to her on Monday (06/19/17) about an incident that happened concerning one of the aides, but did not know whether or not it was truthful. The nurse said the FM did not say what happened. The RN voiced everything was brought to the attention of the DON on Monday morning, around 11:00 a.m., but she already knew about it. The DON, entered the office shared with RN #71 at 1:18 p.m. she said NA #79 told her yesterday morning (06/19/17) , and reported the NA thought she had told the med (medication) cart nurse. The DON said the LPN did not identify it as an allegation of abuse, and it was still being investigated. The abuse, neglect and exploitation policy, with an implementation date of 11/15/16, was reviewed on 06/20/17 at 11:47 a.m. The policy defined verbal abuse as follows: the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The definition of abuse was noted as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Number seven (7) of the abuse policy required when suspicion or reports of abuse, neglect or exploitation or reports of abuse occur, an investigation is immediately warranted. Once the resident is cared for and the initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: Interview the involved resident, if possible, and if the resident is cognitively impaired interview several times to compare responses. Other interviews may include family members, roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. During a discussion with the administrator, on 06/20/17 at 1:45 p.m., she verbalized acknowledgement that anyone could have reported the allegation of abuse, including the nurse aide.",2020-09-01
169,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-06-26,656,D,1,0,UZ4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to develop person-centered, individualized care plan with measurable goals and appropriate interventions for one (1) of four (4) sampled residents. Resident identifier: #4. Facility census: 53. Findings included: a) Resident #4 The medical record was reviewed on 06/25/19 and continued through 06/26/19. Resident #4 was an elderly resident with [DIAGNOSES REDACTED]. On 04/24/19 a nurse's note conveyed that a venous stasis ulcer was beginning to open on the top of the right foot. Nursing notified the physician. The physician gave orders to cleanse the venous stasis ulcer to the top of the right foot with normal saline, pat dry, apply Silversorb gel to the wound bed, and cover with a dry dressing every day shift and as needed. A nurse's note dated 04/30/19 described the wound to the top of the right foot as full thickness tissue loss, 80% black tissue and 20% slough. The next nurse's note related to the stasis ulcer to the top of the right foot occurred on 05/18/19, when the physician gave new orders for [MEDICATION NAME] (antibiotic) 875 milligram (mg)/125 milligrams (mg) orally twice daily for seven (7) days for wound. A physician's hand-written progress note dated 05/18/19 assessed that the right foot has open area, and skin surrounding it has [DIAGNOSES REDACTED] and some purulent drainage. The diagnostic impression was [MEDICAL CONDITION] of the right foot. The plan was to administer [MEDICATION NAME] 875 mg. twice daily for a week. Review of the weekly wound observation tool dated 06/07/19 found the nurse described the stasis ulcer to the top of the right foot as 100% black, scab-like tissue with a small amount of serosanguinous drainage. The wound measured 75 millimeters long by 22 millimeters wide. A weekly wound observation tool dated 06/21/19 assessed that the stasis ulcer was 100% black, scab-like tissue with a small amount of serosanguinous drainage. Measurements were 70 millimeters long by 30 millimeters wide. Per a nurse's note dated 06/22/19 at 3:11 PM, a nursing assistant (NA) called the nurse to the room. The former director of nursing (DON) was present and was assessing the resident's right foot. The right foot was noted to be swollen and red with two (2) open areas between toes with one (1) white maggot visible. The DON notified the resident's physician, who in turn gave orders to transfer her to the hospital for evaluation. The family was at the bedside at the time. On 06/25/19 at 4:45 PM the interim DON provided a copy of the resident's care plan. Review of this care plan found there were no goals for the stasis ulcer, and no specific interventions for the stasis ulcer. - Page twelve (12) of the care plan had a focus that she was on diuretic therapy related to [MEDICAL CONDITION] from venous stasis and recurring stasis ulcer/[MEDICAL CONDITION]. The goal stated she would be free of any discomfort or adverse side effects of diuretic therapy. - Page thirteen (13) of the care plan had a focus that the resident was on antibiotic therapy ([MEDICATION NAME]) related to infection (venous stasis of right lower leg/foot). The goal stated the following: 1. The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Interventions were the following: 1. Administer antibiotic medications as ordered by the physician, and monitor/document side effects and effectiveness every shift 2. Monitor/document/report as needed adverse reaction to the antibiotic therapy 3. Monitor/document/report as needed signs and symptoms of secondary infection related to antibiotic therapy such as oral thrush, persistent diarrhea, and vaginitis/itchy perineum or discharge 4. Report pertinent lab test results to the physician. An interview was conducted with the administrator and the DON on 06/25/19 at 5:15 PM. It was discussed that there were no measurable goals or specific intervention in the resident's care plan related to the stasis ulcer to the top of the right foot. They listened and expressed understanding. No further information was provided prior to exit on 06/26/19.",2020-09-01
170,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,656,D,0,1,5N8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record reviews and staff interviews, the facility failed to develop a person-centered comprehensive care plan for two (2) of twenty one (21) care plans reviewed during the Long Term Care Survey Process (LTCSP). The care plan for R2 was not developed to address her end-of-life wishes and the care plan for R1 did not address the use of an arm sling. Resident identifiers: R1 and R2. Facility census: 53. Findings included: a) R2 During a medical record review on 07/10/19 revealed the care plan had not been developed to reflect R2's wishes for her end-of-life care. In an interview on 07/10/`19 at 9:35 AM with the Nursing Home Administrator verified, the care plan did not address the end-of-life wishes for R2. b) R1 During an interview and observation on 07/08/19 at 12:30 PM, R1 reported she was wearing an arm sling because she had broken her arm and dislocated her shoulder during a stay at another facility. Random observations during the survey revealed R #1's continued use of the right arm sling. Review of the medical record on 07/09/19, revealed an orthopedic note dated 07/18/18 with a [DIAGNOSES REDACTED]. The treatment included a right arm sling. The Occupational Therapy Discharge Note dated 07/30/2018 to 09/25/18, states under the section titled Equipment issued .pt (patient) continues to wear sling per her preference. The current care plan with a revision date of 07/09/19, is silent in regards to R1's continued use of the right arm sling. During an interview on 07/09/19 at 11:00 AM, Licensed Practical Nurse (LPN) #39 confirmed R1's care plan does not identify the arm fracture or address the sling she continues to wear for comfort.",2020-09-01
171,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,657,D,0,1,5N8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan had been revised to reflect the discontinued use of a diabetic medication for R45. This was found to be true for one (1) of twenty one (21) care plans reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: R45 Facility census: 53. Findings included: a) R45 During a medical record review on 07/09/19 revealed the care plan for R2 had not been revised to reflect the discontinuation of the diabetic medication [MEDICATION NAME]. In an interview on 07/09/19 at 2:11 PM with the Director of Nursing, verified the care plan for R45 had not been revised to indicate the diabetic medication [MEDICATION NAME] had been discontinued on 03/06/19.",2020-09-01
172,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,684,D,0,1,5N8D11,"Based on observation, medical record review and staff interview, the facility failed to ensure R52 received treatment and care in accordance with professional standards of practice. During a random observation it was discovered the oxygen concentrator was delivering air flow to R52 at a rate of four (4) liters and not the prescribed two (2)-three (3) liters. This was true for one (1) of two (2) residents reviewed for Respiratory Care Services during the Long Term Care Survey Process (LTCSP). Resident identifier: R52. Facility census: 53. Findings included: a) R52 During an observation on 07/09/19 at 3:50 PM for R52, it was discovered the oxygen concentrator was delivering air flow to R52 at a rate of four (4) liters and not the ordered 2-3 liters via nasal cannula for shortness of breath. In an interview on 07/09/19 at 3:55 PM with E60 Licensed Practical Nurse (LPN) verified the oxygen concentrator for R52 was providing an air flow of four (4) liters and not the ordered two (2)-three (3) liters.",2020-09-01
173,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,689,D,0,1,5N8D11,"Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. A bottle of shampoo/body wash was accessible to residents in the unsecured community bathroom. This practice had the potential to affect more than a limited number of residents. Facility census: 53. Findings include:d a) Observations During initial tour observation of the middle of the facility hallway by activities room on 07/08/19 at 10:35 AM, discovered the community bathroom door open and unlocked. An eye wash station is located inside the bathroom and a 12 ounce bottle of Soothe and Cool Shampoo and Body Wash was found sitting in the basin of the eye wash station. The label stated, External use only. Avoid contact with eyes. b) Interview Immediately following the observation, Employee #69 walked into the open door of the bathroom and removed the bottle of the shampoo/body wash from the basin of the eye wash station. Upon inquiry she stated, No this bottle does not belong in the bath area or the eye wash station. Employee #69 agreed it is an accident hazard due to being accessible to residents.",2020-09-01
174,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,695,D,0,1,5N8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to provide respiratory care services, consistent with professional standards of practice. This was true for one (1) of two (2) residents reviewed for respiratory services. During an observation it was discovered R52 was receiving her oxygen air flow at four 4 litters and not the ordered two (2)-three (3) liters. Resident identifier: R52. Facility census: 53. Findings included: a) R52 During a medical record review on 07/09/19, revealed the physician's orders [REDACTED]. An observation on 07/09/19 at 3:50 PM, it was discovered the oxygen concentrator for R52 had an air flow set on four (4) liters. An observation by E60, licensed practical nurse (LPN) verified the oxygen concentrator for R52 was providing an air flow of four (4) liters and not the ordered two (2) to three (3) liters as per orders.",2020-09-01
179,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2019-07-10,842,D,0,1,5N8D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure care and treatment was being provided in accordance with professional standards. This was true for two (2) of twenty- one (21) residents physician's orders [REDACTED]. R14 was not receiving oxygen therapy and still had an order for [REDACTED]. Facility census: 53. Findings include a) R14 During a medical record review on 07/10/19 revealed physician's orders [REDACTED]. In an interview with the Director of Nursing (DON) on 07/10/19 at 8:28 AM, verified the order for oxygen therapy should have been discontinued for R14 since she was no longer receiving oxygen. b) R52 During a medical record review on 07/09/19, revealed the physician's orders [REDACTED]. This order was not specific as to the correct amount of oxygen air flow R52 was to receive. In an interview with the Director of Nursing (DON) on 07/10/19 at 8:28 AM, verified the order for R52 was non-specific as to the correct amount of oxygen 2-3L she was to receive. For staff having to decide what air flow to provide 2-3L would be a decision outside their scope of practice.",2020-09-01
181,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,550,D,0,1,DL7D11,"Based on random observation, staff interviews and policy review, the facility failed to promote care for residents in a manner that maintained or enhanced dignity. The staff entered a resident's room without knocking, identifying themselves, or obtaining permission. This practice had the potential to affect a minimal number of residents. Resident identifiers: #24 and #31. Facility census 52. Findings included: a) Resident #24 and #31 During an observation of a resident room, on 09/24/18 at 11:30 AM, revealed Nurse Aide (NA) #40 walked into the room without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. NA #40 walked over to Resident #24's bed and stated, It is time to go to the bathroom. NA #40, turned around and left the room. A few minutes later NA#40 returned to room with NA #17 without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. The NA's walked over to Resident #24's bed. NA #17 went around to the far side of the bed. NA #40 was on the opposite side of the bed closest to the Resident in the A - bed and the door. NA#40 reached up and pulled down Resident #24's bed covers exposing the resident in an adult brief to her roommate with the door to the resident's room wide open for anyone to view inside. In an interview on 09/24/18 at 11:32 AM, NA #40 and #17, revealed the NA's forgot to knock on the residents door, identifying themselves and ask for permission prior to enter the room. The NA's also agreed they should have closed the entrance door to the room and pulled the curtain between the residents prior to pulling down Resident #24's bed covers. An interview on 09/24/18 at 12:00 PM, with the Assistant Administrator #13, she was informed of the observation above and she stated, I will address this matter. A review of the facility policy, on 09/27/18 at 2:00 PM, titled Promoting/Maintaining Resident Dignity with a revision date of 08/30/18, stated, Maintain Privacy. Staff shall knock on doors and properly announce themselves before entering.",2020-09-01
182,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,583,D,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, staff interview and policy review, the facility failed to provide privacy for a resident during personal care. Staff failed to pull the curtain while performing personal care and close the door to the resident room. This practice had the potential to affect a minimal number of residents. Resident identifier: #24. Facility census 52. Findings included: a) Resident #24 During an observation of room [ROOM NUMBER], on 09/24/18 at 11:30 AM revealed Nurse Aide (NA) #40, walked into the room without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. NA #40 walked over to Resident #24's bed, in which she resides in the b bed, and stated, It is time to go to the bathroom. NA #40, turned around and left the room. A few minutes later NA#40 returned to room with NA #17 without knocking, identifying themselves, and asking for permission to enter Resident #24 and #31's room. The NA's walked over to Resident #24's bed. NA #17 went around to the far side of the bed. NA #40 was on the opposite side of the bed closes to the Resident in the A - bed and the door. NA#40 reached up and pulled down Resident #24's bed covers exposing the resident in an adult brief to her roommate with the door to the resident's room wide open for anyone to view inside. In an interview on 09/24/18 at 11:32 AM, NA #40 and #17, revealed the NA's forgot to knock on the residents door, identifying themselves and ask for permission prior to enter the room. The NA's also agreed they should have closed the entrance door to the room and pulled the curtain between the residents prior to pulling down Resident #24's bed covers. An interview on 09/24/18 at 12:00 PM, with the Assistant Administrator #13, she was informed of the observation above and she stated, I will address this matter. A review of the facility policy, on 09/27/18 at 2:10 PM, titled Resident Right to Privacy During Care with a revision date of 08/30/18, stated, Privacy curtains are to be pulled during direct patient care. The facility's policy stated that additionally the staff will maintain privacy by knocking on doors and properly announcing themselves before entering resident rooms.",2020-09-01
183,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,761,D,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure all multi-dose vials of insulin were dated when initially opened for used and needle-punctured. According to manufacturer's guidelines, [MEDICATION NAME]left in a multi-dose vial beyond twenty-eight (28) days of opening must be discarded. By not dating the multi-dose vial when initially opened, nursing staff had no way of knowing when to discard the vial. This practice had the potential to negatively impact the safety and/or potency of the insulin. This was evident for one (1) of ten (10) opened and used multi-dose vials of insulin observed. Resident identifier: #26. Facility census: 52. Findings include: a) Resident #26 Opened and used (needle punctured) multi-dose vials of insulin were observed on 09/27/18 at 10:53 AM. An opened and needle punctured vial of [MEDICATION NAME]for this resident contained no date to indicate when it had initially been opened for use. The label on the vial indicated pharmacy filled that prescription on 09/13/18. Licensed nurse employee #25 (E#25) was present at this time. She said staff should have dated this vial when initially opened to ensure that staff disposed of the vial twenty-eight (28) days after it was first opened for use. She said the [MEDICATION NAME]is used as sliding scale coverage for this resident's blood glucose checks per the glucometer. On 09/27/18 at 11:10 AM the director of nursing (DON) provided a copy of their policy titled Labeling of Medications and Biologicals with revision date of 08/30/18. Page two (2) and item number eight (8) of this policy stated All opened or accessed vials should be discarded within twenty-eight (28) days unless the manufacturer specified a different (shorter or longer) date for that opened vial. An interview was conducted with the administrator and assistant administrator on 09/27/18 at 1:15 PM. No further information was provided prior to exit.",2020-09-01
184,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2018-09-27,842,D,0,1,DL7D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , medical record review, and staff interview, the facility failed to ensure accurate medical transcription and documentation of a physician's orders [REDACTED]. A nurse wrote a physician's orders [REDACTED]. This order was transcribed onto the medication administration record at 2% strength. Nurses documented twelve (12) times they administered a 2% strength dose. However, pharmacy provided this prescription at 0.5% strength. Per a nursing drug handbook information, this ophthalmic ointment is only available at 0.5% strength. This was evident for one (1) of four (4) residents observed during medication pass out of thirty-four (34) medication administration observations. Resident identifier: #50. Facility census: 52. Findings included: a) Resident #50 During a medication administration observation on 09/26/18 at 9:10 AM, licensed nurse employee #26 (E#26) administered [MEDICATION NAME] 0.5% ophthalmic ointment to this resident's right eye. Observation of the electronic medical record found directive to administer [MEDICATION NAME] 2% ointment to the right eye. Review of the hard copy medical record revealed a hand-written physician's verbal order which was written by a nurse on 09/18/18 at 3:00 PM. This order directed to instill [MEDICATION NAME] ointment 2% topically to the right eye twice daily for seven (7) days related to irritation, redness, swelling. Review of the facility's Nursing (YEAR) drug handbook which was located at the nurses' station, found that [MEDICATION NAME] ophthalmic ointment is only available at the 0.5% strength. An interview was conducted with the assistant administrator on 09/26/18 at 9:15 AM regarding this scenario. She said this was a transcription error. The medication administration record (MAR) was reviewed on 09/26/18. The MAR contained a typed order to administer [MEDICATION NAME] ointment 2% to the right eye topically twice daily for seven (7) days. Nursing staff initialed on the electronic MAR twelve (12) times that they administered [MEDICATION NAME] 2% ointment to the right eye (including 09/26/18 for the 9:00 AM dose). An interview was conducted with the administrator and the assistant administrator on 09/27/18 at 1:15 PM where it was discussed that nursing on twelve (12) occasions documented on the MAR that they instilled [MEDICATION NAME] ointment 2%, although the pharmacy supplied [MEDICATION NAME] ophthalmic ointment 0.5%. They acknowledged their understanding. No further information was provided prior to exit.",2020-09-01
192,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,578,D,0,1,M7ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure all elements of the advance directive were completed for three (3) of 14 residents reviewed during the long-term care survey process. Facility identifiers: #1, #6, #27. Facility census: 39. Findings included: a) Resident #1 Review of Resident #1's West Virginia Physician order [REDACTED]. No length of time had been entered into the space provided on the form. During an interview on 04/09/19 at 1:30 PM, Social Worker #4 agreed Resident #1's POST form did not specify the length of time for the IV fluids trial period. On 4/9/2019 at 2:25 PM, a progress note was written which stated, This DSS (Director of Social Services) and administrator spoke with resident's HCS (Health Care Surrogate) (name of health care surrogate) this date regarding resident's POST form. This DSS asked for clarification of a defined trial period of IV fluids and HCS stated that 1 month would be ideal. This DSS and administrator assured HCS that this would be written in and if the HCS would ever like to change it this can be done. No concerns noted at this time. Will continue to monitor and report any new changes. b) Resident #6 Review of Resident #6's West Virginia Physician order [REDACTED]. The defined trial period was not stated. The POST form did not include an area on the form to indicate the defined trial period. The POST form was dated 05/15/2006 and had been reviewed on 09/26/17 according to the form. During an interview on 04/09/19 at 1:30 PM, Social Worker #4 agreed Resident #6's POST form did not specify the defined trial period for IV fluids or feeding tube. Social Worker #4 stated this POST form was an old form. She stated Resident #4's Health Care Surrogate would be contacted to clarify the interventions and complete a new form. On 04/11/19 at 9:46 AM, Social Worker #4 stated an updated POST form had been completed for Resident #6. c) Resident #27 Review of Resident #27's medical records revealed a West Virginia Physician order [REDACTED]. The POST form had not been signed by the resident's medical power of attorney or health care surrogate. Resident #27 did not have medical decision-making capacity. During an interview on 04/09/19 at 1:30 PM, Social Worker #4 agreed Resident #27's POST form had not been signed by the resident's medical power of attorney or health care surrogate. On 04/11/19 at 9:46 AM, Social Worker #4 stated Resident #27's POST form had been signed by the resident's representative.",2020-09-01
193,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,584,D,0,1,M7ZP11,"Based on observation, resident interview, and staff interview , the facility failed to provide a safe clean home like environment to the extent possible. A random observation of a dependent resident's bedside phone revealed the phone to be grossly dirty and in need of cleaning and sanitizing. This practice had the potential to affect more than limited number of residents. Resident identifier: #17. Facility census: 39. Findings included: a) Resident #17 Observation of Resident#17's bedside telephone, on 04/10/19 at 9:20 AM, revealed a lot of built up crusty dirt and debris inside the phone cradle, where the ear piece of the phone rested when not in use. Inspection of the earpiece revealed some dried debris coating the outer surface of the earpiece that would lay against the resident's ear when she spoke on the phone. This surveyor asked the resident, When was the last time the phone had been cleaned? The resident replied, I don't remember when it was ever cleaned. This surveyor pointing at the phone, asked the resident if she talked on that phone. The resident replied, Oh yes, I talked to my daughter all the time. On 04/10/19 at 9:23 AM, this Surveyor went into the hallway and asked nurse aide (NA#13) to step into resident 17's room. NA#13 was asked to pick up the resident's phone and look at the cradle. The nurse aide picks up the phone and looking at the cradle gasped, Oh! I will get housekeeping to clean this immediately.",2020-09-01
194,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,641,D,0,1,M7ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) to reflect Resident #19's urinary continence status. This was true for one (1) of fourteen (14) sampled residents. Resident identifiers: #19. Facility census: 39. Findings included: a) Resident #19 Review of Resident #19's medical records, found the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. Neuromuscular dysfunction of bladder is a problem in which a person lacks bladder control due to a brain, spinal cord, or nerve condition. Review of Resident #19's admission MDS assessment with an assessment reference date (ARD) of 03/01/19, which found section H - Bladder and Bowel indicates the resident has an indwelling Foley catheter. Under Section H 0300 urinary incontinence the MDS was coded 3, to indicate the resident is always incontinent (no episodes of incontinence). Review of the Resident Assessment Instrument (RAI) the appropriate answer is Code 9, not rated: if during the 7-day look-back period the resident had an indwelling bladder catheter, condom catheter, ostomy, or no urine output (e.g., is on chronic [MEDICAL TREATMENT] with no urine output) for the entire 7 days. Interview with the Director of Nursing (DON) on 04/10/19 at 12:15 p.m., after review of the admission MDS with ARD of 03/01/19, she confirmed the MDS was coded in error. She confirmed the answer should have been 9 not 3. She confirmed the admission MDS with ARD of 03/01/19 was inaccurate.",2020-09-01
195,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,656,D,0,1,M7ZP11,"**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 develop a care plan to include the contact information of a resident's Hospice service provider; and implement care plan interventions related to oxygen therapy, positioning, and skin integrity. This was true for three (3) of fourteen (14) resident care plans reviewed during the annual long-term care survey process. This practice had the potential to affect more than a limited number of residents. Resident identifier: #2, #17, and #1. Facility census: 39. Findings included: a) Resident #2 (R#2) Review of records revealed R#2 was admitted to Hospice services on 07/09/18 and was admitted to the facility on [DATE]. Review of R#2's care plan, on 04/10/19 at 2:54 PM, revealed the Hospice 24-hour contact information was not included in the care plan. An interview, on 04/10/19 at 3:50 PM with the MDS nurse responsible for developing resident care plans, confirmed R#2 care plan was developed without including the Hospice 24-hour contact information. The MDS nurse said the resident already had Hospice services when she came to the facility, and the Hospice 24-hour contact information should have been included when the facility first developed the resident's care plan. The MDS nurse stated she would update the care plan now with the Hospice 24-hour contact information. b) Resident #17 (R#17) Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) 02/18/19, on 04/10/19 at 09:46 AM, revealed the resident has clear speech, makes them self-understood and understands. The resident's Brief Interview for Mental Status (BIMS) score was twelve (12) indicating the resident is moderately impaired. R#17 did not exhibit any behaviors. The resident is totally dependent with bed mobility, meaning full staff performance every time. The resident needs supervision with eating and is totally dependent with all other activities of daily living (ADLs). ADLs include bed mobility, transfers, dressing, toileting, personal hygiene, and bathing. Resident has impairment in both lower extremities. Some [DIAGNOSES REDACTED]. 1. Oxygen Review of R#17's care plan, on 04/10/19 at 10:28 AM, revealed the resident has chest pain related to [MEDICAL CONDITION] with an intervention: Oxygen (02) via nasal prongs as ordered. Observations, on 04/10/19 at 8:44 AM, revealed resident's oxygen flow meter was set close to 4L (liters per minute). Review of the current orders revealed, oxygen at 2L per nasal cannula continuous related to decrease O2 sats (blood oxygen saturation). On 04/10/19 at 9:01 AM, Registered Nurse (RN#91) and RN#3 entered resident #17's room. This surveyor requested RN#91 look at the oxygen meter to see what rate the flow meter was on. RN#91 stated the 02 was on 3 1/2L, confirming the oxygen rate was not 2L as was ordered and indicated in the care plan. RN#91 adjusted the resident's oxygen rate to 2L as ordered and care planned. 2. Positioning Review of R#17's care plan, on 04/10/19 at 10:28 AM, revealed the resident has an activities of daily living (ADL) self-care performance deficit. Two of the interventions include, Bed mobility: The resident requires extensive to total assistance with repositioning at all times. Transfer: The resident requires Hoyer lift and is dependent on 2 staff for transfer. On 04/08/19 at 12:35 PM, during an interview with the resident, restorative nurse aide (NA#61) entered the room with the resident's lunch tray and sat it on the over bed table. opened items for the resident on the tray, placed butter on the resident's potatoes, NA#61 assisted the resident with her napkin, raised the head of the resident's bed to about seventy five (75) degrees from (45) degrees, and pleasantly ask the resident if there was anything else she wanted, then left the room. Before leaving the nurse aide did not check to make sure the resident could reach items on her tray, or if R#17 was positioned comfortably and/or in good body alignment to facilitate eating. R#17 was lying low in the bed before NA#61 raised the head of the bed. However, when the nurse aide raised the head of the bed the resident slid down even more into the bed. The resident's lower back was curved and raised off the bed surface unsupported in the bend of the bed. The resident's upper torso was hunched over and her chin pointed down to her neck. R#17 struggled to reach the items on her lunch tray. The resident's body positioning was poorly aligned and did not facilitate affective swallowing. This surveyor asked the resident, Are you comfortable? The resident replied, No, I'm not comfortable! This surveyor asked the resident if she could straighten her own self up in the bed, and R#17 answered, No, I can't do it, I need help. This surveyor requested the resident use her call light to get assistance to help straighten her up in the bed. NA#61 answered the call light, and agreed the resident needed pulled up in the bed and repositioned. NA#61 left the room and returned with NA#2 to assist in repositioning the resident in her bed after surveyor intervention. c) Resident #1 Review of Resident #1's medical records revealed the resident had a skin tear on her coccyx, a skin tear on her foot, and a deep tissue injury on her left hip. Weekly wound assessments of the skin tear on the foot and the deep tissue injury on the hip had been documented in the progress notes and on a wound weekly observation tool. The skin tear on the coccyx was first observed on 03/26/19 and the wound was measured as 5 cm x 2.5 cm at that time. No further assessments of the coccyx skin tear could be located in the medical records. Resident #1's comprehensive care plan contained the focus, I have a potential for impairment to skin integrity r/t (related to) fragile skin. The interventions included, I will have weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Resident #1 had an order for [REDACTED]. Sure Site is a transparent dressing used to protect a wound while it heals. On 04/11/19 at 10:30 AM, Assistant Director of Nursing (ADoN) #23 was observed changing Resident #1's coccyx Sure Site dressing. ADoN #23 stated she was going to have the physician assess Resident #1's coccyx skin tear to determine if a different treatment and dressing would be beneficial. Resident #1's coccyx wound was addressed in the following progress notes: (The notes are typed as written.) - 03/26/19 at 6:50 PM: Skin tear remains suresite C/D/I (Clean, dry, intact) . - 3/27/19 at 3:04 AM: Skin tear suresite C/D/I . - 03/27/19 at 11:30 AM: Resident with skin tear to her coccyx. Sure site is CDI . - 03/28/19 at 6:25 PM: .Skin tear remains to coccyx . - 03/29/19 at 7:50 PM: .Skin tear remains to coccyx . - 03/30/19 at 5:09 AM: Skin tear remains to coccyx . - 03/30/19 at 6:51 PM: .Skin tear remains to coccyx . - 03/31/19 at 2:44 AM: .Skin tear remains to coccyx . - 04/02/19 at 2:53 AM: .Skin tear remains to coccyx . - 04/03/19 at 1:11 AM: .Skin tear remains to coccyx . - 04/06/19 at 12:37 AM: .Skin tear remains to coccyx . During an interview on 04/11/19 at 1:05 PM, the Director of Nursing (DoN) stated she was unable to locate updated assessments of Resident #1's coccyx skin tear. The DoN stated skin tears do not require assessments on the wound weekly observation tool. During an interview on 04/11/19 at 1:56 PM, the Administrator and Director of Nursing were informed the facility failed to implement Resident #1's comprehensive care plan intervention to perform weekly treatment documentation including measurement of each area of skin breakdown. The Administrator and Director of Nursing had no further information regarding the matter. No information was provided through the completion of the survey.",2020-09-01
196,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,684,D,0,1,M7ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #4 received treatment and care with professional standards of practice and the comprehensive person-centered care plan. This was true for one (1) of fourteen (14) residents reviewed. Resident identifier: #4. Facility census: 39. Findings included: a) Resident #4 Review of medical records for Resident #4 found a physician's orders [REDACTED]. oxygen saturation level below 92% (percent) and Check oxygen saturation (SPO2) every shift. Review of the Medication Administration Records (MAR) for 01/01/19 through 04/09/19 found the MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 04/10/19 at 1:15 p.m., found the staff had failed to document the results of the SPO2 % as the physician order [REDACTED]. She confirmed the nurses were not following the physician's orders [REDACTED].>",2020-09-01
197,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,842,D,0,1,M7ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record for three (3) of 14 residents reviewed during the long-term care survey process. The facility failed to document wound care on Resident #1's Treatment Administration Record. The facility failed to ensure Resident #27's tube feeding order contained all required elements. The facility failed to ensure Resident #10's [DIAGNOSES REDACTED]. Resident identifiers: #1, #27, #10. Facility census: 39. Findings included: a) Resident #1 Resident #1 had an order for [REDACTED]. Sure Site is a transparent dressing used to protect a wound while it heals. On 04/11/19 at 10:30 AM, Assistant Director of Nursing (ADoN) #23 was observed changing Resident #1's coccyx Sure Site dressing because the dressing was soiled with stool. The Sure Site dressing removed had a date of 04/10/19 on it. Resident #1's Treatment Administration Record did not include the order to change the resident's coccyx dressing every seven (7) days and as needed. Resident #1's progress notes contained notations that the Sure Site dressing was clean, dry, and intact, but did not contain information regarding when the dressing was changed. During an interview on 04/11/19 at 1:01 PM, the Director of Nursing agreed Resident #1's coccyx dressing change was not included on the resident's Treatment Administration Record. She stated the resident's coccyx dressing was changed frequently because the resident was incontinent of stool, soiling the dressing. During an interview on 04/11/19 at 1:56 PM, the Administrator was informed Resident #1's coccyx dressing change was not included on the resident's Treatment Administration Record. She had no further information regarding the matter. No information was provided through the completion of the survey. b) Resident #27 Resident #27 had the following tube feeding order: [MEDICATION NAME] 1.2 Cal Liquid (Nutritional Supplements). Give 240 cc via [DEVICE] every 4 hours for sole source feeding give with 120cc h2o flush. (Typed as written.) [DEVICE] feedings can be administered by bolus, which involves the feeding being administered with a syringe over a short or period of time, by infusion over a specified, longer period of time, or by continuous infusion. Resident #27's tube feeding order did not specify how the feeding was to be administered. On 04/11/19 at 11:10 AM, Licensed Practical Nurse (LPN) #62 was observed administering Resident #27's tube feeding. She administered the tube feeding by bolus, using a syringe, over approximately ten (10) minutes. During an interview on 04/11/19 at 12:58 PM, the Director of Nursing (DoN) was informed Resident #27's tube feeding order did not specify how the feeding was to be administered. The DoN confirmed the tube feeding was to be administered by bolus. The DoN stated Resident #27 tolerated bolus tube feedings best. During an interview on 04/11/19 at 1:56 PM, the Administrator was informed Resident #27's tube feeding order did not specify how the feeding was to be administered. She had no further information regarding the matter. No information was provided through the completion of the survey. c) Resident #10 Resident #10 had an order for [REDACTED].#10's comprehensive care plan also contained the focus, The resident uses antidepressant medication r/t (related to) depression. Resident #10's [DIAGNOSES REDACTED]. During an interview on 04/10/19 at 10:50 AM, the Director of Nursing (DoN) was informed Resident #10's [DIAGNOSES REDACTED]. During an interview on 04/10/19 at 2:08 PM, the Administrator confirmed a [DIAGNOSES REDACTED].#10's [DIAGNOSES REDACTED].",2020-09-01
198,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2019-04-11,880,D,0,1,M7ZP11,"Based on observation, resident interview, and staff interview , the facility failed to implement an ongoing infection prevention and control program (IPCP) to help prevent, recognize, and control the onset, cross-contamination, and spread of infection to the extent possible. A random observation of two nurse aides tidying a dependent resident's bed revealed a breach in infection control principles when a nurse aide held the used bed linens against her uniform. This practice had the potential to affect more than limited number of residents. Resident identifier: #17. Facility census: 39. Findings included: a) Resident #17 Observations, on 04/10/19 at 5:22 PM, revealed Nurse Aide (NA#25) and Nurse Aide (NA#40) in Resident (R#17)'s room. The resident was lying in the bed, NA #25 was straightening the bed linens, and NA#40 was standing at the left side foot of the resident's bed with her arms full of a large amount of wadded up blankets against the uniform of her upper body. Interview with the nurse aides confirmed the blankets NA#40 was holding had just came off the resident's bed. NA #25 said she was straightening the bed and piled the blankets in NA#40's arms to get them out of her way as she was fixing the bed. Both NA #25 and NA#40 confirmed and acknowledged holding used bed linens against their uniform was a breach in infection control principles they were taught in their nurse aide training. According to the Centers for Medicare & Medicaid Services (CMS) laundry includes resident's personal clothing, linens (i.e. sheets, blankets, pillows), towels . CMS Guidance for handling laundry includes, The facility staff should handle all used laundry as potentially contaminated and use standard precautions. CMS Guidance states one of the practices facilities should use, is; Staff should handle soiled textiles/linens with minimum agitation to avoid the contamination of air, surfaces, and persons. Guidance from CMS also states, The facility practices must include how staff will handle and transport the laundry with appropriate measures to prevent cross-contamination. This includes but is not limited to the following; Contaminated linen and laundry bags are not held close to the body . ;",2020-09-01
200,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,242,D,0,1,HZCX11,"Based on medical record review, resident interview and staff interview, the facility failed to ensure a resident received his desired two (2) showers per week for two (2) of the most recent six (6) weeks. This was evident for one (1) of four (4) residents reviewed for choices. Resident identifier: #18. Facility census: 39. Findings include: a) Resident #18 During an interview with Resident #18, on 04/17/17 at 11:59 a.m., he said he would prefer to have showers three (3) times per week. He stated his belief that staff is aware of this desire, but too busy to honor his choice for three (3) showers per week. He said he does not always get even two (2) per week. Review of the significant change minimum data set (MDS) with assessment reference date (ARD) of 03/03/17, found his brief interview of mental assessment (BIMS) score was fourteen (14) out of a possible score of fifteen (15). A BIMS score of fourteen (14) indicates intact cognition. According to this assessment, the resident required extensive assistance for personal hygiene, and required physical help in part of the bathing activity. Review of the shower records, on 04/18/17 at 9:56 a.m., found this resident was scheduled for two (2) showers per week, on Tuesdays and Fridays. Further review found that of the past six (6) weeks, were two (2) weeks where he received only one (1) shower per week. There was no evidence found that he had refused showers, or that he was out of the facility those weeks. The week of 03/12/17 through 03/18/17, he received only one (1) shower, on 03/17/17. The week of 03/26/17 through 04/01/17, he received only one (1) shower, on 03/31/17. An interview was conducted with licensed practical nurse (LPN) #40, on 04/18/17 at 10:12 a.m. She said she was unaware this resident wanted three (3) showers per week. She said if a resident requested changes in his shower schedule, she tells the assistant director of nursing (ADON) #76, who would then make changes in the shower schedule. An interview was then conducted with nurse #76 on 04/18/17 at 10:29 a.m. She said when residents first come to the facility, they are asked how often they want to receive showers. She said after they have been here awhile, sometimes they might make changes. Upon inquiry as to whether two (2) showers per week were this resident's preference, she replied in the affirmative. She said she was not aware of this resident having asked anyone for three showers per week. She asked him at this time, and he replied that he would like three (3) showers per week. At this time he selected Tuesdays, Thursdays, and Saturdays for his shower days. Nurse #76 said she would change the shower schedule to honor his request. Next, we discussed the recorded showers for the most recent six (6) weeks that are located in the shower book at the nurse's station. Nurse #76 reviewed the shower book, and reviewed computer entries. She found that the only documentation on 03/14/17 and on 03/28/17 pertaining to showers just said not applicable. She could find no evidence that he refused showers on those dates, or that he was out of the facility on those dates. She then went to her office to see if she might find other shower sheets that had not been filed for some reason. The outcome was that she could find no evidence that he received two (2) showers per week during the weeks of 03/12/17 through 03/18/17, and 03/26/17 through 04/01/17.",2020-09-01
201,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,246,D,0,1,HZCX11,"Based on staff interview, resident interview and record review, the facility failed to ensure reasonable accommodations were attempted to allow Resident #2 to be able to have his preference of a shower. This was true for one (1) of three (3) residents reviewed for the care area of choices during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #2. Facility census: 39. Findings include: a) Resident #2 During an interview with the resident, at 12:04 p.m. on 04/17/17, the resident said he would like to be able to take a shower instead of a bed bath. He said he gets his bed baths two times a week but he is unable to shower because the shower chair hurts his hip. Review of the bathing schedule in the facility's point of care computer system, at 10:30 a.m. on 04/18/17, found the resident was coded as receiving, bathing, on every Tuesday and Friday during the months of (MONTH) and April, (YEAR). The point of care system noted the resident prefers a shower. At 10:30 a.m. on 04/18/17, Registered Nurse (RN) #23, the facility consultant for minimum data set (MDS) said the system does not designate a bed bath or a shower, just bathing. At 11:00 a.m. on 04/18/17, Nurse Aide (NA) #59, said she has occasionally bathed the resident. She said the resident wants a bed bath because she believed he had a fear of the shower. She thought the resident had fallen in the shower before. NA #59 said the showers/bed baths are recorded on paper before being put in the computer. The following paper information was provided by NA #59: --03/14/17, bed bath, resident says shower chair hurts him --03/17/17, the resident received a bed bath --03/21/17, bed bath, resident said he wanted to take a shower, then said he did not want one --03/31/17, resident requests bed bath complains of pain with shower. NA #59 was unable to locate all the paper documentation of the resident's bathing schedule. Review of the current care plan found staff should prove a sponge bath when a full bath or shower can not be tolerated. Review of the most recent, quarterly MDS with a assessment reference date (ARD) of 01/27/17, found the resident scored a 15 out of 15 on his brief interview for mental status (BIMS). A score of 15 indicates the resident is cognitively intact, and is the highest score obtainable. At 11:27 a.m. on 04/18/17, the assistant director of nursing (ADON) #76, was interviewed. ADON #76, said, They tell me his hip hurts when he gets a shower. ADON #76 said the facility has two (2) shower chairs, a smaller one and a larger one. She said the facility did not have a shower bed because the showers are so small. She was asked if the facility had tried anything else such as padding the shower chair or any intervention that might make it possible for the resident to shower. She was not aware of any interventions tried by the facility At 11:30 a.m. on 04/18/17, the resident was interviewed with ADON #76 present. The resident again said he wanted to take a shower. He said he slips and slides in the shower chair, causing his hip to hurt. NA #10 was also in the resident's room when the resident was interviewed. NA #10 said, I don't remember when, but the last time I tried to shower him, he never made it through the whole shower because his hip was hurting, he slips in the shower chair. At 9:57 a.m. on 04/19/17, Chief Nursing Officer, RN #43 was interviewed. RN #43 was unable to provide evidence the facility had tried other means to accommodate the resident's preference for showers instead of bed baths.",2020-09-01
202,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,272,D,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed an ensure two (2) of three (3) residents reviewed for the care area of dental status had an accurate comprehensive Minimum Data Set (MDS) in the care area of dental status. Resident identifiers: #22 and #18. Facility census: 39. Findings include: a) Resident #22 Observation and review of the most recent, significant change MDS with an assessment reference date (ARD) of 02/28/17, found the facility coded the resident's dental status correctly as the resident has no dentures and no natural teeth. The Care Area Assessment (CAA), which is also a part of the MDS, noted the resident's dental status would not be care planned. The information on the dental CAA asked if dental status is a problem or need. The facility responded with: Potential. The nature of the problem was noted by the facility as, [AGE] year old male admitted from another facility. Resident alert oriented to self and place. Resident has confusion. Resident has behavior issues at times where resident will refuse medications and care at times from staff. Resident ambulates with supervision. Has a history of falls due to weakness. Resident will use a WC (wheelchair) when staff puts him in one. Resident needs staff assist with care, hygiene and ADLS (activities of daily living). Resident does not always participate in activities. Resident eats in dinning room and has to be assisted to dining room from staff. Resident does feed self needs cues at times from staff. Resident is incontinent of bladder at times has had some accidents with incontinence of BM (bowel movements). Resident has not been physical with others. This information did not reference the resident's dental status. At 11:23 a.m. on 04/18/17, the administrator and social services director (SSD) were interviewed regarding the resident's dental status. Both employees were unable to provide evidence the resident's dental status was addressed on the CA[NAME] At 11:23 a.m. on 04/18/17, the SSD provided an oral assessment, dated 01/06/17, noting the resident says he does not want any dentures. She confirmed this information was not present on the CAA for dental status. At 8:20 a.m. on 04/19/17, the above information was discussed with Registered Nurse (RN) #43, the facility's chief nursing officer. RN #43 provided no further information. b) Resident #18 Observation on 04/17/17 at 12:21 p.m., found this resident had four (4) teeth on top, and several teeth on the bottom in the middle. He said he had some cavities that might need fixed, or might need some pulled and a denture made. The medical record was reviewed on 04/18/17. Review of the significant change minimum data set (MDS), with assessment reference date (ARD) 03/03/17, found in the section pertaining to dental, the nurse assessed him as having no teeth (edentulous). A nutritional assessment dated [DATE] addressed his own teeth were in poor condition. A neuroscience consult dated 04/07/17 included as assessment noting dental caries on the smooth surface of a tooth (teeth) penetrating into the pulp. On 04/18/17 at 11:19 a.m., licensed social worker #1 said this resident was to see the dentist in (MONTH) or (MONTH) of this year, but the resident refused. She showed a psychosocial progress note dated 02/10/17 which said that after this resident had a teeth audit, it was recommended that he have dentistry services. However, the resident refused and would not like to be seen by a dentist at this time. On 04/18/17 at 11:19 a.m., the administrator said she would provide a copy of the dental section of the 03/03/17 significant change MDS. On 04/18/2017 at 11:39 a.m., an interview was conducted with assistant director of nursing #76 about the 03/03/17 significant change MDS which said he was edentulous. She said that was in error, as he does have some natural teeth.",2020-09-01
203,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,278,D,0,1,HZCX11,"Based on medical record review and staff interview, the facility failed to ensure the accuracy of a minimum data set for Resident #10 in the area of pressure ulcers. This was evident for one (1) of three residents reviewed for death, and out of sixteen (16) Stage II sampled residents. Resident identifier: #10. Facility census: 39. Findings include: a) Resident #10 The medical record was reviewed on 04/18/17. According to the medical record, this resident developed a Stage II pressure ulcer on his nose on 02/01/17. It was an in-house acquired pressure ulcer, caused by his glasses It was located on a corner of his nose near the left eye. Facility staff asked his medical power of attorney (MPOA) to have his glasses adjusted due to pressure from the nose pieces causing the wound. Facility staff applied foam padding to the nose pieces until the glasses were adjusted. On 02/13/17, facility staff notified the physician and the MPOA of the healed Stage II wound at the corner of his left eye. Review of the 30-day minimum data set (MDS) with assessment reference date (ARD) of 02/02/17, found it correctly assessed the resident as having one (1) Stage II pressure wound. It assessed correctly that the pressure wound was not present on the most recent prior assessment. Review of the 60-day MDS with ARD 03/06/17, found it correctly assessed that he had no current pressure wounds. However, the space was left blank in which to indicate the number of pressure ulcers that were noted on the prior assessment that have now completely closed. During an interview with the corporate MDS registered nurse #23 on 04/18/17 at 1:30 p.m., she said since a Stage II was identified on the 30-day MDS, then it should have been assessed on the 60-day MDS as there having been a previous Stage II wound.",2020-09-01
204,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,280,D,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and facility policy review, the facility failed to afford a resident the right to participate in their care planning. One (1) was not invited to participate in care plan meetings. This practice affected one (1) of two (2) residents reviewed for care planning. Resident identifier: #8. Facility census: 39. Findings include: a) Resident #8 The resident was admitted to the facility on [DATE]. The resident is her own responsible party. A review of Resident #8's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/17, was conducted on 04/18/17 at 9:00 a.m. Section C-Cognitive Patterns of the assessment revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) assessment. A score of 15 indicated the resident was cognitively intact at the time of the assessment. An interview with Resident #8 on 04/18/17 at 9:30 a.m., revealed the resident had not been to a care plan meeting since she was admitted to the facility. The resident stated no staff had ever discussed her care plan nor invited her to any care plan meeting. The resident stated she would love to attend a care plan meeting. A review of Resident #8's Care Plan (Target Date 06/30/17), on 04/18/17 at 9:40 a.m., revealed the following intervention: Promote participation in care planning process-Invite to team conference. Further review of the medical record, on 04/18/17 at 9:55 a.m., revealed the facility had conducted a care plan meeting for Resident #8 on 08/18/16. A progress note dated 08/21/16 stated Family did not attend plan of care meeting on 08/18/16. There was no documentation that the resident attended or was invited to the meeting. No documentation of any further care plan meetings or evidence of any invitations to the resident was found in the record. An interview with the Administrator, on 04/18/17 at 10:10 a.m., revealed she could not provide any documentation Resident #8 had ever been invited to or attended a care plan meeting. The Administrator stated she had no further documentation to show another care plan meeting had been conducted for Resident #8 since 08/18/16. A review of the facility's policy titled Resident/Family Participation-Assessment/Care Plans, with a revision date of (MONTH) 2007, revealed Each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and care plan.",2020-09-01
205,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,312,D,0,1,HZCX11,"Based on observation, record review, staff interview and resident interview, the facility failed to provide activities of daily living (ADL) care to Resident #39 who was unable to perform the care herself. Resident #39 was observed with multiple long hairs on her chin and indicated she needed the staff to remove them for her. This was true for one (1) of four (4) residents reviewed for the care area of ADL's during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #39. Facility census: 39. Findings include: a) Resident #39 An observation of Resident #39, during Stage 1 of the QIS, at 12:09 p.m. on 04/17/17, found several long hairs on her chin. A review of Resident #39's medical record, at 8:00 a.m. on 04/19/17, found the resident required extensive assistance of staff to carry out her personal hygiene ADL's. An additional observation and interview with Resident #39, at 8:45 a.m. on 04/19/17, with the Assistant Director of Nursing (ADON) and Social Service Director (SSD) present found the hair was still present on her chin. When asked if she would like to have the hair removed from her chin Resident #39 stated, Yes they are getting long and they have to remove them for me. The ADON agreed the staff needed to remove the hair from Resident #39's chin and instructed her assigned Nurse Aide to remove the hair.",2020-09-01
206,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,505,D,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician was promptly notified of an abnormal laboratory value for one (1) of five (5) resident's reviewed for the care area of unnecessary medications. The physician is to be notified promptly in order for appropriate action to be taken if indicated for the resident's care. Resident identifier: #16 Facility census: 39. Findings include: a) Resident #16 On 01/09/17, the physician ordered the following laboratory values: --Lipid profile, --[MEDICAL CONDITION] profile, and --Comprehensive metabolic panel (CMP) According to the laboratory report, the results of the testing were available to the facility on [DATE]. On 01/12/17, the physician was notified of the laboratory values. The physician provided orders to discontinue the resident's [MEDICATION NAME] and obtain a BMP (Basic Metabolic Panel) in the a.m. The results of the 01/09/17, CMP noted the following abnormal values: --BUN (blood urea nitrogen) was high, 67, (Normal range is 6-35) --Creatinine was high- 2.3, (Normal range is 0.5 - 1.7) --B/C (BUN to Creatinine) ratio was high- 29.1 (Normal range was 7-18) --Sodium was high- 144, (Normal range is 136-142) --GFR ( glomerular filtration rate-measures the level of kidney function to determine your stage of kidney disease) was low - 19.83, (Normal range is greater than 60) On 01/13/17, a basic metabolic panel (BMP) was obtained as ordered. The results of the BMP are as follows: --Sodium was high- 143, (Normal range is 136 - 142) --Potassium was high - 5.6, (Normal range is 2.5 - 5.3) --BUN was high- 72, (Normal range is 6 - 35) --Creatinine was high - 1.8, (Normal range is 0.5 - 1.7) --GFR was low - 26.6, (Normal range is greater than 60) At 3:04 p.m. on 04/18/17, the Registered Nurse (RN) minimum data set (MDS) consultant was interviewed. She was unable to provide information the resident's physician was ever notified of the second laboratory values obtained on 01/13/17 and available to the facility on [DATE]. At 8:05 a.m. on 04/19/17, the Chief Nursing Officer/Registered Nurse (RN) #43 was also unable to provide verification the resident's physician was aware of the abnormal laboratory values obtained on 01/09/17 in a prompt manner. RN #43 did provide a copy of a nurses note on 01/16/17 at 10:35, which noted: Resident's labs reviewed and adjusted r/t (related to) new lab regimen. The first lab was obtained on 01/09/17 and was available to the facility on [DATE]. This lab was not reviewed by the physician until 01/12/17. The second laboratory value was obtained on 01/13/17. The copy of the laboratory report was noted as being obtained on 04/18/17, the date of surveyor intervention.",2020-09-01
207,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-04-19,507,D,0,1,HZCX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a copy of an abnormal laboratory value was available in the medical record for physician review. This was true for one (1) of five (5) resident's reviewed fro the care area of unnecessary medications during Stage 2, of the Quality Indicator Survey (QIS). Resident identifier: #16. Facility census: 39. Findings include: a) Resident #16 Medical record review on 04/18/17, at 2:00 p.m. found the resident's physician ordered a BMP (Basic Metabolic Panel) to be completed on the morning of 01/13/17. At 3:04 p.m. on 04/18/17, the Registered Nurse (RN) minimum data set (MDS) consultant, #23 was interviewed. She was unable to provide a copy of the BMP, ordered on [DATE], by the resident's physician. A copy of the laboratory value was provided to the surveyor later in the day by RN #23. The laboratory report noted the BMP was collected on 01/13/17 at 5:16 p.m. The date received by the laboratory was 01/13/17. The date the results of BMP were provided was 04/18/17 At 8:05 a.m. on 04/19/17, the Registered Nurse , chief nursing officer, #43, was notified of the above findings. She confirmed the facility was unable to find the laboratory value from 01/13/17. The facility had to contact the laboratory to obtain the test on 04/18/17.",2020-09-01
209,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2018-05-03,656,D,0,1,GLW711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to ensure person-centered comprehensive care plan developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs for two (2) of seventeen (17) residents reviewed. Resident #4's care plan failed to address [MEDICAL CONDITIONS] and contractures. Additionally, Resident #8's care plan failed to address the use of an anticoagulant. Resident identifiers: #4 and #8. Facility census: 37. Findings included: a) Resident #4 Review of Resident #4's medical record began on 05/01/18 at 11:15 a.m., found the resident was admitted [DATE]. [DIAGNOSES REDACTED]. Review of Resident #4's physician progress notes [REDACTED]. Observation of Resident #4 on 04/30/18 at 11:30 a.m., found resident appeared to have contractures of upper and lower extremities. This observation was confirmed by the Occupational Therapist. Interview with the Director of Nursing (DON) on 05/02/18 at 11:15 a.m., she confirmed after review of the comprehensive care plan, the care plan did not include [MEDICAL CONDITIONS] and multiple contractures of upper and lower extremities. b) Resident #8 Resident #8 had an order for [REDACTED]. Resident #8 also had an order to Monitor for signs/symptoms of bruising/bleeding/skin alterations, every shift, due to [MEDICATION NAME] therapy. Resident #8's Medication Administration Record [REDACTED]. However, Resident #8's comprehensive care plan did not have a focus related to the medication [MEDICATION NAME]. During an interview on 05/01/18 at 1:29 PM, the Director of Nursing (DoN) agreed Resident #8's comprehensive care plan did not have a focus related to the medication [MEDICATION NAME].",2020-09-01
210,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2018-05-03,657,D,0,1,GLW711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan for three (3) of seventeen (17) resident's comprehensive care plans reviewed. The facility failed to revise the comprehensive care plan for Resident #21 in the area of skin integrity when he developed an actual skin impairment. The facility failed to revise the comprehensive care plan for Resident #30 in the area of an overall decline and hospice involvement. The facility also failed to revise the comprehensive care plan for Resident #26 when incontinence associated [MEDICAL CONDITION] and skin tears resolved. Resident indicators: #21, #30, #26. Facility Census: 37. Findings included: a) Resident#21 Resident #21 had an order for [REDACTED].>On [DATE], the weekly Skin Observation Tool documented Resident has redden (sic) area to the area behind top of left ear d/t (due to) oxygen hose, which is being treated. No other skin tears or bruising noted. On [DATE] at 10:39 AM, Licensed Practical Nurse (LPN) #81 was observed performing care to Resident #21. The top of Resident #21's left ear was observed to be reddened. LPN #81 inserted new foam protectors on Resident #21's oxygen tubing to protect the top of his ear. LPN #81 stated the foam protectors needed to be reapplied periodically because Resident #81 removed them. She also stated Hydrogel was being applied to the reddened area on the top of Resident #21's left ear. Resident #21's comprehensive care plan contained the focus, The resident has potential for impairment to skin integrity r/t (related to) fragile skin. However, the comprehensive care plan did not contain a focus or interventions related to the reddened area on Resident #21's left ear. During an interview on [DATE] at 12:32 PM, the Director of Nursing (DoN) agreed Resident #21's comprehensive care plan did not contain a focus related to his actual skin impairment or the specific interventions being performed for the condition. b) Resident #30 Review of Resident #30's closed medical records [REDACTED]. The [DIAGNOSES REDACTED]. Resident # 30 experienced an overall decline and was placed on Hospice care on [DATE] due to her poor prognosis. Resident #30 expired at the facility on [DATE]. Review of Resident #30's comprehensive care plan dated [DATE], was not revised when the resident experienced an overall decline which required hospice care. Interview with the Director of Nursing (DON) on [DATE] at 2:15 p.m confirmed the care plan was not revised after Resident #30 experienced an overall decline which resulted in hospice care. c) Resident #26 Resident #26's medical record review began, on [DATE] at 1:10 p.m., revealed no skin impairment (skin tears and incontinence associated [MEDICAL CONDITION] (IAD)). Additionally, she was care planned for skin tear to right thigh dated [DATE]. Review of Resident #26's compressive care plan found the resident was care planned for IAD dated [DATE]. Additionally, the resident was care planned for skin tear to right thigh dated [DATE]. Both IAD and skin tear had resolved over three (3) weeks ago. Interview with the Director of Nursing (DON) on [DATE] at 2:15 p.m confirmed the care plan was not revised after Resident #26's skin impairments (IAD and skin tear) had resolved. She confirmed it should have been revised.",2020-09-01
211,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2018-05-03,761,D,0,1,GLW711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation amd staff interview, the facility failed to store pharmaceuticals in accordance with currently accepted standards of professional principles. The multi-dose bottle of [MEDICATION NAME] stored in the medication cart on the facility's second floor was not dated when it was opened. This was discovered during the facility task of medication adminstration and had the potential to affect all residents on the second floor who were prescribed [MEDICATION NAME]. Facility census: 37. Findings included: a) Facility task - medication pass On 05/02/18 at 7:49 AM, the morning medication pass was observed by Registered Nurse (RN) #28. During medication administration, a multi-dose bottle of [MEDICATION NAME], a laxative, was removed from a drawer in the medication cart and a dose was poured into a glass for administration to a resident. The [MEDICATION NAME] bottle had been previously opened. However, the [MEDICATION NAME] bottle was not dated when it was opened. RN #28 agreed the multi-dose bottle of [MEDICATION NAME] was not dated when it was opened. On 05/02/18 at 8:55 AM, the Director of Nursing (DoN) was notified the multi-dose bottle of [MEDICATION NAME] stored in the medication cart on the second floor was not dated when opened. The DoN stated, We'll fix it.",2020-09-01
212,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-06-07,278,D,1,0,5ZTQ11,"> Based on record review and staff interview, the facility failed to ensure an accurate assessment for one (1) of six (6) residents. Resident #12's 30-day minimum data set (MDS) assessment for section M, Skin conditions revealed the dimensions of unhealed stage 3 or 4 pressure ulcers or eschar was entered incorrectly. Resident identifier: #12. Facility census: 40. Findings include: a) Resident #12 A review of the MDS, assessment reference date 03/22/17, showed the resident had one (1) stage two (2) pressure ulcer. Further review of the MDS, revealed measurements for length and width for a stage three (3) or four (4) pressure ulcer. An interview with Assistant Director of Nursing (ADON) #42 on 06/07/17 at 1:38 pm, advised she had entered the measures incorrectly in this section. She commented she would be corrected this section of the MDS.",2020-09-01
214,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2017-06-07,514,D,1,0,5ZTQ11,"> Based on record review and staff interview, the facility failed to ensure accurate and complete medical records for two (2) of six (6) residents. Resident #4 and Resident #12 had medical records that were not complete. Resident identifiers: #4 and #12. Facility census 40. Findings include: a) Resident #4 Resident #4 experienced a fall on 02/19/17, at 1:20 p.m. After the fall, he reported left hip pain. Resident was sent to a local hospital's emergency room for evaluation and treatment on 02/19/17 at 2:09 p.m. A nursing note written at 9:14 p.m., on 02/19/17 stated, Resident returned from (name of outside hospital), no orders, no paperwork. Resident was at hospital about 2 1/2 hours. When Assistant Director of Nursing (ADON) #42 was asked on 06/06/17 at 1:00 p.m. if records from the emergency room evaluation performed on 02/19/17 had been obtained for resident's file, she contacted the outside hospital to obtain the records. The emergency room evaluation performed on 02/19/17 was faxed to the long-term care facility on 06/06/17. The print date and time indicated on the records was 06/06/17 at 3:15 p.m. Interview with ADON #42 on 06/07/17 at 10:35 a.m. revealed that it was not an unusual occurrence for a resident to be returned from evaluation at a local hospital without accompanying paperwork. However, ADON #42 commented the hospitals call the long-term facility with a report on the resident prior to transfer. b) Resident #12 Medical record review on 06/06/17 revealed Resident #12 Appointment of Health Care Surrogate was not in the medical record. On 06/07/17 at 8:15 a.m., the administrator brought a copy of the appointment of health care surrogate form. She stated the facility had to redo this form because they could not locate the original. She said it should have been in the medical record. The form was dated 06/06/17. At 11:00 a.m. on 06/07/17 Social Worker #17, stated she had contacted the family and they could not locate the original appointment of health care surrogate form.",2020-09-01
216,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2018-02-16,740,D,1,0,EN1S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview, family interview, and staff interview, the facility failed to provide behavioral health care and services and/or treatment to assist Resident #49 in maintaining her highest practicable mental, and psychosocial well-being. The facility failed to provide individualized behavioral health services to assist the resident in coping with her disease process. The resident's care plan did not offer needed guidance to direct care staff to meet the resident's needs with respect to the resident's anxiety and depression. This was found for one (1) of four (4) residents reviewed for behaviors. Resident identifier: #49. Facility census: 102. Findings include: a) Resident #49 Review of the resident's medical record on 02/12/18 at 1:20 PM, revealed this [AGE] year-old resident, admitted to the facility in (MONTH) (YEAR), had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/10/18 identified the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. The assessment also identified she continuously displayed inattention with fluctuating disorganized thinking and she demonstrated behaviors 1-3 days. When compared to the previous assessment, her Mood score had increased to 14 (indicating moderate depression). She required assistance with all activities of daily living (ADLs) and was occasionally incontinent of bladder and always incontinent of bowel. She received antipsychotics, antidepressants, and antianxiety medications (meds) daily. She had bed and chair alarms and had had more than 2 falls since admission. The MDS with an ARD of 10/11/17, identified a BIMS of 14 (cognitively intact), with continuous inattention and fluctuating disorganized thinking. Her Mood score was 8 indicating mild depression. No behaviors were noted in that assessment. She required assistance with all ADLs, received antipsychotics, antidepressants, and antianxiety meds daily and had bed and chair alarms. In an evaluation of Resident #49 on 04/03/17, the psychiatrist's summary noted Resident #49's [MEDICAL CONDITION]'s disease was currently being treated with Tetrabenazine ([MEDICATION NAME]) (a medicine used to treat involuntary movements of [MEDICAL CONDITION]'s disease) to suppress her motor symptoms. The summary included, It is important to be aware that this treatment might aggravate mood problems such as depression. The treatment plan stated, The patient will benefit from the continued use of [MEDICATION NAME] 50 mg (milligrams) (a medication that can be used to treat [MEDICAL CONDITIONS] disorder, and depression) at bedtime. A smaller dose of 25 mg can be added in the daytime to reduce irritability. Because of the concern of [NAME]D ([MEDICAL CONDITION]) symptoms and possible development of depression, the patient might benefit from adding [MEDICATION NAME] 10 mg per day, which can be increased after two weeks to 20 mg per day. The Psychotherapy section stated (typed as written): Although the patient presents with some cognitive impairment, she might benefit from supportive psychotherapy to help her accepting and coping the changes in her living arrangement. The resident's records were silent regarding supportive psychotherapy appointments and or visits. The following behaviors were noted in the resident's medical record since 10/18/17: -- 10/18/17 The plan of care note stated, .She has a [DIAGNOSES REDACTED]. She takes [MEDICATION NAME], and Klonopin. She has obsessive thoughts/behaviors and compulsive behaviors. She is very impulsive and uncontrolled movements. She gets up on her own due to her impulsive and obsessive behaviors -- 10/19/17 5:20 AM Resident's bed alarm going off and her call light was on, nurse found resident standing by bathroom door. Assisted to bathroom and returned to bed. -- 10/19/17 5:50 AM Resident found standing at nurse's station, bed alarm and call light sounding. Resident requested her morning medications. --10/21/17 6:37 PM Resident stumbling in hallway without assistance, chair alarm sounding. Redirection attempts ineffective. --10/22/17 11:21 AM Resident continues this morning to get up unassisted, one time she turned off her alarm and walked out into the hall. --10/30/17 6:37 PM Resident was tearful at 10:00 AM. Upset the Activities Director was busy. --11/19/17 6:35 AM Resident combative with staff during cares/attempted redirection. Striking at staff, attempting to bite staff. --11/20/17 5:59 AM Resident up at present in wheelchair, self transferring frequently throughout shift. Adamant on getting up and calling her mom. Repeatedly asks about med times. Resident attempted to grab/strike write before/during transfers. --11/22/17 3:46 AM Up and down several times without assistance. Continues to be fixated on time, getting meds early, and using bathroom. Demands staff to be right with her when light or alarm sounds. --11/23/17 6:15 AM up in wheel chair fixated on finding the shower team --11/26/17 8:30 PM Nurse Aide (NA) heard alarm and found resident standing up by bed. --12/06/17 9:40 AM waiting for mother in hall and got up unassisted and fell . Resident is very anxious and tearful. --12/10/17 2:32 AM NA reported resident trying to throw herself to the ground while being assisted to the bathroom. Resident reported she had nothing to live for and acknowledged she was depressed. --12/18/17 Activity Director has attempted to redirect resident from being obsessed with her time for medications, bowel movements, calling her mother, whether or not her call bell is working and so forth on many occasions over the past several days. Resident has not been easily redirected most of the time. Resident states she has not been sleeping at night. --12/21/17 8:30 AM Resident agitated this morning, throwing self onto floor from wheel chair multiple times. States she is putting herself on the floor because no one will pay attention to her. --12/21/17 12:00 PM Spoke with physician regarding resident's intentional falls and informed him Medical Power of Attorney (MPOA)/mother was asking if he could adjust her meds since she is not sleeping at night. --12/22/17 4:14 AM Resident hit NA in face while assisting her with transferring --12/26/17 4:26 AM Resident self-transferring, ambulating ad-lib unassisted to bathroom, out of bed to chair. Demands immediate attention/help with requests. --12/29/17 3:40 PM Resident upset the activities director was not in the building and she could not reach her mother by phone. Threw herself to floor multiple times. Behaviors stopped once she talked to her mother. --01/18/18 10:44 AM The care plan meeting note stated, .She has a [DIAGNOSES REDACTED]. She takes [MEDICATION NAME], and Klonopin. She has obsessive thoughts/behaviors and compulsive behaviors. She is very impulsive and uncontrolled movements. She gets up on her own due to her impulsive and obsessive behaviors .Resident does not sleep well at night. She chooses to only eat lunch, however her weight is good. Her mother visits several times a week. Resident is very anxious and wants to sit up and wait on her mom until she arrives. She sleeps well in the afternoon and will nap when her mother is here .Facility has tried 1:1 care at times due to impulsivity and frequent falls . --01/30/18 4:17 AM Resident asked to brush teeth in bathroom and then refused once in bathroom. Push NA away and fell to floor while being assisted to bed. Refused help for NA and got self back to bed. --02/01/18 2:14 AM Nurse called to assist NA in restroom. Resident noted to be speaking non-sense. Resident fighting aide and fell to floor. Placed in scoop chair resident stated, Why are you guys so mean all the time? --02/01/18 2:45 AM Resident out of bed and in scoop chair at nurse's station. Continually getting out of chair and throwing self into staff. --02/01/2:55 AM Physician notified and [MEDICATION NAME] 1 milligram IM ordered. --02/01/18 3:15 AM Resident O[NAME] (out of control) attempting to run down hallways falls in floor --02/01/18 3:16 AM Resident refuses assistance. O[NAME] again. Resident had hard impact fall --02/01/18 3:55 AM Three person assist back to bed and [MEDICATION NAME] injection given --02/01/18 6:06 AM [MEDICATION NAME] has not been effective. Resident still up and down out of chair. Still asking repetitive questions and worrying excessively about her shower. --02/01/18 11:06 AM Nurse discussed behaviors with physician. Dr. (name) stated he would try a neurology consult if needed. --02/04/18 4:54 AM rang call light several times between 3:30 and 4:30 AM. Got out of bed unassisted at 4:54 AM and fell into bathroom door. Repeatedly asked what time do I get my meds? --02/05/18 2:00 AM UP and down since midnight. Heard alarm and found resident opening curtain. --02/06/18 5:30 AM NA assisted resident back to bed from bathroom, resident stiffened arms and legs and both fell . Resident told NA Ha Ha I get my meds now. --2/11/18 2:25 PM At 7 AM resident was standing outside her door calling for the nurse to help her back to bed. Fifteen minutes later resident found sitting on floor near wheel chair. The care plan focus for anxiety stated (typed as written), Resident has anxiety r/t (related to) admission, long-standing history, medical condition as evidenced by worrying daily about activities, meal times, medication times, sleep patterns, bowel habits, progression of disease, staffing and family. Resident is easily distracted and can become preoccupied with several concerns or issues at once. Resident is persistent and will insist and demand at times that her needs and requests be met immediately. The goal was, Resident to have a reduction in anxious episodes to less than daily through next review. Interventions included, 1. Administer medication as ordered for anxiety. 2. Assist resident in calling her family when she is worried about them. 3. Dry erase added to resident's room to record daily staffing, and other frequently asked questions for resident. 4. Observe for and document and s/sx (signs/symptoms) of side effects such as, but not limited to [MEDICAL CONDITION], agitation and hallucinations. 5. Offer activities to help distract resident when she is feeling anxious. 6. Provide emotional support and calm reassurance to resident if she is sad, tearful or anxious. 7. Resident requires constant reassurance at times. Allow her to express feelings and reassure her that her concerns are being heard. The care plan lacked specific approaches for staff to utilize in response to Resident #49's increased anxiety, and [MEDICAL CONDITION] ([NAME]D). The care plan lacked meaningful activities related to Resident #49's customary routines, interests, or preferences and failed to include diversional activities during the evening and nights when she displayed most of her behaviors. Resident #49's mother/medical power of attorney (MPOA) was interviewed by telephone on 02/12/18 at 6:30 PM. She reported Resident #49 was very smart, but became confused at times. The resident's mother reported the resident loses her balance when she walks, but can walk to the bathroom with the assistance of one. She has a history of [NAME]D and used to see a local therapist for this. The MPOA stated the resident had to have things in her room just right or she got upset. The MPOA stated, She (Resident #49) is very restless, her anxiety is terrible. According to the MPOA, Resident #49 used to like to read and watch movies, but now it seemed like she could not comprehend, she was very fidgety and could not concentrate. According to the resident's mother, the resident liked to socialize, liked to be wheeled down the hall and see everyone, and liked it when the other residents said hello. Resident #49 and her mother/MPOA were interviewed on 02/13/18 at 10:15 AM. Resident #49 reported she was unable to sleep at night, had trouble concentrating, and often felt anxious. When asked to describe how she felt when she was anxious, Resident #49 stated, Very nervous, can't sit still. She acknowledged her jerking movements became more pronounced with her anxiety, she got up independently at times which often resulted in a fall, and that she put herself on the floor at times for attention. Resident #49 stated she could not concentrate; that thoughts just flow through her head. She also stated she was not sure what would make her feel better, but would like to feel less anxious and more comfortable in her environment. Resident #49 and her mother/MPOA acknowledged Resident #49 had not been offered supportive psychotherapy as recommended by the psychiatrist. The resident felt the facility was not meeting her psychosocial needs. During an interview on 02/13/18 at 1:00 PM, Activities Director (AD) #194 reported Resident #49 was more anxious and had a decreased attention span since her admission. She stated Resident #49 slept in the afternoons and was up most of the night. After reviewing the resident's care plan during this interview, the AD agreed it was not individualized to meet Resident #49's needs. There were no specific activities listed for Resident #49 to do during the night when she was awake and lacked specific activities to distract the resident when she was feeling anxious. The facility's Administrator reviewed the resident's care plan during an interview on 02/13/18 at 1:19 PM and agreed Resident #49's care plan was not individualized and lacked interventions to guide staff in addressing Resident #49's anxiety, depression, and [NAME]D. The Administrator acknowledged the facility had not attempted to send Resident #49 to a neurologist, that no follow up psychiatric appointments were made until the previous week, and no supportive psychotherapy counseling was arranged.",2020-09-01
217,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2018-02-16,742,D,1,0,EN1S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident and family interview, and staff interview, the facility failed to ensure a resident with [MEDICAL CONDITION]'s Chorea received appropriate treatment and services to assist the resident to attain the highest practicable mental and psychosocial well-being. The facility failed to utilize outside resources to assist Resident #49 in coping with her progressive disease process. The facility failed to develop a care plan to provide guidance to direct care staff regarding the resident's individual needs. No individualized plans were in place to address her mental and physical expressions of distress. Diversional meaningful activities were not based on the resident's preferences, and/or abilities. This was found for one (1) of four (4) residents reviewed for behaviors. Resident identifier #49. Facility census: 102. Findings include: a) Resident #49 Review of the medical record on 02/12/18 at 1:20 PM, revealed Resident #49 is a [AGE] year-old admitted to the facility in (MONTH) (YEAR). [DIAGNOSES REDACTED]. Resident #49 was evaluated by a psychiatrist on 04/03/17. The summary notes for the evaluation noted Resident #49's [MEDICAL CONDITION]'s disease was currently being treated with Tetrabenzene ([MEDICATION NAME]) (a medicine used to treat involuntary movements of [MEDICAL CONDITION]'s disease) to suppress her motor symptoms. It is important to be aware that this treatment might aggravate mood problems such as depression. The treatment plan stated, The patient will benefit from the continued use of [MEDICATION NAME] 50 mg (milligrams) at bedtime. A smaller dose of 25 mg can be added in the daytime to reduce irritability. Because of the concern of [NAME]D ([MEDICAL CONDITION]) symptoms and possible development of depression, the patient might benefit from adding [MEDICATION NAME] 10 mg per day, which can be increased after two weeks to 20 mg per day. The Psychotherapy section stated (typed as written): Although the patient presents with some cognitive impairment, she might benefit from supportive psychotherapy to help her accepting and coping the changes in her living arrangement. The resident's medical record contained no evidence of supportive psychotherapy appointments or visits. The resident's electronic medical record included the following behaviors since 10/18/17: --10/18/17 The plan of care note stated, .She has a [DIAGNOSES REDACTED]. She takes [MEDICATION NAME], and Klonopin. She has obsessive thoughts/behaviors and compulsive behaviors. She is very impulsive and uncontrolled movements. She gets up on her own due to her impulsive and obsessive behaviors . --10/19/17 5:20 AM Resident's bed alarm going off and her call light was on, nurse found resident standing by bathroom door. Assisted to bathroom and returned to bed. --10/19/17 5:50 AM Resident found standing at nurse's station, bed alarm and call light sounding. Resident requested her morning medications. --10/21/17 6:37 PM Resident stumbling in hallway without assistance, chair alarm sounding. Redirection attempts ineffective. --10/22/17 11:21 AM Resident continues this morning to get up unassisted, one time she turned off her alarm and walked out into the hall. --10/30/17 6:37 PM Resident was tearful at 10:00 AM. Upset the Activities Director was busy. --11/19/17 6:35 AM Resident combative with staff during cares/attempted redirection. Striking at staff, attempting to bite staff. --11/20/17 5:59 AM Resident up at present in wheel chair, self transferring frequently through out shift. Adamant on getting up and calling her mom. Repeatedly asks about med times. Resident attempted to grab/strike write before/during transfers. --11/22/17 3:46 AM Up and down several times without assistance. Continues to be fixated on time, getting meds early, and using bathroom. Demands staff to be right with her when light or alarm sounds. --11/23/17 6:15 AM up in wheel chair fixated on finding the shower team --11/26/17 8:30 PM Nurse Aide (NA) heard alarm and found resident standing up by bed. --12/06/17 9:40 AM waiting for mother in hall and got up unassisted and fell . Resident is very anxious and tearful. --12/10/17 2:32 AM NA reported resident trying to throw herself to the ground while being assisted to the bathroom. Resident reported she had nothing to live for and acknowledged she was depressed. --12/18/17 Activity Director has attempted to redirect resident from being obsessed with her time for medications, bowel movements, calling her mother, whether or not her call bell is working and so forth on many occasions over the past several days. Resident has not been easily redirected most of the time. Resident states she has not been sleeping at night. --12/21/17 8:30 AM Resident agitated this morning, throwing self onto floor from wheel chair multiple times. States she is putting herself on the floor because no one will pay attention to her. --12/21/17 12:00 PM Spoke with physician regarding resident's intentional falls and informed him Medical Power of Attorney (MPOA)/mother was asking if he could adjust her meds since she is not sleeping at night. --12/22/17 4:14 AM Resident hit NA in face while assisting her with transferring --12/26/17 4:26 AM Resident self-transferring, ambulating ad-lib unassisted to bathroom, out of bed to chair. Demands immediate attention/help with requests. --12/29/17 3:40 PM Resident upset the activities director was not in the building and she could not reach her mother by phone. Threw herself to floor multiple times. Behaviors stopped once she talked to her mother. --01/18/18 10:44 AM The care plan meeting note included, .She has a [DIAGNOSES REDACTED]. She takes [MEDICATION NAME], and Klonopin. She has obsessive thoughts/behaviors and compulsive behaviors. She is very impulsive and uncontrolled movements. She gets up on her own due to her impulsive and obsessive behaviors .Resident does not sleep well at night. She chooses to only eat lunch, however her weight is good. Her mother visits several times a week. Resident is very anxious and wants to sit up and wait on her mom until she arrives. She sleeps well in the afternoon and will nap when her mother is here .Facility has tried 1:1 care at times due to impulsivity and frequent falls . --01/30/18 4:17 AM Resident asked to brush teeth in bathroom and then refused once in bathroom. Push NA away and fell to floor while being assisted to bed. Refused help for NA and got self back to bed. --02/01/18 2:14 AM Nurse called to assist NA in restroom. Resident noted to be speaking non-sense. Resident fighting aide and fell to floor. Placed in scoop chair resident stated Why are you guys so mean all the time? --02/01/18 2:45 AM Resident out of bed and in scoop chair at nurse's station. Continually getting out of chair and throwing self into staff. --02/01/2:55 AM Physician notified and [MEDICATION NAME] 1 milligram IM ordered. --02/01/18 3:15 AM Resident O[NAME] (out of control) attempting to run down hallways falls in floor --02/01/18 3:16 AM Resident refuses assistance. O[NAME] again. Resident had hard impact fall --02/01/18 3:55 AM Three person assist back to bed and [MEDICATION NAME] injection given --02/01/18 6:06 AM [MEDICATION NAME] has not been effective. Resident still up and down out of chair. Still asking repetitive questions and worrying excessively about her shower. --02/01/18 11:06 AM Nurse discussed behaviors with physician. Dr. (name) stated he would try a neurology consult if needed. --02/04/18 4:54 AM rang call light several times between 3:30 and 4:30 AM. Got out of bed unassisted at 4:54 AM and fell into bathroom door. Repeatedly asked what time do I get my meds? --02/05/18 2:00 AM UP and down since midnight. Heard alarm and found resident opening curtain. --02/06/18 5:30 AM NA assisted resident back to bed from bathroom, resident stiffened arms and legs and both fell . Resident told NA Ha Ha I get my meds now. --2/11/18 2:25 PM At 7 AM resident was standing outside her door calling for the nurse to help her back to bed. Fifteen minutes later resident found sitting on floor near wheel chair. The care plan focus for anxiety stated (typed as written): Resident has anxiety r/t (related to) admission, long-standing history, medical condition as evidenced by worrying daily about activities, meal times, medication times, sleep patterns, bowel habits, progression of disease, staffing and family. Resident is easily distracted and can become preoccupied with several concerns or issues at once. Resident is persistent and will insist and demand at times that her needs and requests be met immediately. The goal was, Resident to have a reduction in anxious episodes to less than daily through next review. Interventions included, 1. Administer medication as ordered for anxiety. 2. Assist resident in calling her family when she is worried about them. 3. Dry erase added to resident's room to record daily staffing, and other frequently asked questions for resident. 4. Observe for and document and s/sx (signs/symptoms) of side effects such as, but not limited to [MEDICAL CONDITION], agitation and hallucinations. 5. Offer activities to help distract resident when she is feeling anxious. 6. Provide emotional support and calm reassurance to resident if she is sad, tearful or anxious. 7. Resident requires constant reassurance at times. Allow her to express feelings and reassure her that her concerns are being heard. The resident's care plan lacked specific approaches for staff to utilize in response to Resident #49's increased anxiety, and [MEDICAL CONDITION] ([NAME]D). The care plan lacked meaningful activities related to Resident #49's customary routines, interests, or preferences and failed to include diversional activities during the evening and nights when she displayed most of her behaviors and is unable to sleep. During an interview on 02/13/18 at 10:15 AM with Resident #49 and her mother/MPOA, Resident #49 reported she felt tired all the time, was unable to sleep at night, had trouble concentrating and often felt anxious. When asked to describe how she felt when she was anxious, Resident #49 stated, Very nervous, can't sit still. She acknowledged her jerking movements became more pronounced with her anxiety, that she got up independently at times which often resulted in a fall, and put herself on the floor at times for attention. Resident #49 stated she cannot concentrate, thoughts just flow through her head. Resident #49 stated she was not sure what would make her feel better, but would like to feel less anxious and more comfortable in her environment. Resident #49 and her mother/MPOA acknowledged Resident #49 had not been offered supportive psychotherapy as recommended by the psychiatrist. Resident #49 expressed she felt the facility was not meeting her psychosocial needs. During an interview on 02/13/18 at 1:00 PM, the Activities Director (AD) #194 reported Resident #49 was more anxious and had had a decreased attention span since her admission. She stated Resident #49 slept in the afternoon and was up most of the night. The AD reviewed the care plan during this interview and agreed it was not individualized to meet Resident #49's needs. There were no specific activities identified for Resident #49 to do during the night when she was awake and lacked specific activities to distract the resident when she was feeling anxious. The facility's Administrator reviewed the care plan and medication administration records (MARs) during an interview on 02/13/18 at 1:19 PM. She acknowledged the records were incomplete regarding the monitoring of behaviors and the efficacy of non-pharmacological interventions. She agreed Resident #49's care plan was not individualized and lacked interventions to guide staff in addressing Resident #49's anxiety, depression, and [NAME]D. The Administrator acknowledged the facility had not attempted to send Resident #49 to a neurologist or make follow up psychiatric appointments until the previous week, and no supportive psychotherapy counseling was arranged.",2020-09-01
219,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,550,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure dignity during medication administration for Residents' #84 and #38. This was a random opportunity for discovery. Resident identifiers: #38 and #84. Facility census: 97. Findings included: a) Resident #38 At 11:48 AM on 04/01/19, Licensed Practical Nurse (LPN) #15, was observed obtaining the resident's blood sugar in the hallway, opposite the dining room on the Reflections unit. Record review found a physician's orders [REDACTED]. The resident's last full minimum data set (MDS), an annual, with an assessment reference date (ARD) of 11/06/18 coded the resident as having a score of 3 on the brief interview for mental status (BIMS). A score of 3 indicates the resident has severely impaired cognition. The resident would be unable to say if she preferred her blood sugar to be obtained in the hallway. On 04/01/19 at 2:13 PM, LPN #15 said she had just attended an in service about not giving medications while residents are in the dining room eating but nothing was said about obtaining blood sugars in the hallway. She was unaware she shouldn't obtain blood sugars in the hallway. On 04/02/19 at 1:02 PM, the above observation was discussed with the administrator. No further information was received before the close of the survey on 04/03/19 at 5:00 PM. b) Resident #84 At 11:44 AM on 04/01/19, Resident #84 was observed in the hallway, across from the dining room on the Reflections Unit, with LPN #15 and Resident #34. LPN #15 raised the resident's shirt and was attempting to inject insulin into the abdomen of Resident #84. The resident became combative. She was waving her hands and trying to push away the insulin. The Resident was making growling noises. LPN #15, said to the surveyor, Well I guess I will try this later. Record review found Resident #84's last full minimum data set (MDS), a significant change MDS, with a reference assessment date (ARD) of 12/11/18 coded the resident as having memory problems both long and short term. Daily decision making was severely impaired. On 04/01/19 at 2:13 PM, LPN #15 said she had just attended an in service about not giving medications while residents are in the dining room eating but nothing was said about obtaining blood sugars in the hallway. She said she was unaware she shouldn't give injections in the hallway. LPN #15 said she later gave the injection to the resident in the hallway, after the resident calmed down. Record review found Resident #84 has a physician's orders [REDACTED]. On 04/02/19 at 1:02 PM, the above observation was discussed with the administrator. The administrator had no comment. At 1:30 PM on 04/02/19, the administrator provided a copy of the medication administration audit report noting the resident received the [MEDICATION NAME] at 12:04 PM on 04/01/19.",2020-09-01
220,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,558,D,0,1,P29Y11,"Based on observation and resident/staff interviews, the facility failed to keep the call light easily accessible for Resident #21. This was a random opportunity for discovery. Facility census: 97 Findings included: a) On 04/03/119 it was observed at 8:30 a.m. the call light was down in the floor between the bed and a nightstand as it had been on the day of tour 04/01/19 . Interview with the administrator immediately after this observation revealed the resident does keep the call bell on the floor in that position, but they could get her a cow bell or some kind of bell that may work to provide her with some way of communication with staff should she need help.",2020-09-01
224,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,686,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, and to prevent infection in a pressure ulcer. There was a delay in treatment for [REDACTED]. This was true for One (1) of two (2) reviewed for care of pressure ulcers. Resident identifier: #6. Facility census: 97. Findings included: a) Resident #6 A review of Resident #6's medical record at 8:27 a.m. 04/02/19 found a wound culture which was collected on 10/23/18. The results of this wound culture was released to the facility on [DATE] and indicated the resident had staphylococcus in the wound. A nurse wrote on the lab result that it was noted on 10/28/18. The certified nurse practitioner (CFNP) did not sign the lab until 10/29/18 at which time she ordered [MEDICATION NAME] 500 mg every day for 10 days. Review of the Medication Administration Record [REDACTED]. An interview with the Nursing Home Administrator at 8:00 a.m. on 04/03/19 confirmed Resident #6 was not started on her antibiotic for the wound infection until 10/30/18. She stated, I don't know where the delay came from.",2020-09-01
225,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,758,D,0,1,P29Y11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #98's medication regimen was free from unnecessary [MEDICAL CONDITION] medications. She received two doses of as needed [MEDICATION NAME] prior to the facility implementing non pharmacological interventions. This was true for One (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #98. Facility census: 97. Findings include: a) Resident #98 A review of Resident #98's Medication Administration Record [REDACTED].m Further review of the medical record found no evidence the facility implemented any non pharmacological interventions prior to the administration of this medication. An interview with the Nursing Home Administrator at 11:06 a.m. on 04/03/19 confirmed there was not any non pharmacological interventions implemented prior to the administration of the as needed [MEDICATION NAME].,2020-09-01
227,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,770,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain a physician ordered laboratory test for Resident #80. Resident #80's physician ordered a [MEDICAL CONDITION] Stimulating Hormone (TSH) test to be performed on 12/08/18 and there was not evidence this test was performed. This was true or one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #80. Facility census: 97. Findings included: a) Resident #80 A review of Resident #80's medical record at 12:28 p.m. on 04/03/19 found a lab result for a TSH that was drawn on 11/27/19. The physician reviewed this lab report on 11/28/18 and wrote the following, This is improving. Next TSH should be drawn in 10 days and fax me the results. Ten (10) days from 11/28/18 would have been 12/08/18. The medical record contained no evidence that this TSH level was obtained on or around 12/08/18. An interview with the Nursing Home Administrator at 3:02 p.m. on 04/03/19 confirmed this TSH level was never obtained.",2020-09-01
228,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,773,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that Laboratory testing was only performed when ordered by a physician and that when a Laboratory Testing was performed that the ordering physician was promptly notified of the results. Resident #80 had a [MEDICAL CONDITION] Stimulating Hormone (TSH) level obtained on 11/27/18 and there was no order in the medical record for this TSH. For Resident #38 the facility failed to notify the attending of a lab result. This was true for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #80 and #38. Facility census: 97. Findings included: a) Resident #80 A review of Resident #80's medical record at 12:28 p.m. on 04/03/19 found a lab result for a TSH that was drawn on 11/27/19. Further review of the medical record found no physician order for [REDACTED].>An interview with the Nursing Home Administrator at 1:38 p.m. on 04/03/19 confirmed there was no physician order for [REDACTED]. b) Resident #38 On 02/19/19, the facility collected a specimen for a Chem 7 and HGB A1C. (A Chem 7 test can be used to evaluate kidney function, blood acid/base balance, and your levels of blood sugar, and electrolytes. The hemoglobin A1C test tells you your average level of blood sugar over the past 2 to 3 months.) Review of the resident's electronic medical record at 1:00 PM on 04/03/19, found no evidence of the results of the Chem 7 and HgbA1c obtained on 02/19/19. At 1:29 PM on 04/03/19, the Director of Nursing was asked if she could find the results of the laboratory values for the Chem 7 and the HGB A1C 1C. At 3:03 PM on 04/03/19, the DON provided a copy of the laboratory report, obtained on 02/19/19. The report indicated the laboratory results were faxed to the facility at 2:07 PM on 04/03/19. The DON said the report had been in the physician's box awaiting his signature for the past 2 months. The DON provided a copy of a nursing note, dated 02/19/19 noting the lab results were received and faxed to the physician. The DON was unable to provide evidence the physician actually reviewed the faxed report.",2020-09-01
229,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,804,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #36's food was at a safe and appetizing temperature during the noon meal on 04/01/19. This was a random opportunity for discovery. Resident identifier: #36. Facility census: 97. Findings included: a) Resident #36 Record review found Resident #36 was admitted to the facility on [DATE]. The resident was residing on the Reflections unit. The Reflections Unit required a code to be entered on a key pad to both enter and exit the unit. The unit houses 20 residents when full. The unit is not a certified Alzheimer's/Dementia unit. Residents on this unit have cognitive loss. Observation of the noon meal on 04/01/19 found the resident received his meal at approximately 12:30 PM. The Resident was seated alone at a table beside the back wall of the dining room. At 2:20 PM on 04/01/19, the Resident was still seated at the same table continuing to eat his noon meal. He had eaten his broccoli. A BBQ sandwich, tater tots, and milk remained. At 2:20 PM on 04/01/19, the resident's Licensed Practical Nurse (LPN) #15, said the Resident likes to eat, He will eat all day long, so we just let him. The resident's current care plan was reviewed with LPN #15. An intervention on the care plan noted the resident would receive food as an intervention to distract the resident from wandering. The care plan did not include providing continuous food. At 2:31 PM on 04/01/19, the dietary manager was asked to take the temperature of the resident's meal. The temperature of the BBQ was 64 degrees, tater tots were 66 degrees. The DM obtained the temperature of his milk and said, It's at 68 degrees and continuing to rise. The DM said the temperatures were not acceptable. We could do more meals a day, we have done that before. She said she did not realize the resident liked to have food all day long. The DM checked the pantry and said there is plenty of milk in the refrigerator and snacks are available. She said, At least the resident's tray needed to be heated in the microwave if he was going to take a long time to eat it. On 04/02/19 at 1:02 PM, the administrator said she was unaware of the above observation and interviews.",2020-09-01
230,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,842,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #38's medical record was complete and legible. This was found for one (1) of twenty-one (21) records reviewed. Resident identifier: #38. Facility census: 97. Findings included: a) Resident #38 Review of the consultant pharmacist reports dated 04/16/18 and 11/15/18 found the pharmacist made medication recommendations after review of the Resident's current medications. The report required the physician to write a response, sign and date the recommendations. Review of a laboratory report of a [MEDICATION NAME] acid collected on 12/19/18 found the physician had made only a mark on the laboratory report. At 1:29 PM on 04/03/19, the Director of Nursing reviewed the consulting pharmacist reports. The DON confirmed she could not read the date the physician reviewed the 04/16/18 and 11/15/19 reports. The 04/16/18 reports had only a one single mark of a pen which was did not represent a month, day or year. She believed the report for 11/15/18 was signed in (MONTH) but she could not read the date or the year. The DON could not say the reports were reviewed timely when the physician's writing was illegible. In addition, the DON unable to read the date on [MEDICATION NAME] Acid lab from 12/19/18. She said the mark on the laboratory report was the physician's signature but she did not see a date.",2020-09-01
231,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-04-03,880,D,0,1,P29Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, medical record review, and staff interview the facility failed to the facility failed to ensure staff used appropriate infection control practices to prevent the development and transmission of infectious and communicable disease within the facility. Facility staff failed to use proper technique during perineal care to eliminate the spread of infectious diseases for Resident #16. Oxygen tubing was found to be maintained in an unsanitary manner for Resident #30. This was a random opportunity for discovery. This practice had the potential to affect more than an isolated number of Residents. Resident Identifiers: #16, #30. Facility Census: 97. Findings included: a) Resident #16 On 04/03/19 at 1:19 PM Nurse Aide (NA) #36 and NA #141 were observed as they provided perineal care (washing genitalia and surrounding area) for Resident #16. NA #36 presented to bedside with gloves donned (to put on gloves), with one wet soapy wash cloth, one wet wash cloth without soap, one dry wash cloth, and no wash basin. NA #36 draped all wash clothes across top of left upper bed rail and positioned Resident supine (on back), unfastened Resident's brief and folded the front of brief down and tucked it under the Residents buttock. Resident's brief was visibly soiled with a bowel movement and urine. NA #36 proceeded with perineal care by separating Resident's legs that were bent at the knees and very stiff (due to contractures) and made one wipe down the front of the perineum across the labia with the soapy wash cloth. NA #141 then assisted NA #36 to turn resident to her right side and NA #36 folded soiled soapy wash cloth over one time and wiped one pass up the Resident's buttocks. NA #36 then wiped the perineal area one time from front to back bewteen the buttocks with the wash cloth that was said to be a rinse wash cloth containing only water, then wiped one time between the buttocks with the dry wash cloth. NA #36 then pulled soiled brief out from under resident, rolled brief up and laid brief on top of trash bag on foot of bed with soiled washcloths on top. Without removing soiled gloves, NA #36 then walked over to resident's dresser, opened top drawer with soiled gloves on, shuffled through clothing and obtained heel protectors from drawer and placed them on resident. NA #36 then separated soiled brief from soiled washcloths, removed soiled glove from right hand only, and placed items in separate trash bags. While continuing to wear soiled glove on left hand, NA# 36 covered resident up with sheet with both hands, lowered bed with right ungloved hand, and placed call bell on resident's chest with left hand. NA#36 then removed soiled glove from her left hand and handed trash bags to NA# 141 for disposal, and went to bathroom and washed hands. Review of Perineal Care policy with revise date of 10/16/16 included the following instructions for perineal care for a female resident without an indwelling catheter: -Wet wash cloth and apply soap or skin cleansing agent. -Wash perineal area, wiping from to back. -Separate labia and wash area downward from front to back. -Continue to wash perineum moving from inside outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Do not use same washcloth or water to clean the urethra or labia. -Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. -Gently dry perineum. - Instruct or assist the resident to turn on her side with her top leg slightly bent, if able. -Rinse wash cloth and apply skin cleansing agent. -Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. Do not reuse the same wash cloth or water to clean the labia. -Rinse thoroughly. -Dry area thoroughly. -Discard disposable items into designated containers. -Remove gloves and discard into container. Wash and dry your hands thoroughly -Reposition the bed covers. Make resident comfortable. Review of employee record revealed NA #36 attended in-service training on 01/15/19 for education of perineal care and hand hygiene and successfully completed staff competencies for female incontinence care (perineal care) in bed and proper hand washing technique observed by Director of Staff Development Registered Nurse (RN) #20. During an Interview on 04/03/19 at 2:43 PM, Director of Staff Development Registered Nurse #20 verified NA# 36 was in attendance for in-service training on 01/15/19 for perineal care of residents, and NA #36 demonstrated competency in care area by successfully completing skills evaluation check off. b) Resident #30 During an observation on 04/01/19 at 11:06 AM, it was noticed the Nasal Cannula (NC) (oxygen tubing that goes in the residents nose) was on the floor. The oxygen machine running, Licensed Practical Nurse (LPN) #1 was asked to come to the room. She removed the tubing and said, that she was going to replace it with a new one. On 04/03/19 at 4:40 PM, Administrator was informed of findings.",2020-09-01
232,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2017-04-20,272,D,0,1,GGWL11,"Based on record review and staff interview, the facility failed to conduct an accurate comprehensive minimum data set (MDS) assessment for one (1) of nineteen (19) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The comprehensive assessment for Resident #152 did not accurately reflect that the resident received an anticoagulant medication. Resident identifier: #152. Facility census: 104 Findings include: a) Resident #152 Medical record review, on 04/19/17 at 10:57 a.m., revealed an Medication Administration Record [REDACTED]. The comprehensive MDS assessment with the Assessment Reference Date (ARD) of 03/31/17 did not accurately indicate Resident #152 was receiving an anticoagulant. On 04/19/17 at 4:20 p.m., during an interview with the MDS Coordinator, she verified the MDS (Section N: Medications) with the ARD of 03/31/17 did not reflect Resident #152 as taking an anticoagulant.",2020-09-01
234,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2018-04-25,685,D,0,1,CEG811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician's orders to irrigate ears after the completion of treatment to loosen ear wax. This affected one resident of one reviewed for reviewed for hearing. Resident identifier: #90. Facility census: 94. Findings included: a) Resident #90 The medical record for Resident #90 was reviewed on 04/24/18 at 9:22 [NAME]M. Resident #90 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 30-day Minimum Data Set (MDS) assessment, dated 04/12/18, indicated the resident had adequate hearing. The physician's orders were reviewed and the Medication Administration Record [REDACTED]. The physician's orders directed staff to Instill application in both ears three times a day for ear wax for five days in ear canal with [MEDICATION NAME]. Irrigate with lukewarm tap water 20 minutes after last dose. A nurse's note dated 04/18/18 at 8:59 [NAME]M. stated the resident told the nurse she knew her ears were full of wax because the nurse yesterday told her so. The nurse called the physician and discontinued a 2nd round of the [MEDICATION NAME] Solution and ordered a consult with an ear specialist regarding possible ear wax impaction. On 04/23/18 at 10:32 [NAME]M. an initial interview was conducted with Resident #90. The resident stated she had been receiving drops in her ears for wax build up and the nurse was supposed to suction her ears out after the drops were completed and didn't. The resident stated she was going to go to an ear doctor because she could not hear well out of her right ear and the nurse said it was because it was full of wax. On 04/24/18 at 9:01 [NAME]M., Resident #90 was re-interviewed and was able to hear all questions asked during the interview. The resident was asked, Can you hear okay since you still have wax in your ears? The resident stated there were no problems with hearing. On 04/24/18 at 9:36 [NAME]M. Registered Nurse (RN) #138 was interviewed. RN #38 stated she tried to irrigate the resident's ears on 04/16/18 because the resident told her the nurse didn't do it when the last drops were given two days prior. RN #138 could not confirm if the nurse irrigated the resident's ears or not. RN #138 stated the resident was in the process of receiving an appointment with the ear doctor for an appointment for ear wax removal. On 04/24/18 at 2:24 P.M. the Interim Director of Nursing (DON) #45 was interviewed. Interim DON #45 stated the facility received physician orders on 04/8/18 for the [MEDICATION NAME] Solution for the resident's ears. The Interim DON #45 stated she called the nurse who was suppose to irrigate the ears on 04/14/18 on the last dose and the nurse stated she did not do it. The Interim DON #45 stated a second physician's order for another round of [MEDICATION NAME] Solution was ordered, but was discontinued and on 04/18/18 the physician ordered the resident to be seen by a ear doctor instead. The Interim DON #45 verified the nurse did not follow the physician's orders to irrigate the ears after the last dose of [MEDICATION NAME] Solution on 04/14/18.",2020-09-01
236,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2018-04-25,758,D,0,1,CEG811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to conduct gradual dose reductions for [MEDICAL CONDITION] drugs in an effort to discontinue those drugs for one of six residents reviewed for Unnecessary Medications. Specifically, the facility failed to attempt a gradual dose reduction for Resident #100's anti-psychotic medication. [MEDICATION NAME], with no evidence of justification for the medication. Resident identifier: #100. Facility census: 94. Findings included: a) Resident #100 The behavior management policy, last revised on 05/30/17, was provided by the interim director of nursing (DON) on 04/25/18 at 9:48 AM. The policy read in pertinent part: --It is the policy of this facility to enhance the quality of life for each resident by assuring the optimal level of functioning with the least restrictive yet safe environment. A [MEDICAL CONDITION] drug is any drug that affects brain activities . These drugs include drugs in the following categories: anti-psychotic . Initiate and maintain a behavior monitoring record . Attempt to manage the behavior through non-pharmacological interventions . Notify the legally responsible party if medical intervention is needed and complete informed consent for psycho-active medication consent and have signed . Maintain clinical documentation to record behavior exhibited and response to interventions and observation of continued behaviors . If medication is necessary, monitor for side effects and the resident's response to the medication and any unusual drowsiness . New physician orders [REDACTED]. Medications will be monitored by the consultant pharmacist, DON or his/her designee and dose reduction attempted at least every three to six months as ordered by physician. Resident #100 admitted to the facility on [DATE], with a current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments and care plans were reviewed on 04/24/18 at 9:26 AM. According to the 04/3/18 MDS assessment, the resident was rarely or never understood. He had short term and long term memory problems. He exhibited no behaviors. The resident was totally dependent on staff for all activities of daily living (ADL). The care plan, initiated 03/18/18 and revised 04/18/18, identified the resident received a daily anti-psychotic medication and was at risk for adverse side effects. Interventions included collaborating with the provider to identify opportunities to decrease medication dosage and then evaluate for new or recurring behavioral symptoms. The care plan, initiated 01/25/17 and revised 04/15/18, identified the resident had impaired cognitive function related to [MEDICAL CONDITION] as evidenced by hitting, pinching and grabbing during care. Interventions included offering non-pharmacological interventions to resident such as a back rub, offering snacks, repositioning as well as if the resident becomes combative or agitated with care then staff were to return later to provide care if possible when the resident had calmed down. On 04/23/18 at 3:37 PM, the resident was lying in bed with his eyes closed. He was unable to be aroused when spoken to. The resident's roommate indicated the resident slept all day. Earlier in the day, the resident was sitting up in his wheelchair with his eyes closed. He was unable to be aroused when spoken to. On 04/24/18 at 8:57 AM, 2:35 PM, and 3:36 PM, the resident was observed to be lying in bed with his eyes closed. The resident's representative was interviewed on 04/24/18 at 9:03 AM. She explained the resident was at another nursing facility for a few months prior to his admission at this facility. She indicated she was not aware the resident received the anti-psychotic medication [MEDICATION NAME]. She said that the resident had never had any behaviors or been aggressive with staff that she was aware of. She said the staff had always told her that he was a great patient. She did not feel that the medication was necessary. She wondered if the medication contributed to the resident's drowsiness. She indicated the resident had stopped speaking over the past several months. The resident's representative was interviewed again on 04/25/18 at 9:43 AM. She said the facility had called her the previous night and informed her that she had signed the consent for [MEDICATION NAME] back in (MONTH) (YEAR). They provided her with the consent, but she still could not remember signing the paperwork. She could not believe that she would sign it. She again stated that the resident had never had any behaviors. She said the resident did not have any behaviors at the previous facility either, except he would call out sometimes. She said when the facility called her last night, they told her they were going to get him off of the [MEDICATION NAME]. She hoped the resident had not become addicted to the medication resulting in side effects or withdrawal after getting him off of the medication. She did not believe the medication was necessary. The 4/18 physician orders [REDACTED]. The resident had the following orders: 11/27/17 - Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) 25 milligram one tablet by mouth at bedtime related to dementia with behavioral disturbance. 11/27/17 - Resident receives [MEDICATION NAME] for dementia with behavior disorder AEB (as evidenced by) verbal aggressive behaviors. On 04/15/18, the order was revised to include the behaviors of grabbing and hitting. Staff were to observe for these behaviors during each shift and document whether the behavior was present or not. The resident had zero behaviors documented for the month of (MONTH) (YEAR). 12/27/17 - Resident receives [MEDICATION NAME] for dementia with behaviors. Observe for side effects or medication such as changes in appetite, dry mouth or drowsiness. The staff were to document if the side effects were present or not. There were no documented side effects for the month of (MONTH) (YEAR). Further review of the resident's medical record was completed on 04/24/18 at 10:00 AM. Review of the psychoactive medication informed consent revealed the resident's representative had signed the form on 01/23/17, the day of admission. The consent was for 25 mg of [MEDICATION NAME] every night. The form did not document that any non-drug approaches had been ineffective. The medical [DIAGNOSES REDACTED]. The target symptoms were restlessness and agitation. The beneficial effects were no more restlessness or agitation. The proposed course of the medication was indefinite. Review of the pharmacy recommendations revealed the pharmacist had recommended a gradual dose reduction (GDR) five times since admission. On 02/3/17, the recommendation documented in pertinent part, (Resident #100) has dementia and receives an antipsychotic, Quetiapine 25 mg hs (at night). Recommendation: Please consider reducing the dose of Quetiapine [MEDICATION NAME] to 12.5 mg hs with the eventual goal of discontinuation, while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. This recommendation was declined by the physician documenting that the resident was stable. On 04/14/17, the recommendation documented in pertinent part, (Resident #100) has received Quetiapine [MEDICATION NAME] 25 mg daily for behavioral or psychological symptoms of dementia since 01/23/17. Recommendation: Please consider a gradual dosage reduction to 12.5 mg daily, with the end goal of discontinuation of therapy. The Director of Nursing (DON) at the time wrote on the form, Resident does well on this dose. Therefore the physician declined the recommendation. On 10/20/17, the recommendation documented in pertinent part, (Resident #100) receives [MEDICATION NAME] 25 mg hs for behavioral or psychological symptoms of dementia since 01/23/17. Regulations require at least a quarterly review to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose. No reduction has been attempted. Recommendation: For the initial attempt at gradual dose reduction (GDR) in the facility, please consider decreasing to 25 mg every other day at bedtime while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. Please note: Per federal nursing facility regulations, this individual does not meet criteria for GDR to be deemed clinically contraindicated because a GDR has not yet been attempted in the facility following the most recent admission. This recommendation was declined by the physician documenting that the resident was stable. On 01/12/18, the recommendation documented in pertinent part, (Resident #100) receives [MEDICATION NAME] 25 mg hs for behavioral or psychological symptoms of dementia since 01/23/17. Regulations require at least a quarterly review to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose. No reduction has been attempted. Recommendation: For the initial attempt at gradual dose reduction (GDR) in the facility, please consider decreasing to 25 mg every other day at bedtime while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. Please note: Per federal nursing facility regulations, this individual does not meet criteria for GDR to be deemed clinically contraindicated because a GDR has not yet been attempted in the facility following the most recent admission. This recommendation was declined by the physician documenting that the resident was stable. On 04/16/18, the recommendation documented in pertinent part, (Resident #100) receives [MEDICATION NAME] 25 mg hs for behavioral or psychological symptoms of dementia since 01/23/17. Regulations require at least a quarterly review to determine the effectiveness of the antipsychotic and the potential for reducing or discontinuing the dose. Recent eMAR (electronic medication administration record) indicates no aggressive behaviors. Recommendation: Please consider decreasing to 25 mg every other day at bedtime for 14 days then discontinue while concurrently monitoring for re-emergence of target and/or withdrawal symptoms. Please note: Per federal nursing facility regulations, this individual does not meet criteria for GDR to be deemed clinically contraindicated because a GDR has not yet been attempted in the facility following the most recent admission. This recommendation had the following comment from the interim DON, Reviewed with doctor by phone and received order to DC (discharge) [MEDICATION NAME]. Order written 04/24/18. Review of the physician progress notes [REDACTED]. There was no rationale for the continued use of [MEDICATION NAME]. Review of the MAR from 01/17 to 04/18 revealed that the resident was observed to have restlessness or agitation on three dates, 05/12/17, 06/26/17, and 06/27/17. The resident was not observed to have any side effects from the [MEDICATION NAME] from 01/17 to 04/18. Review of all progress notes from 01/17 to 04/18 revealed the resident was mostly pleasant and cooperative with staff. There was a behavior note from 06/26/17 that the resident became combative and was hitting staff while applying a cream to the resident's face. No other behavior concerns noted. On 4/24/18 at 7:26 PM, the interim DON documented in the progress notes her conversation with the doctor and resident's representative. She called the doctor and requested a dose reduction trial for [MEDICATION NAME] and the doctor told her to discontinue the medication. Certified nurse aide (CNA) #120 was interviewed on 04/24/18 at 3:50 PM. She had worked at the facility for two years, so she was very familiar with the resident. She said he had never had behaviors since being at the facility. The resident had never verbalized anything to her. He was only able to grunt. The resident always had his eyes closed. He was not always asleep, he just had his eyes closed. She said the resident was never combative. He was physically incapable of being combative because he was too contracted. She never had any issues with the resident. The Director of Social Services (DSS) and Social Worker (SW) #88 was interviewed on 04/24/18 at 4:01 PM. The DSS indicated they had a meeting every week to report on [MEDICAL CONDITION]. They talked about who had came on and off [MEDICAL CONDITION]. The SW said the resident was nonverbal. He used to be able to say a couple words, but now he was unable to talk. The resident did not move very much and he did not have any behaviors. He was not combative. She said the resident was admitted on [MEDICATION NAME]. He was on it at his previous facility. She thought he may have had more behaviors when he was there. Both the DSS and SW said that nursing was the one that kept track of GDRs (gradual dose reductions) and discussed changes to medications. They both indicated that the physician did not like to do dose reductions. The interim DON was interviewed on 04/24/18 at 4:17 PM. She started at the facility towards the end of (MONTH) (YEAR). She believed the resident was taking [MEDICATION NAME] due to a history of behaviors. She said the resident did not currently have behaviors. She could not speak to when he was first admitted . She confirmed the resident was admitted on the [MEDICATION NAME] and there had been no changes to the medication since admission. She said that a dose reduction should have been attempted sometime over the last year. She confirmed that the pharmacy had made several recommendations for a dose reduction, but the doctor had always declined the recommendation due to the resident being stable. She said there was not much she could do if the doctor did not agree with the pharmacist for a dose reduction. She said she would try to speak with his doctor to get a dose reduction. The interim DON was again interviewed on 04/25/18 at 9:48 AM. She said she had spoken with the doctor and received an order to discontinue the [MEDICATION NAME].",2020-09-01
237,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2018-06-12,755,D,1,0,LZL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and review of the facility's guidance tool for insulin storage, the facility failed to discard two (2) vials of insulin after having been opened for use for greater than twenty-eight (28) days. Another insulin vial was not inscribed with the date of initial opening, which rendered it so that it could not be determined as to what date to dispose of that vial. This was evident for one (1) of five (5) medication carts, and affected Residents #17 and #57. Facility census: 94. Findings include: a) Resident #17 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #17 which was marked as having been initially opened on 05/05/18. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. This guidance tool for the storage of medications stated that [MEDICATION NAME] may be used for twenty-eight (28) days after having been initially opened, and may be stored in a refrigerator or at room temperature from thirty-six (36) degrees Fahrenheit (F) to eighty-six (86) degrees F. b) Resident 57 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of Humalog insulin for Resident #57 which was marked as having been initially opened on 05/10/18. The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #57 which was delivered to the floor on 05/03/18. There was no date inscribed to indicate when this vial of insulin had been initially opened for use. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. This guidance tool for the storage of insulin stated that Humalog insulin may be used for twenty-eight days after having been initially opened. She agreed this vial of Humalog should be disposed of. This guidance tool for the storage of insulin stated that [MEDICATION NAME] may be used for twenty-eight (28) days after having been initially opened. E#133 acknowledged it could not be determined when the twenty-eight (28) storage days ended since there was no date to signify when the vial of insulin was initially opened. She agreed this vial of [MEDICATION NAME] should be disposed of. The administrator was informed on 06/11/18 at 2:10 p.m. of the two (2) vials of insulin which were opened and in use for greater than twenty-eight (28) days. She was informed of the vial of insulin whose initial date of opening could not be determined, and therefore could not be determined when the maximum length of time for use ended. On 06/11/18 at 3:00 p.m. the administrator provided a copy of the facility's insulin storage recommendations as provided by their consultant pharmacy. She said nursing staff attended mandatory nurses' meetings on 06/07/18 which were presented at 7:15 a.m., 2::00 p.m., and 3:15 p.m. She provided a copy of the attendance record sheets which were signed by fifty-one (51) staff persons comprised of registered nurses, licensed practical nurses, nursing assistants, and feeding assistant. She said hand-outs were given to nurses titled How Long Should You Keep Your Open Insulin Vials?, and Centers for Medicare and Medicaid Services (CMS) document titled Medication Storage (and Labeling). She said nursing staff should have been aware of the storage guidelines for insulin vials related to when to discard an opened vial.",2020-09-01
239,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-10-08,609,D,1,0,RZPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon staff interview, observation and record review, the facility failed to ensure that an allegation of neglect was reported to the state survey agency and the state protective services agency. A resident's responsible party made a complaint that after she requested he be put to bed, her family member was left unattended in his wheelchair for two hours in his room, resulting in a fall. This was found for one (1) of seven (7) residents reviewed. Resident identifier: #54. Facility census: 103. Findings included: a) Resident #54 Record review revealed a complaint documented on 09/03/19 from a family member to Social Worker #132. The description of the concern was (typed as written): MPOA (Medical Power of Attorney) concerned that she left resident at 7:30 (PM) with his call light on to lay down and he fell at 9:30 (PM) from his wheelchair. (The incident report for the fall also documented he was found on the floor in front of his wheelchair.) Niece had requested he be transferred to bed or wheelchair to prevent fall. (Social Worker #132 explained on 10/8/19 at 2:35 PM she meant to write recliner but wrote wheelchair in error.) She feels he is not being repositioned or moved out of wheelchair and gets tired. The niece remarked she .would like resident to not be left in wheelchair unattended. Move to recliner or bed. Social Worker #132 stated on 10/8/19 at 2:35 PM she had educated Nursing Staff to not leave resident #54 in his wheelchair unattended previously on 8/20/19, and this had been added to his care plan. A care plan note written by Social Worker #132 on 8/20/19 stated in part (typed as written): Resident's niece attended meeting. Resident lacks capacity and is a full code. His niece is his POA and MPO[NAME] He has a [DIAGNOSES REDACTED]. He takes [MEDICATION NAME] and [MEDICATION NAME]. Niece would like him to be out of his wheelchair and in his bed or recliner more during the day. The investigation of the complaint was done by Administrator #144. During an interview on 10/8/19 at 2:47 PM, Administrator #144 agreed resident #54 had been left in his wheelchair for two hours after the niece had left the building. She agreed Nursing staff had been requested to transfer him to bed. She was advised the niece's expressed complaint on the morning after the fall, 9/3/19 that after she had requested resident #54 be put to bed, he was instead left in his wheelchair for two more hours unattended and then fell was an allegation of neglect, and should have been reported as such to all appropriate agencies. She acknowledged understanding of the statement. d) The review of resident #54's record found sufficient evidence to substantiate the facility failed to report an allegation of abuse/neglect.",2020-09-01
240,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2019-10-08,689,D,1,0,RZPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon staff interview, observation, and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. A resident was observed without ordered leg rests and chair alarms. This was found for one (1) of seven (7) residents reviewed. Resident identifier: #54. Facility census: 103. Findings included: a) Resident #54 Record review found a complaint documented on 9/3/19 from his family member to Social Worker #132. The concern was (typed as written): MPOA (Medical Power of Attorney) concerned that she left resident at 7:30 (PM) with his call light on to lay down and he fell at 9:30 (PM) from his wheelchair. (The incident report for the fall also documented he was found on the floor in front of his wheelchair.) Niece had requested he be transferred to bed or wheelchair to prevent fall. (Social Worker #132 explained on 10/8/19 at 2:35 PM she meant to write recliner but wrote wheelchair in error.) She feels he is not being repositioned or moved out of wheelchair and gets tired. The niece remarked she .would like resident to not be left in wheelchair unattended. Move to recliner or bed. Social Worker #132 stated on 10/8/19 at 2:35 PM she had educated Nursing Staff to not leave resident #54 in his wheelchair unattended previously on 8/20/19, and this had been added to his care plan. A care plan note written by Social Worker #132 on 8/20/19 stated in part (typed as written): Resident's niece attended meeting. Resident lacks capacity and is a full code. His niece is his POA and MPO[NAME] He has a [DIAGNOSES REDACTED]. He takes [MEDICATION NAME] and [MEDICATION NAME]. Niece would like him to be out of his wheelchair and in his bed or recliner more during the day. Review of resident #54's current physician's orders [REDACTED]. Resident #54 was observed at least four times each day during the investigation. On 10/8/19 at 10:50 AM, resident #54 was observed in his wheelchair just outside of his room adjacent to the Nursing Station. He was greeted, and nodded in acknowledgement. He was observed to have no leg rests on his chair, and there was also no type of chair alarm present. At 10:53 AM, Nursing Assistant #86 was asked if he was supposed to have leg rests on his wheelchair. She said: Yes, I haven't had time to put them on yet. She was asked if he was supposed to have a chair alarm in place. She said: No, he only has an alarm on his bed. Registered Nurse #147 was interviewed on 10/8/19 at 10:55 AM. She was also asked about the leg rests, and she said: He is supposed to have them on his chair at all times. She was asked about the chair alarm, and she said: He is supposed to have the alarms in bed, in his recliner, and in the wheelchair. The review found sufficient evidence to substantiate the facility failed to ensure resident #54 received adequate supervision and assistance devices to prevent accidents.",2020-09-01
241,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,558,D,0,1,G76I11,"Based on observation and interview, the facility failed to ensure a call light and bed controller was accessible and within reach for two (2) residents. This was a random opportunity for discovery. Resident identifiers: #26 and #313. Facility census: 62. Findings included: a) Resident #26 On 02/10/20 at 3:02 PM, Resident #26's call light and bed controller were not in reach. The call light and bed controller were located at the head of the bed, behind the headboard on the left side of the headboard. Resident #26 was lying across the middle of the bed. Resident #26's feet were on the floor, body angled across the bed, and her head lying near the wall. Resident #26 had a nutritional shake in her hand and was yelling, I can't get up, I can't drink my milk. On 02/10/20 at 3:04 PM, Employee #[AGE], Nursing Assistant (NA), entered the room when asked by the surveyor. On 02/10/20 at 3:06 PM, Employee #6, NA, entered Resident #26's room to assist NA #[AGE]. On 02/10/20 at 3:09 PM, Employee #6, Nursing Assistant, placed the call light and bed controller after the surveyor asked where the call light and bed controller were located. On 02/12/20 at 3:13 PM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 0[DATE]20. b) Resident #313 On 02/11/20 at 8:53 AM, Resident #313's bed controller was observed to be located behind the headboard, on the right side of the bed. Resident #313, who has capacity to make medical decisions, was asked if he could adjust his bed. Resident #313 stated that the did not know where the controller was located. On 02/11/20 at 9:01 AM, Employee #96, Clinical Quality Consultant, placed the bed controller in reach of Resident #313. On 02/12/20 at 3:13 PM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
242,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,583,D,0,1,G76I11,"Based on observation and staff interview, the facility failed to ensure resident privacy. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents. Resident identifier: #26. Facility census: 62. Findings included: a) Resident #26 During the initial tour of the facility on 02/10/20 at 11:18 AM, Resident #26's window blinds handle, used to opening and closing the blinds, was observed to be off of the blinds and lying in the windowsill. On 02/10/20 at 11:22 AM, Employee #51, Maintenance Assistant, entered the room. Employee #51 examined the window blinds and attempted to place the handle back on the window blinds. Employee #51 stated that the window blinds were broken. Employee #51 stated that she would have someone repair the window blinds that day. Employee #51 was asked if the blinds could be pulled to allow the resident privacy since Resident #26's bed was against the wall as well as located on the side of the room with the window. Employee #51 stated that the blinds could not be closed. On 02/10/20 at 3:02 PM, the window blind was still broken and the handle to the window blind was still lying in the windowsill. Employee #[AGE], Nursing Assistant (NA), was asked to enter the room since Resident #26 was calling for help. On 02/10/20 at 3:06 PM, Employee #6, NA, entered the room to assist NA #[AGE] with providing care for Resident #26. On 02/10/20 at 3:09 PM, after Resident #26 was transferred to her wheelchair, the surveyor asked NA #6 and NA#[AGE] what do they do when providing personal care to Resident #26 since the window blinds do not close. NA #6 and NA #[AGE] stated that Resident #26 takes herself to the bathroom. When NA #6 and #[AGE] were asked how do staff members ensure privacy when assisting Resident #26 with changing clothes, assisting with bathing, or any other aspect of care, NA #6 and NA #[AGE] did not provide an answer. On 02/11/20 at 9:04 AM, the window blinds for Resident #26 were still broken, with the handle lying in the windowsill. On 02/11/20 at 9:06 AM, the Director of Nursing (DON), was asked to enter Resident #26's room. The DON examined the window and window blinds, stating that the blinds could not be adjusted, nor opened and / or closed, and she would have someone fix the blinds. On 02/12/2020 at 3:13 PM, the findings were discussed with the Administrator and the DON. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
243,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,684,D,0,1,G76I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. This was a random opportunity for discovery. Resident identifier: #26. Facility census: 62. Findings included: a) Resident #26 During the initial tour of the facility on 02/10/20 at 11:18 AM, a fall mat was observed to be propped up against the exterior wall of Resident #26's room. The fall mat was located between the exterior wall and the tv cabinet. On 02/10/20 at 11:22 AM, Employee #52, Maintenance Assistant, observed the fall mat leaning against wall. On 02/10/20 at 3:02 PM, Resident #26 was lying across the middle of the bed. Resident #26's feet were on the floor, body angled across the bed, and her head lying near the wall. The fall mat was laying on the floor beside of Resident #26's bed. Employee #[AGE], Nursing Assistant (NA) entered Resident #26's room on 02/10/20 at 3:04 PM and NA #6 entered Resident #26's room at 3:06 PM. Both NA #6 and NA #[AGE] noted that the fall mat was located beside Resident #26's bed. A review of Resident #26's physician orders [REDACTED].#26 did not have an order for [REDACTED]. On 02/11/20 at 9:06 AM, the Director of Nursing (DON) entered Resident #26's room with the surveyor. The DON noted that the fall mat was against the exterior wall, between the wall and the tv cabinet. In an interview with the DON on 02/11/20 at 2:10 PM, the DON stated Resident #26 did not have an order for [REDACTED]. The findings were discussed with the Administrator and the DON on 02/12/2020 at 3:13 PM. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
245,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,867,D,0,1,G76I11,"Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance (QA&A) committee corrected quality deficiencies it had or should have had knowledge of. This practice has the potential to effect all residents currently residing in the facility. Facility census: 62. Findings included: a) Cross reference deficiency cited at F 8[AGE] During an interview on 0[DATE] at 8:44 AM with the Administrator, the findings related to Quality Assurance were discussed with the Administrator. The Administrator stated that they are currently reviewing the action steps related to the deficient practice. The Administrator discussed future ways that they would track and trend with regard to the pneumococcal vaccinations. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
247,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,883,D,0,1,G76I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop, maintain and follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice for two (2) of five (5) residents reviewed for the provision of immunizations. Resident identifiers: #62, #20. Facility census: 62. Findings included: a) Resident #62 Record review indicated Resident #62, [AGE] years of age, was administered 13-valent pneumococcal conjugate vaccine (PCV13) vaccine on 08/17/16. No documentation was found to indicate the resident either received the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. During an interview on 02/12/20 at 10:05 AM, Infection Control Nurse (ICN) #66 verified there was no evidence to indicate the facility made an attempt to determine if the Resident had been offered or administered the PPSV23 vaccine. ICN #66 stated the facility had no process or procedure in place for monitoring the provision of both vaccines (PPSV23 and PCV13 vaccines) and said, I didn't know there were two vaccines and they both had to be given. Review of the facility's Pneumococcal Vaccine (Series) policy implemented on 11/27/17, stated the type of pneumococcal vaccine will be offered to Residents in accordance with current CDC guidelines and recommendations. The policy further stated: Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. b) Resident #20 Record review indicated Resident #20, [AGE] years of age, was administered 13-valent pneumococcal conjugate vaccine (PCV13) vaccine on 08/17/16. No documentation was found to indicate the resident either received the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. During an interview on 02/12/20 at 10:05 AM, Infection Control Nurse (ICN) #66 verified there was no evidence to indicate the facility made an attempt to determine if the Resident had been offered or administered the PPSV23 vaccine. ICN #66 stated the facility had no process or procedure in place for monitoring the provision of both vaccines (PPSV23 and PCV13 vaccines) and said, I didn't know there were two vaccines and they both had to be given. Review of the facility's Pneumococcal Vaccine (Series) policy implemented on 11/27/17, stated the type of pneumococcal vaccine will be offered to Residents in accordance with current CDC guidelines and recommendations. The policy further stated: Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received.",2020-09-01
248,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,552,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure Resident #50 was afforded the opportunity to be informed of, and participate in, his treatment while a resident at the facility. This was true for one (1) of two (1) residents reviewed for the care area of Language and communication during the long-term care survey process. Resident identifier: #50. Facility census: 65. Findings included: a) Resident #50 A review of Resident #50's medical record, at 8:27 a.m. on 02/26/19, found Resident #50 had two (2) admissions to the facility since 05/01/18. Resident #50 was admitted to the facility on [DATE] and was discharged to home on 08/06/18. He was then readmitted to the facility on [DATE] and is currently still residing in the facility at the time of this review. Further review of the record found two (2) physician's determination of capacity forms. The first form was completed by Resident #50's attending physician on 05/18/18 and was the capacity form in effect from 05/18/18 until his discharge home on 08/06/18. Review of this form found Resident #50's attending physician indicated Resident #50 lacked capacity to make medical decisions. The reason given for this decision by the attending physician read as follows, Significant barrier to communication d/t (due to) thick accent/limited English use. The second capacity statement was completed by Resident #50's attending physician on 01/04/19 and was the current capacity statement in effect at the time of this review it indicated Resident #50 lacked capacity to make medical decisions due to inability to process information, delusions, hallucinations, and dementia secondary to Parkinson disease. Further review of Resident #50's medical record found Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated he was cognitively intact. The medical record contained no indication he had a [DIAGNOSES REDACTED]. A review of a physician's progress note completed on 01/4/19, the same day the physician completed the capacity statement found the following, Orientation: Normal - Alert and orientated X 2. Affect is broad. Thought processes are intact. No visible signs of anxiety or depressed state. An interview with the Social Worker at 9:24 a.m. on 02/26/19 confirmed Resident #50 scored a perfect score on the BIMS. She stated, There is nothing wrong with his memory. She stated, I can understand him, and he can understand me. Some people have trouble understanding him, but I don't. She indicated, she did not know why the physician had taken his capacity to make medical decisions away from him and felt it should be reevaluated. She stated, He is sharp as a tack and does not appear to have any dementia problems. She indicated she was not aware that he could not make his own medical decisions. An interview with the Director of Nursing (DON), at 1:14 p.m. on 02/26/19, confirmed Resident #50 was deemed incapacitated by the attending physician on 05/18/18 and again on 01/04/19. She indicated she did not know why the attending physician completed the capacity statements in this manner and indicated she would have him to review Resident #50 for capacity. An interview with the Nursing Home Administrator, on 02/27/19 at 7:45 a.m., confirmed Resident #50's attending physician was at the facility on 02/26/19 in the evening hours and evaluated Resident #50's capacity status. She stated, He (referring to the attending physician) stated Resident #50 had capacity and that he had just made a mistake because it was hard for him to understand Resident #50 due to the fact Resident #50 spoke Spanish. She later provided a new completed capacity form completed by the attending physician on 02/27/19 that indicated Resident #50 had capacity to make medical decisions.",2020-09-01
249,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,561,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview and family interview, the facility failed to ensure one (2) of two (2) residents reviewed for the care area of choices, had the opportunity to participate in their usual daily routine for dining. Resident #6 was not offered a choice to get up in chair and attend lunch in the atrium. Resident #47 did not get the choice to sleep in and have breakfast served at her preferred time. Resident identifiers: #6, #47. Facility census: 65. Findings included: a) Resident #6 On 02/25/19 at 12:30 PM Resident was observed setting in bed eating lunch. Resident's Medical Power of Attorney (MPOA) was present at bedside and stated that Resident was usually up in chair by now and eats her lunch in the dining hall. MPOA said she had just questioned Nurse Aide (NA) #12 as to why Resident was not up in a chair or eating in dining hall. NA #12 informed MPOA that she did not have enough help to get Resident up with lift. During an interview with Resident #6, on 02/25/19 at 12:35 PM, Resident #6 expressed her personal preference was to be up in chair after breakfast and to go to the atrium to eat her lunch. Resident stated it took two (2) people to get her up, and this morning they were too busy to get her up. At 11:08 AM on 02/26/19 during an interview NA #12 stated, When I have hall 26-30, I never have help, restorative was supposed to help but they usually don't. Yesterday I couldn't find anybody to help me get her (Resident #6) up and it takes two people for the lift. She is usually up in chair by 10:00 and goes to dining hall for lunch. When I work that hallway (Rooms 26-30) I am usually by myself. NA #12 verified that being up chair by mid-morning prior to lunch was the Resident's personal preference and part of her usual daily routine. During an interview, on 02/27/19 at 8:26 AM, Director of Nursing (DON) stated that NA #6, who was assigned to care for Resident #6 was assigned with a restorative aid for assistance. DON specified NA #6 should have found the restorative aide and asked for her for help with resident transfer from bed to chair, and that not having anyone to help her should not have made this an issue. Record Review revealed pulmonology consult dated 01/16/19 listed an intervention in Resident #6's plan of care for her to be out of the bed to the chair every day. b) Resident #47 During an interview with the resident's responsible party (RP) at approximately 3:15 PM on 02/25/19, the RP said the resident always liked to sleep in and have breakfast around 10:00 AM when she was at home. The RP felt staff woke the resident up too early which made her combative. The RP said, Staff don't listen to me when I try to tell them to give her breakfast at 10:00 and don't wake her up so early. Staff want to get her up at 5:00 AM so she can eat at 7:00 AM. Review of the nursing notes found the following entry: 2/15/2019 08:21 Care Plan Note: Annual Care conference held on 2/13/19. No Nursing concerns noted. Nursing reports that Medication review by pharmacy was completed in (MONTH) 2019 with no medication recommendations. No Activity concerns noted, Resident continues to participate well and remains very social. Discussed information provided by Director of Dietary, (name of dietary manager); Resident is currently on a mechanical soft diet eating an average of 76-100% of meals with her weight remaining stable. Reviewed CNA (certified nursing assistant) Reports: Resident does not like to get up in the mornings and can be quite grumpy at times and at times refusing her breakfast tray, but once up she is pleasant. Resident's POA (power of attorney) states that all you can do is encourage her to get up and eat breakfast say that she can lay back down when finished if she wants. She also states that Resident prefers to not get up until around 10 am. Social Worker reviewed advance directives, preferences for care. No issues or concerns noted. Care Plan reviewed. Review of the Resident's current care plan found the problem: Risk of altered nutrition/hydration status related to cognitive deficits related to dementia and [DIAGNOSES REDACTED]. A goal associated with the problem was: Resident will consume 51% or greater at most meals through next review. Interventions included: Resident prefers to wait until 10:00 AM or after for breakfast. At 8:36 AM on 02/26/19 08:36 AM, the resident's nursing assistant (NA) #12 was interviewed. NA #12 said the breakfast trays came out around 7:00 AM. She said the resident was served breakfast, but she didn't eat anything. NA #12 said the trays have already been picked up. Observation of the resident at 10:00 AM on 02/26/19, found she was in her room sitting in her wheelchair watching television. Continued observation of the resident found she did not receive a tray. At 10:19 AM on 02/26/19, the food service director, (FSD) #39 was asked if Resident #47 received a tray at 10:00 AM. FSD replied, We don't cook a meal at 10:00 AM. She said if the resident was hungry, she could ask for some food items from the, always available menu, and the kitchen staff would get her something to eat. Review of the resident's most recent minimum data set (MDS), an annual, with an assessment reference date (ARD) of 01/21/19 found the resident scored a 7 on her brief interview for mental status (BIMS). A score of 7 indicates the resident's cognition is severely impaired. At 11:15 AM on 02/26/19, the administrator said the resident can have a tray at 10:00 AM if she wants one. The resident's BIMS score was discussed with the administrator. The administrator verified that most likely the resident could not advise staff it was 10:00 AM and she wanted a breakfast tray with a BIMS score of 7. The administrator said she would take care of the situation and the resident could receive breakfast at 10:00 AM from now on.",2020-09-01
251,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,622,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure documentation regarding the specific reason for the transfer on the Notice of Discharge or Transfer was provided to the guardian and ombudsman for one (1) of one (1) residents reviewed for the care area of hospitalization . Additionally, the physician did not document the reason for the resident's transfer. Resident identifier: #70. Facility census: 65. Findings included: a) Resident #70 Review of Resident #70's medical records revealed an emergency transfer to the hospital on [DATE] at 2:15 AM. The reason for the transfer according to the medical records was, Resident physically struck roommate, causing unsafe environment. A Notice of Transfer of Discharge was completed on 12/31/18. The Notice of Transfer or Discharge stated, Due to the reason indicated below a discharge or transfer from this center will be necessary. - The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this center. - The transfer or discharge is necessary for your welfare and your needs cannot be met in this center. - The safety of other individuals in this center is endangered. - The health of other individuals in this center is endangered. Each of the discharge or transfer reasons had a box before the item that could be checked as appropriate. None of the reasons for discharge or transfer had been checked. The Notice of Transfer or Discharge stated Resident #70's guardian was verbally notified on 12/31/18. The time of notice was not given. A facsimile communication report showed the Notice of Transfer or Discharge was sent to the ombudsman on 01/18/19. No physician documentation regarding the reasons for Resident #70's transfer was in the medical records. The resident was ultimately not permitted to return to the facility. During an interview, on 02/27/19 at 12:21 PM, the Director of Nursing (DoN) agreed the reason for Resident #70's transfer or discharge was not indicated on the Transfer or Discharge form. The DoN was also unable to locate documentation by the resident's physician regarding the reason for transfer. During an interview, on 02/27/19 at 3:45 PM, the facility administrator was informed the reason for Resident #70's transfer or discharge was not indicated on the Transfer or Discharge form. She was also informed the physician did not document the reasons for the resident's transfer. She had no further information regarding the matter. No further information was received through the completion of the survey.",2020-09-01
252,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,626,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician documentation regarding the reason the resident was not permitted to return to the facility for one (1) of one (1) residents reviewed for the care area of hospitalization . Additionally, the facility failed to provide written notice to the resident's guardian and to the ombudsman specifically stating the resident would not be permitted to return to the facility. Resident identifier: #70. Facility census: 65. Findings included: a) Resident #70 Review of Resident #70's medical records revealed an emergency transfer to the hospital on [DATE] at 2:15 AM. The reason for the transfer according to the medical records was, Resident physically struck roommate, causing unsafe environment. A nursing note written at 12/31/2018 at 12:45 PM stated, This nurse called facility medical director, (physician name) regarding resident's status in facility pending return from hospital. (Physician name) expressed to this nurse that he did not feel comfortable accepting him back because he felt that the resident has had an increase in combative behavior and feels that we have to take into consideration our other resident's well-being. He feels that this resident may be a danger to other resident's going forward. It is also his belief that he requires more care than we are able to provide. At this time, we are unable to meet his needs and he will not accept him back in facility as a resident. A nursing note, written on 12/31/2018 at 1:20 PM stated, (Guardian name), guardian notified by this nurse that (physician name) has decided to not accept this resident back into this facility as he feels that this resident requires more care than we can provide. (Resident's name's) ongoing increase in behaviors towards staff and other resident's places the safety of our resident's at risk. It was explained that we had to take into account the safety of all residents at this time and in doing so, he cannot return. A Notice of Transfer of Discharge was completed on 12/31/18. The Notice of Transfer or Discharge stated, Due to the reason indicated below a discharge or transfer from this center will be necessary. - The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this center. - The transfer or discharge is necessary for your welfare and your needs cannot be met in this center. - The safety of other individuals in this center is endangered. - The health of other individuals in this center is endangered. Each of the discharge or transfer reasons had a box before the item that could be checked as appropriate. None of the reasons for discharge or transfer had been checked. The Notice of Transfer or Discharge gave the effective date of transfer as 12/31/18. The destination of transfer was a local hospital's emergency room . The Notice of Transfer or Discharge stated Resident #70's guardian was verbally notified on 12/31/18 the time of notice was not given. A facsimile communication report showed the Notice of Transfer or Discharge was sent to the ombudsman on 01/18/19. During an interview, on 02/27/19 at 10:52 AM, Medical Records Clerk #35 stated she was unable to locate written information to Resident #70's guardian or to the ombudsman specifically stating the resident would not be permitted to return to the facility. Medical Records Clerk #35 was also unable to locate physician documentation regarding the reason Resident #70 would not be permitted to return to the facility. She stated no physician discharge summary was completed because Resident #70 was transferred to the hospital instead of discharged . During an interview on 02/27/19 at 12:21 PM, the Director of Nursing (DoN) stated the only notice provided to Resident #70's guardian and the ombudsman was the afore-mentioned Notice of Transfer or discharge date d 12/31/18. The DoN was unable to locate written information to the guardian and ombudsman specifically stating the resident would not be permitted to return to the facility. She was also unable to locate documentation by Resident #70's physician stating the reasons the resident would not be permitted to return to the facility. During an interview, on 02/27/19 at 3:45 PM, the facility administrator was informed Resident #70's guardian and the ombudsman were not provided written information specifically stating the resident would not be returning to the facility. The administrator was also informed Resident #70's physician did not document the reasons the resident would not be permitted to return to the facility. The administrator had no further information regarding the matter. No further information was received through the completion of the survey.",2020-09-01
253,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,641,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for Resident #69 in the area of prognosis, for Resident #23 in the area of dental and prognosis, and Resident #68 in the area of discharge/return to the community. This was true for three (3) of 16 MDSs reviewed during the long term care survey. Resident Identifiers: #69, #23, and #68. Facility Census: 65. Findings included: a) Resident #69 A review of Resident #69's medical record, on 02/26/18 at 10:32 AM, found Resident #69 was admitted to hospice services on 09/25/18. A review of a signficant change MDS with an Assessment Reference Date (ARD) of 09/29/18 found Section J1400 Prognosis was marked to indicate Resident #69 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. This was not accurate considering Resident #69 was admitted to hospice services on 09/25/18. An interview with the MDS Coordinator Registered Nurse (RN) #66, at 3:00 PM on 02/27/19, confirmed this section was coded incorrectly. She stated, Since she was a hospice resident this should have ben marked yes not no. b) Resident #23 1. Dental Observations of Resident #23, on 02/25/19 at 1:58 PM, found Resident #23 was edentulous. She was observed sitting in her Geri- Chair in her with her mouth open. Her entire mouth could be observed and there were no teeth in her mouth. A review of Resident #23's medical record, at 1:12 PM on 02/26/19, found on 08/27/18 Resident #23 was assessed as having no natural teeth. Review of a Signficant Change MDS with an Assessment reference date (ARD) 09/18/18 found Section L Oral/Dental Status L Dental was marked Z. None of the above were present. This indicated Resident #23 had no dental problems. This was inaccurate and should have been marked B. No natural teeth or tooth Fragments (edentulous) . An interview with the MDS Coordinator Registered Nurse (RN) #66, at 3:00 PM, on 02/27/19 confirmed this section was coded incorrectly. She agreed B should have been marked since Resident #23 was edentulous. 2. Prognosis A review of Resident #23's medical record at 1:12 p.m. on 02/26/19 found Resident #23 was admitted to hospice services on 09/14/18. Review of a Signficant Change MDS with an ARD 09/18/18 found section J1400. Prognosis was marked to indicate Resident #23 did not have a condition or choric disease that may result in a life expectancy of less than 6 months. This was not accurate considering Resident #23 was admitted to hospice services on 09/14/18. An interview with the MDS Coordinator Registered Nurse (RN) #66 at 3:00 p.m. on 02/27/19 confirmed this section was coded incorrectly. She stated, Since she was a hospice resident this should have ben marked yes not no. c) Resident #68 Record review found Resident #68 was admitted to the facility on [DATE]. Upon admission, he expected to return home and discharge planning was initiated. The resident returned home on 12/15/18. Review of the resident's admission MDS with an ARD of 11/7/18, found the resident expected to return to the community after his nursing home stay. The MDS indicated the resident participated in answering questions regarding discharge to home and his expectations. A question on the MDS asks if the resident wanted to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community. The question was to be answered by checking one of the following: Yes, no, or unknown or uncertain. The facility checked unknown or uncertain. Directions from the ARI Manual: Code 0, No: if the resident (or family or significant other, or guardian or legally authorized representative) states that he or she does not want to talk to someone about the possibility of returning to live and receive services in the community. Code 1, Yes: if the resident (or family or significant other, or guardian or legally authorized representative) states that he or she does want to talk to someone about the possibility of returning to live and receive services in the community. Code 9, Unknown or uncertain: if the resident cannot understand or respond and the family or significant other is not available to respond on the resident ' s behalf and a guardian or legally authorized representative is not available or has not been appointed by the court. Resident #68 was alert, oriented, and had capacity to make medical decisions. The resident scored a 15 on his brief interview for mental status (BIMS). A score of 15 is the highest score obtainable and indicates the resident has cognition is intact. On 02/26/19 at 4:00 PM, the facility social worker, the author of the MDS, verified the MDS was coded incorrectly.",2020-09-01
254,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,656,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to implement a care plan for one (1) of sixteen (16) residents whose care plans were reviewed. Resident #47's care plan regarding her morning meal preference time was not implemented. Resident identifier: #47. Facility census: 65. Findings included: a) Resident #47 During an interview with the resident's responsible party (RP), at approximately 3:15 PM on 02/25/19, the RP said the resident always liked to sleep in and have breakfast around 10:00 AM when she was home. The RP felt staff woke the resident up too early which made her combative. The RP said, Staff don't listen to me when I try to tell them to give her breakfast at 10:00 and don't wake her up so early. Staff want to get her up at 5:00 AM so she can eat at 7:00 AM. Review of the nursing notes found the following entry: 2/15/2019 08:21 Care Plan Note Note : Annual Care conference held on 2/13/19. No Nursing concerns noted. Nursing reports that Medication review by pharmacy was completed in (MONTH) 2019 with no medication recommendations. No Activity concerns noted, Resident continues to participate well and remains very social. Discussed information provided by Director of Dietary, (name of dietary manager); Resident is currently on a mechanical soft diet eating an average of 76-100% of meals with her weight remaining stable. Reviewed CNA (certified nursing assistant) Reports: Resident does not like to get up in the mornings and can be quite grumpy at times and at times refusing her breakfast tray, but once up she is pleasant. Resident's POA (power of attorney) states that all you can do is encourage her to get up and eat breakfast say that she can lay back down when finished if she wants. She also states that Resident prefers to not get up until around 10am. Social Worker reviewed advance directives, preferences for care. No issues or concerns noted. Care Plan reviewed. Review of the Resident's current care plan found the problem: Risk of altered nutrition/hydration status related to cognitive deficits related to dementia and [DIAGNOSES REDACTED]. A goal associated with the problem was: Resident will consume 51% or greater at most meals through next review. Interventions included: Resident prefers to wait until 10:00 AM or after for breakfast. At 8:36 AM on 02/26/19 08:36 AM, the resident's nursing assistant, (NA) #12 was interviewed. NA #12 said the breakfast trays came out around 7:00 AM. She said the resident was served breakfast but she didn't eat anything. NA #12 said the trays had already been picked up. Observation of the resident at 10:00 AM on 02/26/19, found she was in her room sitting in her wheelchair watching television. Continued observation of the resident found she did not receive a tray. At 10:19 AM on 02/26/19, the food service director, (FSD) #39 was asked if Resident #47 received a tray at 10:00 AM. FSD replied, We don't cook a meal at 10:00 AM. She said if the resident was hungry she could ask for some food items from the, always available menu, and the kitchen staff would get her something to eat. Review of the resident's most recent minimum data set (MDS), an annual, with an assessment reference date (ARD) of 01/21/19 found the resident scored a (7) on her brief interview for mental status (BIMS). A score of 7 indicated the resident's cognition was severely impaired. At 11:15 AM on 02/26/19, the administrator said the resident could have a tray at 10:00 AM if she wanted one. The resident's BIMS score was discussed with the administrator. The administrator verified that most likely the resident could not advise staff it was 10:00 AM and she wanted a breakfast tray with a BIMS score of 7. The administrator said she would take care of the situation and the resident could receive breakfast at 10:00 AM from now on.",2020-09-01
255,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,684,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer medication in accordance with physician orders. This was a random opportunity for discovery. The facility did not obtain the resident's pulse or systolic blood pressure before administering the beta-blocker, [MEDICATION NAME]. Resident identifier: #47. Facility census: 65. Findings included: a) Resident #47 Medical record review found a physician's orders [REDACTED]. Systolic is the first number of the resident's blood pressure. Systolic blood pressure, measures the pressure in your blood vessels when your heart beats. The order was effective on 12/29/18. [MEDICATION NAME] is a beta-blocker. Beta-blockers affect the heart and circulation. [MEDICATION NAME] is used to treat heart failure and hypertension. Review of the resident's medication administration (MAR) for (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019, found the medication was given daily; however, there was no evidence staff obtained the resident's pulse or blood pressure before administering the medication. On 02/26/19 at 9:05 AM, the director of nursing (DoN) verified staff would not know if the resident's medication should be held if pulse and systolic blood pressure were not obtained before administration. The DoN said staff should record the pulse on the MAR. The DoN was unable to provide verification the physician's orders [REDACTED].",2020-09-01
256,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,745,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #50 was provided medically-related social services to enable him to attain and/or maintain his highest practicable physical, mental and psychosocial well-being. This was true for one (1) of two (2) residents reviewed for the care area of communication during the long-term care survey. Resident identifier: #50. Facility census: 65. Findings included: a) Resident #50 A review of Resident #50's medical record at 8:27 a.m. on 02/26/19 found Resident #50 had two (2) admissions to the facility since 05/01/18. Resident #50 was admitted to the facility on [DATE] and was discharged to home on 08/06/18. He was then readmitted to the facility on [DATE] and is currently still residing in the facility at the time of this review. Further review of the record found two (2) physician's determination of capacity forms. The first form was completed by Resident #50's attending physician on 05/18/18 and was the capacity form in effect from 05/18/18 until his discharge home on 08/06/18. Review of this form found Resident #50's attending physician indicated Resident #50 lacked capacity to make medical decisions. The reason given for this decision by the attending physician read as follows, Significant barrier to communication d/t (due to) thick accent/limited English use. The second capacity statement was completed by Resident #50's attending physician on 01/04/19 and was the current capacity statement in effect at the time of this review it indicated Resident #50 lacked capacity to make medical decisions due to inability to process information, delusions, hallucinations, and dementia secondary to Parkinson disease. Further review of Resident #50's medical record found Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 which indicates he is cognitively intact. The medical record contained no indication he had a [DIAGNOSES REDACTED]. In fact, a review of a physician's progress not completed on 01/4/19 the same day he completed the capacity statement found the following, Orientation: Normal - Alert and orientated X 2. Affect is broad. Thought processes are intact. No visible signs of anxiety or depressed state. An interview with the Social Worker at 9:24 a.m. on 02/26/19 confirmed that Resident #50 scored a perfect score on his brims. She stated, There is nothing wrong with his memory. She stated I can understand him, and he can understand me. Some people have trouble understanding him, but I don't She indicated, she did not know why the physician had taken his capacity to make medical decisions away from him and felt it should be reevaluated. She stated, He is sharp as a tack and does not appear to have any dementia problems. She indicated she was not aware that he could not make his own medical decisions. An interview with the Director of Nursing (DON) at 1:14 p.m. on 02/26/19 confirmed Resident #50 was deemed incapacitated by the attending physician on 05/18/18 and again on 01/04/19. She indicated she did not know why the attending physician completed the capacity statements in this manner and indicated she would have him to review Resident #50 for capacity. An interview with the Nursing Home Administrator on 02/27/19 at 7:45 a.m. confirmed Resident #50's attending physician was at the facility on 02/26/19 in the evening hours and evaluated Resident #50's capacity status. She stated, He (referring to the attending physician) stated Resident #50 has capacity and that he had just made a mistake because it was hard for him to understand Resident #50 due to the fact Resident #50 spoke Spanish. She later provided a new completed capacity form completed by the attending physician on 02/27/19 that indicated Resident #50 had capacity to make medical decisions.",2020-09-01
257,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,757,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #62's drug regimen was free from unnecessary medications. Resident #62 received three (3) excessive doses of an antibiotic. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during the long term care survey process. Resident identifier: 62. Facility census: 65. Findings included: a) Resident #62 A review of Resident #62's medical record, at 9:21 AM on 02/27/19, found a physician's orders [REDACTED]. This order had a start date of 02/04/19. A review of Resident #62's Medication Administration Record [REDACTED]. Resident #62 was only prescribed 20 doses by her attending physician. An interview with the Director of Nursing (DoN), at 11:16 a.m. 02/27/19, confirmed Resident #62 received three (3) extra doses of Cipro. She stated, It looks like they took the first three (3) doses from the Emergency box and then gave the 20 doses that were ordered from the pharmacy also.",2020-09-01
258,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,842,D,0,1,DBDN11,"Based on record review, observation, and staff interview the facility failed to ensure Resident #23's medical record was complete and accurate. Resident #23 had multiple dental assessments contained in her record that were not accurately completed. This was true for one (1) of 16 sampled residents. Resident identifier: 23. Facility census: 65. Findings included: a) Resident #23 An observation of Resident #23, at 1:58 PM, on 02/27/19 found she edentulous. She was observed sitting in her Geri Chair. Her mouth was opened and could be easily observed. This observation revealed Resident #23 had no teeth. A review of Resident #23's medical record, at 1:12 PM on 02/26/19, found the following dental assessments which were inaccurately completed: 12/18/18 Indicated Resident #23 had no dental problems. 04/01/18 Indicated Resident #23 had no dental problems. 04/26/18 Indicated Resident #23 had no dental problems. 09/23/16 Indicated Resident #23 had no dental problems. An interview with the Director of Nursing on 02/26/19 at 01:50 PM confirmed Resident #23 was edentulous and the above mentioned assessments should have been marked to indicate this, but they were not.",2020-09-01
260,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,641,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of four (4) resident's reviewed for the care area of nutrition had an accurate and complete minimum data set (MDS). This failed practice had the potential to affect a limited number of residents. Resident identifier: #40. Facility census: 56. Findings included: a) Resident #40 Record review on 03/13/18 at 11:00 AM, found the resident was admitted to the facility on [DATE]. The residents first weight was recorded as 271.3 pounds on 10/06/17. A significant change in status MDS with an assessment reference date (ARD) of 02/01/18, noted the resident's current weight was 221 pounds. The MDS coded the resident as having no weight loss, (5% or more in the last month or loss of 10% or more in last 6 months.) An interview with the dietary manager (DM) #20, at 12:14 PM on 03/13/18, confirmed the resident had an actual weight loss of 18.54 % as calculated by dietary manager at the time of the MDS with an ARD of 02/01/18. The DM verified the MDS was coded incorrectly.",2020-09-01
261,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,656,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of nutrition had a measurable care plan to address fluid intake. In addition, one (1) of three (3) residents reviewed for pressure ulcers failed to have interventions in place, as directed by the care plan, to promote healing of existing pressure ulcers and/or prevent the development of new pressure ulcers. Resident identifiers: #40 and #26. Facility census: 56. Findings included: a) Resident #40 Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: --Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. A second care plan focus/problem, dated 03/12/18: --Resident has a urinary tract infection. The goal associated with the problem: --Resident's urinary tract infection will resolve with no complication. Interventions included: --Encourage fluids as tolerated. A comprehensive nutritional assessment, completed by the registered dietician on 01/26/18, noted the resident required 2070 milliliters of fluid a day. At 2:45 PM on 03/14/18, the director of nursing (DON) verified the facility did not keep any records to determine how much fluids any residents may or may not have consumed during the day. The facility only records the percent of food consumed by residents in a day. She was unable to verify how the facility determined the resident had an inadequate intake of fluids as specified on the care plan or how the facility would monitor daily fluid intake to ensure the resident consumed the required milliliters of daily fluid. The resident also had a urinary tract infection and the DON confirmed the facility could not verify fluids were encouraged as stated on the care plan. b) Resident #26 Review of the care plan, dated 02/12/18, found the current problem/focus: --Resident has or was admitted with pressure injuries to left inner foot, right gluteal fold, unstageable to right outer foot, and blanchable reddened area to right lateral foot, Deep tissue pressure injury to left inner heel. Potential for further pressure injury related to diabetes mellitus, [MEDICAL CONDITION] with bilateral leg contractures, recurrent hip dislocation, chronic pain, [MEDICAL CONDITION] requiring transfusion, hypertension, [MEDICAL CONDITION], dry skin and scalp, [MEDICAL CONDITION] and muscle wasting. Including the following pressure ulcers: --Stage 4 pressure ulcer to the right (middle) outer foot --Stage 2 pressure ulcer to the left buttock --Resolved Stage 2 pressure ulcer to the left elbow --Unstageable pressure ulcer to the right outer foot (distal, below little toe) The goal associated with the focus/problem: --Resident will have no further pressure ulcer formation noted through next review period. Interventions included: --May use knee/ankle abductor cushion between knees to help prevent further skin breakdown, --Resident will have elbows heels floated as allowed by the resident while in bed. Observation of the resident with the director of nursing (DON) at 1:57 p.m. on 03/13/18, found the resident did not have the abductors on and did not have elbows/heels floated as directed by the care plan. When asked why he did not have the abductors on, the resident said, I had them on earlier, they took them off when they pulled me up in the bed and didn't put them back on. At 2:06 p.m. on 03/13/18, the DON confirmed the resident's care plan addressing pressure ulcers was not followed as written.",2020-09-01
262,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,657,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan was revised in the area of nutrition for one (1) of four (4) residents reviewed for the care area of nutrition. This failed practice had the potential to affect a limited number of residents. Resident identifier: #5. Facility census: 56. Findings included: a) Resident #5 Resident #5 had an order written [REDACTED]. This order was discontinued on 10/25/17 because the resident preferred a different nutritional supplement. Review of Resident #5's comprehensive care plan on 03/13/18 revealed the focus of Risk of altered nutrition/hydration status related to inadequate intake of food and fluids contained the intervention of 2-cal, 60 ml, twice a day. During an interview on 03/13/18 at 1:07 PM, the Director of Nursing (DON) was informed Resident #5's comprehensive care plan continued to include the intervention of 2-cal, 60 ml, twice a day even though this nutritional supplement had been discontinued 10/15/17. The DoN had no further information regarding this matter.",2020-09-01
263,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,684,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physician orders [REDACTED]. This failed practice had the potential to affect a limited number of residents. Resident identifier: #5. Facility census: 56. Findings included: a) Resident #5 Resident #5 had an order written [REDACTED]. Medication side effects were ordered to be monitored. Review of Resident #5's Medication Administration Record [REDACTED]= SE and 2 = No SE. However, side effects had not been monitored. Resident #5 was also prescribed another medication, [MEDICATION NAME], for depression and appetite stimulation. The resident was also to be monitored for side effects of [MEDICATION NAME]. The MAR indicated [REDACTED]. However, the MAR indicated [REDACTED]. During an interview on 03/13/18 at 1:07 PM, the Director of Nursing (DoN) was informed physician's orders [REDACTED].#5 for side effects of [MEDICATION NAME] was not followed in March, (YEAR). The DoN had no further information regarding this matter.",2020-09-01
264,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,686,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to provide care and services to promote the healing of existing pressure ulcers and prevent development of additional pressure ulcers for one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident #26 did not have pressure relieving devices in place as directed by the care plan. Resident identifier: #26. Facility census: 56. Findings include: a) Resident #26 Review of the care plan, dated 02/12/18, found the current problem/focus: --Resident has or was admitted with pressure injuries to left inner foot, right gluteal fold, unstageable to right outer foot, and blanchable reddened area to right lateral foot, Deep tissue pressure injury to left inner heel. Potential for further pressure injury related to diabetes mellitus, [MEDICAL CONDITION] with bilateral leg contractures, recurrent hip dislocation, chronic pain, [MEDICAL CONDITION] requiring transfusion, hypertension, [MEDICAL CONDITION], dry skin and scalp, [MEDICAL CONDITION] and muscle wasting. Including the following pressure ulcers: --Stage 4 pressure ulcer to the right (middle) outer foot --Stage 2 pressure ulcer to the left buttock --Resolved Stage 2 pressure ulcer to the left elbow --Unstageable pressure ulcer to the right outer foot (distal, below little toe) The goal associated with the focus/problem: --Resident will have no further pressure ulcer formation noted through next review period. Interventions included: --May use knee/ankle abductor cushion between knees to help prevent further skin breakdown, --Resident will have elbows heels floated as allowed by the resident while in bed. Observation of the resident with the director of nursing (DON) at 1:57 PM on 03/13/18, found the resident did not have the abductors on and did not have elbows/heels floated as directed by the care plan. When asked why he did not have the abductors on the resident said, I had them on earlier, they took them off when they pulled me up in the bed and didn't put them back on. At 2:06 pm on 03/13/18, the DON confirmed the resident's care plan was not being followed as written. On 03/14/18 at 12:56 PM the absence of the devices, knee/ankle abductor and the floating of the elbows and heels were again discussed with the DON. The resident has a history of pressure ulcer development and healing since his admission to the facility on [DATE]. The DON confirmed these devices were implement to prevent future skin breakdown and promote the healing of existing pressure ulcers.",2020-09-01
265,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,692,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to recognize, evaluate, and address the nutritional needs of one (1) of four (4) residents reviewed for the care area of nutrition. In addition, the facility failed to to ensure proper hydration was provided to one resident during a random opportunity for discovery. Resident identifiers: #40 and #30. Facility census: 56. Findings included: a) Resident #40 During an interview with the resident on 03/12/18 at 10:12 AM, she said, I get mashed potatoes for every meal, I don't know why they can't fortify something else-like some macaroni and cheese for a change. The resident said she was losing weight because she can not eat and the food is not good. Record review found the resident was admitted to the facility on [DATE]. The resident's weight was recorded as 271.3 pounds on 10/06/17. The last weight recorded was 219 pounds on 03/12/18. A 19.28% weight loss since admission. Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. Interventions included: --Dietary to provide fortified foods one item per tray, initiated on 01/24/18, --Honor food preferences, --Dietary to provide 8 ounces of whole milk with meals, yogurt at 2pm and 1/2 sandwich hs (at night time) Two comprehensive nutritional assessments were completed by the registered dietician (RD) since the resident's admission. On on 10/07/17 and 01/29/18. On 10/07/17, the nutrition summary noted: --New admission. [AGE] year old female .BMI (body mass index) indicates obesity; no interventions warranted due to diagnosis. Will allow resident time to adjust to facility, encourage po (by mouth) intake, and monitor weights per policy .Weight fluctuations may occur due to diuretic . Weight loss meetings were held, on 12/01/17 and 01/12/18. --12/01/17, Weight meeting held with IDT (interdisciplinary team) members. Weight loss trend continues. PO intake 51-75% of most meals. RD recommendations reviewed 11/30/17 and new order received for house shake BID. Currently receiving whole milk with meals, yogurt daily and 1/2 sandwich at QHS. Resident has a [DIAGNOSES REDACTED]. --01/12/18, Weight meeting held with IDT members. Resident has [DIAGNOSES REDACTED].Several interventions in place including whole milk with meals, yogurt daily at 2 pm per request. HS snack of choice, handmade chocolate milkshakes BID (twice a day), one fortified food item per tray . Review of the hospital discharge summary, dated 10/05/17 found the resident has a surgical history of, Laparoscopic gastric banding surgery. (Laparoscopic gastric banding is surgery to help with weight loss. The surgeon places a band around the upper part of your stomach to create a small pouch to hold food. The band limits the amount of food you can eat by making you feel full after eating small amounts of food.) Normally a person with this surgery would need to eat several small meals daily, instead of three (3) large meals per day. The facility physician also noted the resident had Laparoscopic gastric banding surgery on the, New Patient History and Physical. Observation of the resident's noon meal on 03/12/17 found she had chicken and dumplings and mashed potatoes. Observation of the noon meal again on 03/13/17 found the resident had roast beef and mashed potatoes. At 12:14 PM on 03/13/18, the dietary manager verified the resident does have mashed potatoes for every lunch and supper meal-that is the food we fortify. He confirmed the resident only receives fortified oatmeal for breakfast and fortified mashed potatoes with every lunch and supper. He was not aware the resident had said she was tired of mashed potatoes and could no longer eat them. He said he could fortify some macaroni and cheese as requested by the resident. The DM said he is also unaware the resident had lap band surgery and did not know what kind of a diet the resident should receive after having the surgery. He confirmed the facility had never considered the lap band surgery as contributing to the resident's weight loss. At 8:20 AM on 03/14/18, the resident said she was unable to eat large meals at one setting because of her surgery. She said, If I had the right foods, I could eat more. She said she just requested a hot bowl of chicken noodle soup for lunch. That's all I want and it can even be from a can, just a bowl of hot chicken noodle soup. At 8:57 AM on 03/14/18, the resident's weight loss was discussed with the administrator. She was asked if anyone had every considered the resident's Laparoscopic gastric banding as contributing to her weight loss? The administrator was also advised the resident had been receiving mashed potatoes for every lunch and supper since 01/24/18 because the DM said this was the only food item his staff fortified. A third observation of the resident's noon meal at 12:20 PM on 03/14/18, with nursing assistant, NA #91, found the resident received mashed potatoes again. (She did have chicken noodle soup). At 1:16 PM on 03/14/18, the dietary manager was asked why the resident had mashed potatoes again. He stated, my staff only knows how to fortify mashed potatoes, I have to train them to fortify other food items, like the macaroni and cheese-I don't want them to do it the wrong way. Review of the facility's document entitled, Increasing the calorie content of a meal pattern, was reviewed with the DM. Lunch and dinner meals can be [MEDICATION NAME]/fortified with: --Extra margarine to vegetables and starches, serve cheese, cheese sauce, margarine, sour cream on meats, vegetables, or starches; --Offer fortified soup, fortified mashed potatoes or fortified pudding with meals; offer [MEDICATION NAME] milk as a beverage with meals. The DM said those were good ideas for fortifying foods and he would train his staff. At the close of the survey on 03/15/18 at 6:00 PM the facility provided no further information on Resident #40. No information was provided the facility staff addressing the resident's weight loss was aware of the Laparoscopic gastric banding surgery or considered this surgery as contributing to weight loss and attempted to provide a diet that could be tolerated by the resident. b) Resident #30 A random observation of Resident #30 on 03/12/18 at 12:10 PM, found there was no drinks with her lunch and no water pitcher on table or in the room. Resident #30 said, I would like to have had something to drink with my lunch, all I have had today to drink was a shake drink in that little box. On 03/13/18 at 10:00 AM, the director of nursing (DON) was notified about Resident # 30 not having any drinks with the her lunch yesterday. She was asked if she could find her fluid intake for yesterday. She said do not document fluid intake only meal percentages. During an observation on 03/13/18 at 10:24 AM, Resident #30 had a drink on her table. On 03/13/18 at 10:40 AM, the DON said yesterday Resident # 30 didn't get drinks on her tray because her tray was sent to the atrium and the drinks are put on the table not on the tray, but not sure why she was not given anything to drink in her room.",2020-09-01
266,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,757,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #62's medication regimen was free from unnecessary medication. Resident #62 was administered an antihypertensive ([MEDICATION NAME]) medication outside of the physician prescribed parameters. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #62. Facility census: 56. Findings included: a) Resident #62 Review of Resident #62's medical records found a physician order [REDACTED]. Review of Resident #62's Medication Administration Record [REDACTED] --11/26/17- blood pressure was 118/68. --11/27/17- blood pressure was 118/78. --12/05/17- blood pressure was 118/70. --12/11/17- blood pressure was 118/74. --12/13/17- blood pressure was 118/68. Interview with the Director of Nursing (DON) on 03/13/18 at 11:30 AM found after review of the MARs for (MONTH) and (MONTH) (YEAR). Resident was administered [MEDICATION NAME] when the medication should have been held as directed by the physician prescribed parameters.",2020-09-01
267,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,758,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure [MEDICAL CONDITION] medications prescribed on an as needed basis or PRN were limited to a 14 day order, nor did the facility address non-pharmacological interventions prior to the administration of as needed, PRN [MEDICAL CONDITION] medications for one (1) of five (5) residents reviewed for unnecessary medications. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #61. Facility census: 56. Findings include: a) Resident #61 Record review for Resident #61 found physician order [REDACTED].>--[MEDICATION NAME], give 0.25 mg (milligrams) by mouth every 12 hours as needed for anxiety. Order date 11/02/17 and start date 11/03/17. Review of the MAR indicated [REDACTED] --11/03/17 at 8:13 a.m. --11/05/17 at 10:30 p.m. --11/06/17 at 7:30 p.m. --11/07/17 at 7:49 p.m. --11/08/17 at 8:15 p.m. --11/12/17 at 7:59 p.m. Interview with the Director of Nursing (DON) on 03/15/18 at 11:45 AM confirmed non-pharmacological interventions were not implemented prior to the administration of PRN [MEDICAL CONDITION] medications. Facility failed to attempt non pharmalogical interventions prior to the administration of an anti anxiety medication. ([MEDICATION NAME]) Resident #61",2020-09-01
270,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,842,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to ensure each resident's medical records was complete and accurate. Resident #62 had an inaccurate lab value, International normalized ratio (INR) documented on the resident's anticoagulant ([MEDICATION NAME]) flow record. For Resident #29, the resident's weekly wound/pressure ulcer flow sheets were blank and/or inaccurate. Resident identifiers: #62 and #29. Facility census: 56. Findings included: a) Resident #62 Review of Resident #62's medical records found a [MEDICATION NAME] (anticoagulant) Flow sheet in which read: INR 15.1, normal range is 2.0 to 3.0. Interview with the Director of Nursing (DON) on 0n 03/13/18 at 11:30 AM, confirmed the lab was documented in error. This error was confirmed by Resident #62's physician at 3:47 PM on 03/13/18. b) Resident #29 Resident #29 had pressure ulcers on the right upper/inner posterior thigh and the left outer ankle. Resident #29's right thigh pressure ulcer had been present since (YEAR). Despite the presence of pressure ulcers, Resident #29's Weekly Licensed Nurse Skin Evaluations indicated No for the question Any existing ulcers (previously identified)? for the following dates: --03/02/18 --02/16/18 --01/26/18 --01/19/18 A Weekly Wound Evaluation for Resident #29 on 01/05/18 indicated a left ankle wound was identified on 01/05/18. Weekly Wound Evaluations on 01/12/18, 01/19/18, and 01/26/18 also indicated Resident #29's left ankle wound was identified on 01/05/18. However, Weekly Wound Evaluations on 01/29/18, 02/05/18, and 02/12/18 indicated Resident #29's left ankle wound was identified on 01/05/16. A Weekly Wound Evaluation on 02/14/18 indicated Resident #29's left ankle wound was identified on 01/05/18. Weekly Wound Evaluations on 02/23/18 and 03/09/18 indicated Resident #29's left ankle wound was identified on 01/05/16. Additionally, during review of Resident #29's medical records, Weekly Wound Evaluations for Resident # 29's left ankle wound and right thigh wounds could not be located for the time period between 02/23/18 and 03/09/18. During an interview on 03/14/18 at 12:06 PM, the Director of Nursing (DoN) was informed about the following issues: --Resident #29's Weekly Licensed Nurse Skin Evaluations which indicated No for the question Any existing ulcers (previously identified)? even though the resident did have pre-existing skin ulcers. The DON had no additional information regarding this matter. --The discrepancies on the Weekly Wound Evaluations which indicated Resident #29's left ankle wound was identified on 01/05/18 and 01/05/16. The DoN stated the 01/05/16 dates had been entered in error. --The absence of Weekly Wound Evaluations for Resident's left ankle and right thigh wounds for the week between 02/23/18 and 03/09/18. On 03/14/18 at 1:21 PM, the DON confirmed no Weekly Wound Evaluations had been performed between 02/23/18 and 03/09/18.",2020-09-01
271,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-11-06,609,D,1,0,L1WQ11,"> Based on policy review, record review, and staff interview, the facility failed to report allegations of abuse and neglect within the required timeframe. This deficient practice was found for three (3) of four (4) residents reviewed for the care area of abuse. Resident identifiers: #65, #26, #40. Facility census: 65. Findings included: a) Policy Review A review of the facility's abuse policy titled, Abuse, Neglect and Exploitation, implemented on 11/27/17 and last revised on 02/01/19 abuse and neglect are to be reported to the required agencies within specified time frames. b) Resident #65 Per a review of the facility's abuse and neglect logs during the survey, Resident #65 was noted to have an incidence of abuse and/or neglect in (MONTH) 2019. Resident #65's abuse/neglect investigation with an incident date of 08/29/19 was reviewed on 11/05/19 at 12:16 PM. According to the investigation, the incident occurred between 11:00 AM and 4:00 PM on 08/29/19. Per the fax sheets attached to the investigation, the incident was reported to Adult Protective Services (APS), the Nurse Aide Registry, and the Office of Health Facility Licensure and Certification (OHFLAC) on 08/30/19 at 4:25 PM, more than 24 hours after the incident occurred. The Ombudsman was faxed on 08/30/19 at 4:26 PM, more than 24 hours after the incident occurred. c) Resident #26 Per a review of the facility's abuse and neglect logs during the survey, Resident #26 was noted to have had two (2) incidences of abuse and/or neglect in (MONTH) 2019. Resident #26's abuse/neglect investigation with an incident date of 09/10/19 was reviewed on 11/05/19 at 10:50 AM. According to the investigation, the incident occurred on 09/10/19 at 9:00 AM. Per the fax sheets attached to the investigation, the incident was reported to APS on 09/11/19 at 5:21 PM, more than 24 hours after the incident occurred. OHFLAC was notified on 09/11/19 at 5:22 PM, more than 24 hours after the incident occurred. The Ombudsman was notified on 09/11/19 at 5:27 PM, more than 24 hours after the incident occurred. Resident #26's abuse/neglect investigation with an incident date of 09/26/19 was reviewed on 11/05/19 at 11:20 AM. According to the investigation, the incident occurred on 09/26/19 at 11:00 AM. Per the fax sheets attached to the investigation, the incident was reported to APS on 09/27/19 at 4:22 PM, more than 24 hours after the incident occurred. The Nurse Aide Registry and OHFLAC were notified on 09/27/19 at 4:23 PM, more than 24 hours after the incident occurred. The Ombudsman was notified on 09/27/19 at 4:24 PM, more than 24 hours after the incident occurred. d) Resident #40 Per a review of the facility's abuse and neglect logs during the survey, Resident #40 was noted to have had an incidence of abuse and/or neglect in (MONTH) 2019. Resident #40's abuse/neglect investigation with an incident date of 08/17/19 was reviewed on 11/05/19 at 12:52 PM. According to the investigation, the incident occurred on 08/17/19 at 5:30 PM. A documented entitled, Employee Disciplinary Form found in the investigation report listed the signatures of both the alleged perpetrator and the alleged perpetrator's supervisor, along with the date of the incident (08/17/19) and indicated that the alleged perpetrator was to be suspended pending a full investigation. Per the fax sheets attached to the investigation, the incident was reported to APS on 08/19/19 at 4:42 PM, more than 24 hours after the incident occurred. The Nurse Aide Registry and OHFLAC were notified on 08/19/19 at 4:43 PM, more than 24 hours after the incident occurred. The Ombudsman was notified on 08/19/19 at 4:44 PM, more than 24 hours after the incident occurred. e) Staff Interview An interview was conducted with the facility's Social Worker (SW) on 11/06/19 at 9:07 AM regarding the delay in reporting the abuse/neglects for Residents #65, #26, and #40. She stated that she reports incidents of abuse and/or neglect within 24 hours of when she is made aware of them, but sometimes events occur on the weekends or at other times she is not in the facility, so she is notified late. She agreed that the above incidences were not reported timely and added that she has been working on some education for other nursing home staff so that they can report abuse in her (the SW's) absence. An interview with the facility's Administrator on 11/06/19 at 9:55 AM also confirmed that the above incidences were not reported timely. On 11/06/19 at 12:19 PM the Administrator provided a copy of an inservice given to all staff on the premises that day regarding the proper procedures for reporting abuse and/or neglect.",2020-09-01
273,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,584,D,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, sanitary, and homelike environment. This was a random opportunity for discovery. Resident identifier: #11, #38, and #41. Facility census: 51. Findings include: a) room [ROOM NUMBER] / 104 bathroom During the initial tour on 01/13/20 02:42 PM, a commode riser in the bathroom, shared by resident's in rooms [ROOM NUMBERS], was observed to be rusted as well as missing paint. On [DATE] at 2:47 PM, the commode riser was in the bathroom, placed over the toilet. The bathroom is shared by residents in both room [ROOM NUMBER] and room [ROOM NUMBER]. The commode riser appeared to have a rust-colored substance on the front brace, running the length of the brace bar. Also, the back two (2) legs had a rust-colored substance beginning about 1/4 down the front as well as sides of the commode riser. The adjustable holes, used for adjusting the height of the commode, had a rust-colored substance on them as well as rust-colored debris inside the adjustment holes. The arms of the commode riser had rust on the arm braces, extending to the back braces of the commode. In addition, the commode riser had nine (9) separate quarter-sized areas of a brown, dried substance, beginning one inch below the commode seat and extending in a scattered pattern. On [DATE] at 2:51 PM, Employee #178, Licensed Practical Nurse (LPN), observed the commode riser and confirmed the commode riser was rusted and had dried fecal matter present. On [DATE] at 2:52 PM, Employee #200, Registered Nurse (RN), entered the resident bathroom and stated the bedside commode was rusted and would be removed immediately and replaced. RN #200 put on medical exam gloves before removing the bedside commode from the resident's room. At 5:00 PM on [DATE], Director of Nursing stated the bedside commode had been replaced.",2020-09-01
275,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,609,D,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure an allegation of neglect was reported immediately, but not later than two hours after a resident had received a serious injury. Resident #46 sustained an acute [MEDICAL CONDITION], which was caused by neglect of the facility staff. The facility did not report this serious injury to the State Survey Agency or Adult Protective Services. Resident identifier: #46 Facility census: 51. Findings included: a) Resident #46 Review of the Admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 0[DATE], revealed the functional status in Section G, concerning transfers, assessed Resident #46 as--total dependence --with two plus person physical assistance when moving from a seated to standing position. The Resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which means the Resident had no cognitive impairment at the time of assessment. Review of the care plan initiated on 06/22/19, revealed the following Problem: Resident is at risk for falls due to impaired mobility, [MEDICAL CONDITION] ([CONDITION]) effects and history of falls. Approach: Transfer with maximum assistance of two (2) staff. Guard extremities with transfers and positioning. Review of the Resident's Kardex Report, revealed Resident #46 was marked as two (2) assist with transfers with an effective date of 06/22/19. A Kardex is a medical information system used by nurses and nursing assistants to communicate important information regarding a resident's care. A progress note, dated 07/22/19 at 9:40 AM, revealed Licensed Practical Nurse (LPN) #36 was called to Resident's room. Resident #46 and Nursing Assistant (NA) #202 were on the floor, Resident complained of right knee pain and area was malformed. Physician notified and order received for x-ray. The x-ray report completed on 07/22/19 at 12:27 PM, for Resident #46 found: Significant fracture deformity with comminution of the distal femur. Acute fracture of proximal fibula and tibia. The Incident and Accident report was completed on 07/22/19. The report noted the fall was witnessed. NA #202 lost her balance while transferring the resident. The Resident and NA #202 fell to the floor, Resident #46 had complaint of pain in right knee and the x-ray showed a fracture. Review of the Five - Day Follow-Up report to the proper State authorities on 07/31/19, revealed findings were substantiated. Resident #46 sustained a distal femur fracture requiring surgical interventions, when lifted improperly by NA #202 when completing the transfer. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE] at 11:00 AM, verified NA #202 had transferred Resident #46 improperly without the assistance of another staff member, which resulted in a serious injury for the Resident. This failed practice caused actual harm to Resident #46 when she was transferred without the assistance of two staff members (in violation of her care plan) and sustained a fall that resulted in a fractured femur. An interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on [DATE] at 1:57 PM, revealed the DON identified the fall sustained by Resident #46 on 07/22/19 as an accident and not neglect, so she didn't report it within two hours. The DON also reported she waited until Resident #46 returned from the hospital on [DATE] to complete the interview with Resident #46. It was only at this time she submitted the allegation of neglect to all the appropriate State agencies. The NHA also verified there was no allegation of neglect reported within two hours to Adult Protective Services or the State Survey Agency.",2020-09-01
278,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,692,D,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to provide a diet as ordered by a physician. This was a random opportunity for discovery. Resident identifiers: 1. Facility census: 51. Findings include: a) Resident #1 Record review found a diet order, dated [DATE]: Regular Special Instructions: BITE SIZE MEATS 5 SMALL MEALS/DAY **2 HANDLED CUP AT ALL TIMES. On 01/14/20 at 11:38 AM, Resident #1's tray had been delivered to her room. The following items were on Resident #1's tray for the noon meal: full serving of meat, full serving of mashed potatoes, roll, slice of pie, bowl of tomato soup, orange jello in a plastic cup, vanilla pudding in a plastic cup, a bowl of applesauce, and a bowl of sliced beets. Employee #161, Nurse Aid (NA), was placing the items and setting up Resident #1's tray. NA #161 was asked if the amount of food on Resident #1's tray was what normally comes for her for the lunch and dinner meal? NA #161 stated the number of items on Resident #1's tray was the normal amount that is placed on her tray. On 01/14/20 at 11:59 AM, during an interview with Employee #201, Dietary Manager(DM), DM #201 was asked what should be on a tray for a resident who is ordered small meals? DM #201 stated for small meals, the resident should be served half (1/2 ) the serving of meat and potatoes that the recipe calls for. The resident should not have pudding or jello on their tray. The pudding and / or jello or a supplement would be served to the resident around 2:00 PM. On 01/14/20 at 12:02 PM, DM #201 accompanied the surveyor to view Resident #1's lunch tray. DM #201 stated the Resident's family had voiced that they wanted her to have extra pudding and jello on her tray. DM #201 stated there was no order of clarification to the existing diet order of small meals, 5 times a day for Resident #1. DM #201 observed Resident #1's lunch tray and confirmed the amount of food on the resident's tray was not consistent with the diet order. Review of Resident #1's medical record revealed the following note dated 0[DATE]20 at 2:27 PM, Nursing Progress Note: IDT staff meeting regarding residents weight loss. Resident current weight is 1[AGE].70 lbs. January weight variance report shows that the resident has loosed 20lbs or 11.2% in 182 days, loss of 12 lbs or 7.1% in the last 91 days, loss of 22 lbs or 12.2% in 32 days. Resident has been very sick , in and out of acute care hospital stay. Resident has currently been taking [MEDICATION NAME] [AGE]mg po (by mouth) daily to remove fluid. Resident consumes 1-25% of a regular diet ( 5 small meals daily). Resident consumes a supplements of glucerna. At this time RD recommends that residents glucerna to be D/C(discontinued) and to start Ensure [MEDICATION NAME] 4 oz, po bid (twice a day) with med pass. Resident is currently working with pt (physical therapy) and ot (occupational therapy) for strengthening as well as transferring and encouraging po intake. Resident has family visitors frequently and family encourages resident to eat, as well as bring in home cooked foods. Resident has little to no energy and staff is assisting with all meals. Physician aware of weight loss and new order to d/c glucerna and start Ensure [MEDICATION NAME] 4 oz po bid with med pass. Daughter aware of weight loss and this nurse asked if there was anything that we could try to help with eating. Daughter states that she loves soft desserts and she loves soup and broth , as well as Italian ice, jello with fruit in it as well as ice cream, and oatmeal for breakfast. Dietary clerk called and made aware of the request to be sent on the tray. Nursing staff to encourage po intake and also assess residents weight weekly and monthly. On 01/14/20 at 3:27 PM, the findings were discussed with the Administrator. During an interview with the Director of Nursing (DON), the DON stated she had spoken with the family and had entered in a note into the system. The DON stated Resident #1's diet order had not been modified. The DON stated the progress note on 0[DATE] was to inform the dietary department of Resident #1's preferences for her meals. No further information was provided by the end of the survey on [DATE] at 5:00 PM.",2020-09-01
279,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,842,D,0,1,URBH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #42 for a Pharmacy Regimen Review for [MEDICATION NAME]. This was true for one (1) of five (5) residents reviewed for unnecessary medications. This had the potential to affect more than a limited number of residents. Resident identifier: #42. Facility census 51. Findings included: a) Resident #42 During a medical record review on 01/14/20, it was discovered that a Pharmacy Regimen Review for [MEDICATION NAME] had been presented for a gradual dose reduction on 0[DATE] for Resident #42. The Physician disagreed with the recommendation on 0[DATE]. Further investigation provided no evidence Resident #42 had ever taken [MEDICATION NAME]. In an interview with the Director of Nursing (DON) on 01/14/20 at 2:36 PM, the DON reported Resident #42 had never been on [MEDICATION NAME]. She also called the hospital pharmacy and they had no record indicating Resident #42 ever received [MEDICATION NAME].",2020-09-01
280,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2020-01-15,880,D,0,1,URBH11,"Based on observation, record review, policy review, and staff interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment with regard to respiratory services. This was a random opportunity for discovery. Resident Identifiers: #1 and #34. Facility census 51. Findings include: a) Resident #1 During the initial tour on 01/13/20 at 12:57 PM, Resident 1's Bilevel Positive Airway Pressure (bi-pap) mask was observed lying on the bedside table, not in a bag. There was not a bag for storage present in the Resident's room. On 01/13/20 at 12:59 PM, Employee #54, Nursing Assistant (NA), entered the resident's room. When asked how bi-pap masks were stored, NA #54 stated that they were supposed to be in a bag. NA #54 confirmed a storage bag was not in the Resident's room. NA #54 stated she would inform the nurse and left to get the resident a bag. On 01/14/20 at 3:27 PM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on [DATE] at 5:00 PM. b) Resident #34 During the initial tour on 01/13/20 at 11:09 AM, Resident #34's nebulizer mask was observed lying on the table, bedside the resident's recliner. There was not a bag present in the resident's room. Resident #34's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/03/19, noted the resident had a score 15 on the Brief Interview for Mental Status. A BI[CONDITION] score of 15 is the highest score obtainable and indicates that the resident is cognitively intact. Resident #34 stated that she never has a bag and that she would like one, since sometimes the staff drop the mask on the floor. On 01/13/20 at 11:26 AM Employee #149, Nursing Assistant (NA), was asked to enter Resident #34's room. NA #149 was asked how nebulizer hand units and masks were supposed to be stored when not in use. NA #149 stated, they were supposed to be in a bag. NA #149 noted that there was no bag in Resident #34's room and went to inform the nurse. A review of the facility's policy entitled, Aerosol/Nebulizer Treatments revealed the following: .7. After completion of therapy remove mask or retrieve hand unit and place in pre-labeled patient bag. On 01/14/20 at 3:27 PM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on [DATE] at 5:00 PM.",2020-09-01
281,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2017-12-07,656,D,0,1,WMI211,"Based on record review and staff interviews, the facility failed to ensure care plans included measurable goals. This was found for one (1) of seventeen (17) residents in the final resident sample. Resident identifier: #30. Facility census: 45. Findings include: a) Resident #30 Review of the resident's care plan found the following goals were not written in measureable terms that would allow for achievement toward the goal to be evaluated: -- Resident will have stable mood & behaviors or be redirected daily. What mood and behaviors were to be addressed and how one would determine whether they decreased was not identified. -- Resident will have ADL (activities of daily living) needs met daily. There was no methodology by which this could be determined. -- Pressure injuries will show healing as evidence by decrease in area through the next evaluation. No location of the injuries or measurements were included to render this goal measurable. -- Optimal breathing pattern will be maintained, O2 (oxygen) via NC (nasal cannula) per orders. What would be considered optimal for this resident was not identified in order enable evaluation of achievement toward the goal. At lunch time on 12/07/17, these findings were brought to the attention of the Director of Nursing, and with the Care Plan Nurse prior to exit on 12/07/17.",2020-09-01
282,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2017-12-07,756,D,0,1,WMI211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the pharmacist failed to identify a medication irregularity for Resident #30. The resident received [MEDICATION NAME] and [MEDICATION NAME] for behavioral disturbances, but had not exhibited any behaviors after experiencing a major decline in both her functional abilities and behaviors. Resident identifier: #30. Facility Census: 45. Findings include: a) Resident #30 Observations at lunch time on 12/04/17 noted this resident in the dining room. The resident moved very little and did not vocalize to any extent. Several staff tried to feed the resident, and even obtained ice cream, but she refused to eat more than a few bites of her meal. Medical record review on 12/04/17 at 1:51 p.m. found Resident #30 was admitted from the community on 09/08/17 and discharged [DATE] to a psychiatric hospital. She reentered the facility from an acute care facility on 10/06/17. Her discharge to the psychiatric facility Minimum Data Set (MDS) assessment for 09/15/17, identified she only needed supervision for her activities of daily living (walking, eating, etc.) except for requiring extensive assistance for toileting. According to her Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/11/17, her [DIAGNOSES REDACTED]. This assessment identified the resident did not walk and required total care for most activities of daily living. No behaviors were assessed during the look back period for this assessment. On 12/06/17 at 11:18 a.m., medical record review found the resident was receiving [MEDICATION NAME] delayed release 250 mg at 8:00 a.m. and 8:00 p.m. for dementia with behavioral disturbances. The resident was also on Donepezil ([MEDICATION NAME]) 10 mg at 20:00 (8:00 p.m.) for unspecified dementia with behavioral disturbances Since her return and major decline, she had not had behaviors, yet remained on [MEDICATION NAME] and [MEDICATION NAME]. From 11/23/17 through 8:00 a.m. on 12/06/17, the electronic Medication Administration Record [REDACTED]. She took her [MEDICATION NAME] daily during this period. On 12/06/17 at 8:40 a.m., an interview with the Social Worker (SW) revealed the resident had behaviors and was sent to a psychiatric facility. While there, the resident became ill and was sent an acute care facility twice. The second time, the resident was admitted to the hospital. The said the resident was seriously ill, and her prognosis was grave. She had the resident returned to the facility as the facility could provide the needed care and the resident would be closer to her family. The SW agreed the resident had not exhibited any behaviors since she had returned to the facility. An interview with Registered Nurse (RN) #40 mid-morning on 12/07/17 verified the resident had not had behaviors since her return to the facility. The RN provided a copy of the resident's (MONTH) (YEAR) behavior flow sheet. No behaviors were noted. The RN provided a copy of the resident's drug regimen review and said there was no additional documentation by the pharmacist regarding the resident's medications. Review of the Chronological Record of Medication Regimen Review for Resident #30, found the pharmacist had reviewed the resident's medications on 10/11/17 and 11/11/17. The pharmacist noted the resident received [MEDICATION NAME] 250 BID (twice a day) dementia and [MEDICATION NAME] for anxiety. The review noted the [MEDICATION NAME] dosage was decreased (although not noted by the pharmacist, the [MEDICATION NAME] was discontinued.) There was no indication the pharmacist identified the use of [MEDICATION NAME] and [MEDICATION NAME], in the absence of behaviors and the resident's overall decline, as an irregularity.",2020-09-01
283,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2017-12-07,758,D,0,1,WMI211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interviews, the facility did not ensure Resident #30's drug regimen was free of unnecessary medications. The resident had a significant decline in her functional and behavioral status, yet she continued to receive [MEDICATION NAME] and [MEDICATION NAME] for dementia with behavioral disturbances. Resident identifier: #30. Facility Census: 45. Findings include: a) Resident #30 Observations at lunch time on 12/04/17 noted this resident in the dining room. The resident moved very little and did not vocalize to any extent. Several staff tried to feed the resident, and even obtained ice cream, but she refused to eat more than a few bites of her meal. Medical record review on 12/04/17 at 1:51 p.m. found Resident #30 was admitted from the community on 09/08/17 and discharged [DATE] to a psychiatric hospital. She reentered the facility from an acute care facility on 10/06/17. Her discharge to the psychiatric facility Minimum Data Set (MDS) assessment for 09/15/17, identified she only needed supervision for her activities of daily living (walking, eating, etc.) except for requiring extensive assistance for toileting. According to her Admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 10/11/17, her [DIAGNOSES REDACTED]. This assessment identified the resident did not walk and required total care for most activities of daily living. No behaviors were assessed during the look back period for this assessment. On 12/06/17 at 11:18 a.m., medical record review found the resident was receiving [MEDICATION NAME] delayed release 250 mg at 8:00 a.m. and 8:00 p.m. for dementia with behavioral disturbances. The resident was also on Donepezil ([MEDICATION NAME]) 10 mg at 20:00 (8:00 p.m.) for unspecified dementia with behavioral disturbances Since her return and major decline, she had not had behaviors, yet remained on [MEDICATION NAME] and [MEDICATION NAME]. From 11/23/17 through 8:00 a.m. on 12/06/17, the electronic Medication Administration Record [REDACTED]. She took her [MEDICATION NAME] daily during this period. On 12/06/17 at 8:40 a.m., an interview with the Social Worker (SW) revealed the resident had behaviors and was sent to a psychiatric facility. While there, the resident became ill and was sent an acute care facility twice. The second time, the resident was admitted to the hospital. The said the resident was seriously ill, and her prognosis was grave. She had the resident returned to the facility as the facility could provide the needed care and the resident would be closer to her family. The SW agreed the resident had not exhibited any behaviors since she had returned to the facility. An interview with Registered Nurse (RN) #40 mid-morning on 12/07/17 verified the resident had not had behaviors since her return to the facility. The RN provided a copy of the resident's (MONTH) (YEAR) behavior flow sheet. No behaviors were noted.",2020-09-01
284,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,550,D,0,1,SPY211,"Based on observation and staff interview, the facility failed to preserve one (1) resident's dignity during a mealtime. Private medical information was discussed with this resident in the presence of other residents dining at the same table. This was found during a random opportunity for observation. Resident identifier: #252. Facility census: 52. Findings included: On 12/03/18 at 12:07 PM, facility Urologist #179 was observed speaking to Resident #252 about confidential medical information while she was eating lunch. Two (2) other residents were dining at the table with Resident #252. Urologist #179 asked Resident #252 about potentially placing a catheter because she can't pee. At 12:12 PM, Urologist #179 was interviewed about the observations. He said that most of the residents in the facility know each other and that a lot of them have catheters. He added, What (Resident #252) said to me didn't make sense anyway. He said the alternative would have been to interrupt Resident #252's lunch and take her to her room to have the conversation in private instead. He said he thought talking to her in front of others while she was eating lunch was a preferable method to communicate the information. He then said, You're right, and added that maybe it should have been a private conversation. On 12/06/18 at 8:39 AM the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided prior to the end of the survey.",2020-09-01
287,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,584,D,0,1,SPY211,"Based on observation, and staff interview, the facility failed to ensure that two (2) of 18 sampled residents' rooms and equipment were in good repair. Resident Identifiers: Resident #16 and Resident #1. Facilty census: 51. Findings included: Observations made 12/03/18, at 12:11 PM, revealed both side rails on Resident #16's bed were scraped and rough and areas on the resident's door and walls were scraped. Observations made 12/03/18, at 3:01 PM, revealed scraped walls behind Resident #1's bed and holes in the wall outside the bathroom. An interview with the Maintenance Supervisor, on 12/06/18, at 11:55 AM, confined the areas needing repair in the rooms occupied by Resident #16 and Resident #1. The Maintenance Supervisor stated the areas would be repaired.",2020-09-01
289,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,600,D,0,1,SPY211,"Based on observation, and staff interview the facility failed to ensure the residents were free from abuse, including but not limited to verbal and physical abuse. Resident identifier: #28. Facility census: 52. Findings included: a) Resident # 28 During an observation on 12/03/18 at 11:35 AM, Residents were in dining room trays had just arrived. Physical Therapist Assistant (PTA) #180 was seen by Surveyor take the doll in a blanket from Resident #28 without asking or explaining what she was doing. She then pulled Resident # 28 forward by placing her hand on the back of the resident's head. The resident yelled for her to let go of her head. That is when PTA #180 put her face very close to the face of the resident and said, you are not being very lady like in a loud and harsh tone. She then very roughly placed this resident in a wheelchair. Licensed Practical Nurse (LPN) # 96 was trying to tell the resident what they were doing but was not allowed the time to do so by PTA #180. LPN# 96 realized this resident was not in her wheelchair and PTA # 180 appeared to be frustrated by huffing and throwing up her arms. The correct wheel chair was collected by LPN# 96. Again Resident #28 was not told what they were going to do. PTA #180 got behind the resident placing both hands on her upper back and pushed her forward she directed LPN #96 to place the gait belt behind her. This action of pushing her forward appeared to scare the resident as evidenced by her facial expression and she yelled loudly, stop you are hurting me. PTA #180 did not stop her actions towards Resident #28. It looked as though PTA #180 was pushing her out of her wheelchair. PTA #180 roughly pulled the resident into her wheelchair. When she was removing the belt now in front of the resident she once again put her face inches from the resident's face and repeated, You are not very lady like in a loud tone of voice. On 12/05/18 at 3:20 PM, DoN revealed LPN#96 told her on that day that PTA #180 was rude to the resident right in front of the surveyor and not to ask her to assist PTA#180 again. DoN said that everyone refers to PTA #180 as Sarg (short of Sergeant). The Director of Physical Therapy (DPT) #181 stated that she has had others complain about her being rude and rough with people before. DPT said that there is only a few patients that will allow PTA#180 to work with them. On 12/06/18 at 10:23 AM, during an interview LPN #96, stated that she reported to the DoN that PTA #180 was very rude and rough with Resident # 28 while transferring her to her wheelchair to eat lunch. She said, I didn't like the way she spoke to her by telling her she is not very Lady like and not allowing me enough time to explain to her what we were doing. Review of the employee file for PTA#180 the facility could not provide information that they had had any training dealing or caring for residents with Dementia or Alzheimer.",2020-09-01
290,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,655,D,0,1,SPY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to fully develop a baseline care plan to address pertinent care needs upon admission. This affected one (1) of 18 residents reviewed for care plans. Resident identifier: #252. Facility census: 52. Findings included: a) Baseline Care Plan Resident #252 was admitted to the facility on [DATE]. On 12/04/18 at 09:20 AM, review of Resident #252's base line care plan (titled Admission Care Plan) revealed only to have resident name written at top, no admitted , no resident identifiers, and no initiation dates for goals or plan of care and no progress dates. On 12/05/18 at 8:40 AM review of the facility's policy titled Care Planning Process with review and revise date of 11/08/18, stated an initial care plan addressing the specific needs of the resident will be developed by the IDT team within 48 hours after admission. During an interview on 12/05/18 at 8:48 Director of Nursing (DoN) #99 agreed care plan was incomplete with no date or time of implementation, no date of admission. DoN #99 also stated that the missing information on the care plan made the care plan unacceptable to use.",2020-09-01
292,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,697,D,0,1,SPY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and resident interview, the facility failed to provide pain management in accordance with physician's orders for one of 18 sampled residents who experienced pain. Resident identifier: #16. Facility census: 52. Findings included: a) Resident #16 1. A review of the Medication Administration Policy, effective date 02/20/18, page 7, verified per standard protocol, medications can be administered one (1) hour before or one (1) hour after scheduled time. 2. An interview with Resident #16, on 12/03/18, at 12:11 PM, revealed the resident suffered from painful arthritis but did not always receive pain medication in a timely fashion, stating staff are usually late with the medication. 3. Review of the medical record showed Resident #16 to have a physician's orders for a [MEDICATION NAME] every 12 hours, [MEDICATION NAME] 25 mcg/hr once a day every third day. 4. A review of the Medication Administration Record, [REDACTED]. The medication was administered late 23 times in (MONTH) (YEAR) and was late with administration four times during the month of (MONTH) (YEAR). Examples of the late administration were as follows: --[MEDICATION NAME] was given late on 11/14/18 through 11/18/18, 11/20/18, 11/22/18, 11/23/18, 11/27/18, 11/27/18, 11/29/18,11/30/18, 12/01/18, 12/2/18, and 12/03/18. 5. Further review of the MAR indicated [REDACTED]. The medication was given late on 11/13/18, 11/16/18, 11/22/18 and 11/28/18. 6. A review of (MONTH) MARs showed the dose of [MEDICATION NAME] was late 7 of the 10 documented administered doses. Doses were administered late on 09/02/18, 09/05/18, 09/11/18, 09/14/18, 09/17/18, 09/20/18, and 09/23/18. The 20:00 dose was administered as late as 22:16 on 9/23/18 and 22:17 on 09/05/18. 7. An interview with the Director of Nursing, on 12/05/18, at 10:19 AM, revealed medications are to be given within the hour of the time ordered. She further stated I understand these pain meds are being given late and the resident is experiencing pain.",2020-09-01
293,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,804,D,0,1,SPY211,"Based on observation, staff interview, resident interview, and record review, the facility failed to provide food and drink that was safe and at an appetizing temperature. Residents reported being served cold food that was not palatable. This had the potential to affect more than a limited number of residents. Resident identifier: #16. Facility census: 52. Findings included: a) Resident #16 During an interview on 12/03/18 at 2:12 PM Resident #16 stated the food was still being served cold, that she liked her soup hot and it was never warm enough for her eat. Resident council minutes dated 10/01/18 revealed Resident #16 voiced a concern of cold food when delivered with corrective action as trays would be passed in a more timely manner and facility do a test tray. Resident council minutes dated 11/05/18 also revealed that Resident #16 complained the food was not hot when served. b) Test Tray On 12/05/18 at 11:39 AM observation for test tray started when staff started passing trays in B/C wing solarium. At 11:46 AM trays split between carts for meal tray hall pass. At 11:51 AM just prior to being served, notified staff that the last tray left on meal cart will be tested . Test tray temperatures obtained by Dietary Manager (DM) #170 at 11:55 AM consisting of: --Ground spaghetti with meat temperature 125 degrees Fahrenheit (F). --Spinach 1/2 cup temperature of 118 degrees (F). --Ground citrus cup temperature 48 degrees (F) --Chocolate milk temperature 51 degrees (F) --Grape juice temperature 51 degrees (F) --Gelatein (nutritional supplement) temperature 48 degrees (F) --Garden Salad temperature 60 degrees (F) c) Dietary Manager Interview During an interview on 12/05/18 at 2:30 PM Dietary Manger (DM) #170 stated she was aware that some of the residents have complained about cold food, and they have tried staggering out the meal times and tray line processing to allow meal trays to be delivered more timely while hot.",2020-09-01
295,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2018-12-07,880,D,0,1,SPY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The nurse failed to use a protective barrier when she placed the two inhalers on the resident's side table and failed to provide isolation precautions by not posting signs alerting the public of an infection control risk for residents in isolation. These were random Resident opportunities for discovery. Identified Residents #14 and #16. Facility census was 52. Findings included: a) Resident #14 On 12/04/18 at 7:45 AM, Licensed Practical Nurse (LPN) #78 failed to place a barrier on Resident's #14 bedside table before laying to inhalers on the table. LPN#78 said she realized what she did as soon as she did it and that is why she wiped the inhalers off with an alcohol pad. On12/04/18 at 12:38 PM, Director of Nursing (DoN) was informed of observation and said that LPN#78 had already told her about it. b.) Resident #16 Observations during the tour, on 12/03/18, at 12:00 PM, , revealed no precautionary measures alerting staff and visitors to obtain more information about care provided to Resident #16 before entering the room. b.) A review of the medical record for Resident #16, showed the resident was being isolated in Contact Isolation for an infection as of 11/25/18, c.) An interview with LPN #137, on 12/03/18, at 01:51, revealed Resident #16 was being isolated for [MEDICAL CONDITION] but verified there was no sign on the door to alert staff and visitors that extra precautions would be required when entering the room. LPN #137, further stated, a sign that stated STOP should have been on the resident's door. d.) An interview with the infection control nurse, on 12/03/18, at 2:10 PM, verified the isolation policy required a sign on the door but stated it must have fallen off. e.) Review of the policy and procedure Isolation Procedure, dated (MONTH) 5, 2007, showed a large sign will be placed on the outside of the resident's door informing all to see the nurse before entering the room.",2020-09-01
298,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,241,D,0,1,UN5811,"Based on observation and staff interview, the facility failed to ensure Resident #7 was provided with a dignified dining experience during the breakfast meal on 03/06/17. This was a random opportunity for discovery. Resident identifier: #7. Facility census: 81. Findings include: a) Resident #7 During an observation at 9:02 a.m. on 03/06/17, Nurse Aide (NA) #65 was observed feeding Resident #7. NA #65 was standing at the residents bedside instead of being seated where she could be at eye level with Resident #7. An interview with NA #65, at 9:06 a.m. on 03/06/17, confirmed she was standing instead of sitting down while feeding Resident #7. She stated she should have been sitting, but there was no chair in the residents room to sit on so she had to stand. She stated, You can look in all these rooms there are no chairs in any of them.",2020-09-01
299,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,246,D,0,1,UN5811,"Based on observation, resident interview, and staff interview, the facility failed to provide reasonable accommodations of individual needs for one (1) of thirty-five (35) residents during a random opportunity for discovery during Stage I and Stage II of the Quality Indicator Survey (QIS). A resident's call light was not within reach. Resident identifier: #78. Facility census: 81. Findings include: a) Resident #78 During Stage 1 of the Quality Indicator Survey (QIS), on 03/05/17 at 2:54 p.m., an observation revealed Resident #78's call light was not within his reach while he was lying in bed. During Stage 2 of the QIS, an observation and interview with Specialist Maintenance 2 (SM2) #19, on 03/08/17 at 8:32 a.m., found Resident #78's call light on the floor, and not within the resident's reach. SM2 #19 verified the placement of the call light was out of reach of the resident, and the resident would not be able to use the call light. During Stage 2 of the QIS, on 03/08/17 at 9:05 a.m., the resident was lying in his bed and he was observed by the assistant director of nursing (ADON) #45. The resident's call light was lying on the floor. Resident #78 was asked by this surveyor whether he used his call light and Resident #78 stated, Yes, I use my call light. The ADON picked the resident's call light off the floor and attached his call light within the resident's reach. The resident was asked by this surveyor to ring his call light. The resident reached down and pushed the button and the light turned red on the wall. The ADON agreed the resident's call light was not in reach and therefore the resident was unable to use his call light for assistance if wanted to.",2020-09-01
301,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,272,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct an accurate comprehensive Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed for the care area of accidents. The MDS assessment for Residents #26 was inaccurate in the area of behavior patterns. Resident identifier: #26. Facility census: 81. Findings include: a) Resident #26 A review of Resident #26's medical records, on 03/07/17 at 1:30 p.m., revealed an admission date of [DATE]. The medical records contained an annual MDS with an assessment reference date (ARD) of 01/13/17. This MDS, in item E1000A for Wandering - Impact, indicated Resident #26's wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g. stairs, outside of the facility). Further review of the medical records on 03.07/17 at 2:00 p.m., found no evidence and/or documentation Resident #26 wandered into dangerous areas. Tthere was no evidence found during the look back period for the referenced MDS for the behavior of wandering. During an interview, on 03/07/17 at 3:45 p.m., the Director of Nursing (DON) and the Social Service Director (SSD), both confirmed the MDS with an ARD of 01/13/17 was inaccurate. The MDS was immediately corrected by the SSD.",2020-09-01
302,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,274,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, minimum data set (MDS) 3.0 resident assessment instrument (RAI) manual, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for one (1) of twenty-one (21) residents Stage 2 sample residents during the Quality Indicator Survey (QIS). Resident #63 experienced a significant change when the resident and/or her responsible party elected to participate in hospice services. Resident identifier: #63. Facility Census: 81. Findings include: Review of Resident #63's medical records found the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nursing notes dated 12/21/16 read, . social worker spoke with resident concerning hospice services and the resident in agreement moved to private room for comfort . Review of physician progress notes [REDACTED]. Patient with a history of craniotomy with a poor prognosis sent back to nursing home with hospice . Hospice consulted Prognosis poor. Hospice services started on 12/27/16 for the [DIAGNOSES REDACTED]. A five (5) day MDS assessment with an assessment reference date (ARD) of 12/26/16 and a discharge tracking death in facility MDS with ARD of 12/30/16 were found in the residents record, no further MDS assessments were found in the record. Review of the MDS 3.0 resident assessment instrument (RAI) manual read, A significant change status MDS is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A significant change status assessment must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving his/her highest practicable well-being at whatever stage of the disease process the resident is experiencing. During an interview on 03/07/17 at 2:00 p.m., Employee #24, MDS coordinator, stated she missed the significant change. She further explained her corporate office stated it was not necessary to complete the significant change MDS. Director of Nursing and the Nursing Home Administrator notified on 03/07/16 at 3:15 p.m., of the missed significant change MDS for Resident #63. No further information provided.",2020-09-01
303,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,282,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement the care plan for one (1) of one (1) residents reviewed for the care area of Hospice. The facility did not have current notes written by licensed Hospice staff. In addition, the facility was not provided with a schedule indicating when the visits of the Hospice nurse aide (NA) would occur. Resident identifier: #6. Facility census: 81. Finding include: a) Resident #6 Review of the physician's orders [REDACTED]. Review of the care plan found the following problem: --Patient is on Hospice care related to: End of life care. The goal associated with the problem was: --Patient will be comfortable and have needs meet thru next review. Approaches included: --All Hospice staff visits will be documented in resident chart. --Social services to visit twice a month, NA (nurse aide) 2-3 times per week, nurse to visit 1-2 times per week and as needed to assess and manage care, weekly volunteer companion. --NA schedule for Hospice to be posted in resident's room. Observation of the resident's room found the (MONTH) calendar for hospice nurse aide visits was not posted in the resident's room. At 12:04 p.m. on 03/07/17, NA #14 found a calendar for the month of (MONTH) (YEAR), but was unable to locate the March, (YEAR) calendar. NA #14 said the calendar is usually on the resident's bulletin board. NA #14 said she thought the Hospice NA visits the resident on Tuesdays, Wednesdays and Thursdays. At 12:04 p.m. on 03/07/17, notes written by the Hospice staff were located in a binder at the nurses desk by Registered Nurse (RN) #23. The most recent nurses' note in the binder was dated 02/21/17. An interview with the director of nursing (DON), at 12:51 p.m. on 03/07/17, found the Hospice agency is now documenting their notes in the computer and the facility has access to these notes. At 12:56 p.m. on 03/07/17, the administrator reviewed the Hospice notes in the computer and confirmed the last Hospice note was written on 02/21/17. The administrator provided a copy of the NA schedule for (MONTH) (YEAR) and confirmed the March, (YEAR) schedule was not available to the facility. The administrator said she would contact the Hospice agency as the nursing notes were not up to date. The DON said the Hospice nurse had visited the facility since 02/21/17. At 1:00 p.m. on 03/07/17, the DON confirmed the care plan was not implemented as directed.",2020-09-01
305,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,332,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of medication administration, reconciliation of the observed medication administration with medical records, staff interviews, and policy and procedures on administering medication, the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. Two (2) errors were identified during thirty-two (32) observed opportunities, making the facility's medication error rate 6.25%. This affected one (1) of three (3) residents observed during medication administration observations. Resident identifiers: #3. Facility census: 81. Findings include: a) Resident #3 During the medication pass observation, on 03/07/17 at 8:43 a.m., Charge nurse-licensed practical nurse (CN-LPN) #50, was observed administering medications to Resident #3. Reconciliation of the observed medications administered with the resident's medical record revealed two (2) medication errors. Error #1: [MEDICATION NAME] 24 micrograms (mcg) give one capsule by mouth, one (1) time a day, every two (2) days related to constipation. This medication next dose is to be given at 9:00 a.m. on 03/08/17. Error #2: Disdol 50,000 units by mouth one (1) time a day every Thursday related to Vitamin D Deficiency. This medication is to be administered on Thursday 03/09/17. In an interview and review of the Medication Administration Record [REDACTED]. At 8:10 a.m. on 03/08/17, the Director of Nursing (DON) was made aware of the medication errors identified for Residents #3 during the medication administration observation. No further information provided. A review of the facility's policy on medication administration on 03/08/17 at 10:00 a.m., revealed the facility follows the five (5) rights: right resident, right drug, right dose, right route, right time, are applied for each medication being administered.",2020-09-01
309,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,412,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and medical record review, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of dental services, obtained dental services in a timely manner. Resident identifiers: #87 and #38. Facility census: 81. Findings include: a) Resident #87 During an interview with Resident #87, at 1:12 p.m. on 03/05/17, he said his teeth were hurting He said he needed to have his teeth pulled and was trying to, Get up there to get them pulled. He said he had seen a dentist but no one was helping him get the teeth pulled. He said, I have money and can pay for it. The resident also said he wanted a set of dentures. Observation found the resident had several missing teeth. Review of the resident's last full minimum data set (MDS), an annual with an assessment reference date (ARD) of 06/24/16, found the dental section was coded with obvious or likely cavity or broken natural teeth. Review of the care plan found the following problem: --At risk of dental problems related to some natural teeth loss, possible carious teeth. The goal associated with the problem was: --Will be free of complications related to dental/oral issues thru next evaluation. The approaches included: --Assistance with oral care as needed, --Inspect oral cavity for bleeding of gums or other issues, and --Refer to dental services as needed. An interview with the resident and Registered Nurse (RN) #35, the assistant director of nursing, at approximately 3:00 p.m. on 03/06/17, found the resident told RN #35 his teeth had been bothering him for about one year. He said, I have money to pay to get my teeth pulled and I can get an ambulance to go get them done. RN #35 said Employee #21 had scheduled the resident to see a dentist. She said the resident's responsible party had not followed up with the facility to make an appointment to get the resident's teeth extracted. At 4:15 p.m. on 03/06/17, Employee #21 said she had documentation she had been trying to get the responsible party to sign the resident's paper work so he could get his teeth extracted. She said the responsible party didn't think the resident really wanted his teeth pulled, he just wanted to get out of the facility for a while and go for an outing. She said the resident believed he would be hospitalized for [REDACTED]. She said the resident really doesn't understand he wouldn't be at the hospital. Employee #21 said the facility physician had already given clearance for the surgery. She (referring to the responsible party) is dragging her feet because she has to be there for the surgery. Observation found the referral for the oral surgeon was on the medical record unsigned by the responsible party. Employee #21 provided the following documentation: --(Name of responsible party had an appointment scheduled with this author on 05/06. She did not show. This author has tried on several occasions to reach her via phone, leaving messages with employees at the number provided. This author will sent a letter to her known address. A meeting needs to be made with the RP (responsible Party), Resident and SW (social worker) to discuss full mouth extractions and plan of care as discussed with Dr. (name of dentist) and this author for this resident. The note was dated 05/20/16. A second note dated 10/06/16, dental (name of oral surgeons) to mail paperwork to MPOA (medical power of attorney) to sign before consult to be scheduled. The MPOA has in the past (2x) asked for conference with this resident and author to discuss the plan of treatment ie: being without teeth for 12 months while gums heal but has not shown for either. Certified mail to be resent on 10/07 with request for meeting, copy to be on file with this author. The next note was dated 11/02/16, RP returned phone call stated she did not see it necessary to have extractions at this time. Employee #21 provided a copy of the dental consult, dated, 04/06/16, Patient presents with pain in upper and lower teeth. X-rays were faxed her from (name of hospital) .Exam and X-ray shows the need for extraction of all remaining upper teeth by the oral surgeon. Remaining lower teeth need scaling and root planing and [MEDICATION NAME]. He is in need of upper denture and a lower partial . A dental consult note dated 04/08/16, (name of Employee #21) called from Golden living stating that they received clearance/permission from family members to have teeth extracted by the oral surgeon for Pt. Filled out referral and emailed to (Name of facility with the oral surgeon) and they will call Golden Living with appointment. At 2:22 p.m. on 03/07/17, the director of nursing (DON) and RN #21 were asked to provide further evidence the responsible party was aware of the dental consult on 04/06/16 noting the resident was having pain and needed further dental services. They were asked what would be their next step if a responsible party did not respond to needed treatment. Also the permission for the dental work remained on the facility's medical record and the dentist note indicated the referral was emailed to the facility, not the responsible party. Review of the resident's annual minimum data set (MDS) with an assessment date (ARD) of 06/24/16 found the resident scored a 15 on the brief interview of mental status (BIMS). A score of 15 is the highest score obtainable and indicates the resident is cognitively intact. A health care surrogate was appointed for the resident on 07/17/15. On 03/07/17, Employee #3, was asked to provide a copy of the information sent to the responsible party of Resident #87. At 4:50 p.m., on 03/07/17, information was provided for another resident, not Resident #87, by the administrator. The administrator was asked about the 10/06/16, note which said the resident would be without teeth for a year until his gums healed. The administrator was unaware as to how that conclusion was determined and by whom. At 9:00 a.m. on 03/08/17, RN #21 said the facility had been in contact with the resident's responsible party and arrangements were being made to ensure the resident received dental services. b) Resident #38 Observation of the resident, at 3:22 p.m. on 03/05/17, during Stage 1 of the Quality Indicator Survey (QIS) found the resident has missing teeth. Review of the most recent annual MDS, with an ARD of 02/01/17, found the resident was coded as having obvious or likely cavity or broken natural teeth. Review of the documentation regarding dental services was provide on the afternoon of 03/07/17 by the DON. The following was documented in the facility progress notes: --02/09/16, Letter mailed in regards to dental exam. SASE (abbreviation unknown) with consent forms enclosed. Power of Attorney (POA) must be present for exam, eval. (evaluation) and X-Rays. POA to contact this author with availability for scheduling. --04/11/16, Certified letter mailed on this date by this author in regards to dental audit and suggestion that this resident to be seen by (name of dentist). A carbon copy of the letter in on file with this author. --04/25/16, Certified letter green card signed and returned to this author. No consent has been returned as to date. At 4:50 p.m. on 03/07/17, the administrator was asked what the facility did to follow up the the POA regarding the dental appointment scheduled. At 8:30 a.m. on 03/08/17, the administrator was unable to provide information on how the facility addressed the unresponsiveness of the responsible parties of Resident's #87 and #38. Both resident were determined to need dental services and the facility said neither responsible party had acted on getting the needed dental services. The guidance to surveyors directs, for Medicaid residents, the facility must provide the resident, without charge, all emergency dental services, as well as those routine dental services that are covered under the State plan. The administrator was unable to provide information the responsible parties of Resident's #87 and #38 were aware the dental services could be provided without cost to the resident.",2020-09-01
310,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,441,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and resident interview, the facility failed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The facility failed to maintain a sanitary environment for one (1) of 35 residents observed during Stage 1 of the Quality Indicator Survey (QIS). An observation revealed a large, dried yellowish-brown urine like substance underneath the resident's bed. Resident identifier: #9. Facility census: 81. Findings include: a) Resident #9 On 03/05/17 at 12:33 p.m., an observation made in Resident #9's room revealed a large stain of a brownish/yellow substance that was dried. The brownish/yellow substance covered the area underneath the resident's bed. It extended out one side of the bed and a little from the end of the resident's footboard. An observation also revealed the resident had a urinary catheter that hung on the side of the bed near the floor. Staff interview conducted, on 03/05/17 at 3:41 p.m., confirmed the resident had a urinary catheter due to [DIAGNOSES REDACTED] (impairment in motor sensory function or sensory function of the lower extremities. At 2:30 p.m. on 03/06/17, an observation revealed the brownish/yellow stain that was under the resident's bed on 03/05/17 was gone. Housekeeper #74 was observed cleaning in Resident #9's room. She said she had been asked to clean up urine from the floor under the resident's bed. She said a nurse aide had asked her to clean up the urine because the resident's catheter bag had been leaking. At 3:00 p.m. on 03/06/17, Registered Nurse (RN) #23 said she did not know about the stain under the resident's bed and did not know if the resident's catheter bag was leaking. At 3:39 p.m. on 03/06/17 Registered Nurse (RN) #23 said she went ahead and changed Resident #9's catheter bag. She said she did not know if it was leaking, but she went ahead and changed it anyway. An interview with Nurse Aide #65, on 03/06/17 at 3:44 p.m., revealed she had been in the resident's room earlier in the day and asked Housekeeper #74 to clean up the floor under the resident's bed. She said she did not know what was under the bed. She said it could have been urine, she was not sure. She was asked if she had seen the substance earlier in the day. She said it was possible that she had seen it when she was in the room in the morning, but she was not sure. During an interview with Resident #9, on 03/06/17 at 3:54 p.m., the resident said her catheter bag leaked often, and she had told the staff about it before. She said she knew when her catheter bag leaked because she could smell it. She indicated she had told the nursing staff earlier in the day, and they did not change the catheter bag, but did clean up the floor under her bed.",2020-09-01
311,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,505,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the attending physician of the results of a physician ordered Comprehensive Metabolic Panel (CMP) and a B-Type Natriuretic (excretion of sodium in urine) Peptide (BNP) for Resident #120. This was true for one (1) of three (3) residents reviewed for the care area of hospitalization during Stage 2 of the Quality Indicator Survey. Resident identifier: #120. Facility census: 81. Findings include: a) Resident #120 A review of Resident #120's medical record, at 3:13 p.m. on 03/06/17, found a physician's order dated 11/07/16 for a CMP and a BNP related to a [DIAGNOSES REDACTED]. Further review of the record found no results for the CMP and BNP nor was their any evidence the attending physician and/or Nurse Practitioner was notified of the results. At 8:39 a.m. on 03/07/17, the Director of Nursing was asked to provide the results of the CMP and BNP ordered on [DATE]. At 9:43 a.m. on 03/07/17, Registered Nurse (RN) #23 provided the results of the CMP and the BNP. These results indicated the lab was obtained on 11/08/16 and the results were reported to the facility on the same date. The results were not signed by the physician and/or Nurse Practitioner nor did the facility provide any evidence nursing staff had reported these results to the attending physician. A final interview with the DON, at 12:00 p.m. on 03/07/17, confirmed there was no evidence in the record the physician and/or Nurse Practitioner was notified of the results. She indicated the Nurse Practitioner was going to send over her notes and if they indicated she knew about the results she would provide them to the surveyor. At the time of exit on 03/08/17 at 11:45 a.m. no further information was provided.",2020-09-01
312,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,507,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to maintain the results of a physician ordered Comprehensive Metabolic Panel ( CMP) and B-Type Natriuretic (excretion of sodium in the urine) Peptide (BNP) in Resident #120's medical record. This was true for one (1) of three (3) residents reviewed for the care area of hospitalization during Stage 2 of the Quality Indicator Survey. Resident identifier: #120. Facility census: 81. Findings include: a) Resident #120 A review of Resident #120's medical record, at 3:13 p.m. on 03/06/17, found a physician's orders [REDACTED]. Further review of the record found no results for the CMP and BNP. At 8:39 a.m. on 03/07/17 the Director of Nursing (DON) was asked to provide the results of the CMP and BNP ordered on [DATE]. At 9:43 a.m. on 03/07/17, Registered Nurse (RN) #23 provided the results of the CMP and the BNP. These results indicated the lab was obtained on 11/08/16 and the results were reported to the facility on the same date. However; the print date on the results was 03/07/17 and at the top of the page was a fax line which indicated these results were faxed to the facility on [DATE] at 8:50 a.m. which is after they were requested by the surveyor. A final interview with the DON, at 12:00 p.m. on 03/07/17, confirmed they could not locate the original lab results in Resident #120's record and that is why they had to be faxed to the facility from the lab when requested.",2020-09-01
313,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2017-03-08,514,D,0,1,UN5811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medical record was complete and accurate. Resident #75's Medication Administration Record [REDACTED]. Resident #99 had an inaccurate [DIAGNOSES REDACTED]. Resident identifiers: #75 and #99. Facility census: 81. Findings include: a) Resident #75 Record review found the resident was admitted to the facility on [DATE]. He was discharged to the hospital on [DATE]. Review of the (MONTH) (YEAR), MAR found a physician's orders [REDACTED]. (If yes, go to notes.) Acceptable level of pain is 0. Nonpharmacological interventions include, but not limited to distraction, repositioning and food/drink. The MAR indicated [REDACTED].) On some occasions on the MAR indicated [REDACTED]. The DON confirmed the MAR indicated [REDACTED]. b) Resident #99 A review of Resident #99's discharge order on 03/07/17 at 3:30 p.m., found Resident #99's is receiving [MEDICATION NAME] (an anticoagulant) for deep-vein [MEDICAL CONDITIONS] [MEDICATION NAME]. A review of the resident's physician order [REDACTED].#99 is receiving [MEDICATION NAME] 5,000 units twice a day subcutaneously related to [MEDICAL CONDITIONS] of native coronary artery without [MEDICAL CONDITION] pectoris. On 03/07/17 at 3:45 p.m., the DON reviewed Resident #99's discharge and physician orders [REDACTED].#99.",2020-09-01
315,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,657,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to revise comprehensive care plans when residents experienced changes in condition. This was true for three (3) of 17 residents reviewed during the long-term care survey process. Resident #2's comprehensive care plan was not updated regarding medications. Resident #12's comprehensive care plan was not updated regarding urinary elimination. Resident #36's comprehensive care plan was not updated regarding nutrition. Resident identifiers: #2, #12, #36. Facility census: 72. Findings included: a) Resident #2 Review of Resident #2's comprehensive care plan revealed the following foci: - (Resident name) receives antidepressant medication ([MEDICATION NAME]) r/t (related to) depression, poor nutrition. - (Resident name) receives antipsychotic medications ([MEDICATION NAME]) r/t behavior management. Review of Resident #2's comprehensive care plan revealed she was not currently prescribed two (2) of the medications contained in the comprehensive care plan. [MEDICATION NAME] ([MEDICATION NAME]) was discontinued on 4/1/19. [MEDICATION NAME] (aripiprazole) was discontinued on 6/10/19. During an interview on 07/10/19 at 12:01 PM, the Director of Nursing agreed Resident #2 was no longer receiving [MEDICATION NAME] and [MEDICATION NAME], although she was care planned to receive these medications. No further information was provided prior to the survey exit conference. b) Resident #12 Upon observation on 07/08/19 at 1:00 PM, Resident #12 was noted to have an indwelling urinary catheter. Review of Resident #12's comprehensive care plan revealed the following focus: (Resident name) has bladder incontinence r/t (related to) Activity Intolerance, History of UTI (urinary tract infection), Impaired Mobility, Physical limitations, Obesity. Interventions were using disposable briefs, checking for incontinence, cleaning peri-area after each incontinence episode, handwashing before and after delivery of care, having call light within easy reach, observing for signs and symptoms of urinary tract infection, and observing for and reporting any possible causes of incontinence. Resident #12's comprehensive care plan also included the following focus: (Resident name) is at risk for Urinary Tract Infection r/t (related to) indwelling catheter, obesity, poor hygiene. Interventions were encouraging adequate fluid intake, giving antibiotic therapy as needed, having the call light within easy reach, observing vital signs and for signs and symptoms of urinary tract infection, obtaining laboratory testing, and assisting resident with hand washing after being toileted. Interventions related to maintaining the indwelling urinary catheter, such as daily catheter care, were not contained in the comprehensive care plan. During an interview on 07/09/19 at 2:00 PM, the Director of Nursing agreed Resident #12's comprehensive care plan contained a focus related to urinary incontinence, although he has an indwelling urinary catheter. She also agreed Resident #12's comprehensive care plan did not contain interventions relating to care of his indwelling urinary catheter. During an interview on 07/09/19 at 3:17 PM, the Administrator was informed of the above-described findings. No further information was provided prior to the survey exit conference. c) Resident #36 During the screening portion of the Long-Term Care Survey Process (LTCSP) on 07/08/19, Resident #36 appeared thin. On 07/10/19, a copy of Resident #36's weights for the past year as well as Resident #36's current care plan was requested for review. Per documentation provided by the facility, Resident #36's weights for the past year were as follows: 07/08/19 - 84.4 pounds 07/05/19 - 84.0 pounds 07/03/19 - 83.4 pounds 06/19/19 - 90.9 pounds 06/04/19 - 92.4 pounds 05/30/19 - 90.1 pounds 05/21/19 - 89.2 pounds 05/14/19 - 87.3 pounds 05/07/19 - 87.4 pounds 04/03/19 - 93.2 pounds 03/04/19 - 95.6 pounds 02/19/19 - 96.1 pounds 01/16/19 - 96.4 pounds 12/04/18 - 97.0 pounds 11/14/18 - 97.3 pounds 11/06/18 - 97.4 pounds 10/09/18 - 98.0 pounds 09/10/18 - 98.6 pounds 08/02/18 - 97.4 pounds A review of Resident #36's weight records during the survey revealed that Resident #36 had experienced a gradual and progressive weight loss trend since 09/10/18. Resident #36 had a slight weight gain for a few weeks after 05/14/19, after which point Resident #36's weight plummeted again, continuing the months-long progressive weight loss trend. During the survey, a review of Resident #36's care plan revealed the following nutritional goal, last revised on 01/09/19, (Resident's Name) will maintain adequate nutritional status as evidenced by maintaining weight with no s/s (signs/symptoms) of malnutrition through next review date. On 07/10/19 at 3:03 PM, the facility's Registered Dietitian (RD) agreed that the care plan goal had not been revised to reflect Resident #36's months-long weight loss trend and that maintaining weight was not an appropriate goal for someone with continued weight loss. The facility's Director of Nursing (DoN) was present during this interview and had no comment regarding the situation. No further information was provided prior to the survey exit conference.",2020-09-01
317,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,686,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was true for one (1) of one (1) residents reviewed for the care area of Pressure Ulcers. Resident identifier: #222. Facility census: 72. Findings included: a) Resident #222 A review of Resident #222 medical record at 9:36 a.m. on 07/09/19 found Resident #222 was admitted to the facility on [DATE] in the evening hours. Further review of the record found a Head to Toe Skin Check dated 06/28/19 at 8:12 p.m. which was completed by Registered Nurse (RN) #54. This form indicated Resident #222 had a Pressure ulcer to her Coccyx and her left heel. However the sections were the length, width, depth, and pressure ulcer stage were to be documented was left blank and not completed. Further review of the medical record found an Admission Data Collection Assessment which was completed on 07/01/19. The assessment was created by RN #59 and revised by RN #54. This assessment under section 7. Physical Examination: Skin Integrity [NAME] Skin Conditions found Resident #222 had a pressure ulcer to her coccyx and her left heel. The sections to record the length, width, depth and pressure ulcer stage was again left blank on this assessment. The medical record also contained two (2) Skin - Weekly Pressure Ulcer Record one for each wound previously identified. The Weekly Pressure Ulcer Record for the Left Heel was completed on 07/04/19 at 9:05 a.m. by the Wound Care RN #32 this assessment indicated the date of onset for this wound was 06/28/19 and the resident was admitted with this wound. Wound Care RN #32 measured the wound and staged the pressure ulcer and documented the wound was 4.2 centimeters (CM) long, 3.6 cm wide, .1 cm deep and was a Stage II pressure ulcer. This was the first time since the residents admission on 06/28/19 the measurements of the wound and the stage had been assessed. The Weekly Pressure Ulcer Record for the Coccyx was completed on 07/04/19 at 9:13 a.m. by Wound Care RN #32 this assessment indicated the date of onset for this wound was 06/28/19 and the resident was admitted with this wound. Wound Care RN #32 measured the wound and staged the pressure ulcer and documented the wound was 2.5 cm long, 1.1 cm wide, .1 cm deep and was a Stage II pressure ulcer. This was the first time since the residents admission on 06/28/19 the measurements of the wound and the stage had been assessed. A review of the Treatment Administration Record (TAR) for Resident #222 since the time of admission until present found the pressure ulcer to the coccyx and the pressure ulcer to the left heel were not treated until 07/05/19. A review of the Physician order [REDACTED].#222's pressure ulcers: --wound to coccyx: cleanse wound with normal saline. pat dry. apply skin prep peri wound. apply puracol collagen dressing to wound bed. cover with bordered foam dressing. change q MWF (Every Monday, Wednesday, and Friday) and prn (as needed). This order had an order date of 07/03/19 with a start date of 07/05/19. -- wound to left heel: cleanse wound with normal saline. pat dry. apply skin prep peri wound. apply silver alginate dressing to wound bed. cover with bordered foam dressing. change q MWF (every Monday, Wednesday, and Friday) and prn (as needed). This order had an order date of 07/03/19 with a start date of 07/05/19. There were no orders for the treatment of [REDACTED]. An interview with the Wound Care RN #32 at 10:14 a.m. on 07/10/19 confirmed Resident #222 was admitted to the facility on [DATE] at which time the pressure ulcer to the coccyx and to the left heel was identified. He agreed the wound was not measured or staged until he returned to work on 07/03/19. He also agreed the wound had no treatment orders in place until he returned to work on 07/03/19. Wound Care RN #32 stated that typically wounds are measured, staged, and a treatment is ordered within the first 24 hours after admission. He indicated that he was off from work for a few days and that is why there was a delay. He agreed that someone should have done the measuring, staging and treatment orders in his absence. During an Interview with the Director of Nursing (DON) at 10:28 a.m. on 07/10/19 the above findings were reviewed. She agreed that someone should have measured, staged and treated the pressure ulcers prior to 07/03/19 in the absence of Wound Care RN #32. She stated that she would review the record and if she found any additional information she would provide it. At the time of exit no additional was provided. An additional interview with Wound Care RN #32 at 11:04 a.m. on 07/10/19 revealed he did treat Resident # 222's pressure ulcers on 07/03/19. He indicated that he did the treatment before he put the order in and it was not documented in the medical record that it was performed. No further information was provided prior to the survey exit conference.",2020-09-01
318,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,690,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident with an indwelling urinary catheter received appropriate care and services. Daily catheter care was not documented for Resident #12. This was true for one (1) of one (1) resident reviewed for the care area of urinary catheter. Resident identifier: #12. Facility census: 72. Findings included: a) Resident #12 Upon observation on 07/08/19 at 1:00 PM, Resident #12 was noted to have an indwelling urinary catheter. Resident #12 had an order written [REDACTED]. The catheter was to be changed as needed for dysfunction. Resident #12's current orders did not contain orders for daily catheter care. Proper care and cleaning of the catheter, the insertion site, and the urine drainage bag are important to help prevent infection. Resident #12's comprehensive care plan included the following focus: (Resident name) is at risk for Urinary Tract Infection r/t (related to) indwelling catheter, obesity, poor hygiene. Interventions were encouraging adequate fluid intake, giving antibiotic therapy as needed, having the call light within easy reach, observing vital signs and for signs and symptoms of urinary tract infection, obtaining laboratory testing, and assisting resident with hand washing after being toileted. Interventions related to maintaining the indwelling urinary catheter, such as daily catheter care, were not contained in the comprehensive care plan. During an interview on 07/09/19 at 2:00 PM, the Director of Nursing agreed Resident #12's comprehensive care plan did not contain interventions relating to care of his indwelling urinary catheter. During an interview on 07/09/19 at 3:17 PM, the Administrator was informed of the above-described findings. She was also informed Resident #12's current orders did not contain orders for daily catheter care. During an interview on 07/09/19 at 4:00 PM, Corporate Registered Nurse (RN) #83 stated daily catheter care for Resident #12 was not specifically documented on the Documentation Survey Report used by Nursing Assistants to record care provided. However, daily bathing activity and bladder elimination was documented on the Documentation Survey Report. Corporate RN #83 stated she believed daily catheter had been performed at these times. She added the task Catheter care with soap and water, rinse and pat dry to the Documentation Survey Report. No further information was provided prior to the survey exit conference.",2020-09-01
319,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,692,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, staff interview, and review of additional documents provided by the facility, the facility failed to ensure residents maintained acceptable parameters of nutritional status by failing to provide diets as ordered and to monitor and address weight loss consistently and timely. This deficient practice was found for two (2) of four (4) residents reviewed for the care area of nutrition. Resident identifiers: #36, #23. Facility census: 72. Findings included: a) Resident #36 During the screening portion of the Long-Term Care Survey Process (LTCSP) on 07/08/19, Resident #36 appeared thin. On 07/10/19, a copy of Resident #36's weights for the past year as well as all documentation regarding Resident #36 from the facility's Registered Dietitian (RD) for the past year was requested from the facility's Director of Nursing (DoN). Additionally, a copy of the facility's weight management policy along with Resident #36's orders was requested. Per documentation provided by the facility, Resident #36's weights for the past year were as follows: 07/08/19 - 84.4 pounds 07/05/19 - 84.0 pounds 07/03/19 - 83.4 pounds 06/19/19 - 90.9 pounds 06/04/19 - 92.4 pounds 05/30/19 - 90.1 pounds 05/21/19 - 89.2 pounds 05/14/19 - 87.3 pounds 05/07/19 - 87.4 pounds 04/03/19 - 93.2 pounds 03/04/19 - 95.6 pounds 02/19/19 - 96.1 pounds 01/16/19 - 96.4 pounds 12/04/18 - 97.0 pounds 11/14/18 - 97.3 pounds 11/06/18 - 97.4 pounds 10/09/18 - 98.0 pounds 09/10/18 - 98.6 pounds 08/02/18 - 97.4 pounds According to the documents provided by the facility, Resident #36 had been assessed by the RD two (2) times in the past year. A full Nutrition RD Assessment had been completed on 12/05/18 and a Nutrition Note had been completed on 05/14/19. A review of Resident #36's weight records revealed that Resident #36 had experienced a gradual and progressive weight loss trend since 09/10/18 which was not identified by the RD until eight (8) months later on 05/14/19. Per the weight records, Resident #36 had a slight weight gain for a few weeks after 05/14/19, after which point Resident #36's weight plummeted again, continuing the months-long progressive weight loss trend. During the survey, a review of the facility's Weight Management policy, last revised (MONTH) (YEAR), found that Weekly At Risk Review Meetings will be conducted on each resident with weight loss until the IDT (Interdisciplinary Team) determines weight has stabilized and can discontinue from weekly review. The policy also stated that residents with insidious weight loss would be identified using a Weights & Vitals Exception Report that would be reviewed at the morning meeting either the day of or the day before the Weight At Risk Review Meeting. Per the policy, Insidious weight loss refers to a gradual, unintended, progressive weight loss over time. On 07/10/19 at 3:04 PM, the above information was discussed with the facility's Certified Dietary Manager (CDM), RD, Administrator, DoN, and Corporate Registered Nurse (RN) #83. These individuals stated that each resident with weight loss was discussed in a weekly IDT meeting held on each Wednesday. They added that the meeting had been cancelled last week, but that Resident #36's weight loss had been addressed in a binder that was not part of the medical record. When the above individuals were asked why the information in this binder was not added to the medical record for Resident #36, the DoN stated that just because the information was not present in the format that this surveyor was looking for, that didn't mean the weight loss was not addressed. The DoN then stated that a decision had been made as of 07/05/19 to stop using the binder as the sole source of information regarding weekly weight reviews and start putting the information regarding weekly weight meetings in the medical record. The RD repeatedly stated, I'm only here on Wednesdays, and added that she would address the weight loss that day (07/10/19). A copy of the information from the aforementioned binder regarding Resident #36's weight loss was requested from the facility's Administrator on 07/10/19 at 3:20 PM. At that time, the Administrator stated in direct contradiction of the staff's statements above that there was no information regarding Resident #36's weight loss in the binder, but that the weight loss would have been discussed that day (07/10/19) had surveyors not been in the building. At that time, a Performance Improvement Plan (PIP) regarding weight monitoring was voluntarily provided for review by the Administrator. The PIP indicated that a problem had been discovered with weights in (MONTH) 2019, four (4) months prior to the survey and during Resident #36's progressive weight loss trend. The PIP stated that, as a monitoring procedure, the DoN or designee would review all weight alerts in the electronic medical record daily during morning clinical meeting to identify residents with weight changes. On 07/10/19 at 3:45 PM, the facility's RD and CDM provided a new nutrition note completed that day (07/10/19) for review, along with a typed schedule indicating that Resident #36's weight was scheduled to be discussed with the IDT on 07/10/19. In the Nutrition Note, the RD acknowledged that Resident #36 had a BMI (body mass index) indicating underweight status, a weight loss trend, and a significant weight loss of 8.7 percent over the past 30 days. The RD documented that Resident #36 had poor to fair meal intakes and overall good acceptance of a supplement with occasional poor acceptance. The RD did not calculate Resident #36's estimated nutrient needs in the note, nor did the RD address whether Resident #36 was meeting their nutritional needs. The RD recommended to continue the current nutritional plan of care with no changes and recommended that Resident #36 begin taking [MEDICATION NAME] (an antidepressant medication) to stimulate appetite. On 07/10/19 at 4:05 PM, the facility's DoN and Corporate RN #83 stated that a weekly weight meeting had been held on 07/05/19, after they had previously stated that the meeting for that week had been cancelled. They added that not all the notes from the meeting on 07/05/19 had been entered in the medical records of the residents discussed. No further information was provided prior to the survey exit conference. b) Resident #23 During a review of medical records it was revealed that Resident #23 was diagnosed with [REDACTED]. Resident #23 was noted to be losing weight: -On 01/16/2019, Resident #23 weighed 173 pounds -On 07/03/2019, Resident #23 weighed 143 pounds which is a -17.34 % Loss. -On 04/03/2019, the resident weighed 158 pounds -On 07/03/2019, the resident weighed 143 pounds which is a -9.49 % Loss. On 01/22/19 Resident #23 was sent out to a local hospital. According to the nursing notes it was due to having a [MEDICAL CONDITION]. He did not return to the facility until 02/20/19. While out of the facility he had surgery to remove his gallbladder, at which time a feeding tube and a t-tube (used to drain bile) were inserted. Resident #23 returned to the facility with the feeding tube and [DEVICE]. There are many nutritional notes by the facilities Registered Dietitian (RD) starting on 04/03/19 read as follows: Resident triggering for Signiant weight loss of 15 pounds in three (3) months, Resident with a weight gain in one (1) month. Current weight 157.8 pounds. Resident was receiving enteral bolus via feeding tube after meals. if he consumes less than 50 % of meals. On 05/01/19 note reads as follows: Resident continues to trigger for weight loss. Down 21.7 pounds in 180 days and 7.1 pounds in 30 days. Current weight 150.7. Resident on a regular puree diet and one (1) can of Two Cal via feeding tube if he consumes less than 50% of meals. Registered Dietitian (RD) recommends double portions. On 05/14/19 note reads as follows: Resident continues to trigger for weight loss. Down 9.1 pounds in one (1) month. Current weight 148.7. feeding tube removed on 05/08/19 due to not being used. Nursing will continue to monitor weights and resident will receive double portions. On 05/22/19 note reads as follows: Resident continues to trigger for weight loss. Down 12.1 pounds in two (2) months and 5.6 pounds in one (1) month. Current weight 145.1 pounds. Staff recorded 51-75 % consumption of meals. Staff also report resident not eating well and has felt nauseous. On 06/12/19 note reads as follows: Resident continues to trigger for weight loss, however weight has been stable between 144-150 pounds for 30 days. Current weight 143 pounds. On 07/10/19 at 12:00 PM, observation of lunch Resident # 23, he is ordered double portions for meals. Observation of the lunch that was served the portion sizes appeared to be the same as the other puree diets. Which was one (1) rounded mound of mashed potatoes, one (1) rounded mound of cornbread, one mound of carrots, and chili with beans on the plate unable to determine the amount because it was at a runnier consistence. Resident #23 did not receive a meal as ordered. The physicians order dated 03/01/19, for a regular diet, puree texture, nectar consistency, double portions. Also, the printed-out meal tickets state on the bottom double portions. On 07/10/19 at 12:28 PM, Certified Dietary Manager (CDM), was asked to observe the portion size on the plate belonging to Resident #23. He was asked if he should have received two scoops of everything? He stated, yes, unless they used a larger scoop. We went back to the serving area and there was not a larger scoop being used. On 07/10/19 at 12:30 PM, Cook #71 was asked if he served Resident #23 double portions on his tray today for lunch? He stated, that he gave him double protein. When he was asked if he gave double scoops of the meal, he stated that gave the large scoop and when he was asked to show what size scoop he used, he then stated, that he put two (2) scoops of everything on his plate. KM # was asked if he saw two (2) scoops of anything on the plate he did not answer. On 07/10/19 at 1:06 PM, RD stated, that Resident # 23 is supposed to get two scoops using a regular size scoop not the large scoop. She said, that will re-educate the CDM and Cook #71 She was asked about the weight loss trending down and she replied that Resident #23 is such a good eater she feels like if he got double portions his weight would be more stable. She went on to say that if he was getting double portions his weight should have been stabilized. On 07/10/19 at 4:00 PM, RD entered the room to present a noted that she stated she had written earlier this morning at 12:48 PM, and that Resident #23 had had a Four (4) pound weight increase. Weight was stable between 143-147 for seven (7) days, Weights were decreased to monthly due to weight range stable for four weeks from 05/21/19 to 06/10/19. Diet is meeting estimated needs on regular portions-but double portions ordered do to excellent intake and continues to trigger for weight loss. During this time, it was pointed out to the RD that the note she is now saying she wrote this morning was actually created on 07/10/19 at 2:30 PM, and she was asked if she still thought a double portion size meal were in the best interest of the resident? She stated, that he probably did not need them. She was asked if she remembered that at 1:00 PM, today she stated, that she feels like if Resident #23 was getting his double portions his weight would stabilize? She did not answer. On 07/10/19 at 4:05 PM, the facility's DoN and Corporate RN #83 stated that a weekly weight meeting had been held on 07/05/19, after they had previously stated that the meeting for that week had been cancelled due to a holiday. They added that not all of the notes from the meeting on 07/05/19 had been entered in the medical records of the residents discussed. However, he was on the list to be discussed today. Corporate RN #83 proceeded to show his name on the list, but he was not listed. DoN agreed that the notebook that she had with her was not a part of the medical record. No further information was provided prior to the survey exit conference.",2020-09-01
320,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,761,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Four (4) multi-dose medications located in medication carts were not dated when the medication was first accessed or opened. These were random opportunities for discovery made during the medication storage and labeling facility task. Resident identifiers: #59, #29, #65. Facility census: 72. Findings included: a) Resident #59 On [DATE] at 9:10 AM, inspection of the 'long hall' medication cart was performed. One (1) of 12 insulin pens in this medication cart did not have a date to indicate when the medication was first opened. This insulin pen was Humalog insulin for Resident #59. The label on the insulin pen indicated the medication was delivered from the pharmacy to the facility on [DATE]. Labeling multi-dose medications when first opened or accessed is important to determine the expiration date of the medication. Insulin pens have an expiration date determined by when the pen was used for the first time. Licensed Practical Nurse (LPN) #44 confirmed the Humalog insulin pen for Resident #59 was not dated when first opened or accessed. During an interview on [DATE] at 10:30 AM, the Director of Nursing stated facility policy was to date insulin pens when opened. However, she stated Resident #59's insulin pen could not be outdated or expired because it had been delivered from the pharmacy on [DATE]. The facility's policy entitled, Medication Administration-Preparation and General Guidelines - Vials and [MEDICATION NAME] of Injectable Medications stated, The date opened and the initials of the first person to use the vial are recorded on multidose vials. On [DATE] at 3:18 PM, the Administrator was informed of the above-described findings. No further information was provided through the completion of the survey. b) Resident #29 During an observation on [DATE] at 9:21 AM, of the medication cart being used by Registered Nurse (RN) #47, revealed that, the one (1) of the three (3) vials of a multi-use insulin (a medication used to control glucose levels for people who have diabetes) did not have a date on the vial to indicate when this medication was initially opened. [MEDICATION NAME] (name of the insulin) belonged to Resident # 29. It is a professional standard to label the vial with the date it was initially accessed, because after initial access the medication has the potential to loss potency and the effectiveness to treat the glucose levels for diabetic patients. Also a multi-use nasal spray ([MEDICATION NAME]) belonging to Resident #29 did not have a date on the bottle to indicate when it was initially opened. This was true for two (2) of two (2) nasal sprays in this medication cart. c) Resident #65 During an observation on [DATE] at 9:21 AM, of the medication cart being used by Registered Nurse (RN) #47, revealed that two (2) of two (2) nasal sprays [MEDICATION NAME] did not have a date on the bottle to indicate when this medication was initially used. This medication belonged to Resident #65. On [DATE] at 9:26 AM, Registered Nurse #47 was witness and verified there was not a date on the medication bottles to indicate the initial date it was used. During an interview on [DATE] at 11:39 AM, Director of Nursing was informed of findings. She had no comment. No further information was provided prior to the survey exit conference.",2020-09-01
321,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,842,D,0,1,L7T111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #222 and Resident #12's medical record was complete and accurate. For Resident #222 the Nursing Admission Data Collection tool was inaccurate in the area of dental status. Resident #12's quarterly pain evaluation was inaccurate. This was true for two (2) of 17 records reviewed during the long term care survey. Resident identifiers: #222 and #12. Facility census: 72. Findings included: a) Resident #222 A review of Resident #222's medical record at 9:00 a.m. on 07/09/19 found an Admission Data Collection assessment dated [DATE]. A review of this assessment found the following under section B. Oral Health/Dentition 1. Condition of Teeth/oral Cavity both [NAME] Natural Teeth Intact B. Edentulous were marked as being true for Resident #222. Edentulous is defined in the Resident Assessment Instrument manual as meaning no natural teeth. A review of Webster's dictionary found the word Edentulous means toothless. Interview with the Director of Nursing (DON) at 2:05 p.m. on 07/09/19 confirmed that both Edentulous and Natural Teeth intact were both marked as being true for this resident. No further information was provided prior to the survey exit conference. b) Resident #12 Resident #12 had a Quarterly Pain Evaluation on 07/09/19. The question At any time during the last 5 days, has the resident been on a scheduled pain management regimen? was answered as No. Review of Resident #12's medical records revealed an order written [REDACTED]. On 07/09/19 at 2:00 PM, the Director of Nursing (DoN) was informed Resident #12's Quarterly Pain Evaluation on 07/09/19 documented the resident was not on a scheduled pain management regimen although the resident was on [MEDICATION NAME] daily for pain. The DoN stated the nurse completing the pain evaluation may not have considered [MEDICATION NAME] as a pain medication because the medication has other uses. On 07/09/19 at 3:17 PM, the above-described findings were reported to the Administrator. No further information was provided prior to the survey exit conference.",2020-09-01
322,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2019-07-10,880,D,0,1,L7T111,"Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was true for the nurse failing to use a barrier during medication administration. This was a random opportunity for discovery during an observation of medication administration. Resident identifier: #55. Facility census 72. Findings included: a) Resident #55 During an observation on 07/09/19 at 9:01 AM, Registered Nurse (RN) #47 was administrate ring medications to Resident # 55. She entered the resident's room with a medication cup containing pills and an inhaler (used to treat asthma). RN #47 placed the Brevo inhaler placed inhaler on bedside table without using a barrier. On 07/09/19 at 9:12 AM, RN #47 was asked about not using a barrier when she placed the inhaler on the bedside table. She stated, that she just forgot, they have told her over and over to use a barrier. On 07/09/19 at 11:39 AM, Directior of Nursing (DoN) was informed of the observation of the barrier not being used during a medication administration. She had no comment. No further information was provided prior to the survey exit conference.",2020-09-01
326,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,561,D,1,0,BYSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, and medical record review, the facility failed to honor Resident #11 choices regarding an aspect of her life in the facility which was significant to the resident. The resident was not afforded the opportunity to receive showers according to her preferences and choice. This was true for one (1) of eight (8) residents reviewed. Resident identifier: #11. Facility census: 83. Findings included: a) Resident #11 On 10/09/18 at 12:45 PM, observations revealed Resident #11 appeared clean and groomed. An interview with Resident #11 revealed the resident did not always get her showers as they were scheduled or when she wanted them. The resident said she preferred showers and did not care much for a bed bath. Resident #11 stated she had told nursing staff many times about the fact she did not always get her showers and that she wanted them in the afternoons not mornings. Resident#11 could not recall the names of the different staff she said she had spoken with. Resident #11 said, You got different nurses coming in here from other nursing homes filling in, you just can't always keep up with their names. We got a new administrator now and I am hoping things will change around here. The resident said she was to have her showers on Wednesday and Saturday, in the afternoons or evenings, but never mornings. Resident #11 said she never refused showers because she likes showers. Resident #11 said she had refused only one time a few weeks ago, when a nurse aid came into her room in the morning to try to give her a shower, instead of the afternoon when she was supposed to get them. Review of records, on 10/10/18 at 8:40 AM, revealed the resident was admitted to the facility on [DATE]. An annual minimum data set (MDS) assessment reference date (ARD) of 07/07/18 showed the resident had adequate hearing and clear speech. The resident could understand and make herself understood. Resident #11's Brief Interview for Mental Status (BIMs) score is fifteen (15) indicating resident is cognitively intact. The MDS showed it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. In section G all activities of daily living (including bathing) were marked, activity itself did not occur There were two (2) exceptions; supervision with eating and bed mobility was marked activity only occurred once or twice. The previous quarterly MDS with an ARD of 05/16/18 showed the resident was totally dependent for bathing. An interview with Resident #11, on 10/15/19 at 1:45 PM, revealed the resident was adamant that she did not get her showers all the time like they were scheduled. The resident again denied refusing showers and stated she enjoyed and wanted showers. Resident #11 said she had only refused a shower once a few weeks ago, when staff came in her room while she was eating breakfast and said they were going to clean her up. The resident said, I still had food in my mouth, I was still eating, and I told her no you are not. I get my showers in the afternoons not in the mornings. Later that afternoon when I asked a different nurse aid when I was going to get my shower for that day. That nurse aid said she was told I had refused a shower that morning, so I wasn't going to get one at all that day. The resident said she told the nurse aid she wanted her shower, just not in the morning. The resident said she did not get a shower at all that day. On 10/16/19 at 10:10 AM, review of Resident #11 shower records for the past three (3) months revealed the second half of (MONTH) the resident had five (5) opportunities for showers and received three (3) showers. Noted for the second half of (MONTH) was showers on 07/14/18, 07/25/18, and 07/28/18 shower. Noted was a refusal on 07/18/18 and a bed bath on 07/21/18. The resident had nine (9) opportunities for showers in August, and received five (5) showers (08/01/18, 08/04/18, 08/08/18, 08/11/18, and 08/15/18). On 08/29/18 the shower record was left blank with no indication what occurred. The resident had nine (9) opportunities for showers in September, and received four (4) showers (09/01/18, 09/05/18, 09/08/18, and 09/29/18). Noted were two (2) bed baths on 09/12/18 and 09/15/18. It was noted Resident#11 refused a shower three (3) times on 09/26/18. It was noted Resident#11 refused a shower three (3) times on 10/03/18. An interview with Resident Care Specialist, also known as Nurse Aide (NA) NA#48, on 10/16/18 at 11:16 AM, revealed she was knowledgeable concerning the care Resident #11 was to be given. NA#48 stated she was not aware of Resident #11 ever refusing care, specifically showers. NA#48 stated Resident #11 likes her showers and she never knew her to refuse a shower. On 10/16/18 at 11:20 AM, an interview with NA#27 and NA#38 revealed both were familiar with Resident #11 and the care provided to the resident. Both NAs agreed Resident #11 was very particular and precise in what she wants and how she wants it done. Both said the resident will give directions on how she wants something done, even if you had her before and knew how she wanted it done. NA#27 said, If she (Resident #11) said something happened it did, she (Resident #11) has a better memory than I do. NA#38 agreed with what NA#27 had just said, and stated Resident #11 likes her showers, but likes them in the afternoon because she sits up late and is not a morning person.",2020-09-01
327,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,580,D,1,0,BYSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, family interview and staff interview the facility failed to ensure they notified the responsible parties for two (2) of 25 sampled residents when those residents experienced a change in condition, had a new treatment ordered and experienced a significant error in administration of a medication. Resident #5 had a computerized tompography (CT) scan performed to rule out a fracture. Resident #3 experienced a [MEDICAL CONDITION] and was not given a medication to treat [MEDICAL CONDITION] activity. Resident identifiers: #5 and #3. Facility census: 83. Findings included: a) Resident #5 An interview with Resident #5's Medical Power of Attorney on 10/14/18 at 6:00 PM revealed Resident #5 had a CT scan. The MPOA said the facility did not inform him of the results from the CT scan. A progress note dated 07/30/18 stated, Xray of right lower extremity reports [MEDICAL CONDITION] changes but could not rule out fracture of tibia. Discussed with FNP family nurse practicioner and MPOA medical power of attorney. New orders given for CT w/o contrast of right lower extremity on 8/3/18 at (name of local hospital). MPOA (medical power of attorney) aware. A progress note dated 08/3/18 stated, Resident OOF out of facility for CT scan via (name of ambulance company) per stretcher with two (2) attendants. Further review of progress notes did not reveal a note indicating the MPOA was informed of the results of the CT. On 10/15/18 at 11:38 AM Licensed Practical Nurse #72 and Scheduler #16 looked through the resident's thinned medical record and located the results of the CT. There was no indication the facility had informed the MPOA of the results from the CT completed on 08/03/18. The CT scan report dated 08/03/18 did have hand written notes showing the family nurse practicioner was notified and that there was a new order for an orthopedic consult. However, there was no note to reflect the MPOA was notfieid of the CT results. b) Resident #3 A review of the medical record for Resident #3, noted a progress note, on 09/29/18, that Resident #3 had a [MEDICAL CONDITION] early this morning beginning at 3:15AM. The [MEDICAL CONDITION] ended approximately 3:34 AM. Resident #3 had physician orders [REDACTED]. Further review of the medical record, noted no notification to the resident's physician informing the physician that the medication had not been administered in accordance with physician's orders [REDACTED]. Additionally, there was not notification to the resident's responsible party that the resident had a [MEDICAL CONDITION] nor notification of the omission of the physician's orders [REDACTED].",2020-09-01
329,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,625,D,1,0,BYSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview the facility failed to provide notification of bed hold policy at time of hospital transfer. This was true for one (1) of one (1) resident reviewed. Resident identifier: #2. Facility census: 83 Findings included: a) Resident #2 Resident #2 was admitted for rehabilitation, on 05/19/18 status [REDACTED]. Resident has capacity. Resident has a history of pathologic fractures due to [MEDICAL CONDITION] metastasized to bones. Resident #2 was Sent to hospital on [DATE] for Femur IM Nail placement on 08/05/18 and returned to facility on 08/08/18. Resident #2 was sent to the hospital on [DATE], for left Humerous open reduction. The Humerous is the long bone located in the upper arm of the body which extends from the shoulder joint to the elbow. Resident was pulling herself to left side of bed by pulling on bed side bar. Resident heard her left arm snap accompanied by acute onset pain. Was sent out and returned to facility on 09/07/18. The resident was again sent to the hospital on [DATE] and has not returned to the facility. Review of records, on 10/09/18 at 11:15 AM, revealed no bed hold notices for Resident#2 for the dates the resident was sent to the hospital. Resident #2 was sent to the hospital on [DATE], 09/02/18, and 09/22/18. Review of facility 'Transfer and Discharge Procedure', on 10/15/18 at 4:00 PM, revealed #13 under Procedure for Transfer or Discharge said, Facility designee provides notice in writing of the facility's Bed Hold and readmission policies to the resident and the resident's representative. Review of the facility's 'Bed Hold/Leave of Absence' Policy revealed under the 'Procedure' for 'Bed Hold Notification' #1 states Upon admission or leave of absence, a facility designee will provide the resident, and/or the responsible party written information concerning the option to exercise the 'Bed Hold /Leave of Absence' Policy. 1b states Upon Leave of Absence, a Bed Hold Authorization form is distributed to the resident and/or the responsible party. Under 'Procedure' for 'Bed Hold Notification' #3 states, A copy of the bed hold authorization form must be sent with the resident at the time of transfer. In case emergency transfer, written notice to the resident and/or the responsible party is provided within 24 hours of the transfer. On 10/16/18 at 10:37 AM, interview with the District Director of Clinical Services, Administrator, interim Assistant Director of Nursing (ADON), and Director of Legal Operations, revealed the surveyor was unable to find transfer and bed hold documentation for Resident #2 requested to review the documentation. The District Director of Clinical Services said, I did not know you wanted the bed holds, but I can go into our system and print them for you. This surveyor was given a printed blank bed hold form, not specific to any resident. This surveyor requested to review copies of what was specifically given to Resident #2 when she was sent to the hospital 08/04/18, 09/02/18, and 09/22/18. On 10/16/18 at 3:34 PM, the interim ADON came to this surveyor and said, We've looked, and the facility does not have any of the discharge/transfer bed hold documentation for Resident#2.",2020-09-01
330,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,641,D,1,0,BYSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and medical record review, the facility failed to complete an assessment to accurately reflect two (2) resident's status. This was a random opportunity for discovery. Resident #2's assessment did not accurately reflect the resident's range of motion ability nor accurately reflect the resident's status concerning a fracture. Resident #11's assessment was inaccurate concerning activities of daily living (ADL). This practice has the potential to affect more than a limited number of residents. Resident identifier: #2 and #11. Facility census: 83. Findings included: a) Resident #2 Review of medical records, on 10/09/18 at 11:00AM, revealed the resident was admitted to the facility on [DATE] status [REDACTED]. Resident #2 had capacity and a history of pathologic fractures due to [MEDICAL CONDITION] metastasized to bones. Resident #2 was sent to the hospital on [DATE] for a Femur IM (Intramedullary) Nail on 08/05/18. The femur is a bone of the leg situated between the pelvis and knee. Intramedullary nail fixation has become the standard of treatment for [REDACTED]. The resident returned to facility on 08/08/18. Review of records, on 10/09/18 at 11:15 AM, revealed a quarterly minimum data set (MDS) with an assessment reference date (ARD) 8/22/18. The MDS reflected resident had adequate hearing and vision, clear speech, can make self-understood and understands. Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 15 indicating the resident was cognitively intact with no impairment. The resident needed extensive assistance with activities of daily living (ADLs), except supervision with meals and was totally dependent for bathing. The resident needed extensive assistance with balance during surface to surface transfer, moving on and off toilet, and resident was not steady only able to stabilize with staff assist. Functional limitations in range of motion (ROM) revealed there was 'NO' impairment on both sides for upper or lower extremities. Under active diagnosis, Section I: Musculoskeletal, other fractures ( ) was not marked to indicate the resident had a fracture. On 10/16/18 at 9:53 AM interview and review of records with the Minimum Data Set Registered Nurse (MDS RN#29) revealed Resident #2's quarterly minimum data set (MDS) assessment reference date (ARD) of 08/22/18 was inaccurate in the areas of ROM and fractures and would be corrected. MDS RN#29 stated she did not do Resident #2's quarterly MDS, but was training another nurse and would follow up to ensure that all MDS were accurately completed. b) Resident #11 Review of records on 10/10/18 at 8:40 AM, revealed the resident was admitted to the facility on [DATE]. An annual minimum data set (MDS) assessment reference date (ARD) of 07/07/18 showed the resident had adequate hearing and clear speech. The resident could understand and make herself understood. Resident #11's Brief Interview for Mental Status (BIMs) score is fifteen (15) indicating resident is cognitively intact. In section G most of the activities of daily living (including bathing) were marked, activity itself did not occur. There were two (2) exceptions; supervision with eating and bed mobility was marked activity only occurred once or twice. On 10/16/18 at 9:53 AM interview with Minimum Data Set Registered Nurse (MDS RN#29) revealed Resident #11's annual minimum data set (MDS) assessment reference date (ARD) of 07/07/18 was inaccurate. MDS RN#29 agreed section G concerning ADLs was inaccurate, that the ADLs occurred more than once or twice during the seven (7) day look back period. MDS RN#29 stated she would correct the MDS to reflect the resident's accurate status at that time.",2020-09-01
331,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,656,D,1,0,BYSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview the facility staff had not developed care plans for two (2) randomly observed and one (1) sampled resident. Resident #7 expressed concern with hallucinations. No care plan interventions were developed to monitor for adverse reactions of antidepressant use which included hallucinations. Resident #20 did not have a care plan developed for the use of a vagal stimulator. Resident #44 was found to have an identified behavior of disrobing and staff had not developed a care plan for this behavior. This was evident for two (2) random residents and one (1) resident identified in the complaint sample. Resident identifiers: #7 , #20 and #44. Facility census: 83 Findings included: a) Resident #7 Resident #7 expressed he was having hallucinations when he was interviewed during the tour on 10/09/18 at 9:58 AM. He stated staff did not listen to him when he had expressed this concern many times. A review of the medical record on 10/10/18 at 10:00 AM revealed Resident #7 was taking an antidepressant medications. One of the interventions listed was to monitor adverse reactions that could be a side effect. Discussion with Administrator Designee (AD) #51 at 10:35 AM on 10/10/18 revealed AD #51 was not aware of the resident having hallucinations and that he would be scheduled to be seen by the physician on a visit next week. A review of a nursing summary report dated 10/01/18 did not show that hallucinations had been identified as a concern to monitor. Review of the care plan on 10/10//18 and 10/11/18 at 9:30 a AM . did not show that hallucination had been identified as an actual problem which needed to be monitored and treated once it was noted as an adverse reaction. b) Resident #44 During a random observation, on 10/16/18, at 09:40 AM, Resident #44 was observed from the hallway, exposed from the waist down. The resident was noted to have an incontinence brief on visible to those passing by the doorway. Further observation noted Resident #44 holding her gown in her hand and exposing the upper and lower body with the brief remaining. On 10/16/18, at 09:50 AM, an interview with CNA #11, revealed that Resident #44 was noted to disrobe, and she tries to pull the curtains when this behavior is occurring. A review of the comprehensive care plan, completed 08/27/18, for Resident #44, did not identify a focus area for this behavior nor any interventions to assist staff to care for the Resident when this behavior is occurring. On 10/16/18, at 12:10 PM an interview with the Social Services Director verified this behavior noted by staff had not been addressed on the care plan for Resident #44's problem of disrobing and being exposed to those passing by the room. b) Resident #20 Review of records, on 10/10/18 at 10:15 AM, revealed some of Resident#20's [DIAGNOSES REDACTED]. Review of the resident's care plan revealed the facility failed to develop a person-centered comprehensive care plan for Resident#20 to address the specialized needs and care related to the resident's vagal stimulator, which is to be used during [MEDICAL CONDITION] activity. The care plan is not resident specific to include a description of proper use of the vagal stimulator, any precautions, or any indication the device is implanted in the resident. Vagal refers to the vagus nerve the longest nerve in the autonomic nervous system in the human body, which controls functions of the body that are not under voluntary control (such as heart rate and breathing). According to the [MEDICAL CONDITION] Foundation, Vagus nerve stimulation (VNS ) prevents [MEDICAL CONDITION] by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. It is sometimes referred to as a pacemaker for the brain. A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. If a person is aware of when a [MEDICAL CONDITION] happens, they can swipe a magnet over the generator in the left chest area to send an extra burst of stimulation to the brain. For some people this may help stop [MEDICAL CONDITION]. A magnet is used to activate or deactivate the device. Review of Resident#20's care plan, on 10/10/18 at 10:15 AM, revealed a focus area ' impaired Neurological status related to [MEDICAL CONDITION] disorder . Interventions included Give medications as ordered. Observe/document for effectiveness and side effects. Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No short wave diathermy. Observe labs and report any sub therapeutic or toxic results to MD. Obtain and observe lab/diagnostic work as ordered. Report results to MD and follow up as indicated. POST [MEDICAL CONDITION] TREATMENT: Turn on side with head back, hyper-extended to prevent aspiration, Keep airway open, After [MEDICAL CONDITION] take vital signs and neuro check, Observe for [MEDICAL CONDITION], headache, altered L[NAME] (level of consciousness), paralysis, weakness, pupillary changes. [MEDICAL CONDITION] D[NAME]UMENTATION: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity. [MEDICAL CONDITION] PRECAUTIONS: Do not leave resident alone during a [MEDICAL CONDITION]. Protect from injury. If resident is out of bed, help to the floor to prevent injury. Remove or loosen tight clothing. Don't attempt to restrain resident during a [MEDICAL CONDITION] as this could make the convulsions more severe. Protect from onlookers, draw curtain, etc. Another intervention related to [MEDICAL CONDITION] activity is under the focus of risk for falls. The intervention is, Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No short-wave Diathermy. Date Initiated: 06/15/17. Review of records for Resident#20, on 10/10/18 at 2:00 PM, revealed an order for [REDACTED]. The MAR indicated [REDACTED]. No details concerning the [MEDICAL CONDITION] activity occurring on 08/27/18 was found in the record; no description on how long the [MEDICAL CONDITION] lasted, or if the vagal stimulator was used, or what interventions or precautions were used other than the ordered medication. On 10/10/18 at 2:40 PM, interview with Registered Nurse (RN#105) assigned to care for the resident on 10/10/18, revealed RN#105 was not aware the resident had a vagal stimulator or what a vagal stimulator even was. RN#105 said this was her first day at the facility, that she was from a sister facility and did not know the residents. This surveyor suggested that perhaps another nursing staff that regularly worked at the facility and who was familiar with the resident, show this surveyor and the assigned RN#105 responsible for the care of Resident#20 the resident's vagal stimulator and the appropriate way to use it. Licensed Practical Nurse (LPN#72) showed this surveyor and RN#105 the procedure to use the vagal stimulator if the resident had a [MEDICAL CONDITION]. LPN#72 felt the resident's upper left chest and showed RN#105 the outline of the implanted vagal stimulator, then LPN#72 showed RN#105 the magnet hanging on the back of the resident's wheel chair that is used to operate the vagal stimulator. LPN#72 said there was also a magnet on the cart. LPN#72 said, the resident has been at the facility for ten (10) years and if he is having a [MEDICAL CONDITION], you swipe the magnet over the implanted vagal stimulator one (1) time, and only one (1) time. RN#105 said she had never came across one of those (vagal stimulator) before in her nursing career (RN#105 said she had been a RN since (MONTH) (YEAR), but a LPN for several years). On 10/10/18 at 5:45 PM, review of orders revealed an order dated 3/30/17, If resident has [MEDICAL CONDITION] activity last greater than 3 minutes, then RN to swipe magnet once over VNS Generator. If needed, can repeat after 5 minutes. Avoid swiping magnet immediately after single swipe. Notify physician and RP of use. Every shift for [MEDICAL CONDITION]. Another order dated 3/31/2017 revealed, Device: Keep vagal Stimulator (used during [MEDICAL CONDITION] activity) in plain sight and handy at all times. Use vagal stimulator if he has more than one [MEDICAL CONDITION] in a row by rubbing magnet on left upper chest. No short wave diathermy, microwave diathermy, ortheraputic ultrasound diathermy. Every shift for [MEDICAL CONDITION] Interview with RN#29, on 10/16/18 at 9:53 AM, revealed RN#29 agreed Resident#20's care plan did not have person-specific interventions in the care plan concerning specific care and services to be implemented for the use of the resident's vagal stimulator, no indication the device is implanted, nor any description of the steps staff should follow for the use and operation of the vagal stimulator. There were no instruction in the care plan on the use of, required precautions, or locations of the magnets necessary for the operation of the vagal stimulator. RN#29 is responsible for completing resident's comprehensive assessments and developing and revising resident's care plans. RN#29 agreed the care plan should have been developed to include a focus area concerning the resident's implanted vagal stimulator with specific care and services to be implemented for the use of the resident's vagal stimulator and would immediately correct the care plan. There are different types or models of vagus nerve stimulation devices. The facility was unable to tell this surveyor what model the resident had. On 10/10/18 at 3:37PM, RN#44 Staff Development. When asked for all training to staff on vagal stimulator. RN #44 said we don't have anyone in the building with a vagal stimulator. RN#44 said she has not done any training on vagal stimulators since she has had the job. When asked how long she has had the position, she replied, The last part of April. The Staff Development RN#44 said she would look at previous records prior to her having the position to see if there ever was any training concerning a vagal stimulator. On 10/10/18 at 4:17 PM, interview with , RN#44 (Reigstered nusre/Staff Development) revealed there has been no training on [MEDICAL CONDITION] or vagal stimulators since at least (YEAR). RN Staff Development said she only looked back to (YEAR). When asked again if anyone in the facility had a vagal stimulator, she replied, No one. .",2020-09-01
333,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,695,D,1,0,BYSJ11,"> Based on medical record review and staff interview there were no physician orders for oxygen use for two (2) of two (2) residents who were receiving oxygen treaments. Resident identifiers are: #1 and #8. Census; 83 Findings included: a) Resident #1 During observations of 10/09/18. the resident was observed in the dining room at the table with portable oxygen in place. It was set for 2 liters per minute. Another observation on 10/09/18 at 4 pm. in the hallwasy, she was in her wheelchair with portable oxygen set for 2 liters per minute. A review of the medical record on 10/10 /18 at 2:00 pm did not show the resident had orders for oxygen therapy. A reveiw of the current care plan indicated there was no oxygen therapy being listed as a concern with treatment. Discussion with the administrator desigee#51 on 10/10/18 at 2:30 p.m. revealed she would have to see what had happended to the oxygen order. It may have not gotten carried over from the previous month. b) Resdient #8 The resident was observed in bed in her room during the initial tour of10/09/18 at 9:48 a.m. The resident did have oxygen being administered at that time. Review of the resident's medical record showed there was no order noted for oxygen thereapy. Additionally, the current care plan did show there was a problem listed as oxygen therapy and have interventions noted. Nursing notes of 10/02/18 stated the resident's oxygen saturation level dropped and oxygen had to be administered. A new order for oxygen was found at 4 pm after the surveyor had brought it to their attention.",2020-09-01
335,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,742,D,1,0,BYSJ11,"> Based on medical record, staff and resident interview it was found that the faciilty failed to provide services for a resident with such psychosocial issues as hallucaintions. This was evident for one (1) of 25 residents reviewed in the sample. Resident identifier: #7. Census: 83. Findings included: a) Resident #7 Resident #7 expressed during interview of the initial tour, on 10/09/18 at 9:58 AM, he was having halluciantions. He stated he had told staff before and they would not listen to him. He said the halluciantions seem so real to him. A review of a nursing assessment dated 10 01/18 shows several problem areas for the resident but halluinations was not identifed as needing addressed and treated. Resident #7 did recieve anitdepressants and halluciantions was a side effect listed in the current care plan as needing monitored due to the use of antidepressants. During interview, with Administrator Designee (AD) #51 on 10/10/18 at 10:35 AM, it was determined that the resident had not been monitored for hallucination. AD #51 said the resident would be evaluated by the phyisician on the following Tuesday.",2020-09-01
337,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,761,D,1,0,BYSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and policy and procedure review, the facility failed to ensure all drugs and biologicals were labeled in accordance with professional principles for two (2) of (2) medication carts. Four (4) medications were not dated when opened and put into use. Findings included: a.) An observation of the East Short Hall cart, on 10/14/18, at 6:30 PM revealed the following: 1.) A vial of [MEDICATION NAME] was observed in the medication cart and not dated and in use. 2.) An interview, on 10/14/18, at 6:30 PM, with LPN #150, verified there was no date on the medication when opened and the insulin was being administered to a resident. b.) An observation of the West Short Hall cart, on 10/16/18, at 09:20 AM, revealed the following: 1.) A vial of [MEDICATION NAME] R insulin was observed in the medication cart, with no date when opened and put into use. 2.) A [MEDICATION NAME] Flex pen was observed in the medication cart, with no date when opened and put into use. 3.) A [MEDICATION NAME] Flex pen was observed in the medication cart, with no date when opened and put into use. 4.) An interview, on 10/16/18, at 09:25 AM , with LPN #34, verified the medications did not have a date when opened and all medications observed above were being administered to residents. c.) A review of the Policy and Procedure 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, no date, notes that medications, once opened, will not be retained longer than the manufacturer's guidelines. An interview, on 10/16/18, at 09:20 AM, with LPN #20 and LPN #34, verified all insulin should have been dated when opened to ensure not administering the medication past the acceptable date established by the manufacturer.",2020-09-01
338,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,773,D,1,0,BYSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to provide or obtain laboratory services when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws for two (2) of 25 sampled residents. The facility failed to ensure laboratory tests were completed for Resident #3. Resident identifier:: Resident #3. Findings included: a.)Resident #3 A review of the current physician's orders [REDACTED].) A review of the laboratory section of the medical record revealed no documented results for the [MEDICATION NAME] level ordered for (MONTH) (YEAR). An interview, on 10/15/18, at 02:30 PM with LPN#7, revealed no results were received and placed on the medical record. Upon further investigation, LPN#7 stated the lab had not been drawn according to the laboratory book. Additionally, the repeat Ammonia level ordered 08/20/18 was not done as well. Review of the available labs, revealed Resident #3 had previously had higher levels than normal of [MEDICATION NAME]/[MEDICATION NAME] Acid at level 110 (normal range indicated 50-100 MCG/ML) {microgram/ milliliter} and Ammonia levels at level 40 (normal range indicated as 9.0-33.0 UMOL/L) {micromole per liter}.",2020-09-01
339,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,804,D,1,0,BYSJ11,"> Based on observation, staff and resident interview it was found the facility staff had not always served attractive food. This was determined through a random observation . There are 10 residents who receive pureed diets. Resident identifier: #42. Facility census: 83 Findings include: a) Resident #42 During dinner meal observations on 10/14/18, the resident who was eating alone in his room was noted to have puree kielbasa. The item was very thin and running into other items on the plate, such as the red potatoes and cabbage. When Resident #42 saw the puree item he stated, well that is interesting. The observation of the unattractive runny purred food was discussed with the food service supervisor and the corporate regional manager of food service on 10/15/18 at 1:50 PM. They had no comment.",2020-09-01
341,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,835,D,1,0,BYSJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, observation, family interview, and resident interview the facility failed to ensure effective oversight and management of its operations. This failure resulted in deficient practices in the following areas: Notification of changes, nursing services, quality of care, and freedom from neglect. Resident #20 had a vagal nerve stimulator device used to control [MEDICAL CONDITION]. The facility staff were not trained on how to use this device. Some of the nursing staff assigned to care for the resident did not know the resident had the device. Resident #7 had experienced hallucinations and the staff did not acknowledge the resident's mental health issues in order to provide treatment for [REDACTED].#5 had experienced a stage IV pressure. The resident was dependent for turning and repositioning. Staff were not providing turning and repositioning every two (2) hours as indicated in the care plan. Staff did not timely assess and monitor Resident #2 at for changes in condition. On 10/10/18, at 2:35 PM, after consultation with the state agency a determination of immediate jeopardy was made. The facility failed to ensure that emergency medication was provided to a Resident #3 in accordance with physician's orders [REDACTED]. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 8:44 PM. The facility implemented in-services for direct care staff regarding [MEDICAL CONDITION] care. Resident #3's physician was notified and orders for Intramuscular (IM) [MEDICATION NAME] was obtained. IM [MEDICATION NAME] was available in the emergency cart. Resident identifiers: #2, #7, #3, #5, and #20. Facility census: 83. Findings included: a) Resident #7 Resident #7 expressed he was having hallucinations when he was interviewed on 10/09/18 at 9:58 AM. He stated staff did not listen to him when he had expressed this concern many times. A review of the medical record on 10/10/18 at 10:00 AM revealed Resident #7 was taking an antidepressant medications. One of the interventions listed was to monitor adverse reactions that could be a side effect of the antidepressant medications. Discussion with Administrator Designee (AD) #51 at 10:35 a.m on 10/10/18 revealed AD #51 was not aware of the resident having hallucinations. AD #51 said he would be sccheduled to be seen by the physician on a visit next week. A review of a nursing summary report dated 10/01/18 did not show that halluciantions had been identified as a concern to monitor. Review of the care plan, on 10/10//18 and 10/11/18 at 9:30 a m., did not show that hallucination had been identifed as an actual problem which needed to be monitored and treated due to being a potential side effects from the antidepressant. b) Resident #3 A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, revealed the [MEDICATION NAME] gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two (2) nursing staff, Licensed Practical Nurse (LPN) #105 and LPN #55, at this time, verified the medication was not documented on the MAR and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box revealed the cart did not contain any dose of the [MEDICATION NAME] gel ([MEDICATION NAME]) available to administer for Resident #3. Observations of the Automated Dispensing Unit, on 10/10/2018, at 8:50 AM, verified the [MEDICATION NAME] gel was not available. LPN #55 attempted to request the [MEDICATION NAME] gel for Resident #3 from the pharmacy, using the computer, after verifying the [MEDICATION NAME] gel was not available in the facility, but the request did not go through. The nurse responded, it must already have been re-ordered. It was then stated, by LPN #55, the [MEDICATION NAME] gel may have been locked up in the Director of Nursing's office. An interview, on 10/10/18, at 09:25 AM, with the Administrator Designee, verified the [MEDICATION NAME] is not in the building. An interview with the (name) Pharmacy, on 10/10/18, at 11:20 AM, verified the [MEDICATION NAME] gel had been ordered, on 12/22/16 and 06/14/2017. Further interview with the (name) Pharmacy, revealed the pharmacy had sent a request on 12/07/17 with additional follow-up requests on 12/08/17 and 12/12/17 to obtain a new physicians order with written script. To date, the facility had not sent the request for a current order and script to the pharmacy. On 10/10/18, at 2:35 PM, after consultation with the state agency a determination of immediate jeopardy was identified. The facility failed to ensure that emergency medication ([MEDICATION NAME] Gel) was provided to Resident #3 in accordance with physician's orders [REDACTED]. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 8:44 PM. The facility implemented in services for direct care staff regarding [MEDICAL CONDITION] care. Resident #3's physician was notified and orders for Intramuscular (IM) [MEDICATION NAME] was obtained. IM [MEDICATION NAME] was available in the Emergency cart. On 10/11/18, at 11:55 AM, the Administrator Designee and RN#150 brought a prescription container of [MEDICATION NAME] gel to the surveyor. The Administrator Designee, stated it was not where the Director of Nursing (DoN) had told her to look but after the DoN thought about it, she had us to break the lock to get it. The [MEDICATION NAME] gel produced by the Administrator Designee and RN#150 had an original date of 06/14/17 with instructions to discard After 06/15/18. Both the Administrator Designee and RN #150 verified there was no current medication available in the facility to be used in case Resident #3 sustained a [MEDICAL CONDITION] greater than 5 minutes requiring medication to be administered. Further interviews, on 10/16/18, at 10:35 AM with RN#110 verified, meds are pulled based on discard date and RN#106 added, only meds to be destroyed are in the nurse's office (DoN) and that is where the outdated [MEDICATION NAME] was found. Further review of the medical record revealed Resident #3 had documentation of a [MEDICAL CONDITION] occurring on 08/17/18. There was no timed event for the duration of the [MEDICAL CONDITION]. The facility failed to provide [MEDICAL CONDITION] care that documented: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity as noted in Resident #3s care plan. Both [MEDICAL CONDITION] occurred during the time there was not a current prescription of the [MEDICATION NAME] gel available for the Resident and when the [MEDICATION NAME] Gel had not been available. The current physician's orders [REDACTED].) A review of the laboratory section of the medical record revealed no documented results for the [MEDICATION NAME] level ordered for (MONTH) (YEAR). An interview, on 10/15/18, at 2:30 PM with LPN #7, revealed no results were received and placed on the medical record. Upon further investigation, LPN #7 stated the lab had not been drawn according to the laboratory book. Additionally, the repeat Ammonia level ordered 08/20/18 was also not done. Review of the available labs, revealed Resident #3 had previously had higher levels than normal of [MEDICATION NAME]/[MEDICATION NAME] Acid at level 110 (normal range indicated 50-100 MCG/ML) {microgram/ milliliter} and Ammonia levels at level 40 (normal range indicated as 9.0-33.0 UMOL/L) {micromole per liter}. c) Resident #5 Notification of changes An interview, with Resident #5's Medical Power of Attorney (MPOA), on 10/14/18 at 6:00 PM, revealed Resident #5 had a (computed tompography (CT) scan. The MPOA said the facility did not inform him of the results from the CT scan. A progress note dated 07/30/18 stated, X-ray of right lower extremity reports [MEDICAL CONDITION] changes but could not rule out fracture of tibia. Discussed with FNP 'family nurse practicioner' and MPOA 'medical power of attorney.' New orders given for CT w/o (without) contrast of right lower extremity on 8/3/18 at (name of local hospital). MPOA (medical power of attorney) aware. A progress note dated 08/3/18 stated, Resident OOF 'out of facility' for CT scan via (name of ambulance company) per stretcher with 2 attendants. Further review of progress notes did not reveal any evidence indicating the MPOA was informed of the results of the CT. The CT scan report dated 08/03/18 did have hand written notes showing the family nurse practicioner was notified and that there was a new order for an orthopedic consult. However, there was no note to reflect the MPOA was notfieid of the CT results. On 10/15/18 at 11:38 AM Licensed Practical Nurse (LPN) #72 and Scheduler #16 looked through the resident's thinned medical record and located the results of the CT. There was no evidence the facility had informed the MPOA of the results. LPN #72 and Scheduler #16 confirmed the facility had no evidence to support they had informed Resident #5's MPOA of the results from the CT. A review of the facility's survey history revealed a complaint survey completed on 08/17/18 resulted in a deficient practice at F580 (notification of changes). Turning and Repositioning A review of Resident #5's treatment sheet revealed an order to turn and reposition the resident every two (2) hours due to increased risk of skin breakdown. Care plan review revealed Resident #5 had been treated for [REDACTED]. The care plan reflected the resident was incontinent of bowel and bladder and moved around in bed by sliding. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was totally dependent for bed mobility. Multiple observations on 10/10/18 between (9:00 AM and 1:00 PM) revealed Resident #5 was positioned with pressure off his right side. An interview with Nurse Aide (NA) #50 at 1:00 PM on 10/10/18 revealed the nursing staff were supposed to turn/reposition Resident #5 every two (2) hours but sometimes they were not able to do this due to staffing issues. Observations of Resident #5 on 10/10/18 at 1:48 PM revealed Resident #5 was positioned with pressure off his left side. Continued observations between 1:48 PM and 6:00 PM revealed the resident in the same position with pressure off his left side. On 10/10/18 at 6:06 PM during an interview with Registered Nurse (RN) #34 the RN said she would fix that when she was told the resident had been on the right side with pressure off the left side for the multiple observations between 1:48 PM and 6:00 PM. A review of the treatment record for (MONTH) (YEAR) revealed an order dated 07/10/18. The order indicated the resident would be turned every (two) hours, every shift due to an increased risk of skin breakdown. On 10/02/18 there was no documenation showing the resident had been turned on 7:00 AM - 7:00 PM shift. On 10/03/18 there was no documentation showing the resident had been turned every two (2) hours on 7:00 PM -7:00 AM shift. On 10/05/18 there was no documentation the resident had been turned during 7:00 AM -7:00 PM shift. On 10/06/18 there was no documentation the resident had been turned during 7:00 PM -7:00 AM shift. On 10/07/18 there was no documentation to show the resident had been turned during 7:00 PM-7:00 AM shift. On 10/09/18 there was no documentation to reflect the resident was turned during 7:00 AM-7:00 PM or 7:00 PM-7:00 AM. On 10/13/18 there was no documenation to show the resident had been turned during 7:00 PM-7:00 AM shift. On 10/14/18 there was no documenation the resident had been turned during 7:00 AM-7:00 PM shift. The resident's care plan reflected a focus area related to the resident's pressure ulcer to the right and left coccyx. The care plan indicated the resident was at risk for further skin breakdown related to imobility, refusal to turn and reposition, incontineince of bowel and bladder. Staff interview and record review as well as observations did not reflect the resident's refusal to be turned/repositioned. During a family interview, on 10/14/18 at 6:00 PM, Resident #5's family member said the resident had experienced a terrible pressure ulcer while at the facility. An interview with wound care RN #31 on 10/10/18 at 10:47 AM revealed Resident #5's wound was on the coccyx and had originated in (MONTH) (YEAR). The resident was on a wound VAC (vacuum assisted closure) for about eight (8) months. d) Resident #20 Review of records, on 10/10/18 at 10:15 AM, revealed some of Resident#20's [DIAGNOSES REDACTED]. Review of records revealed the resident had a vagal stimulator to be used during [MEDICAL CONDITION] activity. Vagal refers to the vagus nerve the longest nerve in the autonomic nervous system in the human body, which controls functions of the body that are not under voluntary control (such as heart rate and breathing). According to the [MEDICAL CONDITION] Foundation, Vagus nerve stimulation (VNS) prevents [MEDICAL CONDITION] by sending regular, mild pulses of electrical energy to the brain via the vagus nerve. It is sometimes referred to as a pacemaker for the brain. A stimulator device is implanted under the skin in the chest. A wire from the device is wound around the vagus nerve in the neck. If a person is aware of when a [MEDICAL CONDITION] happens, they can swipe a magnet over the generator in the left chest area to send an extra burst of stimulation to the brain. For some people this may help stop [MEDICAL CONDITION]. A magnet is used to activate or deactivate the device. Review of Resident#20's care plan, on 10/10/18 at 10:15 AM, revealed a focus area of impaired Neurological status related to [MEDICAL CONDITION] disorder. Interventions included Give medications as ordered. Observe/document for effectiveness and side effects. Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No shortwave diathermy. The same intervention related to [MEDICAL CONDITION] activity concerning the vagal stimulator is under the focus of risk for falls. The intervention, Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. No short-wave Diathermy. Date Initiated: 06/15/17. Review of records for Resident#20, on 10/10/18 at 2:00 PM, revealed an order for [REDACTED]. Review of the medicine administration record (MAR) revealed no [MEDICATION NAME] was given in the month of (MONTH) or (MONTH) (YEAR). The MAR showed in the month of (MONTH) one (1) dose was given on 08/27/18, indicating [MEDICAL CONDITION] activity had occurred. No details concerning the [MEDICAL CONDITION] activity occurring on 08/27/18 was found in the record; no description on how long the [MEDICAL CONDITION] lasted, or if the vagal stimulator was used, or what interventions or precautions were used other than the ordered medication. On 10/10/18 at 2:40 PM, interview with Registered Nurse (RN#105) assigned to care for the resident on 10/10/18, revealed RN#105 was not aware the resident had a vagal stimulator or what a vagal stimulator even was. RN#105 said this was her first day at the facility, that she was from a sister facility and did not know the residents. This surveyor suggested that perhaps another nursing staff that regularly worked at the facility and who was familiar with the resident, show this surveyor and the assigned RN#105 responsible for the care of Resident#20, the resident's vagal stimulator and the appropriate way to use it. Licensed Practical Nurse (LPN#72) showed this surveyor and RN#105 the procedure to use the vagal stimulator if the resident had a [MEDICAL CONDITION]. LPN#72 felt the resident's upper left chest and showed RN#105 the outline of the implanted vagal stimulator, then LPN#72 showed RN#105 the magnet hanging on the back of the resident's wheel chair that is used to operate the vagal stimulator. LPN#72 said there was also a magnet on the cart. LPN#72 said, the resident has been at the facility for ten (10) years and if he is having a [MEDICAL CONDITION], you swipe the magnet over the implanted vagal stimulator one (1) time, and only one (1) time. RN#105 said she had never came across one of those (vagal stimulator) before in her nursing career (RN#105 said she had been a RN since (MONTH) (YEAR), but a LPN for several years). On 10/10/18 at 5:45 PM, review of orders revealed an order dated 03/30/17, If resident has [MEDICAL CONDITION] activity last greater than 3 minutes, then RN to swipe magnet once over VNS Generator. If needed, can repeat after 5 minutes. Avoid swiping magnet immediately after single swipe. Notify physician and RP (representative) of use. Another order dated 3/31/2017 revealed, Device: Keep vagal Stimulator (used during [MEDICAL CONDITION] activity) in plain sight and handy at all times. Use vagal stimulator if he has more than one [MEDICAL CONDITION] in a row by rubbing magnet on left upper chest. No short-wave diathermy, microwave diathermy, therapeutic ultrasound diathermy. Every shift for [MEDICAL CONDITION] On 10/10/18 at 3:37PM, interview with RN#44 Staff Development, revealed when asked for records on all training given to staff concerning a vagal stimulator. RN#44 said, We don't have anyone in the building with a vagal stimulator. RN#44 said she has not done any training on vagal stimulators since she has had the job since the last part of (MONTH) (YEAR). The Staff Development RN#44 said she would look at previous records, prior to her having the position, to see if there ever was any training given concerning [MEDICAL CONDITION] or vagal stimulators. Interview with RN#44 Staff Development, on 10/10/18 at 4:17 PM after RN#44's review of training back through (YEAR), revealed no training on [MEDICAL CONDITION] or vagal stimulators. When asked again if anyone in the facility had a vagal stimulator, RN#44 replied, No one. This surveyor informed RN#44 that Resident#20 had a vagal stimulator. RN#44 left the room and came back a little while later and said, she was the only one that was not aware the resident had a vagal stimulator, that she had spoken to staff and everyone else knew about it and how to use it. When RN#44 was asked what model vagal stimulator the resident had, and how long he had had it, she was unable to say, but said she would try to find out. At the time of exit the facility had not given this surveyor the information on the model of the vagal stimulator or how long Resident #20 had it. On 10/10/18 at 7:35 PM, interview with LPN#47, evening shift nurse assigned to the resident revealed the LPN was not aware Resident #20 had a vagal stimulator or what a vagal stimulator was. When asked what the nurse would do if the resident had a [MEDICAL CONDITION] LPN#47said she would give him his PRN (as needed) medicine for [MEDICAL CONDITION]. When asked what the care plan intervention meant by Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. The LPN did not know, and said she had never seen any device bedside, and was unable to describe what a vagal stimulator was. An interview with Resident Care Specialist, also known as a Nurse Aide (NA) NA#35, on 10/10/18 at 7:40 PM, revealed NA#35 considered the Resident#20 total care. NA#35 said the resident needed a lot of care and he did have [MEDICAL CONDITION]. Upon inspection of the resident's wheel chair with NA#35, this surveyor pointed to the magnet attached to the back of the wheel chair and asked NA#35 what it was. NA#35 replied it was a wheel chair alarm, that a lot of residents had them so that staff would know when they stood up out of their wheel chairs. e) Resident #2 admitted originally on 05/19/18 status [REDACTED]. Resident had capacity. resident had a history of [REDACTED]. Review of records, on 10/09/18 at 11:15 AM, revealed a quarterly minimum data set (MDS) with an assessment reference date (ARD) 8/22/18. The resident had adequate hearing and vision, clear speech, can make self-understood and understands. Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 15 indicating the resident was cognitively intact with no impairment. The resident needed extensive assistance with activities of daily living (ADLs), except supervision with meals and is totally dependent for bathing. Pertinent [DIAGNOSES REDACTED]. On 10/09/18 at 1:05 PM review of record revealed a late entry situation background assessment recommendation (SBAR) Change in Status dated 09/22/18 at 4:40 PM. Review of SBAR Summary revealed documented vitals signs (blood pressure, temperature, pulse, and respirations) were taken on 09/19/18. The oxygen saturation noted was taken 09/18/18. Nurses note stated, What I think is going on with the resident is: has received first Cemo for metastisis of CA ([MEDICAL CONDITIONS] that has spread) had recently fracture to left arm while being turned and upon assessment her left elbow was very warm to touch Temp (temperature) -99.1. Additional Nursing Notes as applicable: Rp (representative) in facility and stated to send her mother to (name of specific hospital) ER (emergency room ) because that is where [MEDICAL CONDITION] doctors are. The hospital requested by family was not the nearest hospital to the facility. The family had to request resident be sent for evaluation. When reviewing the SBAR summary and SBAR no vital signs (VS) were recorded at the time the resident was having a change of condition, accept in a nurse's note a recorded temperature taken one time. The District Director of Clinical Services said the system pulls the last recorded VS into a note when no new VS are entered. Review of the SBAR dated the day Resident #2 was sent to the ED, 09/22/18, showed VS from 09/19/18, and oxygen saturation noted was taken 09/18/18. There were no recorded current VS reflecting the resident's actual status at the time of the change in condition. The instructions included on the SBAR were 1. Evaluate the resident, 2. Check vital signs, 3. Review record, 4. Review and interact care path or acute change in condition file card, and 5. Have relevant information available and reporting. The SBAR noted the situation is a change in condition noted as confusion with change in vials (written as typed) starting on 09/22/18. Stayed the same since change started with no change in symptoms. This condition, symptom, or sign has not occurred before. On the SBAR section 'Other relevant information', it was noted had family in from out of town all morning was laughing and taking pictures. Under section 'B' of the form under number three (3) instructions say (Be sure this is the most current set of vital signs that goes with your evaluation of the resident) The vital signs recorded on the form was actually taken on 09/19/18, the change in condition occurred on 09/22/18. The change in the resident's condition included increased confusion and slurred speech. The RN assessment revealed I think the problem may be has received first Cemo for metastisis (typed as written) of CA ([MEDICAL CONDITIONS] that has spread) had recently fracture to left arm while being turned and upon assessment her left elbow was very warm to touch Temp (temperature) -99.1. Nursing Notes for additional information on change of condition: Rp (representative) in facility and stated to send her mother to (name of specific hospital) ER (emergency room ) because that is where [MEDICAL CONDITION] doctors are. The physician was notified on 09/22/18 at 12:15 PM. Review of Hospital Emergency Department documentation dated 09/22/18, revealed at the time of the initial examination the resident was only alert to self, was hypotensive, and had elbow pain and swelling. She was treated for [REDACTED]. A chest x-ray was concerning for pneumonia. She did respond to IV fluid hydration and was no longer hypotensive. The resident required hospitalization for IV antibiotics. The resident's blood pressure was significantly lower than usual and she was hypotensive with a systolic of 70's. According to the family this afternoon she began having decreased alertness and became slightly altered. Throughout the evening she continued to become more altered and less responsive. The family noticed the residents left elbow was significantly more swollen and tender. (The resident had a [MEDICAL CONDITION] arm earlier in the month) On 10/16/18 at 12:55 PM, review of hospital discharge summary dated 09/29/18, revealed Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The admitting [DIAGNOSES REDACTED]. Primary discharge [DIAGNOSES REDACTED]. Notations in the hospital records revealed, . The family notice that the wound appeared to be red and somewhat tender, and in addition notice that she had mental status changes today.and family asked that she be transferred for further evaluation The patient was initially hypotensive (low blood pressure) on arrival with elevated temperature, . On 10/16/18 at 3:11 PM, interview with Director of Legal Operations, the District Director of Clinical Services, Administrator, and interim Assistant Director of Nursing (ADON), revealed the SBAR was the documentation concerning what led up to sending Resident to the Emergency Department for evaluation. The Director of Legal Operations said the family was the ones that requested the resident be sent, and asked this surveyor if she had read the SBAR. This surveyor confirmed the SBAR dated 09/22/18 had been reviewed. The Director of Legal Operations said, The resident had been laughing earlier with the family, it was the family that requested the resident be sent. This surveyor said, Yes, the family did request the resident be sent, but don't you think nursing staff should have assessed and intervened without the family having to make the request, considering the condition the resident was in when she arrived at the hospital? No reply was made to the surveyor's question. After a pause, the Director of Legal Operations asked, Have you seen the hospital record? This surveyor replied, Yes, I have them. After another pause, the Director of Legal Operations said, I just wanted to know in case you wanted me to get them for you.",2020-09-01
344,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2018-10-16,880,D,1,0,BYSJ11,"> Based on observation and staff interview the facility failed to ensure they maintained an infection control program designed to provide a safe, sanitary environment and help prevent the development and transmission of communicable diseases and infections. A wash basin was found lying on the floor in Resident #5's room. Resident #9's catheter bag was touching the floor. The aforementioned practices had the potential to affect more than an isolated number of residents. Resident identifiers: #5, and #9. Facility census: 83. Findings include: a) Resident #5 On 10/09/18 at 12:20 PM an observation in Resident #5's room revealed a gray plastic wash basin on the floor across from the bed, near the wall. The basin was not stored in a bag and was directly on the floor. On 10/09/18 at 12:25 PM Licensed Practical Nurse (LPN) #7 came in the room and was asked about the wash basin on the floor. He said it was probably there because it was dirty. He threw it away. b) Resident #9 An observation of Resident #9's catheter bag, on 1:35 PM on 10/09/18, revealed the catheter bag was sitting directly on the floor. On 10/09/18 at 1:40 PM, LPN #62 was told about the observation made at 1:35 PM. She said she would take care of it.",2020-09-01
345,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2017-03-10,225,D,0,1,7ZXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, record review, and staff interview, the facility failed to thoroughly investigate incidents that occurred with two residents (#47 and #119). Resident identifiers: #47 and #119. Facility census 132. Findings include: a) Resident #47 On 03/07/17 at 3:22 p.m., the most recent Minimum Data Set (MDS) assessment with an Assessment Reference Date of 01/15/17 for Resident #47 was reviewed. The MDS indicated the resident had [DIAGNOSES REDACTED]. At 3:28 p.m. the care plan was reviewed. An Immediate Needs care plan was completed on 02/14/17 for the left hand and left forearm that was purple and bruised. Interventions included: to monitor daily and observe for infection, inflammation, redness, and tenderness. Review of resident form, dated 02/14/17 at 4:00 p.m., had a statement from the resident, It happened this a.m. when they were changing my shirt. The form indicated there was a large ecchymotic (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) area noted to left hand extending up the left forearm while up in a while up in motorized wheelchair. The injury was described as a large purple, ecchymotic area that start at top of left hand and extends up left forearm to elbow. The area measured 19 centimeters (cm) by 38 centimeters. The resident denied pain. The second page of the Resident Form was titled Incident Review and was blank. A nursing notes, dated 02/14/17 at 7:00 p.m., noted the resident was up in his motorized wheelchair with a large ecchymotic area to his left hand and left forearm measuring 19 cm by 38 cm, dark purple, denies pain. The nurse documented the resident states the bruise occurred when his shirt was being changed on the morning of 02/14/17. The medical power of attorney was present and notified and the physician notified. On 03/07/17 at 5:06 p.m., Resident #47 was interviewed. The resident stated the bruise on his left arm happened one morning when the staff were assisting him to get his shirt on. He stated the staff were holding his arm to get it into his shirt. The resident denied being abused and stated he bruises very easily. On 03/07/17 at 5:29 p.m., Registered Nurse (RN) #56 was interviewed. RN #56 stated she worked the day the bruise was found on the resident's left arm. The RN stated the resident reported to her it happened that morning when he was getting his shirt on. She completed a resident form, but did not report abuse, no further investigation on her part was done. RN #56 stated social services picks up the resident forms and follows up. On 03/08/17 at 10:36 a.m., Licensed Practical Nurse (LPN) #163 was interviewed. LPN #163 stated she recalled the incident and stated the resident told her it happened when the staff was helping him get dressed. LPN #163 stated the staff held his arm to help get it in the arm hole and then a bruise occurred. On 03/08/17 at 3:43 p.m. interviews were done with the Social Service Director (SSD) #14 and the Director of Nursing (DON) #105 regarding the incident. The DON stated the resident's incident report was completed by RN #56. The form was picked up by Licensed Social Worker (LSW) #78 and then returned to the DON. The second page of the investigation was not completed by LSW #78. DON #105 stated she interviewed RN #56 and ask her what happened. RN #56 told her the resident reported the bruise at 4:00 p.m. that day and told her it happened with dressing that morning, but the resident had been up in his chair and she was not sure of what happened. The DON verified she didn't do any follow up with the staff or the resident on the bruise. SSD #14 stated that she was going to re-open the case and complete the investigation because it was not done on 02/14/17 when the nurse completed the incident report On 03/08/17 at 4:11 p.m., RN #56 was re-interviewed. RN #56 stated the resident reported the bruise to her around 4:00 p.m. on 2/14/17. RN #56 stated the resident told her the bruise happened when the staff was helping him get dressed that morning. She stated he had been up in his scooter and had had another incident awhile back where he ran his scooter into the wall and got a bruise. She was not sure how he really got the bruise. She stated she did not question him further about how the bruise occurred. b) Resident #119 Resident #119 was admitted on [DATE] and readmitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 12/11/16 significant change Minimum Data Set (MDS) assessment, the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 9 out of 15. Resident #119 required extensive assistance of two persons for toileting. The care plan, initiated 12/15/16, identified the resident is incontinent with impaired mobility putting her at risk for impaired skin integrity and further complications. Interventions included: provide assist with toileting per facility protocol and provide incontinence care as needed. Resident #143 (Resident 119's roommate) was interviewed on 03/06/17 at 11:09 a.m. She said staff fussed at her roommate for having to go to the bathroom too often. She said one girl did yell at her telling her she just went to the bathroom. Resident #143 could not recall who the staff was. She told social services about the incident. Resident #119 was interviewed on 03/06/17 at 3:47 p.m. She said one of the nurse aides had told her you just went to the bathroom. On 03/07/17 at 2:57 p.m., the resident was interviewed again. She said she had to go to the bathroom two to three times a night. The nurse aide came in and said oh, you have to go to the bathroom again. You just went 10 minutes ago. It made her feel bad at the time. According to the investigation report, dated 01/16/17: --Incident date: unknown --Incident was reported on 01/16/17 by resident who said the incident happened a couple of days ago. --Alleged perpetrator: Nurse Aide (NA) #31 --Name of victim: Resident #119 --Reported to APS (adult protective services): Yes --Name of complainant: Resident #119 According to the follow up report for this investigation, dated 01/21/17: --Alleged perpetrator: NA #31 --Substantiated: Yes --Upon investigation, residents/staff were interviewed. It was reported that NA #31 at times is in a hurry and she has an attitude when asked for assistance. No reports of physical/ mental abuse were noted. NA #31 was counseled and will be moved to working another shift with more supervision. (This report was faxed to the State nurse aide registry on 01/21/17) According to the staffing schedule in January, NA #31 worked the nights of 01/16/17, 01/18/17, 01/20/17, and 01/21/17. According to the investigation report, dated 01/16/17: --Incident: unknown --Alleged perpetrator: NA #211 --Name of victim: Resident #119 --Name of complainant: Resident #143 (roommate) According to the follow up report for this investigation, dated 01/21/17: --Alleged perpetrator: NA #211 --Substantiated: Yes --Upon investigation, interviews with residents and staff reported that NA #211 can have an attitude with residents and that she needs to be more sensitive with resident's requests for assistance with using the bathroom or with transfers. NA #211 to be counseled and moved to a different shift with more supervision. (This report was faxed to the State nurse aide registry on 01/21/17) According to the staffing schedule in January, NA #211 worked the nights of (MONTH) 01/17/17, 01/19/17, and 01/20/17. There were six resident interviews completed and documented for both investigations on 01/18/17. (Two days after the incident was reported). No staff interviews were documented. Social Services Employee (SSE) #78 was interviewed on 03/07/17 at 2:17 p.m. He said he interviewed six (6) residents on 01/18/17. He said he talked with three (3) staff and they did not say anything. APS was not assigned to investigate. The Nursing Home Administrator (NHA) #161 and SSE #78 were interviewed on 03/07/17 at 4:00 p.m. The NHA said when they received an allegation, they would ensure the resident was safe. They interviewed the residents and staff involved. They reported to APS, law enforcement and the nurse aide registry. She said they did not substantiate it upon investigation. She said, Sometimes they suspended the staff and sometimes they didn't. It depended on if physical abuse was involved. It depended on the seriousness. She said in this case, she couldn't suspend them. SSE #78 did not remember the dates he talked with staff. The record contained no evidence of interviews with staff. The NHA said they did a preliminary investigation and the resident was not fearful. They would have normally talked with the staff and let them know there was an allegation against them. SSE #78 did not ask about the specific event. The NHA said, the investigation could have been better. The Director of Nursing (DON) #105 was interviewed, on 03/07/17 at 5:09 p.m., and she said the two nurse aides were supervised during their shift after the allegation. The nurse was to go into the rooms along with the nurse aides. She said SSE #78 had talked with the nurse aides, but she did not know what he told them regarding the investigation. At 5:25 pm., the DON said she did not know if the incident was reported to the State nurse aide registry. She said there was nothing in the NA's personnel files regarding the investigation, allegation or reporting to the State nurse aide registry. She confirmed there was confusion regarding the investigation. The NA #211 was interviewed on 03/08/17 at 10:05 a.m. She said she never talked with SSE #78 in (MONTH) regarding any incident. The last time she had talked with SSE #78 was when she first started. She was unaware of any recent investigation. She said her coworker, NA #31 had received a call from SS #78. The NHA #161 was interviewed, on 03/08/17 at 10:15 a.m., and she said they were re-opening the investigation. The SSD #14 was interviewed on 03/08/17 at 11:00 a.m. She said she was off in (MONTH) and did not know much about this investigation. She state they re-opened this investigation as a result of surveyor intervention.",2020-09-01
347,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,641,D,0,1,J1N911,"Based on medical record review and staff interview, the facility failed to complete an accurate minimum data set (MDS) assessment for one (1) of forty-three (43) assessments reviewed. The MDS for Resident #41 did not accurately reflect the resident's status for end-of-life prognosis. Resident identifier: #41 Facility census: 134. Findings included: a) Resident #41 A review of the medical record, for Resident #41 on 04/23/18, revealed the quarterly MDS with assessment reference date (ARD) of 02/18/18 did not correctly record this resident having a life expectancy of less than six (6) months. A review of the certification narrative signed by the physician on 08/25/17, and re-certification on 02/21/18 had Resident #41 with a prognosis of six (6) months or less life expectancy. Resident #41 received hospice services since 08/25/17. In an interview, with the MDS Coordinator on 04/25/18 at 9:40 AM, the MDS Coordinator verified the quarterly MDS with the ARD of 02/18/18 did not include the prognosis of life expectancy of less than six (6) months for Resident #41.",2020-09-01
349,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,684,D,0,1,J1N911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide treatment and care needed in accordance with professional standards of practice to meet the physical, mental and psychological needs for one (1) of forty three (43) residents reviewed related to pain medication. Resident identifier: #121. Facility census: 134. Findings included: a) Resident #121 Review of the physician orders [REDACTED]. Instructions include to give if the residents pain level is four or greater on a pain scale of one (1) - ten (10). The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) monthly MAR indicated [REDACTED]. Review of nursing notes also found no evidence of obtaining the level of pain. On 04/25/18 at 8:46 AM, Registered nurse #147 agreed the pain levels had not been obtained in accordance with the physician order. Review of nursing notes also found no evidence of obtaining the level of pain. On 04/25/18 at 8:46 AM, Registered Nurse #147 agreed pain levels had not been obtained in accordance with the physician order.",2020-09-01
350,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,697,D,0,1,J1N911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to ensure one (1) of 43 residents received treatment and care in accordance with professional standards related to the recognition and management of pain. Resident identifier: #121. Facility census: 134. a) Resident #121 Review of Resident #121's care plan revealed a start date of 02/12/18 with a problem of pain monitoring and management due to a healing right [MEDICAL CONDITION] and arthritis. On 04/24/18 at 9:16 AM Resident #121 explained she had pain most of the time. Medical record review revealed a physician's orders [REDACTED]. Instructions included to give the medication if the residents pain level was four (4) or greater on a pain scale of one (1) - ten (10). The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. Review of nursing notes also found no evidence of obtaining the level of pain. On 04/25/18 at 8:46 AM, Registered nurse #147 agreed pain levels were not obtained in accordance with the physician order.",2020-09-01
354,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,842,D,0,1,J1N911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interview the facility failed to complete and maintain accurate medical records for two (2) of two (2) residents whose medical records were reviewed for tube feeding during the survey process. Resident #41 and #77 had enteral feeding orders that did not include caloric values. Resident identifiers: #41 and #77. Facility census: 134. Findings included: a) Resident #41 A review of the medical record for Resident #41 on 04/25/18 revealed the enteral feeding order did not include the caloric value. The medical record revealed an enteral feeding order for the following: [MEDICATION NAME] 1.2 tube feeding via [DEVICE] ([DEVICE]) 1100 cubic centimeters (cc) total to run at 1100 cc/hour on at 10:00 PM off at 8:00 AM, nightly with 30 cc/hour water to flush to run continuously; flush with 15 cc of water after each medication; change tubing daily upon start of new bottle, start date for order 11/28/17. In an interview with Registered Nurse/Unit Charge Nurse (RNUCN) #147 on 04/25/18 at 12:01 PM, RNUCN #147 verified the enteral feeding order did not include the caloric value for Resident #41. b) Resident #77 A review of the medical record for Resident #77 on 04/25/18 revealed the enteral feeding order did not include the caloric value. The medical record revealed an Enteral Feeding order for the followng: Advance Glucerna 1.2 by 10 milliliters (ml) every eight (8) hours to goal rate of 80 ml/20 cc flush; to run from 10:00 PM to 6 PM; flush with 15 cc of water before and after each medication administration; change tubing daily upon start of new bottle. Percuaneous endoscopic gastronomy (peg). Start date for order 02/26/18. During an interview with RNUCN #147, on 04/25/18 at 4:25 PM, RNUCN #147 verified the enteral feeding order for Resident #77 did not reflect the caloric value.",2020-09-01
356,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2018-04-26,883,D,0,1,J1N911,"Based on record review, staff interview and policy review, the facility failed to ensure a resident and/or the resident's representative has the opportunity to refuse the influenza vaccine prior to annual administration. Resident #62 received the influenza vaccine during the (YEAR) flu season without a current signed consent. This was found for one (1) of five (5) residents reviewed. Resident identifier: #62. Facility census: 134. Findings included: a) Resident #62 Review of Resident #62's medical record, on 04/24/18, revealed she received the influenza vaccine on 10/04/2017. The influenza vaccination consent form was signed by Resident #62's representative on 07/23/15. Registered Nurse (RN) #69 / Unit Manager reviewed Resident #62's medical record during an interview on 04/24/18 at 11:15 AM, and confirmed the influenza consent form was dated (YEAR) and was signed by her late husband. RN #69 reported Resident #62's son is now responsible for signing consents. The facility Influenza Vaccine policy states under section 5. Individuals receiving the vaccine, or their legal representative, will be required to sign a consent form prior to the administration of the vaccine .",2020-09-01
358,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,550,D,0,1,S31911,"Based on observation, staff interview and policy review, the facility failed to ensure a resident received care in a manner that promoted dignity for one (1) of thirty (30) sampled residents. The facility posted signs with care needs described in plain view and failed to knock prior to entering the resident's room. Resident identifier: Resident # 107 Census: 134 Findings included: An observation on 06/24/19, at 11:24 AM, revealed a sign was posted above Resident #107's bed noting Do not use Chux ( a disposable underpad.) The sign was in plain view of anyone passing by. An additional observation on 06/25/19, at 08:22 AM, revealed HK#102 entered the room of Resident #107 carrying linen, without knocking or announcing herself. An interview on 06/25/19, at 11:16 AM, with LSW#23, revealed that information about dignity is gone over with staff during inservices and staff have been instructed to knock prior to entering the room. It was further stated no signs should be put up for instruction of care. On 06/25/19 , at 12:14 PM, a review of the facility's resident rights policy dated, 02/2018, under section 4.c., showed residents should have personal and medical information protected and not displayed openly for others to see.",2020-09-01
359,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,580,D,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to contact a resident's physician concerning an order not being implemented. The physician was not contacted when a resident's family refused a decrease in the dosage of a medication stemming from a gradual dose reduction order. This practice affected one (1) of thirty (30) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #12. Facility census: 134. Findings included: a) Resident #12 A review of the Resident's medical record, on 06/25/19 at 2:00 PM, revealed a Physician Recommendation Form with the dose reduction order [MEDICATION NAME] 10 milligrams daily decreased to [MEDICATION NAME] 5 milligrams daily dated 04/14/19. Licensed Practical Nurse (LPN) #191 wrote the note Family refused beside the order on 04/16/19. A review of the Nurses Notes, on 06/25/19 at 2:15 PM, revealed a note written by LPN #191 daughter refused pharmacy recommendations dated 04/16/19. Further review of the medical record revealed the reduction order written by the physician on 04/14/19 for [MEDICATION NAME] was never implemented and the physician was not contacted. An interview with the Alzheimer Unit Nurse Manager (AU-UM), on 06/25/19 at 2:30 PM, revealed there was no documentation that the physician was notified concerning the [MEDICATION NAME] order not being implemented. The AU-UM stated the order should have been implemented when the physician wrote the order on 04/14/19 and should have been contacted immediately once the family refused.",2020-09-01
362,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,609,D,0,1,S31911,"Based on record review, resident interview and staff interview, the facility failed to report an allegation of verbal abuse to the appropriate and required state agencies. This was a random finding while investigating an allegation of missing items. This failed practice had the potential to affect a limited number of residents. Resident identifier: #8. Facility census: 134. Findings included: a) While conduting interviews with residents on 06/24/19 during the initial tour revealed Resident #8 reported she had missing property. The surveyor asked the staff for any information regarding their actions to locate the missing items. The staff presented the surveyor with a concern report dated 01/23/19 which in the problem section stated the resident had reported the staff had yelled at her, been verbally abusive. In the response section it was addressing a missing item. The abuse of staff yelling at her had not been reported to the appropriate and required state agencies. Social worker #213, on 06/26/19 at 08:49 AM state there was no further evidence to show the staff had reported the alleged verbal abuse to the appropriate and required state agencies.",2020-09-01
363,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,610,D,0,1,S31911,"Based on record review, resident interview and staff interview, the facility failed to an allegation of verbal abuse. This was a random finding while investigating an allegation of missing items. This failed practice had the potential to affect a limited number of residents. Resident identifier: #8. Facility census: 134. Findings included: a) While conduting interviews with residents on 06/24/19 during the initial tour revealed Resident #8 reported she had missing property. The surveyor asked the staff for any information regarding their actions to locate the missing items. The staff presented the surveyor with a concern report dated 01/23/19 which in the problem section stated the resident had reported the staff had yelled at her, been verbally abusive. In the response section it was addressing a missing item. The abuse of staff yelling at her had not been investigated. Social worker #213, on 06/26/19 at 08:49 AM state there was no further evidence to show the staff had completed a thorough investigation of the alleged verbal abuse.",2020-09-01
364,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,656,D,0,1,S31911,"Based on observation, record review and staff interview, the facility failed to implement the care plan for bilateral padded side rails on a resident's bed. The facility failed to ensure that the side rails were covered by padding as directed on the care plan. This had the potential to affect one (1) of 30 residents. Resident identifier: #64. Facility census: 134. Findings included: a) Resident #64 An observation, on 06/24/19 at 11:31 AM, revealed the padding on the side rail of Resident #64's bed was missing and exposed the side rail on the right side of the bed. A record review of the care plan, on 06/24/19, revealed an intervention Padded siderails that is up at night and down during the day. An interview with Registered Nurse (RN) #172, on 06/24/19 at 1:13 PM, confirmed the padding should have covered the entire bed side rail and stated, I will call maintenance to come fix it immediately.",2020-09-01
365,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,657,D,0,1,S31911,"Based on medical record review and staff interview, the facility failed to revise a Care Plan for a resident that was utilizing side rails. The Resident was ordered 1/2 side rails and the care plan directed to use 1/4 side rails. This practice affected one (1) of thirty (30) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #61. Facility census: 134. Findings included: a) Resident #61 A review of the Resident's physician orders, on 06/25/19 at 9:45 AM, revealed the order Bilateral 1/2 side rails when in bed for turning and positioning with a date of 09/04/18. A review of the Resident's Care Plan, on 06/25/19 at 9:55 AM, revealed the problem Resident requires staff assist for daily care due to impaired mobility with the intervention Bilateral 1/4 side rails as ordered. The Care Plan was dated 09/04/18. An interview with Registered Nurse-Unit Manager (RN-UM) #72, on 06/25/19 at 10:15 AM, revealed the Resident's Care Plan was incorrect and needed to say 1/2 side rails as ordered. The RN-UM stated he would fix the issue.",2020-09-01
370,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,758,D,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's drug regimen was free from an unnecessary [MEDICAL CONDITION] drug. an order for [REDACTED]. Resident identifier: #12. Facility census: 134. Findings included: a) Resident #12 A review of the Resident's medical record, on 06/25/19 at 2:00 PM, revealed a Physician Recommendation Form with the dose reduction order [MEDICATION NAME] 10 milligrams daily decreased to [MEDICATION NAME] 5 milligrams daily dated 04/14/19. Licensed Practical Nurse (LPN) #191 wrote the note Family refused beside the order on 04/16/19. A review of the Nurses Notes, on 06/25/19 at 2:15 PM, revealed a note written by LPN #191 daughter refused pharmacy recommendations dated 04/16/19. Further review of the medical record revealed the reduction order written by the physician on 04/14/19 for [MEDICATION NAME] was never implemented and the physician was not contacted. An interview with the Alzheimer Unit-Nurse Manager (AU-UM), on 06/25/19 at 2:30 PM, revealed the reduction order for [MEDICATION NAME] from (MONTH) 2019 was never implemented. The AU-UM stated there was no documentation that the physician was notified concerning the [MEDICATION NAME] order not being implemented. The UM stated the order should have been implemented when the physician wrote the order on 04/14/19 and should have been contacted immediately once the family refused.",2020-09-01
373,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,842,D,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate medical records. A resident's nurses notes contained the wrong medication in a note concerning notification to the responsible party for an order change. This practice affected one (1) of thirty (30) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #12. Facility census: 134. Findings included: a) Medical Record Review A review of the Resident's medical record, on 06/25/19 at 2:00 PM, revealed a Physician Recommendation Form with the dose reduction order [MEDICATION NAME] 10 milligrams daily decreased to [MEDICATION NAME] 5 milligrams daily dated 04/14/19. A review of the Nurses Notes, on 06/25/19 at 2:15 PM, revealed a note written by LPN #191 daughter refused pharmacy recommendations for [MEDICATION NAME] to be decreased dated 04/16/19. b) Interview An interview with the Alzheimer Unit-Nurse Manager (AU-UM), on 06/25/19 at 2:30 PM, revealed the nurses note should have read [MEDICATION NAME] and not [MEDICATION NAME]. The AU-UM stated the note was innacurate due to the Resident not being ordered [MEDICATION NAME].",2020-09-01
375,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2019-06-26,883,D,0,1,S31911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of Centers for Disease Control (CDC)recommendations, the facility failed to ensure each resident received pneumococcal vaccines in accordance with accepted guidelines. This was evident for two (2) of five (5) residents who were eligible to receive a vaccine. Resident identifiers: R#15, and R#115. Census: 134 Findings included: a) Resident #15 (R#15) A review of the medical record for R#15, on 06/26/19 at 08:15 AM, noted R#15 was admitted to the facility on [DATE] and a consent for pneumococcal vaccinations was signed to accept the vaccination on this date. The record showed the resident had received the Prevnar 13 vaccination in (YEAR). Further review of the medical record did not show any record of a [MEDICATION NAME] 23 (PPSV23) being administered since the resident's admitted . An interview, on 06/26/19 at 08:21 AM, with RN#230, verified R#15 was eligible for PPSV23, but had not received it to date. b) Resident #115 (R#115) A review of the medical record for R#115, on 06/26/19 at 08:25 AM, showed an admission date of [DATE] and a consent signed by the legal representative, on 03/08/19, consenting to the administration of the pneumococcal vaccination. Further review of the record did not show any record of a pneumococcal vaccination being administered since the resident's admitted . An interview, on 06/26/19, at 08:31 AM, with RN#230, verified R#115 was eligible for the Prevnar 13 (PCV13) vaccination and to date the vaccination had not been administered. An interview with the Assistant Administrator on 06/26/19, at 08:52, confirmed understanding that R#115 was eligible and should have received the vaccine. c) Policy and Procedure An interview with RN#152 on 06/26/19, at 07:05 AM, revealed the facility follows Centers of Disease Control (CDC) guidelines for vaccinations and was also verified by the Assistant Administrator in a follow-up interview on 06/26/19 , at 08:52 AM. A review of Centers for Disease Control Guidelines , noted that PCV13 is to be administered one year after the date of receiving PPSV23. Additionally, if an adult received the PCV13 first, the PPSV23 would be administered one year from when the PCV13 vaccination was received.",2020-09-01
377,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2017-01-11,280,D,0,1,PS4J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #19's care plan was revised when he sustained a change and/or increase in behaviors. This was evident for one (1) of fifteen (15) Stage 2 sampled residents. Resident identifier: #19. Facility census: 183. Findings include: a) Resident #19 Review of the medical record found pertinent [DIAGNOSES REDACTED]. His wife also resided at the facility. The brief interview for mental status (BIMS) score was six (6), which indicated severe cognitive impairment for decision making. During medical record review, the quarterly minimum data set (MDS) with assessment reference date (ARD) 10/25/16, assessed that he had incidents of physical behaviors directed toward others which occurred one (1) to three (3) days in the look back period. In comparison, his admission MDS, with ARD 08/08/16, assessed that he had no behaviors directed toward others in that look back period. During an interview with MDS registered nurse #11 on 01/10/17 at 3:30 p.m., she said the nurse aides documented he had one (1) episode of sexual behaviors on 10/19/16, and one (1) instance of wandering a few days later. She corroborated the wandering behaviors with nursing progress notes. She did not know what type of sexual behavior he exhibited on 10/19/16. Review of the care plan at this time found he had a care plan focus and individualized interventions for wandering, but nothing related to sexual or other types of behaviors. MDS nurse #11 said they probably would not have care planned for only an isolated instance of sexual behaviors. Review of the medical record found numerous instances of behaviors recorded in nurse progress notes as follows: --On 08/20/16, a nurse aide reported he pulled his wife's hair and told her to knock it off. Also,his wife was heard yelling from the bathroom. The resident stood outside the bathroom door and told the wife not to make him come in there and choke her. Staff separated the two (2) residents and monitored them. --On 11/17/16, he wandered into another resident's room and tried to get into a female resident's bed, thinking it was his wife. The other resident scratched him. --On 11/18/16, he yelled at other residents while eating supper in the dayroom, but was easily redirected. --On 11/28/16, he was very agitated on the first part of the shift, combative with staff, and grabbed staff by the throat. Staff was unable to redirect him without causing more agitation. --On 11/30/16,, the resident was (typed as written) very sexual harassment to female staff doing p.m. (evening) cares. --On 12/10/16, he yelled and became agitated with his wife. Redirection and 1:1 was successful. An interview was completed with registered charge nurse (RN) #49 on 01/10/17 at 3:55 p.m. She said she was unaware of any sexually acting out behaviors except for that recorded in nurse progress noted on 11/30/16. She said she would not have updated the care plan based on that one instance. She said there is no record of sexual behaviors occurring on 10/19/16 except for the one (1) checkmark in the column denoting sexual behaviors that was entered into the computer by a nursing assistant. The check mark does not describe what he may have done that day. She said she wondered if it may have been check marked in error. An interview was completed with registered charge nurse (RN) #193 on 01/11/17 at 1:00 p.m. She said due to an increase in his behaviors, she thought the care plan should have been revised. To remedy that problem, she said she revised the care plan today to include a focus related to sexually inappropriate behaviors with his wife and staff. She said she also revised the care plan to include a focus related to behaviors of frequently yelling at his wife, and behaviors of frequently yelling at staff with activities of daily living cares. She also revised the care plan to include some individualized interventions for those behaviors.",2020-09-01
380,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2018-03-28,550,D,0,1,T7WG11,"Based on observation, staff interview and policy review, the facility failed to promote dignity for two of 35 residents by posting personal care information and instructions above resident's beds in a viewable manner. This had the potential to affect a limited number of residents. Resident identifiers #95 and #97. Facility census: 176. Findings included: a) Resident #95 An observation on 03/27/18, at 8:37 AM, revealed an orange sign posted above Resident #95's bed disclosing personal care information noting to crush meds and administer through peg tube. b) Resident #97 An observation on 03/27/18, at 1:50 PM, revealed a sign posted above Resident 97's bed in a viewable area disclosing personal information about the residents swallowing problem. c) Staff interview An interview with Staff #162, on 03/27/18 at 1:50 PM, revealed signs are posted above beds for direction but a notebook is available at each bedside for placement of personal care information to protect it from view. d) Facility policy A review of the undated facility policy titled Confidentiality of Information and Personal Privacy revealed, The facility will safe guard the personal privacy and confidentiality of all residents' personal and medical records.",2020-09-01
381,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2018-03-28,684,D,0,1,T7WG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure two of 35 sampled residents, received care and treatment according to the resident's plan of care to maintain the highest level of personal functioning. Resident identifiers: #97 and #38. Facility census: 176. Findings included: a) Resident #97 1. Right palm guard A review of the medical record of Resident #97 revealed a current physicians order for the resident to wear a right palm guard at all times except for hygiene and range of motion. Observations of Resident #97 on 03/26/18 at 01:33 PM, 03/27/18 at 08:40 AM and 03/27/18 at 01:44 PM, revealed no right palm guard present. During the observations made, Resident #97 was not receiving range of motion or hygiene care. An interview on 03/27/18 at 01:44 PM, with Staff #162 verified the right palm guard for Resident #97 was not present on the resident's right hand. It was further verified the order was for the resident to have the right palm guard on at all times except for range of motion and hygiene. 2. Floor mat A review of the medical record for Resident #97 revealed a current physician's orders [REDACTED]. A review of the current care plan, dated 01/17/18, revealed this resident to be a high risk for falls and was to have the floor mat by the bed for safety. An observation of Resident #97's room on 03/27/18 at 08:44 AM, revealed no floor mat in place beside Resident #97's bed. An additional observation on 03/27/18 at 01:50 PM, revealed no floor mat beside the bed of Resident #97. An interview on 03/27/18 at 01:50 PM, with Staff #162, confirmed the order to have a floor mat beside the bed for Resident #97 was a current order and current care plan intervention. It was further stated, the floor mat had mistakenly been placed beside another resident's bed and not by Resident #97's bed as ordered by the physician and directed by the resident's plan of care. b) Resident #38 Review of medical records reveal a physician order [REDACTED]. Continued review of the medical records revealed no evidence the blood pressure was obtained as ordered. A blood pressure summary report revealed documented blood pressures two times for the month of (MONTH) (YEAR), two times for the the month of (MONTH) (YEAR), and two times for the month of (MONTH) (YEAR). On 03/28/18 at 8:42 AM the facility director of nursing (DON) agreed the blood pressure values ordered by the physician were not documented in the medical records.",2020-09-01
382,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2019-05-15,656,D,0,1,1KH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to implement a comprehensive person-centered care plan for three of 35 residents reviewed . The facility failed to provide pressure relieving devices, failed to provide the correct oxygen administration flow rate and failed a cover a wound as outlined in the comprehensive person-centered care plan. Resident identifiers: # 147, #158 and #78. Facility census 180. Findings included: a) Resident #147 (R#147) Record review on 05/14/19 at 7:49 AM, noted the comprehensive person-centered care plan for R#147 had a problem identified for a potential risk for impairment in skin integrity. As an intervention, R#147 was to receive pressure relieving devices while in bed and in the chair. A wedge was ordered to be placed under the left leg to float the heel while in bed. An observation made with RN#63, on 05/14/19 at 7:54 AM, verified there was no wedge under the left leg of R#147. RN#63 retrieved a wedge on the TV stand and stated, we will correct that. An interview, on 05/14/19 at 2:20 PM, with the Assistant Director of Nursing (ADON) verified the wedge should have been in place. b) Resident #158 During observation on 05/13/19 at 2:56 PM, Resident #158 sat in her chair. She wore oxygen per nasal cannula at 3 liters per minute as delivered from an oxygen concentrator. The record reviewed on 05/14/19 revealed a the current care with a revision date of 04/17/19 for an oxygen setting of 4 liters (continuous) per minute via nasal cannula. Observation on 05/14/19 at 10:49 AM found her using her oxygen at 3 liters per minute, rather than at 4 liters per minute as the care plan directed. An interview conducted with registered nurse supervisor #41 (RN #41) on 05/14/19 at 11:00 AM verified the resident's oxygen concentrator was delivering oxygen at 3 liters per minute per nasal prongs, rather than at 4 liters per minute as the care plan directed. Upon inquiry, she said this resident does not reset the oxygen settings by herself. Rather, nursing sets the flow rate for oxygen delivery. RN #41 then adjusted the flow rate to four (4) liters per minute at this time. This failure to implement and/or follow the care plan was relayed to the director of nursing (DON) on 05/15/19 at approximately 9:30 AM. No further information was provided prior to exit. c) Resident #78 An observation, on 05/13/19 at 11:40 AM, revealed Resident #78 had a visible bloody wound on forehead. The wound was open to air and was not covered. A second observation, on 05/13/19 at 1:30 PM, revealed Resident #78 continued to have an uncovered wound on forehead that remained uncovered. A record review of the physician orders [REDACTED]. The physician order [REDACTED]. The care plan stated, 3/21/19- clean right side of forehead with NS, apply band aid daily. An interview with Licensed Practical Nurse (LPN) #152, on 05/13/19 at 1:35 PM, confirmed Resident #78's wound on forehead should be covered per care plan and physician order. LPN #152 stated that Resident #78 has been known to take off the bandaid. A record review of care plan, on 05/14/19, revealed the behavior of removal of bandaid from forehead wound by Resident #78 had not been care planned. Care plan had not been revised to reflect Resident #78's behavior.",2020-09-01
383,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2019-05-15,657,D,0,1,1KH411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to revise the resident's person-centered comprehensive care plan to meet the resident's medical and physical needs. The facility failed to revise the care plan to reflect the resident's behavior of band-aid removal that exposed wound on forehead. The failed practice affected one (1) of 35 residents. Resident identifier: #78. Facility census: 180. Findings included: a) Resident #78 An observation, on 05/13/19 at 11:40 AM, revealed Resident #78 had a visible bloody wound on forehead. The wound was open to air and was not covered. A second observation, on 05/13/19 at 1:30 PM, revealed Resident #78 continued to have an uncovered wound on forehead that remained uncovered. A record review of the physician orders [REDACTED]. The physician order [REDACTED]. The care plan stated, 3/21/19-clean right side of forehead with NS, apply band aid daily. An interview with Licensed Practical Nurse (LPN) #152, on 05/13/19 at 1:35 PM, confirmed Resident #78's wound on forehead should be covered per care plan and physician order. LPN #152 stated that Resident #78 has been known to take off the band-aid. A record review of care plan, on 05/14/19, revealed the behavior of removal of band-aid from forehead wound by Resident #78 had not been care planned. Care plan had not been revised to reflect Resident #78's behavior.",2020-09-01
386,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2019-05-15,697,D,0,1,1KH411,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure pain management was provided to a Resident consistent with professional standards of practice. Non-pharmacological interventions were not provided for a resident experiencing pain. This practice affected one (1) of thirty-five (35) residents reviewed for pain management during the Long Term Care Survey Process (LTCSP). Resident identifier: #153 Facility census: 180. Findings included: a) Resident #153 An interview with the Resident, on 05/14/19 at 10:15 AM, revealed the staff does not attempt any non-pharmacological interventions for pain. The Resident stated they just give me medication. An interview with LPN #350, on 05/14/19 at 10:25 AM, revealed she does not attempt any non-pharmacological interventions before giving the Resident her pain medications. A review of the Resident's Care Plan was conducted on 05/14/19 at 10:55 AM. The Care Plan, with an initiation date of 04/05/19, had a focus of Resident is on pain medication therapy with the goal of Resident will be free of any discomfort or adverse side effects from pain medication. The Care Plan did not include any non-pharmacological interventions for pain. Further review of the Resident's medical record, on 05/14/19 at 11:20 AM, revealed no documentation the Resident was receiving non-pharmacological interventions before pain medication was administered. An interview with the Director of Nursing (DON), on 05/14/19 at 12:55 PM, revealed the nursing staff should be offering and implementing non-pharmacological interventions for pain before administering any pain medications. The DON stated she could not find where any non-pharmacological interventions for the Resident were in place.",2020-09-01
387,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-03-22,246,D,0,1,49H511,"Based on observation, staff interview and resident interview, the facility failed to provide services with reasonable accommodation of residents' needs. Resident #42's call light was out of reach and coiled behind a large chair against the wall with the button end attached to the head of the bed, while the resident was seated in a wheelchair positioned at the foot of the bed with her back to the head of the bed. This practice affected one (1) of forty (40) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifier: #42. Facility census: 109. Findings include: a) Resident #42 An observation of Resident #42, during Stage 1 of the QIS on 03/20/17 at 10:45 a.m., revealed the Resident's call light was out of reach, attached to the pillow case at the head of the bed. The resident was seated in a wheelchair at the bottom of the bed. The call light was behind her and out of reach. Resident #42 stated during an interview at the time of the observation, I can never reach my light, I just have to wait till someone passes or comes in because I can't turn around in this chair to reach it. Registered Nurse (RN) #47 entered the room during the interview and verified the call light was not in reach of the resident. She stated, The call light is supposed to be in reach at all times and there is no way she (Resident #42) could have reached her call bell to call for assistance. RN #47 immediately positioned the call light within reach for the resident.",2020-09-01
388,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-03-22,278,D,0,1,49H511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the individual assessing and certifying the accuracy of Section [NAME] of Resident #45's 5 day Minimum Data Set (MDS), failed to ensure the assessment was accurate regarding resident behaviors. This was found for one (1) of twenty-two (22) Stage 2 sample residents whose MDS's was reviewed during the Quality Indicator Survey (QIS). Resident identifier: #45. Facility census: 109. Findings include: a) Resident #45 On 03/21/17 at 3:40 p.m., a medical record review revealed Resident #45 was originally admitted to the facility in (MONTH) 2013. He was discharged on [DATE] to an inpatient Hospice facility. His [DIAGNOSES REDACTED]. The Director of Nursing (DON) stated during an interview on 03/21/17 at 3:48 p.m., Resident #45's had intermittent behaviors included resisting care and hitting staff. A continued medical record review, on 12/22/17 at 9:15 a.m., of the 5 day MDS with an assessment reference date (ARD) of 12/30/16, found item E0200, item [NAME] Physical behavioral symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually) coded as 0 Behavior not exhibited. Social Worker (SW) #53 provided copies of behavioral monitoring on 12/22/17 at 9:30 a.m. She explained resident behaviors are documented in the nursing progress notes and Resident #45 must not have had any behaviors during the seven (7) day look back period from 12/30/16. Further medical record review, on 12/22/17 at 9:45 a.m., revealed a nursing progress note dated 12/26/16 at 22:05 (10:05 p.m.) (typed as written), Resident (Resident #45) was quite alert tonight and quite unexpectedly without warning slapped aide across the right cheek during p.m. care as well as punching her in the breast . Upon asking SW #53 for a copy of the previous progress note and after reviewing the progress note, she stated, He certainly had behaviors on that day. MDS coordinator #141 entered the SW office and after reviewing the previous progress note and 5 day MDS, she stated, yes MDS is certainly coded incorrectly for not having any behaviors.",2020-09-01
389,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-03-22,280,D,0,1,49H511,"Based on record review and staff interview, the facility failed to revise a care plan when the resident had a change in the brief interview for mental status (BIMS) score. This is true for one (1) of twenty-two (22) records reviewed. Resident identifier: #63. Facility census: 109. Findings include: a) Resident #63 Review of the care plan with a revision date of 08/31/16 revealed the resident had a BIMS of 14 our of 15 which represents the highest level of cognitive functioning. Review of the minimum data set (MDS) with an assessment reference date (ARD) of 02/08/17 revealed the residents BIMS to be nine (9) representing a decline in cognitive functioning. The care plan did not reflect this change. On 03/22/17 at 1:22 p.m., Registered Nurse #141 agreed the care plan should have been updated to represent the decline in cognitive functioning.",2020-09-01
392,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2018-06-20,582,D,0,1,W8I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of current Centers for Medicare and Medicaid Services (CMS) guidelines and staff interviews, the facility failed to issue appropriate liability and appeal notices. Specifically, the facility failed to issue the Notice of Medicare Non Coverage (NOMNC) letter within the required time frame for three residents (#77, #263, #264) of three sampled residents. Additionally, the facility failed to properly issue the Skilled Nursing Facility Advance Beneficiary Notice of Non Coverage (SNFABN) letter for two residents (#77, #263) of three sampled residents. Resident identifiers: #77, #263, #264. Facility census: 113 residents. Findings included: a) The list of residents discharged in the last six months was provided by the Nursing Home Administrator (NHA) after entrance to the facility on [DATE]. According to the list, Resident #77 remained in the facility after he was discharged from skilled services on both 03/15/18 and 05/31/18. Resident #263 remained in the facility after she was discharged from skilled services on 01/05/18. Resident #264 was discharged home after she was discharged from skilled services on 02/13/18. b) The NONMCs and SNFABNs for Resident #77, Resident #263, and Resident #264 were reviewed on 06/19/18 at 3:25 PM. Review of the NOMNCs and SNFABNS revealed they were not issued in accordance with the guidelines. c) One NOMNC for Resident #77 documented a last covered day of 05/31/18. The resident's Power of Attorney (POA) signed the form on 05/31/18, which was the same day services ended. The second NOMNC for Resident #77 documented a last covered day of 03/15/18. There was no SNFABN issued with the NOMNC. d) The NOMNC for Resident #263 documented a last covered day of 01/05/18. The resident signed the form on 01/04/18, which was one day prior to services ending. There was no SNFABN issued with the NOMNC. e) The NOMNC for Resident #264 documented a last covered day of 02/13/18. The resident signed the form on 02/12/18, which was one day prior to services ending. f) Interviews 1) Social worker (SW) #92 was interviewed on 06/19/18 at 4:05 PM. She had worked at the facility for three months. She said the social worker was responsible for issuing the NOMNCs and getting them signed. The NOMNCs had to be issued two days prior to the resident's last covered day. She said the SNFABN was prepared by the Minimum Data Set (MDS) staff and the business office. She issued the NOMNC for Resident #77. She said she called and did a verbal notification with the resident's Power of Attorney (POA). The POA could not get to the facility for a couple days to be able to sign it. She did not complete the verbal portion of the NOMNC since the POA could sign the paper at a later date. She recognized she should have completed the verbal portion and the NOMNC would have been issued on time. She looked in the resident's chart and she did not have a progress note related to the conversation with the POA about the resident's last covered day. 2) SW #138 was interviewed on 06/19/18 at 4:24 PM. She had worked at the facility for one year. She issued the NOMNC for Resident #263. She said she could not get in touch with the resident's POA in order to get the NOMNC completed on time. She knew she did not get the NOMNC completed in time and took responsibility for it. She did not make a progress note regarding trying to get in touch with the PO[NAME] She did not remember the NOMNC for Resident #264, but acknowledged that it was completed late. She did not know why the NOMNC was not issued on time. 3) SW #138 was interviewed on 06/20/18 at 9:29 AM. Her process for when she cannot get in touch with a POA to issue a NOMNC varies based on the situation. She said sometimes they would extend coverage until the POA could be contacted and then issue the NOMNC with the two-day notice. If someone is upset that they did not get the notice on time, they try and see if services could be extended. When she completes a verbal notification, she explains why services are being discontinued for the resident. She explains their right to appeal and the appeal process. For the SNFABN form, she explains what the payment would be and goes over the different options they could choose. She said when a resident received a SNFABN, the MDS staff completed the reason for the resident being discontinued from skilled services and the business office completed the payment portion of the notice. MDS then e-mails the SW team to let them know which NOMNCs and SNFABNs needed issued. 4) MDS staff members #115 and #28 were interviewed on 06/20/18 at 9:37 AM. MDS staff member #115 said anyone who was going to remain in the facility and not return to the community received a SNFABN. The NOMNCs and SNFABNs were to be given two days prior to the resident's last covered day. MDS staff member #28 said they received training on 03/29/18 regarding SNFABNs. They did not complete SNFABNs prior to 03/29/18. 5) The Business Office Manager (BOM) was interviewed on 06/20/18 at 10:41 AM. She said the facility started doing SNFABNs after they received training on 03/29/18. She said the new regulation was not fully understood and there was a lot of confusion related the SNFABN. She completed the estimated cost portion of the SNFABN, MDS completed the reasoning for why the resident was being discharged from services, and SW issued the notice. MDS staff emailed the SW to let them know which notices needed to be provided. She said the SNFABN is given at the same time as the NOMNC. Both notices were to be given two days prior to the resident's last covered day so the resident had time to appeal if they wished to do so. 6) The NHA was interviewed on 06/20/18 at 10:50 AM. She said they had identified that they had an issue with the timeliness for NOMNCs. They knew they weren't issuing the SNFABN as they should. She said she completed an in-service with the staff in (MONTH) (YEAR) to provide education regarding the SNFABNs and NOMNCs. Since the training, the business office asks which NOMNCs need to be given in their morning meeting so she can keep track of them. She reviewed the NOMNC for Resident #77 with the last covered day of 05/31/18. She recognized that the NOMNC was not issued timely and recognized the NOMNC would have been given after their in-service. She said they needed to do a better job with auditing and come up with a better system than what they had been doing. 7) The NHA was interviewed on 06/20/18 at 12:54 PM. She had a call with their company regarding SNFABNs on 03/09/18. She completed the in-service with her staff on 03/26/18. She could not find the sign in sheet for the in-service. They discussed both NOMNCs and SNFABNs. An audit tool was a part of the training, but they had not been using it. She said all NOMNCs and SNFABNs should be given two days prior to the resident's last covered day. g) Review of the current guidelines for the Centers of Medicare and Medicaid Services instructions for the NOMNC letters of notice, revealed in pertinent part, .The NOMNC must be delivered at least two calendar days before Medicare covered services end .The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice . If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. 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. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested . Refer to https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/Instructions-for-Notice-of-Medicare-Non-Coverage-NOMNC.pdf Review of the current guidelines for the Centers for Medicare and Medicaid Services instructions for the SNFABN letters of notice, revised 1/2018, revealed in pertinent part, .Medicare requires SNFs (skilled nursing facilities) to issue the SNFABN to Original Medicare, also called fee-for-service (FFS), beneficiaries prior to providing care that Medicare usually covers . Refer to https://www.cms.gov/Medicare/Medicare-General-Information/BNI/FFS-SNFABN-.html",2020-09-01
395,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-08-11,156,D,1,0,C6IS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon family interview, staff interview, record review, and facility policy review, the facility failed to ensure that one (1) of eleven (11) (Resident #115) sampled residents family representative was informed of the resident's rights and Medicare charges, and failed to obtain a consent for treatment upon admission. Facility census: 114. Findings include: a) Resident #115 Review of the resident's clinical record revealed he was admitted to the facility on [DATE] and discharge to home on 07/03/17. The resident's admissions [DIAGNOSES REDACTED]. On 06/15/17, the physician determined the resident lacked the capacity to make health care decisions. The admission agreement was signed by the resident's representative and Social Worker (SW) #38 on 07/03/17, but there was no signed consent for treatment in the resident's clinical record. During an interview on 08/08/17 at 4:01 p.m., SW #38 stated one of her responsibilities included obtaining the resident's signature, or the signature of the resident's representative on admission paperwork, which included consent for treatment, resident rights, and Medicare charges. SW #38 stated this information was obtained on admission to the facility within one (1) to two (2) days. SW #38 confirmed she had obtained Resident #115's representative signature on 07/03/17, but was unable to provide why the consent for treatment, resident rights and Medicare charges were not obtained on admission to the facility. During an interview on 08/08/17 at 4:20 p.m., Business Office Manager (BOM) #121 stated the social worker did all the admission paperwork with residents and their families. The BOM #121 stated the corporate expectation was for all admission paperwork to be completed within 72 hours of admission. During a telephone interview on 8/9/17 at 1:21 p.m., Resident #115's representative stated she was in the facility daily from 06/27/17 until the resident's discharge to home on 07/03/17. The representative stated she was in the facility for 20 out of 24 hours each day and confirmed she had signed the admission paperwork on 07/03/17. The family representative was not provided any explanation of facility services, she was just asked to sign the papers. On 08/08/17 at 5:00 p.m., review of the facility's policy entitled Admission Policy, revised 04/19/17, found it included, Center will explain to residents on admission the special characteristics or service limitations of the center, which are also identified in the admission packet.",2020-09-01
396,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-08-11,204,D,1,0,C6IS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, staff interviews, clinical record review, and review of home health records, the facility failed to provide a safe and orderly discharge for Resident #115. The facility failed to arrange for post discharge services as ordered by the physician. This affected one (1) of four (4) sampled residents reviewed for discharged to home with home health services. Facility census: 114. Findings include: a) Resident #115 Clinical record review revealed Resident #115 was admitted to the facility on [DATE] and discharged to home on 07/03/17. On 07/03/17, the physician ordered, Discharge to home with home health, physical therapy, occupational therapy, nurse aide, and nursing. The 07/03/17 nursing discharge summary did not include any evidence of a referral to home health services. The 07/03/17 Physical Therapy (PT) discharge summary recommended, Continued home health services and 24/7 (24 hours a day, 7 days a week) supervision due to poor safety awareness. The Occupational Therapy (OT) discharge summary stated discharge destination, Private home with home health services. The resident's clinical record contained no evidence of an assessment or discharge planning done by Social Work (SW). The clinical record contained no evidence of a referral to home health services. During an interview on 08/08/17 at 1:59 p.m., PT #23 stated Resident #115 required ongoing PT services at discharge. PT #23 stated the SW made the referrals to a home health agency. During an interview on 08/08/17 at 2:17 p.m., OT #14 stated Resident #115 required ongoing OT services at discharge. OT #14 stated the SW made the referrals to a home health agency. During an interview on 08/08/17 at 4:01 p.m., SW #38 stated she had not completed an admission assessment for Resident #115 for determining his discharge needs. SW #38 stated she saw the resident only on his day of discharge. SW #38 stated she was unable to provide any evidence that a referral to home health services had been done. During an interview on 08/09/17 at 10:21 a.m., Licensed Practical Nurse (LPN) #114 stated she completed the nursing discharge summary for Resident #115. LPN #114 stated if she had been aware of a need for home health services she would have included the information in the discharge summary. Additionally, LPN #114 stated the SW set up home health services. During an interview on 08/09/17 at 10:55 a.m., Assistant Director of Nursing (ADON) #65 she had met with resident's representative on 07/03/17. The representative wanted to take Resident #115 home. ADON #65 stated she obtained the physician order [REDACTED].#38 to make the referral and the rehabilitation department to supply a walker with wheels and a wheelchair with leg rests. In a telephone interview on 08/09/17 at 1:21 p.m., the family representative confirmed ADON #65 had informed her the facility would make a referral to home health on 07/03/17. The representative stated they had left the facility at 1:00 p.m. on 07/03/17. She said she contacted the home health provider on 07/05/17 at 10:00 a.m. and was informed no home health referral had been made from the facility. The representative provided intake information and the name of the resident's community physician at that time. Review of Home Health records reveal the initial intake for services was obtained on 07/05/17. Initial physician orders [REDACTED]. The facility provided the home health agency with information via fax on 07/06/17 at 2:20 p.m.",2020-09-01
397,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-08-11,283,D,1,0,C6IS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and clinical record review, the facility failed to provide a physician discharge summary for one (1) of four (4) (Resident #115) sampled residents reviewed for discharged to home with home health services. Facility census 114. Findings include: a) Resident #115 Clinical record review revealed Resident #115 was admitted to the facility on [DATE] and discharged to home on 07/03/17. Resident #115's [DIAGNOSES REDACTED]. A 07/03/17 physician's orders [REDACTED]. The clinical record contained no physician discharge summary. During an interview, on 08/10/17 at 1:20 pm, the Administrator stated Resident #115's clinical record did not contain a physician discharge summary or recapitulation of his stay in the facility. The facility did not contact the home health agency until 2 days after the resident's discharge, but the facility still did not have a discharge summary identifying the resident's individual care and treatment.",2020-09-01
398,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-08-11,309,D,1,0,C6IS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, clinical record reviews, and facility policy review, the facility failed to provide ongoing assessment and evaluation after falls for one (1) of ten (10) (Resident #115) sampled residents to determine the need for revision of interventions to minimize future falls. Facility census: 114. Findings include: a) Resident #115 Clinical record review revealed Resident #115's [DIAGNOSES REDACTED]. The 07/03/17 Minimum Data Set 5-day assessment indicated the resident required extensive assistance of 2 persons with bed mobility, transfers, walking, and toilet use. He had experienced two (2) or more falls since admission with no injury. A 06/15/17 physician determined resident lacked long term capacity to make health care decisions. The 06/27/17 care plan for falls included interventions of, assure lighting is adequate and keep room free of clutter, check on resident frequently, encourage resident to call for assistance, hipsters at all times, low bed, toilet every two hours. A 06/29/17 at 11:46 a.m. nurse's note stated, Resident found on floor in front of nurses station on the floor. Resident denies any pain. No injuries noted. Family and MD (doctor) notified. Neuro checks and vital signs in place. Will continue to monitor resident. Review of neurological assessment flow sheet indicated neuro checks were performed on 06/29/17 at 2:30 p.m., 10:30 p.m., on 06/30/17 at 6:30 a.m., 3:30 p.m., 11:30 p.m. and 07/01/17 7:30 a.m., 3:30 p.m. The facility had no incident report for this fall. The clinical record contained no interdisciplinary team (IDT) evaluation of the resident fall. A 06/30/17 at 10:00 p.m. nursing note stated Resident #115 was witnessed sliding from his wheelchair by the nurses' station. The record contained no IDT evaluation of the resident's fall. During an interview on 08/09/17 at 9:50 a.m., Registered Nurse (RN) #130 stated she completed the 06/29/17 at 11:46 nurse's note. She confirmed she did not complete the incident report for the fall. RN #130 confirmed neurological checks should have been restarted with the new fall at every 15 minutes x 4, every 30 minutes x 6, every hour x 4, every 4 hours x 5 and every 8 hours x 6 for any unwitnessed fall or a witnessed fall with head injury. All neuro checks were documented on the neurological flowsheet. During an interview on 08/09/17 at 10:02 a.m., Licensed Practical Nurse (LPN) #30 stated when a resident fell , the resident was given a head to toe assessment for injury and neurochecks were documented on a flowsheet every 15 minutes x 4, every 30 minutes x 6, every hour x 4, every 4 hours x 5 and every 8 hours x 6 for any unwitnessed fall or any fall with head injury. LPN #30 stated the nurse documented the fall in the nurses' notes and completed an incident report. During an interview on 08/09/17 at 10:55 a.m., Assistant Director of Nursing (ADON) #65 stated after every fall the IDT team reviewed the fall in the morning meeting to determine the need for any revision to care plan interventions. The IDT documented any revisions in the clinical record. ADON #65 confirmed no IDT evaluation had been done for Resident #115's 06/29/17 or 06/30/17 falls. The facility's Fall Management policy dated 01/2015, stated, If the fall is unwitnessed or the resident hit their head during the fall initiate neurological checks per policy . Document incident, resident status, related interventions and notifications in the nurses notes . If the individual continues to fall the IDT will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions.",2020-09-01
400,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2018-11-07,880,D,1,0,Z7KV11,"> Based on observations and staff interviews, the facility failed to ensure staff utilized proper hand hygiene and wound care procedures for 1 of 3 sampled residents requiring wound care. (Resident #9 ). Facility census 113. The findings are: a.) Resident #9 On 11/05/18 at 10 am, Registered nurse ( RN) #7 was observed providing wound care on Resident #9's left heel. RN #7 entered the room to provide care and placed all dressing supplies on resident's bed clothes without any barrier to protect wound supplies. RN #7 then washed her hands with soap and water for 8 seconds and applied gloves. RN #7 pulled trash can close to resident sitting in her chair and degloved. RN #7 did not wash her hands or use hand sanitizer and regloved and removed old dressing. RN #7 did not have saline to cleanse wound. RN #7 degloved and did not wash or sanitize her hands. RN #7 left the room to obtain saline. RN #7 returned to the room, regloved her hands but did not wash her hands prior to regloving. RN #7 completed wound care, removed her gloves, bagged her trash and left the room. RN #7 washed her hands with soap and water for 5 seconds in the utility room. During an interview, on 11/5/18 at 10:15 am, RN #7 provided no for not washing her hands with soap and water after changing her gloves. RN #7 provided no explanation for the lack of barrier to place wound supplies and properly disposing of trash with gloved hands. During an interview on 11/5/18 at 10:30 am, the Administrator and Director of Nursing (DON) confirmed staff are to use hand sanitizer when changing gloves or soap and water for 20 seconds if hands are visibly soiled. The DON confirmed all wound supplies should be placed on a barrier and not on the resident's bed linens. The DON stated all staff disposing of trash should were gloves.",2020-09-01
401,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,157,D,1,1,FUQO11,"> Based on resident interview, staff interview, and record review, the facility failed to notify a resident of a room change for one (1) resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifier: #47. Facility census: 98. Findings include: a) Resident #47 An interview with Resident #47 on 08/03/17 at 10:00 a.m. revealed she had been moved to a new room without any notice. The resident stated she could not remember the exact date but the move recently took place. The resident stated she had left her room to visit another resident and upon returning the staff was moving her belongings to a room across the hall. The resident stated she became very upset because nobody told her she was switching rooms. An interview with Licensed Social Worker (LSW) #15 on 08/03/17 at 10:45 a.m. revealed a resident is supposed to be contacted before a room change occurs in order to provide options and to ease the transition for the resident. The LSW stated she did not contact Resident #47 before the room change on 07/03/17 because she was unaware the resident was switching rooms until the change was completed. An interview with the Administrator on 08/08/17 at 12:00 p.m. revealed she is the one who ordered the room change to occur on 07/03/17. The Administrator stated she let the resident's daughter know about the change and instructed the nursing staff to inform the resident. The Administrator stated she cannot be certain if the nursing staff informed the resident prior to the room change. A review of Resident #47's medical record on 08/08/17 at 12:30 p.m. revealed no indication the resident was informed of the room change prior to it occurring. A review of the resident's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/17, was conducted on 08/08/17 at 12:45 p.m. Section C-Cognitive Patterns of the assessment revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) assessment. A score of 14 indicated the resident had little to no impairment at the time of the assessment.",2020-09-01
402,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,164,D,1,1,FUQO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to offer privacy during a medical treatment and ensure medication packets with pharmacy labels were disposed of in a manner that protected personal, medical, and health information. Personal identifiers including a resident's name, physician, diagnosis, and medication were listed on the pharmacy labels. These were random observations. Resident identifiers: #74, #89, and #108. Facility census: 98. Findings include: a) Medication Packets A random observation of the West Hall on 08/01/17 at 12:20 p.m. revealed three (3) visible empty medication cards/packets in the trash can of the medication cart. The following medication cards contained the resident's full name, physician, diagnosis, and medication orders [REDACTED] -Resident #89-Entacapone 200 mg-1 tablet four times a day for [MEDICAL CONDITION] -Resident #89-[MEDICATION NAME]/[MEDICATION NAME] 25 mg-250 mg-1 Tablet by mouth four times a day for [MEDICAL CONDITION] -Resident #108-[MEDICATION NAME]-[MEDICATION NAME] 5 mg-325 mg An interview with the Director of Nursing (DON) on 08/01/17 at 12:25 p.m. revealed the nursing staff is supposed to take a black marker and cover all resident information before discarding the medication packets. b) Blood Draw A random observation of the West Hall on 08/07/17 at 9:00 a.m. revealed Resident #74 having his blood drawn by Phlebotomist #222 in the hall beside the West Wing Nurses Station. An interview with the Director of Nursing (DON) on 08/07/17 at 9:05 a.m. revealed blood draws should be done in the resident's room or a private location.",2020-09-01
403,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,246,D,1,1,FUQO11,"> Based on observation, staff interview, and record review, the facility failed to provide services with reasonable accommodation. Two resident's call lights were out of reach. This practice affected two (2) of forty (40) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifiers: #101 and #138. Facility census: 98. Findings include: a) Resident #101 An observation of Resident #101 during Stage 1 of the QIS on 08/02/17 at 8:45 a.m. revealed the resident's call light was on the floor beside the bed out of reach of the resident. An interview with Certified Nurse Aide (CNA) #46 on 08/02/17 at 8:55 a.m. revealed Resident #101's call light should not be on the floor and should be within reach of the resident at all times. A review of Resident #101's Care Plan was conducted on 08/03/17 at 8:00 a.m. The Care Plan dated 05/16/17 with a focus of High Risk for Falls included the intervention Ensure call light is within reach and encourage the resident to use it for assistance as needed. Provide prompt response to all requests for assistance to be implemented by Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. b) Resident #138 An observation of Resident #138 during Stage 1 of the QIS on 08/02/17 at 8:50 a.m. revealed the resident's call light was attached to the bed while the resident was up in his chair. An interview with Certified Nurse Aide (CNA) #46 on 08/02/17 at 8:55 a.m. revealed Resident #138's call light should be within reach of the resident at all times. A review of Resident #138's Care Plan was conducted on 08/03/17 at 8:15 a.m. The Care Plan dated 07/06/17 with a focus of Risk for Falls included the intervention Ensure call light is within reach and encourage the resident to use it for assistance as needed to be implemented by Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses.",2020-09-01
404,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,272,D,1,1,FUQO11,"> Based on record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of twenty (20) residents. A community acquired pressure ulcer was not accurately assessed as a pressure ulcer risk on an admission/5 day minimum data set (MDS) assessment. The failed practice affected one (1) resident reviewed. Resident identifier: #116. Facility census: 98. Findings include: a) Resident #116 A review of the medical record for Resident #116 was conducted at 4:00 p.m. 08/01/17. His admission/5 day MDS with an assessment reference date (ARD) of 02/16/17 revealed he had a pressure ulcer upon admission to the facility. Specifically, Section M skin conditions question M0210 of the MDS, Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? was answered yes by the facility. Also, questions MO300 G1 and G2 Number of unstageable pressure ulcers due to suspected deep tissue injury in evolution (SDTI) and Number of these unstageable pressure ulcers that were present upon admission or reentry were both answered 1 by the facility. Section M0100 determination of pressure ulcer risk, however, was contradictory to the other responses given. Question M0100 a, Resident has a stage 1 or greater, a scar over boney prominence, or a non-removable dressing/device was answered no in spite of the presence of the one (1) SDTI identified in the assessment. This matter was discussed with reimbursement assessment coordinator #58 at 10:15 a.m. 08/03/17 and she stated she would have answered the question M0100 a Resident has a stage 1 or greater, a scar over a boney prominence or a non-removable dressing/device as yes, because a SDTI is pressure and worse than a stage 1 (pressure ulcer). She provided evidence the MDS was corrected prior to survey completion.",2020-09-01
405,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,279,D,1,1,FUQO11,"> Based on record review and staff interview, the facility failed to develop a comprehensive individualized care plan including measurable goals and interventions for a resident who received hospice services. The failed practice affected one (1) of twenty (20) residents reviewed. Resident identifier: #80. Facility census: 98. Findings include: a) Resident #80 During a record review conducted at 11:00 a.m. 08/08/17 for Resident #80, it was established the resident was ordered and received hospice services since 06/02/17. Examination of the care plan found a focus problem of Resident is a hospice Resident last revised 07/29/17. There were no goals or interventions associated with the identified focus in the care plan. During an interview with reimbursement assessment coordinator #58 at 11:42 a.m. 08/08/17, she was asked if the facility formulated care plans when a resident received hospice to describe collaboration between the facility and hospice. She replied Yes, and how to reach them (hospice), and what days the aides come. This matter was discussed with the director of nursing (DON) at 11:30 a.m. 08/08/17. While she was able to locate areas in the care plan where hospice was mentioned, there was no detailed plan for coordination of care between the facility and hospice as well as a process of information exchange between both entities to assure the needs of Resident #80 were met.",2020-09-01
406,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,280,D,1,1,FUQO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to revise a Care Plan for a resident with behaviors. This practice affected one (1) of twenty (20) residents reviewed. Resident identifier: #154. Facility census: 98. Findings include: a) Resident #154 An observation on 08/02/17 at 10:30 a.m. revealed Resident #154 was receiving one on one care by Nurse Aide (NA) #83. The resident was yelling and attempting to get out of bed without assistance. The resident was cursing at the N[NAME] An interview with NA #83 on 08/02/17 at 10:35 a.m. revealed the resident was started on one to one care due to increased behaviors. The NA stated the resident was attempting to get out of his bed and chair unassisted and cursing at the staff more. A review of the Progress Notes on 08/07/17 at 10:45 a.m. revealed the resident was having increased attempts to ambulate unassisted, increasing hostile verbalizations towards the staff, and was receiving one to one care on 07/31/17, 08/01/17, 08/02/17, 08/03/17, 08/04/17, and 08/05/17. A review of the physician's orders [REDACTED]. A review of the Care Plan, dated 07/26/17, was reviewed on 08/07/17 at 11:00 a.m. The Care Plan did not not include the one to one care interventions or the increased behaviors the resident was exhibiting since 07/31/17. An interview with the Director of Nursing (DON) on 08/08/17 at 10:00 a.m. revealed the Care Plan had not been updated for the resident's increased behaviors or the one to one care interventions.",2020-09-01
407,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,282,D,1,1,FUQO11,"> Based on observation, record review, and staff interview, the facility failed to implement care plan interventions for residents at risk for falls. Resident #101 and #138 did not have their call lights within reach as directed on their care plans. This practice affected two (2) of forty (40) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifiers: #101 and #138. Facility census: 98. Findings include: a) Resident #101 An observation of Resident #101 during Stage 1 of the QIS on 08/02/17 at 8:45 a.m. revealed the resident's call light was on the floor beside the bed out of reach of the resident. An interview with Nurse Aide (NA) #46 on 08/02/17 at 8:55 a.m. revealed Resident #101's call light should not be on the floor and should be within reach of the resident at all times. A review of Resident #101's Care Plan was conducted on 08/03/17 at 8:00 a.m. The Care Plan dated 05/16/17 with a focus of High Risk for Falls included the intervention Ensure call light is within reach and encourage the resident to use it for assistance as needed. Provide prompt response to all requests for assistance to be implemented by Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. b) Resident #138 An observation of Resident #138 during Stage 1 of the QIS on 08/02/17 at 8:50 a.m. revealed the resident's call light was attached to the bed while the resident was up in his chair. An interview with Nurse Aide (NA) #46 on 08/02/17 at 8:55 a.m. revealed Resident #138's call light should be within reach of the resident at all times. A review of Resident #138's Care Plan was conducted on 08/03/17 at 8:15 a.m. The Care Plan dated 07/06/17 with a focus of Risk for Falls included the intervention Ensure call light is within reach and encourage the resident to use it for assistance as needed to be implemented by Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses.",2020-09-01
411,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,514,D,1,1,FUQO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to maintain an accurate and complete medical record The failed practice affected one (1) of twenty (20) residents. A physician's orders [REDACTED]. Resident identifier: #80. Facility census: 98. Findings include: a) Resident #80 During a record review performed at 11:00 a.m. 08/08/17 for Resident #80, it was established the resident was ordered hospice services on 06/02/17. The monthly physician's orders [REDACTED].#28 was interviewed at 11:18 a.m. 08/08/17. She said that in (MONTH) (YEAR) the pharmacy had taken over the task of monthly changeover (preparing physician's orders [REDACTED]. She said the order must have been dropped off the monthly orders when the pharmacy took over. Review of the hospice tab in the medical record found Resident #80 was still receiving the services as intended.",2020-09-01
413,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,578,D,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete the Physician order [REDACTED]. The POST forms were found to be incomplete for Resident #36 and #14. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #36 and #14. Facility census: 99. Findings included: a) Resident #36 A review of the medical record on 08/22/18 revealed the POST form for Resident #36 did not include the physician's printed name or contact phone number. In an interview with the nursing home administrator (NHA) on 08/22/18 at 3:30 PM, verified the POST form did not include the physician's printed name or contact phone number. b) Resident #14 Review of the medical record on 08/22/14 revealed Resident #14 lacks capacity and has a designated health care surrogate (HCS). Resident #14's POST form dated 05/07/18, lacks a signature under section D for the HCS. In addition, Section [NAME] contains staff signatures instead of the HCS contact information. The Director of Nursing (DON) reviewed Resident #14's POST form at 3:20 PM on 08/22/18 and confirmed the above errors.",2020-09-01
417,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,690,D,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview and staff interview, the facility failed to ensure that services are provided to maintain bladder continence to the extent possible for 1 of 4 residents reviewed for toileting. The facility failed to provide a toileting program as ordered by the physician and addressed in the care plan for Resident #92. Facility census: 99. Findings included: a) Resident #92 An interview with Resident #92 on 08/21/18, at 8:45 AM, revealed, it takes a long time to answer the light. They (staff) say they will come back and they don't which sometimes being incontinent. Resident #92 stated that staff do not ask her to toilet but wait until she asks to go to the bathroom. A review of the medical record for Resident #92 revealed a physician's orders [REDACTED]. A review of the comprehensive care plan for Resident #92 revealed an intervention for toileting program every 2 hour and PRN. An interview with RN#109 on 08/22/18, at 03:02 PM, revealed the care plan was not developed to outline steps of the toileting program and the program was not being implemented every two hours because of a software issue. It was further stated by RN#109, that the every two hour toileting does not pop up on the Certified Nursing Assistant's (CNA's) Ipad and verified the every two hour toileting intervention was not being implemented. When asked how the program is being implemented, RN#109 stated we're not.''",2020-09-01
418,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,744,D,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to develop and implement a care plan to address the individualized needs of a resident diagnosed with [REDACTED].#82's expressions of distress/[MEDICAL CONDITION] ([NAME]D) thus preventing her from attaining or maintaining her highest practicable mental and psychosocial well-being. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #82. Facility census: 99. Findings included: a) Resident #82 Review of the medical record on 08/22/18, revealed Resident #82 was admitted to the facility in (MONTH) (YEAR) with a [DIAGNOSES REDACTED]. Her annual minimum data set assessment with an assessment reference date of 08/09/18 includes the following Diagnoses: [REDACTED]. Resident #82 experienced two or more falls without injury since the previous assessment and is receiving the following daily meds: antipsychotic, antianxiety and antidepressant. Random observations on 08/20/18 and 08/21/18 found Resident #82 cleaning her room, making her bed and repeatedly folding items as she verbalized complaints about the cleaning practices of the staff. The care plan with a revision date of 08/21/18 lists the following focus: --(Name) has a behavior problem r/t Compulsiveness. The goal states: (Name) will have fewer episodes of deliberately getting self on floor to clean before bed by review date. Interventions note the following (typed as written): Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him/her as passing by. Establish limits for inappropriate behaviors resident has [NAME]D behaviors about cleaning. she often gets on the floor deliberately to clean. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternative location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential cause. --(Name) is at risk for falls r/t impaired mobility, poor safety awareness, impaired cognition, use of medications with fall related side effects, history of falls. The goal is: (Name) will not sustain serious injury through the review date. Interventions: Encourage participation in activities that promote exercise, physical activity for strengthening and improving mobility. Ensure call light is within reach and encourage resident to use it for assistance as needed. 2 non-skid strips in front of residents toilet to prevent sliding. Ensure resident is wearing appropriate footwear when transferring or mobilizing in w/c (wheelchair). Provide a safe environment with: code alert to w/c at all times, non-skid strips at bedside bed, raised mattress, and bed/chair alarms. After reviewing Resident #82's care plan on 08/22/18 at 10:30 AM, the Director of Nursing agreed the goals are non-measurable and the care plan lacks person-centered non-pharmacological interventions to address Resident #82's compulsive actions.",2020-09-01
419,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,761,D,0,1,7DWR11,"Based on observation and staff interview, the facility failed to date medications when opened and put into use for one (1) of two (2) medication carts observed. Insulin and Sodium Chloride tablets were not dated when opened. Facility census: 99. The findings include: During observation of the medication cart, on the West wing of the facility, on 08/23/18, at 01:25 PM, two medications were found not be dated when opened and put into use. 1) A bottle of Sodium Chloride tablets was opened but there was no date of when the medication was opened and put into use. An interview with LPN#112, on 08/23/18, at 01:25 PM, confirmed there was no date on the bottle and the bottle was opened and in use. 2) An injectable insulin pen for Resident #85 was observed to have no date when opened . An interview with LPN#112, on 08/23/18, at 01:25 PM, verified the insulin pen had not been dated when put into use. LPN#112 further stated it was opened on 8/15 and proceeded to date the insulin pen at this time. An interview with LPN#31, on 08/23/18, at 2:40 PM, revealed that it is the requirement that when a new medication is opened, it has to be labeled and dated when it is opened. When I train someone on the cart, that is how I train them.",2020-09-01
421,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,842,D,0,1,7DWR11,"Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record for each resident. Resident #82's influenza consent is incomplete and lacks a date consent was obtained. This was true for one (1) of five (5) residents reviewed for influenza vaccines. Resident identifier: #82. Facility census: 99. Findings included: a) Resident #82 Review of the medical record on 08/22/18 at 9:30 AM, revealed Resident #82 received the influenza vaccine on 10/19/17. An undated influenza informed consent form identifies a phone consent from the Resident's daughter. The influenza consent form was reviewed with the Director of Nursing (DON) on 08/22/18 at 10:30 AM. The DON acknowledged the influenza consent form lacked the date the consent was obtained form Resident #82's daughter.",2020-09-01
424,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2018-08-24,921,D,0,1,7DWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident's environment was safe for one (1) of twenty-nine (29) rooms observed on the East unit. The baseboard heater in room [ROOM NUMBER] East was rusty from water damage. Facility census: 99. Findings included: a) room [ROOM NUMBER] East On 08/23/18, at , 08:23 AM an area of rust was observed on the baseboard heater in room [ROOM NUMBER] East which is occupied by four residents who utilize a wheelchair for mobility. The baseboard heater is located near the resident's sink with the area of rust being at the closest end to the sink. There was also damage to the front of the baseboard heater unit. The cover of the baseboard heater was bowed inward. An interview with Maintenance Supervisor #16, on 08/23/18, at 08:40 AM, revealed the rust was caused from water from the sink spilling onto the heating unit, and the damage to the front of the baseboard heater was caused by wheelchairs scraping the unit. Further investigation revealed the baseboard heater in room [ROOM NUMBER] East did not have a ground fault circuit interrupter. Further interview with Maintenance Supervisor #16, on 08/23/18, at 08:40 AM, revealed that the facility would update the breaker before fall. Further interview with Maintenance Supervisor #16, on 08/23/18, at 09:20 AM, revealed they have decided to remove the unit from use.",2020-09-01
426,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,578,D,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to properly record a resident's advanced directives in the medical record regarding specifying the length of a trial period of intravenous fluids (IVFs). This was true for one (1) of one (1) sampled residents reviewed for the care area of advanced directives. This practice had the potential to affect a limited number of residents. Resident identifier: #41. Facility census: 97. Findings included: a) Resident #41 A review of Resident (R#41)'s medical record, on 09/09/19 at 4:11 PM, revealed the Physician order [REDACTED].#41 POST indicates the resident is a 'Do Not Resuscitate (DNR)'. Review of the R#41's POST revealed the trial period for IV (Intravenous) fluids was not designated in section C. Section C read, IV fluids for trial period no longer than ___. Section C was left blank and did not instruct for how long the trial period should last. On 09/11/19 at 10:51 AM an interview with the Director of Nursing (DON) revealed the DON confirmed R#41's POST should have been filled out in its entirety. The DON agreed Section C of R#41's POST should have designated how long the trial period for IV fluids should last.",2020-09-01
428,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,583,D,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure personal privacy during incontinence care. This was true for one (1) of one (1) sampled residents reviewed for the care area of incontinence. This practice had the potential to affect a limited number of residents. Resident identifier: #81. Facility census: 97. Findings included: Review of Resident (R#81)'s recent thirty (30) day minimum data set (MDS) with an assessment reference date (ARD) 08/24/19 revealed the resident's Brief Interview for Mental Status (BIMS) with a score of three (03) indicating resident is cognitively severely impaired. The resident is dependent for bathing and needs extensive assistance with all other activities of daily living. Resident #81 is frequently incontinent of bladder and bowel. Some pertinent [DIAGNOSES REDACTED]. Observations of Nurse Aid (NA#118) providing incontinence care for R#81 on 09/12/19 at 08:59 AM, revealed NA#118 failed to maintain R#81 personal privacy. NA#118 forgot to place a plastic bag to dispose of used soiled supplies within the area the NA was working. When NA#118 went to get the plastic bag she opened the privacy curtain and forgot to close the curtain back. The resident was fully exposed if anyone should have open the resident's room door while she was being cleaned and her brief was being changed. NA#118 confirmed she compromised the resident's privacy while providing incontinence care when she forgot to pull the privacy curtain back to block the view from the doorway.",2020-09-01
432,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,689,D,0,1,EQG311,"Based on observation, staff interviews and resident interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible. Resident #3 was observed having a cigarette and lighter on his person. This practice was true for one (1) of two (2) residents who smoked. Resident identifier: #3. Facility census: 97. Findings included: a) Resident #3 Observed Resident #3 in the designated resident smoking area, on 09/10/19 at 11:32 AM, remove a cigarette and lighter from his person and begin smoking. Resident #3 put the lighter in his pocket. A review of the facility smoking policy and procedure during the survey found under Procedure 8. Facility staff will: a. Secure smoking materials in a locked area when not in use by the resident/patient for both independent and supervised smokers. 9. a. Smoking materials will be maintained by the facility staff and provided to the resident/patient on request. c. Smoking materials will be returned to the facility staff upon completion of smoking. An interview with Licensed Practical Nurse (LPN) #32 on 09/ 12/19 at 8:05 AM found that no smoking materials were locked up in the medication room for Resident #3. An interview conducted on 09/12/19 at 8:07 AM with Resident #3 found this resident stated that he had no cigarettes or lighter in his room. On 09/12 at 11:58 AM the Nursing Home Administrator (NHA) stated that she had interviewed Resident #3 and he had cigarettes and a lighter in his room. The NHA stated that the cigarettes and lighter were removed from Resident #3 room and reeducated the resident as to the policy and procedure regarding smoking materials.",2020-09-01
433,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,692,D,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review the facility failed to fully address the nutritional status of its residents when the facility's clinical team and Registered Dietitian failed to address weight change timely. This deficient practice was found for 2 out of 5 residents reviewed for the care area of nutrition. Resident identifiers: #60 and #39. Facility census: 97. Findings included: a) Resident #60 On 09/10/19 at 12:21 PM Resident #60 was observed eating lunch. Resident #60 appeared thin and frail during the observation. A review of Resident #60's weight records during the survey found that Resident #60 had experienced a significant weight loss of 18 percent of his body weight in three (3) months. On 05/08/19 Resident #60 weighed 156.2# and on 08/09/19 he weighed 128.4 pounds. During the survey, a review of the facility's weight policy, last reviewed on 05/29/19, found that, Weight loss concerns will be discussed at the weekly clinical meetings. However, no weekly clinical meeting notes were found for Resident #60. During the survey, all documentation regarding Resident #60's nutritional status was requested from administration. On 09/11/19 at 11:52 AM Regional Director of Clinical Operations (RDCO) #64 stated that there was no documentation and that the facility's Registered Dietitian (RD) had not addressed Resident #60's nutritional status since his weight change. b) Resident #39 On 09/10/19 at 12:18 PM Resident #39 was observed eating lunch. She appeared thin and frail upon observation. A review of Resident #39's weight records during the survey found that she had lost 29.8 pounds since her admission to the facility on [DATE]. Per weight records, on 06/14/19 Resident #39 weighed 100 pounds and on 08/09/19 she weighed 70.2 pounds. During the survey, a review of the facility's weight policy, last reviewed on 05/29/19, found that, Weight loss concerns will be discussed at the weekly clinical meetings. However, no weekly clinical meeting notes were found for Resident #39. During the survey, all documentation regarding Resident #39's nutritional status was requested from administration. On 09/11/19 at 11:52 AM Regional Director of Clinical Operations (RDCO) #64 stated that there was no documentation and that the facility's Registered Dietitian (RD) had not addressed Resident #39's nutritional status since her weight change.",2020-09-01
434,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,756,D,0,1,EQG311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document the clinical rationale for not following pharmacy recommendations to discontinue a medication determined to be contraindicated for Resident #82. This deficient practice affected one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #82. Facility census: 97. Findings included: a) Resident #82 Resident #82 was selected by the Long-Term Care Survey Process (LTCSP) system for a review for unnecessary medications. A review of Resident #82's physician's orders [REDACTED].#82 received [MEDICAL TREATMENT] treatments three (3) times weekly. On 09/11/19 at 8:10 AM Resident #82's pharmacy consultation reports from (MONTH) 2019 were received and reviewed. Per the reports, the facility's Pharmacist recommended on 04/24/19 that the facility's Attending Physician discontinue Resident #82's Duloxetine HCl ([MEDICATION NAME]), a medication used to treat depression and anxiety, as Duloxetine HCl was contraindicated in residents receiving [MEDICAL TREATMENT]. The Attending Physician signed the report and provided written agreement with the recommendation on 05/02/19. Additionally, the Pharmacist's report stated, If this therapy is to continue, it is recommended that a) The prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for adverse effects. A review of Resident #82's Medication Administration Record [REDACTED]. On 09/11/19 at 1:09 PM the facility's Director of Nursing (DoN) provided information regarding Resident #82's Duloxetine HCl indicating that the medication had been discontinued on 05/02/19 and restarted on 05/09/19 because the discontinuation failed. Documentation regarding the failure was requested from the DoN. On 09/11/19 at 1:27 PM Regional Director of Clinical Operations (RDCO) #64 stated that Resident #82 requested to restart the Duloxetine HCl. Documentation regarding the risks versus the benefits for restarting the medication was requested from RDCO #64 at that time. During a phone interview on 09/11/19 at 1:40 PM in the presence of RDCO #64, the Attending Physician acknowledged that he did not document the clinical rationale for restarting the Duloxetine HCl in Resident #82's medical record. No further information was provided prior to exit.",2020-09-01
435,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2019-09-12,791,D,0,1,EQG311,"Based on medical record review, observation, resident interview and staff interview, the facility failed to assist Resident #46 to obtain needed dental appointments for extraction of two (2) decayed and broken teeth. This was a random opportunity for discovery. Resident identifier: #46. Facility census: 79. Findings include: a) Resident #46 Observation and interview, on 09/09/19 at 4:15 pm, found the residents had few of her own teeth, which was decayed and broken .Resident #46 also voiced the dentist had seen her in the facility and had recommended to have two (2) of her teeth extracted. She could not recall the date of the exam but the staff had told her she would have to pay for it before they would make the appointment and she had told them she could not afford to have the teeth extracted. Review of Resident #46's medical records found on 02//22/19 the dentist had recommended she have two (2) teeth (#3 and #19 teeth) extracted. Tooth #19 was decayed and #3 tooth was broken at the gum level per the dentist consultation on 02/22/19. Nurse's notes for Resident #46 found a note written on 04/09/19 at 2:40 pm by Employee #132. registered nurse (RN) which read: (Dentist's name) made recommendations during last visit to have some teeth extracted. Spoke with the Business Office Manager (BOM) and since the resident has Medicaid insurance the procedure will have to be paid up front. Resident states She does not have the means to do this at this time. On 09/12/19 at 11:45 am, an interview with the Director of Nursing (DON), confirmed the facility had not assisted the resident in receiving needed dental care. She confirmed an appointment would be made as soon as possible.",2020-09-01
440,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,561,D,0,1,JURJ11,"Based on interview and medical record review, the facility failed to ensure one (1) of 30 residents had been able to make choices about aspects of their life that were significant to them. Resident #52 was not offered a choice regarding why type of eggs he was served. He wanted fried or boiled eggs. Resident identifier: #52. Facility census: 79. Findings include: a) Resident #52 During an interview, on 01/08/18 at 10:09 a.m., Resident #52 said he liked fried and boiled eggs but did not get these. He said he had mentioned this to Assistant Account Manager (AAM) #70. On 01/09/18 at 10:35 a.m. Account Manager (AM) #66 was asked what type of eggs the facility served. He said they used liquid eggs but no fried or boiled eggs. AM #66 said he could start getting eggs to fry or boil. At 10:40 a.m., on 01/09/18, AAM#70 was asked if the resident had ever mentioned anything to her about wanting fried or boiled eggs. She said he had asked her for those type of eggs but she told him they were not on the menu.",2020-09-01
442,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,641,D,0,1,JURJ11,"Based on medical record review and staff interview, the facility failed to ensure the accuracy of minimum data set assessments (MDS). The admission MDS and a quarterly MDS incorrectly assessed the status of Resident #10's pressure ulcers. This was evident for one (1) of thirty (30) sampled residents. Resident identifier: #10. Facility census: 79. Findings include: a) Resident #10 The medical record was reviewed on 01/09/18. Section M of the admission MDS, with assessment reference date (ARD) 08/10/17, assessed this resident had no stage 1 or greater pressure ulcers. It assessed that she had no unhealed pressure ulcers. The weekly skin assessment, dated 08/10/17, and completed by former registered nurse Employee #200, was reviewed. It assessed this resident had a pressure sore on the right heel, and wore Rooke boots while in bed. An interview was conducted with the assistant director of nursing (ADON) on 01/09/18, ending at 3:15 p.m. She said the admission MDS, with ARD 08/10/17, incorrectly assessed that the resident had no pressure ulcer. She acknowledged that nursing's 08/10/17 weekly skin review stated that the resident had a pressure sore on the right heel. Based on her review of nurse progress notes and nursing assessments, she said this 08/10/17 weekly skin review was the first mention by nursing of the right heel pressure ulcer, and it should have been captured in the admisison MDS. Review of the quarterly minimum data set (MDS), with assessment reference date (ARD) of 10/30/17, found that it assessed a Stage 2 pressure ulcer that was not present upon admission. It assessed the onset date of the oldest Stage 2 pressure ulcer as 10/17/17. This was in addition to an unstageable pressure ulcer covered by slough and/or eschar, which was also not present upon admission. A situation, background, assessment, request (SBAR) communication form dated 10/11/17, reported a change in condition as resident has a pressure ulcer starting on her coccyx. The reporting nurse registered nurse #200) stated she thought the resident is sitting on her buttocks too long during the day. An interview was conducted with the assistant director of nursing (ADON) on 01/09/18, ending at 3:15 p.m. She said the quarterly MDS, with ARD 10/30/17, was inaccurate in section M when it assessed an unhealed Stage 2 pressure ulcer with onset date of 10/17/17. The ADON said registered nurse Employee #200 completed the 10/11/17 SBAR, and asked the ADON to look at the resident's coccyx. The ADON said she completed an assessment of the resident's coccyx, and found it was only slightly reddened and had no opened area. The ADON said she forgot to document her findings that there was no Stage 2 pressure ulcer, and no one informed the MDS nurse of the correction.",2020-09-01
443,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,657,D,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise care plans for one (1) of thirty (30) residents. Resident #52's care plan had not been revised to show his current level of interest for activities. Resident #66's care plan for a tube feeding had not been revised. Resident identifiers: #52, #66. Facility census: 79. Findings include: a) Resident #52 On 01/08/18 at 9:36 AM during an interview, Resident #52 said he did not care for most of the group activities. He indicated he did not want to get up in his wheelchair, and preferred to remain in bed. He said he had been at a different nursing home where they gave out pictures to look for certain items as well as word search puzzles to complete. He said he liked these type of puzzles and would enjoy doing them. He said the facility had not provided any for him in a while. He said he primarily watched television and he had a cell phone. On 01/09/18 at 4:00 PM Activity Manager (AM) #7 said Resident #52 was more active in the summer/fall when the weather was nice. AM #7 said the resident would move around the facility in his wheelchair and sit outside during warm weather. AM #7 said it had been several weeks since the resident had been up out of bed and in his wheelchair. She said for the past several weeks he had remained in bed. A progress note, by AM #7, dated 01/09/19 at 5:15 PM stated, Went to visit (Resident #52) about independent activities. Took him word searches and picture puzzles as he requested. During an interview, on 01/10/18 at 10:00 AM, Resident #52 said he had completed all of his word search and picture puzzles and would enjoy doing more. A review of the resident's care plan for activities revealed the following interventions: --Please assist me with my phone when I need help. --Provide with activities calendar. --The resident's preferred activities are: being outside when the weather is nice, watching TV (television) and talking to others. --Prefer to spend most of my time resting in bed watching TV and talking on the phone, Encourage me to spend more time oob (out of bed) and out of my room throughout each day. There was no indication the care plan for activities had been revised to include possible recreational stimulating activities since the resident was no longer wanting to get out of bed. No further interventions beyond watching TV and talking with others had been initiated. AM #7 confirmed the resident had few visitors. b) Resident #66 An observation, on 01/10/18 at 7:15 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident had slid down in the bed with their head flat. An observation, on 01/10/18 at 7:45 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident had slid down in bed with their head flat. Upon closer observation, it was discovered the resident was receiving an enteral feeding via a pump. An immediate interview, on 01/10/18 at 7:45 AM, with Licensed Practical Nurse (LPN) #3, revealed the enteral feeding is started daily at 6:00 AM. The LPN stated the resident's head should be elevated during his feeding. The LPN stated she would seek assistance from another staff member to help pull the resident up in bed. The LPN stated the resident slides down in bed all the time. The LPN stated she had not communicated the resident's frequent sliding down in bed to her supervisor. The LPN stated there were no current interventions in place to prevent the resident from sliding down. A record review, on 01/10/18 at 7:50 AM, revealed the resident was initially admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Further record review, on 01/10/18 at 7:55 AM, revealed the resident had a physicians enteral feed order for Glucerna 1.5 at 94 ml (milliliters) q (every) hr (hour) times 16 hours via pump with a start time daily of 6:00 AM. The order was dated 01/05/18. A review of the Care Plan was conducted on 01/10/18 at 8:20 AM. The Care Plan, with a revision date of 12/19/17, contained the focus of tube feeding and care needs with the intervention of the head of the bed being elevated 30 degrees at all times. The care plan did not include the resident sliding down in the bed when the head is elevated. An interview, on 01/10/18 at 8:45 AM, with Nurse Aide (NA) #57, revealed the resident slides down a lot and has to be pulled up at least twice a shift if not more. The NA stated she has not reported this behavior to anyone. The NA stated everyone knows he does it. An interview with the Director of Nursing (DON), on 01/10/18 at 8:55 AM, revealed she had no idea the resident slid down in bed especially during enteral feedings. The DON stated any staff member who knew the resident was sliding down in bed should have reported it immediately. The DON stated the resident's behavior should have been added to the Care Plan and interventions should have been put into place to ensure the resident remained elevated.",2020-09-01
447,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,745,D,0,1,JURJ11,"Based on medical record review and staff interview, the facility failed to ensure one (1) of thirty (30) residents received medically related social services necessary to maintain the highest practicable psyschosocial well-being. Resident #24 had three (3) pair of pants all of which were in the laundry and the resident had to go out to a medical appointment in shorts during winter weather. Resident identifier: #24. Facility census: 79. Facility census: a) Resident #24 On 01/08/18 at 1:17 PM, said it was hard to find pants to fit him because of his size. He said he went out to a medical appointment earlier in the day wearing only shorts. The area was experiencing cold, winter weather conditions on 01/08/18. Resident #24 said he had three (3) pair on pants but they were all in the laundry at the time of his appointment. Resident #24 said he had a hard time finding pants due to his size. On 01/09/18 at 4:18 PM, the Administrator #63 said she did not know the resident had went out to an appointment in shorts nor was she aware the resident only had three (3) pair of pants. At 4:25 PM on 01/09/18, Business Office Director ##51 said the resident had expressed a desire to get his personal spending allowance transferred to the facility. This money currently goes to the resident's family. The resident's family does not frequently visit or bring him clothing. The resident had no money at the facility to buy personal clothing. On 01/09/18 at 4:30 PM, Account Manager #77 said she knew the resident needed pants but due to his size it was hard to find anything that had been donated to the facility that he could wear. She also said she had tried a local establishment that had doanted clothing but had not been able to find any pants for the resident. On 01/09/18 at 4:45 PM, Administrator #63 provided information showing she had ordered the resident two (2) pair of fleece open-bottom pants.",2020-09-01
448,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,756,D,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the pharmacist identified and reported irregularities to the attending physician and director of nursing, and those reports would be acted upon. A resident, whose [DIAGNOSES REDACTED]. On three (3) occasions in (MONTH) (YEAR) and (MONTH) (YEAR), the resident went greater than three (3) days with no bowel movement and no nursing interventions to treat the lack of bowel movements. The pharmacist failed to identify and report this irregularity to the physician and director of nursing. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of thirty (30) sampled residents. Resident identifier: #6. Facility census: 79. Findings include: a) Resident #6 The medical record was reviewed on 01/09/18. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The physician also ordered [MEDICATION NAME] 5-325 mg. every twelve (12) hours as needed (prn) for pain. [MEDICATION NAME] is an opiod pain medication. Opiods block pain signals in the brain and in other parts of the central nervous system by attaching to something called mu-receptors. When opiods attach to mu-receptors in the bowel, they can cause opiod induced constipation (OIC). OIC is on of the most common side effects of opiod use, and can last for the length of treatment. Further review of physician's orders [REDACTED]. If the laxative was ineffective, the physician ordered one (1) application of Fleet enema rectally. Review of the resident's bowel movement records from 12/01/17 through 01/09/18 revealed three (3) instances where the resident went greater than three (3) days without a bowel movement, as follows: --She had a bowel movement on 12/01/17, and no evidence of another until six (6) days later on 12/07/17. --She had a bowel movement on 12/14/17, and no evidence of another until six (6) days later on 12/20/17. --She had a bowel movement on 12/30/17, and no evidence of another until five (5) days later on 01/04/18. Review of the medication administration records (MAR) for (MONTH) (YEAR) and (MONTH) (YEAR) found no evidence that Milk of Magnesia or Fleet enema was administered. Review of nurse progress notes for the time frames of 12/01/17 through 12/07/17, and 12/14/17 through 12/20/17, and 12/30/17 through 01/04/18 revealed no evidence that she had been offered a laxative, or that the lack of bowel movements for greater than three (3) days had occurred, or of any abdominal assessments and/or bowel sound assessments by nursing. Review of the care plan revealed interventions to observe for side effects of pain medication, and observe for constipation. Review of the monthly consultant pharmacist review summaries found that the pharmacist identified no irregularities in (MONTH) (YEAR) and (MONTH) (YEAR). During interview with the assistant director of nursing (ADON) on 01/09/18 at 2:00 p.m., she agreed the pharmacist initialed the Clinical Pharmacist Medication Regimen Review Summary in (MONTH) (YEAR) and (MONTH) (YEAR) that there were no pharmacy recommendations. The ADON provided copies of all the most recent consultant pharmacist recommendations to the physician, and the physician's responses. Pharmacist recommendations most recently occurred in April, August, October, and (MONTH) (YEAR). There were none for (MONTH) (YEAR) or (MONTH) (YEAR). Interviews were completed with licensed nurse #56 and registered nurse #47 on 01/10/18 at 9:24 AM. They said she is always incontinent. An interview was also completed with licensed nurse #38 on 01/10/18 at 9:24 AM. She reviewed the current MAR, then agreed the resident has no daily bowel medicine ordered. She agreed she has a prn order for Milk of Magnesia if she goes three (3) days without a bowel movement, and a Fleet enema if the Milk of Magnesia was unsuccessful. She said the resident has not received any Milk of Magnesia or Fleet enema this month, and there have been no refusals on the MAR. An interview was completed with the administrator and the director of nursing on 01/10/18 at 1:30 PM. They said they have standing orders for bowel protocol to treat on the third day if a resident has no bowel movement. No further information was provided after informing them that there was no evidence per MAR indicated [REDACTED]. The DON said the resident used to be on Senna daily, but the resident refused it. On 01/10/18 at 1:35 PM an interview was conducted with the resident. Upon inquiry, she said she sometimes has trouble with constipation. At this time, informed her that she has orders for Milk of Magnesia when needed for constipation.",2020-09-01
450,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,791,D,0,1,JURJ11,"Based on medical record review and staff interview, the facility failed to ensure they assisted one (1) of five (5) residents in obtaining dental care. Resident #20 complained of having an issue with a tooth and was concerned about the payment. Resident identifier: #20. Facility census: 79. Findings include: a) Resident #20 On 01/08/18 at 3:37 PM, Resident #20, said a tooth in the back of her mouth on the right side was bothering her. She said she was told it would take $80.00 to see the dentist. She felt her insurance would not cover a visit to the dentist. On 01/10/18 at 9:35 AM, during an interview with Resident #20, the resident said she had told Receptionist #41 about needing to see the dentist but was not sure when she had told him. During an interview with Receptionist #41, on 01/10/18 at 9:40 AM, he said he had talked with the resident and tried to make a dental appointment for her but the resident declined the appointment because she was not sure if her insurance would cover the appointment. The resident received assistance from Medicaid. Receptionist #41 said he had not told anyone else at the facility about the resident's concerns about payment for the dental office visit. An interview with Social Worker #11 revealed she had no knowledge of the resident having requested to see a dentist or having concerns over the payment for the dental visit.",2020-09-01
451,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-01-11,842,D,0,1,JURJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of 30 residents had an accurate and complete medical record. Resident #3's diet order change was not transcribed correctly. Resident identifier: #3. Facility census: 79. Findings include: a) Resident #3 On 01/11/18 at 8:00 AM, a review of Resident #3's physician orders [REDACTED]. An interview with Dietician #74 on 01/10/18 at 8:15 AM, revealed she was not sure if the diet order was correct. Dietician #74 said that Account Manager #66 would have more information about this issue. Account Manager #66 was interviewed on 01/10/18 at 8:20 AM. He provided the diet order and communication slip dated 01/09/18 which showed the resident's diet had been upgraded to regular liquids. He reviewed the clinical physician orders [REDACTED]. He stated this was an error.",2020-09-01
454,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,583,D,0,1,T4YY12,"Based on a random observation for discovery and staff interview, the facility failed to safeguard, ensure, and maintain the privacy and confidentiality of residents' clinical records. A random observation, during a revisit survey, revealed a nurse left a computer screen unlocked and unattended, causing accessibility of all resident's electronic clinical records. This practice had the potential to affect more than a limited number of residents. Census: 85. Findings included: On 01/30/19 at 10:34 AM, this surveyor entered the nurses' station to review resident records. There was no staff in the nurses' station at the time. Several residents were gathered around the nurses' station in wheel chairs and/or strolling by, occasionally a resident wander into the nurses' station. During the revisit, residents were observed multiple times going into and out of the nurses' station. This surveyor sat down in the nurses' station to review records and a few minutes later accidentally bumped a laptop computer that was sitting on the counter. The computer screen shifted and a list of resident's names appeared on the screen. This surveyor clicked on a few names and was able to go into resident's electronic records. More than five (5) minutes past, before Licensed Practical Nurse (LPN#68) eventually returned to the nurses' station. LPN#68 was asked; if the laptop computer was the laptop from her assigned medicine cart, and what records could be accessed on it. LPN#68 confirmed it was the medicine cart's laptop computer, and that she had sat it on the counter to charge the computer's battery. LPN#68 said the medical records of all the residents could be accessed from the laptop computer. LPN#68 also verified the laptop's screen should have been locked when the LPN left the nurses' station, so that no unauthorized person could access any medical records. LPN#68 confirmed any resident or visitor could have entered the nurses' station and looked at any resident's medical records on the laptop computer while the screen was unattended and unlocked.",2020-09-01
455,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,600,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and staff and resident interviews, the facility failed to protect two (Resident #54 and #73) of three sampled residents from verbal and physical abuse from Resident #69. The facility census was 87. Findings include: On 11/13/18 at 4:16 PM, the clinical record for the perpetrator, Resident #69 was reviewed. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/23/18 revealed Resident #69 was noted to have a Brief Interview for Mental Status score of 13 out of 15, indicating no impairment. The MDS revealed that Resident #69 was having no hallucinations, no verbal or other behaviors, no rejection of care. On 11/13/18 at 5:00 PM, a review of Resident #69's care plan was completed. A concern dated 03/27/18 and updated 05/27/18 noted, Socially inappropriate, yells and curses at staff and residents. Approaches were, Transfer to psych if ordered by MD, ask not to yell staff or residents, notify MD (physician) of behaviors, allow to voice concerns. Another concern, dated 08/22/18, documented, Verbally and physically abusive to staff and residents, with approaches including, Educate not to threaten other residents, ask for assistance with residents who annoy me. There was no entry on the care plan regarding where Resident #69 was to be seated in the dining room or the need for staff presence. 1. On 11/13/18 at 10:05 AM, Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment, dated 10/16/18, revealed Resident #54 had a Brief Interview for Mental Status (BIMS) score of five out of 15 indicating severe cognitive impairment. The MDS indicated that Resident #54 did not exhibit physical or verbal behaviors. Review of Resident #54's care plan, dated 08/22/18, on 11/13/18 at 10:08 AM revealed a concern, I sometimes feel jealous when other residents show interest in my companion. Interventions included Please make sure I am not around other residents who have a HX (history) of aggressive behaviors. On 11/13/18 at 4:08 PM, a review of an Incident/Accident Report, dated 08/22/18, was completed. The incident report noted that Resident #69 struck Resident #54 on the arm in the dining room. The form revealed the residents were separated. An Investigation Follow-Up form also dated 08/22/18 was reviewed. Under the section Recommendations/New Interventions, Unit Manager (UM) #56 documented that Resident #54 should be kept away from residents with a known hx (history) of physical or verbal abuse. The section did not identify specific interventions or residents that Resident #54 should be kept from. Review of Progress notes dated 11/02/18 by Unit Manager #56 revealed that she was called to the dining room and found Resident #69 with his back towards the resident he attempted to strike (Resident #54). No physical contact was made, but (Resident #69) did use foul language and made threatening remarks towards (Resident #54). Plan in place to change this resident's table to another location in the dining room. (Resident #69) to be monitored closely during dining hours. No Incident/Accident report was located for the 11/02/18 incident. An interview was completed with Resident #69 on 11/12/18 at 11:01 AM. Resident #69 stated that Resident #54 hit me in the face three times in the dining room. He told me to get away from his woman. Resident #69 stated that the incident happened about a month ago and that Resident #54 has been moved away from him in the dining room. On 11/13/18 at 5:29 PM, an observation of the dining room was done. There were five rows of tables set up from left to right. Resident #69 was seated in the dining room at a table to on the first row on the left of the room. There were residents present, but no staff in the dining room. Resident #54 arrived at 5:38 and was left at a table in the center of the dining room (row 3). No staff were present from 5:39 until 5:42. On 11/13/18 at 5:59 PM, an interview was completed with the facility Social Worker (SW) #23. SW #23 said, On 08/22/18 at noon, in the dining room, there was an altercation between (Residents #69 and #54). I was notified by the former administrator that (Resident #69) struck (Resident #54) in the arm one time. There was staff in the dining room and they intervened. (Administrator #115) had (Resident #69) in her office and she had gotten a statement from him. She was telling him that under no circumstances was he to harm another resident. We put (Resident #69) on 1:1 (one staff member staying with him) and he stayed that way 24/7 until 11/01 (18). We paid a security company to sit with him. The day after we stopped the sitter (11/02/19), (Resident #69) went into the dining room and had another altercation with (Resident #54). It was verbal. (Resident #69) threatened to hit the resident. The staff intervened. An interview was completed with the facility Administrator on 11/13/18 at 6:17 PM. When (Resident #69) is in the dining room, staff know to keep them separated. (Resident #69) is on the one side of the dining room and (Resident #54) is on the far opposite side. There is always staff in the dining room when residents are in there. The Administrator said the residents were seated at rows as far apart as they can be. When (Resident #69) is in his bed or his room, he can't move himself so there is no danger. An interview was completed with Resident #54 on 11/13/18 at 7:26 PM. Resident #54 said, He (Resident #69) started on me. I don't know why. He hit me on the wrist. I didn't hit him back. Resident #54 said that there were no issues with Resident #69 before the incident. Resident #54 said there was a second incident He said he would hurt me. We were in the dining room. Resident #54 also said that he still sees Resident #69 in the dining room when they are eating meals, but he doesn't look at me and I don't look at him. On 11/14/18 at 10:00 AM, an interview was completed with Certified Nurse Aide (CNA) #73. CNA #73 stated that she was familiar with Resident #54 and that she had heard about the incident involving Resident #54 and #69 on 08/22/18. Some of the staff had to separate them in the dining room after (Resident #69) hit (Resident #54). No one said specifically not to leave him in the dining room without staff. An interview was completed with Unit Manager (UM) #56 on 11/14/18 at 2:19 PM. UM #56 stated that she was familiar with Resident #69 and #54. (Resident #69) can move himself in his wheelchair. Not very far, but he can. The second time (11/02/18), there wasn't any contact. (Resident #68) was yelling at (Resident #54) with his good arm raised. They (staff) came and got me and I went to the dining room and I moved the table where (Resident #69) sat. When I went in, (Resident #69) was facing (Resident #54) in the wheelchairs. (Resident #69)'s hand was up, but there was no striking. All I did was change the table where he sits. There is always staff in there when they are in the dining room to keep an eye on them. 2. On 11/15/18 at 8:15 AM, the clinical record for Resident #73 was reviewed. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/15/18 at 8:15 AM, a review of the 14-day Minimum Data Set assessment dated [DATE] was completed. Resident #73 was noted to have a BIMS score of 15 out of 15, indicting no cognitive impairment. Resident #73 had no noted deficiency with her hearing. Her speech was unclear and was slurred or mumbled. She usually understood others and comprehends most of the conversation. On 11/14/18 at 10:00 AM, an interview was completed with Certified Nurse Aide (CNA) #73. CNA #73 stated that she was familiar with Residents #69 and #73. She stated, Resident #69 doesn't like her (Resident #73). He calls her a princess and says she is brain dead and things. He repeats the way she talks, and she heard him (Resident #69) and she cried. CNA #73 said that she witnessed Resident #69 calling Resident #73 names from his room while she was working with Resident #73 She stated that Resident #73 was upset and crying. I told the old administrator (Administrator #115) maybe 2 months ago. Administrator #115 is no longer employed at the facility. The Administrator and the SW were asked on multiple occasions during the survey if there was documentation on investigating or reporting the incident. No Progress Notes, Investigations or State reports were located regarding any incidents between Resident #69 and Resident #73. On 11/14/18 at 11:05 AM, an interview was completed with Social Worker (SW) #23. SW #23 said, (Resident #69) told us that (Resident #73) needs more assistance than he does and that bothers him. He called her names to us, but not to her. Resident #73 hasn't reported anything about him. On 11/14/18 at 1:32 PM, an interview was completed with Resident #73. Resident #73 used a spelling board with the help of staff to communicate. CNA #73 assisted with the interview. Resident #73 reported that she was having problems with Resident #69. Resident #69 said something to her. He called her names. Last night she and Resident #69 were waiting to lie down. He said, 'Oh great, the princess first.' He has called me braindead. Resident #73 stated that this was not witnessed by staff. Resident #73 said the comments made her cry in the past. She also said that Resident #69 has made fun of how she talks. Sometimes he makes loud comments from his room that she can hear and sometimes it is when she can see him. Resident #73's room is located across the hall from Resident #69. On 11/14/18 at 1:57 PM, another interview was completed with Resident #69. I've not had any problem with (Resident #73). I've had a problem with the people who care for her. I have to wait every time for them to help me while they help her. Every time she makes a grunt, they run to her. I'm sure I've said that a time or two. I don't talk to her. To the staff I call her the queen because she has to go first. She knows my voice.",2020-09-01
456,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,609,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, abuse policy review and staff interviews, the facility failed to report to the state agency allegations of or suspected abuse for two (Residents #73 and #24) of three sampled residents reviewed for allegations of abuse. The facility census was 87. Findings include: 1. Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/15/18 at 8:15 AM, a review of the 14-day Minimum Data Set (MDS) was completed. Resident #73 was noted to have a BIMS score of 15 out of 15 indicating no cognitive impairment. No State reports were located regarding any incidents between Resident #69 and Resident #73. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS, dated [DATE], was completed on 11/13/18 at 4:16 PM. Resident #69 was noted to have a BIMS score of 13 out of 15, indicating minimal cognitive impairment. The MDS revealed that Resident #69 was having no hallucinations, no verbal or other behaviors, no rejection of care. On 11/14/18 at 10:00 AM, an interview was completed with Certified Nursing Aide (CNA) #73. CNA #73 stated that she was familiar with residents #69 and 73. (Resident #69) doesn't like (Resident #73). He calls her a princess and says she is brain dead and things. He repeated the way she talks, and she heard him and she cried. CNA #73 said that she witnessed Resident #69 calling Resident #73 names from his room while she was working with Resident #73, and that Resident #73 was upset and crying. I told the old administrator (Administrator #115) maybe 2 months ago. Administrator #115 was no longer employed at the facility. CNA #73 said that she was not specifically told not to leave Resident #69 him in the dining room without staff, but there was always staff in there to watch residents. On 11/14/18 at 11:05 AM, a follow up interview was completed with SW #23. SW #23 said, If there is an injury, we would report it. I can report, the DON and the Administrator can report. The State regulations are what we follow. It says if there isn't an injury, it doesn't have to be reported. (Resident #69) told us that (Resident #73) needs more assistance than he does and that bothers him. He called her names to us, but not to her. She hasn't reported anything about him. On 11/14/18 at 1:32 PM, an interview was completed with Resident #73. Resident #73 uses a spelling board with the help of staff to communicate. CNA #73 assisted with the interview. Resident #73 reported that she was having problems with Resident #69. Resident #69 said something to her. He called her names. Last night she and Resident #69 were waiting to lay down (both need staff assistance with a mechanical lift to transfer), He said, 'oh great the princess first.' He has called me braindead. Resident #73 stated that this was not witnessed by staff. Resident #73 said that the comments made her cry in the past. She also said that Resident #69 has made fun of how she talks. I get up first, so I think I should go down first. Sometimes he makes loud comments from his room that she can hear and sometimes it is when she can see him. On 11/14/18 at 1:57 PM, another interview was completed with Resident #69. I've not had any problem with (Resident #73). I've had a problem with the people who care for her. I have to wait every time for them to help me while they help her. Every time she makes a grunt, they run to her. I'm sure I've said that a time or two. I don't talk to her. To the staff I call her the queen because she has to go first. She knows my voice. 2. Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was noted to wander daily. A review of Resident #24's care plan was completed on 11/15/18 at 8:32 AM. On 09/26/18 a concern was noted to be, I occasionally wheel myself in my wheelchair to male residents asking them to kiss me. I mistake them for my husband. Approaches included Explain to the male residents who I approach that I sometimes mistake them for my husband and Redirect me by offering me coffee, snack, activities, etc. On 06/28/18, the care plan was updated to note a concern titled, I wander the facility in my wheelchair daily, going into other resident's rooms, into offices, etc. Approaches included Monitor my whereabouts at all times. No State reports were located regarding an incident between Resident #69 and Resident #24. On 11/13/18 at 5:00 PM, a review of Resident #69's care plan was completed. On 08/23/18, under Interventions, a note was added I kissed a female resident who lacks capacity and who has severely impaired memory and decision making. Educate me that I am not to do this. An interview was completed with SW#23 on 11/13/18 at 6:20 PM. There was an incident with a female resident (Resident #24). She doesn't have capacity to know what she is doing. She went up to (Resident #69) in the dining room in her wheelchair and asked him to kiss her and he did. Someone (didn't remember who) came and reported it to me. They (Residents #69 and #54 were separated. The former Administrator (#115) was aware of the incident. SW #23 said that she was unable to find an incident investigation, or any report submitted to the State. On 11/14/18 at 9:28 AM, an interview was completed with the Administrator. The Administrator said that he was trying to get in touch with the old administrator to see if she did an investigation or if she reported it and that he could not find any documentation of the incident with Resident #24. Another interview was completed with Resident #69 on 11/14/18 at 9:32 AM. Resident #69 said that he can move himself in the wheel chair some. When asked about the incident involving Resident #24, Resident #69 said, A lady kissed me in the dining. She was coming in the dining room and I was going out. I had talked to her before. We were talking. She was confused that I was her husband. She held my hand first and there was some chit chat. Then she kissed me on the lips. Resident #69 stated that he kissed Resident #24 back. When we were talking, I could tell she was confused. I knew I wasn't her husband. I wouldn't know her since my sight has gotten worse. On 11/14/18 at 10:39 AM, a follow up interview was completed with the Administrator. I talked to the former Administrator and the interim DON who was here during the incident with the kissing. They didn't recall doing an investigation and I haven't been able to find any documentation in our files. The administrator stated that he couldn't say if the incident involving Resident #24 was required to be reported, but that he would have. On 11/14/18 at 11:05 AM, a follow up interview was completed with SW #23. SW #23 said, If there is an injury, we would report it. I can report, the DON and the Administrator can report. The State regulations are what we follow. It says if there isn't an injury, it doesn't have to be reported. (Resident #24) was the resident (Resident #69) kissed. I was not part of investigating that. I was with the Administrator (Administrator #115) when she talked to him about that. SW#23 stated the incident happened before an incident with Resident #54, but she wasn't sure what day. If the kissing was abusive towards the resident, it would be reported. We would ask her general questions. She has a care plan because she mistakes residents for her husband. She doesn't have capacity. We would watch her for anxiety (to know if the kissing affected Resident #24). On 11/14/18 at 4:02 PM, an interview was completed with the Director of Nurses (DON). The DON said that if there was an abuse allegation, The nurse or I do an incident report and notify the physician. An S-bar gets done (situation back round assessment and response) by the person doing the incident report. The staff would notify me of the allegation. The social worker, unit manager, Administrator and DON would do an investigation. We would notify the ombudsman and OFLAC (State agency). The social worker would usually do the 24 hour and the 5-day report. We report allegations of abuse or neglect, physical abuse if there is harm. If the person feels scared or threatened, it's still reportable. We report misappropriation of items and allegations of sexual abuse. If a resident makes an allegation that he was struck by a resident, it is reportable. I don't know of anyone else (besides Resident #54) who (Resident #69) says bothers him or any resident who complains about (Resident #69). Review of the facility policy titled Abuse and Neglect Prohibition, dated (MONTH) (YEAR), was completed on 11/14/18 at 6:15 PM. Under Investigation, the policy stated, The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation . in accordance with state law. Under the section titled Reporting and Response, the policy stated, The facility will report all allegations and substantiated concerns of abuse, neglect . to the administrator, State Survey Agency . in accordance with Federal and State law. a. If the events that caused the allegation involve abuse or result in serious bodily injury, a report is made not later than 2 hours after the management staff becomes aware of the allegation.",2020-09-01
457,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,610,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to investigate allegations of abuse for two (Resident #54 and #73) of three sampled residents reviewed for allegations of abuse from Resident #69. The facility census was 87. Findings include: 1. Review of the 11/15/18 at 8:15 AM, Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/15/18 at 8:15 AM, a review of the 14-day Minimum Data Set (MDS) was completed. Resident #73 was noted to have a BIMS score of 15 out of 15 indicting no cognitive impairment. No Progress Notes, Investigations or State reports were located regarding any incidents between Resident #69 and Resident #73. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] was completed on 11/13/18 at 4:16 PM. Resident #69 was noted to have a BIMS score of 13 out of 15, indicating minimal cognitive impairment. On 11/14/18 at 10:00 AM, an interview was completed with Certified Nursing Aide (CNA) #73. CNA #73 stated that she was familiar with residents #69 and #73. (Resident #69) doesn't like (Resident #73). He calls her a princess and says she is brain dead and things. He repeated the way she talks, and she heard him and she cried. CNA #73 said that she witnessed Resident #69 calling Resident #73 names from his room while she was working with Resident #73, and that Resident #73 was upset and crying. I told the old administrator (Administrator #115) maybe 2 months ago. Administrator #115 is no longer employed at the facility. CNA #73 said that she was not specifically told not to leave Resident #69 in the dining room without staff, but there was always staff in there to watch residents. On 11/14/18 at 11:05 AM, a follow up interview was completed with SW #23. SW #23 said, If there is an injury, we would report it. I can report, the DON and the Administrator can report. The State regulations are what we follow. It says if there isn't an injury, it doesn't have to be reported. (Resident #69) told us that (Resident #73) needs more assistance than he does and that bothers him. He called her names to us, but not to her. She hasn't reported anything about him. On 11/14/18 at 1:32 PM, an interview was completed with Resident #73. Resident #73 used a spelling board with the help of staff to communicate. CNA #73 assisted with the interview. Resident #73 reported that she was having problems with Resident #69. Resident #69 said something to her. He called her names. Last night she and Resident #69 were waiting to lay down (both need staff assistance with a mechanical lift to transfer), He said, 'Oh great the princess first.' He has called me braindead. Resident #73 stated that this was not witnessed by staff. Resident #73 said that the comments made her cry in the past. She also said that Resident #69 has made fun of how she talks. I get up first, so I think I should go down first. Sometimes he makes loud comments from his room that she can hear and sometimes it is when she can see him. Resident #73's room is across the hall from Resident #69. On 11/14/18 at 1:57 PM, another interview was completed with Resident #69. I've not had any problem with (Resident #73). I've had a problem with the people who care for her. I have to wait every time for them to help me while they help her. Every time she makes a grunt, they run to her. I'm sure I've said that a time or two. I don't talk to her. To the staff I call her the queen because she has to go first. She knows my voice. On 11/14/18 at 4:02 PM, an interview was completed with the Director of Nurses (DON). The DON said that if there was an abuse allegation, The nurse or I do an incident report and notify the physician. An S-bar gets done (situation back round assessment and response) by the person doing the incident report. The staff would notify me of the allegation. The social worker, unit manager, Administrator and DON would do an investigation. We would notify the ombudsman and OFLAC (State agency). The social worker would usually do the 24 hour and the 5 day report. We report allegations of abuse or neglect, physical abuse if there is harm. If the person feels scared or threatened, it's still reportable. We report misappropriation of items and allegations of sexual abuse. If a resident makes an allegation that he was struck by a resident, it is reportable. I don't know of anyone else (besides Resident #54) who (Resident #69) says bothers him or any resident who complains about (Resident #69). 2. Resident #24 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. She was noted to wander daily. A review of Resident #24's care plan was completed on 11/15/18 at 8:32 AM. On 09/26/18 a concern was noted to be, I occasionally wheel myself in my wheelchair to male residents asking them to kiss me. I mistake them for my husband. Approaches included Explain to the male residents who I approach that I sometimes mistake them for my husband and Redirect me by offering me coffee, snack, activities, etc. On 06/28/18, the care plan was updated to note a concern titled, I wander the facility in my wheelchair daily, going into other resident's rooms, into offices, etc. Approaches included Monitor my whereabouts at all times. No Progress notes, incident reports or State reports were located regarding an incident between Resident #69 and Resident #24. An interview was completed with SW#23 on 11/13/18 at 6:20 PM. There was an incident with a female resident (Resident #24). She doesn't have capacity to know what she is doing. She went up to (Resident #69) in the dining room in her wheelchair and asked him to kiss her and he did. Someone (didn't remember who) came and reported it to me. They (Residents #69 and #54 were separated. The former Administrator (#115) was aware of the incident. SW #23 said that she was unable to find an incident investigation. On 11/14/18 at 9:28 AM, an interview was completed with the Administrator. The Administrator said that he was trying to get in touch with the old administrator to see if she did an investigation or if she reported it and that he could not find any documentation of the incident with Resident #24. Another interview was completed with Resident #69 on 11/14/18 at 9:32 AM. Resident #69 said that he can move himself in the wheel chair some. When asked about the incident involving Resident #24, Resident #69 said, A lady kissed me in the dining. She was coming in the dining room and I was going out. I had talked to her before. We were talking. She was confused that I was her husband. She held my hand first and there was some chit chat. Then she kissed me on the lips. Resident #69 stated that he kissed Resident #24 back. When we were talking, I could tell she was confused. I knew I wasn't her husband. I wouldn't know her since my sight has gotten worse. On 11/14/18 at 10:39 AM, a follow up interview was completed with the Administrator. I talked to the former Administrator and the interim DON who was here during the incident with the kissing. They didn't recall doing an investigation and I haven't been able to find any documentation in our files. The administrator stated that he couldn't say if the incident involving Resident #24 was required to be reported, but that he would have. On 11/14/18 at 11:05 AM, a follow up interview was completed with SW #23. SW #23 said, I was not part of investigating that. I was with the Administrator (Administrator #115) when she talked to him about that. SW#23 stated the incident happened before an incident with Resident #54, but she wasn't sure what day. If the kissing was abusive towards the resident, it would be reported. We would ask her general questions. She has a care plan because she mistakes residents for her husband. She doesn't have capacity. We would watch her for anxiety (to know if the kissing affected Resident #24). Review of the facility policy titled Abuse and Neglect Prohibition dated (MONTH) (YEAR) was completed on 11/14/18 at 6:15 PM. Under Investigation, the policy notes The facility will timely conduct an investigation of any alleged abuse/neglect, exploitation . in accordance with state law.",2020-09-01
459,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,688,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and observation, the facility failed to ensure that a resident with limited range of motion received the prescribed services and equipment to maintain or improve mobility. This affected one out of one resident (Resident #36) with limited range of motion (ROM) reviewed. Resident #36 was prescribed knee extension braces to prevent further contractures of her knees. The facility census was 87. Findings include: Review of the clinical record on 11/15/18 at 8:49 AM revealed an admission history form dated 08/08/14. The admission history documented that Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 10/05/18, documented Resident #36 was completely dependent on two staff for her Activities of Daily Living (ADLs) and had limited range of motion in both of her knees. The clinical record documented a physician's orders [REDACTED]. The Plan of Care (P[NAME]) for impaired mobility, dated 04/16/18 documented to apply bilateral knee extension devices in bed. The nurse aide care plan documented to apply bilateral knee extension devices in bed. On 11/15/18 at 9:08 AM, Resident #36 was observed up in her wheelchair. The bilateral knee extension braces were not observed to be in Resident #36's room. On 11/15/18 at 9:10 AM, Certified Nursing Assistant (CNA) #12 was interviewed. CNA #12 stated that she had been working with Resident #36 for about a month and she was not aware of any knee extension braces that were to be applied while in bed. On 11/15/18 at 9:15 AM, Director of Rehabilitation Services (DOR) #75 was interviewed. DOR #75 stated that when Resident #36 was discharged from Physical Therapy in (MONTH) of (YEAR), Physical Therapy asked for an order for [REDACTED]. DOR #75 was going to demonstrate what the knee extension braces looked like but was only able to locate one brace in Resident #36's room. It was observed on top of the closet. On 11/15/18 at 9:45 AM, the physical therapy discharge summary, dated 03/23/18 was reviewed. The discharge plan documented, in part, for nursing to continue to use positioning devices while in bed. The quarterly physical therapy screening forms were reviewed. The forms were dated 02/02/18, 04/04/18, 07/11/18 and 10/08/18. Each form documented that there had been no changes to Resident #36's range of motion and to continue to use the knee extension braces while Resident #36 was in bed. On 11/15/18 at 9:50 AM a Restorative Nursing program form dated 09/20/18 was reviewed. The form documented a training between Occupational Therapist (OT) #79 and CNAs #15, CNA #68 and CNA #24. The training was specific to Resident #36 in regard to proper positioning while up in her wheelchair and for the knee extension splints while in bed. On 11/15/18 at 4:07 PM, Resident #36 was observed to be lying in bed. The knee extension braces were not applied or visible in her room. On 11/15/18 at 4:23 PM, CNA #24 was interviewed. CNA #24 stated that I've never seen those things (the knee extension braces) and I work with Resident #36 every day that I am here.",2020-09-01
461,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,758,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility failed to complete a gradual dose reduction of [MEDICATION NAME] (an anti-psychotic) as ordered by the physician. This affected one (Resident #15) of five sampled residents reviewed for unnecessary medications. The facility census was 87. Findings included: Review of the clinical record on 11/15/18 at 10:28 AM revealed an admission history form dated 03/14/16. The admission history documented Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 09/16/18, documented a Brief Interview for Mental Status (BIMS) score of nine out of 15, a moderate memory impairment. The MDS documented that Resident #15 was often sleepy and had little energy. The MDS assessed for [MEDICAL CONDITION] and hallucinations and no episodes were documented. The MDS documented that Resident #15 needed extensive assistance of one person to complete her activities of daily living (ADLs). Resident #15 had a plan of care (P[NAME]), dated 04/19/17, that documented dementia with behaviors as exhibited by verbal and physical behaviors towards staff that included hitting, kicking, and using foul language. A P[NAME] intervention, dated 04/20/18, was to do a gradual dose reduction (GDR) of her medications as tolerated. Per the form entitled Note to Attending Physician/ Prescriber, dated 02/08/18, the facility's pharmacist recommended that Resident #15's [MEDICATION NAME] be reduced from 25 mg tablet one time per day to 12.5 mg tablet one time per day because there was no documented behaviors on (the behavior) monitor sheets. On 02/13/18 a physician's orders [REDACTED]. During the clinical record review, no evidence was documented that the physician order [REDACTED]. Review of the physician order [REDACTED].#15 was still taking [MEDICATION NAME] 25 mg one time per day. On 11/15/18 at 12:09 PM the MARs were reviewed from (MONTH) (YEAR) through 11/15/18. The behavior monitoring section for [MEDICAL CONDITION] medication ([MEDICATION NAME]) documented that Resident #15 was not having any psychotic behaviors. On 11/15/18 at 12:22 PM, the Medical Director (MD) #115 was interviewed. He stated Resident #15's [MEDICATION NAME] was to be reduced in (MONTH) (YEAR). He stated that he tries to get all his residents off of [MEDICATION NAME] if they have a [DIAGNOSES REDACTED]. On 11/15/18 at 1:12 PM, Resident #15 was observed to be back in bed and sleeping. On 11/15/18 at 1:20 PM, the District Director, Clinical Resources (DDCR) #112 was interviewed. The DDCR was a Registered Nurse. The DDCR reviewed Resident #15's clinical record and stated that the physician's orders [REDACTED]. On 11/15/18 at 4:08 PM, the Physician's Assistant (PA) #114 was interviewed. His goal was to discontinue Resident #115 from [MEDICATION NAME]. PA #114 stated that he knows that [MEDICATION NAME] is not a recommended drug for elders with dementia.",2020-09-01
463,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,770,D,0,1,T4YY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to ensure laboratory blood testing was obtained per physician order [REDACTED]. Findings include: A comprehensive chart review for Resident #48 was conducted on 11/13/18 at 2:00 PM. The Admission Record identified Resident #48 was originally admitted to the facility on [DATE]. The resident had a re-admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #48's hospital Discharge Summary dated 10/05/18 revealed a physician's orders [REDACTED]. [MEDICATION NAME] is an antibiotic drug used to treat serious, life-threatening infections by gram-positive bacteria that are resistant to less-toxic agents. A Physician order [REDACTED]. A CBC is a laboratory blood test used to evaluate the resident's overall health and detect a wide range of disorders, including [MEDICAL CONDITION], infection and [MEDICAL CONDITION]. Additional laboratory work ordered included a comprehensive metabolic panel (CMP) used to check the status of the residents metabolism, including the health of the kidneys and liver as well as electrolyte and acid/base balance and levels of blood glucose and blood proteins; to monitor known conditions, such as hypertension, and to monitor the use of medications to check for any kidney or liver related side effects. Additionally, the physician ordered an erythrocyte sedimentation rate (ESR or sed rate) which is used to help detect inflammation associated with conditions such as infections, cancers, and [DIAGNOSES REDACTED] diseases, and a [MEDICATION NAME] trough level which is used to determine effective dosage for the antibiotic. The blood tests were to be drawn every 7 days. Review of the plan of care dated 11/03/18 included the Focus of, I receive antibiotic therapy r/t [MEDICAL CONDITION]. Included was an intervention to Obtain ordered labs as indicated. Further review of the clinical record revealed CBC test results dated 11/06/18; however, the clinical record did not contain the CMP, ESR or the [MEDICATION NAME] trough level as ordered by the physician. During an interview conducted on 11/12/18 at 1:00 PM, Unit Manager Registered Nurse (RN) #29 verified the CMP, ESR and [MEDICATION NAME] trough level blood testing was not collected as ordered by the physician. During an interview conducted on 11/15/18 at 12:05 PM, Medical Director #113 verified the facility did not follow his order to obtain the CMP, ESR and [MEDICATION NAME] trough level as written on 10/31/18.",2020-09-01
464,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2018-11-15,809,D,0,1,T4YY12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, resident interview, record review and staff interview the facility failed to ensure Resident # 81 was provided a meal at the regular scheduled time. This meal was not in accordance to Resident #81's needs and preferences. This was a random observation. Resident identifier: #81. Facility Census: 85. Findings included: a) Resident #81 During the initial tour on 01/29/19 at 9:30AM resident was observed sitting in her bed awaiting her breakfast tray. Resident was interviewed where she stated she had not received her breakfast tray and usually it came around 8:00 AM each morning. Resident had self-administered medication on her bedside table in which she stated she could not take without her food. Resident was observed pressing her call light where she informed Nursing Assistant (NA) # 42 she had not received her breakfast tray. NA #42 stated that she would get her a breakfast tray. In an interview, on 01/29/19 at 9:40AM, NA #42 stated Resident #81's breakfast tray just got missed. NA #42 explained that there were four (4) Nursing Assistants passing out breakfast trays that morning and they each thought the other one had delivered a tray to Resident #81. In an interview, on 01/29/19 at 2:40PM, Dietary Manager #89 stated that he was informed by staff that Resident #81 had not received a breakfast tray. Dietary Manager #89 confirmed that he personally made a breakfast tray up and had it delivered to Resident #81's room. Based on record review, on 01/30/19 at 9:00AM, Resident #81 had an active [DIAGNOSES REDACTED]. Based on Care Plan a goal for Type II Diabetes Mellitus is to continue to have no complications. Based on physician orders [REDACTED]. On 1/30/19 at 10:40AM, District Director of Clinical Services (DDCS) #90 provided a copy of a concern form revealing Resident #81's concern of not being provided a breakfast tray without having to ask for a tray. The concern form stated, Resident #81 did not receive a breakfast tray on 01/29/19 from the meal cart during breakfast. Dietary Manager #89 completed the concern form stating, once being notified by staff at 9:30AM Resident #81 did not have breakfast a tray was made and delivered to Resident #81. Documentation revealed that Dietary Manager #89 will monitor passing of breakfast trays for the next few weeks to ensure Resident #81 obtains a meal tray in the future. Unit Manager #71 and Dietary Manager #89 will audit trays to ensure Resident #81 receives daily and will review outcome with the Quality Assurance and Performance Improvement (QAPI) Team.",2020-09-01
468,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,550,D,0,1,QN1C11,"Based on a observation during random opportunity for discovery and staff interview, the facility failed to ensure the dignity of a resident during the dining experience. This affected one (1) resident who partook of her meal in the main dining room while housekeeping staff cleaned the room. Resident #41. Facility census 91. Findings include: a) Resident #41 On 12/02/19 at 1:50 PM Resident #41 sat in the main dining room as she ate her lunch meal. She was the only resident left in the room who was still eating. Three (3) housekeeping staff were engaged in sweeping the floor and cleaning up in the front section of the dining room. Another employee ran a motorized contraception in the dining room which cleaned the floor. No other facility staff were present in the dining room. An interview was conducted with the director of nursing and the administrator on 12/05/19 at 12:15 PM. They said cleaning the dining room while a resident was still eating was not a practice they condoned. They said typically lunch is served in the main dining room from approximately 12:20 PM to about 1:15 PM. They were not sure why she was still in the dining room eating so late. No further information was provided prior to exit.",2020-09-01
469,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,561,D,0,1,QN1C11,"Based on record review, resident and staff interview the facility failed to provide for personal preference related to resident bathing preferences. This affected one (1) of one (1) resident for choices. Resident #59. Facility census 91. Findings included: Resident #59 During an interview with Resident #59 (R#59), on 12/03/19 at 3:30 PM, Resident #59 stated she was showered around midnight. R#59 prefers morning showers, in particular 6:00 AM showers. Further, R#59 does not wish to be awakened to shower. A record review found the current care plan for R#59, with R#59's preferred bedtime listed as between 8:00 PM and 9:00 PM On 12/04/19 at 9:20 AM, during an interview with Nursing Home Administrator (NHA) it was discovered that the facility completed a shower preference audit in June, 2019. R#59 chose morning showers, with 6:00 AM listed on the audit sheet. NHA confirmed this is R#59's choice. During an interview with Registered Nurse/Staff Development Coordinator #37, on 12/04/19 at 10:25 AM, it was confirmed R#59 was showered at: 5:34 AM on 11/29/19, 6:59 AM on 11/26/19, 12:45 AM on 11/22/19, 3:56 AM on 11/19/19, 6:54 AM on 11/15/19 12:01 AM on 11/12/19, 5:11 Am on 11/05/19, 6:59 AM on 11/01/19. RN #37 confirmed these times are not the chosen shower times for R#59.",2020-09-01
470,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,578,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure complete medical records. Specifically, the West Virginia Physician order [REDACTED]. This affected three (3) of three (3) residents reviewed for advance directives. Resident Identifiers: #56, #284, and #285. Facility census 91. Findings included: Record review on 12/03/19, revealed three West Virginia Physician order [REDACTED]. a) POST form for Resident #56, dated 10/25/19, found: 1. no social security number 2. no printed name of MD/DO/APRN/PA or phone number of representative approving orders 3. no name on the second page 4. section [NAME] (preferences as a guide for POST form) was not completed, other than the person preparing form section b) POST form for Resident #284, dated 11/08/19, found: 1. no address 2. no social security number 3. no printed name of MD/DO/APRN/PA or phone number of representative approving orders 4. no information completed in Section E, (preferences as a guide for POST form) other than the person preparing the form section c) POST form for Resident #285, dated 10/21/19, found: 1. no address 2. no social security number 3. no birthdate 4. no information in Section C, (medically administered fluids and nutrition) on the first page 5. no printed name of MD/DO/APRN/PA or phone number of representative approving orders 6. no information completed in Section E, (preferences as a guide for POST form), other than the person preparing the form section An interview with Registered Nurse #58 on 12/04/19 at 1:47 PM, RN #58 revealed the form should be complete in all areas. RN #58 reported that POST forms for R #56, R #284 and R #285 were not complete.",2020-09-01
471,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,655,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review the facility failed to develop and implement a base line care that included instructions needed to provide effective person centered care of the resident which met professional standards of quality care. This was evident for one (1) of one (1) residents reviewed for [MEDICAL CONDITION] care. Resident identifier: #187. Facility census 91. Findings include: a) Resident #187 The medical record was reviewed on 12/03/19. This resident first came to the facility on [DATE]. He received a [MEDICAL CONDITION] during a hospitalization which immediately preceded his admission to the facility. The care plan as related to [MEDICAL CONDITION] was sparse. It directed to [MEDICAL CONDITION] were secured at all times, humidified oxygen (did not include percentage or equipment settings), suction as necessary, keep an [MEDICAL CONDITION] and obturator at bedside - if coughed out, open stoma with a hemostat if tube cannot be reinserted. The care plan did not include the type and size of the airway. Observation of the resident on 12/03/19 at 3:45 PM found him lying in bed with the head of the bed elevated. He received humidification to [MEDICAL CONDITION] from a Heavy Duty Aerosol Compressor. This machine sat upon a bedside table to the left of the resident's bed. A portable suction machine also sat upon the bedside table. There was no suction catheter or yonker at the machine. On the right of the resident's bed an oxygen concentrator sat on the floor. This machine was turned on and was delivering oxygen at six (6) liters per minute (lpm). The opposite end of the oxygen tubing lay in his bed but was not connected to anything. An interview was conducted with licensed nurse #119 (LPN #119) on 12/03/19 at 3:45 PM. She acknowledged the concentrator was set for, and running, at six (6) lpm, but the tubing was laying on the bed and not connected to anything. She said he was not receiving oxygen, rather just humidified air. She said the Heavy Duty Aerosol Compressor was set on 40 on the dial. She said it delivered 28% humidification and showed on another dial as such. She said she would have to check orders to see about the settings as this was the way in which it was set. When told her there was nothing in the physician's orders or the care plan about the settings, she said she would look for the unit manager. She showed that the suction catheters were inside the resident's closet which was located against the wall across from the foot of the resident's bed. At 3:55 PM on 12/03/19 LPN #119 was observed in the front hall talking with unit manager registered nurse #58 (RN #58). The following issues were discussed with RN #58: 1. The suction machine at the bedside had no suction catheter at the bedside for emergency suctioning. 2. The dial on the Heavy Duty Aerosol Compressor was set on 40, and it appears that the setting on the humidifier bottle may be at 28%. However, there are no MD orders or care planned directives as to how to set this machine or the humidifier bottle. 3. The humidifier bottle on the Heavy Duty Aerosol Compressor had an expiration date of (MONTH) (YEAR). RN #58 then walked to the resident's room. While en route, she asked health information coordinator #101 (HIC #101) if they had Tupperware containers and if Resident #187 had one at his bedside. HIC #101 replied they do have Tupperware containers, but that Resident #187 had none yet at his beside. RN #58 agreed the humidifier bottle was beyond the expiration date, and she obtained a fresh one. She looked at the oxygen concentrator. Someone had come in and removed the oxygen tubing from the concentrator and turned it off. She agreed there was no suction catheter at the bedside for emergency if needed. She looked inside the resident's closet which had a jumble of oxygen therapy equipment inside, and found a sterile suction catheter/bag and laid it by the suction machine. She said had the Tupperware box been at the bedside that the suction catheter would have been inside it. She said she understood that it should be at the bedside as in an emergency people want it quickly. She looked at the dial on the Heavy Duty Aerosol Compressor. She said it was set by the respiratory therapist. She was informed that there were no parameters to follow in the physician's orders or the care plan regarding the settings. She said the physician is here today and she will ask him about clarification in the orders. She said she will also update the baseline care plan. Further review of the medical record on 12/04/19 found the following entries for pulse oximetry: -11/28/19 - 97% at 6:28 PM, 94% at 6:55 PM and 94% at 4:19 PM -11/29/19 - 94% at 3:15 PM, and 95% at 7:38 PM -11/30/19 - 94% at 1:18 PM -12/01/19 - 94% at 3:05 PM -12/02/19 - NONE RECORDED -12/03/19 - 98% at 7:27 PM On 12/04/19 at 9 AM an interview was conducted with the director of nursing (DON). It was discussed that pulse oximetry readings were only done and/or recorded sporadically since admission as noted on the dates and times above. She agreed there were no physician's orders or care planned directives as to how often to assess his oxygen level. When asked how often she expected staff to obtain pulse oximetry rates, she said only when the physician orders it. An interview was conducted on 12/04/19 at 9:15 AM with RN #58. She said his pulse oximetry measurement has always been above 92% so they do not routinely check it as he is on room air, not oxygen. When asked what their policy directed for the frequency of pulse oximetry measurement for residents with trachs, she said that staff should check the resident's pulse oximetry whenever they [MEDICAL CONDITION], and before and after suctioning, but they do not always write it down. RN #58 said staff should document each time they assess the pulse oximetry. She acknowledged the standard that it if it is not documented, then it did not happen. An interview was conducted with staff development registered nurse #36 on 12/04/19 at 9:30 AM. When asked what [MEDICAL CONDITION] policy and procedure said about assessing pulse oximetry, she said it just says to assess the patient. She said she obtains pulse oximetry assessment at least before and after care provided to the trach. She said she could not speak for all nurses that they are documenting pulse oximetry results. At 10:30 AM on 12/04/19 RN #58 brought a copy of a policy titled [MEDICAL CONDITION] Management which had a release date of (MONTH) (YEAR) as a Clinical Practice Standard; a copy of a policy titled Spontaneous Decannulation: Reinsertion of [MEDICAL CONDITION] with revision date (MONTH) 2008; and another titled Tracheal Button Insertion, with revision date (MONTH) 2008. None of these address obtaining oxygen levels per pulse oximetry. An interview was conducted with the administrator and the DON on 12/05/19 at 12:15 PM. It was discussed that the baseline care plan was found silent as to the settings of the Heavy Duty Aerosol Compressor and the percentage of humidification; how often to assess and document pulse oximetry measurements; the type and size of the airway, and the provision of all emergency equipment at the bedside which includes suction catheters. They acknowledged understanding. No further information was provided prior to exit.",2020-09-01
472,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,657,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to revise a care plan related to support required for a resident's toileting needs. This affected one (1) of one (1) residents reviewed for the care area of bowel and bladder incontinence. Resident #60. Facility census 91. Findings included: a) Resident #60 A review of Resident #60's quarterly Minimum Data Set (MDS) with the Assessment Reference date (ARD) of 09/17/19 and 11/04/19 finds Resident #60 requires extensive assistance and one (1) person physical support for his toileting needs. Resident #60's Brief Interview for Mental status (BIMS) finds Resident #60 scored a 13 on his BIMS for 11/04/19. A score of 13-15 indicate an intact cognitive response. The MDS's reveals the resident can make himself understood and understands others. A review of the look back period on Resident #60's toileting support for the MDS dated [DATE], revealed the staff provided one (1) person assistance for his toileting support. A review for the look back period for the resident's toileting support for the MDS dated , 11/04/19 finds one (1) person physical assist. In an interview with Resident #60 on 12/02/19 3:38 PM, he was asked what support do you need to use the toilet. The resident stated one (1). An interview was conducted on 12/03/19 at 3:00 PM, with Resident Care Specialist (RCS) #79. When he was asked what support assistance does Resident #60 require to go to the toilet the RCS stated that, Resident #60 required the support of one (1) assistant to use the toilet. A review of Resident #60's care plan on 12/03/19 at 2:10 PM, found a care plan saying: I have an activity of daily living (ADL) self-care performance deficit related to impaired mobility. This care plan focus was initiated on 04/03/19 and a revision was made on 09/25/19. Resident #60's intervention for his toilet use is: the resident requires extensive assistance by two (2) staff for toileting. The date for this intervention is 04/03/19. Resident #60's Kardex ( ) revealed Resident #60's requires the extensive assistance of two (2) staff for his toileting needs. In an interview on 12/03/19 at 3:25 PM, the Care Management Minimum Data Set Director (CMMDSD) Registered Nurse (RN) #33, she was informed of Resident #60 required one (1) assist for his toileting support on the MDS dated [DATE] and 11/04/19. RCA #79 stated that Resident #60 needed one (1) assistance for toileting support. The care plan and the Kardex said two (2) assistance is requires for the resident's toileting support. The CMMDSD said the Kardex/care plan needed to be updated to reflect Resident #60's support required for his toileting needs.",2020-09-01
473,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,684,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. A stat Basic Metabolic panel (BMP)lab was ordered and the staff failed to inform the physician and/or Physician Assistant (PA) timely of the stat BMP lab results. The resident was hosptalized on [DATE] and had a stent placed. This had the potential to affect one (1) of one (1) resident reviewed for stat lab work. Resident Identifier #60. Facility census 91. Findings included: a) Resident #60 A review of Resident #60 medical [DIAGNOSES REDACTED]. diabetic [MEDICAL CONDITION] - 03/13/19 [MEDICAL CONDITION] - 03/13/19, [MEDICAL CONDITION] - 03/13/19, malignant neoplasm of prostrate - 03/13/19, end stage [MEDICAL CONDITION] - 03/13/19, [MEDICAL CONDITION] - 03/13/19, mild cognitive impairment - 03/18/19, muscle weakness - 03/26/19 , difficulty in walking - 03/26/19 , non-St elevation (NSTEMI) [MEDICAL CONDITION] infraction - 05/07/19 present of coronary angioplasty implant graft - 05/07/19. On 04/30/19 at 6:50 AM, Resident #60 refused his shower on night shift. Registered Nurse (RN) #779 stated the resident said, I feel tired and probably take it the next day. A review of the Resident #60's medical records find a progress note on 05/01/19 revealing Resident #60 was being transported by emergency medical system to receive his [MEDICAL TREATMENT]. The resident had his vital signs checked in the truck, prior to leaving out to the [MEDICAL TREATMENT] center. Resident #60's blood pressure was noted to be 90/60. The note stated this blood pressure is average on multiple attempts. The [MEDICAL TREATMENT] center was informed of the resident's blood pressure and the [MEDICAL TREATMENT] center stated the resident could not come to [MEDICAL TREATMENT]. The [MEDICAL TREATMENT] center made the recommendation to have Resident #60's potassium level checked. The PA was notified and order were given to obtain a stat BMP. The resident [MEDICAL TREATMENT] was rescheduled for 05/02/19 at 6:00 AM. A progress note dated 05/01/19 at 8:38PM, LPN #84 wrote that she did not perform Resident #60's dressing. The LPN wrote, Drsg. (sic) today due to him not feeling well. VSS (sic). Skin color pale. Just kept saying lets do it later and time ran out. Sleeping most of the day. No lab results of yet. A review of progress notes finds no note notifying the physician or PA of the stat BMP lab results. There were four (4) copies of the BMP stat lab results from (Medical Center name) in Resident #60's record. The date and the time the facility's system generated the results of the stat BMP lab results on 05/01/19 was at 11:38 AM for three(3) of the lab results and one (1)of the the lab results had the time of 12:27 PM on 05/01/19. Resident #60's physician signed the stat lab results for the BMP on 05/07/19. Resident #60's stat BMP lab results for 05/01/19 were in the resident's chart. The lab results revealed Resident #60's lab results were Glucose -138 High (H) milligrams per deciliter (MG/DL)reference range is 74-100. ( glucose -measure the amount of glucose in your blood).Blood Urine Nitrogen ( Bun)was 47 MG/DL- H, reference range is 7-18, the BUN- measures how much of the waste product you have in your blood). The resident's sodium 134 -L, millimoles per liter (mmol/l -low ), (sodium level checks how much sodium is in the blood), reference range is 136-145, Potassium - 2.9 MMOL/ L-L(Potassium is the amount of potassium in the blood),Reference range is 3.5-5.1, Chloride- 93 MMOL/ L- L , Preference range is 98-107, Creatinine 4.39 MG/DL H, reference range is 0.70-1.30, EGFR in non-African American -13 ML/Min/1.73 m2 = square meters, reference range >=60. On 05/04/19 at 11:48 AM, Licensed Practical Nurse #84, revealed that Resident #60 has shortness of breath (SOB), complaining of abdominal pain, diarrhea times three (3). The resident's Hemoglobin level is 7.2. Hemoglobin is a protein in red blood cells that carries oxygen. The hemoglobin test measures how much hemoglobin is in your blood. The resident's oxygen was 86% on room air. The nurse applied oxygen applied via nasal cannula at two (2) liters per minute. The resident oxygen saturation increased to 94%. The resident's skin color is is pale and he is nauseated. LPN #84 writes Due to his ADB. (abdominal)pain and diarrhea resident is not eating. IDDM. (Insulin Dependent Diabetic Mellitus). The family/health care agent was notified on 05/04/19 at 11:00 AM and the PA was notified at 1:00 PM. A progress note written by LPN #84 on 05/04/19 6:34 PM, revealed Resident was admitted to (hospital name) The resident had an stent placed. Fremont Rideout Health Group Laboratory Services defines Stat test as a test result that are urgently needed for the [DIAGNOSES REDACTED]. The lab performs the test in one (1) hour of less from when the sample was received in the laboratory. The results are available for review. BUN, Chloride, Creatinine, Glucose, Potassium, and Sodium are tests that can be ordered stat. Medline plus.gov dated 02/28/18 reveals that hemoglobin is a protein in red blood cells that carries oxygen. The hemoglobin test measures how much hemoglobin is in your blood. Normal hemoglobin levels generally range from 13.8 to 17.2 grams per deciliter in males. Hemoglobin is an oxygen-carrying protein found in red blood cells. Medlineplus.gov reveals on 04/08/19 that nausea is a symptom of low Potassium. Medline plus.gov dated 10/01/19, finds the body needs Potassium to help your heart and muscles work properly. Potassium levels that are too high or too low may indicate a medical problem. Too little potassium in the blood, a condition known as [DIAGNOSES REDACTED], may indicate loss of bodily fluids from diarrhea. A nursing progress note on 05/06/19 at 6:52 written by LPN # 84 revealed Resident #60 was readmitted from (hospital's name )at approximately 4:30 PM. The LPN stated that, And a stint (sic) was placed in RC[NAME] A physician note dated 05/07/19 7:15 PM, revealed Resident #60 was readmitted . The resident went to (hospital name), and found to have a [MEDICAL CONDITION] infract ([MEDICAL CONDITION]), the patient has a stent. Health line.com says that acute [MEDICAL CONDITION] infarction is the medical name for a [MEDICAL CONDITION]. A [MEDICAL CONDITION] is a life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut off, causing tissue damage. This is usually the result of a blockage in one or more of the coronary arteries. A blockage can develop due to a buildup of plaque, a substance mostly made of fat, cholesterol, and cellular waste products. While the classic symptoms of a [MEDICAL CONDITION] are chest pain and shortness of breath, the symptoms can be quite varied. The most common symptoms of a [MEDICAL CONDITION] include: nausea and short of breath. Mayo clinic reveals 11/15/19 that Coronary angioplasty, also called percutaneous coronary intervention, is a procedure used to open clogged heart arteries. Angioplasty uses a tiny balloon catheter that is inserted in a blocked blood vessel to help widen it and improve blood flow to your heart. A placement of a small wire mesh tube called a stent. The stent helps prop the artery open, decreasing its chance of narrowing again. Most stent's are coated with medication to help keep your artery open (drug-eluting stent's). Rarely, bare-metal stents may be used. A nurse progress note revealed on 05/09/19 at 2:14 PM by LPN #84 revealed Resident #60 left leave of absent (LOA) to a (heart institute name)and returned with a heart monitor on. The heart monitor is to stay on for 48 hours and after the 48 hours it is to stay on until some one from the heart institute comes and take the heart monitor off. On 05/12/19 at 8:25 PM, LPN #777, wrote a nursing progress note revealing Resident #60 was wearing a heart monitor for 48 hrs. Sunday evening he asked when they were coming to get it. Called the number that came with it and they knew nothing about it. After they called their boss they said she would be in today to pick it up. Took it off resident Sunday evening but they still haven't come for it. No further note about whether someone from the heart institute retrieve the heart monitor. No progress note of the results of the heart monitor. The staff provided no evidence upon exiting the building of the 48 hour heart monitor results. A Progress note written by LPN #778 on 05/14/19 at 10:52 AM, revealed Resident #60's stated, Resident's blood pressure running low. [MEDICATION NAME] HCl ('[MEDICATION NAME] Acid)10 milligrams( MG) was held. The record revealed Resident #60 is to be given one (1) 1 tablet by mouth every eight (8) hours related to Cardiac Arrhythmia. The resident's blood pressure on 05/14/19 at 10:58 PM was 94/58. LPN #778 stated that I evaluated the resident and checked BP manually and got 108/64. Over the past two ( 2) hours it has fluctuated 20 points both directions, but continues to be low. Resident states he feels fine and is asymptomatic. Pulse continues to stay between 65-80. The LPN wrote that he called the PA who ordered me to discontinue the [MEDICATION NAME] and [MEDICATION NAME] all together and to have the resident lay and rest until he can evaluate him in person. Will continue to monitor. In an interview on 12/04/19 at 12:00 PM, with Unit Manager #58 confirmed the staff should have notify the Physician/PA of Resident #60's stat BMP lab work on 05/01/19. In an interview with Registered Nurse #36 on 12/04/19 at 12:25 PM, was informed of Resident #60's above status and the staff did not notify the physician of the stat BMP. The resident was hosptalized on [DATE]. The physician signed off that he had reviewed the BMP stat labs of Resident #60 on 05/07/19. RN #36 was asked why the physician was not aware of Resident #60's labs until the day after the resident was re-admitted to the facility on [DATE] and the RN was asked did the lab work have a affects on why Resident #60 had to go to the hospital on [DATE]. The RN made no comment. The RN did make the comment that the nursing staff should have called the Physician and/or the PA of Resident #60's stat BMP lab results on 05/01/19. The RN acknowledges the date the physician signed the lab results is the date the physician was first aware of the results of the stat BMP. No comment made regarding the 48 hour heart monitor results. The PA on 12/04/19 1:53 PM reviewed Resident #60's four (4)lab results with the date of 05/01/19 with the Physician Assistant (PA). The PA confirmed the staff did not notify the physician nor him of the abnormal lab results. Resident #60's potassium level was 2.9 Low. The PA verified the physician reviewed and signed the results of the stat BMP on 05/07/19. No further comment was made related to Resident #60 being admitted for the [DIAGNOSES REDACTED].",2020-09-01
474,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,685,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to ensure a resident received proper assistive device (eye glasses) to maintain vision abilities. Resident identifier: #9. Facility census 91. Findings include: a) Resident #9 An interview was conducted with the resident on 12/02/19 at 1:38 PM. She said her eye glasses came up missing when she was in the hospital about a month or so ago. She said she most recently saw an eye doctor about a year ago, and she was not sure if they can do anything more to help her see better. The medical record was reviewed on 12/04/19. Review of the care plan with revision date 06/06/19 found she was care planned for vision deficits and that she wears glasses to watch TV. The care plan identified that her vision has recently worsened and her optometrist told her this was due to diabetes and [MEDICATION NAME] degeneration. The most recent comprehensive assessment, with assessment reference date 09/10/19, assessed that she was able to see in adequate light. It also assessed that she wore glasses. Review of the electronic health record found nursing assistants documented every day in the most recent 30-day look back period under tasks that she wore no glasses. An interview was conducted with unit manager registered nurse #58 (RN #58) on 12/04/19 at 3:20 PM. She provided evidence that this resident had an appointment in the facility with their contracted eye care provider 360 on 08/13/18. She said the resident had another appointment scheduled with 360 on 02/13/19, but missed the appointment because she was in the hospital. She said she assumes that the appointment with 360 on 02/13/19 was a follow-up only. Upon inquiry as to whether the appointment was rescheduled, she replied in the negative. She said this was the first she has heard of her missing glasses. She spoke her opinion that the glasses she wore were not prescription lenses, but instead were readers. She said the resident did not tell any staff that her readers were gone and she wanted them back. A second interview was completed with the resident on 12/05/19 at 11:05 AM. She said she would love to read large print books if she had her glasses. She said she may or may not watch TV as TV sometimes gets on her nerves. She said her missing glasses were prescription lenses, not readers. She said the lenses got darker in bright light. When asked who she told about the missing glasses, she said everybody. She said someone came by today and told her she has an appointment with the eye doctor here at the facility on 12/10/19. An interview was completed with nursing assistant #82 (NA #82) on 12/05/19 at 11:10 AM. She said she and other nurse aides were aware of the loss of the resident's glasses. She said she has looked for the resident's glasses to no avail. An interview was conducted with RN #58 on 12/05/19 at 11:15 AM. She verified that the vision company 360 will be at the facility next week to check her eyes. An interview was conducted with the director of nursing (DON) and the administrator on 12/05/19 at 12:15 PM. The DON spoke awareness that the resident is now scheduled for an eye exam at the facility next week, and said they will ensure she gets new glasses. No further information was provided prior to exit.",2020-09-01
475,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,695,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure a resident who needs [MEDICAL CONDITION] care and suctioning is provided care that is consistent with professional standard of practice. This affected one (1) of one resident reviewed for [MEDICAL CONDITION] care. Resident identifier: Resident #187. Facility census 91. Findings include: a) Resident #187 The medical record was reviewed on 12/03/19. This resident first came to the facility on [DATE]. He received a [MEDICAL CONDITION] during a hospitalization which immediately preceded his admission to the facility. Physician's orders did not address the humidification bottle's percentage setting, or the percentage pressure setting of the aerosol compressor. Physician's orders did not set parameters for the pulse oximetry measurements for when he should be notified or how often to obtain pulse oximetry measurements. The care plan as related to the [MEDICAL CONDITION] was sparse. It directed to [MEDICAL CONDITION] were secured at all times, humidified oxygen (did not include percentage or equipment settings), suction as necessary, keep an [MEDICAL CONDITION] and obturator at bedside - if coughed out, open stoma with a hemostat if tube cannot be reinserted. The care plan did not include the type and size of the airway. Observation of the resident on 12/03/19 at 3:45 PM found him lying in bed with the head of the bed elevated. He received humidification to [MEDICAL CONDITION] from a Heavy Duty Aerosol Compressor. This machine sat upon a bedside table to the left of the resident's bed. A portable suction machine also sat upon the bedside table. There was no suction catheter or yonker at the machine. On the right of the resident's bed an oxygen concentrator sat on the floor. This machine was turned on and was delivering oxygen at six (6) liters per minute (lpm). The opposite end of the oxygen tubing lay in his bed but was not connected to anything. An interview was conducted with licensed nurse #119 (LPN #119) on 12/03/19 at 3:45 PM. She acknowledged the concentrator was set at six (6) lpm running, but the tubing was laying on the bed and not connected to anything. She said he was not receiving oxygen, rather just humidified air. She said the Heavy Duty Aerosol Compressor was set on 40 on the dial. She said it delivered 28% humidification and showed on another dial as such. She said she would have to check orders to see about the settings as this was the way in which it was set. When told there was nothing in the physician's orders or the care plan about the settings, she said she would look for the unit manager. She showed that the suction catheters were inside the resident's closet which was located against the wall across from the foot of the resident's bed. At 3:55 PM on 12/03/19 LPN #119 was observed in the front hall talking with unit manager registered nurse #58 (RN #58). The following issues were discussed with RN #58: 1. The suction machine at the bedside had no suction catheter at the bedside for emergency suctioning. 2. The dial on the Heavy Duty Aerosol Compressor was set on 40, and it appears that the setting on the humidifier bottle may be at 28%. However, there are no MD orders or care planned directives as to how to set this machine or the humidifier bottle. 3. The humidifier bottle on the Heavy Duty Aerosol Compressor had an expiration date of (MONTH) (YEAR). RN #58 then walked to the resident's room. While en route, she asked health information coordinator #101 (HIC #101) if they had Tupperware containers and if Resident #187 had one at his bedside. HIC #101 replied they do have Tupperware containers, but that Resident #187 had none yet at his beside. RN #58 agreed the humidifier bottle was beyond the expiration date, and she obtained a fresh one. She looked at the oxygen concentrator. Someone had come in and removed the oxygen tubing from the concentrator and turned it off. She agreed there was no suction catheter at the bedside for emergency if needed. She looked inside the resident's closet which had a jumble of oxygen therapy equipment inside, and found a sterile suction catheter/bag and laid it by the suction machine. She said had the Tupperware box been at the bedside that the suction catheter would have been inside it. She said she understood that it should be at the bedside as in an emergency people want it quickly. She looked at the dial on the Heavy Duty Aerosol Compressor. She said it was set by the respiratory therapist. She was informed that there were no parameters to follow in the physician's orders or the care plan regarding the settings. She said the physician is here today and she will ask him about clarification in the orders. She said she will also update the baseline care plan. Further review of the medical record on 12/04/19 found the following entries for pulse oximetry: -11/28/19 - 97% at 6:28 PM, 94% at 6:55 PM and 94% at 4:19 PM -11/29/19 - 94% at 3:15 PM, and 95% at 7:38 PM -11/30/19 - 94% at 1:18 PM -12/01/19 - 94% at 3:05 PM -12/02/19 - NONE RECORDED -12/03/19 - 98% at 7:27 PM On 12/04/19 at 9 AM an interview was conducted with the director of nursing (DON). It was discussed that pulse oximetry readings were only done and/or recorded sporadically since admission as noted on the dates and times above. She agreed there were no physician's orders or care planned directives as to how often to assess his oxygen level. When asked how often she expected staff to obtain pulse oximetry rates, she said only when the physician orders it. An interview was conducted on 12/04/19 at 9:15 AM with RN #58. She said his pulse oximetry measurement has always been above 92% so they do not routinely check it as he is on room air, not oxygen. When asked what their policy directed for the frequency of pulse oximetry measurement for residents with trachs, she said that staff check the resident's pulse oximetry whenever they [MEDICAL CONDITION], and before and after suctioning, but they do not write it down. RN #58 said staff should document each time they assess the pulse oximetry. She acknowledged the standard that it if it is not documented, then it did not happen. An interview was conducted with staff development registered nurse #36 on 12/04/19 at 9:30 AM. When asked what [MEDICAL CONDITION] policy and procedure said about assessing pulse oximetry, she said it just says to assess the patient. She said she obtains pulse oximetry assessment at least before and after care provided to the trach. She said she could not speak for all nurses that they are documenting pulse oximetry results. At 10:30 AM on 12/04/19 RN #58 brought a copy of a policy titled [MEDICAL CONDITION] Management which had a release date of (MONTH) (YEAR) as a Clinical Practice Standard; a copy of a policy titled Spontaneous Decannulation: Reinsertion of [MEDICAL CONDITION] with revision date (MONTH) 2008; and another titled Tracheal Button Insertion, with revision date (MONTH) 2008. None of these address obtaining oxygen levels per pulse oximetry. An interview was conducted with the administrator and the DON on 12/05/19 at 12:15 PM. It was discussed that the baseline care plan was found silent as to the settings of the Heavy Duty Aerosol Compressor and the percentage of humidification; how often to assess and document pulse oximetry measurements; the type and size of the airway; and the provision of all emergency equipment at the bedside which includes suction catheters. It was discussed that physician's orders did not address the settings of the Heavy Duty Aerosol Compressor and the percentage of humidification; physician's orders did not set parameters for the pulse oximetry measurements for when he should be notified or how often to obtain pulse oximetry measurements. It was also discussed that the humidifier bottle in use on 12/03/19 had an expiration date of (MONTH) (YEAR). They acknowledged understanding. No further information was provided prior to exit.",2020-09-01
476,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,758,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the pharmacy first recognized a resident received a psychoactive medication, and then communicated to the physician of the need to consider a gradual dose reductions of the medication. This affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #9. Facility census 91. Findings include: a) Resident #9 Review of the medical record on 12/04/19 found this resident was initially prescribed an antidepressant medication on 07/11/18. The resident has continued on this medication and has remained on the same dose through the current date. Further review of the medical record found no evidence that the pharmacy had even once recommended to the physician the consideration of a gradual dose reduction (GDR). An interview was conducted with Health Information Coordinator #101 (HIC #101) on 12/05/19 at 9:30 AM. She said she reviewed all the pharmacy information for this resident and found nothing related to any pharmacy recommendations to the physician to consider a GDR of this antidepressant. An interview was conducted with registered nurse unit manager #58 (RN #58) on 12/05/19 at 10 AM. She said this resident is a hospice patient who entered hospice in (MONTH) 2019. It was discussed that the pharmacy did not relay to the physician a need for the consideration of GDR for [MEDICAL CONDITION] medications in two (2) quarters separated by at least one (1) month in the first year of administration ever since the start date of the medication on 07/11/19. She was unable to provide evidence that this resident had received a trial GDR of the antidepressant or of pharmacy recommendation to the physician to consider a GDR. Relayed that the physician has the right to decline a GDR if he/she includes a written rationale related to the declination. An interview was conducted with the director of nursing and the administrator on 12/05/19 at 12:15 PM. The lack of pharmacy communication to the physician related to consideration of a GDR for a [MEDICAL CONDITION] medication was discussed. No further information was provided prior to exit.",2020-09-01
477,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2019-12-05,842,D,0,1,QN1C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to maintain medical record on each resident that are complete and accurately documented. Residents inventory of personal effects form were not found in the residents medical record. This had the potential to affect two (2) of twenty -one resident reviewed during the annual survey. Resident #70 and #8. Facility census 91. Findings included: a) Resident #70 Resident #70 was admitted on [DATE]. Resident #70's quarterly Minimum Data Set (MDS) with the assessment reference date (ARD) of 11/24/19, reveals Resident #70 makes self understood, and understands others. Resident Brief Interview for Mental Status (BIMS) reveals Resident #70'S scored a 15 on her BIMS. In an interview on 12/02/19 at 11:54 AM, revealed Resident stated that, she had lost one (1) black skirt two (2) weeks ago. Resident #70 said the laundry told her they would look for the skirt. An interview was conducted with Laundry employee #17 on 12/04/19 at 8:55 AM. Laundry employee #17 stated that she was told about the skirt. She pointed to a note on the wall in the laundry room, which revealed Resident #70 had lost a black skirt. The laundry worker said she is looking for the skirt and if she does not find the skirt, she will do a concern form. The Administrator on 12/04/19 at 9:00AM, when asked where is residents inventory of personal effects forms in found in the resident hard chart. The Administrator stated that, the form should be found under miscellaneous section. A review of Resident #70's inventory of personal effects form in medical record on 12/04/19 at 9:20 AM, found no inventory of personal effects forms. b) Resident #8 Resident #8 was admitted on [DATE]. A review of Resident #8's quarterly MDS with the ARD of 11/24/19, reveals Resident #8 is identified that he can make self understood and understands others. In an interview with Resident #8 on 12/02/19 at 11:41 AM, the resident said he lost 25 diamonds in a gold ring. Resident #8 revealed that he reported this to the administrator a month ago. The Resident said the Administrator told him that he told him he would replace it. In an interview with Laundry employee #17 on 12/04/19 at 8:58 AM, she was asked whether she was asked to look for Resident #8's, 25 diamonds in a gold ring. Laundry employee #17 stated that, I was not aware (Resident's name ) had lost his ring nor was I told to look for the ring. A review of Resident #8's chart on 12/04/19 at 9:22 AM, found no inventory of personal effects form for Resident #8. In an interview and observation with Resident Care Specialist (RCS) #114 on 12/04/19 at 9:25 AM, she looked for Resident #70 and #8's inventory of personal effects forms. The RCS was unable to find a inventory of personal effects form in the residents record. The RCS stated that each resident should have a inventory of personal effects form completed when they are admitted to the facility. This form is found under the miscellaneous section. The RCS #114 asked the Unit Manager (UN) #58 on 12/04/19 at 9:30 AM, where Resident #8 and #70's inventory of personal effects forms could be found. The UN said under the miscellaneous section. The UM confirmed Resident #70's and #8's medical record did not contain their inventory of personal effects form when they had admitted the residents. The facility's policy revealed any persons clothing or possessions retained by the facility for the resident during his or her stay will be identified and inventoried upon admission using the inventory of personal effects form. A copy of the completed form is provided to the resident, another is placed in the resident's medical record and a third copy is included with any valuables placed in the facility safe or a locked cabinet. When the Administrator on 12/04/19 at 11:00 AM, was informed that Resident #8 stated that he had informed him (the Administrator) of losing his 25 diamond in a gold ring a month ago, and the resident stated that, you ( the Administrator) told Resident #8 the ring would be replaced. The Administrator denied every knowing Resident #8 had lost 25 diamond in a gold ring. The Administrator stated that they was unaware the Resident #8 had lost a diamond ring and they would fill out a concern form. The Administrator on 12/04/19 at 1:14 PM, was informed that Resident #8 has no inventory of personal effects form in his medical record. Therefore there is no way to determine whether Resident #8 had 25 diamonds in a gold ring while residing in the facility. The Administrator was informed that their policy stated a copy of the completed form is provided to the resident, another is placed in the resident medical record and a third copy is placed in the facility safe or a locked cabinet. The Business office Director( BOD) #93 and the Administrator confirmed they do not have any record of the inventory in their facility safe or locked cabinet. The Administrator stated that, he was aware the facility staff have been having problems completing an inventory of personal effects form on their residents. The Administrator, also acknowledged that Resident #70 did not have an inventory of personal effects form in her chart.",2020-09-01
479,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,641,D,0,1,ZJL811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure assessments accurately reflect each residents' status. Resident #3's medication assessment inaccurately reflects anticoagulants and Resident #15's assessment lacks a [DIAGNOSES REDACTED]. Resident identifiers: #3 and #15. Facility census: 16. Findings included: a) Resident (R) #3 Review of the medical record on 04/16/19, revealed R #3's daily medications include aspirin 81 milligrams and [MEDICATION NAME] ([MEDICATION NAME] a platelet inhibitor) 75 milligrams daily and no anticoagulants. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/06/19 and the annual MDS assessment with an ARD of 07/13/18 are coded under section N0410E indicating R #3 received an anticoagulant daily during the seven (7) day look back period. During an interview on 04/17/19 at 9:10 AM, the Patient Care Coordinator / Licensed Practical Nurse (LPN) #12 reviewed R #3's MDS assessments and reported they were coded for anticoagulants because she was receiving [MEDICATION NAME] ([MEDICATION NAME]). LPN #12 stated she was unaware the MDS guidelines state not to code [MEDICATION NAME] as an anticoagulant. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.15, dated (MONTH) (YEAR) states under coding instructions for section N medications: [REDACTED]., [MEDICATION NAME], or low- molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] ([MEDICATION NAME]) here. b) R15 During a medical record review for R15 on 04/17/19 revealed the Medium Data Set (MDS) quarterly assessment with the Assessment Reference Date ARD of 01/28/19 did not accurately include [MEDICAL CONDITION] as a [DIAGNOSES REDACTED]. Further review indicated R15 was receiving two (2) medications for [MEDICAL CONDITION]; [MEDICATION NAME] 0.15% ophthalmic solution 3 times daily, 1 drop in right eye for [MEDICAL CONDITION] and [MEDICATION NAME] 2% ophthalmic solution 3 times daily, 1 drop to right eye for [MEDICAL CONDITION] both had a start date of 12/09/18. In an interview on 04/16/19 at 11:30 AM, with E12, Patient Care Coordinator (PCC) verified the MDS for R15 did not include the [DIAGNOSES REDACTED].",2020-09-01
480,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,656,D,0,1,ZJL811,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to develop person-centered care plan for two (2) of fourteen (14) care plans reviewed during the investigation phase of the survey process. The care plan for R1 had not been developed for the [DIAGNOSES REDACTED]. Resident identifiers: R1 and R15. Facility census: 16. Findings included: a) R1 During a medical record review on 04/16/19 for R1 revealed the care plan had not been developed for the [DIAGNOSES REDACTED]. In an interview on 04/16/19 at 1:30 PM with E12 the Patient Care Coordinator (PCC) verified the care plan for R1 had not been developed for [MEDICAL CONDITION]. b) R15 During a medical record review on 04/16/19 for R15 the care plan had not been developed for the intervention of a non-pharmacological topical cream for pain. Further investigation included an order for [REDACTED]. In an interview on 04/16/19 at 1:35 PM with E12 the Patient Care Coordinator (PCC) verified the non-pharmacological topical cream had not been included as an intervention for pain for R15.,2020-09-01
481,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,657,D,0,1,ZJL811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to revise a care plans for two (2) of fourteen (14) care plans reviewed during the investigation phase of the survey process. The care plan for R1 had not been revised to reflect the dosage increase for [MEDICATION NAME] and for R15 the care plan had not been revised to include an assistive gait belt for fall prevention. Resident identifiers: R1 and R15. Facility census: 16. Findings included: a) R1 During a medical record review on 04/16/19 for R1 revealed the care plan had not been revised in the area of [MEDICAL CONDITION] Drug Use for a dosage increase of [MEDICATION NAME]. The physician's orders [REDACTED].>had been increased to 150 milligrams (mg) to be given nightly for a psychological disorder with a start date of 01/30/19. In an interview on 04/16/19 at 1:45 PM with E12 the Patient Care Coordinator (PCC) verified the care plan for R1 had not been revised to reflect the increase of [MEDICATION NAME] from 125 mg to 150 mg. b) R15 During a medical record review on 04/16/19 for R1 revealed the care plan had not been revised to include the assistive gait belt as an intervention for fall prevention. The care plan for R15 had been revised for a fall on 04/09/19, but did not include the physician's orders [REDACTED]. In an interview on 04/16/19 at 1:30 PM with E12 the Patient Care Coordinator (PCC) verified the care plan for R15 had not been revised to include the assistive gait belt as an intervention for falls. E12 also stated she reviews all new orders every Friday and this order had been missed.",2020-09-01
482,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2019-04-17,684,D,0,1,ZJL811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to provide needed care and services in accordance with resident's preferences, goals and to provide professional standard of practice to promote resident's physical, mental and psychosocial needs. This was true for one (1) of five (5) residents reviewed for Unnecessary Medications. R1 did not receive the medication [MEDICATION NAME] as ordered. Resident identifier: R1. Facility census: 16. Findings included: a) R1 During a medical record review on 04/16/19 it was discovered R1 had not received the medication [MEDICATION NAME] as ordered. The physician's orders [REDACTED]. Further investigation of the Medication Administration Record [REDACTED]. --7 of 15 doses not administered with breakfast --8 of 15 doses not administered with lunch --15 of 15 doses not administered with dinner --15 of 15 doses given correctly with a snack In an interview with the Director of Extended Care Services on 04/16/19 at 3:20 PM verified R1 had received 30 doses of [MEDICATION NAME] without food.",2020-09-01
486,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2017-05-09,280,D,0,1,KOWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for Resident #8 when there was a change in an antibiotic medication regimen. This practice was found for one (1) of fourteen (14) Stage 2 sample residents whose care plan was reviewed during the Quality Indicator Survey (QIS). Resident Identifier: #8. Facility census: 16. Findings include: a) Resident #8 A review of Resident 38's medical record, at 2:26 p.m. on 05/09/17, found a physician's orders [REDACTED]. The care plan for Resident #8 was silent for goals and interventions related to the antibiotic medication Bactrim. After reviewing the care plan on 05/09/17 at 3:22 p.m., Registered Nurse (RN) #26 verified the care plan did not contain goals and interventions related to the antibiotic medication Bactrim. She stated , I will check with my co-worker the other Minimum Data Set (MDS) nurse to see if she can find anything. RN #26 reported on 05/09/17 at 3:30 p.m. It just got missed (the antibiotic medication Bactrim) when it was restarted.",2020-09-01
490,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,656,D,0,1,VZPJ11,"Based on observations, medical record review and staff interview, the facility failed to develop and implement a comprehensive care plan for the use of a seat belt alarm restraint for Resident #5. This was true for one (1) one of (1) one residents reviewed for use of physical restraints. Resident identifier: #5. Facility census: 16. Findings included: a) Resident #5 On 05/08/18 at 10:56 AM, during a observation of Resident #5 it was discovered she had a seat belt alarm restraint activated across her waist while she was in a wheelchair. A review of the medical record on 05/08/18 revealed the comprehensive care plan written on 05/02/18 did not address the use of a physical restraint. Interventions must include medical symptoms to justify the use of the restraint, type of restraint, frequency, duration, circumstances for when to be used, and assessment for less restrictive alternatives, also interventions to address potential or actual complications from restraint use such as: increased incontinence, decline in activity of daily living (ADL) or range of motion (ROM), increased confusion, agitation or depression. During interviews with the director of nursing (DON) and Minimum Data Set (MDS) Coordinator on 05/09/18 at 9:30 AM, verified the comprehensive care plan for Resident #5 did not address physical restraints or interventions for using a seat belt alarm restraint.",2020-09-01
491,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,657,D,0,1,VZPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise residents' care plans when conditions or interventions changed. Resident #1 continued to have a care plan for monitoring administration of an anticoagulant medication that was discontinued on 3/25/18, and Resident #10's care plan was not revised to include bilateral contractures of shoulders and hands. This was found for two (2) of thirteen (13) residents reviewed. Resident identifiers: #1, #10. Facility census: 16. Findings included: a) Resident #1 Review of the care plan for Resident #1 on 5/9/18 at 9:00 AM found an active problem for risks of adverse side effects due to daily use of the anticoagulant [MEDICATION NAME]. The goal was to prevent excessive bleeding or bruising by monitoring the resident closely. Review found the medication had been ordered by the Physician for seventeen (17) doses, beginning on 3/9/18 and ending on 3/25/18. An interview was conducted with Registered Nurse (RN) #11 on 5/9/18 at 9:30 AM. She agreed the care plan should have been revised to remove the problem when the final dose of the anticoagulant was stopped on 3/25/18. b) Resident #10 A medical record review for Resident #10 on 05/09/18 revealed the quarterly Minimum Data Set (MDS) with assessment reference date of 02/28/18 reported this resident to have contractures to both hands, both shoulders and both hips. The care plan was not revised to include contractures to both hands and both shoulders under the activity of daily living (ADL) functioning problem. In an interview with the director of nursing (DON) on 05/09/18 at 10:55 AM, verified the care plan had not been revised to include all the contractures for Resident #10.",2020-09-01
494,ST. JOSEPH'S HOSPITAL,515051,AMALIA DRIVE #1,BUCKHANNON,WV,26201,2018-05-09,842,D,0,1,VZPJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident # 5. The physician order [REDACTED]. This was true for one (1) of thirteen (13) medical records reviewed during the survey process. Resident identifier: #5. Facility census: 16. Findings included: a) Resident #5 A review of the medical record for Resident #5 on 05/09/18 revealed the current physician orders [REDACTED]. The physician order [REDACTED]. In an interview with the director of nursing (DON) on 05/09/18 at 9:30 AM, verified the physician order [REDACTED].#5.",2020-09-01
498,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,578,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's advance directives, communicated via the Physician order [REDACTED]. Resident identifier: #38. Facility census: 100. Findings included: a) Resident #38 Review of the medical record found the Resident lacked capacity to make medical decisions, and her son was her legal representative. Review of the current POST form noted the Resident did not wish to be resuscitated, have comfort measures, a feeding tube, or IV fluids for a trial period of no longer than 3-5 days. Under the heading, signature of Patient/Resident, the form noted verbal consent was obtained from (Name of son) via phone on 09/29/19. The physician signed the POST form on 08/01/19, although the POST form indicated the Resident's son did not complete the form until 09/29/19. The date the form was prepared by a facility nurse was 07/29/19. The resident's electronic medical record as well as the current care plan directed, do not attempt resuscitation, or comfort measures. Review of the instructions for the 2016 edition entitled, Using the POST form, section D, found: The patient or representative/surrogate and physician/APRN (Advanced Practice Registered Nurse) must sign the form in this section. These signatures are mandatory. A form lacking these signatures is NOT valid. The physician/APRN then prints his/her name, phone number, and the date and time the orders were written. On 01/29/20 at 10:10 AM, the facility social worker (SW) #81 verified the Resident's son did not sign the POST form. SW #81 said she did not know anything about the POST form because she was not present when the POST form was completed. The POST form was discussed with the administrator at 8:06 AM on [DATE]. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
499,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,580,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record interview and interview, the facility failed to notify the physician when medications were held for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found the resident was ordered to receive [MEDICATION NAME] 5/325 milligrams (mg) via the feeding tube three times daily for pain and [MEDICATION NAME] 0.25 mg via feeding tube three times a day for anxiety. Review of Resident #98's nurses progress notes found on 10/31/19 at 6:55 PM, a Licensed Practical Nurse (LPN) #138 held the [MEDICATION NAME] and [MEDICATION NAME]. Note attached to the holding of [MEDICATION NAME] and [MEDICATION NAME] as follows: Medication held due to drowsiness, spoke with son and he was also in agreement to hold the medication. There was no documentation the physician was notified of the withholding of the medication. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:15 PM, they verified after reviewing the medical records for Resident #98, the physician had not been notified of the withholding of [MEDICATION NAME] and [MEDICATION NAME] on 10/31/19. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
500,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,584,D,0,1,CN2N11,"Based on record review and interview, the facility failed to ensure reasonable care for the protection of resident's personal property from loss or theft for one (1) of one (1) resident reviewed for the care area of personal property. Resident identifier: #58. Facility census: 100. Findings included: a) Resident #58 On 0[DATE] 03:01 PM, the Resident's son said he had no problems with the facility other than, They lose clothes in laundry sometimes they find them, sometimes not. It's just aggravating not a big problem. I have been labeling them myself. Sometimes they don't label them, and I think that is what causes the problem. Review of the notes in the electronic medical record found a progress note, dated 06/27/19 at 9:14 AM, during a care conference for the resident, his son raised his concern that his mother had some articles of clothing that are missing. At 11:44 AM on 01/28/20, the Social Worker (SW) #33 confirmed she could not find information to indicate the investigation into the allegation of missing clothing. SW #33 said someone at the facility should have completed a complaint form, then this allegation would have been assigned to someone in environmental services. She said if an item is missing and we can confirm the Resident had the item, the facility would reimburse the family member or replace the missing item. At 8:06 AM on [DATE], the Administrator was informed of the above information. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
501,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,623,D,0,1,CN2N11,"Based on record review and staff interview, the facility failed to provide the Ombudsman with notification of a resident's transfer to the hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Resident #[AGE] A record review for Resident #[AGE] on 01/28/20, revealed two (2) Minimum Data Sets dated [DATE] and 12/24/20 for transfer to an acute care hospital. Further review indicated there had been no notifications of these hospitalization s sent to the Ombudsman. On 02/03/20 at 1:52 PM, the Nursing Home Administrator (NHA) verified there were no notices sent to the Ombudsman for hospitalization s on [DATE] and 12/24/19. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
502,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,641,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for three of 20 residents. Resident identifiers: #99, #38, #98. Facility census: 100. Findings included: a) Resident #99 Review of Resident #99's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/12/20, stated the resident had two (2) Stage 2 pressure ulcers. Resident #99's Pressure Ulcer Reassessment dated [DATE], documented a Stage 4 pressure ulcer on the left buttock. An initial Pressure Ulcer Assessment also performed on 01/07/20 documented a new unstageable pressure ulcer on Resident #99's sacrum. Resident #99's Pressure Ulcer Reassessments dated 01/14/20 documented a Stage 4 pressure ulcer on the left buttock and a Stage 3 pressure ulcer on the left buttock. During an interview on 02/03/20 at 11:46 AM, the Regional Director of Operations stated Resident #99's MDS with ARD 1/12/20 was incorrect. She stated Resident #99 did not have two (2) Stage 2 pressure ulcers at that time. No further information was provided through the completion of the survey. b) Resident #38 Review of Resident's quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19, coded the resident as receiving an anticoagulant for 2 days during the assessment period. Review of the Medication Administration Record [REDACTED]. At 2:26 PM on 01/29/20, during an interview with the nursing coordinator #139, it was confirmed the MDS was incorrectly coded, and the resident did not receive an anticoagulant. c) Resident #98 Review of the Resident's medical record found a comprehensive (5-day) minimum data set (MDS) with an assessment reference date (ARD) of [DATE], coded as the Resident received a hypnotic medication. Review of the November 2019, physician orders [REDACTED]. At 01/31/20 at 12:54 pm, the MDS registered nurse employee #139, confirmed the MDS was incorrect. In addition, E #139 confirmed the resident was not ordered a hypnotic. E #139 said she would correct this MDS error. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
503,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,656,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a person-centered comprehensive care plan for one of twenty (20) residents reviewed. The care plan for Resident #57 was not developed for the [DIAGNOSES REDACTED].#57. Facility census: 100. Findings included: a) Resident #57 A record review on 01/29/20, revealed the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/20, indicated the Resident had a [DIAGNOSES REDACTED]. During an interview on 01/29/20 at 11:15 AM, the Director of Nursing (DON) verified the care plan had not been developed for the [DIAGNOSES REDACTED].#57. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
504,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,657,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan for one of 20 residents reviewed. Resident identifier: #17. Facility census: 100. Findings included: a) Resident #17 Review of Resident #17's comprehensive care plan revealed the following focus, (Resident's name) has an ADL Self Care Performance Deficit r/t (related to) stroke, left [MEDICAL CONDITION]. Interventions included, Bathing: The resident requires 1 staff participation with bathing.Resident receives a shower on Monday/Thursday and a bed bath the remaining days. Review of Resident #17's task report for January 2020, revealed she received showers on Tuesdays and Fridays. During an interview on 01/29/20 at 9:49 AM, the Director of Nursing (DON) verified Resident #17 received showers on Tuesdays and Fridays, but her care plan stated she received showers on Mondays and Thursdays. The DON stated she would update the care plan to reflect Resident #17 received showers on Tuesdays and Fridays. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
506,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,690,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received the appropriate treatment for [REDACTED]. In addition, this placed the resident at risk for developing antibiotic-resistance. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100,000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. A review of the Medication Administration Record [REDACTED]. Review of the C&S report found [MEDICATION NAME] (Cipro) is Resistant (R) to E coli and not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM, the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
508,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,697,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to manage the resident's pain in accordance with facility policy and physician order. This was true for one (1) of three (3) of residents reviewed for the care area of pain. Resident identifier: #17. Facility census: 100. Findings included: a) Policy Review According to the facility's policy entitled, Medication Administration - general guidelines with effective date 1/1/17 When PRN medications are administered, the following documentation is provided: .Complaints or symptoms for which the medication was given, including any nonpharmacologic interventions attempted by the nursing staff prior to administration of the PRN medication. b) Resident #17 Review of Resident #17's physician's orders [REDACTED]. Resident #17 also had an order initiated 03/01/19 to evaluate for signs and symptoms of pain every four (4) hours. This pain assessment was performed daily at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. From January 1, 2020, through January 14, 2020, Resident #17's pain was assessed as 0 on a scale from 1-10. A score of 0 indicates the absence of pain. On 01/13/20 Resident #17's [MED] with [MEDICATION NAME] order was changed from a scheduled order three times per day to one tablet by mouth every six hours as needed for pain. For this medication, the MAR indicated [REDACTED]. On 01/14/20, Resident #17's pain assessment order was changed to evaluate for signs and symptoms of pain every six (6) hours. This pain assessment was performed daily at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Resident #17's pain was assessed as 0 on a scale from 1-10 at each assessment from 01/14/20 through 01/28/20. On 01/14/20 at 6:55 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 6, on a scale from 1-10. The medication was documented as effective. On [DATE] at 8:07 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 4, on a scale from 1-10. The medication was documented as effective. On 01/20/20 at 7:39 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 5, on a scale from 1-10. The medication was documented as effective. On 01/21/20 at 9:04 AM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 5, on a scale from 1-10. The medication was documented as effective. On 01/22/20 at 8:02 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 4, on a scale from 1-10. The medication was documented as effective. On 0[DATE] at 8:31 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 0, on a scale from 1-10. The medication was documented as effective. On 01/24/20, Resident's [MED] with [MEDICATION NAME] order was changed to one (1) tablet by mouth every six (6) hours as needed for pain, administer after repositioning for pain is ineffective. For this medication, the MAR indicated [REDACTED]. On 01/25/20 at 10:30 AM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. On 01/26/20 at 9:50 AM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. On 0[DATE] at 9:01 PM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. During an interview on 01/29/20 at 10:21 AM, the Director of Nursing (DON) confirmed Resident #17's pain was not assessed prior to receiving as needed pain medication on 01/25/20, 01/26/20, and 0[DATE]. The DON acknowledged the resident's every six (6) hour pain assessments documented no pain and were performed at 12:00 AM, 6:00 AM, 12:00 PM. and 6:00 PM, and not when the as needed pain medication was administered. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
509,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,698,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received Phosphorus supplements as requested. This failed practice had the potential to affect a limited numer of residents. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical record found on [DATE] at 10:23 AM, the [MEDICAL TREATMENT] center physician requested a phosphorus supplement due to the resident's phosphorus level being low at 2. The facility Nurse Practitioner (NP) was notified on [DATE] at 2:17 PM, and said, The nephrologist needs to recommend what phosphorus supplement he wants. On 01/02/20 at 12:16 pm, the [MEDICAL TREATMENT] center was notified concerning what phosphorus supplement the nephrologist wanted. The [MEDICAL TREATMENT] center responded with, (Nephrologist Name) is out of town and will not return till 01/13/20. The Resident's medical record contained no documentation the attending physician was consulted for a phosphorus supplement. In addition, no further communication between the [MEDICAL TREATMENT] center and the facility concerning the phosphorus could be found. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:30 pm, they confirmed there was no documentation to indicate the attending physician was notified concerning a phosphorus supplement. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
512,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,761,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled in accordance with facility policay for one (1) of eight (8) [MED]'s stored in the B-hallway medication cart. Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Policy Review The facility's policy entitled, Vials and [MEDICATION NAME] of Injectable Medications with effective date 01/01/2017 stated, When a vial is opened, the licensed nurse records the opened date on the vial. b) Resident #[AGE] On 01/28/20 at 9:08 AM, the B-hall medication cart was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Resident #[AGE]'s [MEDICATION NAME] Solution Pen-injector ([MED] [MEDICATION NAME]) was not dated when opened. LPN #[AGE] confirmed Resident #[AGE]'s [MED] pen-injector was not dated when opened. The facility's Administrator was informed of the above findings on 01/28/20 at 9:34 AM. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
513,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,773,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the ordering physician of laboratory results outside of the clinical reference range for Resident #98. Additionally, the facility failed to obtain laboratory testing for Resident #57, as directed per physician's orders [REDACTED]. Resident identifiers: #98 and #57. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found an order to obtain an ammonia level. This level was obtained on [DATE] at 3:31 pm. The ammonia level was [AGE] which was critically high. Normal ammonia level is 9-35. Review of the progress notes found the attending physician was not notified of the labortory results until 10/21/19 at 5:11 pm. An interview with the Director of Nursing, on 01/30/20 at 1:10 pm, confirmed, after the review of Resident #98's medical record, there was a delay in notifying the physician of a critical lab. b) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician had ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100.000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. Review of the Medication Administration Record [REDACTED]. Review of the C& S, [MEDICATION NAME] (Cipro) is Resistant (R) to E coli an not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
518,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,583,D,1,0,DQUX11,"> Based on staff interview, family interview and record review, the facility failed to safeguard, ensure, and maintain the privacy and confidentiality of a resident's clinical record. An unauthorized disclosure of Resident#6's clinical record, without Resident#6's consent or knowledge, was given by accident to another resident's family member to take to a consulting physician's appointment. This is true for one (1) of one (1) resident reviewed for privacy and confidentiality. This practice had the potential to affect more than a limited number of residents. Resident identifier: #6. Census: 85. Findings included: a) Resident #6 On 04/16/18 at 1:05 PM, an interview with the Ombudsman information concerning issues that had been brought to the Ombudsman's attention. The Ombudsman stated it was revealed a resident's family member had mistakenly been given another resident's clinical records to take with them to a doctor's appointment. On 04/16/18 at 2:38 PM, an interview with Resident#3's daughter-in-law revealed, upon arriving with Resident #3 at a doctor's appointment in another city, it was discovered she had mistakenly been given Resident #3's roommates medical records to take to the appointment. The daughter-in-law had requested Resident#3 records, but by mistake was given Resident#6's medical records. The daughter-in-law said she returned the records back to the facility, when she returned the resident (Resident #3) back to the facility. Resident#3's daughter-in-law said, she was asked by the facility to not tell Resident #6 (the roommate of Resident #3) what had occurred. The daughter-in-law, also a nurse, said she was very upset about the incident and told the facility she was concerned her mother-in-laws records could also be compromised. On 04/18/18 at 9:30 AM, review of all Resident Council meeting minutes; all Incident/Accident logs; all Grievances/Complaint/Concern logs and reports; and all Reportable incidents with related investigations for the past six (6) months, revealed no incidents or grievances concerning an incident of a resident accidently receiving another resident's medical record to take with them to an appointment. An interview with the director of nursing (DON), on 04/19/18 at 11:29 AM, revealed the DON was aware and confirmed the incident did occur, and that it was a HIPAA (Health Insurance Portability and Accountability Act) violation. The DON, said a nurse accidently gave Resident #3's daughter-in-law Resident#6 medical records, instead of Resident#3's medical records. When asked why it was not logged on the grievance log, the DON said she did not know, but it should have been.",2020-09-01
520,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,609,D,1,0,DQUX11,"> Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required.",2020-09-01
521,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,610,D,1,0,DQUX11,"> Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required.",2020-09-01
524,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,880,D,1,0,DQUX11,"> Based on staff interview, family interview and record review, the facility failed to implement proper infection control monitoring. Soiled clothing was left in Resident #1's drawers and closets creating an infection control concern. This was evident for one (1) of four (4) sampled residents currently in the faciilty. Census: 85. Findings included: a) Resident #1 During the investigation confidential interviews were conducted with family members on 04/16/18 in the afternoon. It was found that Resident #1 was known to remove soiled clothing and place them in the drawer or closet in their room. This issue was known to staff and the care plan interventions required staff to monitor the draweres and closets in the room every shift for soiled clothing and perform visual checks of the area. This was not being implemented and soiled cloting is still being left in these areas and family will come in and notice odors which are coming from the soiled clothing. This procendure could lead to an infection control issue and soiled clothing is not being handled using proper infection control techniques. The issue was discussed with the director of nursing on 04/17/18 in the afternoon. An inservice was conducted on 12/24/17 but this has still not corrected the problem.",2020-09-01
525,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,241,D,0,1,FJSP11,"Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one randomly observed resident, during a dinner time meal. One (1) nurse aid (NA) approached Resident #149 to set the resident up for the meal without speaking to the resident or letting the resident know what the NA was about to do. Resident identifier: #149 and #99. Facility census: 87. Findings include: a) Resident #149 Random observation during the dinner time meal, on 11/06/17 at 5:12 p.m., revealed Resident #149 was reclining in a geri chair beside a dinner table. Nurse Aide (NA) #44 came up behind Resident #149, and without saying anything to the resident or explaining what he was about to do changed the geri chair from a reclining position to a sitting position. The sudden quick movement from a reclining to a sitting position jarred the resident and caused the resident to scream out. b) Resident #99 Random observation during the dinner time meal, on 11/06/17 at 5:22 p.m., revealed NA #44 was feeding Resident #99 as she was leaning to the right side in her gerri-chair, with her head leaning forward. LPN #26 also in the dining room at the time and after observing NA #44 feeding Resident #99 agreed Resident #99 was not in good body alignment to promote feeding. LPN #26 proceeded to reposition the resident and prop the resident with folded blankets, after surveyor intervention, and instruct NA #44 on proper body alignment to promote feeding.",2020-09-01
526,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,279,D,0,1,FJSP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan had measurable and/or individualized objectives for a resident on anti-anxiety medication. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of fifteen (15) Stage II sampled residents. Resident identifier: #88. Facility census: 87. Findings include: a) Resident #88 The medical record was reviewed on 11/09/17. Physician orders [REDACTED]. at bedtime daily for anxiety. Review of the care plan found it lacked individualized, measurable goals for the use of anti--anxiety medications. The care plan did not identify the behaviors the facility intended to treat with the anti-anxiety medication. The care plan did not include measurable goals set for the resident's emotional and/or behavioral condition. Rather, the care plan focus stated (name of resident) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) anxiety disorder. The goals stated Patient will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Their only non-pharmacological interventions were to encourage him to vent his feelings, and listen to his concerns. On 11/09/17 at 9:58 a.m. an interview was conducted with the director of nursing (DON). She said this resident does have targeted behaviors, but they were not listed on the care plan. She acknowledged that there was no focus on the behaviors that caused him to need the [MEDICATION NAME]. She acknowledged that there were no individualized or measurable goals for any targeted behaviors they were treating. She said she would correct these issues right away.",2020-09-01
528,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,431,D,0,1,FJSP11,"Based on observation and staff interview the facility failed to store and label medications. Resident: #48, #81 and #88. 11/08/2017 11:05:14 AM in medication room B and 2 medication carts, LPN #72 Levemir multi vail use wasn't labeled with opened date on vial for Resident #48, LPN #56 11/08/2017 11:15:31 AM Medication Room A and 2 medication carts, LPN #23 pens LPN #4 Humalog pen not labeled with opened date, Resident #81 Novolog pen not labeled with opened date, Resident #88 Based on observations and staff interview, the facility failed to collaborate with the pharmacist, to ensure safety and effective use of medications. An opened and partially used insulin vial was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication. This was evident for three (3) of thirty one (31) opened insulin vials and pens stored in two (2) of four (4) carts. Resident identifiers: #48, #81, #80. Findings include: a) Resident # 48 Observation on 11/08/2017 at 11:05 a.m., found a Levermir vial which belonged to resident # 48 was opened and partially used. There was no date indicating when the vial was intially opened, or the date it should be discarded. The Licensed Practical Nurse (LPN) #72 agreed the date that it was opened should have been on the vial. b) Resident #81 and #80 Observation on 11/08/2017 at 11:15 a.m. found a Humalog pen which belong to Resident # 81 was opened and partially used. There was no date indicating when the pen was was intially opened, or the date to discard. A novolog pen belonging to Resident #80 was opened and partially used. There was no date indicating when the pen was intially opened, or the date to discard. The LPN # 4 agreed that it should have been labeled when it was intially opened. There was a place on the pens to put the opened dates that were blank. Interveiw with the Director of Nursing was completed on 11/09/2017 at 10:30 a.m. she was aware of the findings of the insulin not being dated of when the medication was intially opened and/or to be discarded. She stated the policy required it to be labeled when it is first used with the discard date. The DON says that she has a plan to fix this problem.",2020-09-01
530,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,583,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure Resident #245's medical record was kept confidential. Resident #245's medication orders were observed to be hanging on the magnetic bulletin board in the residents room. This was a random opportunity for discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 Observation of Resident #245's room at 12:34 p.m. on 11/26/18 found her medication list placed on her magnetic bulletin board with a magnet. The list had been printed by the facility and it appeared Resident #245's daughter had placed it on the board with a hand written note which read, Mom's Medications, and No [MEDICATION NAME]. An additional observation with the Director of Nursing (DON) at 1:05 p.m. on 11/27/18, found the medication list was still on the magnetic bulletin board in Resident #245's room. The DON removed the list and indicated it looked like Resident #245's daughter had placed the list there and she would call and talk to them about it. She agreed the medication should not have been posted in the residents room.",2020-09-01
531,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,584,D,0,1,J9FW11,"Based on observation and staff interview the facility failed to ensure Resident #245's wheelchair was in good prepare. The wheelchair was missing an arm rest on one side and the other arm rest was loose. This was a random opportunity of discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 An observation of Resident #245's wheelchair at 9:40 a.m. with the Director of Nursing (DON) found the arm rest on the left side of her wheelchair was missing and the residents right arm rest on her wheelchair was loose. The DON stated, I will have (name of Maintenance Director) to fix it right away.",2020-09-01
532,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,622,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to convey all required transfer information to the receiving hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #43. Facility census: 97. Findings include: a) Resident #43 On 09/17/18 at 5:18 am, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. The Acute Care Transfer form provided to the receiving hospital did not include information regarding usual mental status, ambulation status, skin condition at time of transfer, devices and special treatments. The Acute Care Transfer form contained sections to provide this information. However, the sections were blank. During an interview on11/27/18 at 12:20 PM, the Director of Nursing agreed the information had not been completed on Resident #43's Acute Care Transfer form dated 09/17/18.",2020-09-01
535,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,657,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise care plans when residents had changes in their care related to advance directives, position and mobility, and [MEDICAL TREATMENT] schedule. This was found to be true for three (3) of 23 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifiers: #395, #62, #16. Facility census: 97. Findings included: a) Resident #395 On [DATE] at 1:32 PM it was noted through the screening portion of the Long-Term Care Survey Process that the code status marked on Resident #395's profile in the electronic medical record did not match the code status indicated on the care plan. The code status on the profile in the electronic medical record stated, Resuscitate (CPR); Feeding Tube Long-Term; Patient has a completed POST form dated: [DATE]; Limited Additional Interventions; IV Fluids for a trial period of no longer than: ,[DATE] days. A review of the current Physician order [REDACTED].#395's representative on [DATE], stated to Attempt Resuscitation/CPR and to provide Limited Additional Interventions, IV fluids for a trial period of no longer than ,[DATE]d(ays), and Feeding tube long-term. A previous POST form, signed by Resident #395's representative on [DATE], indicated to provide full interventions as well as IV fluids for a trial period of no longer than ,[DATE]d(ays). It was marked VOID. Resident #395's physician orders [REDACTED]. However, the advance directives documented on the care plan stated, Full interventions, IV fluids for a trial period of no longer than ,[DATE] days, Feeding tube long term. According to date stamps on the care plan, this information was last revised on [DATE] by Registered Nurse Assessment Coordinator (RNAC) #47. During an interview on [DATE] at 2:20 PM, RNAC #47 acknowledged that the advance directive information on the POST form and the care plan did not match and stated she would fix the problem immediately. On [DATE] at 10:42 AM, the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided by the facility prior to the end of the survey. b) Resident #62 Review of the resident current care plan, revised on [DATE], found the following problem: (Name of Resident) has an ADL (activities of daily living) self care performance deficit related to altered mental status,[MEDICAL CONDITION], dementia, [MEDICAL CONDITIONS], contracture to left arm and hand and [MEDICAL CONDITION]. Review of the most recent minimum data set (MDS) an annual, with an assessment reference date (ARD) of [DATE], found the resident was coded as having no contractures. At 8:45 AM on [DATE], the Registered Nurse Assessment Coordinator (RNAC) #47, said the care plan was incorrect. The RNAC noted the resident had contractures when she was admitted to the facility on [DATE]. When the contractures resolved the care plan was never updated to reflect the resident currently has no contractures to the left arm and hand. c) Resident #16 A reviewed of Resident #16's medical record at 9:26 a.m. on [DATE] found the following physician order [REDACTED]. A review of Resident #16's care plan found the following focus statement, : [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. This focus statement was added to the care plan on [DATE]. The goal associated with this focus statement read, : Will have no signs or symptoms complications fro [MEDICAL TREATMENT] through the review date. The revision date for this goal was [DATE] with a target date of [DATE]. The goals associated with this focus statement and goal included, Encourage patient to go for the scheduled [MEDICAL TREATMENT] appointments. Patient receives [MEDICAL TREATMENT] Tuesdays, Thursdays, and Saturdays at 6:15 a.m. at (Name of local [MEDICAL TREATMENT] center) . This intervention was added to the care plan on [DATE]. An interview with Registered Nurse Assessment Coordinator (RNAC) #47, at 9:56 a.m. on [DATE] confirmed Resident #16's care plan was not revised when her [MEDICAL TREATMENT] days and times changed on [DATE] at it should have been.",2020-09-01
536,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,660,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a plan was in place to address the the residents expressed desire to talk to someone about in-home and community agencies available before her discharge to home. This was true for one (1) resident reviewed for the care area of discharge to the community. Resident identifier: #95. Facility census: 97. Findings include: a) Resident #95 Record review at 9:20 AM on 11/27/18, found the resident was admitted to the facility on [DATE]. The resident was discharged to her home on 08/31/18. Review of the minimum data set (MDS), a 5 day Medicare Part A Stay, with an assessment reference date (ARD) of 06/19/18, found the resident participated in completing the MDS. The resident expected to be discharged to the community. When asked the question on the MDS, Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The residents response was, yes. The Resident Assessment Instrument (RAI) manual provides the following direction when answering yes to the above question on the MDS: The goal of follow-up action is to initiate and maintain collaboration between the nursing home and the local contact agency to support the resident's expressed interest in talking to someone about the possibility of leaving the facility and returning to live and receive services in the community. This includes the nursing home supporting the resident in achieving his or her highest level of functioning and the local contact agency providing informed choices for community living and assisting the resident in transitioning to community living if it is the resident's desire. The underlying intention of the return to the community item is to insure that all individuals have the opportunity to learn about home and community based services and have an opportunity to receive long term services and supports in the least restrictive setting. CMS (Centers for Medicare and Medicaid Services) has found that in many cases individuals requiring long term services, and/or their families, are unaware of community based services and supports that could adequately support individuals in community living situations. Local contact agencies (LCAs) are experts in available home and community-based service (HCBS) and can provide both the resident and the facility with valuable information. On 11/27/18 at 10:06 AM, the social worker (SW) #28 was asked for verification of information provided to the resident about all community based services and support systems. There were no notes in the electronic medical record from social services discussing discharge placement. SW #28 said referrals for medical equipment were made and the resident was referred to a Home Health agency before discharge. He was unable to provide any documentation a discussion was held with the resident to determine what other agencies were available in her community. Such as agencies who provide meals, chore services, transportation, and other in-home care and community based services that could be available. On 11/27/18 at 10:17 AM, the supervisor of therapy services, Employee #118, said the therapists recommended the equipment needed at home. We always refer residents to a Home Health agency upon discharge, for a safe transition to the community. [NAME] #118 said her department does not look at other agencies available in the community, That is Social Services. At 10:40 AM on 11/27/18, a visiting social worker, from another company facility, SW #134 said, We will get some training in place to address this.",2020-09-01
538,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,690,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review the facility failed to ensure residents, with an indwelling catheter, received the appropriate care based upon current professional standards of practice and services to prevent urinary tract infections to the extent possible. Also failed to ensure the indwelling Foley catheter was secured to the leg was used to prevent injury, accidental removal. This was true for two (2) of two (2) reviewed for catheter care. Identified Residents were Resident #70 and #6. Facility Census 97. Findings included: a) Resident #70 During an interview on 11/26/18 at 11:39 AM, Resident's husband said that she has ESBL in urine she has a catheter. On 11/28/18 at 9:23 AM, Indwelling Foley Catheter care observation with Nursing Assistant (NA) #40, it was noted the catheter anchor was not on the resident's leg. NA#40 wiped once down the sides of the inner legs (groin area), one down stroke over the outside of the vagina. She then emptied the water basin and left room. When she returned with clean wash cloth and water she wiped the catheter tubing but not at the insertion site, only a section of the tubing about 3 inches from the vagina. Licensed Practical Nurse (LPN) #27 brought in a thigh strip to secure the Foley catheter to the leg. NA #85 wiped the buttock crevices toward the vagina, not away from the vagina to prevent Infections. After the two (2) NAs had finished and put the supplies away they were asked the following; - How often are they in-serviced on catheter care? They both said the last time was in (MONTH) this year. - How do they believe they did? NA # 85 said that, she knew that she should not have wiped towards the vagina and NA #40 said she normally does a better job. Both NAs agreed they did not use proper technic for catheter care. During an interview on 11/28/18 at 10:04 AM, DoN was notified of findings that were observed. She stated that she was disappointed. The Facility Policy, Catheter Care, Urinary Dated; 8/2002. reads: -Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note; Catheter tubing should be strapped to the resident's inner thigh.) - report unsecured catheters to the Charge Nurse. The Facility Policy, Perineal Care Dated, 1,2002, reads: -Wash perineal area wiping from front to back. -Separate labia and wash area downward from front to back - gently wash the juncture of the tubing from the urethra down. -Continue to wash the perineum moving from inside outward to and including the thighs alternating from side to side and using downward [MEDICAL CONDITION]. Do not use the same washcloth or water to clean the urethra or labia. -Wash the rectal area thoroughly, wiping the base of the labia towards and extending over the buttocks, do not use the same washcloth or water to clean the labia. Care Plan from electronic chart: Resident #70 has an Indwelling Catheter for [MEDICAL CONDITION] bladder, 16 FR with 10cc balloon. Patient will be/remain free from catheter-related trauma through review date. Change catheter every 4 weeks and as needed. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. b) Resident #6 On 11/26/18 at 1:35 pm, an observation with Employee #52, Clinical Care Supervisor (CCS) found Resident #6 had an indwelling Foley Catheter. The catheter was not anchored to the resident's leg. Care Plan from electronic chart reviewed: Focus: Resident #6 has an Indwelling Catheter due to a pressure ulcer on coccyx, 20 FR with 10 cc balloon. Goal: Patient will be/remain free from catheter-related trauma through review date. Intervention: 1. Change catheter every 4 weeks and as needed. 2. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. 3. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered 4. URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. An interview on 11/27/18 at 10:00 am with the DON, the DON was informed of findings. No further information provided.",2020-09-01
539,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,698,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure Resident #16 a [MEDICAL TREATMENT] patient received care and services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #16 reported that she is late to [MEDICAL TREATMENT] frequently because the ambulance is always late to get her. Also, Resident #16 had an order for [REDACTED]. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the long term care survey process. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 1. Transportation to [MEDICAL TREATMENT] During an interview with Resident #16 at 12:00 p.m. on 11/26/18, she stated, I am late for [MEDICAL TREATMENT] on a regular basis. She indicated her appointment was set for 12:00 p.m. and the ambulance often times picked her up after her scheduled appointment time. She stated, I am supposed to be on the machine all ready and I am still sitting her waiting for them to come and get me. She stated, This happens at least once or twice a week. At 12:16 p.m. on 11/26/18, the ambulance company was observed arriving to pick up resident #16 for her [MEDICAL TREATMENT] appointment which was scheduled at 12:00 p.m. A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found the following physician order [REDACTED].>Further review of the record found the following dates which Resident #16 was picked up for her [MEDICAL TREATMENT] appointment after her scheduled appointment time: All notes are entered by nursing and are appointment/outing notes. The times used are the effective times of the note which would be the time Resident #16 left the building in route to her [MEDICAL TREATMENT] treatment: 07/18/18 at 12:45 p.m. 08/01/18 at 12:55 p.m. 08/27/18 at 12:03 p.m. 09/04/18 at 1:32 p.m. 09/14/18 at 12:19 p.m. 09/24/18 at 12:51 p.m. 09/28/18 at 12:02 p.m. 10/08/18 at 12:10 p.m. 11/02/18 at 12:04 p.m. 11/12/18 at 12:47 p.m. 11/26/18 at 12:15 p.m. 11/29/18 at 12:03 p.m. An interview with the local [MEDICAL TREATMENT] center staff at 10:09 a.m. on 11/28/18 confirmed Resident #16 as consistently late to [MEDICAL TREATMENT]. She stated, She is late at least once or twice a week and it puts us behind for the rest of the day. An interview with the Director of Nursing (DON) at 11:47 a.m. on 11/28/18 confirmed the nursing notes indicated Resident #16 was picked up late for [MEDICAL TREATMENT] on the dates mentioned above. She stated they would have to address it with the ambulance company because this is the first she has heard of it. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 found she had spoken with the ambulance company and they stated they would try to do better picking up the resident on time. 2. [MEDICATION NAME] A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered.",2020-09-01
541,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,757,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #16's drug regimen was free from unnecessary medications. Resident #16's [MEDICATION NAME] was ordered to be held at certain times on [MEDICAL TREATMENT] days and it was not held as ordered. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered.",2020-09-01
545,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,279,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, and staff interview, the facility failed to include non-pharmacological interventions in the plan of care for one (1) of twenty-two (22) resident care plans reviewed. Resident identifier: #129. Facility census: 107. Findings include: a) Resident #129 Review of Resident #129's clinical record conducted, on 04/04/17 at 9:00 a.m., revealed an original admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. Section I J included the active [DIAGNOSES REDACTED]. The admission physician orders [REDACTED]. The current physician orders [REDACTED]. During an interview conducted, on 04/05/17 at 8:59 a.m., Resident #129 stated difficulty with sleeping and required the use of the medication [MEDICATION NAME] to fall asleep. The resident stated the staff did not provide any other interventions to promote sleep. When queried about other interventions to promote sleep that had worked in the past, the resident stated it was helpful to have the television on at night to promote sleep. During an interview, on 04/05/17 at 9:12 a.m., Assessment Nurse Staff #37 verified the resident's care plan did not include non-pharmacological interventions to address the resident's [MEDICAL CONDITION].",2020-09-01
546,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,280,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview, and staff interview, the facility failed to revise the care plan to include the resident's resistance to turning and repositioning interventions for one (1) Resident of twenty-two (22) resident care plans reviewed. Resident identifier: #129. Facility census: 107. Findings include: a) Resident #129 Review of Resident #129's clinical record, on 04/04/17 at 9:00 a.m., revealed an original admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. Section G0110 A, documented the resident required extensive assistance of two staff members for bed mobility. The current plan of care dated 1/21/2017 included the problem as, Resident has impaired skin integrity related to pressure ulcer to right heel, left shoulder, coccyx. The interventions included to utilize positioning devises as appropriate to prevent pressure over boney prominences. The Activities of Daily Living (ADL) care plan included the intervention to provide the resident with extensive assist of two for bed mobility to turn and reposition. During an interview, on 04/04/17 at 1:20 p.m., Licensed Practical Nurse (LPN) #86 stated the resident frequently refused to be turned and repositioned. LPN #86 stated the resident had been educated on the risk versus benefits of turning and repositioning however the resident frequently refused staff assistance to be turned and repositioned. During an interview, on 04/04/2017 at 3:00 p.m., Resident #129 stated he does not like to be turned or repositioned and expressed an understanding of the risk of further pressure ulcer development and possible delay of current pressure ulcer healing by refusing to be turned and repositioned. The resident verified the staff frequently attempted turning and repositioning however the resident routinely refused to allow the staff to turn and reposition him. During an interview, on 04/05/2017 at 8:00 a.m., Assessment Nurse #37 verified the plan of care was not revised to include the resident's frequent refusals for turning and repositioning.",2020-09-01
547,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,282,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, resident interview and staff interview, the facility failed to implement the plan of care regarding an air mattress for one (1) of twenty-two (22) resident care plans reviewed. Findings include: a) Resident #129 Review of Resident #129's clinical record, on 04/04/17 at 9:00 a.m., revealed an original admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The current plan of care dated 01/21/2017 included the problem of Resident has impaired skin integrity related to pressure ulcer to right heel, left shoulder, coccyx. The interventions included the use of a low air loss mattress as ordered. Review of the manufacturers guidelines for the Aire Select air mattress included on page 4 the following recommendation to, Check patient at least every 8 hours or once per shift to assure proper system operation, otherwise desired therapy may not occur. Documented on page 6, Comfort Setting Adjustment- Mattress pressure can be adjusted by pressing the soft key to reduce mattress firmness, and the firm key to increase firmness. The resident was discharged to the hospital on [DATE] for altered mental status and was readmitted on [DATE]. Review of the Nursing assessment dated [DATE] assessed the resident had the following skin issues noted: --left lateral 5th toe red intact and measured 1.2 centimeters (cm) x 1.8 cm --left lateral outer foot red intact and measured 1.2 cm x 2.8 cm --right heel open with granulation and deep purple present, and measured 4.5 cm x 5.2 cm x >0.1 depth --left buttock red intact and measured13 cm x 10 cm --coccyx open with granulation and measured 4.2 cm x 3.8 cm x 0.8 cm depth --left lateral lower back red intact and measured 8.6 cm x 10 cm --left lateral medial back open with granulation and measured 3.1 cm x 2.8 cm x 0.1 cm --left lateral upper back open with granulation and measured 5.1 cm x 6.7 cm x 0.1 cm depth During observation, on 04/04/17 at 3:20 p.m., the resident's Aire Select air mattress control setting was set at two out of eight lights which indicated the level of firmness. During an interview at that time the resident stated it feels like I am in a hole it doesn't feel like it is inflated, I am uncomfortable. The resident further stated no one ever routinely monitored the air mattress settings to ensure his comfort. During an interview, on 04/04/17 at 3:25 p.m., Licensed Practical Nurse (LPN) #44 was alerted to the resident's complaint about the air mattress not feeling inflated and being uncomfortable. LPN #44 stated, there is no specific setting for the air mattress it is an alternating air mattress that inflates on its own and nursing does not adjust the air mattress settings. They further stated Central Supply Staff #104 was responsible for monitoring the air mattress settings. During an interview, on 04/04/17 at 3:40 p.m., LPN #86 stated they were unaware of the required settings for the resident's air mattress, they further stated, Central Supply Staff #104 sets up the air mattress we don't do anything with them. LPN #86 verified there was no routine monitoring of air mattresses to ensure they were set appropriately to ensure resident comfort. They further stated they only look at the air mattress settings if the resident complains about the air mattress not being inflated to their comfort level. During observation, on 04/04/17 at 3:44 p.m., LPN #86 verified the resident's air mattress control setting was set at two out of 8 lights. LPN #86 pushed the plus sign on the air mattress control panel over and over and stated, I am not sure how to adjust the air mattress. The resident stated they were uncomfortable and needed the mattress inflated and further stated, it feels like I am in hole. Nurse Aide (NA) #77 entered the resident's room and stated the resident, likes it to be in the middle. NA#77 pushed the plus sign on the air mattress control panel and adjusted the air mattress control settings to 5 lights and then hit the lock button. The resident stated they were now comfortable. NA #77 stated they had been employed at the facility for five years and had not been educated on how to change the firmness setting on an air mattress and stated, I just know what to do. During an interview, on 04/05/17 at 8:47 a.m., Central Supply Staff #104 stated when an air mattress was ordered for a resident they placed the air mattress on the bed. They stated the air mattresses have an automatic mode sensor that adjusts to the resident's weight. They stated they do not routinely monitor the air mattress to ensure the proper settings for resident comfort as indicated in the manufacturer's guidelines.",2020-09-01
548,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,309,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well being for three (3) of 35 Stage 2 sample residents. One diabetic resident did not receive adequate oversight of foot wear; one resident did not receive physician ordered lab work; and, one resident did not have a physician's orders [REDACTED]. Resident identifiers: #91, #66 and #115. Facility census: 107. Findings include: a) Resident #91 Resident #91's clinical record was reviewed on 04/05/17 at 10:00 a.m. The resident's admitted to the facility was 10/19/16. Review of the Minimum (MDS) data set [DATE] Section C0500 documented the resident's Brief Interview for Mental Status was 11 indicating the resident was moderately impaired. The resident's care plan included a [DIAGNOSES REDACTED]. Section I2900 of the 03/01/17 MDS included the active [DIAGNOSES REDACTED]. Resident #91 was interviewed, on 04/03/17 at 11:00 a.m. The resident stated while he was hospitalized [DATE] through 02/20/17 his size 8.5 shoes had disappeared from his room. He stated he had told staff upon his return his shoes were missing. Staff replaced his shoes with another pair that he believed had come from the lost and found. The resident stated the shoes he had been given and that he was currently wearing were too small. He stated the shoes were too small and were especially tight across the metatarsal area (directly under the shoe's laces). The shoes were black leather tennis shoes with white stretchy shoe laces. On 04/04/17 at 2:00 p.m. while the resident had visitors he removed his shoes and observed for the size. Stamped into the bottom of the shoes was the size: M6W8 - meaning they were a mens' size 6 or a womens' size 8. Review of the resident's Care Plan, on 04/05/17 at 1:15 p.m., revealed a focus area created on 10/28/16 related to the [DIAGNOSES REDACTED]. Observe feet/toes/ankles/soles/heels noting alteration in skin integrity, color, temperature, and cleanliness. Toenails for shape, length and color. Inspect shoes for proper fit. During review of the resident's medical record, on 04/05/17 at 1:15 p.m., the resident's skin assessments were reviewed. Upon the resident's return from the hospital on [DATE] skin documentation indicated a Stage 2 pressure ulcer measuring 1 (centimeter) cm. x 1 cm. was present on the right outer ankle. Since 02/20/17 skin assessments have been completed weekly by nursing staff and dressings have been provided by nursing staff however, the ill fitting shoes were not identified. Interviews were conducted with two of the Nurse Aides (NA) who cared for Resident #91. NAs #23 and #85 were interviewed on 04/05/17 at 3:00 p.m. NA #23 stated the resident dresses himself, including putting on his shoes, and the only time she might see his feet would be at shower time, which is 2 times per week. NA #85 agreed with NA #23 and stated she did not do daily checks of his feet. Review of the shower records, on 04/05/17 at 3:15 p.m. reflected showers had been given but there was no documentation indicating that the resident's feet had been checked or the status of the feet and shoes. The Director of Nursing (DON) was interviewed, on 04/06/17 at 9:30 a.m. regarding implementation of the Care Plan interventions. No documentation regarding daily checks of the resident's shoes was located. On 04/06/17 at 8:45 a.m., the Administrator stated she had measured Resident #91's feet and found his shoe size should be 8.5. She stated new shoes will be purchased and should be delivered on or about 04/10/17. Despite a plan to make daily observations of a diabetic resident's feet, facility staff failed to identify Resident #91's shoes were 2.5 sizes too small, were uncomfortable, and created a potential for skin breakdown for the diabetic resident. b) Resident #66 Review of Resident #66's clinical record, on 04/06/17 at 10:00 a.m., revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. The resident's current physician orders [REDACTED]. The resident's current medication orders included magnesium oxide 400 mg daily to treat hypomagnesium. The most recent FLP, LFT and magnesium level laboratory test was dated 05/26/16. During an interview, on 04/06/17 at 10:30 a.m., the Director of Nursing verified the most recent FLP, LFT and magnesium laboratory test was dated 05/26/2016 and had been due again in (MONTH) (YEAR). The Director of Nursing verified the physician order [REDACTED]. c) Resident #115 According to the 05/01/16 patient security bracelet policy provided by the Director of Nursing (DON), on 04/06/17 at 2:45 p.m., Patient security bracelets (Wander guard) will be inspected per manufacturer's recommendations but at least a minimum of: every shift for placement, and daily for function. Resident #115 was admitted on [DATE] and readmitted on [DATE]. According to the medication review report, [DIAGNOSES REDACTED]. According to the 01/27/17 significant change minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 6 out of 15. For wandering: behavior of this type occurred daily. The care plan, revised 11/10/16, identified resident exhibits behavior (wandering), known to wander in other resident's rooms uninvited, and wander towards exit door. Interventions included: Utilize and monitor security bracelet per protocol. (This intervention was initiated on 04/5/17) Resident #115 was observed on 04/04/17 at 11:20 a.m. wandering the hallway. She had a wander guard on her ankle. From 04/04/17 through 04/06/17, the resident was observed wandering throughout the facility, in her wheelchair, with a wander guard on her ankle. According to the medication review report, the wander guard was ordered on [DATE] and 04/5/17. The licensed practical nurse (LPN) #115 was interviewed on 4/5/17 at 1:20 p.m. She said there should have been an order for [REDACTED]. The MDS Staff #37 was interviewed on 04/05/17 at 1:30 p.m. She was unable to find a physician order [REDACTED]. The DON #58 was interviewed along with the MDS staff #37 on 04/06/17 at 8:30 a.m. They were supposed to monitor location and functioning of wander guards. They started this monitoring the day before on 04/05/17 for Resident #115. The order was written 04/05/17. At 1:22 p.m., the DON confirmed there was no specific monitoring for this resident.",2020-09-01
549,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,323,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to investigate and develop interventions for a resident who has experienced falls, or who is identified as having risk factors for falling for one (1) of three (3) residents reviewed for accidents out of 35 sample residents. Specifically, the facility failed to ensure a fall investigation was completed for resident #98. Resident identifier: #98. Facility census: 107. Findings include: a) Resident #98 According to the 08/01/16 accidents/ incidents policy provided by the Director of Nursing (DON) on 04/06/17 at 2:45 p.m., The staff member must document the incident on the incident/accident investigation form and conduct an immediate investigation of the accident or incident. Include interview of staff and appropriate witnesses .Every attempt shall be made to determine the cause of the accident/ incident and identify intentions to prevent further occurrence. Resident #98 was admitted on [DATE] and readmitted on [DATE]. According to the medication review report, [DIAGNOSES REDACTED]. According to the 01/31/17 significant change minimum data set (MDS) assessment, the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of 5 out of 15. The care plan, revised 02/04/17, identified resident is at risk for falls: cognitive loss, lack of safety awareness, impaired memory, Parkinson's disease, history of falls. Interventions included Bilateral supports on chair and chair alarms for dynergo and geri-chair; Lap buddy, Pommell cushion for positioning; pressure floor alarm; utilize low bed; and place call light within reach. The resident was observed on 04/04/17 at 11:53 a.m. He was in his room in his wheelchair, asleep. He was leaning to the right side with his head on the door. The resident was observed, on 04/05/17 at 7:20 a.m., he was in his wheelchair leaning to the right side. His lap buddy was off on the left side. Additional observations included: --At 8:45 a.m., a pillow was observed under his right side. He was asleep in his wheelchair. His head was leaning forward. --At 9:32 a.m., he remained in his wheelchair, asleep. He was leaning to the right side, with no pillow underneath. An investigation report was completed on 03/27/17, 02/04/17 and 01/29/17. The investigation report for the resident's fall on 3/29/17 was not available. A change of condition evaluation was completed on 03/29/17. For skin changes: no changes observed were marked and the following was provided, Resident had a fall in his restroom, vitals obtained, no complaints of pain or discomfort. The Licensed Practical Nurse (LPN) #115 was interviewed on 04/03/17 at 9:27 a.m. She said this resident had two falls in the last 30 days with a bruise on his knee. The Nurse Aide (NA) #2 was interviewed on 4/5/17 at 7:30 a.m. She said he gets placed either into a geri-chair or a wheelchair with a lap buddy. The resident would try and stand by himself. He was able to use a call light. The DON was interviewed on 04/05/17 at 7:35 a.m. She said she was not aware of the most recent fall that occurred with injury. She discovered that there was a fall with a bruise/ rug burn below the knee. The family was present that day. There was no investigation filed and the nurse that day forgot to do anything with it. The fall was passed on in report. The LPN #136 was interviewed. She said she thought this resident fell on the 29th of March. She said it was an extremely busy day. The resident had a fall. She checked his leg and placed a bandage on it. She spoke with his wife and the physician. She forgot to fill out an incident report. When asked how he fell , she said she knew he was in the bathroom. She was unaware if the fall was witnessed. She said the purpose of an investigation was to keep track and investigate if there was something that should have been done differently. She said she did complete a change in condition and completed neuro checks. She said the resident was found by a NA but was unsure which NA it was. A NA # 93 was interviewed on 04/05/17 at 8:50 a.m. She said she was not there during the fall, but she thought he was found in the bathroom. She said someone placed him in the bathroom. He was found on the floor. The rehab office coordinator #124 was interviewed, on 04/05/17 at 9:10 a.m. He said they had assessed him. He was to be in his chair or his geri-chair. He tended to lean forward or to the side. The LPN ##115 was interviewed again on 04/05/17 at 9:50 a.m. She said this resident did have an injury after this most recent fall. He had a scrape on his right knee. She said it was red and healing well. She noticed it after his fall. She was not working the day of the fall. The NA #107 was interviewed on 04/05/17 at 10:12 a.m. She said she was there the day he fell , but she did not see the fall. She heard his alarm going off and she went to investigate. He was on the floor in his room. She thought he did have an injury. He had pushed his wheelchair back. He was between the dresser and the first bed on the floor. The lap buddy was on the floor. He was in the room, alone. The DON was interviewed again on 04/05/17 at 11:20 a.m. She said she was unaware of the fall until she asked about his knee this week.",2020-09-01
550,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,325,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to maintain acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrates that this is not possible for two (2) of four (4) residents reviewed for nutritional status of 35 sample residents. Specifically, the facility failed to weigh residents per protocol; and provide timely nutritional interventions with weight loss. Resident identifiers: #142 and #138. Facility census: 107. Findings include: a) Facility standards According to the 11/30/15 weights and heights policy provided by the Director of Nursing (DON) on 04/06/17 at 2:45 p.m., Patients are weighed upon admission and /or readmission, then weekly for four weeks and monthly thereafter. Purpose: to obtain baseline weight and identify significant weight change. According to the 11/28/16 nutrition care process policy provided by the DON, on 04/06/17 at 2:45 p.m., Residents with a nutrition [DIAGNOSES REDACTED]. b) Resident #142 Resident #142 was admitted on [DATE] and readmitted on [DATE]. According to the medication review report, [DIAGNOSES REDACTED]. According to the 02/23/17 quarterly minimum data set (MDS) assessment, the brief interview for mental status (BIMS) was not completed. He was an extensive assist with eating. Weight loss was not marked. Height was 67 inches and weight was 122 pounds. The care plan, revised on 04/06/17, identified resident: --is on a dysphagia advanced diet; --had severe weight loss on readmit over the past 30/90 days with continued inadequate oral intake at meals; --had a recent acute illness; --had swallowing changes; and --had a body mass index (BMI) less than 19 placing resident nutritional at risk for skin breakdown. Interventions included: --weight per medical doctor (MD) orders; --alert dietitian and physician to any significant loss or gain; --monitor changes in nutritional status and report to food and nutrition/ physician; --monitor intake at meals and offer alternate choices as needed; and --order house supplement as ordered. The resident was observed on 04/04/17 at 2:22 p.m. The resident was in his bed with the lights off. His body was observed as frail. The resident was observed again on 04/06/17 at 9:37 a.m. He was in bed with a blanket. He had a wander guard on his ankle. According to the weights and vitals summary, labs and skin reports: --04/01/17: 114 pounds (8% loss x 1 month) --03/29/17: Pre-[MEDICATION NAME] level 9.7 low --03/22/17: Pressure areas healed --03/01/17: 124 pounds --02/17/17: House supplement ordered --02/08/17: 126 pounds (readmission 2/9/17- pressure areas on right buttock and coccyx) --02/01/17: 122 pounds --01/29/17: House supplement ordered --01/25/17: 132 pounds --01/18/17: 126 pounds (16.5% loss x 1 month) --12/13/16: 151 pounds --12/06/16: 145 pounds --Admission - Missing weights According to the nutritional assessment on 04/06/17: weight: 114 pounds; regular/ other diet. Weight loss: 8.1% x 1 month. Pressure ulcers not marked. 03/29/17: pre-[MEDICATION NAME] level 9.7 low. Recommend start a house supplement three times daily (TID) x 60 days, start pro-heal liquid one ounce twice daily BID x 60 days. According to the nutritional assessment on 02/15/17: weight: 122 pounds; regular/ other diet. Weight loss: 15.9% x 2 months. Pressure ulcers: right buttock stage II; coccyx stage II. Recommend start a house supplement BID x 30 days. According to the nutritional assessment on 01/23/17: weight: 126 pounds; regular/ dysphagia pureed diet. Weight loss: 16.6% x one month. Recommend start a house supplement BID x 30 days. Recommend a reweigh to validate weight loss. No pressure ulcers marked. According to the nutritional assessment on 12/12/16: weight: 145 pounds; regular diet; no pressure ulcers marked; Goals include: no significant weight changes, no signs/symptoms dehydration, no skin breakdown. Will continue to follow. According to the skin integrity report: open area to the right buttock on 02/09/17- healed on 03/22/17 and pressure area coccyx stage II on 02/09/17- healed on 03/22/17. According to the (MONTH) activities of daily living (ADL) for oral intake: --04/05/17: Breakfast: refused; Lunch: 50%; Dinner: 50% --04/04/17: All meals refused --04/03/17: Breakfast: 100%; Lunch: 50%; Dinner: 75% --04/02/17: Breakfast: 25%; Lunch: 75%; Dinner: 75% --04/01/17: All meals refused (Average meal intake: 33%) According to the (MONTH) ADL for oral intake: (Average meal intake: 50%) According to the (MONTH) ADL for oral intake: (Average meal intake: 46%) According to the progress notes: --03/28/17: Order for [MEDICATION NAME] TID and to obtain labs. --03/27/17: In dining room at this time for dinner. --03/25/17: Resident has slept in bed most of this shift, takes water but refuses solids. --03/23/17: Weight warning: 124 pounds- 7.5% change --030/7/17: Care plan meeting: Weight: 122 pounds, weight loss x 2 months, consumes 48% --03/01/17: Weight warning: 122 pounds- 7.5% change --02/27/17: Resident ate dinner in the dining room. Laboratory records revealed the following: --03/29/17: Pre-[MEDICATION NAME] level: 9.7 low, [MEDICATION NAME]: 2.3 low. physician progress notes [REDACTED].>--03/28/17: Assessment and plan: [MEDICAL CONDITION] of lower extremities- It could be [MEDICATION NAME]. Will watch it carefully and closely. According to the nursing assessment: --02/9/17: Weight: 126 pounds; [MEDICAL CONDITION]- not present. --012/6/16: [MEDICAL CONDITION]- not present. According to the medication review report: --02/17/17: House supplement two times a day for 30 days. --03/31/17 (order date)- 4/3/17: (start date): Check weights every day shift every Monday (while on [MEDICATION NAME]) --03/28/17: [MEDICATION NAME] 5 milligrams (mg)- give one capsule by mouth three times a day for weight loss. The registered dietitian (RD) #135 was interviewed on 4/6/17 at 2:10 p.m. She said this resident #142 continued to receive the supplements ordered although there was a stop date. She said they would request a reweigh for a resident with a five (5) pound weight loss. The Licensed Practical Nurse (LPN) #41 would alert the physician and the team for any residents with weight loss. She said she relied on the electronic medical record for any triggered weight changes. When she completed her assessment, she would look for the current weight in the weight book from LPN #41. They should have started weekly weights for residents with weight loss. She confirmed this resident had a severe weight loss from the admission weight to the current weight. She said she recently increased his supplement to TID. She also said she did not assess/chart on this resident in March. The DON #58 was interviewed on 04/06/17 at 2:45 p.m. When asked if it was a standard to obtain weights on admission and one weekly for four weeks and then monthly, she said Yes. She confirmed that the same process was completed on readmissions. c) Resident # 138 Resident #138 was admitted on [DATE] and passed away on 11/04/16. According to the medication review report, [DIAGNOSES REDACTED]. According to the 10/25/16 14-day MDS assessment, the resident had severely impaired cognition with a BIMS score of 3 out of 15. She was an extensive assist with eating. Weight loss was not marked. Height was 64 inches and weight was 110 pounds. The care plan, revised on 11/07/16, identified resident is on a mechanically altered diet. At present has inadequate oral intake. [DIAGNOSES REDACTED]. BMI is less than 19 placing the resident nutritionally at risk for skin breakdown. Interventions include: weight per MD orders; alert dietitian and physician to any significant loss or gain; Monitor for changes in nutritional status; monitor intake at meals; house supplement as ordered; total assist with all oral intake. According to the weights and vitals summary: --11/01/16: 95 pounds (13.6% loss since admission) --10/20/16: Nutritional assessment- supplements recommended and never started. --10/12/16: 110 pounds (admission) (Missing weights) According to the nutritional assessment on 10/20/16: weight: 110 pounds; regular/ other diet with nectar thick liquids. Pressure ulcers not marked. Recommend start house supplement TID between meals. Intake: Breakfast: 32%, Lunch: 14%, Dinner: 17%. Refused 10 out of 20 meals reviewed. According to the physician certification and re-certification form for 10/12/16: marked for skilled rehab. Admission was signed off on 10/14/16 and the re-certification was signed off on 10/25/16. According to the standing orders on admission, Weights weekly x four, then monthly. physician progress notes [REDACTED].>--10/28/16: Weight marked as stable. --10/21/16: Weight marked as stable. --10/21/16: Appetite is satisfactory. No significant weight change. Plan: Palliative care. --10/14/16: Plan: comfort care. --10/12/16: With newly diagnosed metastatic poorly differentiated [MEDICAL CONDITION] with mets to brain . According to the hospital patient health summary, 10/5/16: weight: 113 pounds. The medication review report was reviewed and void of any supplement orders. The RD #135 was interviewed on 04/05/17 at 10:15 a.m. She said she placed her recommendations on her recommendation form and the form was then given to the DON, nursing home administrator (NHA) and the unit managers. From there, the nursing staff would contact the physician. She said speech therapy was working with this resident. This resident was not on hospice. She said the supplements were usually started soon, dependent on fax response. She confirmed there was no order written for any supplements. The LPN #41 was interviewed on 04/05/17 at 10:24 a.m. She said she was in charge of the weights. She would write them down on a clipboard. She placed them into the electronic medical record. She confirmed the standard was to get a weight on the day of admission, weekly x 4 and then monthly. She said this resident did not have any weight orders. When asked about the standard orders for this resident, she said the standard orders are things that can be done but doesn't have to be done. The DON was interviewed on 04/05/17 at 11:05 a.m. She said the standard orders should have been put into the electronic medical record. She said this resident was not eating much. She said it was the responsibility of medical records to place the standard orders into the electronic medical record. She confirmed the weight orders were not on the MAR for this resident. She also confirmed there was no order for supplements in the chart. She said physician response time was an issue. The DON #58 and the MDS staff #37 were interviewed on 04/06/17 at 8:30 a.m. They said the fax was sent to the physician regarding the supplement. They did not have a copy of the fax. They confirmed that this resident should have been weighed weekly, but there were only two weights available.",2020-09-01
552,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,441,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility protocol review, staff interview, resident interview and observation, the facility failed to implement the facility protocol for the storage of urinals. This affected four (4) out of 33 resident rooms observed during Stage 1 of the Quality Indicator Survey. Facility census: 107. Findings include: a) Storage of urinals Review of the Nursing Department Infection Control Guidelines Care of Patient Equipment, on 04/04/17 at 10:09 a.m., revealed Personal Care Equipment Urinals were to be covered/stored in the patient's bedside cabinet. During observation of room [ROOM NUMBER], on 04/03/17 at 10:56 a.m. and on 04/04/17 at 9:33 a.m., Resident #103 had an uncovered urinal hanging on their bed side rail, the resident stated that is where it is kept. During observation of room [ROOM NUMBER], on 04/03/17 at 10:14 a.m. and on 04/04/17 at 9:33 a.m., Resident #4 had an uncovered urinal hanging on the grab bar in their bathroom. The resident stated the staff used the urinal to empty their indwelling urinary catheter however they no longer required the use of an indwelling urinary catheter. During an interview, on 04/04/17 at 10:53 a.m., the Director of Nursing verified the resident's indwelling urinary catheter had been discontinued on 02/22/17. During observation of room [ROOM NUMBER], on 04/03/17 at 12:34 p.m. and on 04/04/17 at 9:20 a.m., Resident #129 had an uncovered urinal hanging on the grab bar in their bathroom. In addition, the resident's roommate had an uncovered urinal hanging on the grab bar in the shared bathroom. Both urinals were in direct contact of one another. During observation of room [ROOM NUMBER], on 04/14/17 at 7:45 a.m., Resident #61's urinal was observed on the top of the HVAC unit in their room. The urinal was 1/2 full with urine. The resident stated they placed the urinal there and that he empties and stores his own urinal. During interview, on 04/04/17 at 10:00 a.m., the Director of Nursing verified the observations and stated when not in use the urinals were to be covered.",2020-09-01
553,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-07,514,D,0,1,IF5C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to maintain complete documentation related to pain medication administration for one (1) of three (3) sampled residents reviewed for the care area of Pain Management. Narcotic medications had been accessed and signed out however there was no documentation that they had been administered to the resident. Resident identifier: #91. Facility census: 107. Findings include: The resident's record was reviewed, on 04/05/17 at 10:00 am. The resident's admitted to the facility was 10/19/16. Review of the 03/01/17 Minimum Data Set Section J0100 documented the resident had received an as needed (or prn) pain medication within the 5 days preceding the pain assessment. Sections J0300 and J0400 confirmed the resident experienced pain frequently. And, Section J0600 identified the level of pain to be 8 out of 10. The Brief Interview for Mental Status was 11 indicating the resident was moderately impaired. Resident #91's physician's orders [REDACTED]. Resident #91's Narcotic Record and Medication Administration Record (MAR) for the month of (MONTH) were reviewed, on 04/05/17 at 2:15 p.m., and the revealed the following discrepancies: --On 04/03/17, the narcotic medication Noro 5-325 had been signed out three (3) times from sample Resident #91's narcotic supply in the medication cart and documented in the narcotic book three (3) times, at 5:00 a.m., 11:15 a.m. and 7:30 p.m. Resident #91's Medication Administration Record (MAR) only reflected one (1) administration for 04/03/17 at 11:15 am. The 5:00 a.m. and 7:30 p.m. medications accessed from the narcotic supply were unaccounted for on the MAR. --On 04/01/17 at 6:30 a.m., Noro 5-325 had been signed out from the narcotic supply in the medication cart for sample resident #91 however there was no documentation on the resident's MAR that the medication had been administered. During interview with Resident #9, on 04/03/17 at 11:00 a.m., the resident stated he had received a pain medication earlier in the morning and he was due for one at that time. The resident was observed asking for and receiving a pain medication at 11:15 a.m. The Director of Nursing was interviewed, on 04/05/17 at 9:30 a.m. She was unaware the MAR and narcotic record documentation were inconsistent. At 2:00 pm on 04/05/17, the DON stated a partial audit had been conducted of the facility's narcotic records and no additional discrepancies had been noted. A follow-up interview was conducted with Resident #91, on 04/06/17 at 12:00 p.m., and he confirmed he had received the pain medications in question. The facility policy regarding documentation of narcotic medications requires staff to document within the narcotic record/book when a medication is accessed as well as within the receiving resident's MAR. Additional documentation is required regarding the effectiveness of the medication. The facility failed to reconcile the narcotic medication with the resident's MAR on three occasions, two times on 4/3/17 and one time on 4/5/17.",2020-09-01
554,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2018-06-07,583,D,0,1,DSK711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure personal privacy and confidentiality of health information for a resident. A treatment powder with a pharmacy label containing personal and medical information for a resident was left unattended in a shower room. Personal identifiers including a resident's name, date of birth, medication, and physician, were easily accessible for anyone to view. This was a random observation. Resident identifier: #18. Facility census: 100. Findings included: a) Resident #18 A random observation of the 200 Hall Shower Room, on 06/04/18 at 11:40 AM, revealed one (1) container of [MEDICATION NAME] Topical Powder for Resident #18 was left unattended on a shelf. The container with the pharmacy label attached contained the following information: --Resident's name --Date of birth --Medication --Physician An interview with Registered Nurse (RN) #91, on 06/04/18 at 11:45 AM, revealed the Resident's treatment powder should not have been left in the shower room. The RN stated a resident's personal and medical information should always be protected from others.",2020-09-01
558,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2018-06-07,880,D,0,1,DSK711,"Based on observation and staff interview, the facility failed to prevent the potential for transmission of infection for 1 of 3 residents, whose catheter bag came into contact with the floor. Resident identifier: #80. Facility census: 100. Findings included: a) Resident #80 On 06/04/18, at 12:05 PM and 06/05/18, at 2:56 PM, Resident #80 was observed in bed with the catheter bag touching the floor. An interview on 06/05/18, at 02:59 PM, with CNA #159, revealed that Resident #80's catheter bag needed emptied and verified the catheter bag was touching the floor. It was further stated by Employee #159 that Hospice had put the resident back to bed and failed to wrap the catheter bag straps enough to keep it off the floor.",2020-09-01
559,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-07-09,580,D,1,0,TYZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to notify a resident's responsible party when an existing form of treatment (medication) was discontinued. This was evident for one (1) of seven (7) sampled residents. Resident identifier: #7. Facility census: 101. Findings included: a) Resident #7 The medical record was reviewed on 07/08/19 and 07/09/19. On 02/20/19 the consultant pharmacist completed a consultation report whereby she recommended to discontinue the [MEDICATION NAME] (anti-anxiety medication) 0.5 milligrams every four (4) hours prn (as needed), unless the physician deemed the medication should not be discontinued at that time. The physician accepted the recommendation to discontinue the prn [MEDICATION NAME]. The physician and director of nursing (DON) signed the pharmacy consultation report form on 02/22/19. A nurse progress note dated 05/17/19 conveyed that the resident's responsible party expressed in a telephone conversation earlier that day her concern about the resident no longer having the prn order for [MEDICATION NAME]. After first speaking with the Hospice, the nurse re-entered the order for [MEDICATION NAME] every four (4) hours prn per order of the resident's attending physician. A telephone interview was conducted with the resident's responsible party on 07/09/19 at 3:45 PM. She said she was unaware that the resident's [MEDICATION NAME] was discontinued until about the middle of May, 2019, at which time the resident had a urinary tract infection and was scratching herself. Upon inquiry as to whether she was informed in (MONTH) 2019 of the discontinuation of the [MEDICATION NAME], she replied in the negative. An interview was conducted with the DON and the administrator on 07/09/19 at 4:00 PM. After they reviewed nurse progress notes, physician visit notes, and the 02/25/19 care plan meeting notes, they reported they were unable to find evidence that the responsible party was notified when the [MEDICATION NAME] was discontinued in (MONTH) 2019.",2020-09-01
560,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-07-09,773,D,1,0,TYZC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure the physician was notified promptly of abnormal urinalysis and/or urine culture and sensitivity results. This was evident for two (2) of seven (7) sampled residents out of ten (10) residents treated for [REDACTED]. Resident identifiers: #6, #7. Facility census: 101. Findings include: a) Resident #6 Review of progress notes and encounter summary notes found no evidence that the physician was notified timely of abnormal laboratory results. A urine specimen was collected on 04/30/19. The abnormal urine culture report was dated 05/03/19. The medical record was silent on 05/03/19, 05/04/19, and 05/05/19 for physician notification of the abnormal laboratory results. The medical record was reviewed on 07/08/19 and 07/09/19. A nurse progress note dated 04/30/19 addressed a change in condition was noted. Symptoms included a distended hard bladder, burning and pain in the vaginal area, and decreased urinary output. A second nurse progress note on 04/30/19 conveyed the resident was crying and complaining of vaginal pain, burning, and verbalization that she could not void. After notifying the physician, the nurse straight catheterized the resident and obtained 480 cubic centimeters (cc) of urine with a thick, milky appearance, to be sent for analysis and culture and sensitivity. The resident stated she felt better after her bladder was emptied. A laboratory report form indicated this resident's urine specimen was collected on 04/30/19. The section labeled date reported contained the date 05/03/19 (Friday). On this form the urine culture was deemed positive for Escherichia Coli (E-Coli, an organism typically found in the bowel) with a colony count greater than 100,000. Listed below it were a list of medications to which the E-Coli was either susceptible or resistant. A nurse progress note dated Monday 05/06/19 at 3:11 PM conveyed that the resident was ordered an antibiotic for seven (7) days for a urinary tract infection. Review of physician's orders [REDACTED]. A policy titled Physician/Advanced Practice Provider Notification with revision date 12/01/18, was reviewed at 2:00 PM on 07/09/19. This policy stated that upon identification of a patient who has abnormal lab values, a licensed nurse will report to a physician or advanced practice provider. If unable to contact the attending physician or advanced practice provider, the Medical Director will be contacted. An interview was conducted with the director of nursing (DON) and the administrator on 07/09/19 at 4:00 PM. After they searched the medical record, physician and practitioner encounter notes, and conversed with an employee of the laboratory department, they could provide no evidence prior to exit that the physician was notified of the abnormal laboratory (culture) results in a timely manner prior to 05/06/19. b) Resident #7 Review of progress notes and encounter summary notes found no evidence that the physician was notified timely of abnormal laboratory results. A urine specimen was sent to the laboratory on 05/13/19 for analysis. The abnormal culture report was dated 05/18/19. The medical record was silent on 05/18/19, 05/19/19, 05/20/19, 05/21/19, and 05/22/19 for physician notification of the abnormal urine culture results and the corresponding sensitivity report. The medical record was reviewed on 07/08/19 and 07/09/19. A nurse progress note dated 05/13/19 revealed that a urine specimen was collected per physician's orders [REDACTED]. A nurse progress note dated 05/16/19 stated that nursing was awaiting urine culture results. A nurse progress note dated 05/17/19 at 12:07 PM conveyed the resident's responsible party called to see about the urinalysis results. The nurse conveyed to the responsible party that the resident probably had a urinary tract infection, but they were waiting on the culture results before prescribing an antibiotic. The nurse called the laboratory and allegedly was told {typed as written} culture had completed today and they would fax results once received will call practitioner to get antibiotic if indicated. Another nurse progress note dated 05/17/19 at 1:32 PM found the nurse returned the call to the resident's responsible party about the urine culture. The nurse stated she explained that the resident did have a urinary tract infection but the susceptibility part of the culture was not yet completed. The nurse further stated that once that part of the culture was complete, the facility would let her know about antibiotic. A laboratory report form indicated this resident's urine specimen was collected on 05/13/19. The section labeled date reported contained the date 05/18/19 (Thursday). On this form the urine culture was deemed positive for Escherichia Coli (E-Coli, an organism typically found in the bowel) with a colony count greater than 100,000. Listed below it were a list of medications to which the E-Coli was either susceptible or resistant. Registered nurse #13 (RN #13) signed and dated the 05/18/19 urine culture and sensitivity report on 05/23/19. Nurse practitioner #14 initialed, but did not date, the 05/18/19 urine culture report. Hand-written beside her initials was an order for [REDACTED]. Review of the MAR found she received the first dose of [MEDICATION NAME] on 05/23/19 at 8 PM, and the last dose at 8 AM on 05/30/19. A policy titled Physician/Advanced Practice Provider Notification with revision date 12/01/18, was reviewed at 2:00 PM on 07/09/19. This policy stated that upon identification of a patient who has abnormal lab values, a licensed nurse will report to a physician or advanced practice provider. If unable to contact the attending physician or advanced practice provider, the Medical Director will be contacted. An interview was conducted with the director of nursing (DON) and the administrator on 07/09/19 at 4:00 PM. After they searched the medical record, physician and practitioner encounter notes, and conversed with an employee of the laboratory department, they could provide no evidence prior to exit that the physician was notified of the abnormal laboratory (culture) results in a timely manner prior to 05/23/19.",2020-09-01
561,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-07-09,880,D,1,0,TYZC11,"> Based on observation and staff interview, the facility failed to provide peri-care to a resident in a sanitary manner to help prevent the potential development and/or transmission of communicable diseases and infections. This was evident for one (1) of one (1) residents observed for peri care. Resident identifier: #7. Facility census: 101. Findings include: a) Resident #7 On 07/09/19 at 1:30 PM, peri-care/incontinence care was observed for this resident after an episode of urinary incontinence in her adult diaper. Nursing assistant #12 (NA #12) prepared for the task by laying out a clean adult diaper, a clear plastic trash bag for receipt of soiled linens, another clear plastic trash bag for receipt of soiled disposable items, several unused washcloths, and a small bottle of liquid soap called Med Spa. NA #12 said the facility provides that brand of liquid soap for all the residents. NA #12 first washed her hands in the resident's bathroom. She left the water running, saying that she wanted to ensure the water was not too cold or uncomfortable for which to clean the resident. She laid the washcloths in the sink basin, where she soaked them with the running, warm water. Upon inquiry as to whether the residents had their own plastic wash basins, she replied in the affirmative. She said they use the plastic basins when they give a bed bath. After wringing out the excess water from the washcloths, she then proceeded to clean the resident's perineal area by using the wetted washcloths which had been in the sink basin, and now embedded with liquid soap. Next, she used the wetted washcloths which had been in the sink basin to rinse the perineal area. When asked, she said the resident's room-mate uses their bathroom for toileting. An interviw was conducted with the administrator around the time of exit on 07/09/19. She said the facility does not condone the practice of placing clean washcloths into a resident's sink bowl to use for resident's cleaning.",2020-09-01
562,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,580,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform and consult with the resident's physician and resident or resident representative of a significant weight loss. This was true for one (1) of three (3) residents reviewed in the care area of nutrition. Identified Resident # 90. Facility census 106. Findings included: a) Resident # 90 During a record review on 07/29/19 at 3:41 PM, revealed, that on 02/01/2019, the resident weighed 189 pounds. On 07/04/2019, the resident weighed 169 pounds which is a -10.58 % Loss. Nutritional assessment 07/23/19 most recent weight 169. on 07/04/19, severe weight loss over 180 days11.1 % loss in 6 months. Dietitian recommended a [MEDICAL CONDITION] panel be done. The last TSH was done on 11/22/18. Resident # 90 lacks capacity, her sister is her MPO[NAME] During an interview on 07/31/19 at 10:45 AM, Registered Nurse (RN) #113 was asked if the [MEDICAL CONDITION] panel was done or ordered. She stated, that the Director of Nursing (DoN) is the one who gets the recommendation sheets, but the last DoN that was here has been gone for about two weeks. She states that she is not sure the dietitian even gave someone the sheet. During an interview on 07/31/19 on 10:55 AM, Director of Nursing (DoN) (who just began this position two (2) days ago), asked Unit Manager #80 if anyone has let the physician know about the recommendation for a [MEDICAL CONDITION] panel and the weight loss. UM #80 was unable to find any documentation of anyone asking the physician about the [MEDICAL CONDITION] panel and notifying him and/or the resident representative of the weight loss. A brief interview on 07/31/19 at 11:05 AM, RN #113 stated, that she prints out a report at the first of the month for the month prior of all weight losses the physician to see all weight losses and he signs them. she would not have notified him of her weight loss until the first of Aug. for the month of July. the last weight was done on 07/04/19. During a brief interview on 07/31/19 at 11:10 AM, DoN agreed that there is not any evidence that the physician or family of Resident #90 of the weight loss. On 07/31/19 at 11:18 AM, Administrator was informed about the physician and resident representative not being notified about the weight loss.",2020-09-01
563,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,636,D,0,1,OOIK11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review the facility failed to complete an accurate comprehensive assessment for one (1) of twenty-six (26) Minimum Data Sets (MDS) reviewed during the Long Term Care Survey Process (LTCSP). The MDS for R42 did not include oxygen services. Resident identifier: R42. Facility census: 106. Findings include a) R42 During a medical record review on 07/30/19 revealed the MDS with an annual reference date (ARD) of 05/23/19 for R42 had not been coded to reflect oxygen services. Also the current physician's orders [REDACTED]. In an interview on 07/30/19 at 1:10 PM with E84 Clinical Reimbursement Coordinator (CRC) verified the MDS had not been coded to reflect R42 was receiving oxygen services.,2020-09-01
564,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,656,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record interview and staff interview the facility failed to develop and/or implement the comprehensive care plan for three (3) of 26 sampled residents. The care plan was not implement related to Resident #66 for non-skid footwear. The care plan was not developed for Resident #108 related to end of life choices. The care plan was not implemented for Resident #34 related to bowel protocol. Resident identifiers; #66, #108, #34. Facility census: 106. Findings include: a) Resident #66 Observation on 07/29/19 at 12:51 PM found Resident #66 wearing white footie socks with orange toes. They were not non-skid material. She walked from her wheelchair to her bed slowly, taking numerous small steps. She reached out and held to the bed as she walked. She said she fell on ce recently and did not get hurt. When asked why she was not wearing non-skid footwear, she replied that was her fault. She said she needs to go to Walmart and get some slippers. Observation on 07/29/19 at 2:06 PM found her getting out of bed by herself. She grabbed the wheelchair and pulled it back toward her. She then walked around the wheelchair and sat down in it. She wore white footie socks with orange toes that are not non-skid material. Review of the care plan on 07/30/19 found on page twenty (20) she was deemed at risk for falls and had a history of [REDACTED]. Her most recent falls occurred on 06/20/19 and 06/22/19 related to poor safety awareness. Interventions included to wear non-skid footwear for safety. Further review of the care plan found she requires extensive assistance of one (1) person for transfers with a gait belt. The care plan assessed that she has a history of behaviors which includes walking without assistance. Observation on 07/31/19 at 8:45 AM found her self-propelling in her wheelchair in the 300 hallway and was nearing the end of the hallway circular area. She wore white footie socks with orange toes. This is the second day and third observation of her not wearing non-skid footwear. An interview was completed at this time with licensed nurse #14 (LPN #14), who was present in the hallway. She said this resident is supposed to wear non-skid footwear. She then retrieved a pair of purple, non-skid socks and placed them on the resident's feet in place of the white footie socks with orange toes. These findings of not implementing the care plan for the use of non-skid footwear were reported to the administrator on 08/01/19 at 8 AM. He acknowledged his understanding. b) R108 During a medical record review on 07/30/19, it was discovered the comprehensive care plan had not been developed to include end-of-life choices for R108. In an interview with E111, Licensed Social Worker (LSW) on 07/30/19 at 4:23 PM verified the care plan for R108 had not been developed to include end-of-life choices. c) Resident (R#34) Record review on 07/31/19 on12:20 PM revealed R#34 pertinent [DIAGNOSES REDACTED]. An order dated 06/10/19 stated, Check to see if resident has had BM (bowel movement) and follow BM protocol. Review of BM record revealed in the month of (MONTH) 2019 the resident did not have a BM for seven (7) days between 05/15/19 starting on day shift until 05/22/19 day shift; did not have a BM for three (3) days between 05/23/19 starting on evening shift till 05/27/29 night shift; and did not have a BM for five and a half (5 1/2) days between 05/28/29 night shift through 06/02/19 day shift. Review of R#34's care plan, on 08/01/19 at 08:00 AM, revealed a focus Resident at risk for constipation related to [DIAGNOSES REDACTED]. One of the interventions included Provide medication as ordered ([MEDICATION NAME] scheduled)([MEDICATION NAME] Solution scheduled) ([MEDICATION NAME])(MOM as needed). MOM (milk of magnesium) as needed refers to a laxative used in the facility's bowel regimen/protocol. Another intervention included Provide bowel regimen, utilize pharmacologic agents as appropriate i.e. stool softeners, laxatives, etc, document effectiveness Review of the Medication Administration Record [REDACTED]. The facility failed to implement the resident's care plan interventions regarding constipation. Review of facility's standing orders for bowel regimen/protocol revealed give milk of magnesium (MOM) suspension 400 milligrams (mg)/5 milliliters (ml) give 30 ml by mouth as needed for constipation give it bedtime if no BM in 3 days. Give Ducolax suppository 10 milligram insert one suppository rectally as needed for constipation if no result from MOM by next shift. Fleet enema insert one dose rectally as needed for constipation if no result from Ducolax within 2 hours. If no results from fleet enema, call MD advanced practice provider for further orders On 07/31/19 at 01:04 PM, an interview with licensed practical nurse (LPN#86), revealed the facility's bowel movement protocol is for the nurse to give milk of magnesia if the resident has not had a bowel movement in 3 days. LPN#86 said, If there is no results in 8 hours from the milk of mag then the nurse is to use a suppository. If there's no result from suppository within 2 hours, then the nurses is to use a fleets enema. If there's not any results from the enema, then the nurse is to call the doctor for further orders. LPN#86 confirmed the care plan and BM protocol was not followed.",2020-09-01
565,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,657,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and resident interview the facility failed to ensure the participation of a resident by failing to timely invite and/or notify of their scheduled care plan meeting. The facility also failed to revise a resident's care plan when a medication identified in the resident's care plan was no longer ordered for the resident. Furthermore, the facility failed to revise a resident's care plan when a resident became totally dependent for eating. This was true for three (3) of twenty-six (26) sample residents care plans reviewed during the annual survey. These practices had the potential to affect more than a limited number of residents. Resident identifier: R#102, R#34, and R#32. Facility census: 106. Findings include: a) Resident (R#102) An interview with Resident (R#102), on 07/29/19 at 04:08 PM, revealed the resident was not invited to her last care plan meeting until after the care plan meeting was held. R#102, who has capacity and is blind, said a letter came to her two (2) days after they had the care plan meeting to notify her of the meeting. R#102 stated she found out about the meeting when someone working in the kitchen asked her why she was not there at her meeting. R#102 stated likes to and wants to go to her care plan meetings. When asked how she knew the letter came two days after the meeting, the resident replied, Because when my mail comes here I have them read it to me right then and there. It was two days after I was told they had had my meeting, when I got the letter. When they read it to me it was telling me about the meeting that was scheduled two days before. On 07/30/19 at 02:35 PM review of a care plan meeting note dated 07/08/19 reveled, Late Entry: 1. Attendance (list all in attendance): see sign sheet 2. Family/resident in attendance (Yes/No, who): see sign sheet 3. Summary of meeting (Brief summary. Details are on care plan): Resident was reviewed in care conference on 7/8/19. Reviewed medications, new orders, labs, code status, capacity, weight & diet, and activity plan. Also reviewed areas to be proceeded with on care plan. Review resident rights and notice of non-discrimination. PAS LTC. Wt 117 eating 43% of meals. Taking [MEDICATION NAME]. Attends OOR activities. 4. Advance directive reviewed (yes/no): post, DNR, capacitated Review of the R#102's care plan meeting's sign in sheets revealed the resident did not attend the (MONTH) care plan meeting but did her previous care plan meetings. An interview, on 07/30/19 at 02:40 PM, with Social Worker (SW#111) revealed she makes the notices for the care plan meetings based on the schedule that the Clinical Reimbursement Coordinator makes. The receptionist then mails all care plan meeting notices. Activities delivers notices to the residents in house. When asked if the facility tracks when notices are sent and any responses they might get back from the notices, SW#111 said no they did not. On 07/30/19 at 03:00 PM, an interview with the Clinical Reimbursement Coordinator (CRC#105) revealed SW#111 creates the care plan meeting notice and the receptionist mails them. Activities staff delivers notices directly to the residents in the facility. CRC#105 said they do not do any follow ups to see if resident received their notices or if they are going to attend. We place all sign in sheets in their record. Review of the resident's sign in sheets revealed the resident did not attend her last meeting. CRC#105 said she was not aware the resident did not get the notice timely. An interview with the Activities Director, on 07/30/19 at 03:10 PM, revealed activities staff deliver mail to the resident. The Activities Director said the resident is blind, and she always has us open her mail right then and there. When asked if it was possible that mail could be left unopen in the resident's room. The Activities Director did not think it was possible for mail to be left unopen in the resident's room, because the resident is always asking us to read it right away and is always asking if she has mail. b) Resident (R#34) Resident (R#34)'s care plan was not revised when a medication identified in the care plan was no longer ordered for the resident. Record review on 07/31/19 on12:20 PM revealed R#34 pertinent [DIAGNOSES REDACTED]. Review of R#34's care plan, on 08/01/19 at 08:00 AM, revealed a focus Resident at risk for constipation related to [DIAGNOSES REDACTED]. One of the interventions included Provide medication as ordered ([MEDICATION NAME] scheduled)([MEDICATION NAME] Solution scheduled) ([MEDICATION NAME])(MOM as needed). Interview with Clinical Reimbursement Coordinator, CRC#105 responsible for developing and revising care plans, on 08/01/19 at 08:49 AM, revealed when physician's orders [REDACTED]. After reviewing current orders CRC#105 agreed [MEDICATION NAME] Solution is no longer scheduled for the resident and the care plan should have been revised when the [MEDICATION NAME] Solution was no longer ordered for the resident. c) Resident (R#32) 's care plan was not revised when the resident became totally dependent for eating. On 07/31/19 at 07:53 AM review of records revealed some pertinent [DIAGNOSES REDACTED]. Review of records revealed the facility failed to revise the resident's care plan after the resident had a change in condition to reflect total dependence on staff for eating. Review of records on 07/31/19 at 07:53 AM revealed a significant change minimum data set (MDS) with an assessment reference date (ARD) of 05/16/19. This MDS showed the resident's cognitive status was greatly impaired, had weight loss and the resident was now totally dependent on staff for eating. Review of nutritional assessment dated [DATE], on 07/31/19 at 09:36 AM revealed . with a decline in ability to feed self . Review of orders revealed physician order [REDACTED]. Staff to feed all po intake. Review of care plan on 08/01/19 at 08:36 AM, revealed supervision to one person assist with eating. On 08/01/19 at 08:56 AM, interview with CRC#105 responsible for developing and revising care plans, revealed the CRC agreed the care plan needed revised to reflect the resident's current status of total dependence on staff for eating.",2020-09-01
567,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,685,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review the facility failed to obtain prescription glasses for Resident #66 in a timely manner to maintain optimal visual abilities. This was found for one (1) of one (1) residents reviewed for vision/hearing. Resident identifier: #66. Facility census: 106. Findings include: a) Resident #66 An interview was conducted with this resident on 07/29/19 at 12:48 PM. She said she has trouble seeing with her glasses. She is not wearing her glasses at present. She said she had [MEDICAL CONDITION] removed and should be able to see well with glasses. She said her eyes were examined last year around (MONTH) (2018) and she was supposed to get a new pair of prescription lenses, but she has not yet received them. An interview was conducted with the assistant director of nursing (ADON) on 07/30/19 at 12 PM. She said she thought this resident had new glasses. With the resident's permission, she checked the resident's chest of drawers and found two (2) pairs of glasses. She asked the resident if she could see well out of either pair, to which the resident replied that she could not. The ADON reviewed the medical record and found where this resident had an appointment on 11/19/18 with an optometrist who came to the facility and checked her for complaints of blurred vision and dryness of the eyes. Unit clerk #114 (UC #114) said a prescription for new glasses was written during that visit. She said glasses come in the mail when new ones are prescribed. She said she would contact the company and follow up to see if they mailed hers. On 07/30/19 at 1:15 PM UC #114 said she spoke with a representative from the company who handles the prescription lenses and was told that they were unable to find any record of the glasses having been sent to the resident. She said they told her the resident picked out her frames in (MONTH) (YEAR) at the time of the eye exam. UC #114 also said the representative told her they would complete the paperwork today, and this resident will receive her new glasses in the mail within the next two (2) weeks. An interview was conducted with the administrator on 08/01/19 at 8 AM. He was informed of the lapse in time from the eye exam in November, (YEAR), to the current date of not yet having the new prescription lenses. No further information was provided prior to exit.",2020-09-01
568,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,689,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure an environment as free of accident hazards as possible. This was evident for one (1) of four (4) residents reviewed for falls. A resident with a known history of falls wore footwear when out of bed which was not non-skid. Non-skid footwear was prescribed for use in her care to promote, supplement, or enhance her safety. Resident identifier: #66. Facility census: 106. Findings include: a) Resident #66 Observation on 07/29/19 at 12:51 PM found Resident #66 wearing white footie socks with orange toes. They were not non-skid material. She walked from her wheelchair to her bed slowly, taking numerous small steps. She reached out and held to the bed as she walked. She said she fell on ce recently and did not get hurt. When asked why she was not wearing non-skid footwear, she replied that was her fault. She said she needs to go to Walmart and get some slippers. Observation on 07/29/19 at 2:06 PM found her getting out of bed by herself. She grabbed the wheelchair and pulled it back toward her. She then walked around the wheelchair and sat down in it. She wore white footie socks with orange toes that are not non-skid material. Review of the care plan on 07/30/19 found on page twenty (20) she was deemed at risk for falls and had a history of [REDACTED]. Her most recent falls occurred on 06/20/19 and 06/22/19 related to poor safety awareness. Interventions included to wear non-skid footwear for safety. Further review of the care plan found she requires extensive assistance of one (1) person for transfers with a gait belt. The care plan assessed that she has a history of behaviors which includes walking without assistance. Review of the medical record on 07/30/19 found physician's orders [REDACTED]. Observation on 07/31/19 at 8:45 AM found her self-propelling in her wheelchair in the 300 hallway and was nearing the end of the hallway circular area. She wore white footie socks with orange toes. This is the second day and third observation of her not wearing non-skid footwear. An interview was completed at this time with licensed nurse #14 (LPN #14), who was present in the hallway. She said this resident is supposed to wear non-skid footwear. She then retrieved a pair of purple, non-skid socks and placed them on the resident's feet in place of the white footie socks with orange toes. These findings of the use of non-skid footwear were reported to the administrator on 08/01/19 at 8 AM. He acknowledged his understanding.",2020-09-01
569,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,690,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of Center for Disease Control and Prevention (CDC) guideline, and policy review the facility failed to ensure a resident's Foley Catheter drainage tubing was securely anchored and kept below the resident's bladder. This was true of one (1) of three (3) sample residents reviewed for catheter care. This practice had the potential to effect more than a limited number. Resident identifier: R#34. Facility census: 106. Findings include: Record review on 07/31/19 on12:20 PM revealed R#34 pertinent [DIAGNOSES REDACTED]. The resident has a foley catheter and is dependent for all activities of daily living. Observations of Nurse Aide (NA#76) and NA#81 providing catheter care to Resident (R#34), on 07/31/19 at 02:41 PM, revealed the Foley catheter drainage tubing was not secured or anchored in anyway. NA#81 lifted the drainage bag and placed it on top of the bed above the resident's bladder between R#34's legs. The bed was not in the flat position, the foot of the bed was elevated, and the resident's feet was also placed on pillows. The bag was placed on the pillows and urine in the drainage tube started to flow back toward the resident. The NAs did not notice the urine backflowing until surveyor intervention. This surveyor requested NA#81 move the drainage bag so it would not be above resident's bladder, and would stop the urine from returning back into the resident's bladder. The back flow of urine re-entering the resident's bladder would increase the risk for developing an urinary tract infection. During the provision of care the resident was assisted to turn on to her side. The Foley catheter drainage tube was not secured to the resident's leg. Observations, during the repositioning of the resident to expose the areas being cared for, revealed tension and pulling of the drainage tubing. The pulling and tension of the drainage tube had the potential to cause injury to the resident's urethra and urinary meatus. After NA#76 and NA#81 stated they were finished doing catheter care, this surveyor asked what method the facility used to secure the Foley catheter drainage tube. NA#76 acknowledged the resident did not have an anchor device on and confirmed the catheter drainage tubing was supposed to be secured so it did not pull. Review of the facility's Catheter: Indwelling Urinary - Insertion policy revealed #25 stated Ensure the catheter tubing is secured with catheter tube holder or leg strap. Keep the drainage bag below the level of the patient's bladder and off the floor. Review of the facility's policy Catheter: Indwelling Urinary - Care of policy revealed #13 stated Secure catheter tubing holder to keep the drainage bag below the level of the patient's bladder and off the floor. Catheter CDC Current professional standards of practice for maintenance of Foley Catheters include, Do not let the drainage bag touch or lie on the floor. According to the CDC's (Centers for Disease Control and Prevention) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, a directive listed under 'Proper Techniques for Urinary Catheter Maintenance' is Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. According to Lippincott Nursing Center, an authority for the professional development of nurses providing evidence-based procedure guidance; the principles for managing an indwelling catheter include, The collecting bag should be positioned below the level of bladder at all times and never placed on the floor.",2020-09-01
570,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,695,D,0,1,OOIK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview the facility failed to provide respiratory care services, consistent with professional standards of practice. This was true for one (1) of two (2) residents reviewed for respiratory services during the Long Term Care Survey Process (LTCSP). During an observation it was discovered R42 was receiving his oxygen air flow via nasal cannula at 1.5 litters and not the ordered two (2) liters. Resident identifier: R42. Facility census: 106. Findings included: a) R42 During a medical record review on 07/30/19, revealed the physician's orders [REDACTED]. An observation on 07/30/19 at 12:08 PM, it was discovered the oxygen concentrator for R42 had an air flow set on 1.5 liters. An observation by E24, Licensed Practical Nurse (LPN) on 07/30/19 at 12:10 PM verified the oxygen concentrator for R42 was providing an air flow of 1.5 liters and not the ordered two (2) liters per minute.",2020-09-01
571,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2019-08-01,761,D,0,1,OOIK11,"Based on a random observation and staff interview, the facility failed to secure medications properly when the medication cart on C400 hall was left unlocked. This was true for 1 of 4 medication carts. This had the potential to affect more than an isolated number of residents. Facility census: 106. Findings include: On 07/29/19 at 02:49 PM, random observations on C400 hall, revealed the medication cart was unlocked with no staff observed to be in eyesight. Residents were observed walking in the hall. All residents that smoked residing in the facility used the C400 hallway to exit the building to the outside designated area for smoking. The Practice Development Specialist (PDS#1) coming down the hall stopped and confirmed the medication cart was unlocked and should never be unlocked and unattended at any time. The PDS#1 locked the cart and verified any resident or visitor could have access to any of the various medications stored in the cart when it is unlocked.",2020-09-01
574,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2017-10-04,282,D,0,1,TF8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement care plan interventions for a resident with a [MEDICAL TREATMENT] Arteriovenous (AV) fistula/shunt. Resident # did not have her AV shunt/fistula monitored for bruit and thrill every shift and as needed (prn) as directed by her care plan. This practice affected one (1) of one (1) [MEDICAL TREATMENT] resident in the facility. Resident identifier: #10. Facility census: 102. Findings include: a) Resident #10 Review of the medical record on 10/04/17 at 9:22 a.m. revealed Resident #10 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She has an AV shunt/fistula for [MEDICAL TREATMENT] access. The care plan contained an intervention initiated on 06/16/17 (typed as written): .Protect shunt sites from injury-check for patency, palpate for thrill, and auscultate for bruit q (every) shift and prn (as needed). Document presence or absence and notify MD if absence . (Bruit is the sound of blood flowing through the AV shunt. Thrill is the vibration of blood going through the arm). Inquired about the location of [MEDICAL TREATMENT] AV shunt assessment documentation on 10/04/17 at 10:31 a.m. from Licensed Practical Nurse (LPN) #131 and Registered Nurse (RN) #112 due to being unable to locate documentation in the medical record. LPN #131 commented, It is documented in the TAR (treatment administration record) I will look in the computer. RN #112 proceeded to print copies of the TAR from Resident #10's admitted to present. Review of the TAR's revealed documentation stating (typed as written): Check fistula right arm q shift for bruit and thrill every shift for patency She stated, The nurses work twelve (12) hour shifts so that is why the assessment is just for Day and Night shift. Review of the TAR's in the presence of RN #112 and LPN #131 revealed blank areas for assessment dates of the following: --06/06/17 on Day shift. --06/22/17 on Day shift. --07/23/17 on Day shift. --09/25/17 on Day shift. LPN #131 and RN #112 verified and agreed there were blank spaces for fistula assessment on the TAR. LPN #131 stated, The blank spaces mean the fistula was not assessed for that shift. After review of the TAR and care plan RN #112 stated, No the care plan was not followed for assessment of the fistula every shift. During an interview on 10/04/17 at 11:57 a.m. the Assitant Director of Nursing (ADON) #121 reported, I will be checking to see why these assessments were not done, there is no excuse.",2020-09-01
577,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2017-10-04,514,D,0,1,TF8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurately documented clinical records. Incomplete and/or blank [MEDICAL TREATMENT] communication forms for one (1) of one (1) [MEDICAL TREATMENT] resident whose chart was reviewed during Stage 2 of the Quality Indicator Survey (QIS). This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #10. Facility census: 102. Findings include: a) Resident #10 Review of the medical record on 10/04/17 at 9:22 a.m. revealed Resident #10 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She has an AV shunt/fistula for [MEDICAL TREATMENT] access. Review of the [MEDICAL TREATMENT] communication sheets for (MONTH) and (MONTH) (YEAR) revealed multiple blank areas for pre-[MEDICAL TREATMENT] and post [MEDICAL TREATMENT] for weights and vital signs (vitals) for the following specified dates: ---09/26/17 Post [MEDICAL TREATMENT] weight. ---09/23/17--Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---09/21/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---09/19/17--Pre-[MEDICAL TREATMENT] blood pressure (BP) and pulse. Post [MEDICAL TREATMENT] weight. ---09/16/17--Pre-[MEDICAL TREATMENT] vitals and post [MEDICAL TREATMENT] weight. ---09/14/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---09/11/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---09/09/17-Post [MEDICAL TREATMENT] weight. ---09/07/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight and vital signs. ---09/05/17--.Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight and vital signs. ---09/02/17-Pre [MEDICAL TREATMENT] weight and post [MEDICAL TREATMENT] weight. ---08/31/17-Pre [MEDICAL TREATMENT] weight and post [MEDICAL TREATMENT] weight. ---08/27/17--Pre [MEDICAL TREATMENT] weight and vitals. Post [MEDICAL TREATMENT] weights. ---08/24/17--Pre and post [MEDICAL TREATMENT] weights. ---08/22/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---08/19/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---0817/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---08/15/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. ---08/12/17-Pre [MEDICAL TREATMENT] weight and vital signs. Post [MEDICAL TREATMENT] weight. --08/05/17-Post [MEDICAL TREATMENT] weight. Registered Nurse (RN) #112 reported during an interview on 10/04/17 at 9:41 a.m., The [MEDICAL TREATMENT] communication sheets are on the hard chart which is how they communicate with us and we review them upon _________(name of Resident #10). They are also considered order sheets because they (the [MEDICAL TREATMENT] center) do not use our order sheets. After review of the [MEDICAL TREATMENT] communication sheets for (MONTH) and September, RN #112 agreed and verified for specified dates there were blank areas for pre [MEDICAL TREATMENT] weights, vitals, post [MEDICAL TREATMENT] weights and vitals. She stated, Yes that would be incomplete medical records. During an interview on 10/04/17 at 11:57 a.m. the Assistant Director of Nursing (ADON) #121 reported, I spoke with the [MEDICAL TREATMENT] center and they have computerized records and the paper is just double charting. But they can not print off the [MEDICAL TREATMENT] records because no one would understand them and they are [MEDICAL TREATMENT] records and not part of the chart. She agreed and verified that the communication sheets for (MONTH) and (MONTH) contain blanks for information and considered part of the medical record. Yes it is considered an incomplete medical record. After review of the contract between the facility and the [MEDICAL TREATMENT] company-titled: Nursing Home [MEDICAL TREATMENT] Transfer Agreement which it states: 2. Center Obligations.(d). In providing [MEDICAL TREATMENT] treatment to Designated Residents, Center shall adhere to the requirements of applicable state and federal law and regulations. ADON #121 stated, I will talk with Administrator about the [MEDICAL TREATMENT] center records and ask her to speak with the [MEDICAL TREATMENT] Center.",2020-09-01
579,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,554,D,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations and record review, the facility failed to ensure that a Resident (#26) was provided the opportunity to self administer medications. This affected one out of one sampled resident for self administration of medications. Resident #26 was found with over the counter medications on the overbed table without a physician's orders [REDACTED]. Findings included: a) Resident #26 On 10/15/18 at 11:47 AM, Resident #26 was interviewed in her room. During the initial interview an observation was made of a large bottle of Tums sitting on the resident's overbed table. Resident #26 stated that she always kept the bottle of Tums on the overbed table in case [MEDICAL CONDITION] too bad. Review of the clinical record on 10/16/18 at 2:56 PM revealed an admission history dated 11/21/11. The admission history documented Resident #26 was admitted to the facility with [DIAGNOSES REDACTED]. The quarterly Minimum data set (MDS) assessment, dated 07/30/18, documented that the resident had no memory impairment, no mood disturbances and no behaviors. The plan of care (P[NAME]) for GERD, last updated on 08/09/18, documented an intervention that Resident #26 will take medications as ordered by the physician and to monitor for signs and symptoms of GERD. Further clinica record review revealed that Resident #26 had a physician's orders [REDACTED]. On 10/16/18 at 4:50 PM, Licensed Practical Nurse (LPN) # 31 was interviewed at the 1 west nurse's station. LPN #31 stated that Resident #26 did not have an order to keep medications at bedside, but that her family would bring her in anything she wants. LPN #31 revealed that Resident #26 had [MEDICATION NAME] Migraine and the Tums at her bedside. LPN #31 stated that the facility had previously told Resident #26 that she could not have medications at bedside without an order from a physician., LPN #31 stated that she had reported the medications at bedside to her direct supervisor. On 10/16/18 at 5:24 PM, Resident #26 was interviewed in her room. Resident #26 stated that she bought both the Tums and [MEDICATION NAME] migraine with her own money and no one was going to take it away from her. She stated she often took the Tums after a meal and when she felt the [MEDICATION NAME] wasn't working. Resident #26 stated, I do not care if I'm supposed to have it or not, but I'm keeping it. The Tums were kept out on the overbed table. The [MEDICATION NAME] Migraine bottle and an unopened bottle of Tums were in an unlocked drawer. The resident stated that LPN #31 discussed the importance of the physician being aware of all the medications that she was taking, up to and including, over the counter medications. The resident stated that LPN #31 said that they could even talk to her physician about getting an order and assessment for her to keep the medications at bedside. On 10/17/18 at 9:27 AM, Certified Nursing Assistant (CNA) #11 was interviewed. She stated that she had worked with Resident #26 for five years. CNA #11 stated that when she first saw the bottle of Tums, she reported it to her charge nurse. Since it was still there, she assumed it was allowed. CNA #11 stated that she wouldn't necessarily know if Resident #26 had an order to have medications at bedside or not. On 10/17/18 at 2:14 PM, the nursing home administrator (NHA) was interviewed. The NHA stated that we try to satisfy Resident #26's needs, but sometimes we cave in. Resident #26 will tell us that we're not respecting her resident rights. The NHA was unable to describe a plan to keep the other residents from accessing medications kept at bedside in Resident 26's room. On 10/18/18 at 12:30 PM the policy for self-administration of medications, dated (MONTH) (YEAR), was reviewed. The policy, in part, documented .a physician's orders [REDACTED]. If the interdisciplinary committee grants approval that a resident is able to self administer medications, the nurse manager will notify the maintenance department for the need of supplying a lockable drawer, for the resident's bedside stand, as well as 2 keys for the drawer lock. One key shall be kept in the nursing unit's medication room and the other shall be given to the resident. A self-Medication Administration Record [REDACTED]. The unit nurse shall be responsible for verifying with the resident their self-administration of medication and documenting verification on the resident's self-administration record by placing their initials.",2020-09-01
581,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,656,D,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure the care plan was implemented for one (Resident #20) of 21 sampled residents whose care plans were reviewed. The facility census was 128. Findings include: On 10/17/18 at 3:03 PM, the clinical record of Resident #20 was reviewed. Resident #20 had [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment, dated 07/23/18, documented the resident was cognitively intact; required extensive assistance with bed mobility, transfer and toilet use. Additionally, the MDS stated Resident #20 was occasionally incontinent of bladder and always continent of bowel. The care plan, most recently reviewed/revised 08/06/18, documented Resident #20 had a problem related to her self-care deficit and requirement for staff intervention or assistance to remain clean, neat and free of body odors. An intervention for the problem included to be sure call light is within reach and encourage to use it for assistance. Respond promptly to all requests for assistance. On 10/17/18 at 8:05 AM, the call light monitor screen at the Unit 2 North nurses' station was observed. The monitor indicated the call light of Resident #20 had been initiated at 7:42.21 AM. The call light monitor indicated the call light was answered at 8:31 AM. The length of time between the initiation of the call light and the answering of the call light was 49 minutes. At 8:37 AM on 10/17/18, Certified Nurse Aide (CNA) #97 was interviewed as she exited the room of Resident #20. She was asked if she knew how long the resident's call light had been on. She stated, About 10 min. She stated she had been in another resident's room getting him ready to go out for the day. She was asked what the resident (#20) needed. CNA #97 stated, the resident needed Off the bed pan. At 8:40 AM on 10/17/18, during an interview in the resident's room, Resident #20 was asked if she had been waiting for assistance. She stated, Yes, she was waiting for assistance off the bedpan. On 10/17/18 at 3:36 PM, in the Minimum Data Set (MDS) coordinator's office, the observations were reviewed with the MDS coordinator. She was asked if the resident's care plan had been followed to respond promptly to all requests for assistance. She stated, No.",2020-09-01
582,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,677,D,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview and observation, the facility failed to provide personal grooming and specifically shaving a female resident's chin hair. This affected one (Resident #21) of 21 sampled residents. The facility census was 128. Findings included: a) Resident #21 According to the clinical record, reviewed 10/17/18 at 9:22 AM, Resident #21 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS), dated [DATE], Resident #21 was moderately cognitively impaired, with a Brief Interview of Mental Status (BIMS) score of 11 out of 15. She required supervision to limited assistance with all Activities of Daily Living (ADLs). Resident #21's care plans were reviewed on 10/17/18 at 9:40 AM. A care plan revised on 08/09/18, identified the resident as having a self-care deficit. She required staff intervention or assistance to remain clean, neat and free of body odors. Interventions included providing and assisting with bath or shower, oral care twice a day and as needed, grooming and personal hygiene daily and as needed. Resident #21 was interviewed on 10/15/18 at 4:36 PM. She was observed to have long chin hairs on the right side of her chin. The hairs were approximately three quarters of an inch long. Resident #21 was asked about the hairs. She grabbed them and pulled on them. She said her daughter sometimes pulled them out for her, but she hadn't visited in awhile. She said the staff had never shaved or pulled out her hairs for her. She wasn't aware that she had chin hairs. She said she wished someone had told her that she had hairs on her chin. Resident #21 was observed on 10/16/18 and 10/17/18. She was observed to have long chin hairs on the right side of her chin. The hairs were approximately three quarters of an inch long. Resident #21 was interviewed on 10/18/18 at 8:42 AM. She was asked about her chin hairs. She said she would like them pulled out if the staff wanted to do that. Certified Nurse Aide (CNA) #23 was interviewed on 10/18/18 at 9:04 AM. She said the resident primarily did her ADLs on her own. She said the CNAs encourage and supervise her, but she is able to do her own ADLs. She had not noticed that Resident #21 had long chin hairs. Shaving woman's chins is a part of ADLs and something CNAs would do for residents. If staff notice long chin hairs, then the resident should to be asked about it, and then they would shave the resident if the resident wanted them to. At 9:08 AM, CNA #23 went into Resident #21's room. She verified the resident had long hairs on her chin. She asked the resident if she would like her to shave her chin hairs and the resident said, Yes, if you want to. The Director of Nursing (DON) was interviewed on 10/18/18 at 11:01 AM. She said that CNAs could shave woman's chins if they had long hairs. It depended on the resident and whether they wanted the hairs removed or not. Removing chin hairs was a part of cleaning them. She didn't feel that residents having long chin hairs was an issue. As long as residents were clean, that was what mattered. The Nursing Home Administrator was interviewed on 10/18/18 at 12:50 PM. She said that long chin hairs needed to be addressed with care. CNAs should ask residents whether they wanted their hair removed with their morning routine and daily care. She said it depended on the resident's preference with whether a resident having long chin hairs was an issue or not.",2020-09-01
584,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,761,D,0,1,4GQP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to ensure medications were stored in locked medication carts. This affected one (Unit 3) of seven medication carts. The facility census was 128. Findings included: On 10/16/18 from 9:46 AM to 9:51 AM, an unlocked, unattended medication cart was observed setting outside room [ROOM NUMBER]. At 9:51 AM on 10/16/18, Registered Nurse (RN) #92 returned to the medication cart. She was asked if the medication cart was supposed to be left unlocked and unattended. She stated, No, it's not. The facility's Storage of Medications policy and procedure documented: Policy: Drugs and biologicals are stored in a secure and orderly manner .and are accessible only to licensed nurses and pharmacy personnel.",2020-09-01
586,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,814,D,0,1,4GQP11,"Based on observations and interviews the facility failed to provide proper disposal of garbage. This affected one of one dumpster on the facility grounds. The facility census was 128. Findings included: On 10/17/18 at 10:48 AM an observation was made of one dumpster being used for all the garbage in the facility. The dumpster was located off the loading lock. The dumpster did not have a lid on top and there were bags of garbage both inside the dumpster and around the dumpster on the ground. The area around the dumpster had tied bags of garbage, food waste, Styrofoam cups, plastic cups, disposable gloves and plastic bottles on the ground. On 10/17/18 at 10:53 AM Cook #127 was interviewed. Cook #127 stated that she was aware the dumpster did not have a lid. On 10/17/18 at 2:23 PM the Nursing Home Administrator (NHA) was interviewed. The NHA stated that she did not know why this type dumpster was ordered for the facility. The NHA confirmed that to have proper disposal of garbage a lid was necessary on the dumpster and an area around the dumpster free of garbage.",2020-09-01
587,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2018-10-18,880,D,0,1,4GQP11,"Based on observation, staff interview, and policy review, the facility failed to ensure proper hand hygiene was utilized to administer medications via a feeding tube. This affected one (Resident #86) of one sampled resident observed during medication administration. Additionally, the facility failed to dispose of a contaminated bag of linen in one Resident (#82) of seven resident bathrooms observed during initial sample tour. The facility census was 128. Findings included: 1. On 10/16/18 at 10:56 AM, Licensed Practical Nurse (LPN) #81 was observed as she set up medications for feeding tube administration for Resident #86. Upon entering the resident's room, LPN #81 washed her hands and donned gloves. She turned off the feeding pump and picked up the TV control off the floor and placed it on the bed. Without washing her hands or using hand gel and changing gloves, LPN #81 proceeded to open a clean syringe and disconnect the feeding tube from the tubing. She, inserted the syringe into the feeding tube lumen and administered the medication . At 11:40 AM on 10/16/18, in the hallway outside the room of Resident #86, the observation was reviewed with LPN #81. She was asked if she should have removed her gloves, used hand gel, and donned clean gloves after she handled the TV control from the floor and before she handled the feeding tube and administered the medications. She stated she should have changed her gloves after she handled the TV control from the floor . 2. Observation on 10/16/18 at 10:00 AM during environmental rounds on the West Unit was completed. In Resident #82's room, revealed in the bathroom, a clear plastic bag lying on the floor containing towels, a brief and gloves with bowel contents. Interview with Resident #82 on 10/16/18 at 10:00 AM in his room, revealed he ambulates with his sitting walker and he does utilize his bathroom. Interview with the Certified Nursing Aide (CNA) #55 on 10/16/18 at 10:00 AM in Resident #82's bathroom, revealed when asked about the bag of soiled linen and garbage lying on the Residents bathroom floor, she stated, she should have taken it directly to the soiled utility room. CNA #55 stated, she had forgot about leaving the bag on the floor. When asked why it was important to take it directly to the soiled utility room, she stated because it was Dirty and should not be left on the Resident's bathroom floor where he walked. Review of the facility policy titled, Bed Side Nursing Care, Standards of Nursing Practice, dated revision 04/17 was completed. Under the section Nurse Assistants one of the bullet points states: .maintains a clean, safe environment.",2020-09-01
588,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,550,D,0,1,OS8J11,"Based on observation and interview the facility failed to respect the dignity of residents in a manner that promoted and enhanced quality of life. The facility failed to protect a resident from being exposed and failed to cover catheter bags. The failed practice affected three (3) of 28 residents. Resident identifiers: #20, #15 and #74. Facility census: 140. Findings included: A policy review, titled Code of Ethics/Respect for Patients with revision date of 04/2018 was reviewed. The policy stated, Grooming residents as they wish to be groomed in a manner that prevents exposure and maintains dignity. A policy review, titled Standards of Nursing Practice with revision date of 01/2019 was reviewed. The policy stated, Indwelling Catheter drainage collection bag is to be maintained at level below the bladder, off the floor surface and covered to hide appearance of collection bag contents from general viewing. a) Resident #20 An observation, on 11/05/19 at 7:46 AM, revealed Resident #20 laid in bed with bilateral breasts exposed. The bilateral breasts were visible from the hallway. An interview with Licensed Practical Nurse (LPN) #65, on 11/05/19 at 7:49 AM, confirmed Resident #20 was exposed. LPN #65 stated Oh my goodness. b) Resident #15 An observation, on 11/04/19 at 11:23 AM, revealed Resident #15's catheter bag was not covered. An interview with Certified Nursing Assistant (CNA) #71, on 11/04/19 at 11:42 AM, confirmed the catheter cover was sitting in the window sill not covering the catheter bag. CNA #71 stated, someone must have forgotten to put the cover back on his catheter bag after his morning shower. c) Resident #74 An observation of the 1 North Unit, on 11/05/19 at 9:00 AM, revealed Resident #74 was in bed. The catheter bag was not covered, full of urine, on the floor, and fully visible from the hallway. An interview with Licensed Practical Nurse (LPN) #100, on 11/05/19 at 9:05 AM, revealed catheter bags only have to be covered when residents are in the hallways. An interview with the Administrator, on 11/06/19 at 9:30 AM, revealed catheter drainage bags should always be covered.",2020-09-01
589,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,580,D,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to ensure a resident's physician was notified concerning the lack of availability of a physician's orders [REDACTED]. ventilator mask was lost or misplaced. This practice affected one (1) of twenty-eight (28) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: 121. Facility census: 140. Findings include: a) Resident #121 A review of the facility's policy titled Bedside Nursing Care. Effective date 05/87 with revisions on 01/19 revealed the following: The physician(s), family, significant other and /or POA will be notified of any unexpected or significant change in a resident's condition in a timely manner. The above are notified when the resident's physical, communicative, psychosocial or functional status changes unexpectedly or substantially; the resident is injured; and there is a need for additional direction (change in or an anticipated or unanticipated delay in treatment) in regard to care of the resident. An interview with Resident #121 (R #121), on 11/04/19 at 2:08 PM, revealed the resident's noninvasive ventilator mask was lost or misplaced. R#121 stated that she was unable to use her noninvasive ventilator last night due to her missing ventilator mask. A review of R #121's physician orders, revealed the order Noninvasive Ventilator Setting: Expiratory Positive Airway Pressure (E-PAP) min pressure five (5), E-PAP max pressure twenty (20) , Tidal Volume 400 milliliters (mL), respiratory rate auto, oxygen concentrator flow rate two (2) Liters at bedtime (hs). A review of R #121's medical record, revealed a nursing note created, 11/04/19 at 10:12 PM, Mask missing. Report to day shift to find out next steps to reorder one. An interview with Licensed Practical Nurse (LPN) #60, on 11/05/19 at 2:25 PM, revealed R #121 still did not have a mask for her noninvasive ventilator. LPN #60 stated that the mask, should arrive today, 11/05/19. During an interview with the with LPN #60 on 11/05/19 at 3:31 PM, the LPN #60 stated that there was no documentation that the physician had been notified of the missing ventilator mask that he could find. During an interview with the administrator, on 11/06/19 at 9:55 AM, the administrator states that they used oxygen via nasal cannula during the night shifts and the physician was not notified. No other information was provided prior to the end of the survey on 11/06/19 at 12:00 PM.",2020-09-01
593,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,695,D,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. The physician's orders [REDACTED]. This practice affected one (1) of six (6) residents reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #121. Facility Census: 140. Finding included: a) Resident #121 A review of American Association for Respiratory Care Clinical Practice Guideline -Oxygen Therapy in the Home or Alternate Site Health Care Facility -2007 Revision & Update P1063-1067- Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of [MEDICAL CONDITION]. Oxygen is a medical gas and should only be dispensed in accordance with all federal, state, and local laws and regulations. An observation of Resident #121, on 11/04/19 at 2:06 PM, revealed the Resident was receiving oxygen at two and a half (2.5) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of the Resident's physician order, revealed the order Oxygen two (2) Liters, Route: nasal cannula, Frequency: continuous with rest and four (4) Liters continuous with exertion to maintain oxygen saturation ninety-two (92) % or greater with an order date of 09/17/19. A second observation of Resident #121, on 11/05/19 at 2:16 PM, revealed the Resident was receiving oxygen at three (3) Liters via nasal cannula from an oxygen concentrator. An interview with Registered Nurse (RN) #96 on 11/05/19 at 2:20 PM, verified the Resident was receiving oxygen at three (3) Liters. An interview with Licensed Practical Nurse (LPN) #60 on 11/05/19 at 2:25 PM, verified the resident was ordered oxygen at two (2) Liters via nasal cannula with rest. The LPN verified the oxygen level was wrong.",2020-09-01
594,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,732,D,0,1,OS8J11,"Based on observation and interview, the facility failed to post a Daily Nurse Staffing Report, which included, facility name, current date, the total number and the actual hours worked by (Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides) directly responsible for resident care per shift, along with resident census. The 2 North and 1 West Units did not have the Daily Nurse Staffing Report posted at the start of each shift. These were random observations. Facility census: 140. Findings include: a) Observations Observation of the 2 North Unit, on 11/05/19 at 9:05 AM, revealed the Daily Nurse Staffing Report was blank for the 7 AM to 7 PM shift. Observation of the 1 West Unit, on 11/06/19 at 8:05 AM, revealed the Daily Nurse Staffing Report was blank for the 7 AM to 7 PM shift. b) Interview An interview with the Administrator, on 11/06/19 at 8:30 AM, revealed the Daily Nurse Staffing Reports should be completed and posted at the start of each new shift. The Administrator stated the day shift starts at 7 AM.",2020-09-01
595,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,758,D,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to document and implement non-pharmacological intervention approaches. The facility did not document non-pharmacological intervention approaches on the care plan or in the medical record. The failed practice affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #105. Facility census: 140. Findings included: a) Resident #105 A record review, on 11/05/19 at 11:13 AM, revealed no documentation or implementation of non-pharmacological approaches used for [MEDICAL CONDITION] medications on the care plan or in progress notes of the medical record. An interview with Registered Nurse (RN) #107, on 11/05/19 at 11:50 AM, confirmed no evidence of non-pharmacological interventions documented on the care plan. RN #107 stated, I would expect to see non-pharmacological interventions on the care plan. An interview with Quality Nurse (QN) #186, on 11/05/19 at 3:50 PM, confirmed behavior sheet stated see care plan however no evidence of non-pharmacological intervention approaches were documented on the care plan.",2020-09-01
597,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,236 HULLIHEN PLACE,WHEELING,WV,26003,2019-11-06,880,D,0,1,OS8J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe and sanitary environment that prevented the development and transmission of communicable diseases and infections. Two (2) catheter bags were on the floor and a nurse conducting a dressing change did not provide a barrier for wound supplies nor wash her hands appropriately during the dressing change. These practices affected three (3) of twenty-eight (28) residents reviewed for infection control during the Long Term Care Survey Process (LTCSP). Resident identifiers: #74, #15, and #85. Facility census: 140. Findings include: a) Resident #74 An observation of the 1 North Unit, on 11/05/19 at 9:00 AM, revealed Resident #74 was in bed. The catheter bag was not covered, full of urine, on the floor, and fully visible from the hallway. An interview with Licensed Practical Nurse (LPN) #100, on 11/05/19 at 9:05 AM, revealed catheter bags should never be on the floor. An interview with the Administrator, on 11/06/19 at 9:30 AM, revealed catheter drainage bags should always be off the floor. b) Resident #15 A policy review, titled Standards of Nursing Practice with revision date of 01/2019 was reviewed. The policy stated, Indwelling Catheter drainage collection bag is to be maintained at level below the bladder, off the floor surface and covered to hide appearance of collection bag contents from general viewing. An observation, on 11/04/19 at 11:23 AM, revealed Resident #15's catheter bag hung off the side of the bed touching the floor. The catheter bag was observed folded in half due to contact with floor. Half of the catheter bag hung from the bed and the other half laid on the floor. An interview with Certified Nursing Assistant (CNA) #71, on 11/04/19 at 11:42 AM, confirmed the catheter bag was touching the floor surface. CNA #71 stated that catheter bags touch the floor when a resident's bed is in the lowest position. c) Resident #85 An observation on 11/06/19 at 8:01 AM, of Registered Nurse (RN) #127 providing wound care to Resident #85's pressure ulcer, revealed a breach in infection control practices. RN #127 placed wound care supplies on the over-bed table without providing a clean surface or barrier to work from. RN #127 donned gloves and removed dirty dressing from Resident #85's coccyx. RN #127 cleaned and dried the wound. RN #127 doffed gloves and retrieved a second pair of gloves. RN #127 donned the second pair of gloves without preforming hand hygiene. RN #127 applied santyl ointment and covered area with [MEDICATION NAME] dressing. The RN placed the open ointment on the over-bed table without a barrier. An interview with RN #127, after provision of wound care, revealed RN #127 confirmed that the over-bed table was not cleaned prior to applying wound dressing supplies and that hand hygiene was not preformed after doffing gloves during the wound care dressing change.",2020-09-01
598,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2020-01-15,641,D,0,1,BZFH11,"Based on record review and staff interview, the facility failed to accurately complete section K (nutritional status) of the Minimum Data Set (MDS) assessment for Resident #24. This deficient practice was found for one (1) of five (5) residents reviewed for the care area of nutrition. Resident identifier: #24. Facility census: 44. Findings included: a) Resident #24 On 01/14/20 at 10:30 AM Resident #24's MDS assessment with an Assessment Reference Date (ARD) of 11/21/19 was reviewed. Resident #24's weight on section K of the assessment had been coded as 173 pounds, and significant weight loss over one (1) or six (6) months was coded. A review of Resident #24's weight records during the survey found Resident #24 weighed 171 pounds at the time of the assessment and did not have significant weight loss over one (1) or six (6) months. On 01/14/20 at 3:17 PM the facility's Certified Dietary Manager (CDM) and Registered Dietitian (RD) were interviewed regarding the above discrepancies. The CDM stated that she had used the wrong weight to code the assessment. The RD confirmed the computer system had pulled the wrong comparison weight and therefore had erroneously indicated Resident #24 had significant weight loss over six (6) months. The above information was discussed with the facility's Administrator on 01/14/20 at 4:00 PM, and no further information was provided prior to exit.",2020-09-01
600,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2020-01-15,880,D,0,1,BZFH11,"Based on observation and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection. Resident identifier: #24. Facility census: 44. Findings included: a) Resident #24 While preparing to give medications to Resident #24, on 01/14/2020 at 9:00 AM Licensed Practical Nurse (LPN)#30 placed a medication cup containing Prosource (a protein supplement) inside of a medication cup containing medications. Both cups were on the top of the med cart without a barrier. LPN #30 also placed an inhaler disk on the over bed table without first placing a barrier. This was brought to the attention of LPN #30 whom agreed a barrier should have been used.",2020-09-01
601,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,641,D,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete accurate comprehensive assessments related to medications for two (2) of two (2) residents receiving [MEDICATION NAME] (an antiplatelet drug). Facility census: 44. Resident identifier: #18 Findings included: a) Resident (R) #18 Review of the medical record on 03/06/19 at 08:50 AM, revealed R #18 was admitted to the facility in (YEAR). Her daily medications included [MEDICATION NAME] (generic name for [MEDICATION NAME]). The Medication Administration Record [REDACTED]. The record lacked any information indicating R #18 received an anticoagulant. The comprehensive minimum data set (MDS) assessment with an assessment reference date (ARD) of 08/01/19, indicates R #18 received an anticoagulant daily during the seven day look back period under section N0410E. **The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 manual states under the coding instructions for N0410E Anticoagulant .Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. During an interview on 03/06/19 at 9:30 AM, the Registered Nurse Assessment Coordinator (RNAC) #39, confirmed R #18 did not receive anticoagulants and the comprehensive assessment with an ARD of 08/01/19, is coded incorrectly under section N0410E. b) Resident (R#37) A review of the annual minimum data set (MDS), on 03/05/19 at 10:38 AM, with an assessment review date (ARD) of 02/14/19, revealed Section N 'Medications' (N0410) was marked R#37 was taking an anticoagulant. The MDS inaccurately reflected the status of an anticoagulant for Resident #37 due to the resident was taking [MEDICATION NAME] Tablet 75 MG ([MEDICATION NAME] Bisulfate an antiplatelet, not an anticoagulant. Some pertinent [DIAGNOSES REDACTED]. The resident also had a cardiac pacemaker. On 03/05/19 at 02:12 PM, an interview with Licensed Practical Nurse (LPN#35) revealed the resident was taking [MEDICATION NAME] Tablet 75 MG ([MEDICATION NAME] Bisulfate) one time a day due to the resident having had a stroke. Review of orders revealed [MEDICATION NAME] Tablet 75 MG ([MEDICATION NAME] Bisulfate) Give 75 mg by mouth one time a day for other. LPN#35 said she was going to have the record corrected and the order revised to include the [DIAGNOSES REDACTED].",2020-09-01
602,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,656,D,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to develop a comprehensive person-centered care plan. This was found true for one (1) of seventeen (17) care plans reviewed during the investigation process of the survey. R34 had an order for [REDACTED]. Findings included: a) R34 During a medical record review on 03/05/19 for R34 had a physician's orders [REDACTED]. The care plan was not developed to include this intervention. In an interview 03/05/19 at 11:30 AM, with Employee #39, Registered Nurse Assessment Coordinator (RNAC) verified the care plan did not include the physician's orders [REDACTED].",2020-09-01
603,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,657,D,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to revise R #18's care plan after she refused to wear eye glasses and to update R #4's care plan after the discontinuation of bi-pap (bilevel possitive airway pressure). This was found for two (2) of 17 residents reviewed during the survey. Facility census: 44. Resident identifier: 18 and 4. Findings included: a) Resident (R) #18 During a random observation on 03/03/19, a nurse aide was heard asking R #18 where her glasses were. Additional observations on 03/03/19 and 03/04/19 found R #18 without eye glasses. A review of the medical record on 03/05/19 at 2:30 PM, revealed R #18's [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 01/08/19, is marked yes under section B1200 indicating corrective lenses are used to verify adequate vision when completing section B1000 (the ability to see in adequate light with glasses or other visual appliances). The current care plan with a revision date of 02/04/19, identifies R #18's activities of daily living (ADLS) self-care deficits with a goal to maintain a current level of function. Interventions include (typed as written): .Wears Glasses: Assist/Prompt/Encourage patient to wear glasses and to keep glasses clean and free of debris. Report damage and scratches to Unit Charge Nurse . During an interview on 03/05/19 at 3:45 PM, Registered Nurse Assessment Coordinator (RNAC) #39 reviewed R #18's care plan and acknowledged it was not up to date. She reported R #18 frequently breaks or throws away her glasses. Her son brings in bags of readers to replace the glasses she looses or breaks. b) R4 A review of the medical record for R4 on 03/05/19 revealed the care plan had not been revised for the discontinued use of a bilevel positive airway pressure ([MEDICAL CONDITION]) on 02/11/19. During an interview on 03/05/19 at 3:21 PM with Employee #39 registered nurse assessment coordinator (RNAC) verified the care plan for R4 had not been revised to show the [MEDICAL CONDITION] had been discontinued.",2020-09-01
604,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2019-03-06,684,D,0,1,33PA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and standing orders the facility failed to follow standing orders for bowel protocol for a resident with a [DIAGNOSES REDACTED]. This was true for one (1) of five (5) residents reviewed for 'Unnecessary Medications, [MEDICAL CONDITION] Medications, and Medication Regimen Review'. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #37. Facility census: 44. Findings included: Resident (R#37) Review of records on 03/05/19 at 12:29 PM, revealed some pertinent [DIAGNOSES REDACTED]. Review of the resident's medication regimen revealed R#37 was receiving [MEDICATION NAME] 50 MG (milligram) one (1) tablet by mouth two (2) times a day for pain related to [MEDICAL CONDITION] Arthritis. [MEDICATION NAME] is an opioid pain medication, that can cause opioid induced constipation (OIC). OIC is the most common side effects of opioid use and can last for the length of treatment. The resident was also taking [MEDICATION NAME] 25 MG by mouth one (1) time a day for depression and [MEDICATION NAME] 0.25 mg by mouth one time a day related to Dementia, which both have a side effect of constipation. Another medication the resident was getting was a stool softener, [MEDICATION NAME] Sodium 100 MG capsule two (2) times a day by mouth, for constipation. A review of the annual minimum data set (MDS), on 03/05/19 at 10:38 AM, with an assessment review date (ARD) of 02/14/19, revealed the residents Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 00, indicating Severe Impairment. The resident needs extensive assistance for most activities of daily living, is totally dependent for bathing; and needs supervision for bed mobility, locomotion, and eating. Resident#37 is frequently incontinent of bladder and is continent of bowel. Review of the resident's bowel movement (BM) records for the month of (MONTH) 2019 revealed the resident went greater than three (3) days without a bowel movement. R#37 had a bowel movement on 02/17/19, and no evidence of another until four (4) days later, on 02/21/19. The Physician's standing order for constipation was as follows; if no BM x 3 days check resident's bowel sounds and document. Notify physician if bowel sounds are absent. If positive bowel sounds give milk of magnesium (MOM) 30ml x1, if no results notify physician. The records showed a nurse gave MOM on 02/21/19 the fourth day with results. On 03/05/19 at 03:26 PM an interview with the Unit Charge Nurse, Registered Nurse (RN#16) revealed resident was sent to the hospital 02/01/19 status [REDACTED]. The resident had stopped talking as a result of the stroke but was starting to talk a little now. Review, on 03/06/19 at 08:20 AM, of a neuro consult dated 02/13/19 revealed the resident had a brain infarct (stroke ) on 02/01/19 with lost ability to communicate. On 03/06/19 at 12:35 PM, an interview and review of records with Unit Charge Nurse, Registered Nurse (RN#16) and the Director of Nursing (DON confirmed records showed R#37 had a BM on 02/17/19, with no BMs on 02/18/19, 02/19/19,and 02/20/19. Records showed the laxative MOM was given by the nurse on the fourth day instead of the third day as instructed by the physician. RN#16 and the DON agreed the order was not followed the laxative was not given on the third day.",2020-09-01
608,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2017-08-01,272,D,0,1,UXKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview and staff interview, the facility failed to conduct an accurate comprehensive assessment for one (1) of twenty-two (22) sample residents. The comprehensive assessment for resident #204 did not accurately reflect the resident's dental status. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #204 Facility census: 113 Findings include: During stage one (1) of the Quality Indicator Survey (QIS) general observations, on 07/25/17 at 02:51 p.m., and interview with Resident #204 revealed he had missing teeth. Resident #204 acknowledged that he had missing teeth for a long time, even before he ever came to the facility. A review of the medical record, on 07/31/17 at 11:11 a.m., revealed Resident #204 was initially admitted on [DATE]. The resident was cognitively intact and is able to understand and make himself understood, some [DIAGNOSES REDACTED]. A Nursing Assessment, dated 03/06/17, revealed the resident had no missing teeth, which was inaccurate. Review of a nursing readmission assessment dated [DATE], on 07/31/17 at 12:22 p.m., revealed the resident was accurately assessed as having one or more missing teeth and broken teeth. A review of the admission minimum data set (MDS) with the MDS Nurse #169, on 07/31/17 at 2:14 p.m., with an assessment review date (ARD) of 03/13/17, revealed no missing teeth. The MDS Nurse #169 agreed and confirmed the MDS was inaccurate regarding the resident's oral/dental status.",2020-09-01
609,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2017-08-01,309,D,0,1,UXKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. A medication was not given to the resident as ordered by the physician. This is true for one (1) of one (1) residents reviewed for [MEDICAL TREATMENT] care. This failed practice had the potential to affect a limited number of residents. Resident identifier: #150. Facility census: 113. Findings include: a) Resident #150 Review of records found a physician order [REDACTED]. Beginning on 07/13/17 and continuing to 07/30/17 medical records reveal blood pressures values requiring the [MEDICATION NAME] 0.2 mg as needed physician order [REDACTED]. On 07/31/17 at 2:54 p.m. registered nurse, #14 agreed the physician order [REDACTED].",2020-09-01
610,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-10-02,656,D,1,0,FLIY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and medical record review, the facility failed to follow the care plan for one (1) of eleven (11) sampled residents. A resident who was care planned to transfer with the assist of two (2) was transferred with the assist of one (1). A resident whose care plan directed for a saline mouth wash three (3) times daily was not followed, but was documented as having been done. Resident identifier: #9. Facility census: 113. Findings include: a) Resident #9 1. On 09/29/19 at 5:35 PM, nursing assistant #4 (NA #4) was observed as she provided oral care to this resident in the resident's bathroom as she sat in her wheelchair. Upon inquiry as to when she last toileted this resident, she said it was around 4:30 PM. She said this resident was a one (1) person assist. She said she toilets her about every two (2) hours. She said she would do so again after the trays go out but would do it now if she needed to go. The resident stated, I'm dry, when NA #4 offered to toilet her. 2. On 09/30/19 at 10:40 AM, observed nursing assistant #3 (NA #3) as she assisted the resident into the resident's bathroom to toilet her. She assisted the resident from the wheelchair to the toilet, and from the toilet to the wheelchair by herself. Review of the care plan on 09/30/19 found a focus on page three (3) that the resident requires assistance with activities of daily living due to decreased functional and cognitive status related to the [DIAGNOSES REDACTED]. An interview was conducted with the administrator, director of nursing (DON) and assistant director of nursing #5 (ADON #5) on 10/02/19 at 12 PM. Upon inquiry as to how many persons were required to transfer this resident, the DON said let me check the orders. After checking the physician's orders [REDACTED]. They were told that at least two (2) nursing assistants transferred her as a one (1) person assist, although the care plan specified that she requires transfer assistance with two (2) persons. No further information was provided prior to exit. b) Resident #9 A 09/30/19 review of the care plan found on page nineteen (19) directives to Check mouth for sore three (3) times daily and rinse with NS (Normal saline) followed by cool water rinse to be completed by nurse only. The care plan revision date was 05/22/19. Observation on 09/30/19 at 1:46 PM found licensed nurse #1 (LPN #1) performing mouth care for this resident in the resident's bathroom. She said nurses clean her teeth after each meal and inspect her gums. She used a white toothbrush and brushed her upper denture with water, then used the green toothbrush and brushed her mouth with water. She said the yellow toothbrush was for the lower mini-denture, but the resident was not wearing it. The lower denture was sitting in a denture cup on the counter of her sink. Review of the (MONTH) medication administration record (MAR) found that LPN #1 initialed at 9 AM and 2 PM on 09/30/19 that she Remove dentures and rinse mouth with saline, then replace dentures TID after meals. However, the nurse did not use saline rinse. Observation of an 8 1/2 by 11 inch sheet of paper which was taped to the resident's bathroom wall by the sink stated as typed: Remove dentures at least twice daily. - Clean dentures with soft bristle toothbrush and water ONLY. - Clean mouth and implant posts with soft bristle toothbrush and water ONLY. - Soak Dentures in cup after cleaning in ONLY water (covering O rings) An interview was conducted with LPN #1 on 09/30/19 at 3 PM. She said she did not use saline today because the resident swallows it. She said when she had the mouth ulcers they used saline, but not anymore. She said she uses water and the specially marked toothbrushes only. An interview was conducted with licensed nurse #2 (LPN #2) on 10/02/19 at 11:30 AM. She was asked to explain the procedure she uses for oral care. She said she rinses the upper denture with water, brushes her gums with toothpaste, then puts the dentures back in. She said she has three (3) different toothbrushes that are labeled for their use although all the brushes are alike. She said that for awhile when the resident had mouth ulcers they used saline rinse in her mouth. Now, sometimes she uses saline on the resident and other times just water. She said sometimes the resident will spit and other times not. She said she could see the purpose of the saline when she had the mouth ulcer to try to heal it. She said she no longer has any mouth ulcers. She said she has not seen the resident wear her lower dentures for approximately a couple of months at least. An interview was conducted with the administrator, the director of nursing (DON) and the assistant director of nursing (ADON #5) on 10/02/19 at 12 PM. It was shared that based on observation of oral care and staff interviews, nurses are not always following the physician's orders [REDACTED]. They said that order for saline rinse needs to be changed.",2020-09-01
612,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-10-02,842,D,1,0,FLIY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure its medical records were complete and accurately documented. This was evident for one (1) of eleven (11) sampled residents. A resident had some differing directives for oral care. The medical record sometimes contained inaccurate documentation related to the care and/or treatment provided. Resident identifier: #9. Facility census 113. Findings include: a) Resident #9 Review of the medical record on 09/30/19 revealed this resident has had some concerns with her mouth/gums/lower denture for some time. 1. A current physician's orders [REDACTED]. Notify dentist with concerns. This remains on the current medication administration record (MAR), and is timed at 6 AM, 2 PM and 9 PM daily. Review of the care plan on 09/30/19 revealed an intervention to not use toothpaste on dentures as they are to be cleaned with diluted soap and no moisturizer (provided on the sink). In comparison, a typed directive on a sheet of typing paper taped to the resident's bathroom wall by her sink directed to clean the denture with a soft bristle toothbrush and water only. 2. A current physician's orders [REDACTED]. The remains on the current MAR and is timed at 6 AM and 2 PM daily. Staff interviews found this resident is not wearing her lower denture on a regular, routine basis now. However, nurses continue to document on the MARs that they are checking the O-Rings twice daily. Out of sixty (60) opportunities in September, nurses documented refused or other, see nurse note on only five (5) occasions. An interview was conducted with nursing assistant #5 (NA #5) on 09/30/19 at 1:30 PM. She said the resident's teeth are to be brushed every morning, after each meals, and at bedtime. She said she brushed her teeth at about 7 AM today. She said the resident cannot wear the lower denture as they make her mouth sore, so they are in a denture cup on the sink in the bathroom. An interview was conducted with licensed nurse #2 (LPN #2) on 10/02/19 at 11:30 AM. She said it has been at least a couple of months since she has seen her wear the lower denture. She said we used to have to check O-Rings. She said we should be checking no or 9 on the MAR and indicating she was not wearing the lower denture, rather than just continuing to check it off as done. A second interview was conducted with NA #5 on 10/02/19 at 12:40 PM. She estimates that for the past two (2) months this resident has worn her lower denture for maybe a handful of times, and then just for a minute or two. She said the resident pops it out and will not leave it in. An interview was conducted with NA #4 on 10/02/19 at 12:45 PM. She estimates this resident has refused her bottom dentures for the past three (3) months. 3. A current physician's orders [REDACTED]. This remains on the current MAR and is timed at 9 AM, 2 PM, and 6:30 PM daily. Observation on 09/30/19 at 1:46 PM found licensed nurse #1 (LPN #1) performing mouth care for this resident in the resident's bathroom. She said nurses clean her teeth after each meal and inspect her gums. She used a white toothbrush and brushed her upper denture with water, then used the green toothbrush and brushed her mouth with water. She said the yellow toothbrush was for the lower mini-denture, but the resident was not wearing it. It was sitting in a denture cup on the counter of her sink. The nurse did not rinse the mouth with saline. Review of the (MONTH) medication administration record (MAR) found that LPN #1 initialed at 9 AM and 2 PM on 09/30/19 that she Remove dentures and rinse mouth with saline, then replace dentures TID after meals. However, the nurse did not use saline when observed. An interview was conducted with LPN #1 on 09/30/19 at 3 PM. She said she did not use saline today because the resident swallows it. She said when she had the mouth ulcers they used saline, but not anymore. She said she uses water and the specially marked toothbrushes only. An interview was conducted with licensed nurse #2 (LPN #2) on 10/02/19 at 11:30 AM. She was asked to explain the procedure she uses for oral care. She said she rinses the upper denture with water, brushes her gums with toothpaste, then puts the dentures back in. She said that for awhile when the resident had mouth ulcers they used saline rinse in her mouth. Now, sometimes she uses saline on the resident and other times just water. She said sometimes the resident will spit and other times not. She said she could see the purpose of the saline when she had the mouth ulcer to try to heal it. She said she no longer has any mouth ulcers. She said she has not seen the resident wear her lower dentures for approximately a couple of months at least. An interview was conducted with the administrator, the director of nursing (DON) and the assistant director of nursing #5 (ADON #5) on 10/02/19 at 12 PM. It was discussed that physician orders [REDACTED]. However, when observed and when staff were interviewed, found the saline rinse was not always done as the physician ordered, yet it was documented on the MAR as having been done. The second part of the inaccurate medical record was related to orders to check dentures for all O-Rings and replace any missing twice daily by nurse only. Staff interviews indicate that the resident has not been wearing her dentures for two (2) to four (4) months by estimate. By nurses documentation they are checking O-Rings twice daily they are giving the illusion that she is wearing the lower denture. During the interview ADON #5 said this resident has worn the lower denture on and off depending on her mood. He said he understands her to be wearing the lower denture sporadically. He say they may need to have some supplemental documentation put in place. At 12:50 PM on 10/02/19 gave ADON #5 an update that the aides who work with her also agreed that she has not been wearing the lower denture in the most recent two (2) or three (3) months.",2020-09-01
613,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-10-02,921,D,1,0,FLIY11,"> Based on observation and staff interview the facility failed to ensure it maintained a sanitary and comfortable environment for residents as evidenced by a resident's wheelchair which smelled of urine. This was evident for one (1) of six (6) sampled residents who utilized wheelchairs for out of bed mobility. Resident identifier: #9. Facility census: 113. Resident identifier: a) Resident #9 Observation on 09/30/19 at 10:40 AM found nursing assistant #3 (NA #3) in the process of toileting Resident #9 in her bathroom. At 10:45 AM on 09/30/19, a request was made to see the wheelchair while the resident was sitting on the toilet. Observation found that the wheelchair cushion smelled like urine. The wheelchair cushion and the white-colored sensor pad both looked dry. When the urine smell was reported to NA #3, she then cleaned the wheelchair seat and the wheelchair cushion and the sensor pad with some wipes. She said the resident was dry. She said all the lines in the brief were yellow, meaning that it was still dry. She then wheeled her out into the hallway to people watch until time to go to lunch. Review of the grievances for the past three (3) months found one dated 08/20/19 whereby this resident's family member voiced concerns about her chair being cleaned properly. An email was attached from the administrator dated 08/22/19 at 9:38 AM to the director of housekeeping asking her to personally make sure this resident's chair is cleaned and her cushion gets cleaned as well. It further stated I'm thinking we may need to do this twice weekly. The family said on Tuesday they thought the chair was stinking. An interview was conducted with the Administrator, the director of nursing (DON), and the assistant director of nursing #5 (ADON #5) on 10/02/19 at 12 PM. The DON said they have it on task for her wheelchair to be washed weekly. She said she has a task for the aides to clean her wheelchair. Another interview was conducted with the administrator and the director of nursing (DON) at 3:15 PM on 10/02/19. Review of the wheelchair task for his resident found that her wheelchair was tasked as completed once per week on 09/03/19, 09/10/19, 09/18/19, and 09/24/19. The administrator agreed they may need to step it up to more often than weekly. The DON said the resident sometimes leaks urine, and she has a yeast infection, and so has a smell.",2020-09-01
616,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-11-21,641,D,0,1,HSBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to complete an accurate minimum data set (MDS) assessment for one (1) of twenty-seven (27) assessments reviewed. The MDS for Resident #98 did not accurately reflect the resident's [DIAGNOSES REDACTED]. This had the potential to affect more than a limited number of residents. Resident identifier: #98 Facility census: 113 Findings include a) Resident #98 During a medical record review on 11/20/19 for Resident #98, it was discovered the comprehensive MDS with the assessment reference date (ARD) of 11/12/19 did not accurately reflect the [DIAGNOSES REDACTED].#98 was taking [MEDICATION NAME] 20 milligrams (mg) once daily [MEDICAL CONDITION] 11/06/19. In as interview with the MDS Coordinator on 11/20/19 at 2:36 PM verified the [DIAGNOSES REDACTED].",2020-09-01
617,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-11-21,684,D,0,1,HSBX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice concerning Foley catheter and oxygen therapy. Physicians orders were incomplete and not clarified by staff for the balloon size of Resident (R#105) Foley catheter and the flow rate of oxygen for R#21. This was true for two (2) of forty-one (41) resident's orders reviewed. Resident identifiers: #105 and#21. Facility census: 113. Findings included: a) Resident (R#105) On 11/19/19 at 03:57 PM review of records revealed the resident had an indwelling Foley catheter due to a [MEDICAL CONDITION] bladder. The resident's Brief Interview for Mental Status (BIMS) score is eight (8) indicating cognitively the resident is moderately impaired. R#105 needs extensive assistance with activities of daily living. Review of the resident's care plan, on 11/20/19 at 12:25 PM, revealed the resident was care planned for a 16 French Foley catheter with a 10cc balloon. Appropriate interventions for the care of the indwelling catheter was noted in the care plan. After review of orders, on 11/20/19 at 12:44 PM, revealed an order that only said 16 French Foley, dated 10/29/19. An interview with the Director of Nurses (DoN), on 11/20/19 at 01:01 PM, revealed the resident had been out of the facility to the hospital in October. The DoN said when the resident returned to the facility it looks like staff forgot to include the catheter's balloon size in the order and they should have. The DoN confirmed it was an incomplete order and should have noted the balloon size. b) Resident #21 During a medical record review on 11/19/19 for Resident #21 revealed the order for oxygen therapy did not include a specified air flow rate for administering oxygen. The order read; (MONTH) initiate oxygen via nasal cannula for shortness of breath or low oxygen saturation less that 90%. Notify the physician. The order had a start date of 11/19/19. In an interview with the Director of Nursing (DON) on 11/20/19 verified the order did specify an air flow rate for which oxygen was to be administered for Resident #21.",2020-09-01
618,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2019-11-21,812,D,0,1,HSBX11,"Based on observations and interviews, the facility failed to use proper sanitary practices when serving and handling foods. This has the potential to affect a limited number of residents who are served from this same central locations. Census: 113. Findings included: a) Observations of the dietary department were conducted shortly after entrance on 11/18/19 with the dietary manager, Employee #45. At this time the following sanitation issued were noted: 1. the drip pan under the range top was found to have an accumulation of food debris and in need of cleaning; 2. the inside of the microwave oven had many food spills on the interior and splashes on the roof which needed to be cleaned; and 3. the dietary staff was noted to handle food and non-food items with the same gloves. This has the potential to lead to cross contamination. The staff member would handle pans, utensils, etc and then touch hamburger buns using the same gloves. These issues were verified with the dietary manager who was present at the time of the observations.",2020-09-01
621,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,157,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to immediately notify the physician when Resident #79's blood pressure was outside of the established parameters. This failed practice had the potential to affect one (1) of one (1) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #78. Facility census: 158. Findings include: a) Resident #78 Medical record review for Resident #78, on 03/15/17 at 10:00 a.m., found a physician's orders [REDACTED]. Recheck blood pressure in one (1) hour and if systolic blood pressure (SBP) is greater than 160 millimeters of mercury (mmHg - the unit used to measure blood pressures) call physician. Review of the Resident #78's Medication Administration Record [REDACTED]. At 7:00 p.m. on 01/20/17, recheck of blood pressure was 169/61. Further review of Resident #78's medical records found no evidence the physician was notified. On 03/15/17 at 2:00 p.m., a discussion with Director of Nursing (DON) confirmed the blood pressure for Resident #78 was outside of the physician prescribed parameter. She agreed there was no evidence of physician notification. No additional information was provided prior to exit.",2020-09-01
622,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,202,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure complete and accurate physician/nursing documentation related to the discharge for Resident #225. Specifically, the facility failed to ensure the physician documented why the resident was unable to be cared for at the facility and required immediate discharge. Resident identifier: #225. Facility census: 158. Findings included: a) Resident #225 Review of Resident #225's medical records, on 03/15/17 at 2:15 p.m., found the resident was admitted to the facility on [DATE] at 4:00 p.m. Her admitting [DIAGNOSES REDACTED]. Further review of the medical records found two (2) nursing notes which read: --01/18/17 at 4:00 p.m., Resident arrived from (Hospital's name), resident's son very upset about residents room and the floor she is on (wanted her on the Transitional Care Unit (TCU) and in a private room) son referred to admissions and the Director of Nursing (DON) for resolution. --01/18/17 at 6:30 p.m., per son's request resident sent to (Name of Hospital) for altered mental status. (Doctor's Name) notified. No further documentation could be found in Resident #225's medical records by nurses and/or physician. Interview with the DON and Registered Nurse (RN) #52, on 03/15/17 at 3:30 p.m., found the physician did not documented the event and occurrences leading to the transfer out to the hospital. No No additional information was provided prior to exit.",2020-09-01
623,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,225,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the reportable allegations and incidents to the proper state entities, staff interview, and resident interview, the facility failed to report an alleged incident of neglect as required by state law for Resident #8. In addition, the facility failed to report an allegation of abuse in a timely manner for Resident #151. This was true for two (2) of three (3) residents reviewed for the care area of abuse. Resident identifiers: #8 and #151. Facility census: 158. Findings include: a) Resident #8 An investigation alleging the resident had numerous vials of [MEDICATION NAME] ([MEDICATION NAME] sulfate and [MEDICATION NAME]) Inhalation Solution stored in her room. Resident #8 was interviewed during Stage 1 of the Quality Indicator Survey at 3:00 p.m. on 03/13/17. She stated her daughter had found many vials of this medication in her room during a visit. The resident said she did not know how the vials got into her room. All she knew was her daughter took them home with her. [MEDICATION NAME] Inhalation Solution is a [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways and increases air flow to the lungs. It is used to treat or prevent [MEDICATION NAME] in people with reversible obstructive airway disease. Review of the resident's current physician's orders [REDACTED]. Further review of the care plan found the following problem: --History of pocketing medications and attempting to hoard in her room. The goal associated with the problem was: --Resident will have no episodes of medication pocketing times 90 days. Interventions included: Crush all crushable medications. Monitor for pocketing of medications and examine mouth cavity to determine ingestion of the medication. The resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. A five-day Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/07/17 found the resident's brief interview for mental status (BIMS) was 13. A score of 13 indicates the resident is cognitively intact. The resident had been deemed to lack capacity to make medical decision by both her physician and a psychiatrist. Her daughter was her medical power of attorney. An interview with the director of nursing (DON), at 8:59 a.m. on 03/15/17, found she had he was aware of the incident. The DON said, She had some [MEDICATION NAME] at her bedside is what I heard. The current DON thought the former DON looked into the incident before she left her employment at the facility. The unit manager, Registered Nurse (RN) #52 was interviewed, at 9:03 a.m. on 03/15/17. When asked if she was aware of vials of [MEDICATION NAME] being in the resident's room, she replied, I just know it (referring to the [MEDICATION NAME]) was found, (name of licensed Practical nurse, #24 reported it to me. RN #52 said she interviewed all of the nurses and reported they poured the [MEDICATION NAME] in the nebulizer when the resident gets a treatment. All staff denied leaving [MEDICATION NAME] in the resident's room. She said the resident's daughter found the vials and took them home with her. RN #53 stated the daughter told her the vials were found in a three (3) tiered cabinet in the resident's room, and she believed LPN #24 also saw the vials. RN #52 said she told the daughter she would probably never have an answer as to how they got in the resident's room. RN #52 reported this incident to the former DON and the resident's physician. She said the physician changed the resident treatment from 4 times a day to PRN (as needed). The dates on some of the vials were from 2014 and (YEAR). RN #52 said she never documented her investigation. A telephone interview with LPN #24, at 10:31 a.m. on 03/15/17, revealed the daughter gave her the vials she found in the resident's room. She said she did not count the vials but estimated there were at least more than 50 of them in a baby wipes container. She said the vials were already out of their packages. LPN #24 did not know how the medication could have been in the resident's room. She said she reported the issue to RN #52. At 12:03 p.m. on 03/15/17, the DON confirmed the facility had no written investigation of the incident reported by the daughter and the allegation had not been reported to the proper State authorities. At 2:41 p.m. on 03/15/17, Social Worker #116, was interviewed. She said she was aware of the situation. She said the daughter called her via the telephone and said she found vials of medication in her mother's room. SW #116 said she told RN #52 and the former DON. SW #116 said she did not document the telephone call nor did she report the incident to any state authorities. SW #116 said she did not investigated the allegation. SW #116 said she did not remember when the incident occurred but thought, It wasn't that long ago. A second, face to face interview with LPN #24, at 11:20 a.m. on 03/16/17, found she believed the daughter reported the incident to her sometime shortly after Christmas. She estimated the timeframe to be within the first two (2) weeks of (MONTH) (YEAR). At 8:22 a.m. on 03/17/17, the resident's physician was interviewed. She said she was aware of the allegation. She said she had been monitoring the resident and had noticed no difference in her condition after she changed the medication to PRN. The physician stated, Her breathing has been stable without the treatments. When asked what could happen to the resident if she used too much of the medication, she replied, It could increase your heart rate. She was unaware of all the details involved in investigating the incident. Surveyor: Hoover, Regina M. b) Resident #151 A review of reportable allegations and incidents was conducted on 03/15/17 at 3:25 p.m. The social worker was interviewed at the time and stated that an issue of alleged abuse by staff had not been reported in a timely manner for Resident #151. A report showed an incident had occurred on 11/09/16 which alleged the resident had been handled roughly by a NA (nurse aide) while providing care. The NA had been impatient with her and pushed her into the side rail of the bed instead of allowing her to assist with her own mobility. Further review indicated the incident had not been reported to appropriate state agencies until 11/14/16. This was a five (5) day delay when instances of alleged abuse should be reported immediately which is 24 hours or less after the allegation occurs. No additional information was provided prior to exit.",2020-09-01
624,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,226,D,0,1,4QX611,"Based on a random opportunity for discovery, record review, and staff interview, the facility failed to implement written policy and procedures to prohibit and prevent abuse. Resident identifier: #59. Facility census: 158. Findings include: a) Resident #59 Review of the medical records for Resident #59's roommate, Resident #162, revealed Resident #162 became frustrated due to Resident #59's yelling out behaviors. On 10/23/16 at 4:23 p.m., a nursing note written by Licensed Practical Nurse (LPN) #54, revealed Resident #59's roommate (Resident #162) stated to the nurse concerning Resident #59, if she didn't stop keeping her awake at night she was going to make her life a nightmare, and went on to tell the nurse she would make the behavior stop however she could. During an interview, on 03/15/17 at 2:58 p.m., LPN #54 explained she did not believe Resident #59 to be in real danger, she monitored both residents throughout the shift and placed the information concerning Resident #162's threat towards Resident #59 on shift report. Medical records revealed no evidence of monitoring the residents. At 10:47 a.m., on 03/15/17 Register Nurse (RN) #52 stated Resident #162 room change occurred on 11/03/16. Record review found no evidence of additional effort to protect Resident #59 from the threat made by Resident #162. Review of the facility's policy and it procedure (Title OPS287) concerning suspected resident to resident abuse section (5.2) reveals, If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. Resident #162 remained the roommate of Resident #59 until 11/03/16 after the threat on 10/23/16. No additional information was provided prior to exit.",2020-09-01
625,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,250,D,0,1,4QX611,"Based on random opportunity for discovery, record review, staff interview and policy review, the facility failed to provide services to attain or maintain the resident highest practicable physical, mental, psychosocial well-being of residents after verbal threats of harm. Resident identifiers: #59 and #162. Facility census: 158. Findings include: a) Resident #59 Review of the medical records for Resident #59's roommate, Resident #162, revealed Resident #162 became frustrated due to Resident #59's yelling out behaviors. On 10/23/16 at 4:23 p.m., a nursing note revealed Resident #59's roommate (Resident #162) stated to the nurse concerning Resident #59, if she didn't stop keeping her awake at night she was going to make her life a nightmare, and went on to tell the nurse she would make the behavior stop however she could. During an interview, on 03/15/17 at 2:58 p.m., Licensed Practical Nurse (LPN) #54 explained she did not believe Resident #59 to be in real danger, she monitored both residents throughout the shift and placed on shift report Resident #162 threatened Resident #59. Medical records revealed no evidence of monitoring the residents. At 10:47 a.m., on 03/15/17 Registered Nurse (RN) #52 stated Resident #162 room change occurred on 11/03/16. Record review found no evidence of additional effort to protect Resident #59 from the threat made by Resident #162. Resident #162 remained the roommate of Resident #59 until 11/03/16 after the threat of harm was made on 10/23/16. b) Resident #162 On 10/23/16 at 4:23 p.m., a nursing note revealed Resident #162 was unsatisfied with her roommate Resident #59, due to Resident #59 yelling out. Resident #162 also made verbal threats to harm Resident #59. At 10:47 a.m. on 03/15/17, Registered Nurse (RN) #52 stated, Resident #162 remained in the room with Resident #59 until 11/03/16. Review of the facility's policy and it procedure (Title OPS287) concerning suspected resident to resident abuse section (5.2) reveals, If the suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. No additional information was provided prior to exit.",2020-09-01
627,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,272,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's comprehensive Minimum Data Set (MDS) was accurate. The MDS failed to code the resident's use of an antianxiety medication. This was true for one (1) of five (5) resident's reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #114. Facility census: 158. Findings include: a) Resident #114 Medical record review on 03/15/17 found the resident was admitted to the facility on [DATE]. The resident was admitted with a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the most recent admission MDS, with an assessment reference date (ARD) of 02/21/17, found the MDS coded the resident as not receiving [MEDICATION NAME] (an antianxiety medication) within the past seven (7) days. During an interview with Registered Nurse (RN), clinical reimbursement coordinator #130, on 03/15/2017 11:08 a.m., she verified the MDS was incorrect. She said she should have coded the use of [MEDICATION NAME] for one (1) day (02/20/17). No additional information was provided prior to exit.",2020-09-01
628,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,279,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and record review, the facility failed to develop a comprehensive care plan for two (2) of eighteen (18) resident's whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #46 failed to have a care plan developed for the care area of nutritional services and range of motion. Resident #166 did not have a comprehensive care plan developed for the care area of [MEDICAL TREATMENT]. Resident identifiers: #46 and #166. Facility census: 158. Findings include: a) Resident #46 1. Nutritional services The resident was reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS) because the resident has a BMI (body mass index) of less than 22 and was not receiving nutritional supplements. The Resident's current BMI was 18.5. Review of the past three (3) nutritional assessment, completed by the Registered Dietician found the following assessment and documentation: 11/09/16 assessment: --Resident readmitted to facility last month, this is first available weight since readmission, hospital stay may be contributing to with loss noted below. Also noted recent ATB (antibiotic) orders and also oral candidias and ulcer in mouth noted, with meds (medications) per order: likely contributing to decreased intake. Meds include [MEDICATION NAME] may increase appetite, MVI (multivitamin) with minerals. Resident eats in second floor dining room. Likes hot tea with meals; also yogurt with meals. --Noted BMI was less than 19. --Intake is varying at this time, from 25-50% --Diet ordered was Regular/Liberalized diet House supplement BID x thirty days. 01/17/17, assessment: --The registered dietician noted the resident was to have a house supplement 2 times a day. --The intake observation was: -50% on average noted per available ADL (activities of daily living) entries. --The resident was noted to have a nutrition problem. --The interventions were: Regular/Liberalized diet House supplement BID in place. 02/15/17, assessment --Evaluated, continued with House Supplement two times a day. RD (registered dietician) review, weight up 4# this month, desirable. Meds include [MEDICATION NAME] (may increase appetite, MVI with minerals. Resident eats in second floor dining room. Likes hot tea with meals, other preferences noted per tray card. Large portions provided for additional calories. --Resident's intake was recorded as -50% on average intake noted per available ADL entries. Review of the current physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Assigned Licensed Practical Nurse (LPN) #8 was asked if the resident received a supplement at 4:39 p.m. on 03/14/17. After review of the resident's MAR and TAR with this nurse she said, No, she doesn't get anything. Assigned Nurse Aide (NA) #9 said she thinks maybe the resident gets a supplement, once a day. She said she knows the resident likes vanilla shakes. She said she does not record the percentage of the supplement consumed. At 4:44 p.m. on 03/14/17, Cook #97 was interviewed regarding the resident's diet. She said the resident gets large portions of protein, like that would be a piece and 1/2 of meat. When asked about supplements, Cook #97 said the resident does not get a supplement. Observation of breakfast, on 03/15/17 at approximately 8:35 a.m., found the resident did not have extra portions. She had eggs, toast, and 2 pieces of bacon. NA # 44 verified the resident did not have extra portions on her breakfast tray. The Dietary Manager (DM) was interviewed at 4:40 p.m. on 03/15/17. The DM said the resident gets a house supplement two times a day. The DM was asked how he monitors if the resident is consuming the house supplement. He replied, he doesn't do any monitoring, that's the nurse's job. He said, It's nursing responsible to relay the message to me. When asked about the care plan, he replied, That is for the nursing staff, I don't look at that either. At 4:56 p.m. on 03/15/17, the Director of Nursing (DON) confirmed the percentages of supplement consumed by resident's are to be on the medication administration record. She confirmed Resident #46's percentages had not been recorded because the Resident did not have an order for [REDACTED]. Observation of the evening meal, at 5:30 p.m. on 3/15/17, found the resident received one (1) piece of fish, green beans, potatoes, a roll and dessert. Nurse Aides #62 and #9 verified the resident did not have large portions of food. Her food was the same size as the other resident's eating in the second floor dining room. The Speech Therapist #171 was also in the dining room feeding another resident. She did not believe the resident received extra portions on her tray. The resident did not receive yogurt with her meal as suggested in the 11/09/16 dietary assessment. An interview with Resident #46, at 5:30 p.m. on 03/15/17, found she said she didn't always like the food served. She was aware she could have a substitute but she probably wouldn't eat that either. She said, I just don't have an appetite, I wouldn't eat anything anyway. She said sometimes she get a shake that comes in a carton, like milk. She said she likes those and will drink them when she gets one. At 8:50 a.m. on 08/16/17, the Registered Dietician (RD) was interviewed. She says she monitors the effectiveness of her interventions by, I just ask the staff. This surveyor explained the staff appear confused as to if the resident even receives a house supplement, and there is no recording of the percentages of the house supplement the resident consumed. This surveyor asked the RD how a large portion of food would be effective when the resident was only eating less than 50% of her meals. She had no immediate answer for this question. Review of the current care plan, revised on 09/07/16 found the current problem: --(Name of resident) has a BMI less than 19. The goal associated with this problem was: --(Name of resident) will have no significant weight changes through next review. Approaches included: --Provide diet as ordered The current care plan was discussed with the Clinical Reimbursement Coordinator #100, at 2:30 p.m. on 03/16/17. The resident's care plan was not individualized with her current physician's orders [REDACTED]. An intervention to provide diet as ordered could be an approach for any resident who receives nutrition from the kitchen. 2. Range of motion Observation of Resident #46, on 03/13/17 at 1:57 p.m., found the resident said she was unable to open her left and right hand. Further observation found the resident had three (3) hand splints lying on her bedside night stand. The resident said she likes to wear them at night times. Interview with the assigned Licensed Practical Nurse (LPN) #24, at 1:22 p.m. on 03/14/17, found she was identified as having contractures of both hands. Review of the care plan found the problem: --Resident exhibits alteration in functional mobility related to decrease ROM (range of motion) to bilateral lower extremities and bilateral hands (contractures). The goal was: --Resident will have no increase in contractures x 90 days. Approaches included: --Splint type: Resident to wear bilateral lower leg brace while out of bed for support from weakness due to long term debility. Review of the most recent, quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/17, found the resident was coded as having no contractures. Review of the physician's orders [REDACTED]. At 5:00 p.m. 03/14/17, the assigned Nurse Aide (NA) #9 said the resident has never had a leg brace since she has worked here for the past two (2) years. NA #9 said the resident does wear hand splints at nights. During an interview with the assigned Licensed Practical Nurse (LPN) #8, at 1:22 p.m. on 03/14/17, she said the resident never had any leg braces. At 5:04 p.m. on 03/14/17, this surveyor and NA #9 looked in the resident's room and found no evidence of any leg braces. At 5:10 p.m. on 03/14/17, the resident said she did not have any leg braces. At 5:08 p.m. on 03/14/17, the Certified Occupational Therapy Assistant (COTA), #166 and the Director of Rehabilitation, Physical Therapist (PT) #162 were interviewed and asked if the resident needed to have hand splints or leg braces. PT #162 provided documentation the resident had been seen by therapy and hand splints were ordered in (MONTH) of (YEAR). She knew nothing about the leg braces. PT #166 was asked if the resident had contractures of her hands. She stated she would look at her tomorrow and would let me know. At 8:15 a.m. on 03/15/17, NA #27 said the resident was wearing both hand splints this morning when she arrived. She assisted the resident with getting up and getting dressed and she removed the hand splints. She described the splints as being the palm protectors on the resident's night stand. At 8:58 a.m. on 03/16/17, Occupational Therapist (OT) #169 said she had looked at the resident and did not feel she had a contracture. She said the resident opened her right hand and opened the left hand about half way She said the resident has [MEDICAL CONDITION] arthritis. She said, It looks like a contracture but she can open it halfway on the left side. At 10:00 p.m. on 03/16/17, the Director of Nursing (DON) said she found the physician's orders [REDACTED]. On 10/09/15, the order was discontinued and a new order written for a right resting hand splint to be worn from 6:00 p.m. - 8:00 p.m. with range of motion prior to application. The order for the left palm protector to be worn from 6:00 p.m. to morning, remained as written on 08/31/15. The DON said she never found any orders to discontinue the resting hand splint or the palm protector. The DON was advised the staff showed this surveyor two palm protectors being applied to both hands when the resident goes to bed and removed when she gets up in the morning. The DON said she would have therapy evaluate the resident again. At 3:20 p.m. on 3/16/17, the OT #169 said she evaluated the resident and she needs the hand splints. At 2:17 p.m. on 03/16/17, the Clinical Reimbursement Coordinator was interviewed regarding the care plan. The resident had no leg braces and is wearing hand splints without an order. The care plan says the resident has contractures, the MDS says she does not. He said he would look at the care plan and address the issues. b) Resident #166 A review of Resident #166's medical record, completed on 03/16/17 at 12:30 p.m., revealed Resident #166 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #166's care plan was reviewed. It did not address her ongoing [MEDICAL TREATMENT] treatment and care/services need for the correlation of care with the outside [MEDICAL TREATMENT] provider. The Director of Nursing, during an interview on 03/16/17 at 3:00 p.m., stated she did not see Resident #166's [MEDICAL TREATMENT] care/services addressed on her comprehensive care plan. No additional information was provided prior to exit.",2020-09-01
629,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,280,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise three (3) of eighteen (18) resident care plans when the residents changed status for behaviors, restorative services, and [MEDICAL TREATMENT]. Resident identifiers: #59, #31, and #183. Facility census 158. Findings include: a) Resident #59 Review of Resident #59's nursing notes revealed documented behaviors of yelling out with mental status changes on 10/23/16, 11/10/16, and 2/25/17. The behavior of yelling out and the mental status change of Resident #59 disrupted her roommate to the point Resident #59's roommate requested a room change. Review of Resident #59's care plan with a revision date of 03/15/17 revealed no evidence of the resident having behaviors of yelling out with mental status change. On 03/16/17 at 2:12 p.m., Registered Nurse #100 agreed the care plan should have included at least a focus update. b) Resident #31 A review of the care plan for this resident on 03/14/17 in the afternoon revealed the resident had interventions in the care plan for the use of 1-2 pound dowel rod do the following exercises in sets of three (3) for ten (10) repetitions/sets, right biceps curls, right shoulder abduction and adduction and left wrist extension/flexion. This had an initiation date of 12/15/16. It was related to the problem of loss of range of motion in upper extremities due to functional deterioration. Interview with rehab staff, on 03/17/17 at 8:20 a.m., revealed the resident no longer receives this treatment intervention. Most of these orders are for six (6) weeks and that timeframe would have been over by now and no new orders were written. The resident has experienced slight decline in her abilities due to age and declining condition. The care plan had not be revised to reflect these services were no longer being implemented. c) Resident #183 On 03/15/17, a review of the medical record indicated Resident #183's current physician's orders [REDACTED]. Further review showed a progress note for 01/11/17 indicating the resident's [MEDICAL TREATMENT] catheter had been removed on 12/13/16. The current care plan had not been revised to remove the intervention to maintain smooth catheter clamps at the bedside (and on resident when out of bed) in case of breakage or excessive bleeding from catheter. An interview with Clinical Reimbursement Coordinator #100, on 03/15/17 at 10:45 a.m., verified the intervention to maintain smooth catheter clamps at the bedside (and on resident when out of bed) in case of breakage or excessive bleeding from the catheter should have been removed since Resident #183 had his [MEDICAL TREATMENT] catheter removed on 12/13/16, and no longer required the use of smooth blue clamps. No additional information was provided prior to exit.",2020-09-01
630,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,282,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observation and staff interviews, the facility failed to implement the care plans for two (2) of eighteen (18) Stage 2 sample residents. The facility did not implement Resident 124's care plan related to poor safety awareness and [MEDICAL CONDITION]. They also failed to implement Resident 114's care plan regarding behavior monitoring for [MEDICAL CONDITION] medications. Resident identifiers: #124 and #114. Facility census: 158. Findings include: a) Resident #124 A review of the medical record on 03/14/17 revealed the care plan interventions to wear knee high compression stockings in the morning and take them off at bedtime due to bilateral leg [MEDICAL CONDITION], hipsters to be worn at all times due to risk of falls and Derma sleeves to bilateral upper extremities to be worn at all times for bruising/skin tears had not been implemented. A physician's orders [REDACTED]. --Knee high compression stockings in the morning and take them off at bedtime was written on 12/30/16; --Hipsters at all times due to history of falls was written on 12/30/16; and --Bilateral derma sleeves for bruising/skin tears to be worn at a times was written on 05/20/16. An observation of Resident #124, on 03/15/17 at 3:17 p.m., revealed the resident had no knee high compression stockings on, no hipsters applied to hips and no bilateral Derma sleeves applied to her arms. On 03/15/17 at 3:25 p.m., Registered Nurse (RN) #34 verified Resident #124 did not have on compression stockings, hipsters or bilateral Derma leaves. b) Resident #114 Record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] 0.5 milligrams, 1/2 tablet (0.25 milligrams) twice a day, as needed for a [DIAGNOSES REDACTED]. The medication, [MEDICATION NAME] was administered on 02/20/17, 02/24/17 and 02/27/17 according to the Resident's MAR. Review of the current care plan found the following problem, created on 02/23/17: --Resident is at risk for complications related to the administration of [MEDICAL CONDITION] medications. The goal associated with the problem is: --Resident will have the smallest most effective dose without side effects x 90 days. Interventions included: --Complete behavior monitoring flow sheet The unit charge Registered Nurse (RN) #52 verified, on 03/15/17 at 10:54 a.m., she was unable to find documentation of the behaviors the resident exhibited to warrant the use of [MEDICATION NAME] and was unable to find documentation of any non-pharmacological interventions implemented before given the medication. The resident's record contained no behavior monitoring sheets. At 10:54 a.m. on 03/15/17, the DON was made aware of the above information. She was unable to provide any further documentation of the behaviors exhibited to warrant the use of [MEDICATION NAME] and unable to provide documentation of the non-pharmacological interventions implemented before giving the medication. The DON verified the facility had not followed the care plan as there was no behavior monitoring flow sheet for (MONTH) (YEAR). The PRN medication [MEDICATION NAME], was not administered in (MONTH) (YEAR). No additional information was provided prior to exit. b) Resident #114 Record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] 0.5 milligrams, 1/2 tablet (0.25 milligrams) twice a day, as needed for a [DIAGNOSES REDACTED]. The medication, [MEDICATION NAME] was administered on 02/20/17, 02/24/17 and 02/27/17 according to the Resident's MAR. Review of the current care plan found the following problem, created on 02/23/17: --Resident is at risk for complications related to the administration of [MEDICAL CONDITION] medications. The goal associated with the problem is: --Resident will have the smallest most effective dose without side effects x 90 days. Interventions included: --Complete behavior monitoring flow sheet The unit charge Registered Nurse (RN) #52 verified, on 03/15/17 at 10:54 a.m., she was unable to find documentation of the behaviors the resident exhibited to warrant the use of [MEDICATION NAME] and was unable to find documentation of any non-pharmacological interventions implemented before given the medication. The resident's record contained no behavior monitoring sheets. At 10:54 a.m. on 03/15/17, the DON was made aware of the above information. She was unable to provide any further documentation of the behaviors exhibited to warrant the use of [MEDICATION NAME] and unable to provide documentation of the non-pharmacological interventions implemented before giving the medication. The DON verified the facility had not followed the care plan as there was no behavior monitoring flow sheet for (MONTH) (YEAR). The PRN medication [MEDICATION NAME], was not administered in (MONTH) (YEAR). No additional information was provided prior to exit.",2020-09-01
632,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,318,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and record review, the facility failed to recognize, a resident with a limited range of motion (ROM), was incorrectly assessed to determine the services needed. This was true for one (1) of three (3) residents reviewed for the care area of range of motion during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #46. Census: 158. a) Resident #46 Observation of Resident #46, on 03/13/17 at 1:57 p.m., found the resident said she was unable to open her left and right hand. Further observation found the resident had three (3) hand splints lying on her bedside night stand. The resident said she likes to wear them at night times. Interview with the assigned Licensed Practical Nurse (LPN) #24, at 1:22 p.m. on 03/14/17, found she was identified as having contractures of both hands. Review of the care plan found the problem: --Resident exhibits alteration in functional mobility related to decrease ROM (range of motion) to bilateral lower extremities and bilateral hands (contractures). The goal was: --Resident will have no increase in contractures x 90 days. Approaches included: --Splint type: Resident to wear bilateral lower leg brace while out of bed for support from weakness due to long term debility. Review of the most recent, quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/17, found the resident was coded as having no contractures. Review of the physician's orders [REDACTED]. At 5:00 p.m. 03/14/17, the assigned Nurse Aide (NA) #9 said the resident has never had a leg brace since she has worked here for the past two (2) years. NA #9 said the resident does wear hand splints at nights. During an interview with the assigned Licensed Practical Nurse (LPN) #8, at 1:22 p.m. on 03/14/17, she said the resident never had any leg braces. At 5:04 p.m. on 03/14/17, this surveyor and NA #9 looked in the resident's room and found no evidence of any leg braces. At 5:10 p.m. on 03/14/17, the resident said she did not have any leg braces. At 5:08 p.m. on 03/14/17, the Certified Occupational Therapy Assistant (COTA), #166 and the Director of Rehabilitation, Physical Therapist (PT) #162 were interviewed and asked if the resident needed to have hand splints or leg braces. PT #162 provided documentation the resident had been seen by therapy and hand splints were ordered in (MONTH) of (YEAR). She knew nothing about the leg braces. PT #166 was asked if the resident had contractures of her hands. She stated she would look at her tomorrow and would let me know. At 8:15 a.m. on 03/15/17, NA #27 said the resident was wearing both hand splints this morning when she arrived. She assisted the resident with getting up and getting dressed and she removed the hand splints. She described the splints as being the palm protectors on the resident's night stand. At 8:58 a.m. on 03/16/17, Occupational Therapist (OT) #169 said she had looked at the resident and did not feel she had a contracture. She said the resident opened her right hand and opened the left hand about half way She said the resident has [MEDICAL CONDITION] arthritis. She said, It looks like a contracture but she can open it halfway on the left side. At 10:00 p.m. on 03/16/17, the Director of Nursing (DON) said she found the physician's orders [REDACTED]. On 10/09/15, the order was discontinued and a new order written for a right resting hand splint to be worn from 6:00 p.m. - 8:00 p.m. with range of motion prior to application. The order for the left palm protector to be worn from 6:00 p.m. to morning, remained as written on 08/31/15. The DON said she never found any orders to discontinue the resting hand splint or the palm protector. The DON was advised the staff showed this surveyor two palm protectors being applied to both hands when the resident goes to bed and removed when she gets up in the morning. The DON said she would have therapy evaluate the resident again. At 3:20 p.m. on 3/16/17, the OT #169 said she evaluated the resident and she needs the hand splints. At 2:17 p.m. on 03/16/17, the Clinical Reimbursement Coordinator was interviewed regarding the care plan. The resident had no leg braces and is wearing hand splints without an order. The care plan says the resident has contractures, the MDS says she does not. He said he would look at the care plan and address the issues. No additional information was provided prior to exit.",2020-09-01
638,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,412,D,0,1,4QX611,"Based on record review and staff interview, the facility failed to obtain a dental assessment for one resident with a physician's order. This is true for one (1) of four (4) residents reviewed for dental care. Resident identifier: #59. Facility census: 158. Findings include: a) Resident #59 Review of records for Resident #59 revealed a physician order dated 01/04/17 to schedule the resident an appointment with dentist due to an oval growth on the right upper gum. Continued review of the records found no evidence Resident #59 was evaluated by a dentist. On 03/16/17 at 1:00 p.m., Registered Nurse #52 stated the appointment did not occur. She also stated Resident #59 has an appointment for a dental assessment on this same day 03/17/17 at 2:30 p.m. No additional information was provided prior to exit.",2020-09-01
640,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,431,D,0,1,4QX611,"Based on observation, review of the guidelines in Appendix PP of the State Operations Manual, and staff interview, the facility failed to ensure the consultant pharmacist maintained a formal system for safe and secure use and storage of medications. There was no permanently affixed storage container in the refrigerator for the secure storage of controlled medications. This practice had the potential to affect no more than an isolated number of residents. Facility census: 158. Findings include: a) Observation of the 3rd floor medication room, on 03/16/17 at 9:55 a.m., revealed the medication refrigerator contained two (2) boxes with thirty (30) milliliter vials of Lorazepam lying on the top shelf of the refrigerator. b) Licensed Practical Nurse (LPN) #26 was present at the time of the observation of the medication refrigerator. She verified the two (2) boxes in the medication refrigerator containing narcotic (Lorazepam) was not in a permanently affixed container in the refrigerator. c) The State Operations Manual (SOM), Appendix PP includes The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. d) In an interview, with the Unit Manager (UM) #11, on 03/16/17 at 10:05 a.m., she agreed the medication refrigerator had no permanently affixed container for the storage of Ativan in the refrigerator. e) The Director of Nursing (DON) was informed, on 03/16/17 at 11:32 a.m., the medication refrigerator on 3rd floor had no permanently affixed container in which to store the Ativan. No additional information was provided prior to exit.",2020-09-01
641,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,441,D,0,1,4QX611,"Based on medical record review and staff interview, the facility failed to maintain an effective infection control program to prevent, to the extent possible, the onset and spread of infection. During Stage 1 of the Quality Indicator Survey, random opportunities found two (2) residents to have oxygen equipment which was soiled or stored in a manner for potential contamination. Resident identifiers: #138 and #30. Facility census: 158. Findings include: a) Resident #138 On 03/13/17 at 1:33 p.m., Resident #138's oxygen tubing was lying directly on the floor without a barrier and the oxygen concentrator was found to without an air filter. At 8:45 a.m. on 03/17/17, the oxygen concentrator was again observed with no air filter. b) Resident #30 On 03/13/17 at 1:58 p.m., Resident #30's oxygen concentrator was observed to have a heavy layer of visible dust on the air filter. Registered nurse #52 was informed of the oxygen tubing being on the floor and the problems with the oxygen concentrators, on 03/17/17 at 9:09 a.m., and she stated she would have the concentrators checked. No additional information was provided prior to exit.",2020-09-01
642,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-03-17,502,D,0,1,4QX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly obtain all physician ordered laboratory (lab) services to meet the needs of residents. Resident #166 had orders for a Basic Metabolic Panel (BMP), [MEDICATION NAME]/International Ratio (PT/INR) and ammonia level to be obtained on 10/21/16 which was not obtained by the facility. Resident #78 has an order for [REDACTED]. Resident identifiers: #166 and #78. Facility census: 158. Findings include: a) Resident #166 A review of Resident #166's medical record, on 03/15/17 at 11:34 a.m., found a physician's orders [REDACTED]. The results of these labs could not be found in the resident's medical record. On 03/16/17 at 11:08 a.m., the Director of Nursing (DON) indicated the BMP, PT/INR and the ammonia level which was ordered for 10/21/16 were not obtained therefore no lab results could be provided. b) Resident #78 A review of Resident #78's medical record, on 03/16/17 at 10:34 a.m., found a physician's orders [REDACTED]. The results of these labs could not be found in the resident's medical record. On 03/16/17 at 11:08 a.m., the Director of Nursing (DON) indicated the BMP ordered for 01/21/17 was not obtained therefore no lab results could be provided. No additional information was provided prior to exit.",2020-09-01
644,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,553,D,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on record review, resident interview, and staff interview, the facility failed to ensure a resident's right to participate in the development of her person-centered plan of care. This was a random opportunity for discovery for one (1) of thirty-one (31) residents during the initial screening process. This practice had the potential to affect more than a limited number of residents. Resident Identifier: #150. Facility census: 156. Findings include: a) Resident #150 The initial interview with Resident #150, on 04/23/18 at 11:12 AM, revealed the resident did not receive a summary of her initial care plan when admitted , or for any care plan since her admission to the facility on [DATE]. The resident was unaware of what care areas, goals, or interventions were in her care plan. The resident denied ever seeing a care plan or signing one. On 04/25/18 at 11:33 AM, a review of the resident's last quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/14/18 found the resident assessed as having clear speech, as able to be understood, and able to understand others. Resident #150's Brief Interview for Mental Status (BIMS) score of fifteen (15) identified the resident was cognitively intact. On 04/25/18 at 04:15 PM, a review of records with the Director of Nursing (DON), revealed a summary of care conference form with no signature in the designated section to indicated the resident attended the meeting. The DON agreed there was no signature, and without the signature, the DON could not know if the resident attended. The facility did not provide any evidence the resident was included in the development of her care plan by the conclusion of the survey.",2020-09-01
645,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,558,D,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to accommodate the needs of one (1) randomly observed resident. Observations found a resident with her feet hitting against the footboard of the bed without anything for comfort to reduce pressure when the head of her bed was elevated. This was evident for one (1) randomly observed resident. Resident identifier: #20. Facility census: 156. Findings included: a) Resident #20 Observations of the resident noted: - On 04/23/18 at 5:24 p.m. her feet touched the footboard, even though staff had pulled her up in the bed not long ago. She was confused and disoriented, and not able to interview regarding her comfort level - On 04/25/18 at 9:15 a.m. the head of her bed was elevated, and her toes were against the footboard of the bed. - On 04/25/18 at 4:00 p.m. head of her bed was slightly elevated. Her toes touched the footboard. - On 04/25/18 at 5:37 p.m. the head of her bed was elevated, and her feet touched the footboard of the bed. None of the observations found application of any interventions to lessen the pressure on her feet and toes from the footboard. Medical record review on 04/25/18 found this resident's most recent quarterly minimum data set (MDS) with an assessment reference date of 01/16/18 assessed her as needing the extensive of assistance of two (2) or more persons for bed mobility. The assessment also identified her as short of breath when lying flat, when sitting at rest, and on exertion. According the assessment, the resident was 66 inches tall and weighed 266 pounds, and was assessed as being at risk for pressure ulcer development. She also had a [DIAGNOSES REDACTED]. During an interview on 04/25/18 at 6:00 p.m., the director of nursing (DON) said they did not approve of residents' feet hitting the footboards of their beds. She said there were other things they could use to prevent this from occurring, such as pillows or wedges. On 04/26/18 at approximately 9:30 a.m., these findings were discussed the administrator. The facility provided no further information prior to the survey exit conference.",2020-09-01
646,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,561,D,0,1,FJW311,"Based on resident interview, staff interview, and record review, the facility failed to accommodate a resident's choice of when he could shower. This was a random opportunity for discovery during the initial screening process of the annual survey. Resident identifier: #119. Facility census: 156. Findings included: a) Resident #119 During an interview on 04/23/18 at 10:54 AM, Resident #119 said Unit Manager (UM) #13 told him he could only have two (2) showers a week. He reported that two (2) weeks ago he only got one (1) shower because the shower room was closed. He said if could have more showers his skin would heal. On 04/23/18 at 1:00 PM, the resident's concern was discussed with the Director of Nursing (DoN). When told Resident #119 wanted more than two (2) showers a week, she agreed he should have more showers if he wanted them more often. She said that she would talk to the floor manager (UM #13) about his showers. During an interview on 04/24/18 at 2:46 PM, Resident #119 said the Unit manager told him she would have to look at the shower schedule before she could give him more showers a week and that no showers were given on Sundays. He said he was hoping to get a shower on Sundays for when he had visitors. He said currently he could only have a shower on Tuesday and Thursday so by Sunday he said he was pretty ripe. During an interview on 04/24/18 at 2:54 PM, Unit Manager #13 said she did not recall this resident asking for more showers and she would look into finding him another shower day, but they did not give showers on Sundays because it was closed. According to the UM, the cleaning crew did a heavy cleaning on the shower tiles on Sundays. When asked if it took all day to clean the shower, and if not could he get a shower before or after the cleaning, she stated she would have to check with housekeeping first. She further stated that it would not happen right away because she would have to redo the shower schedule and added there was not enough staff for him to have more showers. On 04/24/18 at 3:36 PM, when informed of what UM #13 had said, the DoN said, I can't believe that she would say that! I just did an education sheet with her yesterday about allowing him to have more showers when he wants and she agreed to accommodate his needs. She claimed he would receive a shower whenever he wanted. A review of Resident #119's care plan dated 03/25/17, found it identified the resident's preference was to shower three (3) days a week.",2020-09-01
648,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,607,D,0,1,FJW312,"Based on abuse prohibition policy review, a review of grievances and staff interview the facility failed to ensure they implemented their abuse prohibition policy for identifying allegations of neglect, reporting allegations of neglect and identifying whether a resident's missing money involved misappropriation of property. They failed to identify and report an allegation of neglect for one of four (4) grievances reviewed. The facility also failed to identify whether a resident's missing money constituted misappropriation of property for one (1) of four (4) grievances reviewed. A grievance for Resident #154 stated the resident's catheter bag was not checked, for a long period of time and was leaking. Resident #110's grievance reflected that he had six (6) one (1) dollar bills missing. Resident identifiers: #110, #154. Facility census: 155. Findings included: a) Resident #154 A review of the facility's grievance/concerns for the month of (MONTH) (YEAR) found the facility had received a grievance/concern from Resident #154 on 07/10/18. The documentation on the grievance/concern stated, Resident states no one checked her cath (catheter) bag from 4 pm Friday to 1 pm Saturday. When it was checked it was found to be leaking. The resolution of the grievance/concern stated, Staff re-educated on Policy/Procedure of catheter observation and emptying of bedside drain. During an interview with Social Worker (SW) #1, on 07/24/18 at 11:45 AM, the SW said the facility had investigated this issue and found that the resident's catheter bag had been checked and the resident was not upset. She said the resident had no mental anguish and that was why they did not consider the issue as an allegation of neglect. A review of the facility's abuse prohibition policy, revision date 07/01/18, revealed neglect was defined as, The failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also stated the facility would identify incidents or allegations which needed investigated. b) Resident #110 A review of the facility's grievance/concern forms from the month of (MONTH) (YEAR) revealed a grievance/concern for Resident #110 dated 07/05/18. The form stated, Resident states he is missing 6 one dollar bills. On 07/24/18 at 1:47 PM Registered Nurse (RN) #1 said she was the staff member to whom this concern was reported. She said she remembered Resident #154 talking to her about the missing money and telling her he thought he left it in his drawer. RN #1 said she also knew the resident was sick during the time the money was reported missing. The money was later found in the laundry. During an interview with Clinical Quality Specialist (CQS) #152 and RN #1 on 07/24/18 at 1:47 PM, both were asked how the facility determined if they were dealing with a situation of misappropriation of property. CQS #152 said she realized the facility should have documented more of the details surrounding the resident's statement when the money was reported missing on 07/05/18. She agreed that the details on the grievance/concern form did not give enough information to show whether the facility had a situation involving misappropriation of property. A review of the facility's abuse prohibition policy, revision date 07/01/18, revealed the policy defined misappropriation of property as, The deliberate misplacement, exploitation, or wrongful temporary or permanent use of patient's belongings or money without the patient's consent. The policy also stated the facility would identify possible incidents or allegations which need investigation.",2020-09-01
649,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,609,D,0,1,FJW312,"Based on policy review, staff interview, and a review of grievances/concerns for the month of (MONTH) (YEAR), the facility failed to ensure an allegation of neglect was reported. Resident #154 had reported that her catheter bag had not been checked for a long period of time and was leaking. Resident identifier: 154. Facility census: 155. Findings included: a) Resident #154 A review of the facility's grievance/concerns for the month of (MONTH) found the facility had received a grievance/concern from Resident #154 on 07/10/18. The documentation on the grievance/concern stated, Resident states no one checked her cath (catheter) bag from 4 pm Friday to 1 pm Saturday. When it was checked, it was found to be leaking. The resolution of the grievance/concern stated, Staff re-educated on Policy/Procedure of catheter observation and emptying of bedside drain. During an interview with Social Worker (SW) #1, on 07/24/18 at 11:45 AM, the SW said the facility had investigated this issue and found that the resident's catheter bag had been checked and the resident was not upset. The grievance concern documentation showed where the facility had conducted an in-service training on 07/10/18 for Foley catheter care. SW #1 said the resident suffered no mental anguish from the situation and that was why they did not consider the issue to constitute an allegation of neglect. During the interview, on 07/24/18 at 11:45 AM, SW #1 confirmed this issue was not reported as an allegation of neglect. A review of the facility's abuse prohibition policy, revision date 07/01/18, revealed neglect was defined as, The failure of the Center, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy also stated the facility would identify possible incidents or allegations which need investigation and report allegations involving neglect within 24 hours.",2020-09-01
652,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,657,D,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to revise the care plans for three (3) of thirty-one (31) residents reviewed. Resident #109's care plan was not revised after a palm guard to prevent ADL (activities of daily living) decline was discontinued. Resident #80's care plan was not revised to include care/treatment for [REDACTED]. Resident #402's care plan was not revised to include the use of oxygen. Resident identifiers: #109, #80, and #402. Facility census: 156. Findings included: a) Resident #109 Review of the resident's care plan found a focus/problem of, Resident is at risk for decline in ADL's (activities of daily living) related to compromising functional ability. The goals associated with the problem were: - Resident will continue to feed self independently after set up through next review. - Resident will continue to participate in ADL care through next review. Interventions included: - Patent to wear right palm guard from 2:00 p.m. to 8:00 a.m. (MONTH) remove for hygiene. Remove and perform skin check every shift, however, (Name of Resident) is not compliant with wearing palm guard. At 10:12 a.m. on 04/24/18, the Director of Nursing (DON) confirmed the palm guard was discontinued on 03/13/18. b) Resident #80 Observation on 04/23/18 at 3:40 p.m. found this resident lying in bed. He had contractures of both hands. There were no splints, palm guards, or any type of device in place to either hand. On 04/24/18 at 10:30 a.m., observations found he held both hands firmly closed. There were no splints, palm guards, rolled washcloths, or any devices in either hand. An observation at 12:15 p.m. on 04/24/18, accompanied by Registered Nurse Employee #13 (E#13), found a white washcloth placed partially in his left hand, and a thin, smaller, yellow-colored cloth was placed partially in his right hand. When asked whether the cloths were placed in his hands later than 10:45 a.m. that morning, E#13 replied in the affirmative and said she had placed them. On 04/24/18 at 12:15 p.m., E#13 removed the cloths in preparation for inspection of the palms of both hands. When the nurse removed the cloths from his hands, a foul-smelling odor was immediately noted. When asked if the foul odor came from the cloths that were in his hands, E#13 stated I can't put my nose on them to smell them. E#13 tried to move the resident's contracted fingers so the palms could be visualized. His fingers were drawn down tightly, which made visualization of the palms inadequate. She moved the resident's right thumb about one-quarter of an inch outward, which then allowed visualization of a dry, reddened area on the skin of the fourth finger of the right hand. The thumbnail of the right hand lay directly on top of, and pressing against the described reddened area of the fourth finger. The right thumbnail was smooth, but long. It protruded beyond the flesh at the tip of the thumb a quarter of an inch. It needed trimmed. At 3:15 p.m. on 04/24/18 occupational therapist Employee #171 and wound nurse/registered nurse E#120 came to the resident's bed. A white washcloth and a thinner yellow cloth lay on his chest. The resident's palms could only be visualized partially. E#120 said they were aware of the reddened area to the right fourth finger and were monitoring and treating it. He said the right thumbnail needed trimmed. Observation on 04/25/18 at 2:25 p.m., accompanied by licensed nurse Employee #80 (E#80) found no cloths, palm guards, or any devices in either hand. When asked why there was no padding or cloth between the thumbnail and the fourth finger of the right hand to reduce pressure, she then attempted to thread the yellow cloth into the resident's right hand. She ensured it padded the skin between the right thumbnail and the reddened area to the fourth finger beneath it. The thumbnail of the right hand was still long as previously noted. The nurse agreed the thumbnail was too long. She said she had some clippers and would cut and trim the thumbnail. The nurse also attempted to place a washcloth in the palm of the resident's left hand. Review of grievances on 04/24/18 at 4:00 p.m. found one from the daughter of Resident #80 dated 02/19/18. It stated, Daughter concerned resident's hands are not being cleaned and nails aren't being clipped as often as they should be. The corrective action from Unit 3 Nursing Staff stated, Ordered hands to be cleaned daily and nails trimmed every Tuesday and Friday. Review of the (MONTH) Medication Administration Record [REDACTED]. The (MONTH) MAR indicated [REDACTED]. Staff initialed its completion on 03/06/18 and 03/09/18. The space for 03/13/18 was left blank. This too, was on the MAR for one (1) week. Review of the resident's care plan on 04/24/18 at 4:00 p.m. found an area of focus for the resident being dependent for ADL care as evidenced by multiple contractures. A goal included that he would be clean, dry and odor free through next review. The care plan was not fully developed/revised to include cleaning his hands daily and/or how to accomplish that task. The care plan was not fully developed/revised about the need for nail trimming as it related to the pressure of the thumbnail cutting into the contracted fourth finger beneath it. The care plan included an intervention for staff to use palm guards. Observations found no use of the palm guard on either hand. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said there should not have been an odor to the hand as it was possible to clean his hands. She acknowledged that the care plan was not revised to address the special needs for cleaning his hands and trimming of his nails following the grievance filed on 02/19/18. During this interview, it was also discussed that the care plan directed staff to use a palm guard, although it was not being used. She agreed the resident's care plan should have been revised related to mobility and the positioning needs of his contracted hands, as he no longer used the palm guard. On 04/26/18 at approximately 9:30 a.m., these findings discussed shared with the administrator. No further information was provided by the facility prior to exit. c) Resident #402 On 04/16/18, Resident #402 was ordered oxygen 28% via [MEDICAL CONDITION] collar as needed. Resident #402's comprehensive care plan included an intervention for oxygen 45% via heated [MEDICAL CONDITION] collar. During an interview on 04/24/18 at 11:29 a.m., the Center Nurse Executive (CNE) agreed the intervention on Resident #402's comprehensive care plan for oxygen 45% via heated [MEDICAL CONDITION] collar was not current. The CNE agreed the intervention needed revised to oxygen 28% via [MEDICAL CONDITION] collar as needed.",2020-09-01
657,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,690,D,0,1,FJW311,"Based on observation and staff interview, the facility failed to ensure staff provided perineal care (peri care) in a manner to prevent the potential development of urinary tract infections to the extent possible for Resident #99. This was evident for one (1) of one (1) residents reviewed for urinary tract infections. Resident identifier: #99. Facility census: 156. Findings include: a) Resident #99 Observations on 04/24/18 at 11: 39 AM, noted nurse aide (NA) gathering supplies and providing incontinence care for this resident. NA Employee #86 (E#86) placed several clean, folded washcloths directly into the sink basin, shared with two (2) other residents in this room. She ran warm water from the faucet over them until they were completely submerged. E#86 squeezed out the excess water with her gloved hands, then took them to the resident's bed. The resident was incontinent of soft, semi-formed stool which was contained in the perineal and rectal areas and between her legs. E#86 at first cleaned the resident from the front to the back with one of the washcloths as the resident lay on her left side. She disposed of that washcloth into a clear, plastic bag. When E#86 got to the last washcloth, there was still bowel movement in the vulva/perineal area. She folded over the last, used wash cloth repeatedly, and made three (3) more swipes with that soiled wash cloth to remove the last of the bowel movement from the vulva and perineal area. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said it was against the facility's policy to soak washcloths in a sink basin. She said staff were supposed to use the resident's plastic wash basin for that purpose. The DON also agreed that it was not an acceptable practice to reuse a soiled washcloth to clean the perineal area of an incontinent resident. She said she would do staff education to all staff right away. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit. Observations on 04/24/18 at 11: 39 AM, noted nurse aide (NA) gathering supplies and providing incontinence care for this resident. NA Employee #86 (E#86) placed several clean, folded washcloths directly into the sink basin, shared with two (2) other residents in this room. She ran warm water from the faucet over them until they were completely submerged. E#86 squeezed out the excess water with her gloved hands, then took them to the resident's bed. The resident was incontinent of soft, semi-formed stool which was contained in the perineal and rectal areas and between her legs. E#86 at first cleaned the resident from the front to the back with one of the washcloths as the resident lay on her left side. She disposed of that washcloth into a clear, plastic bag. When E#86 got to the last washcloth, there was still bowel movement in the vulva/perineal area. She folded over the last, used wash cloth repeatedly, and made three (3) more swipes with that soiled wash cloth to remove the last of the bowel movement from the vulva and perineal area. During an interview with the director of nursing (DON) on 04/25/18 at 6:00 p.m., she said it was against the facility's policy to soak washcloths in a sink basin. She said staff were supposed to use the resident's plastic wash basin for that purpose. The DON also agreed that it was not an acceptable practice to reuse a soiled washcloth to clean the perineal area of an incontinent resident. She said she would do staff education to all staff right away. These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit.",2020-09-01
659,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,758,D,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of six (6) residents reviewed for unnecessary medications was free from antipsychotic medications. The facility administered [MEDICATION NAME] (an antipsychotic medication) intramuscular (IM), without a physician's orders [REDACTED]. In addition, the physician ordered [MEDICATION NAME] to be administered intravenously (IV) when there was no evidence the resident exhibited any behaviors. Resident identifier: #109. Facility census: 156. Findings include: a) Resident #109 Medical record review found the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medication administration records (MARs) for the period from 11/01/17 to 04/24/18, found the resident was ordered a [MEDICATION NAME] IM (intramuscular) injection on the 28th day of every month. Several dosage changes to the [MEDICATION NAME] had been made by the resident's physician since 11/28/17. On 01/17/18, a new physician's orders [REDACTED]. In addition, the physician ordered [MEDICATION NAME] 50 milligrams IM when not aggressive-today or tomorrow. Review of the nursing notes found the Family Nurse Practitioner (FNP) increased the dosage of [MEDICATION NAME] on 01/17/18 because, (Typed as written), Resident aggressive behaviors towards the nurse that started today. The nurse reports the CNA (certified nursing assistant) asked her to help position him. She was unaware the resident had told the CNA he wanted to be left alone. The nurse said she started to help him and he grabbed her hand and bent if backwards and then punched her in the stomach. Resident in the room and shouting expletives towards the other nurse and this provider. He asked this provider to leave or he stated he would hit me. There was no evidence to indicate the staff attempted any non-pharmacological interventions or just simply left the resident alone as he requested on 01/17/18. Also, the FNP noted the staff member was a new nurse most likely unfamiliar with the resident and his behaviors. The FNP even documented the resident had asked the CNA to leave him alone and the new nurse was not advised of this request before she attempted to provide care. The resident had no recorded behaviors on 01/18/18 when the extra dose of [MEDICATION NAME] 50 milligrams was administered. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] 350 milligrams was also administered on 01/28/18. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] [MEDICATION NAME] Solution 100 milligrams. Inject 350 milligrams one time a day starting on the 28th and ending on the 28th every month. The injection was not provided on 02/28/18 as directed by the physician's orders [REDACTED].>There was no explanation provided on the (MONTH) (YEAR), MAR indicated [REDACTED]. Review of the (MONTH) (YEAR), MAR found an order for [REDACTED].>[MEDICATION NAME] Solution 100 milligrams ([MEDICATION NAME]). Inject 350 milligrams intramuscular one time a day starting on the 28th and ending on the 28th, every month due to [MEDICAL CONDITION]. Further review of the (MONTH) (YEAR), MAR found, [MEDICATION NAME] 350 milligrams, intramuscular was given on 03/02/18 and 03/28/18. The orders directed the [MEDICATION NAME] IV be given on 03/28/18. Review of the physician's orders [REDACTED]. The nursing notes did not reference why the [MEDICATION NAME] was administered on 03/02/18. There was no evidence the resident had any behaviors on 03/02/18. Review of the behavior monitoring logs for (MONTH) (YEAR) found the resident was being monitored for rejection of care. The resident had no behaviors recorded for the entire month of (MONTH) (YEAR). The (MONTH) (YEAR) behavior monitoring log failed to list the behaviors for which the resident was being monitored. The log indicated the resident had no behaviors during the entire month of (MONTH) (YEAR). The behavior monitoring log for (MONTH) (YEAR) had no behaviors listed for staff to monitor and the log indicated the resident had no behaviors for the entire month. At 2:41 p.m. on 04/24/18, the Director of Nursing reviewed the resident's medical record. She confirmed she was unable to find a physician's orders [REDACTED]. Solution, 100 milligrams ([MEDICATION NAME]). Inject 350 milligrams intramuscular, on 03/02/18. The DON also reviewed the January, February, and (MONTH) (YEAR) behavior monitoring logs and confirmed staff should have documented any behavior exhibited by the resident on the behavior monitoring logs and the logs should have contained the behaviors for which the staff were monitoring. The DON was asked why 50 milligrams of [MEDICATION NAME] was ordered on [DATE] when the resident was having no behaviors. She replied, That's a good question, I don't know and the FNP who wrote that order doesn't work here anymore. The DON suspected the [MEDICATION NAME] was administered on 03/02/18 because the staff missed the dose that should have been administered on 02/28/18 but she could not verify that assumption because there was no documentation present in the chart.",2020-09-01
665,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2018-04-26,883,D,0,1,FJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure eligible residents were offered and/or administered the pneumonia vaccinations appropriate for them. This was evident for three (3) of five (5) randomly sampled residents who were eligible to receive pneumococcal vaccinations. Resident identifiers: #99, #79, and #80. Facility census: 156. Findings include: a) Resident #99 Review of the resident's medical record on 04/25/18 found this resident entered the facility in (YEAR). There was no evidence that she received, or was offered, the Prevnar 13 and/or the [MEDICATION NAME] 23 pneumonia vaccination. b) Resident #79 Review of the medical record on 04/25/18 found this resident came to the facility in (YEAR). There was no evidence that he received, or was offered, the Prevnar 13 pneumonia vaccination. c) Resident #80 Review of the resident's medical record on 04/25/18 found this resident came to the facility in (YEAR). There was no evidence that he received, or was offered, the Prevnar 13 pneumonia vaccination. d) During an interview with nurse practice educator registered nurse Employee #167 on 04/25/18 at 4:27 p.m., she confirmed Resident #99 was eligible for the Prevnar 13 and the [MEDICATION NAME] 23 vaccinations, and that Residents #79 and #80 were eligible for the Prevnar 13 vaccination. She said she had looked for, but was unable to find, evidence the residents were offered or received the vaccinations. She showed that the facility's policy directed to offer the [MEDICATION NAME] 23 and Prevnar 13 with a twelve (12) month interval between the two (2) vaccinations. e) During an interview with the director of nursing on 04/25/18 at 6:00 p.m., the findings for these three (3) residents were discussed. All three (3) of the residents were eligible for the Prevnar 13 and/or [MEDICATION NAME] 23 vaccination, but no evidence could be provided by the nurse practice educator to verify the vaccinations were offered or given to the three (3) randomly chosen residents. f) These findings were shared with the administrator on 04/26/18 at approximately 9:30 a.m. No further information was provided by the facility prior to exit.",2020-09-01
666,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,550,D,0,1,33QL11,"Based on observation and staff interview, the facility failed to treat each resident with respect and dignity in a manner and in an environment to promote maintenance or enhancement of his or her quality of life. Resident #153's bilateral nephrostomy bags had no cover and Resident #126's urinary catheter bag had no cover. Facility census: 155. Findings included: a) Resident #153 Observation on 04/29/19 at 3:11 PM, found bilateral nephrostomy bags lying on the bed. Neither bag was covered. At this time, licensed practical nurse (LPN) #24 agreed the bags should have a cover on them. Observation of the bilateral nephrostomy bags again on 04/30/19 at 8:00 AM found no covering on either bag. At this time nurse aide (NA) #29 explained that upon completing care the bilateral nephrostomy bags had no cover. At 2:30 PM on 04/30/19, registered nurse (RN) #88 agreed the bags should be covered and would order the correct supplies. b) Resident #126 Random observation of Resident #126, on 4/30/19 at 1:10 PM, revealed the Resident's urinary catheter bag hanging under his wheelchair uncovered and had urine showing from the bag. This observation occurred in the dining room on the third floor during the lunch meal. The catheter bag was viewable by anyone entering the third-floor dining room. An interview with Nurse Aide (NA) #86 on 04/30/19 at 1:12 PM, revealed Foley catheter bags are to be covered at all times. Observed NA #86 apply a cover to Resident #126's Foley catheter bag on 04/30/19 at 1:15 PM. Assistant Director of Nursing (ADON)#122 was present at the above time on the third floor and she was asked to come to the into the dining room and she observed Resident #126's Foley catheter bag was uncovered and had urine showing from the bag. The ADON acknowledge the Foley Catheter bag needed a cover.",2020-09-01
667,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,561,D,0,1,33QL11,"Based on resident interviews, review of shower logs, and staff interviews, the facility failed to honor resident choices pertaining to the number of showers received per week, and pertaining timely assistance out of bed each morning to enable him/her to partake of breakfast in the dining room. This affected two (2) of two (2) residents reviewed for choices. Resident identifiers: #101, #36. Facility census: 155. Findings include: a) Resident #101 During resident interview on 04/30/19 at 8:41 AM Resident #101 stated she desires two (2) showers per week and is scheduled to receive two (2) showers per week. She said she rarely receives showers since her former nurse aide is no longer is assigned to her for showers. She said she could not recall the date of her last shower. Review of the most recent quarterly minimum data set (MDS), with assessment reference date (ARD 03/29/19, assessed that she required total assistance with bathing and extensive assistance with hygiene. This was also true for the former MDS with ARD 01/02/19. Review of her care plan found no evidence of her refusing care or bathing. On 04/30/19 at 4:00 PM an interview was conducted with the assistant director of nursing (ADON). She said this resident is scheduled to receive showers twice weekly on Tuesdays and Fridays. The ADON provided copies of the shower log for this resident for the months of (MONTH) and (MONTH) 2019. Per these shower log documents, out of seventeen (17) opportunities for a scheduled shower, this resident received a shower once on 03/09/19. All of the other entries in response to the question type of bath said not applicable. The ADON agreed that since only one (1) shower was documented in this two (2) month period of time, it looks like she received only one (1) shower in that time frame. She added that this resident is scheduled for a shower this evening. An interview was conducted with the administrator on 05/01/19 at 9:45 AM. She agreed that if it was not documented that a shower was taken, then a shower did not occur. b) Resident #36 During an interview on 04/29/19 at 1:11 PM, Resident #36 stated, that she likes to get up before lunch, but it does not always happen. Two (2) days ago she was told they could not get her up because the lift requires two (2) people, and they were too busy. She went on to say that they had got her before by just one (1) Nurse Aide (NA). She had to request that there always be two (2), because when it is one (1) they hurt her (she is a paraplegic). She said that the reason she wants up as early as possible because the food is hot if you get it from down stairs. During an interview on 04/30/19 at 2:37 PM, Unit Manager # was asked if two (2) people are supposed to use the lift. She answered yes. She was asked if there were times when it was done with only one person, she said, that they are not supposed to, but there has been some NA's that she has had to re-educate about always having two (2) people. She did not disagree that there were times that one person had used this lift alone. She found an education sheet that she had placed in the education and communication book. The staff are to sign the posting to indicate that they read it and understand it and there were seven (7) names on the paper. She was asked if there was more than seven people that worked on the 2nd floor she said, oh yes. She was asked if she was aware that Resident #36 was not able to get out of the bed when she wants too. She said, that no one had told her that. She said that she will make sure she gets up when she wants to.",2020-09-01
668,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,580,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical review, resident and staff Interviews, the facility failed to notify the physician when a wound treatment was not performed. This affected one (1)of three ( 3) residents who were reviewed for the care area of skin conditions. Resident Identifier #4. Facility Census 155. Finding included: a) Resident #4 In an interview on 04/30/19 at 4:18 PM, Resident #4 revealed she has sores on both legs, the fluid builds up, and drain out of her legs. Resident #4 said her treatment is to have her legs wrapped. Resident #4 scored a 12 on her Brief Interview for Mental Status (BIMS) on a significant change of status with an Assessment Reference Date (ARD) of 01/23/19. A score of 8-12 indicates moderately impaired cognitively. Under section B, the Resident makes self-understood is coded as understood, and the resident's ability to understand others is coded as understands clear comprehension. On 04/30/19 at 2:53 PM, Licensed Practical Nurse (LPN) #6 said the resident is taking a diuretic medication ([MEDICATION NAME] and [MEDICATION NAME])( a diuretic increase urine production in the kidneys, promoting the removal of salt and fluid from the body). LPN #6 revealed that Resident #4 has an order to have her legs wrapped every week, but the resident refuses to have her legs wrapped in the summer due to it is too hot. The LPN thought the Physical Therapy was wrapping Resident #4's legs. Observation of Resident #4's bilateral legs with LPN #6 on 04/30/19 at 3:07 PM, found the resident's legs were not wrapped. Resident's #4's legs were [MEDICAL CONDITION] and had a flaky loose scale. The LPN #6 picked up resident #4's right leg and the observation revealed an open [MEDICAL CONDITION] on the back of her leg, and knee which both were red, and weeping clear fluid. There was a brown crusty scab around the open areas. The left lower leg was excoriated red, with a hard, rough, brown scab of dried blood. There was multiple open lesion on her left leg. Observed a sheet underneath Resident #4's legs which had dried brown/burgundy stains on the sheet. LPN #6 was asked why Resident #4's legs not wrapped. LPN #6 did not make a comment. A review of Resident #4's physician order [REDACTED]. The physician order [REDACTED]. A review of Resident #4's nursing notes on 04/30/19 at 3:11 PM, found LPN #6 had documented Resident #4 had refused to have treatment to her left leg wounds on 04/24/19. A review of Treatment Administration Sheet (TAR) found no one signed off for the treatment to Resident #4's left leg wound on 04/17/19. The LPN #6 wrote refused on the TAR for 04/24/19. The record finds the Nurse Practitioner (NP) and/or the physician was not notified of Resident #4 refusing her treatment to her left leg on 04/24/19 or why the treatment was not performed as ordered on [DATE]. A review of the TAR for the right leg wound treatment found no signatures on 04/18/19 and 04/25/19. There were no notification to the NP and/or physician of why the treatment was not performed as ordered. When LPN #6 was asked why she did not notify the physician when she did not perform Resident #4 treatment to her bilateral legs on 04/24/19. LPN #6 stated that, Nurse Practitioner (NP) #157 was on duty that day. LPN #6 confirmed that she did not notify the NP that Resident #4 refused her treatment on 04/24/19. The LPN stated she did not know why Resident #4 did not receive her wound treatment to her left leg on 04/17/19. LPN #6 also acknowledge Resident #4 did not receive treatment to her right leg on 04/18/19 and 04/25/19. In an interview with NP#157 on 04/30/19 at 3:15 PM, the NP was asked whether the staff notified her Resident #4 had refused her treatment to her left leg, or the staff did not perform wound care to Resident #4's right or left leg at any time in (MONTH) 2019, the NP stated that the staff did not notify her of the wound treatment not being performed for Resident #4's right and left leg in the month of (MONTH) 2019. The Center Nurse Executive (CNE) #22 confirmed the treatment to Resident #4 was not performed by her staff as the physician ordered for the left leg on and on 04/17/19 and 4/24/19. The CNE agreed that Resident #4's right leg treatment was not performed on 04/18/19, and on 04/25/19. The CNE agreed that her staff did not notify a physician nor an NP of the Resident #4's refusal to have her treatment to her left leg and/or why they did not perform Resident #4's treatment to her right and left leg for the above dates.",2020-09-01
671,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,604,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to document the medical symptoms being treated by a physical restraint for one (1) of one (1) residents reviewed for the care area of restraints. Resident identifier: #67. Facility census: #155. Findings included: a) #67 Resident #67 had [DIAGNOSES REDACTED]. She had an order written [REDACTED]. On 05/02/19 at 7:50 AM, the Unit Director was informed Resident #67's restraint order did not document the medical symptoms treated by the restraint. The Unit Director stated she was not aware the medical symptoms were required to be documented. She stated Resident #67 required the seat belt restraint to allow the resident to remain seated in the wheelchair despite the medical symptoms caused by her [MEDICAL CONDITION]'s Disease. The Unit Director stated she would ensure the restraint order was revised to include the medical symptoms being treated by the restraints. No further information was provided through the completion of the survey.",2020-09-01
672,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,607,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Facility Policy, Resident interview, review of records and staff interview the facility failed to implement written policies and procedures that: Prohibit and prevent abuse, neglect, establish policies and procedures to investigate any such allegations. This had the potential the effect unlimited number of residents. Resident identifier: #36. Facility census 155. Findings included: a) Resident #36 Facility policy titled, OPS300 Abuse Prohibition Revision Date: 07/01/18; - Identification of possible incidents and allegation which need investigation -Investigation of incidents and allegations -Reporting of incidents, investigations, and Center response to the results of their investigations. -Initiate an investigation within 24 hours if the event does not result in serious bodily injury. During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse #88 (LPN) refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #88 is going to work. She also stated that she had witnessed this same LPN #88 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW files those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#13. During an interview on 04/30/19 at 3:24 PM, RN-UM #88 was informed of allegation of LPN#13 being rude to Resident #86 and why she did not tell anyone about it. RN-UM#88 said she was not aware of any of this. She said she knows LNP #13 does not smile but she just assumed it was just her personality. She said that this nurse would be here tomorrow if I would want to talk to her. On 05/01/19 at 4:30 PM, SW #124 informed this Surveyor that a report is being done as we speak concerning NA#136 and LPN #13. She went on to say that NA# 136 will be told not to return to work until after the investigation has been completed. She stated, the LPN# 13is being asked to leave now until after the investigation is also completed. Also a reportable and investigation for Resident #86. She stated that they are going to interview all residents that had received care from LPN #13.",2020-09-01
673,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,609,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, resident interview and staff interview the facility failed to report and investigate an alleged allegation of abuse/neglect, not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This had the potential the effect unlimited number of residents. Resident identifier: #36. Facility census 155. Findings included: a) Resident #36 Facility policy titled, OPS300 Abuse Prohibition Revision Date: 07/01/18; - Identification of possible incidents and allegation which need investigation -Investigation of incidents and allegations -Reporting of incidents, investigations, and Center response to the results of their investigations. -Initiate an investigation within 24 hours if the event does not result in serious bodily injury. During an interview on 4/29/19 at 1:24 PM, Resident #36 said, that three (3) staff members that are not allowed in her room anymore. Nurse Aide (NA) #139 was rude to her when her [MEDICATION NAME] (at surgical created stoma to drain urine from the bladder) bag busted opened. She said, that she was covered in urine. This was witnessed by a Licensed Practical Nurse (LPN) #73. She said, that the LPN came back in her room to take her statement, because she said that this incident had to be reported. She also stated that the Social Worker (SW) came to talk to her. She also stated that Licensed Practical Nurse #16 (LPN) refused to change [MEDICATION NAME] bag. It had leaked urine all over her. She said LPN #88 was always rude and snappy when she would ask her a question. She stated that she dreads it when she knows LPN #16 is going to work. She also stated that she had witnessed this same LPN #88 yell at another resident that does not know what she is doing at times. Looking for the reportable that was supposed to done on NA#139 could not be found. During a brief interview on 05/01/19 at 12:30 PM, with Registered Nurse-Unit Manager Director (RN-UM) #88, was asked if she could recall this event and if it was reported. She said yes, she gave the information to the Social (SW) #13 after the morning meeting. She was asked she filled out the, Adult Protective Services Mandatory Reporting Form. She replied no that she does not do that, she writes on a plain sheet of paper and that the SW files those out. It this time she was also informed of the complaint about on LPN#16. During an interview on 05/01/19 at 1:45 PM, SW #13 was asked if she had completed the form for the reportable? She stated, that if she was handed any information about that she would have filled out the form and interviewed the resident. She stated that she will look again. She also informed about the complaint about LPN# 16. During a brief interview on 05/01/19 at 1:55 PM, with SW #13 stated that she cannot find where a report was done and maybe RN-UM #88 may not have given her the information. During a meeting on 05/01/19 at 2:00 PM, RN-UM #88 stated, that she remembers giving her SW # 13, the paper with the complaint on it. She was asked if she had made a copy for herself, and she replied no she did not. During a revisit on 05/01/19 at 3:25 PM, with Resident #36, SW #13 was in her room talking to her about both complaints one on NA#136 and LPN#16.",2020-09-01
674,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,623,D,0,1,33QL11,"Based on staff interview and record review, the facility failed to notify the ombudsman of acute transfers to the hospital. This has the potential to affect two of two residents who had been transferred to the hospital for various reasons and no notice was sent to the ombudsman. The resident identifiers are: #145 and #139. Facility census: 155. Findings included: a) Resident #145 The resident was sent to the hospital for stomach issues resulting in nausea and vomiting. Resident stated during an interview on 5/1/19 that he had been to the hospital recently because his stomach was messed up but he did not have to have surgery. It was found there had been a bowel obstruction. Did not find that information was provided to the local Ombudsman that the resident had been transferred to the hospital. Other information had been given such as bed hold, reason for transfer, etc. but not Ombudsman notification. On 05/02/19 at 11:22 AM Interview with Employee #155 and she stated the social work staff had not been providing discharge information to the ombudsman. The staff had been sending a notice of the residents who had been discharged to home, but not the acute care transfers . They would have to start doing this in the immediate future. b) Resident #157 Resident #157's was discharged to Hospice care on 02/18/19. Review of medical records found no evidence the facility completed a a notice of discharge to the resident/resident representative in writing. On 05/01/19 at 2:25 PM coordinator-clinical reimbursement (CCR) #47 agreed the records did not obtain evidence the facility completed a notice of discharge in writing, for the family.",2020-09-01
675,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,641,D,0,1,33QL11,"**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 a minimum data set (MDS) assessment related to medications the resident received in the look-back period. This was evident for one (1) of five (5) residents reviewed for unnecessary medications out of thirty-one (31) sampled residents. Resident identifier: #44. Facility census: 155. Findings include: a) Resident #44 On 04/30/19 medical record review revealed this resident was an insulin-dependent diabetic. Current physician's orders [REDACTED]. The latter had a parameter to hold the [MEDICATION NAME] if the blood sugar was less that 150 milligrams per deciliter (mg/dl). Review of the most recent minimum data set (MDS) with assessment reference date (ARD) 02/21/19, found she was assessed as having received no insulin injections during the last seven (7) days. Further review of the medical record found physician orders [REDACTED]. Per the (MONTH) 2019 Medication Administration Record [REDACTED]. Another physician's orders [REDACTED]. It had a parameter to hold the [MEDICATION NAME] for a blood sugar of less than 150 mg/dl. Review of the (MONTH) MAR indicated [REDACTED]. An interview was conducted with the director of nursing (DON) on 04/30/19 at 3:00 PM. It was discussed that section N of the 02/21/19 MDS assessed this resident received no insulin injections in the seven (7) day look-back period. The DON agreed this was in error. On 05/01/19 at 9:45 AM an interview was conducted with the administrator. The 02/21/19 MDS error related to insulin usage was discussed. She spoke her understanding. An interview was conducted with MDS registered nurse #25 (RN #25) on 05/01/19 at 10:00 AM. She said she was informed yesterday of the incorrect entry in section N of the 02/21/19 MDS as it related to the number of days this resident received insulin injections in the seven (7) day look-back period. She said she originally entered zero days, and this was in error. She said she now made a modification of that entry to correctly capture that the resident received insulin injections daily in the seven (7) look-back period.",2020-09-01
677,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,657,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the comprehensive care plan for two (2) out of 31 for the area of food preference and [MEDICATION NAME] use. This has the potential to affect less than a limited number of residents. Resident Identifiers #87 and #17. Facility Census 155. Findings included: a) Resident #87 A review of Resident #87's care plan on 05/01/19 at 8:05 AM, finds a care plan with a focus of while in the facility, (resident's first name) Resident #87, states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to her preferences. created on 12/05/18, and revised on 12/12/18. The focus is I like to snack between meals and prefer beaver tails and cheese its.(sic) This intervention was initiated on 12/05/19. A review of Resident #87's participation record finds the resident is not offered beaver tails or Cheez It. on her preferences and interests. The recreation director (RD) #118, on 05/01/19 at 8:15 AM, said Resident# 87 likes someone to read to her, talk about just about anything. The RD said she does most one (1) on one (1) activities with Resident #87. The RD said she had tried crafts, but this does not work. The RD was asked whether she provides beaver tails to Resident #87. The RD stated, What is that. A beaver tail is: a fried dough pastries, individually hand stretched to resemble beaver's tails. The RD confirmed the facility does not give Resident #87 beaver tails. The Assistant Director of Nursing (ADON) #122 on 05/01/19 at 11:15 AM, was asked do you provide a snack called beaver tails and cheese it's to Resident #87. The ADON said what is a beaver tail. The ADON said they do give the resident cheez-it. The Food Service Director (FSD) #154 on 05/01/19 at 12:14 PM, was asked whether she gives beaver tails to the activity department to give to Resident #87. The FSD stated that she did not know what a beaver tail was. b) Resident #17 Review of the care plan on 04/30/19 found a problem of, risk for injury, bruising, or complications related to the use of anticoagulation therapy. Continued review of medical records found a physician order [REDACTED]. to discontinue [MEDICATION NAME] (anticoagulant) due to bleeding [MEDICAL CONDITION] lesion on scalp, advanced age and unable to draw labs. On 05/01/19 at 3:35 PM clinical quality specialist (CQS) agreed the care plan was not revised and presented the care plan with the corrected revision.",2020-09-01
678,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,677,D,0,1,33QL11,"Based on observation, resident interview, and staff interview the facility failed to meet the activity of daily living (ADL) need for Resident #19 related to hygiene care of a contracture. This is true for one (1) of two (2) residents reviewed. Facility census: 155. Findings included: a) Resident #19 On 04/30/19 at 8:30 AM a request was made for registered nurse (RN) #88 to open the contractured left hand of Resident #19. While opening the hand there was a strong odor, the palm had an indentation from the nail on the ring finger, and the nail needed to be trimmed. Resident nurse #88 agreed the left hand needed cleaned and the nail cut. She completed both within a few minutes.",2020-09-01
680,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,686,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to provide pressure ulcer treatment according to professional standards of practice, to promote healing, prevent infection. This was true for two (2) of three (3) reviewed for the care area of pressure ulcers. Identified Residents #136 and #36 Facility census 155. Findings included: a) #136 During an interview on 04/29/19 at 11:32 AM, Resident #136 said that he had sore on buttock. He was asked if the staff came in on a regular basis to two him every two hours. This resident was in a boating accident and suffered a stroke. He was left unable to use his legs and his left arm. He stated that the staff does not help to change his positions every two (2) hours. During an observation on 05/01/19 at 2:23 PM, Licensed Practical Nurse (LPN) # 13 provide wound care for Resident #136 no the buttock. LPN #13 appeared to be unsure of what to do she repeatedly looked to the Registered Nurse Unit Manager (RNUM) # 88 for guidance. RNUM #88 was prompting LPN#13 to wash her hands, intervening and instructing this nurse on how to provide the wound care. During an interview on 04/29/19 at 12:10 PM, RNUM #88 agreed that she had intervened and provided instruction. She also agreed that if she had not the LPN would not have provided care to meet the professional standards. b) Resident #36 During an interview on 04/29/19 at 1:35 PM, Resident #36 stated, that she had pressure ulcers on her buttock and both feet. This resident was a paraplegic. She stated that she has to call for someone to turn her at night, but it is not every two (2) hours. During an observation on 05/02/19 at 7:52 AM, LPN #103 was removing the dressings on the buttock on Resident #36 when the RN-UM #88 prompted LPN #103 to remove the dressing from the left shoulder area before the ones on the buttock area, then again the clean the area on the shoulder first and to wash her hand. Surveyor intervention stopped LPN# 103 from repeated use of a gauze used to clean the wounds using the front and back of the gauze and on only one wound. RN-UM #88 intervened to explain how to apply the dressing on the left gluteal fold. LPN #103 told NA #43 to hold the absorbent pad in place while she opened dressing NA #43 did it without thinking about changing his gloves as he should have. LPN #103 asked if she should wash her hands more than once, she was not organized taking longer than it should have taken. Resident # 36 reminded her that she had not had anything to eat yet. It was 9:08 AM, instead of setting up as her table with all the items she would need to use for each wound site she fumbled around and repeatedly asked for RN-UM #88 to open things. Areas were the left shoulder, multiple Pressure wounds on the buttock and gluteal folds, left and right foot. Resident # 36 instructed LPN#103 on how to change her [MEDICATION NAME]. During a post procedure interview on 05/02/19 at 9:23 AM, LPN #103 stated, that she thought she did very well. When the many problems were pointed out she stated that she does not normally care for this resident. During an interview on 05/02/19 at 9:25 AM, RN-UM # 88 stated that she thought LPN# 103 could have done better, but in her defense night shift normally do the dressing. She did agree that LPN #13 and LPN #103 should have the skill set to perform these tasks without prompting and intervention. c) Facility policy Facility policy titled, Wound Dressing: Aseptic Revision Date: 11/28/17 included: -Prepared label with date and initials. -If patient has multiple wounds: Treat less contaminated wound first -In separate locations: Treat each as a separate procedure",2020-09-01
682,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,690,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, medical record review, staff interview and facility policy review, the facility failed to ensure appropriate catheter care based on current professional standards of practice. This was true for three (3) of Three (3) residents reviewed in the care area of catheter care. Identified Residents #93, #80, and #153. Facility census 155. Findings included: Facility Policy titled, Nephrostomy Tube Care Dated 01/02/14 -Tape tubing to prevent tension on tube and assure tube is not kinked. -Plus, it contains the steps to cleansing the wound and dressing change. -Keep nephrostomy tube below the level of the bladder Facility Policy titled, Ostomy Care. Dated: 01/02/19 The Facility did not provide a policy of the care of a Supra-pubic Catheter a) Resident #93 During an interview on 04/29/19 at 1:59 PM, Resident # 93 was asked where were her nephrostomy tubes and the collection drainage bags. Resident #93 pulled her shirt up and pulled the folded drainage bags out of the wraste band of her pants. She was asked if she always keeps the foley bags there and she said, well yes most of the time or I set on them so they don't fall in the floor. During an interview on 04/30/19 at 4:00 PM, registered Nurse-Unit Manager #88 was asked if the staff has been trained on the care of nephrostomy foley bags. She answered yes. She was asked if we could interview a Nurse Aide that provides care for Resident #93. During an interview on 04/30/19 at 4:12 PM, Nurse Aide #21 was asked if she knows where Resident # 93 keeps her foley bags. She said if she is in bed they are beside of her or under her. If she is in her wheel chair they are behind her, sometimes she holds them like a baby and sometimes she has them under her clothes. She said, that she had not seem them in the wraste of her pants. During an interview on 04/30/19 at 4:18 PM, RN-UM#88 said that she is not sure if the NA's know how to position or the care of that type of foley, but she will educate them. During an interview on 05/01/19 at 10:11 AM, RN-UM #88 verified that Resident #93 had her Nephrostomy foley bags folded and in the wraste of her pants, urine was leaking from them. The tubes had sediment in them. Resident # 93 said that she has to squeeze that slimy stuff out of them. RN-UM#88 not to do that and she would tell the nurse to flush them the resident did not know what flush the tubes meant, it was explained to her and said no one has ever done that . Physicain orders copied from the elctronic chart pretaining to the care of the nephrostomy tubes: Flush bilateral nephro tubes with 10 mL NSS every shift. every day shift related to DISPLACEMENT OF NEPHROSTOMY CATHETER, INITIAL ENCOUNTER Verbal Active 04/24/2019 During an observation on 05/01/19 at 4:01 PM, Licensed Practical Nurse (LPN) #13 change the dressing on the nephrostomy tubes. RN-UM #88 asked to observe as well and agreed to not prompt or instruct LPN #13 on what to do. LPN #13 removed the dressing and she opened the package that had steriol gloves and barrier cloth inside the prepackaged kit. LPN #13 stood and looked at the supplies of a few minutes, before the RN-UM #88 said just think about it what do you need to do first. LPN #13 shock her head no. She had to have step by step instruction to preform the wound dressing change. On 05/01/19 at 4:20 PM, LPN #13 was asked if she could do that care without being given instructions. She answerd yes. RN-UM #88 agreed that LPN #13 needed some training and over site, before she would be compentent in wound care. b) Resident #80 During an interview on 04/29/19 at 12:05 PM, with Resident #80 it was noticed that there was not an anchor (a sercure device used to prevent tissue damage and/or accidental removal. On 04/29/19 at 12:24 PM, Nurse Aide (NA) #23 was witness to see no anchor was on catheter. On 04/29/19 at 12:29 PM, Registered Nurse-Unit Manager (RNUM) #88 stated that Resident # 80 does not wear a leg strap because she is an above the knee [MEDICAL CONDITION] and that the foley kits do not come with a anchor device and the legs straps do not work on her. She also asked if she still should have an anchor if she had a supra-pubic catheter. She was asked if she had tried a different type and she stated that she was unaware of anything different, but she will check with central supply for something other then a leg strap. She was asked for a policy for supra-pubic catheter care. One was not provided. On the web site,Nursing best Practicies for Supra Pubic Catheter Care contained the following statement: -Care of - Dressing will be changed daily & prn - Established sites (after 5 - 7 days) without drainage may not require a dressing - All suprapubic catheters must be secured to the abdomen with an appropriate anchoring device (i.e. [MEDICATION NAME] Universal securement device). c) Resident # 153 During initial tour of the facility on 04/29/19 at 11:55 AM Resident #153's nephrostomy bags were lying one on each side of the resident above the level of the kidneys. Again on 04/29/19 at 3:15 PM the nephrostomy bags remained in the same position. On 04/30/19 at 8:30 AM the nephrostomy bags were above the level of the kidneys. At this time nursing assistant (NA) #29 expressed this is the position the bags are always in. Again on this date at at 12:50 PM the nephrostomy bags were in the same position. Review of the facility's nephrostomy tube care with a revision date of 01/02/14, section 24.1 reveals, to keep nephrostomy tube below the level of the bladder. On 04/30/19 at 4:00 PM registered nurse #88 agreed the nephrostomy bags should be below the level of the kidneys.",2020-09-01
683,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,695,D,0,1,33QL11,"Based on observation staff interview and medical record review the facility failed to ensure professional standards of practice in relation to the oxygen rate while using an Oxymizer Pendant (Oxygen tubing that when used you should use a lesser setting or flow rate of oxygen), and orders for the flow rate when the device was in use. Resident # 36. This was true for 1 of 1 reviewed in the care area of respiratory care. Identified Resident #36. Facility census 155. Findings Included: During an observation and interview on 04/29/19 at 1:39 PM, Resident #36 was asked what her Oxygen flow rate was supposed to be. She said at two (2) liters when I use the regular tubing, but one point five (1.5) when I am wearing this one on the portable tank. She was pointing to the tubing with a clear pendant (Oxymizer). The portable tank was set at 1.5 liters. During an interview on 05/01/19 at 4:00 PM, Registered Nurse-Unit Manager (RN-UM) #88 was asked for information about the Oxymizer. During an interview on 05/02/19 at 9:00 AM, RN-UM #88 provided a package insert that came with the oxygen tubing Oxymizer. She was asked if there was another order for a flow rate when using the Oxymizer. She stated, that there was not, but she would get one. On 05/02/19 at 9:45 AM, RN-UM #88 provided an order dated 05/02/19 at 9:35 AM, When resident is up in wheel chair and using Oxymizer Conserving Device, Oxygen rate is to be 1/2 the amount prescribed of two liters/minute. Per Family Nurse Practitioner #158. There was no order for the flow rate until surveyor intervention.",2020-09-01
686,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,755,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, employee reords and staff interview the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and an account of all controlled drugs is maintained. This is related to not signing out a narcotic in the Narcotic book, and the failure to verify the narcotic count by two (2) nurses, and not signing out a narcotic in the Narcotic Count Book when the medication was removed for a Resident. This was a random opportunity for discovery. This had the potential to affect a limited number of residents. Facility census 155. Findings included: a) Narcotic reconciliation During an observation and interview on 05/01/19 at 9:14 AM, Licensed Practical Nurse (LPN) #16 agreed that the Narcotic Log book was incomplete on nine different days that the count sheet was not signed by two nurses, (the nurse coming on shift and the nurse ending their shift). - 04/21/19 at 7:00 AM -04/21/19 at 7:00 PM -04/22/19 at 10:00 PM -04/23/19 at 5:00 AM - 04/23/19 at 11:00 PM -04/24/19 at 6:00 AM - 04/30/19 at 7:00 AM -04/30/19 at 7:00 PM -05/01/19 at 7:00AM Copy of the count sheet page obtained. During an observation and interview on 05/01/19 at 10:13 AM, LPN # 64 agreed that the Narcotic Log book was incomplete and not done on 05/01/19 at 7:00 AM, that the count sheet was not signed by two nurses, (the nurse coming on shift and the nurse ending their shift). A random look at a narcotic count for Resident #49 revealed LPN #64 did not sign his name on the count sheet to indicate he had removed a narcotic from the card holding the medication. The count sheet revealed that there should have been 27 [MEDICATION NAME] left, but the card only had 26 pills remaining. On 05/01/19 at 10:18 AM, Registered Nurse- Unit Manager #88 was asked to witness the inaccurate narcotic count. She only stated that she was disappointed. Review of employee file revealed that LPN #16 received a, Corrective Action Notice, dated 04/10/17 and 04/11/17, for not completing a shift count of controlled substances, during an off going/on coming nurse.",2020-09-01
687,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,757,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's drug regimen was free from unnecessary drugs. A nurse administered insulin to a resident when it was not indicated based on the blood glucose parameters. This was evident for one (1) of five (5) residents reviewed for unnecessary medications out of thirty-one (31) sampled residents. Resident identifier: #44. Facility census: 155. Findings include: a) Resident #44 The medical record was reviewed on 04/30/19. Review of the recapitulation of physician's orders [REDACTED]. It included directives to withhold the insulin if the blood sugar was less than 150 milligrams/deciliter (mg/dl). Further review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Per physician's orders [REDACTED]. However, the nurse administered ten (10) units of [MEDICATION NAME] insulin. During an interview with the director of nursing (DON) on 04/30/19 at 3:00 PM, it was discussed that the resident received ten (10) units of [MEDICATION NAME]on 04/26/19 at 7:30 AM when the blood sugar was only 106 mg/dl. She agreed that the insulin should have been withheld. An interview was conducted with the administrator on 05/01/19 at 9:45 AM. She was informed that on 04/26/19 at 7:30 AM this resident received insulin when she had a blood sugar reading of 106 mg/dl. It was discussed that the physician set a parameter directing to not given the insulin with meals when the blood sugar was less than 150 mg/dl. No further information was provided prior to exit.",2020-09-01
691,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,842,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, the facility failed to ensure medical records were completed completely and accurately. One (1) resident Medication Administration Record [REDACTED]. This had the potential to affected two (2) of thirty- one ( 31) investigative residents reviewed. Resident identifiers: #87 and #154. Facility census: 155. Findings included: a) Resident #87 A review of Resident 87's physician order [REDACTED]. A review of the Medication Administration Record [REDACTED]#87 with an X, and a check mark for her Bilateral Prafo boots at all times as tolerated, may remove for skin checks and hygiene every day and night shift. The Assistant Director of Nursing (ADON) #122 was asked on 05/01/19 at 9:15 AM, what does an X mark on the 04/30/19 from 11:00 PM to 7:00 AM shift indicate for bilateral Prafo boots at all times as tolerated, may remove for skin checks and hygiene. The ADON stated that, she does not know what the X mark indicated. The Director of Nursing (DON) #22 on 05/01/19 at 11:49 AM pulled up Resident #87's Medication Administration Record [REDACTED]. The DON said you document either a yes or a no. She did not know what an X is indicating. The DON called their help desk and they told could not tell the DON what the X mark indicated The DON confirmed they needed a better system to identify whether the staff applies the boots or not, because no one could identify what the X mark indicates. b) Resident #154 Resident #154 received total [MEDICATION NAME] nutrition (TPN) therapy, a method of infusing fluids into a vein to bypass the gastrointestinal tract and provide nutrients needed. Resident #154's Medication Administration Record [REDACTED] (Orders typed as written.) - TPN 1158 ml x 12 hrs @ 130 ml/hr, [MEDICATION NAME] 235 g/799 kcals, Amino acids 90 g/360 kcals, Lipids 45 g/405 kcals, 1564 kcals/day, every 24 hours Run from 7a to 7p start at 64 ml/hr x 1 hr taper up to 130 ml/hr x 11 hrs taper down to 64 ml/hr x 1 hr. - TPN Total [MEDICATION NAME] Nutrition CYCLED 1569 ml over 12 hrs 130 ml/hr Taper up 1 hours/rate 64. Taper down 1 hours/Rate 64. Lumen to use______. In the morning for severe malnutrition. BASE SOLUTION: Electrolytes ____ ADDITIVES: Multivitamins 10 ml [MEDICATION NAME] ____ Regular insulin ____ Vitamin K _____ Famoditine ______ [MEDICATION NAME] (B1) ____ [MEDICATION NAME] (B12) ___ Folic Acid ____ Other ______. Both of the orders were initialed as given by nurses on the MAR. During an interview on 04/30/19 at 4:50 PM, the Clinical Quality Services Registered Nurse stated Resident #154's TPN should be infused at 64 ml/hour for one (1) hour, then 130 ml/hour for ten (10) hours, and then 64 ml/hour for one (1) hour. This equals 1428 total mls to be infused. The Clinical Quality Services Registered Nurse agreed Resident #154's MAR indicated [REDACTED]. She agreed the orders contained two (2) different amounts of TPN to be infused and both orders had been initialed as given by nurses. The Clinical Quality Services Registered Nurse stated she would have the order corrected. No further information was provided through the completion of the survey.",2020-09-01
694,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2019-05-02,881,D,0,1,33QL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of infection control line listings, medical records, and staff interview, the facility failed to practice antibiotic stewardship when it failed to justify the use of antibiotic therapy for a draining wound that was not cultured. This was evident for one (1) of eight (8) residents reviewed on the (MONTH) (YEAR) infection control monthly line listing. Resident identifier: #256. Facility census: 155. Findings include: a) Resident #256 Infection control line listings were reviewed with registered nurse #160 (RN #160) on 05/01/19 beginning at 3:30 PM. The (MONTH) (YEAR) infection control monthly line listing included Resident #256 who was diagnosed with [REDACTED]. Per the line listing, the facility practiced standard precautions. During an interview with infectious disease/infection control registered nurse #160 (RN #160) on 05/01/19 at 4:30 PM, she said there was no culture obtained of the drainage from the rectal abscess. She said the antibiotic therapy was prescribed by physicians due to the appearance of the wound and its drainage, rather than by culture. On 05/01/19 at 9:00 AM an interview was conducted with RN #160. She said they face timed with Third Eye and the physician saw the purulent drainage. Review of a follow-up progress note dated 12/23/18 at 8:49 AM stated: Physician examined resident via TEH Video. Resident had a moderate amount of thick purulent drainage from both his right underarm and perianal and rectal area. Physician ordered a PICC (Peripherally Inserted Central Catheter) line placement and the following antibiotics. [MEDICATION NAME] one (1) gram q. (every) 24 hours and [MEDICATION NAME] 3.375 grams q. 6 (six) hours, both to be administered x (symbol for times) 10 (ten) days. In-house physician to evaluate resident during next visit.Nurse Pro contacted and scheduled for PICC line placement for 12:00 PM today. RN #160 was asked why no culture or sensitivity of the draining wound was obtained. She said she did not know for sure. An interview was conducted with the director of nursing (DON), RN #160, and the corporate quality services employee #155 (CQS) registered nurse on 05/02/19 at 9:30 AM. It was discussed that there was an antibiotic stewardship practice issue when intravenous antibiotics were prescribed, and administered, to treat a resident's wound without first obtaining a culture of the facility-described thick, purulent drainage, to find the identity of the causative organism. It was discussed that this practice also prohibits knowing with certainly if an organism is susceptible or resistant to various antibiotics. It was also discussed that they had no way of knowing if this resident's wounds contained multi-drug resistant organisms which would require contact precautions. No further evidence was provided prior to exit.",2020-09-01
695,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-06-15,157,D,1,0,DQI311,"> Based on record review and staff interview, the facility failed to notify the responsible party when one (1) of three (3) residents reviewed experienced a fall on 06/06/17. Resident identifier: #80. Facility census: 157. Findings include: a) Resident #80 A review of the Incident and Accident records, reported Resident #80 was found on the floor next to her bedresulting in a skin tear to the left upper arm and a bruise on the top of her right foot. No other injuries were noted, and the report stated she was assisted back to her bed by three (3) staff. Neurological checks were implemented and she placed non-skid socks on her feet. The physician was notified and the responsible party was notified. An interview with Resident # 80's legal representative on 06/15/17 at 9:00 a.m., reported she received no call from the facility letting her know about the fall her mother had on 06/06/17. During an interview with the director of nursing (DON) on 06/15/17 at 10:05 a.m., Unit Manager #138, had contacted the wrong person regarding the fall sustained by Resident #80 on 06/06/17. She verified she did not contact the legal representative regarding this fall.",2020-09-01
696,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-06-15,272,D,1,0,DQI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and staff interview, the facility failed to conduct an accurate comprehensive assessment for one (1) of nine (9) sample residents reviewed. The comprehensive assessment for Resident #73 did not accurately reflect the resident's vision status. Resident identifiers: #73. Facility census: 156. Findings include: a) Resident #73 Review records, on 06/13/17 at 8:58 a.m., revealed current care plan showed a focus for the risk for falls. An intervention noted under the focus was to place glasses within reach and to encourage use. Observation of resident of the unit's common room, on 06/13/17 at 11:06 a.m., revealed Resident #73 sitting in her wheelchair appearing clean, neat, well groomed, without wearing any eye glasses. Multiple observations of the resident on 06/12/17 and 06/13/17 revealed the resident not wearing eye glasses, nor were any observations made of eye glasses being within reach of the resident, nor staff encouraging the use of eye glasses. On 06/14/17 at 9:17 a.m., review of the Kardex (resident information system) showed glasses to be within reach. Review of the annual minimum data set (MDS) with an assessment reference date (ARD) of 05/01/17, on 06/14/17 at 5:15 p.m., revealed the resident has impaired vision and sees large print, but not regular print and has no corrective lenses. Noted also in section B, was the resident has moderately impaired vision with no corrective lenses. An interview, on 06/15/17 at 8:43 a.m., with MDS Registered Nurse (RN) #115 agreed the annual MDS was marked to show the resident did not wear glasses. When asked why it was marked no corrective lenses, RN #115 said he did not know. He said we would have to ask the social worker filled out the section of the MDS. RN #118, (another MDS RN) was present during the interview and stated she had helped feed Resident #73 in dining room several times in the past and never saw her with eye glasses on and did not know she wore them. RN#118 stated one day when she was in the dining room she noticed the resident appeared to be having a hard time seeing, then RN#118 heard a Nurse Aide (NA) ask where the resident's glasses were. After that a NA went and got the eye glasses and put them on her (the resident). On 06/15/17 at 8:55 a.m., an interview with Social Worker (SW) #62 revealed the annual MDS with an ARD of 05/01/17 was marked wrong. SW#62 said, I knew the resident had impaired vision I thought it was from [MEDICAL CONDITION]. I did not know she wore glasses. I did not ever see her with them on. SW #62 agreed the MDS inaccurate and should have been marked to reflect the resident wore corrective lenses.",2020-09-01
697,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-06-15,280,D,1,0,DQI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to review and revise the resident's care plan for one (1) of nine (9) resident's care plans reviewed. Resident #73's care plan was not revised to reflect the resident status regarding the use of Dycem in the resident's wheelchair. Resident identifier: #73. Facility census: 156. Findings include: a) Resident #73 Review of current care plan, on 06/13/17 at 8:58 a.m., revealed a focus for the risk for falls, and included the following intervention, Implement the following safety precautions place Dycem in wheelchair to prevent resident from sliding. Dycem is a non-slip material that grips on both sides to secure cushions and inserts to wheelchairs. Observation of Resident #73 throughout the investigation did not reveal any Dycem in the seat of the resident's wheelchair. On 06/13/17 at 2:45 p.m., at the request of the surveyor, LPN #58 and NA#56 checked the resident's wheelchair for Dycem. LPN #58 and NA#56 assisted the resident to a standing position and observed there was not any Dycem in the seat of the wheelchair. Review of records, on 06/13/17 at 12:36 p.m., did not reveal a physician order [REDACTED].",2020-09-01
698,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-06-15,282,D,1,0,DQI311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and staff interview, the facility failed to implement the care plan for one(1) of nine (9) sample residents reviewed. The care plan directed staff to keep Resident #73's eye glasses within reach in a consistent place and encourage use. Resident identifiers: #73. Facility census: 156, Findings include: a) Resident #73 Review of the annual minimum data set (MDS) with an assessment reference date (ARD) of 05/01/17, on 06/13/17 at 8:58 a.m., revealed Resident #73 had [MEDICAL CONDITION] and a brief interview for mental status (BIMS) score of one (1) indicating the resident is cognitively severely impaired. The MDS revealed the resident sometimes makes herself understood and sometimes understands and has a vision impairment. Review of current care plan revealed an intervention, under the focus of risk for falls, and to place glasses within reach and encourage use. The care plan also showed another focus of vision impairment related to the aging process with an intervention of place glasses within reach in a consistent place and encourage use. Observation of resident of the unit's common room, on 06/13/17 at 11:06 a.m., revealed Resident #73 sitting in her wheelchair appearing clean, neat, well groomed, without wearing any eye glasses. Multiple observations of the resident on 06/12/17 and 06/13/17 revealed the resident not wearing eye glasses, nor were any observations made of eye glasses being within reach of the resident, nor staff encouraging the use of eye glasses. Observations in Resident #73's room, on 06/13/17 at 2:45 p.m., revealed the resident not wearing her eye glasses, nor were her glasses visibly in view anywhere in the resident's room. Nurse Aide (NA) #56, after assisting Licensed Practical Nurse ( LPN) #58 in placing and positioning Resident #73 in her wheelchair, was asked by the surveyor about the location of the resident's eyeglasses. NA#56 replied she did not know where they were, and proceeded to wash her hands and left the resident's room without locating the glasses, or ensuring they were in reach, or encouraging the resident to use them. An interview with NA #116, on 06/13/17 at 2:58 p.m., revealed the NA was aware the resident had eye glasses, but thought maybe the family had brought the wrong pair of glasses to the facility and not the resident's eye glasses. When asked why she thought that, NA#116 replied, Because it seems like when they are on, her eye sight is even worse than without the glasses on. When asked had she discussed the resident's eye sight and glasses with anyone, NA #116 said she was unsure and could not remember if she had. When asked if the resident refused to wear her eye glasses, NA #116 said she had never known the resident to refuse to wear her eye glasses if they were given to her. On 06/14/17 at 9:17 a.m., review of the Kardex (resident information system) showed glasses to be within reach. The Kardex is the document that provides the nurse aides with specific instructions to guide them in each individual residents' care needs. An interview, on 06/15/17 at 8:43 a.m., with MDS Registered Nurse (RN) #115 agreed the annual MDS was marked to show the resident did not wear glasses. When asked why it was marked no corrective lenses, RN #115 said he did not know. He said we would have to ask the social worker filled out the section of the MDS. RN #118, (another MDS RN) was present during the interview and stated she had helped feed Resident #73 in dining room several times in the past and never saw her with eye glasses on and did not know she wore them. RN#118 stated one day when she was in the dining room she noticed the resident appeared to be having a hard time seeing, then RN#118 heard a Nurse Aide (NA) ask where the resident's glasses were. After that a NA went and got the eye glasses and put them on her (the resident). On 06/15/17 at 8:55 a.m., an interview with Social Worker (SW) #62 revealed the annual MDS with an ARD of 05/01/17 was marked wrong. SW#62 said, I knew the resident had impaired vision I thought it was from [MEDICAL CONDITION]. I did not know she wore glasses. I did not ever see her with them on. SW #62 agreed the MDS inaccurate and should have been marked to reflect the resident wore corrective lenses.",2020-09-01
699,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-06-15,323,D,1,0,DQI311,"> Based on observations and staff interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible by failing to provide supervision for Resident #141 during incontinence care. A nurse aide, while providing incontinence care, raised Resident #141's bed to its highest position and left the room to obtain necessary supplies. The NA, also after providing incontinence care, borrowed a spray bottle of bleach cleanser from housekeeping to disinfect an area that had become contaminated in the resident's room, and left the spray bleach bottle unattended in the room. This was true for(1) one of (2) two residents observed for incontinence care. Additionally, random observations revealed accident hazards from a cluttered hallway on the first floor. This had the potential to affect more than a limited number of residents. Resident identifier: #141. Facility census: 156. Findings include: a) Resident #141 Observation of Resident #141's incontinent care provided by Nurse Aide (NA) #55, on 06/13/17 at 9:52 a.m., revealed she had not gathered all necessary supplies needed to provide care prior to starting care. NA#55 raised the resident's bed to its highest level, with the resident in it, then realized that she did not have a brief for the resident. NA #55 after looking around the resident's room for a brief, left the room to find a brief, leaving the resident unattended for several minutes with the bed in the highest position. A fall mat was on the floor beside the bed. When NA#55 removed the soiled brief, she tossed it on the fall mat. When NA #55 completed cleaning the resident, she tossed the used soiled wash cloth beside the soiled brief on the fall mat. NA #55 then turned and looked at this surveyor and said, Oh, I should have had my trash bags opened. NA #55 had earlier placed two (2) trash bags on the foot of the resident's bed. NA#55 acknowledged the dirty brief and washcloth should not have been placed on the floor mat, but should have been placed in the trash bags that she had brought in for that purpose. NA #55 agreed she had breached infection control principals by laying the dirty wash cloth and brief on the fall mat. On 06/13/17 at 10:06 a.m., NA #55 was observed requesting to borrow a spray bottle of bleach cleanser from Housekeeping Aide #123 to clean Resident #141's floor mat. Further observations, on 06/13/17 at 10:13 a.m., revealed Housekeeping Aide #123, when seeing NA #55 in the hall, asked NA #55 for the bottle of spray bleach cleanser. NA#55 appeared uncertain where she had left it. The housekeeping aid was heard saying You can't leave it in a resident's room. NA #55 replied she thought she had left it in the dirty utility room and would go and look. Interview with Housekeeping Aide #123, on 06/13/17 at 10:19 a.m., after observing the housekeeping aid walk out of Resident #141's room with the spray bottle of bleach cleanser, revealed the following: Housekeeping Aide #123 said NA#55 had asked her, to borrow a spray bottle of bleach cleanser to clean off something in Resident #141's room. Housekeeping Aide #123 said when she asked NA#55 for it back, NA#55 did not know where it was. Housekeeping Aide #123 said she went to help look for it. When asked where the spray bottle of bleach cleanser was found, Housekeeping Aide #123 said in Resident #141's room. On 06/13/17 at 10:21 a.m., an interview with NA #55 revealed the following. NA #55 admitted she had found the bleach spray bottle in Resident #141's room where she had accidentally left it. NA #55 said she should not have left it the room where Resident #141 or her roommate could have access to the bleach cleanser. Interview with the floor charge nurse, Licensed Practical Nurse (LPN) #15, on 06/13/17 at 10:26 a.m., revealed LPN #15 agreed that raising Resident #141's bed to a high position and leaving the room with the resident unattended was a fall hazard for the resident. The LPN said the resident was already at risk for falls that is why Resident #141 had the fall mat and the bed alarm. LPN #15 said NAs are trained to gather all their supplies before starting care. LPN #15 concurred NA #55 breached infection control principals by laying the dirty wash cloth and brief on the fall mat. LPN #15 also agreed the bleach cleanser being left in the room was a chemical hazard. b) First Floor Hallway On 06/14/17 at 1:50 p.m., random observation of first floor hallway revealed a hallway cluttered with equipment and supplies on both sides of the hallway. On one side of the hallway scattered against the wall were mops, mop buckets, and an electric floor buffer polisher. On the opposite side of the hallway a cart containing the dirty trays from lunch was parked. Further down the hall a cart, with beverage pitchers and drinking glasses on it, was parked crookedly blocking part of the center of the hallway. At 1:55 p.m. on 06/14/17, an interview with RN #78 Registered Nurse, revealed staff has been instructed to use only one side of the hall to store equipment and keep the other side clear for traffic. RN #78 said the staff was not to block or clutter the hallways, staff was not to leave carts and equipment along both sides of the hall. RN#78 agreed, during the time of the interview, the hallway as it was with equipment and supplies on both sides of the hallway was cluttered and an accident hazard for the residents.",2020-09-01
701,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-06-15,441,D,1,0,DQI311,"> Based on observations and staff interviews, the facility failed to implement practices designed to prevent infection and/or cross-contamination for one of two residents observed for incontinence care. A nurse aide breached infection control principals, while providing incontinence care for Resident #141, by laying a soiled brief and wash cloth on the resident's bedside fall mat. This was true for one (1) of two (2) residents observed for incontinence care. This had the potential to affect more than an isolated number of residents. Resident identifier: #141. Facility census: 156. Findings include: a) Resident #141 Observation of Resident #141 incontinent care provided by Nurse Aide (NA) #55, on 06/13/17 at 9:52 a.m., revealed NA #55 removed the resident's soiled brief and tossed it on the fall mat lying on the floor beside the bed. When NA #55 completed cleaning the resident, she tossed the used soiled wash cloth beside the soiled brief on the fall mat. NA #55 then turned and looked at this surveyor and said, Oh, I should have had my trash bags opened. NA#55 had earlier placed two (2) trash bags on the foot of the resident's bed. NA #55 acknowledged the dirty brief and washcloth should not have been placed on the floor mat, but should have been placed in the trash bags that she had brought to the room for that purpose. NA #55 agreed she had breached infection control principals by laying the dirty wash cloth and brief on the fall mat. Interview with the floor charge nurse, Licensed Practical Nurse (LPN) #15, on 06/13/17 at 10:26 a.m., revealed LPN #15 agreed NA #55 breached infection control principals by laying the dirty wash cloth and soiled brief on the fall mat.",2020-09-01
703,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-05-30,610,D,1,0,JTJM11,"> Based on review of the facility's reportable allegations of abuse, neglect, and misappropriation of person property reported to the proper state authorities and staff interview, the facility failed to ensure an alleged violation of neglect and abuse was thoroughly investigated. This was true for one (1) of eighteen (18) investigations reviewed. Resident identifier: #132. Facility census: 118. Findings included: a) Resident #132 On 12/02/18 the resident's responsible party, Medical Power of Attorney (MPOA) reported to staff she was taking resident home because, Staff have beat and bruised her and didn't feed her or give her medication The facility reported the allegation to the nursing home program on 12/02/18. The five day follow up reported to the nursing home program, on 12/07/18, listed the Outcome/Results of investigation as: Allegations unsubstantiated through Resident and staff interviews. There was no statement to substantiate the Resident was interviewed. There were no statements from staff, accompanying the investigation. There was no information indicating the medical record was reviewed to determine: If medications were administered as directed, The residents meal intake, if she fed herself or required assistance from staff, if the resident had any weight loss, etc. The only information, attached to the allegation, was a skin check, completed on 11/28/18, noting the resident had no new bruising. At approximately 10:00 AM on 05/30/19, the Social Worker (SW) #71 and the administrator were asked if the facility had any more information regarding the investigation. At 10:45 AM on 05/30/19, the SW #71 provided 2 hand written statements, dated 12/02/18 and 12/03/18. One statement was written by Registered Nurse (RN) #14 on 12/02/18. POA came into facility and reported to staff she was taking resident home because staff have beat and bruised her and didn't feed her or give her medications. POA then began packing residents belongings and took POA out of facility via WC (wheelchair). I witnessed nurse, who reported resident had taken her medications and had breakfast that morning. I was unable to complete body audit as POA immediately took resident out of facility. The second statement, dated 12/03/18, was from SW #71. The SW noted she had called the MPOA by telephone. The Resident received her breakfast and no new bruises on the resident, although the MPOA would not allow a body audit to be completed. A review of the resident's medical record on 05/30/19 found the resident had a significant weight loss. On 05/04/18 the resident was admitted to the facility. On 05/05/18, the resident's weight was 155.2 pounds. On 11/28/18 the Resident's weight was 125.6 pounds. The resident had a recent fall with bruising. On 11/21/18 a skin check was performed noting the resident had bruising to the left wrist, facial bruising, left side of face, left cheek abrasion and a laceration to right eye brow. There was no reference in the investigation to note if this was the bruising the MPOA was referencing. At 1:00 PM on 05/30/19, the above information was discussed with the administrator. No further information was provided.",2020-09-01
704,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-05-30,641,D,1,0,JTJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for admission transfer and discharge had a complete Minimum Data Set (MDS). Resident identifier: #121. Facility census: 118. Findings included: a) Resident #121 Record review found the resident was admitted to the facility on [DATE]. He was discharged to home on 05/16/19. The MDS was reviewed in an attempt to determine if the resident had expressed a desire to return home, section Q. During the review, several other sections were noted to be incomplete. Review of the Resident's admission, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/10/19 found four (4) sections of the MDS were incomplete: Section C, Cognitive Patterns; Section D, Mood; Section E, Behavior; Section Q, Participation in Assessment and Goal Setting. At 10:10 AM on 05/29/19, the Clinical Reimbursement Coordinator (CRC), Employee #14 verified sections; C, D, [NAME] and Q should have been completed. CRC #14 said the Social Worker, SW #71 completes those sections so she should be interviewed. CRC #14 verified the only admission MDS in the electronic medical record was the MDS with the ARD of 05/10/19. The electronic medical record noted the MDS was accepted; therefore the MDS was transmitted. At 10:15 AM on 05/29/19, SW #71 said she didn't know why the information was not on the MDS. She said she completed it but something must have happened to the information. At 1:00 PM on 5/30/19, the administrator said the MDS was completed but the information was erased.",2020-09-01
708,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-05-30,770,D,1,0,JTJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, event incident log and staff interview, the facility failed to obtain laboratory services for Resident #67, as ordered by the physician. Resident identifier: #67. Facility census: 118. Findings included: a. Resident #67 Review of Resident #67's medical record found an order dated 01/08/19 for a Basic Metabolic Panel (BMP) to be obtained on 01/15/19 due to [MEDICAL CONDITION] (low sodium). Further review found the BMP was not obtained on 01/15/19. The Nurse Practitioner (NP) on 01/15/19 wrote an order to obtain a BMP on Monday (01/21/19). The lab for BMP was not obtained until 01/22/19. Interview with the Director of Nursing on 05/29/19 at 11:00 am, confirmed the lab (BMP) ordered to be done on 01/15/19 and 01/21/19, was not obtained until 01/22/19. No further information was provided.",2020-09-01
709,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-05-30,842,D,1,0,JTJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to ensure the residents medical record was complete and accurate. Resident #123 and Resident #122's physician assessments were not maintained in the residents medical record.For Resident #120 the residents record contained inaccurate information in regards to the hospital he was transferred too and about his medication. This was true for two (3) of 26 residents reviewed during a compliant survey. Resident Identifier: #120, #122 and #123. Facility Census: 118. Findings included: a) Resident #122 A review of Resident #122's medical record at 9:00 a.m. on 05/29/19 found no assessments or documentation from the residents attending physician. At 9:45 a.m. on 05/29/19 physician documentation was requested from the Assistant Director of Nursing. A physician progress notes [REDACTED]. The note indicated the physician had seen the resident on 10/22/18 related to his admission to the facility. At the top of the assessment was text indicating the document was faxed to the facility on [DATE] at 10:09 a.m. An interview with the Medical Records Director at 10:53 a.m. on 05/29/19 confirmed this progress note was not contained in the residents medical record. She stated the physicians nurse is a little behind at sending them the documentation after the physician completes his visit. b) Resident #123 A review of Resident #123's medical record at 9:15 a.m. on 05/29/19 found no assessments or documentation from the residents attending physician. At 9:45 a.m. on 05/29/19 physician documentation was requested from the Assistant Director of Nursing. A physician progress notes [REDACTED]. The note indicated the physician had seen the resident on 02/28/19 related to her admission to the facility. At the top of the assessment was text indicating the document was faxed to the facility on [DATE] at 9:52 a.m. An interview with the Medical Records Director at 10:53 a.m. on 05/29/19 confirmed this progress note was not contained in the residents medical record. She stated the physician's nurse is a little behind at sending them the documentation after the physician completes his visit.",2020-09-01
711,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-08-14,656,D,0,1,KL5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interview, and staff interview the facility failed to develop a person-centered comprehensive care plan to address the resident's medical and physical needs related to mobility. This was true for 1 of 1 residents reviewed for rehabilitation and restorative. This practice had the potential to affect more than a limited number of residents. Resident Identifier #39. Facility census 115. Findings Included: a) Resident (R#39) Review of records, on 08/14/19 at 09:01 AM, revealed pertinent [DIAGNOSES REDACTED]. A cerebral infarction is an inadequate supply of blood to a part of the brain, causing a persistent neurologic deficit in the area affected. According to the Merriam Webster Medical Dictionary, [MEDICAL CONDITION] is muscular weakness or [DIAGNOSES REDACTED] restricted to one side of the body. R#39's [MEDICAL CONDITION] followed a Cerebral Infarction, that affected her left non-dominant side. R#39 was dependent for care. Review of care plan revealed a focus Resident requires assistance for ADL care due to Chronic disease/condition: paralysis to left side, weakness, and contractures. There were no interventions found in the current careplan or in the care plans history that addressed contractures or range of motion for R#39. An interview with occupational therapist (OT#120), on 08/14/19 at 09:14 AM, revealed occupational therapy (OT) has worked with R#39 seven (7) times since being at the facility. OT#120 explained the resident complains of pain so there are limits and restrictions on treatment. The resident chose and was not willing to get out of bed, so we work with her in her bed. A specialized wheelchair was ordered, and the resident refused to use it. We recently picked her up again on case load last week, prior she had therapy from (MONTH) of last year till (MONTH) 2019 then she was out of the facility to the hospital. When she returned from the hospital she was picked back up for services until (MONTH) 2019. Review of orders revealed an order dated 03/11/19 for occupational therapy to evaluate and treat for therapeutic exercises. Review of care plan, on 08/14/19 at 09:44 AM, revealed no interventions in the current care plan or in the history of the care plan that addressed the residents range of motion, contractures, referrals to occupational therapy for evaluations, or mobility needs that might be specific to R#39. An interview with MDS #21 responsible for developing and revising resident's care plans, on 08/14/19 at 09:53 AM, revealed the R#39's careplan was not developed to address range of motion, contractures, or mobility needs. MDS #21 stated she usually always included these areas but agreed R#39's care plan was not developed to include them.",2020-09-01
712,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-08-14,756,D,0,1,KL5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician provided a rational for not completing a pharmacist recommended medication gradual dose reduction (GDR). The facility failed to ensure the Director of Nursing or their representative provide their signature acknowledging the pharmacy recommendations. This practice had the potential to affect more than a limited number of residents. Resident Identifier #93. Facility census 115. Findings included: a) Resident (R#93) On 08/13/19 at 04:10 PM, review of medical records revealed a GDR dated 07/08/19 where the pharmacist recommended the discontinuation of the [MEDICATION NAME] (NSAID) due to the resident receiving corticosteroids, [MEDICATION NAME] 10 mg daily, and [MEDICATION NAME] 800 milligrams (mg) every 8 hours (hrs), concomitantly. The resident was also taking Tylenol 150 mg every 12 hours. The pharmacist recommended the discontinuation of the [MEDICATION NAME] and an increase of the frequency of the Tylenol 650 mg every 8 hours instead of every 12 hrs. The rationale for the pharmacist recommendation was the risk of GI (gastric intestinal) bleeding increases significantly when corticosteroids are used in combination with an NSAID (non-aspirin nonsteroidal anti-[MEDICAL CONDITION] drugs). On the GDR form the Physician's responses was to be recorded. There is a box to check to indicate whether the Physician accepts the recommendation and to have it implemented as written, or the option to accept with modifications to the recommendation, or to decline the recommendation with a rationale as to why the recommendation was declined. None of the options were checked in response to the pharmacist recommendations. In the area on the form were a rationale could be given if declined there was written ? Was this for an acute complaint and not stopped signed by the physician. Then an area for the director of nursing (DON) signature, which was blank. At the bottom of the page there was a note Resident is on 1000 mg every 12 hours. No change. With the signature of a registered nurse, RN#41. An interview with RN#41 revealed when she called the physician to notify her of the GDR, the physician did not want any changes and did not give a rational. RN#41 stated that particular physician no longer worked at the facility. According to the Centers for Medicare and Medicaid Services (CMS), State Operation Manual (SOM), appendix PP 'Guidance to Surveyors for Long Term Care Facilities' revealed regulations concerning unnecessary Medications include; Reducing or eliminating the use of the medication may be contraindicated and must be individualized. If the medication is still being used, the clinical record must reflect the rationale for the continued administration of the medication. During an interview on 08/14/19 at 9:13 AM, DON was asked by Surveyor # about the GDR dated 07/08/19 to discontinue [MEDICATION NAME]. The DON agreed that the Physician did not give a rationale for the continued use of the [MEDICATION NAME], and the only order the Physician gave was to increase R#93's [MEDICATION NAME]. Review of a pharmacy consultation report dated 03/12/19 questioning labs for BMP (basic metabolic panel) every ninety-one (91) days was also not signed by the DON acknowledging awareness of the pharmacist's recommendations. The DON confirmed she has not been signing the GDR's or ensuring they were signed by either her or her designee. She agreed this also was a deficient practice.",2020-09-01
713,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2019-08-14,842,D,0,1,KL5911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain medical records on each resident that are complete and accurately documented. The pain assessments were inaccurately recorded for 1 of 1 residents reviewed for the care area of pain. Resident identifier: #101. Facility census: 115. Findings included: a) Resident #101 Resident #101 had [DIAGNOSES REDACTED]. She was receiving the oral medications [MEDICATION NAME] three (3) times a day for pelvic pain and [MEDICATION NAME] 650 mg every six (6) hours for unspecified pain. She was also receiving the topical medication Biofreeze to her right knee twice a pain for pain. She had a physician's orders [REDACTED]. She was to be asked, Are you free of pain or hurting? A Y for yes or a N for no was to be recorded on the Medication Administration Record (MAR). Review of Resident #101's MARs for (MONTH) and (MONTH) demonstrated the daily pain monitoring was recorded as N for 17 occasions in (MONTH) and five (5) occasions thus far in August. Resident #101's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 07/22/19 indicated resident's worst pain was a level three (3) on a scale from one (1) to ten (10), with ten (10) being the worst pain. A pain evaluation performed on 08/13/19 indicated Resident #101's most recent pain level was zero (0). During an interview on 08/13/19 at 3:08 PM, the Director of Nursing (DoN) was informed Resident #101's MARs for (MONTH) and (MONTH) demonstrated the daily pain monitoring was recorded as N for 17 occasions in (MONTH) and five (5) occasions thus far in (MONTH) in response to the question, Are you free of pain or hurting? The DoN confirmed a N, or no, on the MAR indicated the resident was not free of pain. She confirmed if the resident was not in pain, the question should have been answered Y, or yes. During an interview on 08/13/19 at 4:00 PM, the DoN stated the nurses who recorded N on Resident #101's MARs in response to the question, Are you free of pain or hurting?, had done so erroneously. The DoN stated the nurses had thought the question asked if the resident had pain, and recorded N, or no, because the resident had no pain. Licensed Practical Nurse (LPN) #79 was one of the nurses who recorded N on Resident #101's MARs in response to the question, Are you free of pain or hurting? During an interview on 08/13/19 at 4:08 PM, LPN #79 confirmed she thought the question asked if the resident had pain, and recorded N, or no, because the resident had no pain. LPN #79 stated Resident #101 had never reported pain to her. She stated she had never seen Resident #101 demonstrate signs and symptoms of pain. LPN #79 stated the resident was able to propel herself in her wheelchair and went outside in her wheelchair several times a day. During a follow-up interview on 08/14/19 at 8:17 AM, the DoN stated she was performing in-service education to ensure nurses were recording the correct responses on the MARs in response to the question, Are you free of pain or hurting? The DoN stated she had spoken to the nurses who had recorded an N, or no, on Resident #101's MAR in response to the question, Are you free of pain or hurting? The DoN stated all these nurses indicated they misunderstood the question and denied the resident had ever reported pain. No further information was provided prior to the completion of the survey.",2020-09-01
714,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,550,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, observation, and staff interview, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of dignity were treated with dignity and respect. Resident #31 felt he had to move to a different room because he perceived a nursing staff member did not like him. The facility failed to provide dignity and privacy during a treatment for [REDACTED]. Resident identifiers: #31 and #94. Facility census: 117. Findings include: a) Resident #31 On 08/27/18 at 9:03 AM, the resident was asked whether staff treated him with dignity and respect. The resident replied, (First name of nurse) talked hateful to him. When asked if he reported this he said, Yes, and they moved me over here and kept her over there. He said (first name of the administrator) came and talked to me about it. She is a black lady and he asked me if I was prejudice. I told him I don't think so. She was rude and hateful and I just couldn't get along with her. She was like a drill sergeant. I was in the service too, but I didn't act like that. The incident happened about a month or two ago. The resident said no matter how hard he tried, he just could not get along with her. He really did not want to move to another part of the building, but he felt he had to move to get away from this nurse. He said the girls knew him well on the other hall and he knew them. He had to get used to the new girls when he moved. He also felt his call light was answered quicker on the other side of the building. He wished he could have just stayed where he was. He said he was asked if he wanted to move and he did so only because he could not get along with the one nurse. The resident did deny he was fearful of the nurse. He said it was her attitude and the way she talked that caused him to move. She is a drill sergeant. The resident was admitted to the facility on [DATE]. Review of the census record found the resident was moved from the front hallway to the back hallway on 07/26/18. Review of the facility's reportable allegations of abuse/neglect/misappropriation of property found an allegation reported to the appropriate state authorities on 07/20/18, regarding Resident #31. Licensed Practical Nurse (LPN) #97, previously named by the resident, was reported for, Resident reports that the nurse was upset with him and threw a pillow at him. LPN #97 was suspended pending an investigation. The facility obtained statements from staff working with the resident. Nurse Aide (NA) #81 provided the following statement (typed as written): (name of resident) rung his light, the nurse goes in and ask what does he need, he said he need to be change and would like to have a shower before dinner, the nurse told him he would have to wait because there's other Residents to be take care of beside him, I told him I will be right back and when I got back I heard them arguing. So the nurse walk out of the room, the Resident was crying I told him I would take care of him, he told me that the nurse threw a pillow at him, I ask him why was the curtain pulled he said he told her his back was hurting so she threw a pillow at him and pulled the curtain and walked out. Social Worker (SW) #15 provided a written statement stating she talked to LPN #97 on 07/20/18. LPN #97 said she answered the resident's call light a little after 4:00 p.m. He wanted a shower and she told him he would have to wait until after supper. (Name of LPN) states that she did not have time to care for him and that she did not throw a pillow at him After speaking with the nurse, She left the room, slamming the door. Registered Nurse #76 proved a statement on 07/20/18, she also interviewed LPN #97. According to the statement, LPN #97 denied the allegations. ( . Name of LPN #97) became angry with raised voice when asked about the incident during the interview .she then got up and exited room slamming door behind her. Two additional residents, residing on the unit with Resident #31 at the time of the incident were interviewed. One resident stated, .that sometimes (name of LPN #97) has an attitude, but that she does not have any problems with her. The second resident interviewed did not have any issues. The five day follow up report noted: Substantiated that the nurse did put the pillow on the bed. Upon interviewing the resident, he stated that he did not feel threatened. LPN #97 received an individual performance improvement plan, which she refused to sign. LPN #97 was re-educated on body language and tone of voice and was allowed to return to work. On 08/28/18 at 3:44 PM, the SW #15 said the resident told her he wanted to move, but he did not say it was because of LPN #97. SW #15 provided evidence the resident did receive his shower on 07/20/18, after dinner. On 08/30/18 at 11:12 AM, the administrator said he did talk to the resident and he did ask the resident if he was prejudice. The administrator said the resident requested a room change. He said NA #81 was repeating what the resident told her, not what she saw or overheard. NA #81 could only hear the resident and the nurse arguing. b) Resident #94 On 08/28/18 at 2:33 PM, Licensed Practical Nurse (LPN) #29 failed to close the door to the hallway, did not pull the privacy curtain around the resident's bed, and failed to close the window blinds while providing care to the resident's coccygeal wound. LPN #29 asked Resident #94 to pull his pants down revealing his buttocks. Then he cleansed the wound area and applied a white cream. When asked whether he should have closed the door, the curtain, and window shades, he agreed that he should have. During an interview on 08/28/18 at 3:23 PM, when the Director of Nursing was informed of the observation, she said she would re-educate the nurse. During an interview on 08/28/18 at 4:10 PM, the Administrator was informed about the observation and he stated that was disappointing.",2020-09-01
716,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,600,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure Resident #21 was free from neglect. On 08/23/18, Resident #21, who was assessed as requiring the use of a sit to stand lift for transfers, fell in the shower room when she attempted to stand while being dressed by a nurse aide (NA) without benefit of a lift. This was true for one (1) of five (5) residents reviewed for the care area of abuse and neglect during the Long Term Care Survey Process. Resident Identifier: #21. Facility Census: 117. Findings Include: a) Resident #21 During an interview at 2:42 p.m. on 08/28/18, the resident said she had fallen in the shower room on 08/23/18. According to the resident, Nurse Aide (NA) #41 had dried her off and had her pants and her brief pulled up to her knees. When she got to the assist bar and used the bar to help her stand up, she said, My hands had lotion on them and when I stood up to the assist bar I fell over like a tree. She added that NA #41 got two (2) other NAs (NA #38 and NA #67) to help get her back in her wheelchair. Resident #21 stated staff did not use a lift at any point during her shower or after her fall. A review of Resident #21's medical record at 3:00 p.m. on 08/28/18 found the record void of any documentation related to this fall. The record did however, contain a lift assessment dated [DATE] which indicated the resident was to be transferred via a sit to stand lift. During an interview at 4:07 p.m. on 08/28/18, the Director of Nursing (DON) said she was not aware of the resident's fall and would have to investigate to see what had happened. The information provided by Resident #21 during the interview, including that a lift was not used to transfer her, was shared with the DON. The DON stated if the resident's lift assessment indicated she needed a sit to stand lift, then staff should have used a lift. She also commented that if staff were using a lift, there would need to be two (2) staff members present during the transfer. An additional interview at 8:14 a.m. on 08/29/18, the DON confirmed there was no documentation in the resident's medical record regarding the resident's fall on 08/23/18. She stated the nurse aide told a nurse, but when the nurse went to talk to the resident about it, the resident told the nurse she did not fall. She stated that NA #41 did not perceive the incident as a fall because she let the resident slide down her leg so she did not think that it was a fall. The DON indicated that she was doing some education with the staff about what a fall is. When asked why the staff did not use a sit to stand lift the DON stated, I do not know for sure why she did not use the lift. An interview with the Nursing Home Administrator (NHA) at 5:23 p.m. on 08/29/18 revealed if the resident's lift assessment indicated the resident was to be transferred with a sit to stand lift that the NAs should have been using the lift on her during the shower process. He agreed that this was neglectful on the part of the N[NAME]",2020-09-01
717,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,609,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure an allegation of neglect involving Resident #21 was reported to the appropriate State agencies within 24 hours. Resident #21 fell on [DATE] while in the shower room while being showered by one (1) nurse aide (NA). The resident fell when the NA did not utilize a sit to stand life as assessed on the resident's lift assessment. This was true for one (1) of five (5) residents reviewed for the care area of abuse and neglect during the Long Term Care Survey Process. Resident Identifier: #21. Facility Census: 117. Findings Include: a) Resident #21 During an interview at 2:42 p.m. on 08/28/18, the resident said she had fallen in the shower room on 08/23/18. Resident #21 indicated that she was in the shower room with Nurse Aide (NA) #41. The resident stated when used the assist bar to help her stand, My hands had lotion on them and when I stood up to the assist bar I fell over like a tree. She indicated that NA #41 got two (2) other NAs (NAs #8 and #67) to help get her back in her wheelchair. According to the resident, the staff did not use a lift at any point during her shower or after her fall. A review of Resident #21's medical record at 3:00 p.m. on 08/28/18 found the resident's medical record contained a lift assessment dated [DATE], which indicated the resident was to be transferred via a sit to stand lift. An interview with the Director of Nursing (DON) 04:07 p.m. on 08/28/18 revealed she was not aware of the fall and would have to investigate it and see what happened. The DON was made aware that the resident had reported during her interview that staff did not use a lift to transfer her. The DON said if the resident's lift assessment identified she needed a sit to stand lift, then staff should have used a lift on her and to do that, two (2) staff members would be needed to transfer her. An interview with the Nursing Home Administrator (NHA) at 5:23 p.m. on 08/29/18 revealed if the resident's lift assessment indicated the resident was to be transferred with a sit to stand lift, the NAs should have been using the lift on her during the shower process. He agreed that this neglectful on the part of the N[NAME] He was advised the DON was made aware of this allegation of neglect at 4:07 p.m. on 08/28/18. He indicated that this had not been reported and should have been reported as neglect because the nurse aide should have been using the sit to stand lift as directed by the resident's care plan and lift assessment.",2020-09-01
718,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,641,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to ensure the minimum data set (MDS) assessment for one (1) of four (4) residents reviewed for the care area of dental care, had an accurate and complete minimum data set (MDS) that reflected the current dental status of the resident. Resident identifier: #65. Facility census: 117. Findings included: a) Resident #65 During an interview with the resident on 08/27/18 at 9:23 AM, he said he had no teeth and would like to get some false teeth. He also said his gums got sore at times. Review of the last full Minimum Data Set (MDS), a significant change MDS with an assessment reference date (ARD) of 01/14/18, found the assessor had coded the resident as having obvious or likely cavities or broken natural teeth. The facility care planned the resident for being at risk for oral health or dental care problems as evidenced by broken, loose and carious teeth. At 11:05 AM on 08/28/18, Social Worker (SW) #15, confirmed the resident had never seen a dentist since his admission to the facility on [DATE]. Nursing assessments completed on 04/16/18 and 01/16/18 noted the resident had no natural teeth and no dentures. Observation of the resident's oral cavity on 08/28/18 at 11:29 AM, with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) found the resident did not have any natural teeth. During the observation, the resident said he had dentures at one time, but he thought he left them at his mothers' house. The DON confirmed the MDS completed on 01/14/18 was incorrect.",2020-09-01
722,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,689,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to ensure Resident #21 received adequate supervision and assistance devices. The resident, who was assessed to require the use of a sit to stand lift for transfers, fell in the shower room when she attempted to stand holding on to an assist bar while a nurse aide (NA) pulled up her brief and pant leg. Additionally, according to the resident, she was unable to hold on to the assist bar because she had lotion on her hands. The lift was not used during the entire shower process and only one NA was assisting the resident. This was true for one (1) of one (1) residents reviewed for the care area of accidents during the Long-Term Care Survey Process. Resident Identifier: #21. Facility Census: 117. Findings Included: a) Resident #21 An interview with Resident #21 at 2:42 p.m. on 08/28/18 found she had fallen in the shower room on 08/23/18. According to the resident, NA #41 had dried her off and had her pants and her brief pulled up to her knees. She stated that when she attempted to stand using the assist bar, My hands had lotion on them and when I stood up to the assist bar I fell over like a tree. She added that NA #41 got two (2) other NAs (NA #38 and NA #67) to help get her back in her wheelchair, but they did not use a lift at any point during her shower or after her fall. A review of Resident #21's medical record at 3:00 p.m. on 08/28/18 found a lift assessment dated [DATE] which indicated the resident was to be transferred via a sit to stand lift. During an interview at 4:07 p.m. on 08/28/18, the Director of Nursing (DON) stated she was not aware of the fall and she would have to investigate to see what had happened. When informed that the resident had reported staff did not use a lift to transfer her, the DON indicated if her lift assessment indicated she needed a sit to stand lift they should have used a lift for her. She also commented that if they were using a lift, they would have to have two (2) people to transfer her. At 8:14 a.m. on 08/29/18, the DON reported the nurse aide told a nurse, but when the nurse went to talk to the resident about it, she told the nurse she did not fall. She stated that NA #41 did not perceive the incident as a fall because she let the resident slide down her leg. The DON indicated that she was doing some education with the staff about what should be considered a fall. When asked why the staff did not use a sit to stand lift the DON stated, I do not know for sure why she did not use the lift.",2020-09-01
725,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,730,D,0,1,T9WW11,"Based on employee file review and staff interview, the facility failed to ensure performance reviews were completed at least every twelve (12) months for three (3) of three (3) randomly chosen Certified Nurse Aides (CNAs) reviewed during the Long-Term Care Survey Process. Staff identifiers: #71, #7, and #74. Facility census: 117. Findings included: a) Facility task For the Sufficient and Competent Staffing facility task, review of the employee files of three (3) randomly-chosen CNAs (CNAs #71, #7, and #74) who had been employed by the facility for at least one year, found none of them had a completed performance review during the previous twelve (12) months. During an interview on 08/30/18 at 10:00 AM, the Administrator stated the facility did not complete yearly performance reviews for CNAs.",2020-09-01
726,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,761,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to dispose of two (2) bottles of floor stock medications located in the cabinet of the 100 and 200 hallway medication room that were expired. Facility census: 117. Findings included: a) On 08/28/18 at 9:17 AM, inspection of the 100 and 200 hallway medication room accompanied by Licensed Practical Nurse (LPN) #90 found the following in the cabinets containing floor stock: -- A bottle of [MEDICATION NAME], an [MEDICATION NAME], had an expiration date of 07/2018. -- A bottle of zinc sulfate, a nutritional supplement, had an expiration date of 05/2018. The expiration dates were verified by LPN #90, and she agreed the medications were expired. She stated she would discard the bottles of expired medications. On 08/28/18 at 9:20 AM, Nurse-Unit Manager LPN #20 was informed about the two (2) bottles of expired floor stock medication. She had no further information regarding the matter.",2020-09-01
727,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,772,D,0,1,T9WW12,Deficiency Text Not Available,2020-09-01
728,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,773,D,0,1,T9WW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain and/or notify the physician of laboratory (lab) results for three (3) of twenty-six (26) residents reviewed during the Long Term Care Survey Process. The facility failed notify the physician of the results of a STAT (immediate) lab order for a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC). For Resident #34, the facility failed to obtain a physician ordered [MEDICATION NAME] level, and for Resident #89, the facility failed to obtain a physician ordered BMP. Resident Identifiers: #12, #34, and #89. Facility Census: 117. Findings included: a) Resident #12 A review of Resident #12's medical record at 1:33 p.m. on 08/27/18, found on 07/24/18, Resident #12 was found unresponsive in the morning hours. His vital signs were obtained and found to be normal. The change in condition was reported to the resident's attending physician at 12:27 a.m. on 07/24/18. The only order noted at that time was to continue to monitor resident. Further review of the resident's record found an additional progress note dated 7:39 p.m. on 07/24/18, STAT BMP (Basic Metabolic Panel) and CBC (Complete Blood Count) obtained on 07/24/18 at 6:00 p.m. awaiting results from (name of local hospital). A review of the resident's record found a physician's orders [REDACTED]. The order itself indicated the labs were obtained on 07/24/18 at 6:00 p.m. Further review of the record found no results for this lab obtained on 07/24/18. An interview with the Director of Nursing (DON) at 9:17 a.m. on 08/29/18, confirmed the results of the lab obtained on 07/24/18 were not contained in the resident's medical record. She contacted the medical records department and found they did not have the results either. She then spoke with Registered Nurse (RN) #12 who was the unit manager for Resident #12's unit. RN #12 indicated she did not have the lab either. While the DON was attempting to track down the original lab, License Practical Nurse (LPN) #57 called the local hospital who completed the lab work and obtained a copy of the lab results which she provided to the surveyor. A review of this lab result found Resident #12's WBC was high at 15.81. The DON then reviewed the progress notes and confirmed the physician was never notified of these results. A follow up interview with the DON and Nursing Home Administrator (NHA) at 11:24 a.m. on 08/30/18 revealed they had notified the attending physician of the resident's lab work for 07/24/18 yesterday on 08/29/18 after it was brought to their attention by the surveyor. b) Resident #34 Record review found a physician order [REDACTED]. - Discontinue [MEDICATION NAME] Sprinkles 50 milligrams (mg) by mouth BID (two times a day). - Start [MEDICATION NAME] Sprinkles 250 mg by mouth BID. The [MEDICATION NAME] was ordered for a [DIAGNOSES REDACTED]. - Obtain a [MEDICATION NAME] level in 2 (two) weeks. On 08/29/18 at 9:56 AM, Assistant Director of Nursing (ADON) #57 confirmed the [MEDICATION NAME] level had not been obtained as directed by the physician on 04/23/18. c) Resident #89 Review of Resident #89's medical records found a physician's orders [REDACTED]. Discontinue BMP every 91 (ninety-one) days. Laboratory results were reviewed and found the BMP scheduled in two (2) weeks was obtained on 07/31/18 (approximately 4 weeks). Review of nurse's notes found no evidence of laboratory tests done in the month of (MONTH) (YEAR). The facility provided a communication sheet for 07/18/18 and 07/19/18. This form noted on 07/18/18, Resident #89 refused to have blood drawn for the BMP, Magnesium level and [MEDICAL CONDITION] stimulating hormone (TSH) level. On 07/19/18, Resident #89 had blood drawn for TSH and Magnesium level. Interview with Director of Nursing (DON) on 08/30/18 at 10:15 am, confirmed the BMP was not obtained on 07/19/18 with the TSH and Magnesium level. She confirmed there was no documentation regarding labs in the nurses' notes during (MONTH) (YEAR).",2020-09-01
729,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,842,D,0,1,T9WW11,"Based on medical record review, observation, and staff interview, the facility failed to ensure a complete and accurate medical record for one (1) of twenty-six (26) residents reviewed during the Long-Term Care Survey Process. Resident #114's skin check dated 08/25/18 was incomplete and inaccurate. Resident identifier: #114. Facility census: 117. Findings included: a) Resident #114 Review of Resident #114's medical record found a weekly skin check dated 08/18/18 which reported previously noted skin injury/wounds of deep tissue injury (DTI) to the coccyx, bilateral heels, and left second toe. A weekly skin check dated 08/25/18 reported no identified skin injury/wounds. Observation of Resident #114 with Nurse-Unit Manager Licensed Practical Nurse (LPN) #20 on 08/28/18 at 1:23 PM revealed DTI to Resident #114's bilateral heels and left second toe. The coccyx was not observed due to resident comfort, but LPN #20 confirmed the resident currently had a DTI on her coccyx. LPN #20 stated the skin check dated 08/25/18 was incorrect and should have documented pre-existing skin injuries/wounds on the coccyx, bilateral heels, and left second toe. She stated she would correct the skin check.",2020-09-01
732,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2018-08-30,925,D,0,1,T9WW11,"Based on observation, resident interview, resident representative interview, and staff interview, the facility failed to ensure an effective pest control program. Resident #93 had flies in his room that would light on his feet and face. This was a random opportunity for discovery. Resident identifier: #31. Facility census: 117. Findings included: a) Resident #31 Observation of the resident at 10:30 AM on 08/27/18, found several flies in the resident's room. Flies were on the residents feet and head area. When asked about the flies, the resident said he would just eat them if they bothered him. During a telephone call with the resident's court appointed guardian, the Department of Health and Human Services (DHHR), at 11:00 AM on 08/27/18, the representative with the DHHR said she had been concerned about the amount of flies in the resident's room. She said she talked to the facility and expected the situation would be taken care of. She observed the flies the prior week during a visit with the resident. Observation of the resident again on 08/28/18 at 5:00 PM, found there were less flies in the room; however, a fly was still present on the resident's shoulder. By the time the administrator returned to the resident's room at 5:08 PM on 08/28/18, the fly was gone. The administrator said he would have staff clean the room.",2020-09-01
733,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2017-09-19,166,D,1,1,4U3U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, resident interview, policy review, and review of grievance concern forms, the facilty failed to provide prompt response to grievances regarding personal property. This was true for two (2) of five (5) residents reviewed for personal property during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #136 and #79. Facility census: 119. Findings include: a) Resident #136 On 09/11/17 at 2:14 p.m., a review of the medical record revealed Resident #136 was admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) on admission revealed a score of 15 which indicates intact cognition. During a Stage 1 interview with Resident #136 on 09/11/17 at 3:50 p.m., when asked the question: Have you had any missing personal items? She stated, Yes. When asked Did you tell staff about the missing item(s)? She stated, Yes. When asked Has staff told you they are looking for your missing item(s)? She stated, (Yes). Resident #136 stated she usually keeps her personal items put away but there's not alot of room. She stated her tablet and (DVD) Digital Versatile Disc player went missing on (MONTH) 16, (YEAR). She stated that her son bought her a lockbox and maintenance secured it to the top of her dresser. She further stated the facility was going to replace the tablet but her sister bought her a new one. Review of a Grievance Form dated 10/27/16, Resident #136 reported she was missing a 10 portable DVD player and RCA laptop charger and wall adapter to her cell phone charger. Resident #136 stated in the grievance form they have been missing since 10/26/16. The Social Services Department was assigned to investigate this concern on 10/27/16. According to the documentation on the grievance form, they were unable to locate the missing items and would continue to look and Resident #136 was notified. Social Worker (SW #51) initiated the grievance form. Review of Grievance Form #2 dated 01/27/17, Resident #136 reported her RCA tablet and portable DVD player were missing. Documentation revealed that the facility was searched, items were not found and Resident #136 bought a new portable DVD player. Documented resolution stated the facility replaced the RCA player and Resident #136 was educated about risks of leaving items unattended. Resident is agreeable to having DVD player and tablet locked up when not in use. Resident educated that facility is not liable for any missing or lost items. DVD player replaced by facility. Social Worker (SW #51) stated during an interview on 09/18/17 at 3:00 p.m., when asked Can you describe the process when a resident files a grievance? SW #51 stated the resident fills out a grievance form and social services conducts the investigation. A missing items notice is sent to housekeeping, laundry, the Director of Nursing (DON), and the Nursing Home Administrator (NHA). She stated that once they look for it, they can do the actual investigation within 72 hours. When asked about the delay in replacing the DVD player for Resident #136, she stated she requested a receipt for the missing item and that the resident did not have it but later found it after several months and once they received the original receipt, the business office began the paperwork and the facility replaced the DVD player on 09/11/17. This was eleven (11) months after the items were reported missing. A review of the facility Grievance/Concern Policy and Procedure with a revision date of 02/13/17 was reviewed on 09/18/17 at 3:10 p.m. The Grievance Concern policy stated the facility is to assure prompt receipt and resolution of patient/representative grievance/concern within a reasonable expected time frame for completing the review of the grievance. The department manager will notify the person filing the grievance of resolution within 72 hours by providing a copy of the Grievance/Concern Form to the resident/resident representative. The NHA #96 stated during an interview on 09/19/17 at 9:34 a.m., he is the Grievance Officer. Discussed the grievance forms of Resident #136 indicating tablet and DVD player in which the tablet and DVD player were reported missing on 10/16/16. NHA states facility replaced both. Record review revealed a DVD purchase receipt 09/29/16. On 09/11/17, a medical record review and resident interview revealed the DVD player had not been replaced. Resident #136 reports her family bought her a Kindle to replace the missing tablet. Record review revealed a purchase receipt on 09/11/17 for a DVD player that the facility purchased and was given to the resident on 9/12/17. NHA stated he can't remember a year ago, went through several social workers, is trying to clean things up. I'm not going to lie to you. It should not be. It should not have aken so long to replace. Audit of missing resident property began at beginning of the month. b) Resident #79 During a Stage 2 interview on 09/18/17 at 2:00 p.m., SW #15 stated the resident reported her missing laptop on 01/27/17 and completed a Grievance Concern Form. When asked what happened after the five (5) day follow up? She stated APS said there was no harm when the process was initiated and her receipt was reimbursed. When asked how is follow through to resolution documented and why is the section titled Corrective Action by Facility blank? The SW stated that they are not permitted to write on the form once it has been faxed to OHFLAC, APS, and the Ombudsman. When asked Is this sufficient documentation to show that the concern was followed through to resolution. The SW stated No. On 09/18/2017 at 2:30 p.m., a medical record review revealed Resident #79 was admitted to the facility on [DATE], Dx:[MEDICAL CONDITIONS], wheelchair confined, A Brief Interview of Mental Status (BIMS) on admission revealed a score of 15 which indicates intact cognition.",2020-09-01
735,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2017-09-19,272,D,1,1,4U3U11,"> Based on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment related to pressure ulcer status. This was evident for one (1) of twenty-six (26) Stage II sampled resident. Resident identifier: #95. Facility census: 119. Findings include: a) Resident #95 Review of the medical record on 09/13/17 found this resident came to the facility with four (4) pressure wounds as follows: 1. Left heel deep tissue injury. 2. Right inner foot deep tissue injury. 3. Left foot beneath the great toe unstageable. 4. Right pelvis Stage II pressure ulcer. Review of the weekly skin integrity report found the Stage II to the right upper pelvic bone on 03/23/17 measured 1.0 by 0.5 by centimeters, and less than 0.1 centimeters in depth. The measurements and description of this Stage II wound on 04/05/17 found that it was unchanged. The care plan was reviewed. It identified the presence of a Stage II pressure wound to the top of the right pelvis. Review of the five (5) day admission minimum data set (MDS), with assessment reference date (ARD) 03/29/17, found the MDS failed to assess the presence of the Stage II pressure ulcer which was present upon admission. The discharge MDS, with ARD 04/11/17, was reviewed. Section M assessed that she had no Stage II pressure ulcers. On 09/13/17 at 10:30 a.m., an interview was completed with the director of nursing (DON). The DON said the facility's former wound nurse at that time measured and documented pressure ulcer wounds every Wednesday. She said the most recent wound measurement prior to the resident's 04/11/17 discharge from the facility was completed on Wednesday 04/05/17. The DON provided a copy of the 5-day admission MDS section M, and the discharge MDS section M. She acknowledged the Stage II pressure wound should have been included in the 5-day admission MDS and on the discharge MDS, but were not. On 09/19/17 at 11:00 a.m. an interview was conducted with the administrator related to the incorrect comprehensive assessment of this resident's Stage II pressure ulcer. The administrator provided no further information prior to exit.",2020-09-01
738,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2017-09-19,514,D,1,1,4U3U11,"> Based on record review, staff interview and policy review, the facility failed to maintain accurate and complete medical records for Resident #136 and #79. Findings include: a) Resident #136 A review of the medical record, on 09/18/2017 at 4:20 p.m., revealed the Resident's Inventory Record was blank. The Resident's Inventory Record was to be completed upon admission to record any personal items brought to the facility. b) Resident #79 A review of the medical record, on 09/19/2017 at 11:00 a.m., revealed the Resident's Inventory Record was blank. The Resident's Inventory Record was to be completed upon admission to record any personal items brought tothe facility. c) A review of the instructions to complete the Inventory of Personal Effects, on 09/18/2017 at 1:55 p.m., stated Upon admission, identify the resident's personal belongings by indicating quantity of those items listed. Use the space allowed to write in additional items as necessary. The original copy shall be kept in the resident's chart. The copy is given to the resident or resident representative. Update as necessary throughout the resident's stay by using the space provided. Upon discharge, use the check mark columns to indicate that all personal belongings are accounted for. d) On 09/18/2017 at 4:00 p.m., a review of Resident's Inventory Records were not completed for Resident #136 and #79. NHA reported during an interview on 9/19/2017 at 8:45 a.m., when asked if the Resident Inventory Logs for Resident #136 and #79 were completed accurately?' He stated, No, they are not.",2020-09-01
739,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,225,D,0,1,97BS11,"Based on grievance reviews, abuse/neglect policy review, bed making policy review, and staff interviews the facility failed to ensure investigated allegations of neglect were reported to state agencies in a timely manner. Two (2) of eleven (11) grievances were not reported as required. Resident identifiers: #11 and #101. Facility census: 90. Findings include: a) Resident 11 A grievance form dated 01/09/17, documented by registered nurse, (RN) #112, revealed Resident #11 was discovered to be laying in the bed with a clean pad on top of a soiled pad which had a large area of wetness and bowel particles. The investigation revealed a nurse aide (NA) who was finishing a sixteen (16) hour shift, had placed to clean pad over the soiled pad, because it was the end of her shift. A review of the facility's bed making policy with a revision date of 05/16 revealed a policy statement of, Residents will have beds clean, wrinkle free and tidy with the policy interpretation and implementation, number one (1) being, Beds will be routinely changed and cleaned on a weekly basis, when soiled with body fluids or food and drink. b) Resident #101 A grievance form dated 12/10/16 documented by RN #112, revealed a family member for Resident #101 was informed by a visitor that her relative was incontinent of bowel and was not being cared for. A review of the facility's abuse reporting policy with a revision date of 05/16 number one (1) reveals, a suspected violation neglect will be promptly reported to the administrator, or the designee whom will then promptly notify the State licensing/certification agency responsible for surveying/licensing the facility. At 2:57 p.m., on 01/12/17 the facility administrator stated she did not see these issues as being reportable but in the future will be more aware of what should be reported.",2020-09-01
740,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,246,D,0,1,97BS11,"Based on observation, staff and resident interview, the facility failed to ensure one (1) of thirty five (35) Stage one (1) sampled residents, received services with reasonable accommodation of their individual needs. A resident with contractures of both hands, who did not always have the ability to push the call light button, was not offered an alternative way to alert the staff of the resident's need for staff assistance. This practice had the potential to affect more than an isolated number of residents. Resident identifier: #48. Facility census: 90. Findings include: a) Resident #48 While testing the call system on 01/10/17 at 9:14 a.m., during Stage one (1) of the Quality Indicator Survey (QIS), Resident #48 was asked to push the call bell button. The resident attempted with great difficulty to push the call light button and was unable to activate the call system. Resident #48 has contractures of both hands. To ensure the call system was functioning properly, this surveyor pushed the hand held button and was able to activate the call system. Resident #48 said, I can't always push the button because of my hands. The resident was asked what she did when she was unable to push the call light button and she needed staff to help her. The resident replied, There always seems to be someone around, I just holler for them. When asked if the resident had ever told any staff she had a problem pushing the call light button, the resident replied, Yes, they know I have trouble using my hands. On 01/10/17 at 9:35 a.m., during an interview Licensed Practical Nurse Supervisor (LPN) #44 acknowledged due to Resident #48's contractures the resident would more likely find it easier to use a touch pad than a push button call light. LPN #44, said a touch pad would be provided for the resident. After surveyor intervention the push button call light was replaced with a touch pad to accommodate resident's needs. Resident #48 was observed several times using the touch pad call light without difficulty. An interview with Resident #48, on 01/11/17 at 2:13 p.m., revealed the resident said it was much easier and better to use the touch pad. The Resident expressed she was very happy with the touch pad.",2020-09-01
742,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,278,D,0,1,97BS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to identify the [DIAGNOSES REDACTED].#64. Sample size: one (1) of eighteen (18) residents. Findings include: a) Resident #64. A review of the quarterly MDS dated [DATE] revealed there was no diagnosis listed for the use of [MEDICATION NAME], an antidepressant medication. Section J of the MDS has a list of [DIAGNOSES REDACTED]. Medical record physician orders [REDACTED]. This was discussed with the MDS coordinator on 01/11/17 1:32 p.m After a review of her records, she confirmed the resident had a [DIAGNOSES REDACTED].",2020-09-01
743,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,279,D,0,1,97BS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to develop a comprehensive care plan for Resident #11. The care plan did not address the advance directive implementation for one (1) of one (1) residents reviewed for hospice care during Stage 2. Resident identifier: #11 Facility census: 90. Findings include: a) Resident #11 A review of the medical record on 01/11/17 revealed the Physician order [REDACTED]. An interview on 01/11/17 at 1:35 p.m., with the Licensed Social Worker (LSW) and the Director of Nursing (DON) verified the current care plan for Resident #11 did not address the resident's choices regarding her advance directive and end-of-life care.",2020-09-01
744,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2017-01-12,441,D,0,1,97BS11,"Based on observation and staff interviews, the facility failed to implement practices designed to prevent infection and/or cross-contamination for two (2) of two (2) residents reviewed for administration of nebulizer treatment during medication pass of the Quality Indicator Survey (QIS). This practiced had the potential to affect all residents who received nebulizer treatments. Resident identifier: #88 and #71. Facility census: 90. Findings include: a) Resident #88 On 01/11/17 at 9:22 a.m., observation of Licensed Practical Nurse (LPN) Supervisor #130 preparing to administer Resident #88's nebulizer treatment, revealed Employee #130 laying the mouth piece for Resident #88's nebulizer directly on an unclean surface. Employee #130 when preparing to administer Resident #88's nebulizer treatment, removed the nebulizer mouth piece from the storage container and laid it directly on the resident's turned down bed spread. The area of the turned down bed spread was an area that had been touching the resident's body. The LPN then picked up the mouth piece and gave it to the resident to use. b) Resident #71 Observation of LPN Supervisor #101, on 01/11/17 at 1:30 p.m., revealedthe LPN laying Resident #71's nebulizer face mask on an unclean surface while going to get the resident a glass of drinking water. On completion of administering Resident #71's nebulizer treatment, LPN #101 laid the face mask face down cupped over the nebulizer equipment storage bag, the inside of the mask was touching the outside of the bag. Registered Nurse (RN) #3 was present during the nebulizer treatment and verified the LPN should not have laid the inside of the mask on the outside of the bag. On 01/11/17 at 1:40 p.m., interview with RN #3 confirmed LPN #101 laid the inside of resident's nebulizer face mask on an unclean surface. The RN, who was training the LPN, instructed the LPN to throw away the face mask and get a new face mask. The RN verified the mask could have been laid upside down with the back of the mask touching the surface or the LPN could have asked the resident to hold it while she got the glass of water.",2020-09-01
745,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2018-03-14,880,D,0,1,X41Y11,"Based on observation and staff interview, the facility failed to maintain an effective Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Staff failed to provide/maintain a barrier for a multi dose medication bottle when placed in a resident's room for administration. This practice has the potential to affect more than an isolated number of residents residing in the facility. Resident identifiers: #26. Facility census: 82. Findings included: a) Resident #26 During a medication administration observation on 03/14/18 at 9:00 AM, Licensed Practical Nurse (LPN) #37 entered Resident #26's room to administer oral medications and eye drops. LPN #37 placed the eye drop bottle directly on the bedside table without a barrier next to the resident's breakfast tray and personal items. LPN #37 administered her oral meds and then her eye drops. LPN #37 washed her hands, retrieved the eye drop bottle from the bedside table, placed the unclean bottle on top of the medication cart, unlocked the cart and then returned the bottle into the box inside the medication cart. Immediately following this observation LPN #37 agreed she had placed the multi dose eye drop bottle directly on the bedside table without a barrier and reported she was unaware she needed to have a barrier between the eye drop bottle and the bed side table.",2020-09-01
746,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2019-10-30,550,D,0,1,4UQE11,"Based on observation and staff interview, the facility failed to provide a dignified dining experience as evidenced by standing over a resident while assisting them to eat. Resident #21. Facility census: 89. Findings included: a) Resident #21 On 10/28/19 at 11:52 AM, Nursing Aide (NA) #180 was observed standing over Resident #21 feeding lunch. At no time did NA #180 attempt to sit down when feeding this resident. In an interview with the Director of Nursing (DON) on 10/30/19 at 10:40 AM stated that she would take care of that immediately.",2020-09-01
747,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2019-10-30,625,D,0,1,4UQE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to notify the resident's representative of the bed hold policy, when Resident #6 was transferred to an acute care hospital. This was true for one (1) of three (3) residents reviewed for hospitalization s. This had the potential to affect more than a limited number of residents. Resident identifier: #6 Facility census 89. Findings included: a) Resident #6 A review of the medical record on 10/30/19 for Resident #6 revealed the resident representative was not provided a notice for bed hold when Resident #6 was transferred to an acute care hospital on [DATE]. In an interview with E157, Registered Nurse Supervisor on 10/30/19 at 11:02 AM, reported she was unable to provide any evidence the resident representative for Resident #6 had received the bed hold notice for the hospitalization on [DATE].",2020-09-01
748,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2019-10-30,695,D,0,1,4UQE11,"Based on policy and procedure review, observation and staff interview, the facility failed to ensure oxygen delivery in accordance with professional standards. This practice has the potential to affect one (1) of three (3) residents reviewed for oxygen therapy. Resident identifier: #57. Facility census: 89. Findings included: a) Resident #57 Policy and procedure titled Oxygen Auxiliary Equipment with revision date of (MONTH) (YEAR) was reviewed. The policy and interpretation and implementation stated that all oxygen tubing will be changed on the 15th of each month. The policy and procedure did not state anything about evidence that the oxygen tubing was changed. On 10/28/19 at 12:08 PM found the oxygen tubing coming from adapter on the humidifier bent at 90 degree angle. Licensed Practical Nurse (LPN) #96 entered Resident #57's room and confirmed the tubing was bent. and changed the tubing and humidifier. When asked when the tubing and bubble jugs are changed LPN #96 stated that they were changed on night shift once per week. No dates or identification to show when tubing and/or humidifier had been changed were present on the tubing and/or bubble jug. In an interview with the Director of Nursing (DON), on 10/29/19 at 1:03 PM, the DON stated that the oxygen tubing and bubble jug should have been dated when changed. In addition, the DON stated that there was no evidence the facility could provide to confirm the oxygen tubing and/or bubble jug had been changed as stated in the policy and procedure.",2020-09-01
749,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2019-10-30,883,D,0,1,4UQE11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement a pneumococcal vaccine according to the Center of Disease Control and Prevention (CDC) guidelines. This is true for one (1) of five (5) immunization record review. Resident identifier: Resident #68. Facility census 89. Finding includes: a) Resident #68 Records reveal Resident #68 received valent pneumococcal conjugate vaccine (PCV13) on 06/08/17. There no evidence the resident was offered the valent pneumococcal [MEDICATION NAME] vaccine (PPSV23). The CDC guidelines recommend giving the second pneumococcal vaccination in one year after giving the first vaccine. The facility pneumococcal vaccine policy directs the facility to the pneumococcal vaccines according to CDC guidelines. On 10/29/19 at 4:15 PM Registered nurse #70 agreed the facility failed to offer the Resident #68 the PPSV23 one year after giving the PCV13.,2020-09-01
751,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,280,D,0,1,4DYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to revise a care plan for one (1) of twenty-one (21) sample care plans reviewed for dental status. A care plan was not updated after the medication [MEDICATION NAME] was discontinued. Resident identifier: #1. Facility census: 90. @ Findings include: @ a) Resident #1 A review of Resident #1's care plan on 01/24/17 at 2:00 p.m., revealed the resident had potential for oral discomfort related to dental status as evidence by missing and carious teeth. The care plan intervention was for the resident to use [MEDICATION NAME] gel 10% one (1) application orally every six (6) hours as needed for toothache. This intervention was initiated on 02/23/16. @ A review of the (MONTH) (YEAR)'s physician order on 01/24/17 at 2:05 p.m. for Resident #1 found no physician orders for [MEDICATION NAME] gel 10% every six (6) hours as needed for toothache. In an interview with minimum data set coordinator #63 on 01/24/17 at 3:20 p.m., reviewed Resident #1's record and found the [MEDICATION NAME] Gel 10% was discontinued on 06/29/16. Employee #63 stated, The [MEDICATION NAME] gel was discontinued, and the care plan never was updated to reflect this change.",2020-09-01
752,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,323,D,0,1,4DYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to monitor neuro checks for a resident who had fallen and hit their head on two (2) different occasions. This practice has the potential to affect more than an isolated number of residents. Resident identifier: #61. Census: 90 Findings include: On 01/26/17 at 9:14 a.m., review of records revealed the resident had fallen on 12/21/16 and 01/03/17, both times hitting her head. A fall report dated 12/21/16, revealed Resident #61 fell to the floor and struck her forehead on the floor. The resident was sent to the emergency room for evaluation. Record showed vital signs were taken once right after the fall, with no mention of neuro checks. When the resident returned to the facility from the emergency room visit, a nurse's note revealed neuro checks were within normal limits. After the one entry there is no other mention or reference neuro checks were done. Review on 01/26/17 at 9:34 a.m., of a fall report dated 01/03/17, revealed Resident #61 fell to her knees and hit her head on the treatment cart. The record showed light red area noted to the resident's forehead. No evidence neuro checks were done were found in the records. An interview with the director of nurses (DON) on 01/26/17 at 11:13 a.m., revealed when a resident falls and hits their head, neuro checks should be done for 72 hours until the resident is stable or the physician discontinues the neuro checks. The DON stated neuro checks should be done every fifteen (15) minutes times four (4); then every thirty (30) minutes times four (4); then every hour times four (4); then every two (2) hours times four (4); then every four (4) hours times four (4) for the remaining 72 hours the resident is to be monitored. According to the DON, staff was to monitor and record neuro checks and place the results in the resident's chart. The DON was unable to find any evidence, in the resident's chart or electronic record, neuro checks had been performed either time the resident fell and hit their head on 12/21/16 or 01/03/17. The DON could not find an order either time to discontinue neuro checks. The DON agreed staff should have monitored the resident and obtained neuro checks as per policy or obtained a physician's orders [REDACTED].>On 01/26/17 at 11:26 a.m., review of facility's Fall Policy (NRC-NPSG-006), revealed, The facility will implement neuro checks any time a resident hits his/her head and/or if not known if the resident hit his/her head. Neuro checks will be completed up to 72 hours after the fall and/or until stable and discontinued via physician's orders [REDACTED].>",2020-09-01
754,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,441,D,0,1,4DYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to implement practices designed to prevent the development and transmission of disease and infection and/or cross-contamination. A nurse failed to clean and sanitize a stethoscope, after using it to check the placement of a gastrostomy tube ([DEVICE]) for a resident with influenza symptoms, during Medication Pass of the Quality Indicator Survey (QIS). This practice had the potential to affect more than a limited number of residents in the facility. Resident identifier: #119. Census: 90 Findings Include: a) Resident #119 Observation of licensed practical nurse (LPN) #14 administering medication to Resident #119, on 01/25/17 at 2:40 p.m., revealed the LPN laid a stethoscope on the resident's bed without a barrier, and then placed it back on the medication cart. The LPN used the stethoscope to check the placement of the resident's [DEVICE] prior to giving medication via the [DEVICE]. The stethoscope was laid with the flat surface of the stethoscope's bell directly on the resident's bed. When the LPN was finished giving the medication she placed the stethoscope back onto the medicine cart, without cleaning or sanitizing it, and rolled the cart to another hall. During the time of the QIS there was an influenza outbreak at the facility. The LPN was asked if Resident #119 was showing signs or symptoms of influenza, and LPN revelaed she was showing signs and symptoms of infuenza. An interview with LPN #14, on 01/25/17 at 2:40 p.m., revealed LPN #14 agreed the stethoscope should have been cleaned and sanitized prior to taking it out of Resident #119's room and placing it back onto the medicine cart. The LPN cleaned the stethoscope after surveyor intervention. The DON was in the hall and was informed of the incident. The DON agreed that it was a breach in infection control principals and LPN#14 should have cleaned and sanitized the stethoscope before it could be used for any other resident.",2020-09-01
755,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-01-26,502,D,0,1,4DYT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident was provided services as ordered by the physician. The facility did not ensure physician's orders [REDACTED]. Resident #18's [MEDICAL CONDITION] panel, a laboratory (lab) test, was not obtained as ordered by the physician. Resident identifier: #18. Facility census: 90. Findings include: a) Resident #18 A review of the medical record on 01/24/17 at 1:53 p.m., revealed on 08/24/16 the Pharmacist recommended laboratory (lab) work to monitor the resident's [MEDICAL CONDITION] level and the physician accepted the recommendation on 09/04/16 to have a [MEDICAL CONDITION] panel completed. On 01/25/17 at 8:15 a.m., the Director of Nursing (DON) verified the [MEDICAL CONDITION] panel the physician had ordered on [DATE] for Resident #18 had not been completed.",2020-09-01
757,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,558,D,0,1,RG3511,"Based on observation, resident interview, and staff interview, the facility failed to provide services with reasonable accommodation for residents. Resident #248 and #250's over the bed light cords were not long enough to be easily reached by the residents. This practice affected two (2) of twenty-three (23) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #248 and #250. Facility census: 96. Findings included: a) Resident #248 An observation of the Resident, on 03/19/18 at 1:30 PM, revealed the Resident's over the bed light cord was approximately three inches long. An interview with the Resident, on 03/19/18 at 1:35 PM, revealed the Resident could not reach the over the bed light cord without having to get up out of bed. The Resident stated the light was hard to turn on and off with the short cord. The Resident stated the staff turn has to turn the light off and on. The resident stated she had reported the light several times to the aides. b) Resident #250 An observation of the Resident, on 03/21/18 at 2:45 PM, revealed the Resident's over the bed light cord was approximately three inches long. An interview with the Resident, on 03/21/18 at 2:48 PM, revealed the Resident could not reach the over the bed light cord. An interview with the Administrator, on 03/21/18 at 3:10 PM, revealed the over the bed light cords had extenders which had fallen off. The Administrator stated she would ensure the cords were fixed immediately.",2020-09-01
760,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,585,D,0,1,RG3511,"Based on record review, resident and staff interview and review of the grievance file, the facility failed to initiate and document findings for a grievance for 1 of 4 grievances reviewed. Resident identifier: #90. Facility census: 96. Findings included: a) Resident #90 An interview with Resident #90, on 03/19/18 at 1:49 PM, revealed the resident had seventeen (17) dollars missing and had complained to management about it. A review of the medical record revealed no documentation of Resident #90's complaint being acknowledged, investigated or findings documented of an investigation. An interview with the Administrator and Social Worker, on 03/20/18, at 02:20 PM and 03:05 PM, revealed the facility practice was if something was missing but was found, nothing was documented. A review, of the facility policy and procedure for Grievances dated 11/21/16, revealed Upon receiving the grievance/complaint the Social Service Director or designee will investigate the grievance and report findings to the administrator within five days as possible. The facility will maintain evidence demonstrating the results of all grievances for a period of no less than 3 years from the issuance of the grievance decision.",2020-09-01
761,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,657,D,0,1,RG3511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to ensure two (2) of twenty-three (23) comprehensive care plans had been reviewed and revised by the interdisciplinary team. This practice involved needed revisions for the floating of heels. Resident identifiers: #93 and #248. Facility census: 96. Findings included: a) Resident #93 An observation of the Resident, on 03/19/18 at 2:20 PM, revealed the resident's heels were not floated while lying in bed. An observation of the Resident, on 03/21/18 at 7:55 AM, revealed the resident's feet were not floated while lying in bed. An interview with the Resident, on 03/21/18 at 7:58 AM, revealed the staff does not float her heels. The Resident stated they used to but not anymore. An interview with Certified Nursing Assistant (CNA) #13, on 03/21/18 at 8:05 AM, revealed that she does not float the resident's heels. The CNA stated the resident usually ends up removing the pillow herself because she is up a lot. The CNA stated she has not floated the resident's heels for weeks. The CNA stated she had reported the resident's behavior to the nurse several times. A review of the Resident's physician orders, on 03/21/18 at 8:10 AM, revealed the Resident had an order, dated 02/21/18, to Keep heels elevated at all times while in bed-check every shift. A review of the Resident's Care Plan was conducted on 03/21/18 at 9:00 AM. The Care Plan, with an initiation date of 03/06/18, contained the focus of At risk for pressure ulcer development related to impaired mobility with the intervention Keep bilateral heels elevated, check compliance every shift. b) Resident #248 An observation of the Resident, on 03/21/18 at 7:55 AM, revealed the resident's heels were not floated while lying in bed. An interview with Certified Nursing Assistant (CNA) #13, on 03/21/18 at 8:08 AM, revealed that she does not float the resident's heels. The CNA stated they do not need them floated anymore because they are independent. A review of the Resident's physician orders, on 03/21/18 at 8:15 AM, revealed the Resident had an order, dated 03/02/18, to Keep heels elevated at all times while in bed-check every shift. A review of the Resident's Care Plan was conducted on 03/21/18 at 9:05 AM. The Care Plan, with an initiation date of 03/15/18, contained the focus of At risk for pressure ulcer development related to advancing age and skin fragility with the intervention Keep bilateral heels elevated, check compliance every shift. An interview with the Director of Nursing (DON), on 03/21/18 at 10:30 AM, revealed Resident #93 and #248's heels were only floated when they were first admitted to the facility. The DON stated their heels are no longer being floated because the residents are frequently up and moving. The DON stated the physician orders [REDACTED].",2020-09-01
762,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,684,D,0,1,RG3511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to float residents' heels as ordered by the physician. This practice affected two (2) of twenty-three (23) residents reviewed. Resident identifiers: #93 and #248. Facility census: 96. Findings included: a) Resident #93 An observation of the Resident, on 03/19/18 at 2:20 PM, revealed the resident's heels were not floated while lying in bed. An observation of the Resident, on 03/21/18 at 7:55 AM, revealed the resident's feet were not floated while lying in bed. An interview with the Resident, on 03/21/18 at 7:58 AM, revealed the staff does not float her heels. The Resident stated they used to but not anymore. An interview with Certified Nursing Assistant (CNA) #13, on 03/21/18 at 8:05 AM, revealed that she does not float the resident's heels. The CNA stated the resident usually ends up removing the pillow herself because she is up a lot. The CNA stated she has not floated the resident's heels for weeks. The CNA stated she had reported the resident's behavior to the nurse several times. A review of the Resident's physician orders, on 03/21/18 at 8:10 AM, revealed the Resident had an order, dated 02/21/18, to Keep heels elevated at all times while in bed-check every shift. A review of the Resident's Care Plan was conducted on 03/21/18 at 9:00 AM. The Care Plan, with an initiation date of 03/06/18, contained the focus of At risk for pressure ulcer development related to impaired mobility with the intervention Keep bilateral heels elevated, check compliance every shift. b) Resident #248 An observation of the Resident, on 03/21/18 at 7:55 AM, revealed the resident's heels were not floated while lying in bed. An interview with Certified Nursing Assistant (CNA) #13, on 03/21/18 at 8:08 AM, revealed that she does not float the resident's heels. The CNA stated they do not need them floated anymore because they are independent. A review of the Resident's physician orders, on 03/21/18 at 8:15 AM, revealed the Resident had an order, dated 03/02/18, to Keep heels elevated at all times while in bed-check every shift. A review of the Resident's Care Plan was conducted on 03/21/18 at 9:05 AM. The Care Plan, with an initiation date of 03/15/18, contained the focus of At risk for pressure ulcer development related to advancing age and skin fragility with the intervention Keep bilateral heels elevated, check compliance every shift. An interview with the Director of Nursing (DON), on 03/21/18 at 10:30 AM, revealed Resident #93 and #248's heels were only floated when they were first admitted to the facility. The DON stated their heels are no longer being floated because the residents are frequently up and moving. The DON stated the physician orders [REDACTED].",2020-09-01
765,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2018-03-22,757,D,0,1,RG3511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to address non-pharmacological interventions for ordered pain medications. This practice affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #80. Facility census: 96. Findings included: a) Resident #80 A review of the physician orders, on 03/21/18 at 11:35 AM, revealed the following two orders for pain medication since the resident was admitted on [DATE]: -Tylenol 650 milligrams, by mouth, every 4 hours as needed for pain, with a start date of 03/27/14. -Tylenol (8 Hour Arthritis-Extended Release) 650 milligrams, as needed for pain, with a start date of 09/22/17. A review of Resident #80's Care Plan was conducted on 03/21/18 at 1:35 PM. The Care Plan, with a review date of 09/08/17, contained no non-pharmacological interventions for the pain medications. Further review of the medical record, on 03/22/18 at 8:25 AM, revealed no non-pharmacological interventions were documented. An interview with the Director of Nursing (DON), on 03/22/18 at 8:45 AM, revealed no non-pharmacological interventions for pain medication were in place for Resident #80. The DON stated non-pharmacological interventions should have been on the care plan and in place for the ordered pain medications.",2020-09-01
770,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,550,D,0,1,7QRC11,"Based on observation, staff interview, and policy review, the facility failed to treat each resident with respect and dignity. Part of a resident's room was being used as a storage area for the facility and a partially dressed resident was receiving care in the hallway. This practice affected two (2) of twenty-nine (29) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #50 and #69. Facility census: 96. Findings included: a) Resident #69 An observation of the Resident, on 04/30/19 at 11:50 AM, revealed the Resident was in the Life Skills Room. The Life Skills area consists of two adjoining rooms. The first room, in which the Resident has to pass through to get to their bed and bathroom, was observed to have approximately ten (10) wheelchairs, an oxygen tank, a mechanical lift, and a weight scale stored in the room. There was just enough space for the Resident to get by the equipment to get in and out of their room. An interview with the Administrator, on 04/30/19 at 12:05 PM, revealed the Life Skills area was used as extra storage for the facility's equipment. The Administrator agreed it was not a dignified area for the Resident to be living in. The Administrator stated she would have the equipment emptied out of the room immediately. b) Resident #50 An observation on 04/29/19, at 11:10 AM revealed Resident #50 (R#50) seated in a reclining chair, in the hallway, outside of the 200 Hall shower room. R#50 was covered with a bath blanket that was tucked under the maxillae exposing her upper chest area. NA#2 was observed providing care. An interview, on 04/29/19, at 11:10 AM, with NA#2, revealed care was being provided in the hallway because of the shower room being stuffy. An interview, on 04/30/19 at 11:36 AM, with the Administrator, verified it was unacceptable for the resident to receive care in the hallway covered with a bath blanket and should have been dressed prior to leaving the shower room. A review of Policy NRC-RR-015, Dignity F557, effective 11/15/16, noted Residents shall be sufficiently covered when being taken to areas outside of their room.",2020-09-01
771,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,580,D,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to inform Resident #37's physician of blood sugar levels above the acceptable range. This was true for one (1) of twenty-nine residents reviewed in the sample. Resident identifier: #37. Facility census: 96 Findings included: On 04/30/19 at 3:30 PM, review of Resident #37's physician's orders [REDACTED]. --If blood sugar is 0 - 149 then no insulin required. --If Blood Sugar is less than 60 then call the physician. --If blood sugar is 150 - 200 inject 2 units of [MEDICATION NAME]. --If blood sugar is 201 - 250 inject 4 units of [MEDICATION NAME]. --If blood sugar is 251 - 300 inject 6 units of [MEDICATION NAME]. --If blood sugar is 301 - 350 inject 8 units of [MEDICATION NAME]. --If blood sugar is 351 - 400 inject 10 units of [MEDICATION NAME]. --If blood sugar is 401 - 450 inject 12 units of [MEDICATION NAME]. --If blood sugar is 451 - 999 inject 15 units of [MEDICATION NAME]. --If blood sugar is greater than 450 then call physician. Record review on 04/30/19 at 3:50 PM revealed Resident #37 had a blood sugar over 450 on 03/02/019, 03/04/19, 03/26/19, 03/29/19, 03/31/19, 04/03/19, 04/09/19, 04/13/19, and 04/19/19 (three incidents for this date) and the physician was not notified as ordered for these occurrences. During an interview on 05/01/19 at 8:20 AM, it was verified by the Administrator #7 and Director of Nursing #6 that the facility had no documentation to verify the physician had been notified of the blood sugar readings as ordered. Administrator #7 stated, It's not documented, I have no way of knowing if it was done or not. Director of Nursing #6, They (nursing staff) should have documented talking to the physician in the progress notes in the computer, but it's not there. At 10:05 AM on 05/01/19, Administrator #7 stated We (the facility) don't have a policy for notifying the physician of abnormal blood sugar readings, the only policy we have is on how to administer insulin.",2020-09-01
774,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,656,D,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the implementation of individualized care plan interventions related to pressure ulcer risks. Floating of heels, for residents identified as a high pressure ulcer risk, were not implemented as directed by their care plans. This practice affected three (3) of twenty-nine (29) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #21, #57, and #61. Facility census. 96. Findings included: a) Resident #21 An observation of the Resident, on 04/30/19 at 8:38 AM, revealed the Resident was in bed. Their heels were not floated. A record review, 04/30/19 1:06 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:15 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development related to impaired mobility and incontinence with the intervention of keep bilateral heels elevated, check compliance every shift. The Care Plan was dated 02/04/19. An interview with Registered Nurse (RN) #34, on 04/30/19 at 1:20 PM, revealed the Resident should have their heels floated anytime they are in bed. b) Resident #57 Observations, on 04/29/19 at 11:15 and 2:22 PM, revealed the Resident was in bed. The Resident's heels were not floated on either observation. An interview with Nurse Aide (NA) #78, on 04/29/19 at 2:25 PM, revealed the Resident's heels do not need floated. The NA stated he never floats the Resident's heels. A record review, on 04/30/19 1:24 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:30 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development related to incontinence and decreased mobility with the intervention Keep bilateral heels elevated, check compliance every shift. The Care Plan was dated 03/14/19. c) Resident #61 Observations, on 04/29/19 at 2:00 PM and 3:00 PM, revealed the Resident was in bed. Their heels were not floated on either observation. An interview with Nurse Aide (NA) #78, on 04/29/19 at 3:05 PM, revealed the Resident's heels do not need floated. The NA stated he never floats the Resident's heels. A record review, on 04/30/19 at 1:47 PM, revealed the physician order [REDACTED]. Further review of the Resident's medical record, on 04/30/19 at 1:56 PM, revealed a Care Plan with the focus Resident is at risk for pressure ulcer development with the intervention Keep bilateral lower extremities on pillows at all times in bed to float heels. The Care Plan was dated 09/28/18.",2020-09-01
783,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,814,D,0,1,7QRC11,"Based on observation and staff interview, the facility failed to ensure that refuse was disposed of properly. This deficient practice was found during a random opportunity for discovery and had the potential to affect an isolated number of residents. Facility census: 96. Findings included: On 04/30/19 at 8:59 AM, three (3) dumpsters were observed behind the facility. No staff was present near the dumpsters. Two (2) of the dumpsters had been left open, creating the potential for the entrance of pests into the dumpster. Housekeeping Attendant (HA) #63 entered the dumpster area at 9:02 AM. Upon leaving the area, HA #63 acknowledged that two (2) of the three (3) dumpsters had been open when she approached the area. She said that she closed one (1) of the dumpsters, but that the other dumpster was typically left open because it had a large lid. She added that all three (3) dumpsters were supposed to remain closed. On 04/30/19 at 9:30 AM, the facility's Administrator was made aware of the above findings and agreed that all three (3) dumpsters should have been closed. No further information was provided prior to the end of the survey.",2020-09-01
784,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2019-05-01,842,D,0,1,7QRC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain a complete and accurate medical record for each resident. Resident #23's medical record lacks information related to scheduled psychiatric visits. This was true for one (1) of five (5) residents reviewed for necessary medications. Resident identifier: #23. Facility census: 96. Findings included: a) Review of the medical record on 05/01/19 revealed resident #23's [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/05/19, notes R#23 experienced delusions and rejected care one (1) to three (3) days of the seven (7) day look back period. Medications include an antipsychotic, antidepressants and a hypnotic. The computerized physician orders [REDACTED]. The monthly pharmacy consultation reports note the following physician documentation: --04/22/19 - a gradual dose reduction (GDR) for [MEDICATION NAME] 20 milligrams (mg) daily was declined and states (typed as written): refer to her psychiatrist. --03/15/19 - a GDR for [MEDICATION NAME] 15 mg at bedtime and a recommendation to decrease multiple antidepressants were declined and states (typed as written): refer to her psychiatrist. The medical record lacks any psychiatric evaluations since 05/31/18. *No other psychiatric assessment and plans of care are located in the medical record. During an interview on 05/01/19 at 9:00 AM, the Director of Nursing (DON) acknowledged R#23 visits a psychiatrist regularly. The DON reviewed the chart and confirmed there are no records related to R#23's psychiatric evaluations since 05/31/18.",2020-09-01
788,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-05-03,272,D,1,0,W9H111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to complete an accurate comprehensive assessment regarding the health conditions of two (2) of five (5) sample residents reviewed. One (1) resident received a scheduled pain medication regimen and it was incorrectly assessed. This resident also had a terminal health condition that was not correctly assessed on the comprehensive Minimum Data Set (MDS) assessment. In addition, a second resident who had a chronic disease was also not assessed accurately in regards to prognosis on the comprehensive MDS assessment. Resident identifiers: #1 and #2. Facility census: 92. Findings include: a) Resident #1 1. Pain regimen A record review was performed on [DATE] at 8:30 a.m. Resident #1 was admitted to the facility with a [DIAGNOSES REDACTED]. She also had a history of [REDACTED]. Her admission orders [REDACTED]. On her medication administration report (MAR) the [MEDICATION NAME] was timed for administration at 900 and 2100. Resident #1 was admitted on [DATE] and expired on [DATE]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A review of the MDS section J Health Conditions for the Admission comprehensive MDS with an assessment reference date (ARD) of [DATE] was performed. For question J0100 At any time in the last 5 days, has the resident [NAME] Received scheduled pain medication regimen? The response was no. MDS coordinator #2 was interviewed on [DATE] at 9:00 a.m. She said she agreed that the resident had received a scheduled pain medication, and that the MDS was incorrect. 2. Prognosis During the record review performed on [DATE] at 8:30 a.m., the West Virginia Department of Health and Human Resources Pre-Admission Screening (PAS) was reviewed. The document was completed by a physician at the acute care hospital where Resident #1 was an inpatient prior to transfer to the long term care facility. This PAS is made available to facilities prior to their acceptance of a resident for admission. The PAS for Resident #1 was dated [DATE]. She was admitted to the facility on [DATE]. Page 5 of the PAS states that Resident #1 was deteriorating, and page 6 said she had terminal illness. A note from the attending physician in the facility stated Resident #1's prognosis was guarded and she was for palliative comfort care, dated [DATE]. In review of the comprehensive Admission MDS assessment with an ARD of [DATE], section J Health Conditions was again found inaccurate. Question J1400 Prognosis asked: Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? It was answered No. This matter was discussed with MDS coordinator #2 on [DATE] at 9:00 a.m. She agreed the answer to question J1400 should have been Yes. b) Resident #2 1. Prognosis During the record review performed on [DATE] at 8:00 a.m., a hospital discharge summary dated [DATE] revealed, Plan for today is transfer to PVNRC (Pleasant Valley Nursing & Rehabilitation Center) under hospice care. Review of minimum data set (MDS) with an assessment reference date (ARD) of [DATE] found the health condition section asking if the resident has a condition or chronic disease that may result in a life expectancy of less than six (6) months, answered no. The resident was admitted to the facility on hospice. This matter was discussed with MDS coordinator #2 on [DATE] at 9:00 a.m. She explained she thought the section was entered correctly due to the minimum data set form stating (Requires physician documentation). After discussion MDS coordinator #2 on [DATE] at 9:00 a.m., she agreed the answer to should have been Yes.",2020-09-01
789,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,156,D,0,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to notify the beneficiary/responsible party of the facility's decision to terminate Medicare services for two (2) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal. This failed practice had the potential to affect an isolated number of residents. Resident identifiers: #8 and #13. Facility census: 100. Findings include: a) Staff Interview At 2:15 p.m. on 07/17/17, the facility social worker, (SW) #102, was asked to provide copies of the information given to the three (3) residents selected by the Quality Indicator Survey (QIS) for review of the care area: Liability Notices and Beneficiary Appeal. The QIS automatically selects three (3) residents discharged from Medicare services within the last six (6) months to determine if the appropriate denial notice was provided. The SW #102 said he was unable to find any information for two (2) Residents: #8 and #13. The facility's resident financial coordinator, (RFC) #30 said she did not have copies of any notices given to Residents #8 and #13 at 2:20 p.m. on 07/17/17. b) Resident #8 At 2:20 p.m. on 07/17/17, RFC #30 verified Resident #8 was re-admitted to the facility on [DATE] and was covered by Medicare, Part A services. The resident was discharged from Medicare services on 06/13/17 and remained at the facility. c) Resident #13 At 2:20 p.m. on 07/17/17, RFC #30 verified Resident #13 was re-admitted to the facility on [DATE]. The resident was covered by Medicare, Part A services. Resident #13 was discharged from Medicare services on 03/09/17. The resident left the faciity on [DATE]. At 2:31 p.m. on 07/17/17, the administrator said he checked with the therapy department and he was unable to find the notices given to Resident's #8 and #13 for denial of Medicare covered services.",2020-09-01
791,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,166,D,1,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, resident interview, family interview and review of the facility's grievance concern forms, the facility failed to follow up on Resident #119's representative's grievance and concern regarding a particular nurse aide(NA)assigned to care for her legally blind husband. This was true for one(1) of one(1) resident reviewed for the care area of social services. This practice had the potential to affect an isolated number of residents. Resident identifiers: #119. Facility census: 100. Findings include: a) Resident #119 Resident #119's interview during stage one (1) of the Quality Indicator Survey (QIS), on 07/10/17 at 3:48 p.m., revealed the resident has severely impaired vision and was allegedly told by a staff member to go find the bathroom himself when the resident had requested assistance. Resident #119 said he tripped and fell when he went alone to the bathroom and hurt his left hip. The resident who says he is legally blind cannot see well enough to distinguish the nurses from the Nurse Aides (NA), and is not sure who told him to go to the bathroom on his own. The resident said he was not sure who did it and could not recognize staff by their voice. The resident stated the facility had, raised hell because it was not reported, and was trying to find out who it was. He said he was told they would be disciplined. However, Resident #119 could not tell the surveyor who told him they were trying to find out about the incident. Review of a fall report dated 07/02/17, on 07/12/17 at 9:27 a.m., revealed (typed as written), Noted discolored area on left hip; resident asked what happened he stated, I got up trying to use the bathroom myself and tripped. He is unable to state that date or time of incident. He denied any allegations of abuse, denies any feelings of being threatened. Area does not appear suspicious. No abnormality noted; able to move all extremities; no increase in pain noted. Interview with Social Worker (SW# 102), on 07/12/17 at 4:25 p.m., revealed SW #102 was unaware the resident had reported any staff had told the resident to go find the bathroom himself when the resident had requested assistance. SW #102 said the resident's wife, as she was leaving the building one day, asked that a certain NA no longer be assigned to her husband, and mention something about a phone. When asked why the request had been made, SW #102 said he was not sure and would have to look at the concern and comment report he completed. A copy of the report was requested. Review of Employee concern and comment report dated 07/03/17, on 07/12/17 at 4:35 p.m., revealed Resident's Guardian identified a NA that she no longer wished to be assigned to care for Resident #119. The NA was removed off Resident #119's assignment as requested. There was no other documentation as to why or what might have caused the request to be made, or any follow up regarding the request. On 07/13/17 at 9:52 a.m., a phone interview with Resident #119's wife (MPOA)and this surveyor was conducted. When asked why she had requested a certain NA no longer be assigned to her husband, she replied, Because the NA had told her husband to find the bathroom on his own. She stated the NA said, Find it on his damn own. My husband is legally blind, he fell while trying to go to the bathroom on his own and got a nasty bruise on his hip. When asked if she had told anyone at the facility, she said she discussed it with SW #102 and told him why she did not want the NA to be assigned her husband. On 07/13/17 at 10:01a.m., review of records revealed MPOA was notified, after a nurse discovered the bruise on the resident's hip, on 07/02/17. Neuro checks were completed for the resident. A phone conference was conducted, on 07/13/17 at 10:27 a.m., with the Administrator, SW #102, Surveyor # , this surveyor, and the resident's wife (guardian/Medical Power of Attorney. The wife said she visited her husband on 07/03/17 and spoke with SW #102 and told him about the NA's actions and about some missing items. The wife was assured by the administrator it would be investigated. After the phone call SW #102 said, the NA was moved from the assignment because the wife did request it, but not because any of what the wife had just said on the phone. SW #102 stated it was the first he had heard of the wife's concerns and issues. The administrator stated he was unaware that any of this had occurred, he stated he knew the resident did have auditory hallucinations because he had been in the room with the resident when he has had them. He also stated that if a resident or family member requested a NA not be assigned to them they tried to accommodate them. SW #102 agreed with the administrator they try to accommodate the request. When asked how the facility would know why the request was made, or if there were any issues concerning the care or treatment of [REDACTED]. SW #102 stated, I will investigate it today as an unknown. Review of records, on 07/13/17 at 11:53 a.m., of the last quarterly minimum data set (MDS) with an assessment reference date of 06/15/17, revealed the following. Resident #119 has a Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 10, indicating resident is moderately impaired. The resident usually is understood and usually can understand others. Resident #119 has severely impaired vision with corrective lenses. The resident needs extensive assist for activities of daily living(ADLs), and is not steady but able to stabilize his self with staff assistance, with range of motion he has an impairment on one side of his lower extremity. Resident #119 is frequently incontinent of bladder and bowel and is on a training program. The resident is on scheduled pain medication, insulin injections, antipsychotic, antianxiety, and antidepressant medications. Pertinent [DIAGNOSES REDACTED]. The medical record also revealed the resident had episodes of auditory hallucinations.",2020-09-01
792,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,241,D,1,1,HITB11,"> Based on observation and staff interview the facility failed to ensure that Resident #30 had a dignified dining experience during the breakfast meal on 07/11/17. This was a random opportunity for discovery. This failed practice had the potential to affect an isolated number of residents. Resident Identifier: #30. Facility Census: 100. Findings include: a) Resident #30 At 8:37 a.m. on 07/11/17, during a Stage 1 resident observation Resident #30 was observed being fed by Nurse Aide (NA) # 24. While feeding Resident #30 NA #24 was standing up causing the resident to have to look up at him. An interview with Licensed Practical Nurse (LPN) #85 at 8:40 a.m. on 07/11/17 confirmed NA #24 was standing up while feeding Resident #30. She confirmed the NA should be seated while feeding the resident. She went into the room and advised NA #24 that he needed to sit down while feeding Resident #30.",2020-09-01
793,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,272,D,0,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident review and record review, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were accurate and complete for five (5) of 22 resident's whose MDS assessments were reviewed during Stage 2 of the Quality Indicator Survey (QIS). MDS assessments for Resident's #53, #38, and #119 were inaccurate in the care area of oral/dental status. MDS assessments for Resident #15 was inaccurate in the care area of ulcers, wounds and skin problems. MDS assessments for Resident #47 was inaccurate in the care area of diagnosis. Resident identifiers: #38, #53, #119, #15, and #47. Facility census: 100. Findings include: a) Resident #38 Observation of the resident during Stage 1 of the Quality Indicator Survey (QIS) at 4:04 p.m. on 07/10/17, found the resident had no natural teeth. The resident said she did not have and did not want any dentures. Review of the resident's admission MDS, with an assessment reference date (ARD) of 05/01/17 at 2:00 p.m. on 07/11/17, found section (L), entitled oral/dental status, did not code the resident as having no natural teeth. During an interview with the resident's unit manager, Registered Nurse (RN), at 2:59 p.m. on 07/11/2017, she verified the resident did not have any natural teeth. She said she thought the resident had dentures but her sister took them home with her. The resident's sister was interviewed at 3:59 p.m. on 07/10/17, during Stage 1 of the Quality Indicator Survey (QIS) as a family interview. The sister had previously verified the resident did not have any dentures and did not want any during the telephone interview. Registered Nurse (RN) #27, the MDS Coordinator, said she did not know if the resident had any natural teeth or not. She was asked to observe the resident's oral cavity at 3:16 p.m. on 07/11/17. After observation, RN #27 confirmed Resident #53 had no natural teeth and she further confirmed the MDS should have been coded, no natural teeth or tooth fragments (edentulous). At 3:45 p.m. on 07/11/17, the Director of Nursing (DON) was advised of the above deficient practice. She had no further information to provide. b) Resident #53 An interview with the Resident during Stage 1 of the QIS, at 07/10/17 at 12:30 p.m., revealed the resident had an upper denture and no natural teeth. She said she lost her bottom denture before coming to the nursing home. Review of the admission admission MDS with an ARD of 10/21/17, found the facility did not code the resident's dental status correctly. At 11:19 a.m. on 07/17/17, RN #27 confirmed the admission MDS was not coded correctly. She stated she should have checked box B-noting the resident had no natural teeth or tooth fragments (edentulous). c) Resident #119 During Stage 1 of the Quality Indicator Survey (QIS), on 07/10/17 at 04:01 p.m., observations and interview with Resident #119 revealed he had no natural teeth, and he said he had been edentulous for years. On 07/17/17 at 2:51 p.m., interview with Registered Nurse (RN) and review of the admission nursing evaluation, dated 03/13/15, revealed Resident #119 has denture but the wife said kept the dentures at home because the resident did not like to wear them. Review of records, on 07/18/17 9:26 a.m., of the annual Minimum Data Set (MDS) with an Assessment Reference Date of 12/27/16, revealed the dental status section is marked No as a response to no natural teeth when it should have been marked Yes to reflect, the resident had no natural teeth. On 07/18/17 at 9:18 a.m., an interview with Nurse Aide (NA #29) revealed NA #29 provided oral care for resident since he was admitted . The NA stated the resident had no natural teeth and does not wear dentures, and had no dentures in his room. The NA stated the resident told her his wife had his dentures at home. Interview with the MDS Coordinator RN #27, on 07/18/17 at 10:14 a.m., revealed the MDS Nurse agreed the annual MDS with an ARD 12/27/16, Section L0200b was marked incorrectly, and should have been marked Yes instead of No, indicating, yes, the resident had no natural teeth. d) Resident #15 Observations of Resident #15, on 07/11/17 at 09:32 a.m., revealed the resident had a raw red open area the size of a pea on the bridge of her nose and a smaller scabbed area on the side of her face near her right eye. Interview and review of records with RN #80, on 07/12/17 at 2:59 p.m., revealed RN #80 was not aware of any open or scabbed area on the resident's nose or face, and review of record did not show any treatment was ordered. RN #80 went with surveyor to observe the resident. RN #80 agreed there were open and scabbed areas on the resident's nose and face, and she would let the wound treatment nurse assess. Review of the admission photo taken on 03/10/17 showed the areas were present on admission. On 07/12/17 at 3:13 p.m., review of admission nursing assessment, dated 03/10/17, did not indicate any issues with skin on the resident's nose or face, even though areas are plainly seen on the resident's admission photo. Review of skin assessments dated 03/14/17 and 3/27/17, reviewed on 07/12/17 at 3:17 p.m., identified the area on the resident's nose. On 07/12/17 at 5:22 p.m., review of admission MDS dated [DATE] revealed resident's brief Interview for mental status (BIMS) score was three (3) indicating resident has a severe cognitive impairment. Under section noting skin condition (M1040d.) Open [MEDICAL CONDITION] other than ulcers, rashes, cuts was marked no and should have been marked yes. Interview with RN #44, on 07/19/17 at 10:55 a.m., upon review of Resident #15's admission photo with RN #44, revealed RN #44 agreed the skin area was present at admission and should have been indicated on the admission nursing assessment and admission MDS. e) Resident #47 During a record review, on 07/17/17 at 10:44 a.m., it was discovered the Minimum Data Set (MDS) comprehensive assessment with an assessment reference date (ARD) of 03/26/17, did not include [MEDICAL CONDITION] as a [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. In an interview with the MDS Coordinator, on 07/17/2017 at 11:54 a.m., verified the comprehensive (MDS) assessment for Resident #47, completed on 03/26/17 did not include the [DIAGNOSES REDACTED].",2020-09-01
794,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,278,D,1,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview and observation, the facility failed to ensure the Minimum Data Set (MDS) for two (2) of twenty-two (22) sample residents reviewed during Stage 2 of Quality Indicator Survey (QIS) were accurately completed to represent the resident's status. Resident #88 had inaccurate MDS for the area of pressure ulcers. Resident #82 had an inaccurate MDS for the area of nutrition. Resident identifiers: #88, and #82. Facility Census: 100 Findings include: a) Resident #88 A review of Resident #88's medical record, at 10:00 a.m. on 07/12/17, found a five (5) day MDS with an assessment reference date (ARD) of 05/02/17. The assessment indicated Resident # 88 had one (1) suspected deep tissue injury (SDTI) on left heel. Further review found a weekly skin sweep dated 04/27/16 which read, Left heel area with redness and discoloration with a scab (eschar) to center of area . According to the Resident Assessment Instrument (RAI) manual and the National Pressure Ulcer Advisory Panel (NPUAP) committee the definition of unstageable pressue injury and SDTI as follows: --Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss --Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. --Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. An interview with the MDS nurse, on 07/12/17 at 1:10 p.m., found the MDS with ARD of 05/02/17 was coded in error. She acknowledged it should have been coded as an unstageable - slough and/or eschar due to coverage of the wound bed and present on readmission to the facility. d) Resident #82 Resident #82 had the 04/16/17, 14 day change of therapy Minimum Data Set (MDS) assessment coded as the resident being on a weight loss program. The resident was losing weight due to medical condition and a [DIAGNOSES REDACTED]. The resident was not on a prescribed weight loss regimen. On 07/17/17 at 1:45 p.m., MDS staff confirmed it should not have been coded this way. She confirmed with the dietary manager that this code was in error. Another later quarterly MDS dated [DATE] had the resident as being a weight loss and the resident had supplements and other interventions indicated which would have been accurate.",2020-09-01
795,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,279,D,1,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and staff interviews, the facility failed to develop comprehensive care plans to meet the needs of two (2) of twenty-two (22) Stage 2 residents. The care plan for Resident #151 did not include interventions for [MEDICAL TREATMENT] and the care plan for Resident #161 did not address anticoagulant therapy. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #151 and #161. Facility census: 100. Findings include a) Resident #151 A record review on 07/13/17 revealed the care plan developed on 01/06/17 for Resident #151 did not address interventions for [MEDICAL TREATMENT] for [MEDICAL CONDITION] related to end stage [MEDICAL CONDITIONS]. A review of the current physician's orders [REDACTED]. An interview on 07/13/17 at 11:15 a.m., with Employee #27, registered nurse (RN) agreed the care plan for Resident #151 did not include interventions needed for his [MEDICAL TREATMENT]. b) Resident #161 This [AGE] year-old male, admitted to the facility on [DATE], was reviewed for the care area of unnecessary medication during Stage 2 of the Quality Indicator Survey (QIS). Review on 07/17/17 at 10:15 a.m. of Resident #161's physician orders [REDACTED]. Review of Resident #161's comprehensive care plan initiated on 05/23/17, found no focus, goal or interventions for his use of an anticoagulant medication. When interviewed at 2:15 p.m. on 07/17/17, the Director of Nursing (DON) reviewed the resident's care plan. She confirmed the care did not address his use of an anticoagulant medication.",2020-09-01
796,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,280,D,0,1,HITB11,"Based on record review and staff interview, the facility failed to revise the care plans of two (2) of twenty-two (22) care plans reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #123's care plan was not updated to reflect a decline in activities of daily living (ADL's). Resident #86's care plan was not updated in the care area of accidents. Resident identifiers: #123 and #86. Facility census: 100. Findings include: a) Resident #123 A decline in the residents ADL's was reflected on her last minimum data set (MDS), a quarterly with an assessment reference date (ARD) of 06/20/17 when compared to the previous quarterly MDS with an ARD of 03/20/17. On the 03/20/17 MDS, locomotion on unit: self-performance, was coded as requiring supervision. The most recent MDS, with an ARD of 06/20/17 coded locomotion on the unit as requiring limited assistance. Locomotion off unit: was coded as self-performance, on the 03/20/17 MDS. On the 06/20/17 MDS the activity declined to activity occurred only once or twice - activity did occur but only once or twice. Dressing declined from requiring Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance to Extensive assistance - resident involved in activity, staff provide weight-bearing support. Toilet use declined form requiring Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance to Extensive assistance - resident involved in activity, staff provide weight-bearing support. Review of the resident's current care plan found the problem: --The resident has an ADL self-care performance deficit related to impaired mobility and cognition, dementia, dated 06/10/16. The goal related to this problem was: --The resident will improve current level of function in (bed mobility, transfers, eating, dressing, toilet use and personal hygiene, ADL score through the next review, revised on 04/28/16. At 11:19 a.m. on 07/19/17, the administrator confirmed the care plan was not updated to reflect the current decline in ADL's. b) Resident #86 Review of care plan, on 07/11/17 at 1:30 p.m., revealed a focus Risk of injury related to smoking with the intervention, observe during smoking breaks and alert nursing to any concerns as needed. The facility is a smoke free facility and does not allow smoking on the premises. The care plan needed to be revised to reflect the no smoking policy. The resident was reviewed for accidents hazards as the resident was observed smoking without supervision. Investigation revealed the resident had capacity, had been assessed to be a safe smoker and was allowed to smoke off the facility property. c) Resident #86 Review of care plan, on 07/11/17 at 1:30 p.m., revealed a focus 'Risk of injury related to smoking' with the intervention observe during smoking breaks and alert nursing to any concerns as needed. The facility is a smoke free facility and does not allow smoking on the premises. The care plan needed to be revised to reflect the no smoking policy. The resident was reviewed for accidents hazards as the resident was observed smoking without supervision. Investigation revealed the resident had capacity, had been assessed to be a safe smoker and was allowed to smoke off the facility property.",2020-09-01
807,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2018-08-01,657,D,0,1,68SA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to update a care plan with therapy recommendations. This affected one (Resident #10) of one sampled resident reviewed for therapy. The facility census was 102. Findings included: a) Resident #10 The clinical record was reviewed on 08/01/18 at 7:12 AM. Resident #10 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. A care plan for Resident #10 entitled, resident on a passive range of motion (PROM) program was reviewed on 08/01/18 at 7:15 AM. The care plan revealed an entry dated 07/06/18 noting Resident #10 was on the PROM program for his hips knees and ankles. There was no care plan entry for Resident #10's upper extremities. On 08/01/18 at 7:36 AM, an interview was completed with Occupational Therapist (OT) #221. OT #221 stated Resident #10 was discharged from occupational therapy services on 07/09/18. At discharge, The goal was to have hand splints on an hour a day if he tolerated them. Restorative (nursing aide) was to put the splints on the resident and take them off. On 08/01/18 at 9:42 AM, an interview was completed the Director of Nurses (DON). The DON said following completion of therapy, a resident may be referred to the restorative nursing program. Currently, either the DON or Nurse #18 would review the Therapy to Restorative Evaluation form. She would update the care plan with the new orders. The DON stated on 07/09(18), OT #221 did a Therapy to Restorative Evaluation form that said (Resident #10) should get range of motion to the upper extremities with hand splints. I don't see the order was written and no task was done. It wasn't put on restorative's list of things to complete. We would update the care plan when we write the order. He doesn't have an order, a task and no care plan for the hand splints. .",2020-09-01
808,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2018-08-01,688,D,0,1,68SA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to provide appropriate treatment to maintain range of motion of a resident's hands. This affected one (Resident #10) of one sampled resident reviewed for range of motion. The facility census was 102. Finding include: a) Review of the medical record on 08/01/18 at 7:12 AM revealed Resident #10 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] was reviewed on 08/01/18 at 7:13 AM and noted that Resident #10 had upper extremity limitations on both sides. Resident #10 was also noted to have both short and long-term memory problems and severely impaired decision-making. Resident #10 was totally dependent upon one to two staff members for all activities of daily living. The care plan entitled, resident on a passive range of motion (PROM) was reviewed on 08/01/18 at 7:15 AM. An entry dated 07/06/18 noted Resident #10 was on the PROM program (passive range of motion) for his hips knees and ankles. There was no care plan entry for Resident #10's upper extremities. An interview was completed with Occupational Therapist (OT) #221 on 08/01/18 at 7:36 AM. OT #221 reported she had worked with Resident #10. She stated Resident #10 started to have movement of the left arm and We ended up splinting both hands. We could get those on. She stated, We discharged him to restorative to continue range of motion. She stated Resident #10 was discharged (from OT) on 07/09(18). The goal was to have hand splints on an hour a day if he tolerated them. Restorative (nurse aide) put the splints on and took them off. An observation of Resident #10 was completed on 08/01/18 at 8:12 AM. Resident #10 did not have hand splints in place. His fingers were partially flexed and closed approximately half way. On 08/01/18 at 8:31 AM, an interview was completed with Restorative Aide (RA) #5. RA #5 reported she was familiar with Resident #10. I've been working with him about 3 weeks. Right now, we are working on his lower extremities. We were doing upper body, arms, range of motions. He had hand splints. We (restorative aides) were doing the splints. The (floor) aides (nursing assistants) do that now. On 08/01/18 at 8:39 AM, an interview was completed with Nursing Assistant (NA) #34. NA #34 stated she was familiar with Resident #10. I work with his legs, help him stretch some; and his arms, move his arms, (demonstrated abducting and adducting) the shoulders and stretching his fingers. That's about all I do with his arms. Restorative puts splints on his legs and his arms, I don't do that. He has arm splints that go from his elbows down to his hands. A follow up observation of Resident #10 was completed on 08/01/18 at 9:11 AM. Resident #10 was noted to have leg braces on. No hand splints were observed. An interview was completed with Nurse #71 on 08/01/18 at 9:22 AM. Nurse #71 was identified as the unit manager for Resident #10. Nurse #71 said residents were referred to the restorative aide program by therapy staff. She stated residents would be re-evaluated on a schedule that she was not sure of, and a decision would be made on continuing restorative services. She also noted that if a resident had reached their maximum potential, they would be discharged from restorative and I assume we would stop any splints. After reviewing the record of Resident #10, Nurse #71 stated Resident #10 was getting range of motion and splints to his legs, but not to the upper extremities. On 08/01/18 at 9:42 AM, an interview was completed with the Director of Nurses (DON). The DON said, therapy may refer a resident to restorative nursing when therapy is done. We put them on a 4-6 week restorative program and then we re-evaluate. At that time, we may refer them back to therapy, or we may extend the program or do a management program and have the floor nursing assistants pick that (range of motion or splints) up having the floor nurse monitoring. On 07/09(18), (OT #221) did a therapy to restorative evaluation. It said the resident (#10) should get range of motion (ROM) to upper extremities with hand splints. When therapy does the evaluation, it goes into the computer and I (DON) see it under Progress Evaluations. I would write the physician's orders [REDACTED]. For the 07/09(18) referral, I don't see the order was written and no task was done. It wasn't put on restorative's list of things to complete. We would update the care plan when we write the order. He doesn't have an order, a task and no updated care plan for the hand splints. The hand splints would have been hand rolls just in his palms (to prevent contractures of the fingers).",2020-09-01
810,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,637,D,0,1,QLU411,"**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 Minimum Data Set (MDS) when Resident #100 elected to participate in a Hospice program. This was true for one (1) of one (1) residents reviewed for the care area of death. Resident identifier: #100. Facility census: 101. Findings included: a) Resident #100 Review of Resident #100's medical records found a Hospice referral and her acceptance into the program on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident #100's MDS and found no significant change MDS after the date of admission ([DATE]), to the Hospice Program. Resident #100 expired on [DATE]. Review of the Resident Assessment Instrument (RAI) and Surveyor's interpretative guidelines reads: A Significant Change in Status MDS is required when: A resident enrolls in a hospice program . Interview with the Director of Nursing (DON) and Employee #8, Registered Nurse (RN), MDS coordinator on [DATE] at 5:58 PM, she verified Resident #100 should have had a significant change MDS done within 14 days of her election to participate in a hospice program. The DON further verified the significant change MDS was not completed timely.",2020-09-01
811,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,641,D,0,1,QLU411,"Based on record review and staff interview, the facility failed to ensure Resident #82's quarterly Minimum Data Set (MDS) was accurately coded to reflect his refusals of care. The facility also failed to ensure Resident #85's weights were accurately recorded on his MDS. This was true for two (2) of 23 sampled residents. Resident identifier: #82 and #85. Facility census: 101. Findings included: a) Resident #82 A review of Resident's #82 medical record found a quarterly MDS with an assessment reference date (ARD) of 06/13/19 found under section E0800. Rejection of Care - Presence and Frequency was coded 0. Behavior not exhibited. A review of Resident #82's Activities of Daily Living (ADL) flow sheet for the MDS look back period of 06/07/19 until 06/13/19 found on 06/08/19 Resident #82 refused a shower. This was not accurately captured on the Quarterly MDS with an ARD of 06/13/19. An interview with Social Worker on 08/20/19 at 1:30 p.m. on 08/20/19 confirmed this MDS was inaccurately coded. He stated that he would look at the residents paperwork and get back to me if he found anything else. b) Resident #85 On 08/19/19 at 2:56 PM, a review of Resident #85's weight records found that Resident #85 had experienced numerous weight changes over an extended period of time. On 08/20/19 at 4:21 PM, Resident #85's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/20/19 was reviewed. Section K (nutritional status) of the 06/20/19 MDS indicated that Resident #85 weighed 95 pounds. However, Resident #85's weight records indicated that Resident #85's most recent weight on the ARD of the assessment was 82.4 pounds (82 pounds when rounded per section K instructions). On 08/20/19 at 4:26 PM, Resident #85's quarterly MDS with an ARD of 03/20/19 was reviewed. Section K of the 03/20/19 MDS indicated that Resident #85 weighed 91 pounds. However, Resident #85's weight records indicated that Resident #85's most recent weight on the ARD of the assessment was 88.4 pounds (88 pounds when rounded per section K instructions). On 08/20/19 at 4:28 PM, Resident #85's annual MDS with an ARD of 11/21/18 was reviewed. Section K of the 11/21/18 MDS indicated that Resident #85 weighed 88 pounds. However, Resident #85's weight records indicated that Resident #85's most recent weight on the ARD of the assessment was 89.5 pounds (90 pounds when rounded per section K instructions). During an interview on 08/20/19 at 4:48 PM, the facility's Certified Dietary Manager (CDM) acknowledged that she had incorrectly coded Resident #85's weight on each of the above assessments. She stated, I used the most recent weight, but added that she had mistakenly used the weight closest to when she had completed the assessment and not the weight closest to the ARD for each assessment. The above information was discussed with the facility's Administrator on 08/20/19 at 5:36 PM. No further information was provided prior to exit.",2020-09-01
814,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,677,D,0,1,QLU411,"Based on record review and staff interview, the facility failed to ensure a dependent resident, Resident #7, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADLs) during the long term care survey process. Resident identifier: #7. Facility census: 101. Findings included: a) Resident #7 During observations of Resident #7 on 08/19/19 at 1:56 p.m. found Resident #7 was not recently shaved. A review of Resident #7's medical record on 8/20/19 at 8:47 a.m. found Resident #7 was scheduled to receive a shower twice weekly on Mondays and Thursdays. A review of his ADL flow sheets from 06/01/19 through present found Resident #7 only received a shower on the following dates: -- 06/04/19 -- 06/07/19 -- 06/11/19 -- 06/13/19 -- 06/21/19 -- 07/05/19 -- 07/16/19 -- 07/19/19 -- 08/02/19 -- 08/06/19 -- 08/15/19 Resident #7 received 11 showers out of a total of 22 possible showers. On 08/20/19 at 1:25 p.m. the Director of Nursing (DON) was interviewed in regards to Resident #7's showers. She stated she would check in the medical records and see if they had any other documentation in regards to Resident #7's showers. An additional interview with the DON at 2:38 p.m. on 08/20/19 she confirmed no other documentation was available, other than the ADL flow sheets, to prove Resident #7 received a shower. She stated the nurses shampoo his hair every Monday and Thursday related to his psoriasis. She did confirm they did not give him a full shower it was just a shampoo of his hair.",2020-09-01
815,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,679,D,0,1,QLU411,"Based on record review, resident interview, resident observation and staff interview, the facility failed to implement an ongoing resident centered activity program for Resident #86. This was true for one (1) of one (1) residents reviewed for the care area of activities. Resident identifier: #86. Facility census: 101. Findings included: a) Resident #86 During an interview, on 08/19/19 at 11:50 AM, Resident #86 was asked if he participated in activities. Resident #86 informed the surveyor he did not go to activities because he did not like to only participate in church and bingo. Resident #86 indicted he enjoyed going outside and would participate in those activities. Resident #86 was unaware the facility had any outdoor activities other than a cookout he attended in (MONTH) of 2019. Resident #86 noted he did go outside with his wife when she came to visit. In addition, Resident #86 stated he does not go on shopping outings, but would enjoy going to shopping outings to window shop. Resident #86 states that his wife will shop for items he wants at times and bring them to him when she visits. Resident #86's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/03/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates the resident is cognitively intact and had capacity. A record review of Resident #86's activities participation log from 07/22/19 to 08/20/19 noted the resident had not participated in any outdoor activities. There was no indication he was invited to outdoor activities and he refused. Review of Residents #86's care plan found a focus/problem: --[NAME] prefers to stay in his room but will attend activities of his choice. The goal associated with this problem: --Resident will remain self directed in his room and encouraged to attend OOR activities thru next review. Interventions included: --Calendar provided and displayed in his room with upcoming events --Family will visit often --Invite and encourage to attend --[NAME] enjoys listening to music and being outside On 08/20/19 at 11:02 AM, the surveyor spoke with Employee #49, Activity Director (AD). The surveyor asked Employee #49 what activities were outside. The surveyor was provided a copy of the activity calendar for the month of (MONTH) and August. Employee #49 stated that anything occurring at the gazebo is outside, such as bubble mania, patio pals, popsicles on the gazebo, and the ice cream social; however, the activity calendar did not indicate the location of all the outdoor activities. The calendar did not indicate bubble mania, patio pals, etc. was being held on the gazebo. AD #49 was unable to provide any evidence the resident was aware of or invited to any outdoor activities. AD #49 said she doesn't keep record of activities the resident was invited to and refused. We need to do a better job with that. AD #49 said the facility does go on shopping trips, but Resident #86 was never invited because his wife goes shopping for him and brings in the items he wants. On 08/20/19 at 12:24 PM , Resident #86 was sitting in his room after his lunchtime meal. This surveyor asked Resident #86 if he had participated in any activities the evening of 08/19/19 or any in the day on 08/20/19. Resident #86 stated that he had been out of his room other than for therapy during this timeframe. Resident #86 stated to this surveyor that he would be interested in going to outdoor activities when the staff invited him to come to them. The Administrator and Director of Nursing (DON) were informed of the findings on 08/20/19 at 11:58 AM.",2020-09-01
817,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,687,D,0,1,QLU411,"Based on record review, family interview, resident interview, resident observation and staff interview, the facility failed to ensure Resident #76 received proper treatment and care to maintain mobility and good foot health, in accordance with professional standards of practice. This was true for one (1) of five (5) residents reviewed for the care area of Activities of Daily Living (ADL) during the long term care survey process. Resident identifier: #76. Facility census: 101. Findings include: a) Resident #76 An interview with Resident #76 and her responsible party at 1:51 PM on 08/19/19, revealed Resident #76 had long thick toe nails and needed to see a podiatrist. The responsible party indicated they have been asking them to get her to a podiatrist to get her toe nails trimmed. She stated they are starting to curl under. A review of Resident #76's medical record at 8:54 AM on 8/20/19 found a form titled, Podiatry Informed Consent to Treat. This form indicated Resident #76 was requesting podiatry services for the following complaints, Toe Nails are long thick and painful and can't be cut with ordinary equipment by self or others. This form was completed on 05/07/19 which was Resident #76's date of admission. An interview with Registered Nurse (RN) #114 the wound care nurse at 9:15 AM on 08/20/19 found the podiatrist was last at the facility on 04/19/19 and then he resigned and they have not found a replacement for him yet she said that there is podiatrist here in town that they can send residents if a need arises. She stated Licensed Practical Nurse (LPN) #5 would know more about Resident #76 because he does the wound care on that side of the facility. An observation with LPN #5 of Resident #76 at 9:16 AM on 08/20/19 found the resident had long toenails that were starting to curl under her toes. He agreed the resident needed to be seen by the podiatrist. The resident stated that her toe nails are sore some times and they hurt. When LPN #5 asked what her pain level was on a scale from one (1) to ten (10) the resident stated her pain would be a two (2). An additional interview with LPN #5 at 10:43 AM on 08/20/19 confirmed he set up an appointment with a local podiatrist on 08/27/19 on 1:15 PM. LPN #5 stated he called and got this appointment today and the resident will be seen by the podiatrist on that date. An interview with the Nursing Home Administrator (NHA) on 08/21/19 at 12:00 PM confirmed they knew the residents toe nails were long but they did not know that they were causing her discomfort. He stated that the first we heard of her toe nails causing her discomfort was when LPN #5 was in the room with the surveyor observing her toenails. He stated we have now got her an appointment.",2020-09-01
818,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,692,D,0,1,QLU411,"Based on medical record review and staff interview, the facility failed to assess Resident #46's nutritional needs. This deficient practice was found for one (1) of four (4) residents reviewed for the care area of nutrition. Resident identifier: #46. Facility census: 101. Findings included: a) Resident #46 Record review during the survey found Resident #46 had recently experienced weight loss and was receiving tube feedings as his sole source of nutrition due to an NPO (nothing by mouth) diet order. All documentation from the facility's Registered Dietitian (RD) for the past six (6) months regarding Resident #46's nutritional needs was requested from the facility and provided on 08/21/19 at 10:45 AM. Upon review, Nutrition Assessment's written by the facility's RD were included in the requested information. The most recent two (2) assessments had been signed by the RD on 07/07/19 and 08/10/19, respectively. The 07/07/19 assessment included information regarding the calories, protein, and free water Resident #46's tube feeding regimen provided, but the section labeled, Calculation of Estimated Daily Needs was left entirely blank. The 08/10/19 assessment included neither information regarding the calories, protein, and free water provided by Resident #46's tube feeding regimen nor a calculation of Resident #46's estimated daily needs. During a phone interview on 08/21/19 at 11:27 AM, the facility's RD stated, He's getting a tube feeding, so we know his needs are being met. When asked if she had assessed Resident #46's estimated nutritional needs, she stated, Of course I did. When asked where the calculations were, the RD stated, That's weird that I didn't put that in there. I almost always do. I must have overlooked it. She added, I would have had to have wrote it down. It could have been on a scrap piece of paper. Then she stated, I think I just probably scrolled down to type my note and didn't scroll back up to put it in. At the end of the conversation, the RD stated that she would create addendums to the 07/07/19 and 08/10/19 nutrition assessments to address Resident #46's estimated nutritional needs. On 08/21/19 at 12:07 PM, the above information was discussed with the facility's Administrator. He stated, Thank you.",2020-09-01
819,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,695,D,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the oxygen flow rate was administered as ordered. This was a random opportunity of discovery. Resident identifier: #14. Facility census: 101. Findings included: a) Resident # 14 On 08/19/19 at 11:56 AM, Resident # 14 was in the bed with oxygen concentrator running. The Nasal Cannula was on the floor and the flow rate was set on three (3) liters/per minute. Review of records revealed Resident # 14 had an order for [REDACTED].>--May have oxygen at 2.0 liters/per minute nasal cannula as needed for shortness of breath or chest pain. Dated: 9/18/2018. On 08/20/19 at 1:32 PM, Nurse Aide #111 was in room feeding Resident #14 ice cream. She was asked to provide the rate the oxygen was being delivered. She stated it was set on three (3) liters/per minute. On 08/20/19 at 1:34 PM, Licensed Practical Nurse #122 was asked to witness what the oxygen concentrator was set on. She said, that the flow rate was at three (3) liters/per minute. She was informed that the ordered amount to be delivered was two (2) liters/per minute. She stated, that she will turn it down and let her nurse know. During an interview on 08/20/19 at 1:36 PM, Administrator was informed of findings. He stated that he would talk to the staff about that.",2020-09-01
820,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,758,D,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each residents medication regimen was free from unnecessary [MEDICAL CONDITION] medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident #64's medication regimen contained two (2) duplicate [MEDICAL CONDITION] ([MEDICATION NAME] and [MEDICATION NAME]) medication without a documented rational to continue. Resident identifier: #64. Facility census: 101. Findings included: a) Resident #64 Review of Resident #64's medical records found the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #64's medication regimen found on admission the resident was ordered [MEDICATION NAME] 25 mg at night for treatment of [REDACTED]. On 05/31/19, the consultant pharmacist requested for the physician to evaluate the use of duplicate medication of [MEDICATION NAME] and [MEDICATION NAME]. On 06/05/19, the physician responded the consultant pharmacist request as follows: See above. continue Rx (medication). Written in a different handwriting above read: [MEDICATION NAME] 25 mg at night. [MEDICATION NAME] 0.5 mg at night. Behaviors and anxiety approved. On 06/12/19, the psychologist seen Resident #64 in the facility. No mention of what [MEDICAL CONDITION] medications ordered. Written by psychiatrist, continue current [MEDICAL CONDITION] medications. Interview with the Director of Nursing on 08/20/19 at 2:10 pm. Review of Resident #64's medical records could find no rational as to why the resident was receiving duplicate therapy ([MEDICATION NAME] and [MEDICATION NAME]). No further information provided.",2020-09-01
821,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,791,D,0,1,QLU411,"Based on resident interview, observation, record review and staff interview, the facility failed to arrange and/or make an appointment for one (1) of three (3) residents reviewed for dental services. Resident identifier: #23. Facility census: 101. Findings included: a) Resident #23 During an interview on 08/19/19 at 12:14 PM, Resident # 23 pointed out she had no original teeth on the bottom with dentures on the top and bottom. She went on to say, that last month the last real tooth on the bottom started hurting and the dentist pulled it. She reported, that the dentist told her that when she came back in one week, he would re-insert her dentures. She stated, that she has been eating pureed food, which she is not that happy about. She went on to say, that she was wondering how much longer she was going to have to wait. A review of medical records revealed a nursing note dated 07/30/19 at 12:08 PM: --Resident had tooth #22 extracted by dentist on 07/30/19 --Follow up orders for no drinking through straw for 4 days, and to leave gauze pressure pack in place for 1 hour. --Return to dentist in 1 week to re-insert denture. During an interview with Unit Manager #16 on 08/20/19 at 9:38 AM, was asked if there was an appointment made for Resident # 23 after 07/30/19. She was looking in the electronic chart for follow up appointment for Resident # 23 and was unable to find one. She referred me to Laundry Aide/Driver #40. She stated, she is the person who takes the residents for appointments and makes the appointments. During an interview on 08/20/19 at 9:55 AM, Laundry Aide/Driver #40 was asked if Resident #23 had a follow-up appointment with the dentist. She stated, she did not make a follow up appointment, Because the nurses did not put it in so it would kick back. She was asked if that meant that there was a failure to communicate? She said, yes I think so. She went on to say she would make the appointment today. During an interview on 08/20/19 at 10:58 AM, Administrator was informed about the findings regarding Resident #23. He stated, that he will look into it right now.",2020-09-01
822,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,805,D,0,1,QLU411,"Based on test trays and staff interview, the facility failed to serve food of the correct texture to residents receiving a pureed diet. This deficient practice was found during a random opportunity for discovery and had the potential to affect an isolated number of residents. Facility census: 101. Findings included: a) Pureed Test Tray On 08/20/19 at 1:09 PM, a pureed lunch tray containing turkey, mashed potatoes, and peas was tested by surveyors. The pureed peas were found to contain tough skins that had not been fully processed to a smooth texture. On 08/20/19 at 1:12 PM, the facility's Certified Dietary Manager (CDM) tasted the pureed peas and agreed that they were not the appropriate texture. The CDM stated that kitchen staff did not cook the peas long enough before pureeing them. The above findings were discussed with the facility's Administrator on 08/20/19 at 3:41 PM. No further information was provided prior to exit.",2020-09-01
823,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,806,D,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, sureyor observations and staff interview, the facility failed to provide food that accomodates the resident's preference for one (1) resident. This was a random opportunity for discovery. Resident identifier: #86. Facility census: 101. Findings included: a) Resident #86 During the initial interview, on 08/19/19 at 11:50 AM Resident #86 stated that he did not like peas and garlic and the facilty kept sending him items that he did not like on his mealtime tray. Resident #86 further stated that the staff set that[***]on my plate everyday and I don't eat. I just leave that on my tray and send it back. Resident #86's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/03/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 13. A BIMS score of 13 indicates that the resident is cognitively intact and has capacity. On 08/20/19 at 09:17 AM this surveyor spoke with Employee #87 regarding Resident #86's likes and dislikes. Employee #87, the dietary manager (DM) provided a copy of Resident #86's tray card. The tray card did not indicate any likes or dislikes. This surveyor asked DM #86 to accompany this surveyor to Resident #86's room to note resident's meal preferences. Employee #87 obtained her assessment tool. On 08/20/19 at 09:19 AM, Employee #87 interviewed Resident #86 with surveyor present. Employee #87 asked Resident #86 his preferences for meals, vegetables, and various beverages. Resident #86 indicated his likes and dislikes of various items. Resident #86 indicated that he did not like the following food and beverage items including but not limited to garlic, broccoli, peas, asparagus, cauliflower, tomato juice, and V8 juice. On 08/20/19 at 11:58 AM, the above issues were discussed with both the Adminsitrator as well as the Director of Nursing (DON) of findings for resident preferences. On 08/20/19 at 12:20 PM, the Adminsitrator provided a dietary screen for Resident #86 that was completed on 04/02/19. This screen states under likes and dislikes that tray card system was updated. The assessment does not state whether Resident #86 had any likes or dislikes. Furthur review of Resident #86's tray card system found no likes or dislikes were present on the current tray card.",2020-09-01
825,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2019-08-21,842,D,0,1,QLU411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #5 and Resident #9's medical record was complete and accurate. Resident #5 had a low blood sugar on 07/22/19. The Blood sugar was documented as three (3) different values in different sections of the medical record. Also on 07/22/19 Resident #5 received two (2) doses of [MEDICATION NAME] but only one (1) dose was documented on the medication administration record (MAR). For Resident #9 the resident did not include the correct [DIAGNOSES REDACTED]. This was true for two (2) of 23 sampled residents. Resident identifier: #5 and 9. Facility census: 101. Findings included: a) Resident #5 A review of Resident #5 medical record on 08/20/19 at 11:03 a.m. found the following nursing notes: -- 07/22/19 at 10:47 a.m. [MEDICATION NAME] Emergency Inject 1 vial intramuscularly as needed for [DIAGNOSES REDACTED] related to Type 2 diabetes mellitus without complications. Resident showed 30 blood glucose level during 11:00 accu check. [MEDICATION NAME] was administered to left deltoid. Resident BGL (blood glucose level) showed 55 approximately 15 minutes later. Second Dose of [MEDICATION NAME] was administered to the right deltoid. BGL showed 78 approximately 10 minutes later. This note was written by Liscensed Practical Nurse (LPN) #65. -- 07/22/19 6:03 p.m.Situation: During AM accu check resident found to be unresponsive to tactile stimuli. BS (blood sugar) 34, administered [MEDICATION NAME] 1 MG (milligram) IM (intramuscularly) right deltoid. Re check of BS after 10 minutes, reading 55. Not responding to tactile stimuli. Administered second dose of [MEDICATION NAME] 1 mg IM left Deltoid. Within 10 minutes (First Name of Resident #5) was opening eyes and verbally communicating, mild shaking of hands noted. HOB (head of bed) elevated 45 degrees angle. Fresh water given. Tolerated well. RR (Respiration Rate) 16, unlabored. States I feel funny. Becoming more alert with AM care. This note was written by Registered Nurse (RN) #143. Review of the Medication Administration Record (MAR) found Resident #5 received a dose of [MEDICATION NAME] Emergency IM. Resident #5's BS was documented as 33 and the site of administration was documented as the Left Shoulder. There was no documentation on the MAR to indicate Resident #5 received the second dose of [MEDICATION NAME] that was mentioned in both nurses notes regarding Resident #5's hypoglycemic episode. It should be noted Resident #5's blood sugar was documented at 30, 33, 34 all referring to the same Blood Sugar reading. An interview with the Director of Nursing (DON) at 1:05 p.m. on 08/20/19 confirmed the errors in documentation of the Blood Sugar level and confirmed the second dose of [MEDICATION NAME] was not documented on the MAR and should have been. b) Resident #9 A review of Resident #9's medical record on 08/20/19 at 03:06 PM, found a physician order [REDACTED]. Give 1 tablet by mouth at bedtime related to major [MEDICAL CONDITION], single episode, unspecified. A review of Resident #9's medical record discovered a dietary note dated 01/26/19. Resident #9 was noted to have a weight loss of 11.5 pounds, totaling an 8% weight loss, over the past 3 weeks. A review of the medical record reveled the following notes: -- Weight warning note dated 02/04/19. The note stated [NAME] continues on weekly weights due to weight loss. Her weight is gradually stabilizing. She remains about IBW (ideal body weight). She continues on RNS (Restorative Nursing Services) Dining and is doing well. She is on Nutritional supplements BID (two times a day), multivitamin Q (every) day, and [MEDICATION NAME] Q hs (at bedtime) for appetite stimulant. RD (Registered Dietician) and doctor aware, continue current P[NAME] (plan of care). On 08/20/19 at 05:09 PM, the Director of Nursing (DON), stated [MEDICATION NAME] was ordered for weight loss as an appetite stimulant and referred to the weight meeting note dated 02/04/19. The DON stated that the [MEDICATION NAME] 15 mg was for an appetite stimulant and not for a [MEDICAL CONDITION]. On 08/21/19 at 08:20 AM, spoke with the Administrator regarding the findings of Resident #9's physician order [REDACTED].",2020-09-01
827,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,154,D,0,1,ZQ9211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review it was determined the facility failed to ensure two (2) of five (5) residents reviewed for unnecessary medications who received psychoactive medications were informed of the risks and benefits of psychoactive medications. Failure to provide residents and/or the legal representative information regarding psychoactive medications placed the residents at risk to not be fully informed about their care and potential alternate treatment options. Resident identifiers: #35 and #113. Facility census: 85. Findings include: a) Resident #35 Review of physician orders, on 03/21/17 at 10:15 a.m., revealed Resident #35 received the anti-psychotic medication, [MEDICATION NAME], and the anti-depressant medication, [MEDICATION NAME], daily since 09/09/16. On 03/21/17 at 10:25 a.m., review of the Minimum Data Set (MDS) with an Assessment Reference Date of 02/04/17 revealed the resident had moderately impaired cognitive skills. In an interview, on 03/21/17 at 11:35 a.m., Resident #35 was unable to state any of the medications she received nor what she took them for. Review of the resident's record, on 03/21/17 at 10:43 a.m., revealed a paper form entitled Psychotherapeutic Medication Administration Disclosure. The form included different classifications of psychoactive medications, their benefits, adverse reactions and special concerns for staff to select based on the resident's assessed care needs. While someone had circled the anti-psychotic medication [MEDICATION NAME], the form failed to identify the anti-depressant [MEDICATION NAME]. There were no signatures from the resident, the resident's representative, or facility staff, nor was there any indication verbal consent was obtained. There was no date on the form. In an interview, on 03/21/17 at 2:25 p.m., the Assistant Director of Nursing (ADON) #79 stated the hard copy of the Medication Administration Disclosure should be in the chart under the consent tab. She explained this was the facility's evidence the resident, or their representative, was informed about the use of the medication and it's risks and benefits. She reviewed the record, determined the only copy in it was blank, and stated she would check the thinned chart. She explained the admitting nurse, or the nurse who obtained the physician's orders [REDACTED]. At 2:35 p.m. ADON #79 returned and stated she reviewed the thinned chart and progress notes and was unable to locate any indication the resident or the resident's representative had been provided information regarding the use of, including risks and benefits, of the [MEDICAL CONDITION] medications. b) Resident #113 Review of physician orders, on 03/21/17 at 1:35 p.m., revealed Resident #113 received the anti-depressant [MEDICATION NAME], since 05/04/16. The orders also indicated the resident received the anti-psychotic medication [MEDICATION NAME], since 05/03/16, with a decrease in dose on 12/14/16 and an increase back to the original dose on 12/19/16. Review of the MDS with an ARD of 03/07/17, on 03/21/17 at 2:00 p.m., revealed the resident had severely impaired cognitive skills. In an interview, on 03/21/17 at 11:35 a.m., Resident #113 was unable to state any of the medications she received nor was she able to report what she took them for. Review of the resident's record, on 03/21/17 at 2:15 p.m., revealed a blank Psychotherapeutic Medication Administration Disclosure. The form had the resident's name written on it, but did not identify the classification of the medications, the benefits, adverse reactions or special concerns related to these medications. The form did not indicate whether the resident, or the resident's representative, had been provided this information. In an interview on 03/21/17 at 2:25 p.m., the ADON #79 reviewed the record and determined the only copy in it was blank. She stated, Well, she is a ward of the state, so. When asked if that meant the facility would not provide information about the medication to the resident's representative, she said, Well, no. She then stated she would check the resident's thinned record. At 2:35 p.m., she returned and stated she was unable to locate any indication the resident's representative had been provided information regarding the risks and benefits of the [MEDICAL CONDITION] medications.",2020-09-01
829,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,309,D,0,1,ZQ9211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure one (1) of three (3) residents reviewed for unnecessary medications who received the correct dosage of sliding scale insulin according to physician's orders [REDACTED]. Resident identifier: #113. Facility census: 85. Findings include: a) Resident #113 Physician orders, reviewed on 03/21/17 at 1:35 p.m., revealed an order for [REDACTED]. --Blood sugar of 0 - 150 = 0 units of insulin --Blood sugar of 151 - 200 = 2 units of insulin --Blood sugar of 201 - 250 = 4 units of insulin --Blood sugar of 251 - 300 = 6 units of insulin The (MONTH) (YEAR) Medication Administration Record (MAR), reviewed on 03/22/17 at 9:15 a.m., revealed staff administered an inaccurate dose of insulin on the following dates: -On 02/13/17 at 6:00 a.m., blood sugar was 201 and 2 units of insulin were given instead of the 4 units ordered; --On 02/04/17 at 4:30 p.m., blood sugar was 172 and it appeared staff documented administering 4 units of insulin (the handwriting made it difficult to decipher) instead of the 2 units ordered; and --On 02/14/17 at 4:30 p.m., blood sugar was 374 and staff administered 6 units instead of the 10 units ordered. In an interview on 03/22/17 at 9:26 a.m., Assistant Nursing Director Staff 79 reviewed the Medication Administration Record and acknowledged the errors. She stated she interpreted the 02/04/17 administration as 4 units and agreed staff should follow physician's orders [REDACTED]. In an interview, on 03/22/17 at 9:26 a.m., Assistant Director of Nursing (ADON) #79 reviewed the MAR and verified errors occurred in administering physician order [REDACTED].",2020-09-01
830,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-03-22,325,D,0,1,ZQ9211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observations, the facility failed to provide a therapeutic diet to one (1) of four (4) residents reviewed for nutrition that received therapeutic diets. Resident identifier: #91. Facility census: 85. Findings include: a) Resident #91 Review of the medical record for Resident #91, on 03/22/17 at 12:52 p.m., revealed the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 01/31/17, indicated the resident was supervised for meals and received [MEDICAL TREATMENT] treatment. The most recent care plan, initiated on 01/11/17, was reviewed on 03/22/17 at 1:05 p.m. The care plan indicated the resident was at nutritional concern related to: a [DIAGNOSES REDACTED]. On 02/02/17 the care plan was revised to include the following intervention: Provide liberalized renal diet as ordered: No potatoes, beans or bananas, double meat portions with all meals. A nutritional assessment dated [DATE] indicated the resident had a [DIAGNOSES REDACTED]. The physician orders [REDACTED].#91 indicated double meat portions all meals with a [DIAGNOSES REDACTED]. --A liberalized renal diet with a bag lunch at 11:00 a.m. on Tuesday, Thursday, and Saturday to send with [MEDICAL TREATMENT]; --No potatoes, beans or bananas; and --Double meat portions all meals. On 03/22/17 at 12:52 p.m., the resident was observed in the dining room eating lunch. The diet card did not indicate double meat. The resident was eating a hamburger sandwich with one patty. The Director of Nursing (DON) #3 stated the resident did not receive double meats and the diet card was not printed to include double meats. On 03/22/17 at 12:53 p.m., interview with the Registered Dietician #92 verified the resident was on a liberalized diet with double meat for protein. On 03/22/17 at 2:23 p.m., interview with DON #3 stated dietary received the physician order [REDACTED].#58 he stated it was in his notes, but the double meats did not print on the diet card. On 03/22/17 at 2:26 p.m., interview with Resident #91 stated she could not remember getting double meats on her tray. On 03/22/17 at 2:27 p.m., interview with Director of Dining Services #58 stated he received the diet change, but entered the double portions into the system where it appears in notes but doesn't print on the diet card. He corrected the system so it will print now. He could not confirm if the resident ever received double portions. He verified the diet card did not reflect the correct diet which included double meat portions at all meals. On 03/22/17 at 2:31 p.m., during an interview with DON #3 she stated she received information from [MEDICAL TREATMENT] that the resident's [MEDICATION NAME] level from 02/23/17 was 3.4 which is low, normal limits (3.5-5.7), but had improved and the last [MEDICATION NAME] level on 12/27/16 done at facility of 3.2. On 03/22/17 at 2:34 p.m., review of laboratory results, dated 02/23/17 revealed an [MEDICATION NAME] level 3.4 from [MEDICAL TREATMENT] center and a 12/27/16 [MEDICATION NAME] level 3.2, both of which were low. On 03/22/17 at 2:41 p.m., interview with Nurse Practitioner #119 stated she saw the resident on 01/25/17 and wrote new orders for the resident to receive double meat portions at all meals due to low [MEDICATION NAME] levels.",2020-09-01
833,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,656,D,0,1,H2ZY11,"Based on observation, medical record review, staff interview, and resident interview, the facility failed to ensure the care plans for three (3) of twenty-five (25) residents whose care plans were reviewed addressed the resident's individualized needs. Resident #27's and Resident #6's care plans did not address the residents' reported refusal of showers. Resident #6's care plan did not address the resident's dietary needs due to having no teeth. Resident identifiers: #6, #25, and #37. Facility census: 111. The findings included: a) Resident #27 During a resident interview on 05/17/18 at 10:00 AM, the resident stated showers were not always given as requested and often the resident was told staff were too busy and never returned to help. Review of the resident's care plan dated 03/07/18, revealed Resident #27 required assistance with activities of daily living care. The interventions included a shower preference of Mondays and Thursdays with a notation that Resident #27 often refused showers. According to the resident's medical record, the only shower provided in (MONTH) as of 05/17/18 was one (1) provided on (MONTH) 3, (YEAR). There were no refusals of care marked on the Activities of Daily Living Flow Sheet. During an interview on 05/17/18 at 11:25 AM, the Center Nurse Executive confirmed the ADL sheet revealed only one shower documented with no refusals of showers indicated. An interview with the Administrator on 05/17/18 at 3:22 PM, revealed Resident #27 preferred certain people to assist her and verified refusals had not been documented. It was further stated the resident's care plan did not include Resident #27's preferences or address the resident's refusal of showers. b) Resident #6 Observation of the lunch meal on 05/14/18, revealed Resident #6 received a raw cabbage salad. The resident stated he could not eat hard foods because he had no teeth. A review of Resident #6's care plan found focus area of identifying he was edentulous, but did not include the issue of foods he was not able to chew. An interview with Employee #107, the food service supervisor, on 05/16/18 at 10:25 AM revealed there had been no further evaluation of the foods Resident #6 was having difficulty chewing because of having no teeth. The resident's care plan had not addressed this issue. c) Resident #35 On 05/17/18 11:38 AM, an interview with the director of nursing (DON) revealed the resident had refused showers on 05/12/18 and 05/16/18, but there was no evidence of any attempts to get him to bath later. The issue of the resident's refusal of care and that he would be more receptive to receiving care assisted by certain staff members was not addressed in the care plan.",2020-09-01
836,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,745,D,0,1,H2ZY11,"Based on medical record review and by staff interview, the facility failed to ensure one (1) of twenty-five (25) residents received medically-related social services when the resident refused care. This was evident for Resident #35. Census: 111. Findings include: a) Resident #35 Review of the resident's medical record found documentation the resident refused showers on 05/12/18 and on 05/16/18. There was no evidence staff had waited and approached the resident about bathing later. 05/17/18 11:38 AM, interview with the director of nursing (DON) revealed the resident had refused showers on 5/12/18 and 5/16/18, but there was no evidence of any further attempts to get him to bathe later. She stated the normal procedure was for staff to attempt to get the resident to take a shower and then if the resident refused, go back later and offer again. There was no evidence that social services staff had intervened and offered to see why the resident was refusing the care. Additionally, the resident was known to resist care and to refuse medications at times. This had not been addressed by social services, nor included in the care plan to address the behavior of resisting care.",2020-09-01
837,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,805,D,0,1,H2ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure one (1) of twenty-five (25) sampled residents received food in a form to meet the individual's needs. Resident #6, who was edentulous, received foods he was unable to chew. Resident Identifier: #6. Facility census: 111. The findings included: a) Resident #6 Observation of the lunch meal served on 05/14/18, revealed Resident #6 received cabbage slaw. The resident stated he could not chew raw cabbage. He further stated that he received food items for meals and snacks that he was unable to chew because he had no teeth. A review of the resident's medical record on 05/16/18, found the physician's orders [REDACTED]. An additional observation made during the breakfast meal on 05/16/18 noted a package of unconsumed pretzels. When questioned, Resident #6 stated he had received them as a snack and they were too hard to eat without teeth. An interview with Employee #107, the food service supervisor, on 05/16/18 at 9:45 AM revealed Resident #6 received the red cabbage on Monday because he was on a regular consistency diet. Employee#107 confirmed that the cabbage slaw was not finely chopped. Employee #107 said speech therapy would be consulted to re-evaluate the resident's consistency/texture needs. During an interview on 05/16/18 at 3:00 PM, the Administrator said they would look into having soft snacks as opposed to items difficult for some residents to chew.",2020-09-01
838,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-05-17,808,D,0,1,H2ZY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record, the facility failed to serve therapeutic diets as prescribed by the physician for two (2) randomly observed residents. Resident #5, who was on a renal diet, received a banana. Resident #101 did not receive large portions as ordered until it was brought to the attention of staff. Resident Identifiers: #5 and #101. Facility census: 111. The findings included: a) Resident #5 An observation of the breakfast meal on 05/16/18 at 7:35 AM, revealed Resident #5 received a banana on his tray. The resident told the aide delivering the tray he was not supposed to eat bananas because of being on a [MEDICAL TREATMENT] diet. During an interview on 05/16/18 at lunch time, the resident stated he was not allowed to have certain food items because of having End Stage [MEDICAL CONDITION], but I get them anyway. A review of the resident's medical record on 05/16/18 found a physician's orders [REDACTED]. An interview with Employee #107, the food service supervisor, on 05/16/18 at 9:30 AM, verified Resident #5 received the banana by mistake because, The aide was trying to get the tray line going and looked at the list as a preference instead of an item to withhold from the tray. b) Resident #101 Observations in the dietary department on 05/17/18 at 7:25 a.m., noted dietary staff did not serve the correct food amount as ordered for the resident. The resident was served regular portions as identified on the regular menu rather than large portions. When questioned, the food service manager, who was filling in from a sister facility, verified that was not what a large portion diet was to receive. The tray then had the additional items needed to make it large portions. According to the registered dietitian's approved recommendations, the resident was to have a regular liberalized diet with large portions, ProHeal (a supplement), snacks TID (three times a day) and [MEDICATION NAME] and [MEDICATION NAME] for appetite stimulation for weight gain. The resident had not received the correct portions as required until surveyor intervention.",2020-09-01
842,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,561,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review policy review and staff interview, the facility failed to ensure the resident had the right to make choices about aspects of their life which were important to them. For Resident #106 and Resident #94 the facility failed to allow the resident to make choices about their bathing schedule. For Resident #49 the facility failed to allow her to make choices about her bathing schedule and her religious preferences. This was true for 3 of 5 residents reviewed for the care area of self-determination. Resident identifiers: #49, #106, #94. Facility census: 117. Findings included: a) Resident #49 1. Bathing Schedule: During an interview on 06/24/19 Resident stated, I would like to get more showers, since I have moved over here (Maple Unit) I hardly get any. I am supposed to get at least two (2) a week. Resident was noted to have transferred from Dogwood Unit room [ROOM NUMBER]A to Maple unit room [ROOM NUMBER]B on 05/13/19. Review of Activities of Daily Living (ADL) sheets for Resident #49 revealed Resident received showers for only 4 out of 8 opportunities in May, and 4 out 9 opportunities in June. Record review indicated the shower schedule for when Resident was residing in room [ROOM NUMBER]A in the Dogwood unit was Monday and Thursday. The shower schedule for the Maple Unit while Resident was residing in room [ROOM NUMBER]B was Wednesday and Saturday. After Resident was transferred from room [ROOM NUMBER]A to room [ROOM NUMBER]B on 05/13/19, the Resident went for days in a row from 05/15/19 - 5/18/19 without any type of bathing, and only received two (2) showers (on 06/14/19, and on 06/25/19) thereafter through the end of June. Review of Resident's care plan revealed an active focus point that stated, (Resident's first name) stated that it is important that she has the opportunity engage in daily routines that are meaningful relative to their preferences, with a goal of, Resident will plan and choose to engage in preferred activities daily, and an intervention pertaining to bathing of, It is important for me to choose between a tub bath, shower, bed bath, or sponge bath. On 07/02/19, DON agreed that the Resident did not receive adequate bathing of her choice, and someone should have caught the issue by now by reviewing the ADL sheets. 2. Religious Preferences: During initial screening process on 06/24/19 at 10:56 AM Resident stated she would like to have church every Sunday instead of just once or twice a month. Review of Activities Calendar for the month of (MONTH) 2019 revealed the facility only provided the Resident with one (1) out of (5) opportunities to attend church worship service on Sunday. On 07/01/19 at 8:40 AM during an interview the Activities Director (AD) verified the (MONTH) Activity calendar to only include one (1) opportunity for the Resident to attend church services on Sunday (06/02/19) for the month of June. AD stated activities such as Father's Day celebration, bird watching, and bowling replaced the opportunity for church services on the other Sundays of the month. Review of the Facility's policy REC200 titled Resident/Patient's Choice stated Residents/Patients have the right to participate in leisure and recreation of their choosing. Review of the Facility's policy REC201 titled Spiritual Support stated spiritual and religious activities will be available to residents and their families on a routine basis and include worship services. Review of Resident's care plan revealed an activity focus point that stated, (Resident's first name) stated that it is important that she has the opportunity engage in daily routines that are meaningful relative to their preferences, with a goal the Resident will plan and choose to engage in preferred activities daily, and an intervention that stated:, Encourage and facilitate residents/patients activity preferences daily chronical, bingo, church service, special events, music. During an interview on 07/2/19 at 9:00 AM, social services specialist #96 stated, We (the facility) have piano playing, hymns, and bible study on Tuesdays. But you are right, we don't have actual church services for worship routinely every Sunday. b) Resident #106 1. Bathing Schedule: During an interview on 06/25/19 at 10:30 AM, Resident stated, Not enough showers. I never get bathed on the weekends, they act like I am irritating them. Review of Residents Activity of Daily Living (ADL) sheets for the past two (2) months revealed the Resident was only provided with a bed bath during bathing, no documentation that a shower was ever given or refused. The Resident was not provided with any type of bathing for the following dates: --05/04/19 - Saturday --05/05/19 - Sunday --05/11/19 - Saturday --05/17/19 - Friday --05/18/19 - Saturday --05/19/19 - Sunday --05/24/19 - Friday --05/25/19 - Saturday --05/26/19 - Sunday --06/08/19 - Saturday --06/29/19 - Saturday --06/30/19 - Sunday Review of Dogwood Shower List (unit of which Resident resided) indicated Resident's shower schedule was to be every Tuesday and Friday. Review of Residents care plan revealed an active focus area for bathing that stated: Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to [MEDICAL CONDITION], Dementia, with an intervention of, Provide resident with total assist of 1 for bathing. On 07/02/19 at 9:19 AM, Director of Nursing (DON) agreed that the Resident did not receive any bathing during the weekends as indicated for the dates in (MONTH) and June. No further documentation was provided. c) Resident #94 During an interview with Resident #94 at 3:15 p.m. on 06/24/19 she stated she would like to have at least two (2) showers per week and that is what she is supposed to get but she has only had two (2) showers total since her admission to the facility in February, 2019. Review of the facility's shower schedule at 1:30 p.m. on 06/26/19 found Resident #94 should be showered every Wednesday and Saturday. A review of Resident #94's ADL Flow Sheets for the time period of 02/19/19 (date of residents admission) through current found Resident #94 only received a shower on the following dates: 02/27/19; 04/06/19; 04/17/19 and 05/29/19. Resident had no showers in the Month of 06/2019. Resident #94 had only two (2) documented refusals and only received four (4) of her scheduled 37 showers. An interview with Nursing Home Administrator, and Director of Nursing at 2:06 p.m. on 06/26/19 confirmed Resident #94 had not received her showers as scheduled. They reviewed the ADL documentation and confirmed this would be the only place a shower or refusal would be documented.",2020-09-01
843,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,580,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify the physician and family and/or responsible party promptly of resident's change of condition (fall). This was a random opportunity for discovery. Resident identifiers: #78. Facility census: 117. Findings included: a) Resident #78 Review of Resident #78's medical records found the resident was admitted on [DATE] to the facility. Additionally, the resident had experienced two (2) falls on 06/22/19 at 1:30 a.m. and 1:00 p.m. Review of the incident reports found: (typed as written) Incident #1- 06/22/19 at 1:30 am- Resident found lying on left side of floor. Assessed for injury and pain, ST (skin tear) to back of bilateral hands, ST to posterior LLE (left lower extremities) and left elbow. Immediate actions taken to protect resident: assessed for injury, pain, assisted to bed and treatments to skin tears. Root cause/conclusion: poor safety awareness. Doctor and family notified on 06/22/19 at 1:00 pm of this incident. Incident #2- 06/22/19 at 1:00 pm- Resident on floor in front of chair laying on stomach. Resident denies pain or discomfort currently. BS (blood sugar) 94 currently. Immediate actions taken to protect resident: assessed for injury skin tears to left forehead, left hand, and right forearm dressings.Root cause/conclusion: resident attempted to get out of chair without assistance and fell on to the floor. Doctor and family notified on 06/22/19 at 1:00 pm of this incident. Review of the transfer report dated 06/22/19 at 2:35 pm, found the resident was transferred to a hospital for evaluation and treatment due to fall (06/22/19 at 1:30 am and 1:00 pm). Resident #78 was readmitted to the facility on [DATE]. Review of the History and Physical (H&P) and Discharge Summary found the following: (typed as written) This [AGE] year-old male who is a resident of a nursing home who presents to the hospital with passing out and falling spells. Patient states that last night he was sitting on the side of bed and he leaned forward and suddenly he was on the floor. He thinks he was out for a second or 2 He then again had the same incident this morning. This morning he was sitting in his chair and may have leaned forward but once again he was on the floor. complaint of a mild headache but no other complaints voiced . The patient had evidence of a of a hematoma over his parietal region (left frontal area above the eye) as well as multiple skin tears of his upper and lower extremities. He did not have any suturable areas skin tear and ecchymosis to the top of his head Interview with the Director of Nursing (DON) on 07/01/19 at 9:00 am. The DON stated after review of Resident #78's medical records it was found the physician and family and/or responsible party was not notified of the 06/22/19 at 1:30 am until after Resident #78 had experienced a second fall at 1:00 pm on 06/22/19. No further information provided.",2020-09-01
848,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,610,D,0,1,LUON11,"Based on resident interview, record review, staff interview and policy review, the facility failed to thoroughly investigated, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This had the potential to affect a limited number of people. Resident identifier: #29. Facility census 117. Findings included: a) Resident 29 During an interview on 06/25/19 at 10:20 AM, Resident #29 (who is nonverbal writes with a pen and tablet) stated, that her neck hurts. She wrote that a Nurse Aide (NA) #41, jerked me out my chair to the bed NA #41 was working on night shift. She wrote that it happened on Monday or Tuesday of last week at about 10:00 PM. She reported this to the Social Worker (SW), she gave a description of the NA #41 and pointed her out to SW. She wrote, that the women the women are still here the next night. She also wrote, that the same NA push her into the door hard and hurt her sore feet and happened at 7:00PM. On 06/26/19 a review of the reportable that was provided revealed; Reportable done on 06/20/19, date of incident was on 06/17/19, this report was completed by Social Worker (SW) #49. -There was no evidence that NA #41 was reported to, Nurse Aide registry -There report had the NA named as unknown, even though he named the NA in his statement. -He did not have any witness statements attached to the report. On a typed sheet of paper read as follows: June 20, 2019 Five-day follow-up report Alleged Perpetrator: Unknown Alleged victim: Named Resident #29 Resident #29 reported that someone caring for her had been mean to her. When asked specifically about this she reported that a tall black woman with blonde hair on top of her head jerked her while providing care. She indicated she was in her wheelchair when this occurred, and it caused her foot to bump the door. When asked she indicated she did not have any injury or marks on her from this. She indicated that this person would give her remote when she was back in the bed. SW interviewed Resident#29's roommate. The roommate stated that she did not see any of this occur. She stated there was a time that night when NA was providing care and Resident #29 was groaning. The curtain was pulled so she did not see what occurred. SW interviewed Licensed Practical Nurse (LPN) #93. She reported she was not aware of Resident #29 being upset about any particular treatment. She explained that Resident #29 often groans or raises her voice when being transferred to bed or toileting care. SW interview NA #41, she was the closest fit to the description though not exact. NA #41 did provide care to Resident #29 on 06/17/19. She reported there were instances it was difficult understanding what Resident #29 was requesting. After asking her numerous times her roommate stated she thought she was requesting her remote. NA #41 stated, that she provided the bed remote. When asked about bumping resident #29's foot into anything that she was aware of nor did she jerk her while in her wheelchair. Resident requested not to have that particular NA provide care for her any more, which will be accommodated. The allegation of abuse/neglect will not be substantiated. On the Adult Protective Services Mandatory Reporting Form Resident #29 has capacity Perpetrator: Unknown Date of incident: 06/17/19 Date this report was completed: 06/19/19 Describe incident: Resident alleged NA bumped her foot into doorway and did not give her bed remote. On the form that was faxed to Office of Health Facilities Licensure and Certification Alleged Victim: Resident #29 's Name was noted Alleged perpetrator: Unknown date of incident: 06/17/19 Brief description of incident: Alleged that facility staff came to room to provide care and bumped the resident's foot into a door frame while turning her in the chair. Also, NA did not give her the bed remote while in bed. On 07/01/19 at 4:55 PM, an interview with SW #49 was asked if had had gather witness statements from all employees that worked that night? He shook his head no (to indicate that he does not have any written statements from any employees), he said, that he just ask the employees and he writes the information in, but no signed or written statements. He was asked about why he did not write in the report that the NA #41 had jerked her out of her chair and hurt her. He said, that she did not tell him that, however the attached statements, that Resident #29 had wrote to him, Tall black women with blonde hair on top, jerked me out of my chair to put me in my bed, she hurt my neck. He was asked if NA #41 was put on leave until the investigation was completed? He said no. He was how did he reach the conclusion the allegation was unsubstantiated. He said, that he called NA#41 and she told him that the allegation was false and that had spoken to the nurse that worked that night and she said, that Resident #29 normally makes a moaning sound when she is moved from the chair to the bed. He was asked if he a written statement about that. He went on to say that her roommate told him that she did not see anything because the curtain was pulled but did hear moan. During an interview on 07/02/19 at 9:12 AM, DoN was informed about this report that Social Worker (SW) #49 had done. It was pointed out that it was not a thorough investigation, he did not report to all State required Agencies and that he reported on the Adult Protective Services Mandatory Reporting Form, Allegations Nursing home Program, but failed to report to the Nurse Aide Registry. He also knew who the Alleged Perpetrator was, but he knew who she was, because Resident # 29 pointed her out to the staff and her description was very clear. He said, that he knew who it was from her description. However, he wrote unknown. She agreed that it was not a complete investigation. She was also shown, that he had copies of her written complaint (she is nonverbal) she had written twice that NA #41,jerked her out of her wheel chair and hurt her neck at 10:00 PM and she hit her sore feet on the door at 7:00PM. She agreed he did not do an appropriate investigation. She stated that will talk to him. On 07/02/19 at 10:30 AM, SW #49 provided a copy of; 1:1 Education Form -Employee: NA #41 -Topic of education: Safe Resident Handling Education: -Employee will follow the Care Plan for the resident's lift statuses -Employee will follow the policy for use of gait belt, sit to stand lift, and the total lift devices. This had the signature of the Manager dated 07/01/19 Employee signature NA #41 dated 07/01/119 07/01/19 04:55 PM He does not have any written statements from any employees, said, that he just ask the employees and he writes the information in, but no signed or written statements. He was asked about why he did not write in the report that the NA #41 had jerked her and hurt her. He said, that she did not tell him that, however attached to his He was asked what during his investigation asked him for the schedule for (MONTH) for the NA 06/25/19 10:20 AM neck hurts when she jerks me out my chair and bed NA on night shift on Tuesday and Wednesday last week she reported to ss she showed her the women the women is still here she rush her into the door hard hurt my sore feet she wrote I want to leave this place. 07/02/19 09:12 AM DoN was informed about this report that Social Worker (SW) #49 not doing a thorough investigation, not reporting to all State required Agencies and that he reported on the Adult Protective Services Mandatory Reporting Form, Allegations Nursing home Program, but failed to report to the Nurse Aide Registry. He also knew who the Alleged Perpetrator was, but he knew who she was, because Resident # 29 pointed her out to the staff and her description was very clear. He said, that he knew who it was from her description. However he wrote unknown. She agreed that it was not a complete investigation. She was also shown, that he had copies of her written complaint (she is nonverbal) she had wrote twice that NA #41,jerked her out of her wheel chair and hurt her neck at 10:00 PM and she hit her sore feet on the door at 7:00PM. She agreed he did not do a very good job on this. Reportable done on 06/20/19 by Social Worker 49 Resident # 29 reported that a NA was a tall black women with blonde hair",2020-09-01
849,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,622,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide documentation to the receiving hospital to ensure a safe transfer for Resident #98. This was true for one of eight residents reviewed for the care area of hospitalization . Resident identifier: #98. Facility census: 117. Findings included: a) Resident #98 On 06/26/19 at 2:35 PM, a closed record review of Resident #98's medical chart revealed the Resident had been transferred to the hospital on [DATE]. The facility failed to ensure the necessary Resident information was documented and included in the transfer of the Resident to the receiving hospital. At 2:40 PM on 06/26/19, the Director of Nursing (DON) confirmed, by interview, the hospital discharge forms for the Resident on the transfer date of 06/18/19, .were not given.",2020-09-01
852,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,636,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the care area assessment (CAA) worksheet of the minimum data set (MDS) was completed with current evidence-based information regarding the care area of activities for one (1) of three (3) residents who triggered activities. Resident identifier: #161. Facility census: 117. Findings included: a) Resident #161 Record review at 9:11 AM on 06/27/19, found the resident was admitted to the facility on [DATE]. The resident was discharged from the facility on 05/13/19. Review of the Resident's admission MDS with a reference assessment date of 04/17/19 found the resident triggered the care area of activities. The facility answered-yes, to the question on the CAA worksheet, Will activities-Functional status be address in the care plan? The CAA further indicated if care planning for this problem one of the overall objectives needs to be checked: improvement, slow or minimize decline, avoid complications, maintain current level of functioning, minimize risks, and symptom relief or palliative measure. None of these choices were checked. The CAA required documentation for: Description impact of this problem/need on the resident and your rationale for care plan decision. This was also incomplete. On 06/27/19 at 10:05 AM, the Registered Nurse (RN), (minimum data set coordination), RNMDSC #95 confirmed the CAA worksheet was incomplete.",2020-09-01
854,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,655,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop and implement a baseline care plan for Resident #111's to include the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission and include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders [REDACTED]. Resident identifier: #111. Facility census: 117. Findings included: a) Resident #111 Review of Resident #111's medical records found this resident was admitted to the facility on [DATE] at 6:39 pm, from an acute care facility with [DIAGNOSES REDACTED]. Noted to have impairment of right upper extremity and weakness in the right arm and both legs. Review of the interim care plan dated 02/03/19 found no directions for assistance required to provide Activities of Daily Living (ADL)s which includes bed mobility, transfers, eating, toileting, dressing, grooming, and bathing. Resident #111's experienced a fall on 02/03/19 at 3:30 pm. Resident's progress note states, Resident was being changed by nurse aide at 3:30 pm. Resident was rolling to the right hand side of the bed when the resident rolled herself from the bed to the floor, the bed was raised to waist height as the aide was performing care on the resident. Post fall the resident c/o (complained of) severe left knee and left rib pain. This nurse contacted the on-call physician who gave orders to have resident sent out to the emergency room to be evaluated for potential fractures. Nurse aide who was performing care will complete a statement regarding the incident. Bruise noted on left knee and left cheek. Review of policy for Falls Management reads: Perform neurological assessment for all unwitnessed falls and witnessed falls with head injury This survey requested the statement from the nurse aide providing care for Resident #111 on 02/03/19 at 3:30 pm and neurological checks. No information was provided. emergency room report status [REDACTED]. No fractures or dislocations noted. Resident #111 was seen and examined by the attending physician on 02/04/19. Progress note states, She reports that yesterday she rolled out of bed onto her face during change and hit her face and knee. She was transferred to (name of hospital) where x-rays were done, and they were negative for fracture. She complains of severe pain around the left side of face Mild bruising and tenderness noted around the left periorbital area Resident was evaluated by physical and occupational therapy on 02/04/19. An assessment dated [DATE] at 1:59 performed by a registered nurse (RN) which indicates the resident requires extensive assistance of two or more persons for bed mobility. Interview with the Director of Nursing (DON) on 07/01/19 at 1:10 pm. Resident #111's medical records were reviewed by the DON. She confirmed the licensed staff had not evaluated and developed a baseline care plan to include the assistance needed for bed mobility and no directions for care was provided to the direct care staff. No further information provided.",2020-09-01
857,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,660,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #102's comprehensive care plan included discharge planning. This was true for one (1) of four (4) residents reviewed for the care area of discharge. Resident identifier: #102. Facility census: 117. Findings included: a) Resident #102 Review of Resident #102's medical records revealed she was admitted to the facility on [DATE] and transferred to another long-term care facility on 06/19/19. Resident #102's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 06/12/19, Section Q, Participation in Assessment and Goal Setting, stated the resident expected to be discharged to another facility. Review of Resident #102's Comprehensive Care Plan revealed a care plan focus had not been developed regarding the resident's desire to be transferred to another long-term care facility. During an interview on 06/26/19 at 12:48 PM, the Director of Nursing agreed a care plan focus had not been developed regarding Resident #102's discharge plans. No further information was provided through the completion of the survey.",2020-09-01
859,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,679,D,0,1,LUON11,"Based on resident interview, record review, staff interview and policy review, the facility failed to implement an ongoing resident centered activity program that incorporated Resident #49's preferences of church services. This was true for 1 of 3 residents reviewed for activities. Resident identifier: #49. Facility census: 117. a) Resident #49 During initial screening process on 06/24/19 at 10:56 AM Resident stated she would like to have church every Sunday instead of just once or twice a month. Review of Activities Calendar for the month of (MONTH) 2019 revealed the facility only provided the Resident with one (1) out of (5) opportunities to attend church worship service on Sunday. On 07/01/19 at 8:40 AM during an interview the Activities Director (AD) verified the (MONTH) Activity calendar to only include one (1) opportunity for the Resident to attend church services on Sunday (06/02/19) for the month of June. AD stated activities such as Father's Day celebration, bird watching, and bowling replaced the opportunity for church services on the other Sundays of the month. Review of the Facility's policy REC200 titled Resident/Patient's Choice stated Residents/Patients have the right to participate in leisure and recreation of their choosing. Review of the Facility's policy REC201 titled Spiritual Support stated spiritual and religious activities will be available to residents and their families on a routine basis, including worship services. Review of Resident's care plan revealed an activity focus point that stated, (Resident's first name) stated that it is important that she has the opportunity engage in daily routines that are meaningful relative to their preferences, with a goal the Resident will plan and choose to engage in preferred activities daily, and an intervention that stated:, Encourage and facilitate residents/patients activity preferences daily chronical, bingo, church service, special events, music. During an interview on 07/2/19 at 9:00 AM, social services specialist #96 stated, We (the facility) have piano playing, hymns, and bible study on Tuesdays. But you are right, we don't have actual church",2020-09-01
861,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,687,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure resident #89 received proper treatment to maintain good foot health. This was a random opportunity of discovery. Resident Identifier: #89. Facility Census: 117. Findings include: a) Resident #89 Observations of Resident #89's feet with the Director of Nursing (DON) on 07/01/19 at 10:20 a.m. found the residents toe nails to be long, thick, and brown. The DON stated she needs to see the podiatrist. Later in the morning on 07/01/19 the DON provided the Podiatrist's list and stated the resident was scheduled to see him on 07/10/19. An interview with Social Worker #96 at 11:39 a.m. on 07/01/19 found the Podiatrist comes to the facility every three months. She indicated the Podiatrist was last at the facility on 04/17/19 to 04/18/19 and Resident #89 was not seen on that date. An additional interview with DON at 12:37 p.m. on 07/01/19 confirmed Resident #89 was admitted to the facility on [DATE] and should have been added to the list to see the podiatrist when he as at the facility on 04/17/19 and 04/18/19. She stated that he toe nails are too thick and the nurses would not be able to trim them.",2020-09-01
864,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,690,D,0,1,LUON11,"Based on observation and staff interview, the facility failed to ensure appropriate treatment and services for an indwelling suprapubic catheter. Failed to use of an anchor secure device (used to prevent tissue injury and/or accidental removal, excessive urethral tension, or obstruction of urine outflow. This was true for one (1) of one (1) reviewed for catheter care. Identified Resident # 6. Facility census 117. Findings included: a) Resident #6 On 07/01/19 at 9:14 AM, Registered Nurse (RN) #28 providing suprapubic catheter care. There was some dried blood on the old dressing that was removed and at the insertion site there was large amount of bright red bleeding. There was not a secure anchor device on Resident #6. It was pointed out to RN #28 and she agreed there should have been on this resident. On 07/01/19 at 9:35 AM, RN #28 placed a secure anchor device to the upper right leg. On 07/01/19 at 12:00 PM Director of Nursing was informed of findings.",2020-09-01
867,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,756,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the pharmacist recognized and notified the physician that Resident #31 was receiving two (2) medications from the same drug class. In addition, the physician failed to provide a timely clinical rational for declining a gradual dose reduction for Resident #103. This was true of two (2) of five (5) residents reviewed receiving medications. Resident identifiers: #31 and 103. Facility census: 117. Findings included: a) Resident #31 On 07/02/19 at 11:05 AM, Review of Resident #31's Medication Administration Record [REDACTED]. Diabetic [MEDICAL CONDITION] is a type of nerve damage that can occur if you have diabetes. It most often damages nerves in the legs and feet. The MAR indicated [REDACTED]. Both of these medications were also listed in the Resident's Progress Notes. The facility's Registered Pharmacist (RPh) failed to recognize the medication duplication upon her monthly review of the Drug Regimen Review (DRR) or MAR. On 07/02/19 at 11:30 AM, Review of the Consultation Report, developed by the Facility's RPh on 05/03/19, revealed the RPh's only recommendation to the Physician was to Please discontinue Glimepiride, which is a diabetes medication. During an interview on 07/02/19 at 11:35 AM, the Director of Nursing (DON) confirmed the Resident had received a duplicate drug therapy from 05/03/19 through 05/22/19 of two medications in the same class. b) Resident #103 A review of Resident #103's medical record during the survey revealed that the facility's Consultant Pharmacist recommended via a Consultation Report form on 05/03/19 to attempt a gradual dose reduction (GDR) of Resident #103's ordered [MEDICATION NAME] and [MEDICATION NAME] medications. The form instructed to, Please provide CMS REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual, and provided lines upon which the rationale was to be written. The facility's Family Nurse Practitioner (FNP) signed the recommendation on 05/06/19 and agreed only to decrease the [MEDICATION NAME] medication. No information was documented on the form's provided lines to explain the clinical rationale for the declination of the GDR of [MEDICATION NAME]. The lines had been left completely blank. During the survey, a review of the facility's Medication Regimen Review policy, effective 11/28/16, revealed that an explanation as to why the recommendation was rejected should be provided by the physician or prescriber. Information regarding the clinical rationale was requested from the facility's Director of Nursing (DoN) on 07/01/19 at 9:43 AM. At 9:49 AM, the DoN provided a progress note written by the facility's FNP on 05/15/19 (nine (9) days after the [MEDICATION NAME] GDR was declined by the FNP), directing to continue providing the [MEDICATION NAME] as ordered due to behavioral issues. However, no documentation of behavioral issues was found in the medical record or in Resident #103's Minimum Data Set (MDS) assessments and no further information regarding behavioral issues was provided prior to the end of the survey.",2020-09-01
868,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,757,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed to ensure medication regimens were free from unnecessary drugs for two (2) of five (5) residents. Resident identifiers: #73 and 31. Facility census: 117 Findings included: a) Resident #73 During an interview on 07/01/19 at 3:23 PM, the facility's Consultant Pharmacist (RPh) stated that the records did not have Resident #73 as having an allergy to [MEDICATION NAME]. While during a review of Resident #73's Progress Notes dated 01/26/19 found it to be stated the Resident is allergic to the antibiotic [MEDICATION NAME]. This statement is written on each of the Resident's Progress notes since he was admitted on [DATE]. At the end of Progress Note dated 05/22/19 the Nurse Practitioner (FNP) wrote Start [MEDICATION NAME] 500 mg po daily for 7 days . On the Medication Administration Record [REDACTED]. b) Resident #31 On 07/02/19 at 11:05 AM, Review of Resident #31's Medication Administration Record [REDACTED]. Diabetic [MEDICAL CONDITION] is a type of nerve damage that can occur if you have diabetes. It most often damages nerves in the legs and feet. The MAR indicated [REDACTED]. Both of these medications were also listed in the facility's Progress Notes. During an interview on 07/02/19 at 11:35 AM, the Director of Nursing (DON) confirmed the Resident had received a duplicate drug therapy from 05/03/19 through 05/22/19.",2020-09-01
869,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,758,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that Resident #103 and #73's drug regimens were free from unnecessary [MEDICAL CONDITION] drugs when they failed to perform Gradual Dose Reductions (GDRs) as required. This deficient practice was found for two (2) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #103, #73. Facility census: 117. Findings included: a) Resident #103 A review of Resident #103's medical record during the survey revealed that the facility's Consultant Pharmacist recommended via a Consultation Report form on 05/03/19 to attempt a gradual dose reduction (GDR) of Resident #103's ordered [MEDICATION NAME], a [MEDICAL CONDITION] medication. The form instructed to, Please provide CMS REQUIRED patient-specific rationale describing why a GDR attempt is likely to impair function or cause psychiatric instability in this individual, and provided lines upon which the rationale was to be written. The facility's Family Nurse Practitioner (FNP) signed the recommendation on 05/06/19 and indicated on the form that she declined to perform a GDR of Resident #103's [MEDICATION NAME] medication. No information was documented on the form's provided lines to explain the clinical rationale for the declination of the GDR of [MEDICATION NAME]. The lines had been left completely blank. Information regarding the clinical rationale was requested from the facility's Director of Nursing (DoN) on 07/01/19 at 9:43 AM. At 9:49 AM, the DoN provided a progress note written by the facility's FNP on 05/15/19 (nine (9) days after the [MEDICATION NAME] GDR was declined by the FNP), directing to continue providing the [MEDICATION NAME] as ordered due to behavioral issues. However, no documentation of behavioral issues was found in the medical record or in Resident #103's Minimum Data Set (MDS) assessments and no further information regarding behavioral issues was provided prior to the end of the survey. Therefore, there was no information available to suggest that a GDR of [MEDICATION NAME] would have been clinically contraindicated for Resident #103. b) Resident #73 Review of the facility's Consultation Report written by the facility's Consultant Registered Pharmacist (RPh) and signed by the Physician and Director of Nursing (DON) on 02/05/19 and 02/08/19, respectively, showed that on 02/04/19 the RPh wrote that Resident #73's [MEDICATION NAME] and [MEDICATION NAME] are due for a gradual dose reduction (GDR) review. The Physician accepted the RPh's recommendation with the following modification(s): , Decrease [MEDICATION NAME] to 5 milligrams (mg) by mouth (po) three times daily (tid) . After the document was signed, by both the Physician and the DON, the [MEDICATION NAME] 10mg, which is a [MEDICAL CONDITION] medication, continued to be administered to the Resident three (3) times daily by the Facility Staff. Also the facility's RPh failed to recognize the prescription error when reviewing the Medication Regimen Review (MRR) each month which resulted in the Resident continuing to receive twice the amount of [MEDICAL CONDITION] medication. Thus, the federal guideline for [MEDICAL CONDITION] medication GDR was not implemented. On 07/01/19 at 2:03 PM, the Surveyor and current DON observed the Resident's medication, located in the Medcart, and found the [MEDICATION NAME] prescription label read [MEDICATION NAME] 10 mg Give 1 tablet by mouth 3 times daily for anxiety.",2020-09-01
871,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2019-07-02,791,D,0,1,LUON11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review the facility failed to ensure the necessary dental services were secured for a resident with broken teeth. This deficient practice was found for one (1) of three (3) residents reviewed for the dental care area. Resident identifier: #62. Facility census: 117. Findings included: a) Resident #62 On 06/24/19 at 12:16 PM, Resident #62 stated that one of her bottom teeth was bleeding. Upon observation, it was noted that Resident #62 was missing several of her top row of teeth. Resident #62 stated that she could not remember the last time she had been evaluated by a dentist. Record review during the survey found that Resident #62 was admitted to the facility on [DATE]. On 06/26/19 at 12:57 PM, the only document provided by the facility regarding Resident #62's dental care was reviewed. The document, a consultation report dated 08/08/18, stated, Pt. (patient) needs deep cleaning with curettage (a surgical procedure performed by a dentist, typically under anesthesia), also severed teeth and broken off roots need to be [MEDICATION NAME] down. On 06/26/19 at 3:10 PM, the facility's Director of Nursing (DoN) was asked to provide documentation that the necessary dental work written in the above consult was completed for Resident #62. At 4:56 PM, the DoN stated that this information could not be obtained because the dental office where Resident #62 was a patient was closed. No further information was provided prior to the end of the survey.",2020-09-01
879,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-07-24,242,D,1,0,2NJ511,"> Based on resident interview, staff interviews, and record review, the facility failed to honor resident's preferred schedule for bathing for one (1) of eleven (11) residents. This failed practice had the potential to affect an isolated number of residents. Resident identifier: #63. Facility census: 113. Findings include: a) Resident #63 Resident #63 stated, on 07/20/17 at 3:00 p.m., she would like to receive a full shower with washing of her hair twice a week. She stated she was usually showered once a week. Resident #63 stated she was able to bathe herself at the sink in her bathroom on days she was not showered. Review of the medical records revealed a general nursing progress note written on 12/20/16 at 4:11 p.m. that stated, Spoke with resident today regarding bathing preferences. Resident states that she is getting a shower at least once a week. She states that she would like for this to be changed to twice weekly. She states she bathes at her sink by herself on the days she does not get a shower. During an interview with Nurse Aide (NA) #26, on 07/20/17 at 11;00 a.m., the NA stated Resident #63 was scheduled to receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. Nurse Aid #26 stated that most residents receive showers twice a week, but residents' personal preferences are also taken into consideration. Review of the Shower Schedule confirmed that Resident #63 was scheduled to receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. Review of the bathing section of the Activities of Daily Living (ADL) Records for Resident #63 revealed the following: --05/05/17 - R (refusal of bathing) --05/11/17 - R (refusal of bathing) --05/15/17 - S (shower) --05/31/17 - S (shower) --06/01/17 - S (shower) --06/15/17 - S (shower) --07/05/17 - B (bed bath) --06/06/17 - R (refusal of bathing) --07/13/17 - S (shower) --07/17/17 - R (refusal of bathing) The remainder of the dates on the ADL Records for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), had no documentation of bathing. The Director of Nursing (DON), stated during an interview on 07/20/17 at 11:45 p.m., R means refusal, B means bed bath, and S means shower. Additionally, the Weekly Bath and Skin Report for (MONTH) (YEAR) documented showers were given on 06/01/17, 06/12/17, and 06/14/17. According to Registered Nurse (RN) #150, at 3:00 p.m. on 07/20/17, the weekly bath and skin reports were not completed for (MONTH) (YEAR) or (MONTH) (YEAR). According to Resident 63's care plan, with date of review 06/08/17, Resident requires total assist with bathing. Likes to bathe in her bathroom and prefers to shower only once a week. On 07/20/17, at 12:05 p.m., RN #60 stated Resident #63's Care Plan specified one shower weekly because the resident frequently refused showers. On 07/20/17 at 12:00 p.m., RN #89 stated Resident #63 refused showers at times because she was watching a favorite television program, and did want to be interrupted at that time. On 07/20/17 at 2:00 p.m., RN #150 stated that Resident #63 frequently refused showers. The DON stated during an interview, on 07/25/2017 at 11:40 a.m., that Resident #63's care plan was not individualized to reflect personal preferences regarding showering. DON stated the care plan should reflect Resident 63's preferences for frequency and timing of showers.",2020-09-01
880,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-07-24,274,D,1,0,2NJ511,"> Based on staff interview and medical record review the facility failed to complete a comprehensive assessment after one (1) of eleven (11) residents experienced a significant change in condition. Resident #11 declined from limited to extensive assistance in three (3) activities of daily living (ADLs) and experienced a 5% weight loss in 30 days. This failed practice had the potential to affect an isolated number of residents. Resident identifier: #11. Facility census: 113. Findings include: a) Resident #11 On 07/20/17 at 1:50 p.m. a review of Resident #11's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/17 revealed, in the area of functional status, Resident #11 was assessed as needing limited assistance with dressing, toileting, and personal hygiene. The 30-day MDS with an assessment reference date, of 07/04/17, revealed Resident #11 was assessed as needing extensive assistance with dressing, toileting, and personal hygiene. The resident also had a weight of 152.4 pounds (lbs.) recorded on 06/07/17, and a weight of 142 lbs. recorded on 07/05/17 and 07/12/17. This equaled a weight loss of 6.8% in thirty (30) days. During an interview with RN #89, on 07/20/17 at 3:00 p.m., she confirmed the facility did not complete a comprehensive assessment after the resident experienced a significant change in condition. She said these changes were present on the 14-day assessment. They had hoped the changes would resolve in 14 days, and they did not.",2020-09-01
881,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-07-24,309,D,1,0,2NJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and policy review, the facility failed to ensure neurological checks according to policies and procedures after unwitnessed falls were completed for two (2) out of eleven (11) residents. This failed practice had the potential to affect an isolated number of residents. Resident identifiers: #6, and #11. Facility census: 113. Findings include: a) Resident #6 Record review revealed Resident #6 had nine (9) falls in a sixteen (16) day period. Eight (8) of these falls were unwitnessed according to the Risk Management System reports. The Neurological Assessments were not complete for the following unwitnessed falls on: --Neurological Assessment was not initiated in a timely manner for an unwitnessed fall that occurred on 04/22/2017 at 11:30 a.m. Resident #6 was found in the floor of her room after staff was alerted by her roommate. No injury was observed. Record review revealed neurological assessments were not initiated until 7:00 p.m. on 04/22/2017. --According to the Risk Management System report dated 04/24/2017 at 3:45 a.m., Resident #6 was found sitting on the floor of her room. No injuries were noted. Record review revealed neurological assessments were initiated. However, vital signs were not assessed at 5:30 p.m. According to the facility's Neurological Assessment policy, vital sign evaluation is a component of a complete neurological assessment. Additionally, the neurological assessments ended at 5:30 a.m. on 04/25/17, and were not continued for the thirty (30) hours specified in the policy and procedure. --According to the Risk Management System report dated 04/29/2017 at 4:35 a.m., Resident #6 fell in the doorway of her room while ambulating in facility. A skin tear was noted to her left elbow. Record review revealed neurological assessments were initiated. However, blood pressure was not assessed from initiation of the neurological assessments until 04/29/17 at 8:30 a.m. According to the facility's Neurological Assessment policy, blood pressure evaluation is a component of a complete neurological assessment. --According to the Risk Management System report dated 04/29/2017 at 4:45 p.m., Resident #6 was found in the floor of her room. No injuries were noted. Record review revealed neurological assessments were initiated. However, vital signs were not assessed at 04/30/17 at 2:15 p.m. and 6:15 p.m. According to the facility's Neurological Assessment policy, vital sign evaluation is a component of a complete neurological assessment. Additionally, the neurological assessments ended at 10:15 p.m. on 04/30/17, and were not continued for the thirty (30) hours specified in the policy and procedure. --According to the Risk Management System report dated 05/07/17 at 5:45 p.m., Resident #6 was found in the floor of her bathroom. She was noted to have a bruise on her upper left back. Record review revealed neurological assessments were initiated and completed until 7:00 p.m. on 05/07/17. No neurological assessments were obtained after 7:00 p.m. 05/07/2017 until 7:45 a.m. on 05/08/17. Neurological assessments were resumed at 7:45 a.m. on 05/08/17 and continued until 11:45 p.m. on 05/08/17. However, the level of consciousness was not assessed after 11:45 a.m. on 05/08/17. According to the facility's Neurological Assessment policy, level of consciousness is a component of a complete neurological assessment. --Additionally, record review revealed Neurological Assessments were not initiated for the following unwitnessed fall. According to the Risk Management System report dated 05/07/17 at 6:10 a.m., Resident #6 was reported to roll out of bed. A skin tear was noted to her right hand. --According to the Risk Management System report dated 05/07/17 at 2:10 p.m., Resident #6 fell while attempting to stand from her wheelchair at the nurses' station. No injury was noted. A review of the facility policy for falls revealed, Falls Care Delivery Process, Response to a Patient Fall: Perform Neurological Assessment for all unwitnessed falls with head injury. According to the facility's Neurological Assessment 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. At 5:00 p.m. on 07/24/17 the Director of Nursing (DON) confirmed the facility had no further information to provide regarding the issues mentioned above. b) Resident #11 Medical record review revealed Resident #11, had a [DIAGNOSES REDACTED].#11 had a fall on 07/09/17 at 8:30 p.m. The Risk Management System report reflected, {typed as written}Called to room by CNA (nurse aide). He was laying on floor legs out straight at end of his bed I was going to get back in bed and just slid down on the floor. I am not hurt He is able to move all ext (extremities) without any c/o (complaint of) or s/s (signs/symptoms) of pain. VS (vital sign) obtained. Neuros initiated. A review of the neurological assessment completed after the fall on 07/09/17 revealed the neurological (neuro)assessment began at 8:45 p.m. Neuro checks were completed at 9:15 p.m., 9:45 p.m., 10:15 p.m., and 11:15 a.m. The neurological assessment policy dated with a revision date of 03/01/16 stated, 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. The facility had not completed the neuro assessment every 30 minutes for two hours. The assessment at 10:45 a.m. was not completed. Resident #11 sustained a fall on 06/09/17 at 6:30 p.m. The Risk Management System report reflected, {typed as written} Another resident was passing by room [ROOM NUMBER] and notified this nurse that someone was on the floor in the room. Entered room, observed resident sitting upright on his buttocks, leaning against the wall. States he was sitting on the side of the bed eating dinner, lost his balance, fell back on the bed and rolled out of the bed on the opposite side. Assessed resident and no injury noted. Neuros initiated. A review of the neurological assessment completed after the fall on 06/09/17 revealed the neuro assessment began at 6:30 p.m. Additional neuro checks were completed at 7:00 p.m., 7:30 p.m., and 8:00 p.m., and 10:00 p.m. The 30 minute checks for two (2) hours were not completed as a check at 8:30 p.m. was not done. An interview with the DON, 07/20/17 at 1:00 p.m., revealed there were no further information that the facility could provide any additional information regarding the missing neuro assessments for Resident #11.",2020-09-01
882,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-07-24,312,D,1,0,2NJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interviews, and record review, the facility failed to ensure activities of daily living care was provided for dependent residents for two (2) of eleven (11) residents. Facility failed to ensure Resident #63 received showers twice a week. Facility failed to ensure Resident #11 was offered assistance or cuing with meals. This failed practice had the potential to affect an isolated number of residents. Resident identifiers: #63, #11. Facility census: 113. Findings include: a) Resident #63 Resident #63 stated, on 07/20/17 at 3:00 p.m., she would like to receive a full shower with washing of her hair twice a week. She stated she was usually showered once a week. Resident #63 stated she was able to bathe herself at the sink in her bathroom on the days she was not showered. According to Resident #63's Care Plan with date of review 06/08/17, Resident requires total assist with bathing. Likes to bathe in her bathroom and prefers to shower only once a week. On 07/20/17 at 12:05 p.m., Registered Nurse (RN) #60 stated, Resident #63's Care Plan specified one shower weekly because the resident frequently refused showers. Review of the medical records revealed a General Nursing Progress Note written on 12/20/16 at 4:11 p.m. that stated, Spoke with resident today regarding bathing preferences. Resident states that she is getting a shower at least once a week. She states that she would like for this to be changed to twice weekly. She states she bathes at her sink by herself on the days she does not get a shower. Nurse Aide (NA) #26 said Resident #63 was scheduled to receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. NA #26 stated that most residents receive showers twice a week, but residents' personal preferences are also taken into consideration. Review of the Shower Schedule confirmed that Resident #63 was scheduled to receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. Review of the bathing section of the Activities of Daily Living (ADL) Records for Resident #63 revealed the following documentation: --05/05/17 - R (refusal of bathing) --05/11/17 - R (refusal of bathing) --05/15/17 - S (shower) --05/31/17 - S (shower) --06/01/17 - S (shower) --06/15/17 - S (shower) --07/05/17 - B (bed bath) --06/06/17 - R (refusal of bathing) --07/13/17 - S (shower) --07/17/17 - R (refusal of bathing) The remainder of the dates on the ADL Records for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), had no documentation of bathing. The Director of Nursing (DON) stated during an interview on 07/20/17 at 11:45 p.m. R means refusal, B means bed bath, and S means shower. Additionally, the Weekly Bath and Skin Report for (MONTH) (YEAR) documented showers were given on 06/01/17, 06/12/17, and 06/14/17. During an interview with Registered Nurse (RN) #150, at 3:00 p.m. on 07/20/17, the RN stated the Weekly Bath and Skin Reports were not completed for (MONTH) (YEAR) or (MONTH) (YEAR). The DON reviewed the ADL Reports for Resident #63 for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). On 07/25/17 at 11:40 a.m. the DON stated the ADL reports did not document that showers were given or offered on dates other than those listed above. b) Resident #11 An observation of Resident #11, on 07/19/17 at 10:00 a.m., revealed the resident had a bowl of oatmeal on his bedside table with a lid. During an interview with Registered Nurse (RN) #76, on 07/19/17 at 10:15 a.m., the RN stated the resident was often grumpy and not in a good mood. She said he did not eat much breakfast but wanted to keep his oatmeal this morning. RN #76 said the resident's daughter had contacted the facility and stated she felt her father was depressed. RN #76 indicated Nurse Aide (NA) #123 was assigned to the resident for the day shift. During an interview with NA #123 she said the resident needed help cutting up foods. NA#123 said he liked oatmeal. An observation on 07/19/17 at 12:45 p.m. revealed Resident #11 was attempting to eat oatmeal. At 5:15 p.m. on 07/19/17 RN #76 said the resident did not eat any breakfast on the morning of 07/19/17. An observation on, 07/19/17 at 12:20 p.m., revealed Resident #11 had received his lunch tray. Resident #11 was sleeping. Resident woke up and was trying with difficulty to put sugar in his oatmeal. He requested milk for the oatmeal. NA #87 came into the room to bring the milk. Continued observation revealed Resident #11 appeared unable to feed himself, unable to drink the milk. A straw was attempted but he was unable to get the cup to his mouth to drink and was unable to get a lot of the food in his mouth. On 07/19/17 at 4:00 p.m. the director of nursing (DON) and administrator were informed of the concerns regarding Resident #11's weight loss and lack of assistance with meals. The DoN and administrator were informed that the resident had lost ten (10) pounds since his admission on 06/07/17. At 5:30 p.m. an observation of Resident #11 revealed he was lying in bed with his dinner tray on his over bed table. He had only ate a small portion of his fish. He said he did not want anything else to eat. The Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/04/17 reflected that the resident needed encouragement, oversight and cueing with meals. A review of the resident's weights revealed he weighed 152.4 pounds (lbs.) on 06/07/17, 148.6 lbs. on 06/14/17, 145.8 lbs. on 06/21/17, 141.4 lbs. on 06/28/17, 142 lbs. on 07/05/17, and 142 lbs on 07/08/17 which was the last time he was weighed. The care plan review revealed a problem area dated 06/07/17 which stated, Resident #11 required assistance and was dependent for Activities of Daily Living (ADL) care. An intervention stated Provide resident/patient with set up assist for eating. An additional problem area stated, Resident is a nutritional concern r/t (related to) significant weight loss x 1 month, and dx (diagnosis) [MEDICAL CONDITION](hypertension), HLD ([MEDICAL CONDITION]), depression,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), dementia, refusing snacks, weakness, and [MEDICAL CONDITION] that may impact nutritional status. An intervention stated, Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. Nurse Aide (NA) #58 was interviewed, on 07/19/17 at 1:20 p.m., regarding Resident #11. NA #58 stated he had worked with Resident #11 and was assigned to the resident last week and been assigned to him off and on since the resident was admitted on [DATE]. NA #58 said the resident had declined since admission. He said the resident's daughter came to the facility last week and since that time the resident acted depressed. NA #58 said the resident had trouble cutting up his food. NA #58 said the resident would probably need to be fed given the deline had had experienced. On 07/19/17 at 4:00 p.m. the DoN and administrator were informed of the concerns regarding Resident #11's weight loss and lack of assistance with meals. The DON and administrator were informed that the resident had lost ten (10) pounds since his admission on 06/07/17. On 07/20/17 at 9:00 a.m. an observation of Resident #11 revealed he had eaten some scrambled eggs, a few bites of toast, and oatmeal. He said he fed himself the oatmeal. He also had a weighted fork and spoon on his tray as well as a plastic drinking cup (Kennedy Cup) with a lid and a straw. At 11:00 a.m. on 07/20/17 Certified Occupational Therapy Assistant (COTA) #157 said she had came to the facility this morning due to the surveyor's concerns. She said she had gotten Resident #11 to get up into his chair at his over-bed table to eat breakfast. She said he ate all of his oatmeal, some of his egg and toast. She said she initiated a Kennedy cup for him and weighted utensils because he had a [DIAGNOSES REDACTED]. A note, dated 07/20/17 from COTA #157, stated, Resident is to be in the Maple dining in his w/c (wheelchair) for all meals to facility and increase participation in meal and with verbal cues and to decrease spillage of food and provide Resident a Kennedy cup for all meals and all beverages to decrease risk of spillage. During an interview with the Registered Nurse (RN) #331 and the Dietician on 07/24/17 at 1:30 p.m. they said the resident had been to the assisted Maple Dining Room on 07/20/17, 07/21/17, 07/24/17 and the resident had ate about 75%. RN #331 and the Dietician both stated the resident received cueing during the meals in the Maple Assisted Dining Room and ate well with this assistance. Prior to 07/20/17 the resident had not been out of his room for any meal. He had been mostly in bed when meals were served.",2020-09-01
883,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2017-07-24,325,D,1,0,2NJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and staff interview, the facility failed to ensure one (1) of 11 residents maintained acceptable parameters of nutritional status such as body weight unless the resident's clinical condition demonstrated that it was not possible. Resident #11 experienced a 6.8% weight loss over a period of thirty days and timely nutritional interventions were not addressed. Resident identifier: #11. Facility census: 113. Findings include: a) Resident #11 An observation of Resident #11, on 07/19/17 at 10:00 a.m., revealed Resident #11 had a bowl of oatmeal on his over-bed table. The oatmeal was in a plastic bowl covered with a lid. During an interview with Registered Nurse (RN) #76 on 07/19/17 at 10:15 a.m., the RN stated the resident was often grumpy and not in a good mood. She said he did not eat much breakfast but wanted to keep his oatmeal this morning. RN #76 said the resident's daughter had contacted the facility and stated she felt her father was depressed. A progress note dated 07/19/17, stated the nurse practitioner had seen the resident on 07/19/17 and had increased the [MEDICATION NAME] (antidepressant) to 150 mg (milligram) daily. RN #76 indicated Nurse Aide (NA) #123 was assigned to the resident for the day shift. During an interview with NA #123 at 10:30 a.m. she said the resident would need help cutting up foods. She said he liked oatmeal. An observation on 07/19/17 at 12:45 p.m. revealed Resident #11 was attempting to eat oatmeal. At 5:15 p.m. on 07/19/17 RN #76 said the resident did not eat any breakfast on the morning of 07/19/17. RN #76 said the resident did like oatmeal. An observation on 07/19/17 at 12:20 p.m. revealed Resident #11 had received his lunch tray. Resident #11 was sleeping. Resident woke up and was trying with difficulty to put sugar in his oatmeal. He requested milk for the oatmeal. NA #87 came into the room to bring the milk. Continued observation revealed Resident #11 appeared unable to feed himself, unable to drink the milk. A straw was attempted but he was unable to get the cup to his mouth to drink and was unable to get a lot of the food in his mouth. Nurse Aide (NA) #58 was interviewed on 07/19/17 at 1:20 p.m. regarding Resident #11. NA #58 stated he had worked with Resident #11 and was assigned to the resident last week and been assigned to him off and on since the resident was admitted on [DATE]. NA #58 said the resident had declined. He said the resident's daughter came to the facility last week and since that time the resident acted depressed. NA #58 said the resident had trouble cutting up his food. NA #58 said the facility would probably need to start feeding him. On 07/19/17 at 2:40 p.m., Occupational Therapist #92 stated he was unaware of any problems regarding Resident #11 eating, cutting food or having the need for any assistance with meals or specialized eating utensils. On 07/19/17 at 4:00 p.m. the Director of Nursing (DoN) and administrator were informed of the concerns regarding Resident #11's weight loss and lack of assistance with meals. The DoN and administrator were informed that the resident had lost ten (10) pounds since his admission on 06/07/17. At 5:30 p.m. on 07/19/17 an observation of Resident #11 revealed he was lying in bed with his dinner tray on his over bed table. He had only ate a small portion of his fish. He said he did not want anything else to eat. At 5:35 p.m. on 07/19/17, RN #76 was asked how much breakfast the resident ate this morning and she said she did not think he ate any breakfast. A review of the activities of daily living (ADL) record revealed the resident ate 50% of breakfast on 07/19/17. During an interview with the Director of Nursing (DON) on 07/20/17 at 11:00 a.m., she was asked how the facility calculated meal percentages. She was informed of the resident not eating any breakfast on 07/19/17 and having a 50% of meal consumption recorded on the ADL sheet for 07/19/17. At 12:00 p.m. the DON said she had contacted NA #123 because she was the aide assigned to Resident #11 on 07/19/17 and NA #123 stated she did not know how much the resident ate for breakfast because she just wrote anything down. On 07/20/17 at 9:00 a.m. an observation of Resident #11 revealed he had eaten some scrambled eggs, a few bites of toast, and oatmeal. He said he fed himself the oatmeal. He also had a weighted fork and spoon on his tray as well as a plastic drinking cup (Kennedy Cup) with a lid and a straw. At 11:00 a.m. on 07/20/17 Certified Occupational Therapy Assistant (COTA) #157 said she had come to the facility this morning due to the surveyor's concerns. She said Resident #11 sat up in his chair at his over-bed table to eat breakfast. She said he ate all of his oatmeal, some of his egg and toast. She said she initiated a Kennedy cup for Resident #11 and the weighted utensils because the resident had a [DIAGNOSES REDACTED]. A note dated 07/20/17 from COTA #157 stated, Resident is to be in the Maple dining in his w/c (wheelchair) for all meals to facility and increase participation in meal and with verbal cues and to decrease spillage of food and provide Resident a Kennedy cup for all meals and all beverages to decrease risk of spillage. During an interview with the Director of Nursing (DON) on 07/20/17 at 11:00 a.m., she was asked how the facility calculated meal percentages. She was informed of the resident not eating any breakfast on 07/19/17 and having a 50% of meal consumption recorded on the ADL sheet for 07/19/17. At 12:00 p.m. the DON said she had contacted NA #123 because she was the aide assigned to Resident #11 on 07/19/17 and NA #123 stated she did not know how much the resident ate for breakfast because she just wrote anything down. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/17 reflected that the resident needed encouragement, oversight and cueing with meals. A review of the resident's weights revealed he weighed 152.4 pounds (lbs.) on 06/07/17, 148.6 lbs. on 06/14/17, 145.8 lbs. on 06/21/17, 141.4 lbs. on 06/28/17, 142 lbs. on 07/05/17, and 142 lbs. on 07/08/17, which was the last time he was weighed. The care plan review revealed a problem dated 06/07/17 which stated Resident #11 required assistance and was dependent for Activities of Daily Living (ADL) care. An intervention stated Provide resident/patient with set up assist for eating. An additional problem area stated Resident is a nutritional concern r/t (related to) significant weight loss x 1 month, and dx (diagnosis) [MEDICAL CONDITION](hypertension), HLD ([MEDICAL CONDITION]), depression,[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), dementia, refusing snacks, weakness, and [MEDICAL CONDITION] that may impact nutritional status. An intervention stated, Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. An telephone interview with the Dietician on 07/20/17 at 2:00 p.m. revealed she did not know if the facility had reviewed any food preferences with Resident #11. She said she had been monitoring the resident's weights based on the ADL sheet. She said based on the calories provided by the meals and the percentages recorded as consumed the resident's weight should be stable. She was informed that NA #123 had confirmed she just wrote anything down for the percentage of meal consumed at breakfast on 07/20/17. She was also informed the resident had lost 6.8% in thirty days. On 07/21/17 the Dietician completed a nutritional assessment which stated, Weight loss review. Diet Regular/liberalized with fair to good PO (by mouth) intakes recorded. Able to feed self with supervision. RD (Registered Dietician) sat with resident today to fill out food preference questionnaire. Resident answered appropriately and this was given to DDS (director dietary service) to update Resident is agreeable to starting house supplements TID (three times a day) with meals (chocolate or vanilla) until appetite improves. Will continue to monitor weekly weights as resident will allow. He has been encouraged to eat in Maple dining room for encouragement. Kennedy cup to aid in self feeding. CBW: 142# BMI (body mass index) WNL (within normal limits) Down 10# x 1 month (-6.6%). On 07/10/17 the Dietician completed a nutritional assessment which stated, Weight loss review, Diet: Regular/liberalized diet with good/excellent intakes recorded. Able to feed self with supervision. Staff reports that he does not like the food, however, ADL documentation shows resident consuming 90-100% of meals. DDS has seen the resident to update preferences. Will continue to monitor weekly weights at this time to determine further intervention. Started on [MEDICATION NAME] swish and swallow for mouth pain. CBW (current body weight): 142# BMI (body mass index) WNL (within normal limits) Down 10# x 1 mouth During an interview with the Registered Nurse (RN) #331 and the Dietician, on 07/24/17 at 1:30 p.m., they said the resident had been to the assisted Maple Dining Room on 07/20/17, 07/21/17, 07/24/17 and the resident had ate about 75%. RN #331 and the Dietician both stated the resident received cueing during the meals in the Maple Assisted Dining Room and ate well with this assistance. Prior to 07/20/17 the resident had not been out of his room or up to a chair for meals.",2020-09-01
885,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-12-06,558,D,1,0,S4Q511,"> Based on observation and staff interview, the facility failed to ensure Resident #77's call light was within reach at all times. This was a random opportunity for discovery. Resident identifier: #77. Facility census: 113. Findings included: a) Resident #77 An observation of Resident #77 at 2:55 p.m. on 12/03/18 found her to be sleeping in her bed. Upon closer observation Resident #77's call light was found to be behind her night stand and was not accessible to her should she have needed to call for staff's assistance. Nurse Aide #25 confirmed Resident #77's call light was not in reach. When asked if Resident #77 would be able to use her call light had it been in reach Nurse Aide #25 indicated Resident #77 was able to use and understood how to use her call light.",2020-09-01
886,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-12-06,684,D,1,0,S4Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure residents were provide with the care and services needed for them to maintain and or attain their highest practicable physical, mental and psychosocial well- being. For Resident #35, the facility failed to complete the neurological checks after a fall on three (3) separate occasions. For Resident #109, the facility failed to obtain blood pressures daily for seven (7) days as ordered by the attending physician. For Resident #63, the facility failed to administer antihypertensive medications according to physician's orders [REDACTED]. Resident identifier: #63, #35 and #109. Facility census: 113. Findings included: a) Resident #109 Review of the Resident #109's medical record at 11:30 a.m. on 12/04/18 found a physician order [REDACTED]. A review of the Medication Administration Record for (MONTH) (YEAR) found Resident #109's blood pressure was on documented on the MAR on 09/25/18. Further review of the record found Resident #109''s blood pressure was also obtained on 09/27/18 and was documented in the electronic medical record. However no blood pressure readings were documented in the medical record for 09/26/18, 09/28/18, 09/29/18, 09/30/18, and 10/01/18 as ordered by the physician. An interview with Registered Nurse RN #86 at 5:13 p.m. on 12/04/18 confirmed no blood pressures were obtained on the above mentioned dates as ordered by the physician for Resident #109. b) Resident #35 A review of Resident #35's medical record at 1:45 p.m. on 12/04/18. The resident fell on the following dates: --10/08/18 at 10:35 p.m. Resident sitting on the edge of bed leaned forward and hit head on bedside table current bruise to right eye and small laceration over right eye. --10/08/18 at 12:30 a.m. resident found resting on hands and knees beside bed. Assessed for injury and pain initiated neuro checks. --10/07/18 at 3:00 a.m. resident leaned forward in wheelchair and fell face down onto the floor at Nurses station a small cut noted to right eyebrow with no distress voiced. Resident was assisted to wheelchair brought into nurses station neuro checks started. --10/06/18 at 6:30 a.m. resident was found laying on the floor at bedside unable to explain what happened she was assessed for injury and assisted back into bed. Further review of the Resident #35's medical record found that on 10/08/18 and 10/07/18, a neurological assessment was started for Resident #35 but as not completed at the appropriate time frames as directed by the facility's Neurological Assessment policy. The Neurological Assessment policy indicates a neurological assessment must be performed as indicated or ordered when a resident sustains an injury to the head, and/or has an unwitnessed fall. The neurological assessment frequency is: -- every 30 minutes X (times) two hours, then; -- every one hour X four hours; and -- every four hours X 24 hours. For the fall on 10/06/18 the facility failed to initiate any neurological checks even though the fall was unwitnessed. On 10/07/18 the facility only completed neurological assessment once every hour for five (5) hours and then completed no more assessments. On 10/08/18 the facility completed the 30 minute and one (1) hour checks but did not complete the once every four (4) hour checks for 24 hours. An interview with RN #86 at 5:13 p.m. on 12/04/18 confirmed Resident #35's neurological checks were not completed on 10/07/18 and 10/08/18 and the neurological checks were never initiated on 10/06/18 when he resident had an unwitnessed fall. c) Resident #63 Medical record review for Resident #63, on 12/04/18 at 10:00 a.m., found a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 110 mmHg (millimeters of mercury - the unit used to measure blood pressures). Review of Resident #63's medication administration record (MAR), found blood pressures for the period of 11/01/18 through 11/30/18 as follows: -- 11/03/18 at 8:00 a.m. blood pressure was 105/56. -- 11/04/18 at 8:00 a.m. blood pressure was105/62. Further medical record review, found a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 110 mmHg or heart rate 60 or below. Review of Resident #63's MAR, found blood pressures for the period of 11/01/18 through 11/30/18 as follows: -- 11/02/18 at 8:00 p.m. blood pressure was 105/56. -- 11/03/18 at 8:00 a.m. blood pressure was 105/56. -- 11/04/18 at 8:00 a.m. blood pressure was105/62. This review of Resident #63's BP revealed they were out of the physician ordered parameters on five (5) occasions, yet the medication for which the parameters were ordered, was administered. Per the physician orders [REDACTED]. No evidence was found in the resident ' s medical record to indicate the physician had been notified of the resident receiving the medication outside of the physician ordered parameters. On 12/04/18 at 2:00 p.m., a discussion with Director of Nursing (DON), confirmed the blood pressures for Resident #63 and the medication should not have been administered. She agreed there was no evidence of physician notification.",2020-09-01
888,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-12-06,757,D,1,0,S4Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure each resident's medication regimen was free of unnecessary medications. The facility failed to ensure resident receiving antihypertensive (high blood pressure) medications were given those medications only when indicated and to avoid the potential for adverse consequences. Resident identifier: #63. Facility census: 116. Findings included: a) Resident #63 Medical record review for Resident #63, on 12/04/18 at 10:00 a.m., found a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 110 mmHg (millimeters of mercury - the unit used to measure blood pressures). Review of Resident #63's Medication Administration Record [REDACTED] -- 11/03/18 - 8:00 a.m. - 105/56. -- 11/04/18 - 8:00 a.m. - 105/62. Further medical record review, found a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 110 mmHg or heart rate 60 or below. Review of Resident #63's MAR, found blood pressures for the period of 11/01/18 through 11/30/18 as follows: -- 11/02/18 - 8:00 p.m. - 105/56. -- 11/03/18 - 8:00 a.m. - 105/56. -- 11/04/18 -8:00 a.m. - 105/62. This review of Resident #63's BP revealed they were out of the physician ordered parameters on five (5) occasions, yet the medication for which the parameters were ordered, was administered. No evidence was found in the resident ' s medical record to indicate the physician had been notified of the resident receiving the medication outside of the physician ordered parameters. On 12/04/18 at 2:00 p.m., a discussion with Director of Nursing (DON), confirmed the blood pressures for Resident #63 and the medication should not have been administered. She agreed there was no evidence of physician notification.",2020-09-01
889,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-12-06,761,D,1,0,S4Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure an intravenous (IV) medication bag was labeled with the date it was administered, the time it was administered and by what nurse it was administered when it was hung on the IV pole for administration. This was a random opportunity for discovery. Resident identifier #109. Facility census: 113. Findings included: a) Resident #109 Observations of Resident #109's room at 3:15 p.m. on 12/03/18 found an IV bag with Resident #09's name on it hanging on an IV pole in the residents room. The bag once contained the IV medication of [MEDICATION NAME]. The IV bag was not labeled as to when it was hung for administration or which nurse had hung the medication for administration. The Director of Nursing (DON) came to the room at 3:338 p.m. on 12/03/18. She observed the IV bag and confirmed it was not labeled appropriately when it was hung. She indicated the nurse should have put the date and time and also her initials when she administered the IV medication. She also confirmed the medication bag and the IV pole and pump should have been removed from the residents room because Resident #109 had been out to the hospital since 11/27/18.",2020-09-01
891,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2018-12-06,842,D,1,0,S4Q511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to make sure the medical record was complete and accurate for Resident #117 who had two (2) nursing assessments which were not accurately completed. For Resident # 63, skin checks were not accurately completed in the medical record. This was true for three (3) of ten (10) sampled residents. Resident identifiers: # 117 and #63. Facility census: 113. Findings included: a) Resident #117 A review of Resident #117's medical record at 11:41 a.m. on 12/04/18 found Resident #117 was ordered [MEDICATION NAME] (a diuretic medication) 10 mg twice daily beginning on the day of her admission to the facility 11/12/18. A review of the Medication Administration Record [REDACTED]. A review of the nursing admission assessment dated [DATE] and the nursing expanded assessment dated [DATE] found this diuretic medication was not marked as being received by the resident in section B-3. Medications requiring care planning. Diuretic medication is an option to mark under this section but was not marked on either assessment. An interview with the Director of Nursing (DON) at 1:00 p.m. on 12/04/18 confirmed the nursing assessments dated 11/12/18 and 11/16/18 were not accurately completed and did not reflect the residents use of a diuretic medication. b) Resident #63 Review of Resident #63's medical records found current Skin Integrity Report found the resident had pressure ulcers noted on right medial lower leg, right lateral lower leg, left lateral lower leg and left distal lateral lower leg. Further review found two (2) skin checks dated 11/26/18 and 12/03/18, both documented Resident #63 had pressure ulcers on bilateral legs, right ischial and left buttocks. Interview with the DON on 12/04/18 at 1:00 pm. confirmed the two (2) skin checks dated 11/26/18 and 12/03/18 were inaccurrate concrning pressure ulcers on the right ischial and left buttocks; both areas were healed in early (MONTH) (YEAR).",2020-09-01
892,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,164,D,0,1,X99F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and observation, the facility failed to ensure a medication and pharmacy labels were disposed of in a manner to protect personal, medical, and health information. Personal identifiers including a resident's name and medication were listed on the pharmacy label. This was a random observation. Resident identifier: #13. Facility census: 100. Findings include: a) A random observation of the 200 Hall, on 03/14/17 at 8:45 a.m., revealed one (1) visible empty medication card/packet in the trash can of the medication cart. The following medication card contained the resident's full name and medication order for [MEDICATION NAME] 25 milligrams (mg) on the pharmacy label. An interview with Licensed Practical Nurse (LPN) #1, on 03/14/17 at 8:50 a.m., revealed they only remove the resident's information from discarded medication packets for narcotic medications. The LPN stated all other medication packets are just thrown in the trash. An interview with the Director of Nursing (DON), on 03/14/17 at 11:00 a.m., revealed all empty medication cards/packets should have the resident's information removed before discarding.",2020-09-01
897,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,456,D,0,1,X99F11,"Based on observation and staff interview, the facility failed to ensure resident equipment and chairs were maintained in a safe comfortable operating condition. A chair in a resident's room utilized by the resident and visitors had a large deep tear in the seat cushion. This has the potential to affect more than a limited number of residents. Resident #49. Facility census: 100. Findings include: a) Chair An observation on 03/13/17 at 11:00 a.m., found the seat cushion of a large blue chair in Resident #49's room was torn exposing the chair filling. A large deep slit, approximately 6 inches long was noted in the center of the seat running from the front seat edge towards the back of the chair. Maintenance helpers #130 and #121 agreed the chair cushion needed to be repaired during an interview on 03/13/17 at 12:45 p.m. They reported they routinely make rounds assessing the environment, but the nursing staff need to fill out a slip request for the repair. The maintenance helpers agreed the chair could not be sanitized, should not be used by a resident and removed it immediately.",2020-09-01
898,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2017-03-15,514,D,0,1,X99F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the completeness and accuracy of the clinical record for one (1) of twelve (12) residents reviewed during Stage II of the Quality Indicator Survey. Resident #33's medical record lacked information related to the care and treatment he received, including a discharge summary and plan of care during a recent stay at an acute center. Resident Identifier: #33. Facility census: 100. Findings include: a) Resident #33 Review of the medical record, on 03/15/17 at 10:55 a.m., revealed Resident #33 had two recent stays at acute care centers. He was recently discharged from the hospital and returned to the facility on [DATE]. The computerized nursing observation record, dated 02/16/17 at 04:03 p.m., revealed the resident returned from hospital via an ambulance, and medications and orders were reconciled with physician. The medical record lacks any information related to this recent stay at the hospital including any treatments, testing, or physician's discharge summary. In addition, the records were silent in regards to the Stage II pressure ulcer he developed prior to his transfer to the acute care center on 02/12/16. On 03/15/17 at 11:27 a.m., the medical records supervisor confirmed the chart lacked a discharge summary for Resident #33's recent stay at the acute care center. She contacted the hospital and was told the record could not be released without a physician's signature. Registered Nurse (RN) #78 reviewed the medical record during an interview, on 03/15/17 at 11:30 a.m., and confirmed there was no information related to the resident's recent stay in the acute care center. RN #81 was interviewed, at 11:45 a.m. on 03/16/17, and stated they usually do not get any information from the acute care center related to the resident's treatment, diagnosis, or recent assessments and the hospital rarely addresses the resident's pressure ulcers. Upon return to the facility, the staff nurses do not document in the records any report they receive from the acute care center. RN #81 confirmed Resident #33 still had a Stage II pressure ulcer when he returned to the facility and agreed the chart lacked information related to any treatments or [DIAGNOSES REDACTED]. A copy of the physician's discharge summary was presented to the team at the time of exit. The form lacks any information related to his Stage II pressure ulcer.",2020-09-01
900,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2018-05-02,657,D,0,1,GH3711,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure Resident #38 was invited to attend and participate in care plan meetings. Resident #38 had not been invited or attended a care plan meeting since (YEAR). This practice affected one (1) of twenty (20) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #38. Facility census: 95. Findings included: a) Resident #38 An interview with Resident #38, on 05/02/18 at 10:00 AM, revealed she had not been invited to or attended a care plan meeting in years. The Resident stated the staff does not discuss any aspect of her care plan with her. A review of the Resident's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/07/18, was conducted on 05/02/18 at 10:15 AM. Section C-Cognitive Patterns of the assessment revealed the Resident scored a 15 on the Brief Interview for Mental Status (BIMS) assessment. A score of 15 indicated the Resident had little to no impairment. A review of the Resident's medical record, on 05/02/18 at 11:00 AM, revealed there was no documentation the Resident had been invited to or attended any care plan meetings. An interview with the Director of Nursing (DON), on 05/02/18 at 11:15 AM, revealed all residents or representatives should be invited to attend all care plan meetings. The DON stated Resident #38 had not been attending care plan meetings. The DON stated she could not provide any documentation where Resident #38 had been invited or attended a care plan meeting since (YEAR).",2020-09-01
905,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,550,D,0,1,9FZF11,"Based on observation and staff interview, the facility failed to treat each resident with respect and dignity, and in an environment that promoted maintenance or enhancement of his or her quality of life. Multiple residents were seen by a physician at the same time, a resident was wearing only a brief and could be seen from the hallway, a nurse initialed and dated a wound care dressing after it was on the resident, and a catheter bag was not covered. These practices affected more than a limited number of residents. Resident identifiers: #9, #17, and #59. Facility census: 98. Findings included: a) Resident #17 An observation of the 600 Hallway, on 07/08/19 at 10:15 AM, revealed Resident #17 was sitting up in a chair in his room wearing only a t-shirt and a brief. The Resident did not have pants on. The Resident was fully visible from the hallway. The privacy curtain was not closed and the Resident had nothing covering his lower body. An interview with Licensed Practical Nurse (LPN) #125, on 07/08/19 at 10:18 AM, revealed the Resident prefers not to wear pants when he is up in his chair. The LPN stated the Resident should be covered with a blanket or have his privacy curtain closed when wearing only a brief. b) Resident # 9 On 07/10/19 at 11:00 AM registered nurse (RN) #44, completed wound care for Resident #9. Upon completing the care RN #44 placed the bandage on the resident and then placed a date and initial on the bandage. Registered nurse #44 explained she usually dates and initials the bandage before placement but was nervous, due to being monitored, while completing the care.",2020-09-01
906,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,580,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to immediately contact resident's physicians and the resident's representatives when an incident involving residents occurred. Physicians and resident representatives were not contacted immediately when there was an allegation of sexual abuse. This practice affected two (2) of twenty-three (23) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review 1. Notification of Changes Facility Policy A review of the facility's policy Notification of Changes with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated the facility is to ensure the Center promptly informs the resident, consult's the resident's physician; and notify, consistent with his or her authority, resident representative when there is a change requiring notification. This includes competent individuals. Circumstances requiring notification include a resident's physical, mental, or psychosocial condition. 2. Compliance with Reporting Allegations of Abuse Neglect Exploitation Facility Policy A review of the facility's policy Compliance with Reporting Allegations of Abuse Neglect Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated The Center is to report all allegations of abuse/neglect/exploitation to the approprpriate agencies in accordance with current state and federal regulations. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The Licensed Nurse or designee will respond to the needs of the resident and protect him/her from further incident, notify the Director of Nursing and Administrator, notify the attending physician, resident's family, and medical director, monitor and document the resident's condition-including response to medical intervention and nursing interventions, document actions taken in the medical record, and complete an incident report and initiate an investigation. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility in (MONTH) of 2019 with the primary [DIAGNOSES REDACTED]. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility in (MONTH) 2019 with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home 11 days after admission. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: -06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the Nurses Notes for Resident #89, on 07/10/19 at 11:10 AM, revealed the following notes involving other instances of inappropriate sexual behavior with the Resident: --05/13/19 at 1:25 PM-Resident #89 is sexually inappropriate with staff and difficult to redirect. --05/14/19 at 7:25 AM-Resident #89 is combative with care, physically/verbally/sexually inappropriate with staff. --05/15/19 at 7:25 AM-Resident #89 has behaviors, sexual, physical and verbal. Resident is one on one for these behaviors as of right now. --05/16/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --05/18/19 at 7:25 AM-Resident #89 has inappropriate sexual behavior with CNAs and other staff. --05/20/19 at 7:25 AM-Resident #89 makes sexual remarks. --05/23/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --05/29/19 at 11:10 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --06/09/19 at 8:26 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. The record contained no evidence the physician or legal representative was notified of the inappropriate sexual behaviors exhibited from 05/13/19 through 06/09/19. Further review of the medical record for Resident #89, on 07/10/19 at 11:05 AM, revealed no documentation the the care plan was updated to reflect the inappropriate sexual behaviors exhibited from 05/13/19 through 06/09/19. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the physician was contacted for either resident concerning this incident. The Resident Representative for Resident #89 was also not notified. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON stated she had no documentation that the physician or resident representative had been contacted concerning the incident. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated she had no idea the physician or resident representative had to be contacted for the incident. The DON stated there was no investigation completed and that there were no physician interventions put into place for the allegation on 06/06/19. The DON stated she could not provide any documentation showing that either Resident involved was assessed immediately after the incident occurred. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC stated the physician and all responsible parties should have been notified immediately upon the report of the allegation. The CCQC stated she had reviewed the records for Resident #89 and Resident #252 and there was no documentation the physician or responsible parties were notified. The CCQC verified there was no documentation in Resident #252's record concerning the incident on 06/06/19. The CCQC also stated all required parties would be notified on 07/10/19. The facility only notified the physician and legal representative after identification of the issue by this surveyor. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 that assessments notification of the physician or resident representative, was done for Resident #89 or Resident #252. An interview with the facility's Medical Director and Physician to Resident #89 and #252, on 07/10/19 at 12:30 PM, revealed he does not remember being contacted about the incident where Resident #89 touched Resident #252's breast. The Medical Director agreed he should have been notified.",2020-09-01
910,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,609,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure that an allegation of sexual abuse was reported immediately, but not later than 2 hours after the allegation is made, to the administrator of the facility and to other officials (including to the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. The facility did not report an incident involving a male resident inappropriately touching a female resident's breast. This practice affected one (1) of three (3) reportable incidents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review 1. Abuse Neglect and Exploitation Policy A review of the facility's policy Abuse Neglect and Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated Sexual abuse is non-consensual contact of any type with a resident. 2. Compliance with Reporting Allegations of Abuse Neglect and Exploitation Policy A review of the facility's policy Compliance with Reporting Allegations of Abuse Neglect Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated: --The Center is to report all allegations of abuse/neglect/exploitation to the appropriate agencies in accordance with current state and federal regulations. --Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --The Center will report all alleged violations to the state agency and to all other agencies as required. --The Licensed Nurse or designee will respond to the needs of the resident and protect him/her from further incident, notify the Director of Nursing and Administrator, notify the attending physician, resident's family, and medical director, monitor and document the resident's condition-including response to medical intervention and nursing interventions, document actions taken in the medical record, and complete an incident report and initiate an investigation. --The Director of Nursing, Administrator, or designee will notify the appropriate agencies immediately, as soon as possible, no later than 24 hours after the discovery of the incident, obtain statements from the direct care staff, and follow up with the appropriate agencies to confirm the report was received. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. The Resident was alert and able to make his needs known upon admission. The resident was able to walk on his own. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility on [DATE] with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home on 06/11/19. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: --06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the physician was contacted for either resident concerning this incident. The Resident Representative for Resident #89 was also not notified. Resident #252's record had no documentation about the incident with her breast being touched by Resident #89. There is no documentation the incident was reported to anyone. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON stated she had no documentation that the physician or resident representative had been contacted concerning the incident. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated she could not provide any documentation showing protects were put in place to protect the resident. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC verified no incident report was completed nor was the incident reported to the state. The CCQC stated the incident was reported on 07/10/19 (after surveyor intervention) to all the required agencies. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 the allegation of sexual abuse was reported to the required state agencies within 2 hours of notification of the allegation.",2020-09-01
911,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,610,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to have evidence that an alleged violation of sexual abuse was thoroughly investigated. The facility did not investigate an incident involving a male resident inappropriately touching a female resident's breast. In addition, they failed to implement protections for the resident (alleged victim) while the investigation was conducted. This failed practice affected one (1) of three (3) reportable incidents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #89 and #252. Facility census: #98. Findings included: a) Policy Review A review of the facility's policy Abuse Neglect and Exploitation with an implementation date of 11/27/17 was reviewed on 07/10/19. The policy stated Sexual abuse is non-consensual contact of any type with a resident. b) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on [DATE] with the primary [DIAGNOSES REDACTED]. The Resident was alert and able to make his needs known upon admission. The resident was able to walk on his own. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the medical record for Resident #252, 07/10/19 at 10:55 AM, revealed the Resident was admitted to the facility on [DATE] with fractures sustained from a motorcycle accident. The Resident was fully capacitated. The Resident was discharged from the facility to home on 06/11/19. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: --06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. The female was Resident #252. Further review of the medical records for Resident #89 and #252, on 07/10/19 at 11:05 AM, revealed no documentation the incident was investigated by anyone. c) Interviews An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed Resident #252 had reported to the staff that Resident #89 touched her breast inappropriately on 06/06/19. The DON verified there was no documentation in Resident #252's record concerning the incident. The DON stated she did not know Resident #252 reporting that her breast was touched inappropriately was an allegation of sexual abuse. The DON stated there was no investigation completed and that there were no physician interventions put into place for the allegation on 06/06/19. The DON stated she could not provide any documentation showing that either Resident involved was assessed immediately after the incident occurred. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/10/19 at 11:20 AM, revealed the incident on 06/06/19 with Resident #89 and Resident #252 was an allegation of sexual abuse. The CCQC verified there was no documentation in Resident #252's record concerning the incident on 06/06/19. The CCQC verified no investigation was completed concerning the alleged sexual abuse. An interview with the Administrator, on 07/10/19 at 11:30 AM, revealed she could not provide any documentation from 06/06/19 that assessments were done concerning the allegation, nor an investigation being initiated for Resident #89 or Resident #252 concerning the allegation of sexual abuse.",2020-09-01
912,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,656,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs. A care plan was not developed for a resident with multiple sexual behaviors towards staff and another resident. This practice affected one (1) of twenty-three (23) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #89. Facility census: 98. Findings included: a) Record Review A review of the medical record for Resident #89, on 07/10/19 at 10:45 AM, revealed the Resident was admitted to the facility on (MONTH) 2019 with the primary [DIAGNOSES REDACTED]. The Resident did not have capacity. The Resident had a healthcare surrogate. A review of the Nurses Notes for Resident #89, on 07/10/19 at 11:50 AM, revealed the following note: --06/06/19 at 10:45 AM-Resident #89 inappropriately touched a female resident's breast. Further review of the Nurses Notes for Resident #89, on 07/10/19 at 11:10 AM, revealed the following notes involving other instances of inappropriate sexual behavior with the Resident: --05/13/19 at 1:25 PM-Resident #89 is sexually inappropriate with staff and difficult to redirect. --05/14/19 at 7:25 AM-Resident #89 is combative with care, physically/verbally/sexually inappropriate with staff. --05/15/19 at 7:25 AM-Resident #89 has behaviors, sexual, physical and verbal. Resident is one on one for these behaviors as of right now. --05/16/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --05/18/19 at 7:25 AM-Resident #89 has inappropriate sexual behavior with CNAs and other staff. --05/20/19 at 7:25 AM-Resident #89 makes sexual remarks. --05/23/19 at 7:25 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --05/29/19 at 11:10 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. --06/09/19 at 8:26 AM-Resident #89 is combative with care, physically, verbally, sexually inappropriate with the staff. Further review of the medical record for Resident #89, on 07/10/19 at 11:05 AM, revealed no documentation the the care plan was updated to reflect the inappropriate sexual behaviors exhibited from 05/13/19 through 06/09/19. b) Interview An interview with the Director of Nursing (DON), on 07/10/19 at 11:15 AM, revealed the Care Plan for Resident #89 was not updated to reflect the Resident's sexual behaviors until 07/10/19 after this surveyor identified the issue.",2020-09-01
914,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,677,D,0,1,9FZF11,"Based on observation, record review and staff interview, the facility failed to provide a resident who could not carry out activities of daily living (ADLS) , the necessary services to maintain good grooming for one (1) of 23 sampled residents . Resident identifier: #37 Findings included: Observations on 07/08/19 at 12:18 PM, revealed Resident #37 had long dirty fingernails. An observation on 07/09/19 at 12:10 PM, revealed Resident #37 continued to have the long dirty fingernails. Review of the care plan, on 07/09/19 at 12:15 PM, showed that Resident #37 to be at risk for decline in Activities of Daily living (ADLs), with an intervention requiring assistance of one staff for hygiene. An interview with the DON on 07/09/19 at 03:00 PM, verified Resident #37's fingernails were dirty and there was no documentation of care being completed or care not attempted because of refusal noted.",2020-09-01
915,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,684,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensurephysician orders [REDACTED]. This practice affected 1 of 23 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #150. Facility census: 98. Findings included: a) Resident #150 An interview with R#150, on 07/08/19 at 11:53 AM, revealed the dressing on the right arm covering a peripherally Inserted Central Catheter (PICC) had not been changed since coming to the facility. The resident stated this is the same dressing as I had in the hospital. A record review on 07/09/19 at 01:00 PM, noted a physician's orders [REDACTED]. to change the PICC line dressing every week- one time a day on Friday. A review of the treatment record showed no evidence the treatment was provided 07/05/19 (Friday) as ordered by the physician. An interview on 07/09/19, at 1:30 PM, with the DON, confirmed the dressing ordered 07/05/19 had not been done.",2020-09-01
916,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,689,D,0,1,9FZF11,"Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. A shower room that contained razors and chemical substances was open for anyone to access. This practice had the potential to affect a limited number of residents. Room identifier: 600 Hallway Shower Room. Facility census: 98. Findings included: a) 600 Hallway Shower Room An observation of the 600 Hallway Shower Room, on 07/08/19 at 10:45 AM, revealed the room was not locked and accessible to anyone. The room contained the following items: --Three (3) containers of Medspa Shave Cream with the warning Keep out of reach of children. --Two (2) containers of Remedy Phytoplex Cleanser with the warning For external use only. --Two (2) containers of Medline Anti-Perspirant with the warning Keep out of reach of children-If accidentally swallowed get medical help or contact a Poison Control Center. --Seven (7) capped shaving razors. An interview with Licensed Practical Nurse (LPN) #125, on 07/08/19 at 10:50 AM, revealed the Shower Room is usually unlocked. The LPN stated the razors and grooming products should be locked up.",2020-09-01
917,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,693,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure a resident received tube feeding in accordance with the physician order [REDACTED]. This is true for one (1) of one (1) residents reviewed for tube feeding. Resident identifier: #93. Facility census: 93. Findings included: a) Resident #93 On 07/08/19 at 11:00 AM Resident #93's tube feed (not running) was observed to be [MEDICATION NAME] 1.0 cal, a fiber-fortified therapeutic nutrition. Also observed a kangaroo bag used for flushing the tubing with no open date or initials for who opened it. The physician order, with a start date of 05/13/19, is [MEDICATION NAME] 1.2 cal every eighteen (18) hours @75 millimeters (ml) per hour on at four (4) PM and off at ten (10) AM. On 07/09/19 at 8:00 AM observation found tube feed to be [MEDICATION NAME] 1.0 cal. At 10:10 AM on 07/09/19 licensed nurse (LPN) #51 explained that a few weeks ago the order was changed from [MEDICATION NAME] 1.0 to [MEDICATION NAME] 1.2 due to the 1.0 not being available. Upon availability the order should have been changed back to 1.0. At 10:19 AM LPN #57 confirmed the [MEDICATION NAME] running is 1.0 cal and the kangaroo bag is not labeled with a date and initials. The cooperate consultant agreed the physician order [REDACTED].",2020-09-01
918,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,695,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide respiratory care consistent with the professional standards of practice. The facility failed to administer oxygen to a resident at the correct flow rate as indicated on the physician order. The failed practice affected one (1) of eight (8) residents. Resident identifier: #22. Facility census: 98. Findings included: a) Resident #22 On observation, on 07/08/19 at 1:09 PM, revealed Resident #22 was being administered oxygen via nasal cannula at three (3) liters per minute. A record review of a physician order [REDACTED]. Notify the physician. A second observation, on 07/09/19 at 12:00 PM, revealed Resident #22 was being administered oxygen via nasal cannula at three (3) liters per minute. An interview with Registered Nurse (RN) #44, on 07/09/19 at 12:03 PM, revealed the oxygen flow rate for Resident #22 is ordered for two (2) liters per minute. RN #44 confirmed Resident #22 being administered oxygen at three (3) liters per minute via nasal cannula was not the correct flow rate.",2020-09-01
919,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,730,D,0,1,9FZF11,"Based on personnel record review and staff interview, the facility failed to ensure a performance review was conducted on each nurse aide at least once every 12 months. This practice affected two (2) of five (5) nurse aides reviewed during the Long Term Care Survey Process (LTCSP). Staff identifiers: #1 and #2. Facility census: 98. Findings include: a) Nurse Aide #1 A review of Nurse Aide (NA) #1's Annual Performance Review (APR), on 07/10/19 at 8:55 AM, revealed the NA was hired on 07/21/04. The NA's last APR was conducted on 07/21/16. b) Nurse Aide #2 A review of NA #2's APR, on 07/10/19 at 9:05 AM, revealed the NA was hired on 02/21/91. The NA's last two APRs were conducted on 06/27/17 and 02/21/19. There was no APR conducted in (YEAR). c) Interview An interview with the Human Resource Manager (HRM), on 07/10/19 at 9:25 AM, revealed the APRs for the nurse aides are supposed to be conducted yearly on the anniversary of their hire date or from the date of their last performance evaluation. The HRM verified NA #1 did not have an APR completed since (YEAR) and NA #2 did not have an APR completed on 06/27/18 or 02/21/18 as required. The HRM stated she was new and was trying to get all the APRs updated.",2020-09-01
920,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,758,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's drug regimen was free from an unnecessary [MEDICAL CONDITION] drug. An anti-psychotic medication did not have an acceptable [DIAGNOSES REDACTED]. This practice affected one (1) of six (6) residents reviewed for unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident identifier: #251. Facility census: 98. Findings included: a) Resident #251 A record review, on 07/09/19 at 11:30 AM, revealed the Resident had a physician order [REDACTED]. There was no documentation in the record concerning the medication being ordered for a [DIAGNOSES REDACTED]. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/09/19 at 1:35 PM, revealed nausea, vomiting, and restlessness is not an acceptable [DIAGNOSES REDACTED]. The CCQC stated those are symptoms and not an acceptable diagnosis. The CCQC verified there was no documentation besides the order for the Anti-psychotic medication.",2020-09-01
921,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,761,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. Multiple opened medications stored in the 100 Hall Medication Cart were unlabeled and undated. This practice had the potential to affect a limited number of residents. Facility census: 98. Findings included: a) 100 Hall Medication Cart An observation of the 100 Hall Medication Cart, on 07/10/19 at 7:35 AM, revealed the following medications were opened, undated, and unlabeled: --One (1) bottle of [MEDICATION NAME] Cough Syrup --One (1) bottle of [MEDICATION NAME] --One (1) bottle of [MEDICATION NAME] stock medication An interview with Licensed Practical Nurse (LPN) #46, on 07/10/19 at 7:38 AM, revealed all medications should be labeled and dated when opened. The LPN stated this is my cart so I am not sure how I missed those medications. The LPN stated she would discard the medications.",2020-09-01
922,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,812,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to discard expired food and label a container placed in the refrigerator. The failed practice had the potential to affect a limited number of residents. Facility census: 98. Finding included: a) Kitchen During the initial tour of the kitchen, on [DATE] at 10:15 AM, there was a five (5) pound bag of finely shredded lettuce that was expired with a date of [DATE]. There was a 16 ounce container of Minor's Beef Base Low Sodium with no labeled date of when the facility received or stored the food item. The manufactures date on the can stated [DATE] with no year indicated. An interview with Dietary Manager (DM), on [DATE] at 10:18 AM, confirmed the bag of lettuce was expired and should have been discarded. DM also confirmed the Minors Beef Base container was not labeled with a date. DM proceeded to discard the items immediately from the refrigerator.",2020-09-01
924,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,849,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure residents had physician orders [REDACTED]. Resident identifiers: #251 and #34. Facility census: 98. Findings included: a) Resident #251 A review of the medical record, on 07/09/19 at 1:55 PM, revealed the Resident was admitted to the facility on hospice services on 07/01/19. There was no order for hospice in the record until 07/08/19. An interview with the Clinical Continuous Quality Coordinator (CCQC), on 07/09/19 at 2:30 PM, revealed the hospice order was not written and in the medical record until 07/08/19. b) Resident #34 A record review of progress notes, on 07/08/19 at 1:00 PM, revealed Resident #34 was visited by Valley Hospice on 07/05/19. Further record review of physician orders, on 07/08/19, revealed no current physician order [REDACTED].>A staff interview with DoN, on 07/08/19 at 1:20 PM, revealed Hospice was just started for Resident #34 on 07/05/19. DoN stated, Valley Hospice has not even sent their treatment plan yet. A record review of physician orders, on 07/09/19, revealed a physician order [REDACTED]. Order stated, Admit to Valley Hospice. DX: Unspecified [MEDICAL CONDITION] of the liver. (Order date 06/05/19) Created Date: 7/8/2019 15:27. An interview with Clinical Quality Coordinator (CQC), on 07/09/19 at 3:05 PM, revealed Hospice was started on 07/05/19. The physician order [REDACTED]. CQC stated the date will be changed to reflect the correct order date of 07/05/19.",2020-09-01
925,MOUND VIEW,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2019-07-10,880,D,0,1,9FZF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to ensure that linens were handled in accordance with infection control guidelines and practices, failed to ensure staff used appropriate personal protective equipment when handling soiled linen and failed to provide an infection control program to ensure urinary catheters were cared for in a manner to prevent the spread of infection. This practice had the potential to affect a limited number of residents residing in the facility. Resident identifier: #59. Facility census: 98. Findings included: a) Observation During a observation on 07/09/19, at 10:20 AM, soiled, wet linens were observed outside room [ROOM NUMBER] laying directly on the floor in the hallway. HK#118 was observed to drag the linen back inside the doorway of room [ROOM NUMBER] by holding it with an ungloved right hand. An interview on 07/09/19, at 10:20 AM, HK#118 revealed the resident in the room had placed a soiled diaper in the toilet and had stopped it up causing the toilet to overflow and the linen was used to wipe up the contents that overflowed from the toilet. HK# 118, further added, the linen was not bagged because it would have been too heavy. On 07/09/19, at 12:14 PM, an interview with the Director of Nursing (DON), confirmed putting soiled linen on the floor is a problem. A review of the policy and procedure, titled Soiled Linen and Trash Containers, dated 10/2018, noted loose trash and linen shall be appropriately bagged before placing into a larger storage bin and staff shall wear appropriate personal protective equipment when handling soiled linen or trash. b) Resident #59 An observation, on 07/09/19 at 9:00 AM, revealed Resident #59's catheter bag was laying on the floor beside bed. An interview with DoN, on 07/09/19 at 9:05 AM, revealed Resident #59's catheter bag falls on the floor all the time. A record review of the care plan, on 07/09/19, revealed no focus, goal or intervention related to Resident #59's catheter bag being found frequently on the floor.",2020-09-01
926,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2017-03-23,246,D,0,1,10BJ11,"Based on observation, staff interview and resident interview, the facility failed to ensure a resident received services with reasonable accommodation of their individual needs. This was true for one (1) of thirty five (35) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident #9, who was capable of using the call light, did not have access to their call light. Resident identifier: #9. Facility census: 77. Findings include: a) Resident #9 Observation of Resident #9, during stage one (1) of QIS, on 03/20/17 at 3:32 p.m., revealed the resident's call bell button cord tied to the bed's left side rail. The resident had contractures of the right upper and lower extremities. The resident had impaired mobility of her right arm (elbow and hand). When the resident was asked to push the call light button to see if the call system was functioning properly, the resident attempted to reach for it and was unable to reach the button. The resident said, I can't. The resident was then asked, What do you do when you can't reach the call bell and you need help with something? The resident replied, I just lay here. On 03/20/17 at 3:40 p.m., Nurse Aide (NA) #55 was outside of Resident #9's room in the hall. This surveyor requested NA#55 go into Resident #9's room to have the resident push her call light. NA #55 went in and asked Resident #9 to push her call light. Resident #9 said, I can't. I can't reach it. The resident demonstrated to NA #55 that she could not reach the button. NA#55 unfastened and lengthened the call bell cord so Resident #9 could reach and push the call bell button with her left hand. Interview with NA#55 confirmed Resident #9 could not reach the call bell button prior to NA#55 untying and moving the call bell cord, after surveyor intervention. Interview with DON, on 03/23/17 at 8:35 a.m., revealed the facility would get a call pad for Resident #9 to use, to make it easier for her to access the call system and to accommodate her needs.",2020-09-01
929,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,641,D,0,1,6Z1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of eighteen (18) residents whose records were reviewed had an accurate and complete Minimum Data Set (MDS) which reflected the residents current status. Resident #43's MDS did not reflect the resident had a fall. Resident #70's MDS did not reflect the resident was receiving an antidepressant. Resident identifiers: #43 and #70. Facility census: 80. Findings included: a) Resident #43 Review of an incident/accident report, dated 03/05/18 found the, Resident stood up to pull up her pants and when she went to sit back down, she missed the potty chair and fell on to the floor on her bottom. An x-ray was obtained and no injuries were noted. Review of the MDS, completed after the fall on 03/05/18, a quarterly MDS, with an assessment reference date (ARD) of 03/27/18, coded the resident as having no falls since the last assessment. The last assessment was a significant change MDS with an ARD of 12/26/17. At 1:00 p.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the 03/05/18 MDS was incorrectly coded. At 1:20 p.m. on 05/15/18, the Director of Nursing (DON) was advised of the incorrectly coded MDS. She had no further information to present. b) Resident #70 Review of Resident #70's medical records found a physician order [REDACTED]. Review of the significant change MDS, with an assessment reference date (ARD) of 01/16/18, coded the resident received no antidepressants in the seven day look-back period. At 10:22 a.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the MDS with ARD of 01/16/18 was incorrectly coded. At 11:20 a.m. on 05/15/18, the Director of Nursing (DON) was advised of the incorrectly coded MDS. She had no further information to present.",2020-09-01
930,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,656,D,0,1,6Z1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to develop a comprehensive person-centered care plan in the care areas of indwelling catheter and [MEDICAL CONDITION] medication. This was true for two (2) of 18 care plans reviewed. Resident identifiers: #50 and #70. The facility census was 80. Findings included: a) Resident #50 During an observation on 05/14/18 at 12:44 PM, it was noted Resident # 50 had a Foley Catheter and there was no strap securing it to her leg. An observation on 05/15/18 at 8:25 AM, with NA #51, confirmed there was no strap securing Resident #50's catheter to her leg. She was asked if there should be a strap securing the catheter to her leg to prevent injury. NA #51 said, I don't know I don't do that the nurses do. She stated, she would have the nurse to get one. During a review of the comprehensive care plan the only mention of a Foley Catheter was under the focus statement At Risk for Skin breakdown. Without any mention or direction for Foley Catheter care. During an interview on 05/15/18 at 12:36 PM, with RN #36, She agreed she should have care planned the Foley Catheter and would fix it right away. b) Resident #70 A review of Resident #70's medical records found a physician order [REDACTED]. A review of the comprehensive care plan found no mention of the use of an antidepressant. At 10:22 a.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the care plan did not address the use of an antidepressant ([MEDICATION NAME]).",2020-09-01
931,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,684,D,0,1,6Z1211,"Based on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Neurological checks were not performed after an unwitnessed fall for one (1) of two (2) residents reviewed for the care area of falls and accident hazards. Resident identifier: #27. Facility census: 80. Findings included: a) Resident #27 An incident report for Resident #27 on 5/10/18 at 1:07 PM stated the following: Incident Description: Was notified that resident was found in the floor on the safe floor mat with no injury when observed. Resident unable to give. The immediate action taken stated, Staff reports that resident was checked for injury and no injury found. Unknown if this was an intentional act due to uncontrollable squirming movements. Will consider a fall at this time due to resident unable to tell us why she was moving. The incident report stated there were no witnesses to the fall. The incident report was completed by Licensed Practical Nurse (LPN) #44. The medical record contained no evidence that neurological checks had been initiated for Resident #27 after her unwitnessed fall on 5/10/18. During an interview on 05/15/18 at 1:45 PM, LPN #44 confirmed Resident #27's fall on 5/10/18 had been unwitnessed. LPN #44 also confirmed neurological checks had not been initiated after the fall. She stated facility practice is to initiate neurological checks for residents who have experienced unwitnessed falls but this was not done for Resident #27 on 5/10/18.",2020-09-01
932,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2018-05-16,690,D,0,1,6Z1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure two (2) of two (2) residents reviewed with indwelling Foley catheters, had catheter tubing securely anchored to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. Resident identifiers: #33 and #50. Facility census: 80. Findings included: a) Resident #33. Review of the medical record found the resident was initially admitted to the facility on [DATE] with an indwelling Foley catheter for a [DIAGNOSES REDACTED]. Observation of the resident at 1:03 p.m. on 05/14/17, revealed the resident was lying in bed. The catheter tubing was running along side the bed into the catheter bag which was hooked to the bed frame. Observation of the resident with the Director on Nursing (DON) at 8:15 a.m. on 05/15/18, confirmed the catheter tubing was not properly secured to prevent removal or tissue injury from dislodging the catheter. b) Resident #50 An observation on 05/14/18 at 12:44 PM, found Resident #50 had a Foley Catheter and there was nothing securing the catheter tubing to her leg. An observation on 05/15/18 at 8:25 AM, with NA #51, confirmed there was nothing securing the catheter to Resident #50's leg. She was asked if the catheter tubing should be secured to Resident #50's leg to prevent injury. She said, I don't know, I don't do that the nurses do. NA #51 stated, she would have a nurse to get one. During an interview with Director of Nursing (DON) on 05/15/18 at 9:07 AM, she was informed about the findings. She indicated she would take care of it. c) Facility Policy A review of the Facility Policy, FOLEY CATHETER CARE dated, 07/2008. Found no mention of the use of any type of an anchoring device to secure the catheter from being pulled or tugged which could cause injury. An interview with the Administrator and the DON was conducted on 05/15/18 at 2:05 PM, in regards to the Policy not containing anything about the use of a secure device to secure the catheter to the residents legs. The Administrator said, Now we don't use those on our residents because it causes them to get skin break down. She was informed that it is part of the Regulations and it is used to prevent injury and accidental removal and that they are soft secure devices that do not attach to the skin. The Administrator then asked if this surveyor knew where she could get them or what the order number was? She said that, she would get her supply girl to look into getting something. On 05/15/18 at 2:08 PM, Inventory Personnel #14 came in the room to show this surveyor they had soft leg stabilizers to use as Foley catheter anchors.",2020-09-01
934,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,625,D,0,1,06KF11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to provide the second notice for the Bed Hold Policy to the resident representative via in writing or verbally within 24 hours of discharge to an acute care hospital. This was true for one (1) of three (3) residents reviewed for hospitalization s during the survey process. The resident representatives did not receive the Bed Hold notices timely in writing or verbally when R48 was transferred to the hospital. Resident identifiers: R48. Facility censes: 75. Findings included: a) R48 A medical record review for R48 on 05/13/19 revealed the second Bed Hold Notice had not been provided to the resident representative in writing or verbally within 24 hours when R48 was transferred to the hospital on [DATE]. In an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 05/13/19 at 10:30 AM verified R48's resident representative did not receive the second Bed Hold notice in writing or verbally when he was transferred to the hospital.,2020-09-01
935,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,656,D,0,1,06KF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to develop a care plan for a [MEDICAL TREATMENT] resident with interventions addressing complications related to [MEDICAL TREATMENT], pre and/or post [MEDICAL TREATMENT] assessments, blood pressure parameters, and post [MEDICAL TREATMENT] treatment care upon return to the facility from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. An interview with the resident, on 05/14/19 at 09:39 AM, revealed the staff rarely ever takes her blood pressure or ask her anything specific when she returns to the facility from the [MEDICAL TREATMENT] center. R#32 said, They take my blood pressure in the mornings, most of the time. The residents stated the ambulance people that take her helps her back into the bed, and sometimes the nurse comes in and talks to the ambulance people. The resident said she comes back from the [MEDICAL TREATMENT] center with a dressing over her AV access and it is left on till the next day, and sometimes a nurse will look at it when she gets back from [MEDICAL TREATMENT]. An interview with licensed practical nurse (LPN#87), on 05/15/19 at 02:33 PM, revealed nursing staff does not do an assessment of Resident #32 when the resident returns to the facility from the [MEDICAL TREATMENT] center. LPN#87 stated, The ambulance crew returns the resident to her bed and I review the [MEDICAL TREATMENT] communication form to see if there's any new orders. LPN#87 said, If there is an area the [MEDICAL TREATMENT] center did not fill in on the form, like weights, I will call the center and get that information and fill in their part of the form or ask the ambulance crew. I do not document on the communications form any assessment of the resident when she returns back to the facility from the [MEDICAL TREATMENT] center. When asked why there was no post assessment documented, LPN#87 said, The nurses don't do a resident assessment when they return from [MEDICAL TREATMENT]. This surveyor asked if the nurses did any assessment of the resident's vital signs (VS - blood pressure, pulse, temperature, and respirations), the access site for bruits or thrills any swelling, drainage, or pain, or the resident's over all condition upon returning to the facility from the [MEDICAL TREATMENT] center. LPN#87 replied, The bruits are assessed only when scheduled and its document on the MAR (medication administration record) once every shift. No, the nurses don't assess that (bruits and thrills) when they return from the center On 05/15/19 at 03:39 PM review of R#32's care plan revealed [MEDICAL TREATMENT] interventions was addressed in the focus areas of Potential for fluid volume overload/deficit and Alteration in nutritional status. The focus area read Potential for fluid volume overload/deficit related to [MEDICAL CONDITION] requiring [MEDICAL TREATMENT], diuretic use for heart failure,-has port for [MEDICAL TREATMENT] at this time -12/18/18 [MEDICAL TREATMENT] shunt placed to left arm. The goal is Resident will maintain therapeutic fluid volume as evidenced by no fluid volume overload or deficit through next review date Care plan interventions for potential for fluid volume overload/deficit included: Administer diuretic orders as ordered. Check bruit and thrill q (every) shift and PRN (as needed) to left arm [MEDICAL TREATMENT] shunt. Report to MD (medical doctor) if absent. DermacinRx Prizopak Kit 2.5-2.5 % apply to Fistula (left arm) topically as needed for pain, apply 15 mins before [MEDICAL TREATMENT]. [MEDICAL TREATMENT] Monday, Wednesday, and Friday at 12:00 pm. STAT to pick up at 11:30 pm. No blood pressures or sticks to left arm d/t [MEDICAL TREATMENT] shunt. Notify physician of signs and symptoms of fluid volume overload or deficit such as [MEDICAL CONDITION], increased shortness of breath, increased confusion, fluid retention with decreased urinary output, increased cough and congestion, skin tenting, poor skin elasticity, increased thirst. Snack (NAS-No Added Salt) to be sent with resident on [MEDICAL TREATMENT] days Mon, Wed, and Friday. Some care plan interventions for alteration in nutritional status included: Diet as ordered for nutrition. NAS (No Added Salt) diet, Chopped Meats texture, Thin consistency No Orange Juice No Potatoes No Bananas No [NAME]toes. Obtain Labs per order notify MD of results and follow up as indicated. ProMod Liquid related to other Disorders of Plasma-Protein Metabolis. Report to nurse/MD of any signs or symptoms of dehydration such as dry crack lips and skin, poor skin turgor, elevated temp, rapid pulse. Snack bag- Monday, Wednesday, and Friday due to [MEDICAL TREATMENT]. Weights per orders, Notify MD of any significant changes. At 02:43 PM on 05/15/19, review of Resident #32's care plan and the [MEDICAL TREATMENT] communication record with the director of nursing (DON) revealed the care plan had no interventions noted concerning complications related to [MEDICAL TREATMENT]. It was the DON's expectations that residents receiving [MEDICAL TREATMENT] treatments have a pre and post assessment including vital signs before going out to the [MEDICAL TREATMENT] center, and immediately upon their return the facility following [MEDICAL TREATMENT] treatment. The DON confirmed the care plan did not offer directives for pre and/or post [MEDICAL TREATMENT] assessments of the resident, and should have, nor did it direct what to assess, when and how often to assess, nor parameters the facility desired for the vital signs of a [MEDICAL TREATMENT] resident.",2020-09-01
936,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,657,D,0,1,06KF11,"Based on medical record review, care plan review and staff interview, the facility failed to revise Resident #60's care plan to reflect the date of a pacemaker check had been rescheduled. This was found during a random review of the medical record for one of one reviewed for pacemaker care. Resident identifier: 60. Facility census: 75. Findings included: a) A review of the care plan in the medical record for resident #60 revealed the resident did have a pacemaker. The care plan showed a pace maker check was to be completed in April. There was no evidence that a pacemaker check had been done at that time. Discussion with the director of nursing on 5/15/19 in the afternoon verified that she could not find any documentation showing a pacemaker check. She then had nursing staff search for any information regarding the check. Nursing staff did submit evidence later that a pacemaker check had been completed in (MONTH) and at that time was rescheduled for six months which would be July. A new appointment was set for (MONTH) 26, 2019. The change in the appointment date was not changed on the care plan. The current care plan still stated pacemaker check for April, 2019.",2020-09-01
937,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,684,D,0,1,06KF11,"Based on observation, record review, resident interview, and staff interview the facility failed to ensure resident #74 received an accurate skin assessment reflecting the status of the resident's skin. This was true for one of one resident reviewed for skin conditions (non-pressure). This practice has the potential to affect a limited number of residents. Resident identifiers: R#74 . Facility census: 75. Findings included: a) Resident #74 Observations, on 05/13/19 at 3:35 PM, revealed R#74 had a noticeable asymmetric uneven black brownish area of discoloration, almost the size of a dime, with blurred irregular edges on his left cheek. The area on the resident's cheek had the appearance of a flat irregular mole. Also observed was a large area on the residence right lower forearm of faintly reddish pink discoloration. Review of records, on 05/16/19 at 09:58 AM, revealed neither areas were documented on any skin assessments. On 05/16/19 10:08 AM interview and review of records with Assistant Director of Nurses (ADON #50) revealed both skin areas were not documented on the nursing assessments, neither on the admission assessment or any following assessments as they should have been. The ADON acknowledged the areas were present on the resident and should be evaluated. ADON#50 requested the physician to evaluate the skin areas, as the physician was making rounds that day and resident is on list to be seen. An interview with the resident, on 05/16/19 at 10:55 AM, revealed he has always had the moles they had not newly developed but the one on his cheek had changed a little.",2020-09-01
938,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2019-05-17,698,D,0,1,06KF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to consistently perform pre and post [MEDICAL TREATMENT] resident assessments, before going and/or returning from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: a) Resident #32 Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. Review of the [MEDICAL TREATMENT] communication form, on 05/14/19 at 10:45 AM, show the following information was to be provided on the form by the facility before resident went for [MEDICAL TREATMENT] treatment: Resident's name; date; transported by; condition before leaving facility (Lines to write a narrative about the resident's condition); vital signs before [MEDICAL TREATMENT] (blood pressure, pulse, respirations, and temperature); received meal; and sent snack with resident. Information the [MEDICAL TREATMENT] center was to provide on the communication form was as follows: weight before; weight after; date of physicians visits at [MEDICAL TREATMENT]; labs drawn at [MEDICAL TREATMENT]; problems at [MEDICAL TREATMENT]; medications given; new orders; and vital signs before leaving [MEDICAL TREATMENT]. Review of the past month's [MEDICAL TREATMENT] communication sheets, starting 04/17/19 through 05/15/19, revealed on 04/17/19 the facility filled out the information except whether or not the resident received a meal. On 04/19/19 the facility did not send the [MEDICAL TREATMENT] center any information; the [MEDICAL TREATMENT] center however did send back to the facility a different communication sheet with their required information filled in. On 04/22/19 the facility filled out the information except whether the resident received a meal. On 04/24/19, 04/26/19, 04/29/19, 05/01/19, 05/06/19, 05/08/19, 05/10/19, and 05/13/19 only the resident's name; date; and vital signs were filled in. On 05/03/19 information missing on the form was the condition the resident was in before leaving the facility whether she received a meal or if a snack was sent with her. On 05/15/19 all information from the facility was completed. The [MEDICAL TREATMENT] communication form did not have a section for the resident's assessment upon return to the facility after [MEDICAL TREATMENT] treatment, as often seen on [MEDICAL TREATMENT] communication forms. Review of records, on 05/14/19 at 10:45 AM, revealed various nurse progress notes stating .resident is out at this time to [MEDICAL TREATMENT]. Resident clean, dry, and odor free. The few progress notes that mentioned the resident had returned to the facility, had information from the [MEDICAL TREATMENT] center placed in the note, but no notation or evidence of the facility nurse themselves assessing the resident. Example is a nursing note dated 05/10/19 .Vitals after [MEDICAL TREATMENT]: Blood pressure: 112/77, Pulse: 73, Reparations: 16, Temperature: 98.4, Weight: 115 kg per [MEDICAL TREATMENT] Communication form. An interview with the resident, on 05/14/19 at 09:39 AM, revealed the staff rarely if ever takes her blood pressure when she returns from [MEDICAL TREATMENT] treatment, or ever listens to her AV access with a stethoscope, or ask her anything specific when she returns to the facility from the [MEDICAL TREATMENT] center. R#32 said, They take my blood pressure in the mornings, most of the time. The residents stated the ambulance people that take her helps her back into the bed, and sometimes the nurse comes in and talks to the ambulance people. The resident said she comes back from the [MEDICAL TREATMENT] center with a dressing over her AV access and it is left on till the next day, and sometimes a nurse will look at it when she gets back from [MEDICAL TREATMENT]. On 05/15/19 at 01:25 PM review of orders revealed, [MEDICAL TREATMENT] Monday, Wednesday, and Friday at 12:00 PM. (Name of ambulance service) to pick up at 11:30 AM. No blood pressures or IV sticks to left arm due to fistula graft. Check bruit and thrill to left brachial [MEDICAL TREATMENT] fistula q (every) shift and prn (as needed). An interview with licensed practical nurse (LPN#87), on 05/15/19 at 02:33 PM, revealed nursing staff does not do an assessment of Resident #32 when the resident returns to the facility from the [MEDICAL TREATMENT] center. LPN#87 stated, The ambulance crew returns the resident to her bed and I review the [MEDICAL TREATMENT] communication form to see if there's any new orders. LPN#87 said, If there is an area the [MEDICAL TREATMENT] center did not fill in on the form, like weights, I will call the center and get that information and fill in their part of the form or ask the ambulance crew. I do not document on the communications form any assessment of the resident when she returns back to the facility from the [MEDICAL TREATMENT] center. When asked where the post [MEDICAL TREATMENT] assessment was documented, LPN#87 said, The nurses don't do a resident assessment when they return from [MEDICAL TREATMENT]. This surveyor asked if the nurses did any assessment of the resident's vital signs (VS - blood pressure, pulse, temperature, and respirations); access site for bruits or thrills any swelling, drainage, or pain; or the resident's over all condition upon returning to the facility from the [MEDICAL TREATMENT] center. LPN#87 replied, The bruits are assessed only when scheduled and its document on the MAR (medication administration record) once every shift. No, the nurses don't assess that (bruits and thrills) when they return from the center At 02:43 PM on 05/15/19, review of Resident #32's the [MEDICAL TREATMENT] communication record and care plan with the director of nursing (DON) revealed the [MEDICAL TREATMENT] communication record did not include an area to document a post [MEDICAL TREATMENT] assessment, the facility nurses should perform. It was the DON's expectations that residents receiving [MEDICAL TREATMENT] treatments have a pre and post assessment including vital signs before going out to the [MEDICAL TREATMENT] center, and upon their return the facility following [MEDICAL TREATMENT] treatment. When asked if the nurses did any assessment of the resident's vital signs (VS - blood pressure, pulse, temperature, and respirations); access site for bruits or thrills any swelling, drainage, or pain; or the resident's condition upon returning to the facility from the [MEDICAL TREATMENT] center, the DON confirmed they should be. When asked where the nurses should be documenting their assessment of the resident when returning from [MEDICAL TREATMENT] treatments the DON said it should be at least in the nurses' progress note. The DON said, The bruit and thrill is done every shift and is documented on the MAR. The DON confirmed the order for checking the bruit and thrill PRN (as needed) would be when the resident had a problem or when they returned from [MEDICAL TREATMENT]. This surveyor requested any evidence that any post [MEDICAL TREATMENT] treatment assessments were being done by the facility when the resident return to the facility from the [MEDICAL TREATMENT] center, upon exit no evidence was provided.",2020-09-01
942,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-02-19,656,D,1,0,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and policy review, the facility failed to implement interventions from the care plan related to falls, creating the potential for injury. This deficient practice affected one (1) of five (5) residents reviewed for the care area of falls. Resident identifier: #71. Facility census: 115. Findings included: a) Resident #71 On 02/19/19 at 8:34 AM, Resident #71 was observed in bed eating breakfast from a bedside table. One fall mat was observed on the floor to the resident's right. No fall mat was observed on the floor to the resident's left. A mat was observed propped up against a wall to the resident's right. A review of Resident #71's care plan revealed the following problem, most recently revised on 02/07/19: Resident is at risk for falls and injury related to recent fall prior to admission with displaced right femur fracture s/p (status [REDACTED]. The goal corresponding to the above problem, last revised on 11/09/18, stated, Resident will have no falls with major injury through next review. One (1) of the several interventions related to the above problem, created on 01/30/19, stated, Bilateral (both sides) fall mats while in bed. Check qshift (each shift). On 02/19/19, Licensed Practical Nurse (LPN) #29 was asked if Resident #71 was supposed to have one (1) fall mat or two (2) fall mats at bedside. LPN #29 confirmed that Resident #71 was supposed to have two (2) fall mats at bedside. LPN #29 stated that the fall mat to the left of Resident #71 may have been moved to accommodate the bedside table. On 02/19/19 at 8:43 AM, the facility's Director of Nursing (DoN) was informed of the above findings. At 8:52 AM, the DoN explained that the bedside table does not fit over the fall mat to the left of Resident #71, so the mat must be moved to accommodate the bedside table. However, the care plan directed to provide bilateral fall mats while in bed with no exceptions listed. On 02/19/19 at 9:54 AM, a copy of the facility's Falls Management policy was received and reviewed. The policy, last revised on 03/15/16, stated, Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Resident #71's care plan problem above identified Resident #71 to be at risk for falls and injury. No further information was provided prior to exit.",2020-09-01
943,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-02-19,684,D,1,0,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, and policy review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. The facility failed to complete post-fall assessments for two (2) out of five (5) residents reviewed for the care area of falls. Resident identifiers: #119, #120. Facility census: 115. Findings included: a) Resident #119 A general progress note written for Resident #119 on 10/16/2018 at 7:15 AM, stated, Resident found in floor at this time. Skin tear to left elbow 2 cm x 2 cm unable to approximate edges. Resident safely placed in bed voices no complaints at this time. New order noted- 1) cleanse wound on left elbow with skin tegrity wound cleanser, pat dry, and apply dry dressing change q (every) 7 days and prn (as needed) monitor for s/sx (signs/symptoms) of infection. (Typed as written.) No other resident assessment following the fall was documented. A Change in Condition Communication Form could not be located in the medical records following the fall on 10/16/2018 at 7:15 AM. A general progress note written on 10/16/2018 at 8:00 AM stated, MPOA (medical power of attorney) notified of fall. A general progress note written on 10/16/2018 at 8:25 AM stated, Resident sent to (name of outside hospital) via EMS (emergency medical services) due to increased confusion, pt (patient) and family aware. Another general progress note written on 10/16/2018 at 8:25 AM stated, N/o (new order) send to ER (emergency room ) for eval (evaluation) and treat d/t (due to) increased confusion. Pt and family aware. Review of the facility's Fall Management Protocol stated, If a patient falls .Document accident/incident: As a new event in the Risk Management System (RMS); On a Change of Condition Note . During an interview on 02/18/19 at 11:30 AM, the Director of Nursing (DoN), the DoN was unable to locate resident assessment following the fall other than assessment of the resident's skin condition. The DoN verified a Change in Condition Note had not been performed following Resident #119's fall on 10/16/2018 at 7:15 AM. The DoN also stated a Risk Management System event was not entered following Resident #119's fall on on 10/16/2018 at 7:15 AM. b) Resident #120 Resident #120 experienced a fall on 08/02/18 at 5:50 AM. A Change in Condition Evaluation was initiated. However, assessment of the following items on the Change in Condition Evaluation were not completed. - Mental Status Evaluation - Behavioral Evaluation - Respiratory Evaluation - Cardiovascular Evaluation - Abdominal/GI Evaluation - [MEDICAL CONDITION] Evaluation - Skin Evaluation - Pain Evaluation - Neurological Evaluation - Laboratory Tests/Diagnostic Procedures These areas on the Change in Condition Evaluation were blank. During an interview on 02/18/19 at 11:00 AM, the Director of Nursing agreed assessment of these areas were not completed on Resident #120's Change in Condition Evaluation dated 08/02/18 at 5:50 AM.",2020-09-01
944,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-02-19,689,D,1,0,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and policy review, the facility failed to provide physician-ordered interventions related to falls, creating the potential for injury. This deficient practice affected one (1) of five (5) residents reviewed for the care area of falls. Resident identifier: #71. Facility census: 115. Findings included: a) Resident #71 On 02/19/19 at 8:34 AM, Resident #71 was observed in bed eating breakfast from a bedside table. One fall mat was observed on the floor to the resident's right. No fall mat was observed on the floor to the resident's left. A mat was observed propped up against a wall to the resident's right. A review of Resident #71's active physician's orders [REDACTED]. On 02/19/19, Licensed Practical Nurse (LPN) #29 was asked if Resident #71 was supposed to have one (1) fall mat or two (2) fall mats at bedside. LPN #29 confirmed that Resident #71 was supposed to have two (2) fall mats at bedside. LPN #29 stated that the fall mat to the left of Resident #71 may have been moved to accommodate the bedside table. On 02/19/19 at 8:43 AM, the facility's Director of Nursing (DoN) was informed of the above findings. At 8:52 AM, the DoN explained that the bedside table does not fit over the fall mat to the left of Resident #71, so the mat must be moved to accommodate the bedside table. However, the physician's orders [REDACTED]. On 02/19/19 at 9:54 AM, a copy of the facility's Falls Management policy was received and reviewed. The policy, last revised on 03/15/16, stated, Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. Resident #71's care plan identified Resident #71 to be at risk for falls and injury. No further information was provided prior to exit.",2020-09-01
946,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,156,D,0,1,SWUR11,"Based on resident interview, staff interview and facility record review, the facility failed to ensure residents received and/or were knowledgeable of how to contact State agencies for two (2) of four (4) residents interviewed. Residents were unable to articulate the name of the ombudsman, did not know the purpose of an ombudsman, and did not know how to contact State agencies, or where to find the information in the facility. Resident identifiers: Resident #13 and #126. Facility census: 117 Findings include: a) Resident #13 and #126 During an interview with Resident #126, on 03/22/17 at 10:31 a.m., the resident voiced concerns were reported to the facility staff. Upon inquiry, she said she did not know how to report to State agencies, and did not know the name of the ombudsman or how to contact her. Resident #13, interviewed at 10:38 a.m. on 03/22/17 at 10:38 a.m., said she would refer concerns to the facility. Upon inquiry, the resident said she did not know how to report to State agencies, and did not know how to contact the ombudsman, or the purpose of an ombudsman. Both residents, during the interviews, denied knowledge of where to find contact information for State agencies in the facility. An interview with Social Service Coordinator (SSC) #60, on 03/22/17 at 12:28 p.m., the SSC said signs were posted and residents and/or families were notified of reporting requirements during the 72 hour meeting on admission. When asked how the information was disseminated to all residents and/or families the coordinator said a copy of resident rights was given to residents yearly. Upon inquiry, the coordinator looked at the form and said it did not contain State agency contact information. The SSC confirmed residents were only provided contact information during resident council meetings.",2020-09-01
947,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,157,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the physician when ordered lab work was not completed for two (2) of five (5) Stage 2 sampled residents reviewed for unnecessary medications. Resident #78 was ordered a [MEDICATION NAME] Acid serum level which was not done. There was no evidence the physician was notified of the failure to follow this order. Resident #70 was ordered weekly complete blood count (CBC) blood tests. When a weekly test was omitted, there was no evidence the physician was notified of the failure to follow this order. Resident identifiers: #78 and #70. Facility census: 117. Findings include: a) Resident #78 The medical record was reviewed on 03/20/17. This resident received [MEDICATION NAME] delayed release (DR) 250 milligram (mg) twice daily to treat a diagnosed condition of dementia with behaviors. Physician orders on 01/28/17 directed to draw a [MEDICATION NAME] Acid level the next lab day, then every six (6) months thereafter. A [MEDICATION NAME] Acid level is used to assess the blood level of the medication [MEDICATION NAME]. Review of the lab reconciliation sheet found the phlebotomist was unable to draw blood for the [MEDICATION NAME] Acid level on 01/30/17 because the resident was combative. The reconciliation sheet contained a note the resident was rescheduled for the following day on 01/31/17. Night shift licensed practical nurse (LPN) #17 initialed the reconciliation sheet results of the negative outcome. Review of the 01/31/17 lab reconciliation sheet found this resident was the only resident scheduled on this date for lab work. The phlebotomist again attempted to draw blood for a [MEDICATION NAME] Acid level, but did not succeed because the resident was again combative. Night shift LPN #34 initialed to attest results were not obtained. Further review of the lab reconciliation sheets found this resident had blood drawn on 02/13/17 for a complete blood count and an iron level. There was no [MEDICATION NAME] Acid level drawn on this date. The medical record was further reviewed, and found no [MEDICATION NAME] Acid serum lab results within the medical record. The medical record was silent for physician notification of the failure to obtain a [MEDICATION NAME] Acid level for this resident. During an interview with registered nurse (RN) unit manager #61, on 03/20/17 at 2:15 p.m., she said she was unable to find any [MEDICATION NAME] Acid lab results for this resident. She was also unable to find any evidence the physician was notified of the failure to obtain a [MEDICATION NAME] Acid level. During an interview with the Director of Nursing, on 03/22/17 at 12:30 p.m., she had no further information to provide about the absence of the [MEDICATION NAME] Acid lab tests for this resident. She said she believed the nurse practitioner was informed when the resident was combative, but acknowledged she had no evidence to support that opinion. b) Resident #70 A review of the physician order for [REDACTED]. A review of Resident #70's medical record, on 03/21/17 at 11:30 p.m., revealed there was no results for the 12/08/16 (CBC) labs work in her medical record. The next day, on 03/22/17 at 11:30 a.m., the nurse practice educator registered nurse (NPE-RN) reviewed Resident #70's record and found the resident was combative, and the CBC was not obtained on this date. The NPE-RN was asked whether the physician was informed or obtained at another time. She said she had to look and see. A review of the Medication Administration Record [REDACTED]. The NPE-RN returned, on 03/22/17 at 12:10 p.m., and said she could not find the results for the CBC for 12/08/16. She said the phlebotomist from a hospital comes and obtains the lab work for the facility. She said she felt the staff told the nurse practitioner the lab work was not obtained. The NPE-RN verbalized that is no evidence the physician was notified, and no physician order to indicate the lab was ordered for another time or not to obtain the lab work for this week. The NP-RN confirmed the staff did not follow the physician order, nor notify the physician/nurse practitioner. On 03/22/17 12:35 p.m., the NP-RN said she reviewed the physician progress notes [REDACTED].",2020-09-01
948,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,225,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of reportable allegations, family interview, policy review and staff interview, the facility failed to investigate and/or report allegations of abuse and/or neglect in a timely manner for three (3) of five (5) allegations reviewed. Resident identifiers: #106, #98 and #143. Facility census: 117. Findings include: a) Resident #106 Reportable allegations reviewed, on 03/20/17 at 11:40 a.m., revealed an allegation dated 02/07/17 with an incident date of 02/04/17. The form indicated the family member had reported a concern to the Licensed Practical Nurse (LPN) on the evening of 02/04/17 related to a soiled bed and soiled clothing, and asked for the Nurse Aide (NA) to be removed from Resident #106's care. The family member called and spoke with the center nurse executive (CNE) on 02/06/17 regarding the incident. The CNE then initiated an allegation of abuse and/or neglect and began an investigation. The Social Services Coordinator (SSC) #60, interviewed on 03/22/17 at 9:30 a.m., reviewed the allegation and confirmed it was not reported timely to the administrator or the appropriate State agencies. An interview with the CNE, on 03/22/17, she said the LPN was not aware the family member had alleged neglect, which is why she did not report it. During an interview with Family Member #1, the FM related the event as an allegation of neglect. b) Resident #98 The reported allegation, dated 01/09/17, noted an incident date of 01/07/17. Resident #98 alleged she tried several times in the early morning to get someone to take her to the restroom and was unable, thus resulting in resident becoming incontinent on herself. She also stated she was left on the bedpan that same night for an extended amount of time. A concern/grievance form had been completed on 01/07/17 related to the incident. During the interview with Social Services Coordinator (SSC) #60, she confirmed the incident was not reported to facility staff and/or the appropriate State agencies within the correct timeframe. SSC #60 verbalized the concern form had been slid under her door and she found it upon return to work on 01/09/17, at which time she initiated an investigation and reported it to State agencies. c) Resident #143 An immediate fax reporting of allegations form, dated 02/06/17, indicated a nurse aide observed a linear, dark red abrasion on Resident #143 during a shower on 02/03/17. The resident was unable to give any information, but had a history of [REDACTED]. SSC #60, confirmed the allegation was not reported to State agencies within the appropriate time guidelines. During an interview with the CNE, on 03/22/17, she voiced the interdisciplinary team had reviewed the incident report during morning meeting, and was unable to determine how the resident may have self-inflicted the wound and initiated the investigation. The CNE verbalized the Licensed Practical Nurse (LPN) had assumed the wound may have been self-inflicted and did not recognize the need to immediately report it to the facility or to the appropriate State agencies. d) Review of facility abuse policy The abuse policy, reviewed on 03/20/17, noted a revision date of 07/16/13. The policy noted an injury of unknown origin as an injury which was not observed by any person or the source could not be explained by the patient; and the injury was suspicious because of the extent of the injury or the location of the injury. The policy indicated anyone who witnessed an incident of suspected abuse or neglect was to report the incident immediately to his/her supervisor and injuries of unknown origin would be investigated immediately to determine if abuse or neglect was suspected.",2020-09-01
952,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,258,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, the facility failed to maintain comfortable sound levels for one (1) of two (2) residents reviewed for comfortable sound levels. A comfortable sound level was not maintained in the south back hall of the facility. Resident identifier: #60. Facility census: 117. Findings include: a) Resident #60 In an interview with Resident #60, on 03/21/17 at 10:30 p.m., he said the resident across the hall leaves her television (TV) on loud, and no one can get any sleep. room [ROOM NUMBER]'s television could be heard at high volume in Resident #60's room during the time of this interview. b) Observation of the loud television coming from Resident #60's room Observation of the hall way of Rooms 116 - 131 on the south back hall found the TV in room in Resident #60's room could be heard very at high volume out in the hall way from 9:00 p.m. - 11:10 p.m. on 03/21/17. c) Interview with unit manager-registered nurse (UM-RN) #57 Interview at the entrance of Resident #60's room with UM-RN #57 took place at 11:12 p.m. on 03/21/17. The UM-RN was asked whether the resident television was too loud, she acknowledged the television was turned up too loud and the resident TV needed to be turned down so not to bother other residents. The UM-RN entered the room, and she asked the resident if she could turn the TV down, and the resident allowed the nurse to turn her TV down. The nurse said Resident #60 needed to have head phones so her TV does not bother other residents at the facility.",2020-09-01
953,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,278,D,0,1,SWUR11,"Based on record review and staff interview, the facility failed to ensure a five (5) day Minimum Data Set (MDS) accurately reflected the resident's incontinence status. This was true for one (1) of fifteen (15) residents reviewed for the care area of urinary incontinence, during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #25. Facility census: 117. Findings include: a) Resident #25 A review of Resident #25's five (5) day minimum data set (MDS) with an assessment reference date (ARD) of 12/14/16, on 03/15/17 at 10:00 a.m., revealed the resident was occasionally incontinent of urine. The activity of daily living (ADL) flow record for Resident #25 reviewed, on 03/15/17 at 11:00 a.m., revealed the resident was incontinent forty-eight times, and five (5) times continent during the look back for the 12/14/16 MDS. The ADL flow record revealed the resident's has frequently incontinences. In an interview with clinical reimbursement coordinator (CRC) #32, on 03/15/17 at 11:45 a.m., she reviewed Resident #25's MDS with the ARD 12/14/16 and the ADL flow record during this look back period. The CRC confirmed the MDS was inaccurate related to the resident's incontinences status for this MDS assessment. The CRC said the resident was frequently incontinent not occasional incontinent. She stated she would do a correction to the MDS. On 03/15/17 the CRC provided information that a correction was done. On 03/17/17, an in-service was conducted related to coding urinary continence H 0300 in accordance with the resident assessment instrument manual.",2020-09-01
954,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,279,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and observation, the facility failed to develop a comprehensive care plan regarding a skin condition of a resident. This failed practice affected one (1) of fifteen (15) Stage 2 residents. Resident identifier: #61. Facility census: 117. a) Resident #61 During a resident interview and observation of Resident #61, on 03/21/17 at 9:57 p.m., she had numerous small circular scabs on her arms and face. She also had multiple white circular areas on her arms, which she stated were scars from past scabs. Resident #61 stated she had a nervous condition that made her itch and she kept scratching it open. She said she recently went to a dermatologist and received orders to apply cream on the areas. A review of the medical record conducted on 03/22/17 found a consult report from a dermatologist dated 02/24/17 at 07:15 a.m. This report gave a [DIAGNOSES REDACTED]. The plan per the dermatologist was as follows: --Patient will be allowed to soak in a tub at her domicile twice per week for 20 minutes with 1/4 cup regular bleach and 10-12 inches of water. --After each of those soaking baths patient will apply zinc talc shake lotion obtained from (Pharmacy #1.) --Patient may apply the same shake lotion after her normal showers 5 days a week to crusted areas if there are any. --Follow the booklet given from the state health department regarding infection control keep her fingernails trimmed back at least once a week and wash under the nails once a week with a nail brush and a very mild soap. --Patient will not use soap to wash her skin with or apply anything else to her skin and she will clean her skin with [MEDICATION NAME] gentle skin cleanser liquid and after bathing except on the sore areas she will apply moisture cream. --Patient's physician or care provider will reexamine in 6 weeks and if all [MEDICAL CONDITION] are healed soaking bleach baths can be discontinued if the condition recurs she should go back on the same program. The following physician's orders [REDACTED]. --Cleanse skin with [MEDICATION NAME] for impetigo QD every shift --Resident to soak in tub with 1/4 cup of bleach in 10-12 inches of water for 20 min 2 x wk on t-f if areas resolved d/c after 6 weeks --[MEDICATION NAME] Cream ([MEDICATION NAME]) apply topically every day shift for impetigo --Zinc acetate Lotion 2% apply to affected areas topically every day shift Tue, Fri for impetigo for 6 weeks apply after tub soak. A skin assessment for Resident #61 was performed, on 03/07/17 at 9:00 a.m., which identified [MEDICAL CONDITION] all over body. The current care plan was reviewed with the assistance of Clinical Reimbursement Coordinator (CRC) #32 and Minimum Data Set (MDS) Coordinator #59, on 03/22/17 at 10:32 a.m., and the skin condition was not included in the care plan. CRC #32 stated that since the problem occurred after the last MDS assessment, the floor nurse would then write an episodic care plan that would be included in the current care plan. Assistant Director of Nursing #61 was interviewed, on 03/22/17 at 10:35 a.m., and she said the resident is currently receiving multiple treatments for her skin condition and the wound nurse generally puts in care plans for skin issues. The Director of Nursing was interviewed on 03/22/17 at 11:27 p.m. and she said the resident's skin condition was not in the current care plan.",2020-09-01
955,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,280,D,0,1,SWUR11,"Based on observation, record review and staff interview, the facility failed to revise a care plan related to a non-pressure skin condition for one (1) of fifteen (15) residents reviewed. The care plan was not revised when the status of the wound changed to a bleeding wound. Resident identifier: #106. Facility census: 117. Findings include: a) Resident #106 A medical record review on 03/20/17 revealed an order dated 03/14/17 to cleanse Resident #106's left lower arm with skin integrity wound cleanser, pat dry, apply steri-strips to skin, and monitor every shift for signs/symptoms of infection. Observation of the wound bed at about 1:50 p.m. revealed steri-strips placed over the wound, side by side and formed a dressing appearance. The steri-strips were covered with a line of blackish dried clotted blood and brown discoloration spreading out over the steri-strips. Licensed Practical Nurse (LPN) #71, interviewed at 2:04 p.m., said the wound bed was not covered with a dressing because the wound bed was not open and was secured with steri-strips. The nurse said the resident would pull off a dressing, but not steri-strips, even though placed across the wound bed to form a dressing appearance. During an observation with the center nurse executive (CNE), Licensed Practical Nurse #71 and Nurse Aide #172, the NA reported the wound had drainage since she had cared for the resident and was present all day on 03/20/17. Upon inquiry from the CNE the NA said the only difference was it looked like it might have more steri-strips. The CNE said she had not seen the wound and instructed the nurse to place a cover dressing over the wound bed to secure the secretions. With further discussion the CNE related the resident was on anti-coagulant therapy, which would more easily cause the wound to bleed. She confirmed the plan of care should have been reviewed and revised when the wound bled.",2020-09-01
956,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,282,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to follow the care plan for one (1) of fifteen (15) Stage 2 sampled residents. Resident #39's care plan was not followed related to completing the pain assessment per facility protocol. Resident identifier: #39. Facility census: 117. Findings include: a) Resident #39 The medical record for Resident #39 was reviewed on 03/21/17 found the following pertinent [DIAGNOSES REDACTED]. The physician prescribed [MEDICATION NAME] tablets ([MEDICATION NAME]-[MEDICATION NAME]) every six (6) hours as needed (PRN) for pain. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] During an interview with registered nurse/unit manager director #61, on 03/21/17 at 11:40 a.m., she agreed there were two (2) occasions this month when the resident's pain was not assessed before and after narcotic pain medication administration, nor were there assessments of non-pharmacological treatments attempted before giving the narcotic pain medication on those two (2) occasions. The missing dates and times of the narcotic PRN pain medication assessments were 03/15/17 at 12:00 p.m., and 03/19/17 at 6:00 a.m. On 03/21/17 at 3:05 p.m., the director of nursing (DON) provided the facility's pain management policy/protocol, with a revision date of 11/28/16. This policy stated in part that if PRN medications are given, nursing assessments must document on the back of the MAR indicated [REDACTED]. The facility's policy/protocol also stated patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Nurses must document the effectiveness of PRN medications, ineffectiveness of routine or PRN medications including interventions, follow-up and physician and/or nurse practitioner and/or physician assistant notification. Nurses must also assess and document non-pharmacological interventions and effectiveness. Review of the resident's care plan found an intervention to complete the pain assessment per protocol. The care plan further directed to evaluate pain characteristics, and monitor for both effectiveness and side effects. Prior to exit the DON provided no further information for the 03/15/17 (12:00 p.m.) or the 03/19/17 (6:00 a.m.) missing before or after narcotic pain medication assessment for this resident.",2020-09-01
958,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,312,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene. A resident incontinent of urine did not receive care in a timely manner. Resident identifier: #99. Facility census: 117. Findings include: a) Resident #99 On 03/12/17, during the initial tour, observation revealed an odor of urine in the hallway from the doorway Resident #99's room. A subsequent observation ,on 03/20/17 at 12:55 p.m., again revealed a strong odor of urine in the hallway from Resident #99's room. A follow-up observation at 2:54 p.m., with Licensed Practical Nurse (LPN) #55, confirmed the odor of urine was present. The sheets appeared without wrinkles as though recently placed on the bed. During a random observation, on 03/21/17 at 9:16 p.m., a strong odor of urine/ammonia was present into the hallway. Resident #99's bed was visible from the doorway and the covers were pulled up from the side of the bed. The fitted sheet appeared wet with a brown border along the edge. While observing, family members exited the facility via the hallway. Multiple staff members walked past the door and did not enter to provide care. The staff passed ice, entered in and out of other resident's rooms, and stopped to converse with the nurse. Upon inquiry, at 10:03 p.m., LPN #17 confirmed a strong odor of urine into the hallway, and Resident #99's sheet discolored with a wet appearance outlined with a brown border. The nurse said, I see what you mean. NA #114 said the resident was sometimes incontinent, but toileted herself, and was last checked around dinner time. The NA also stated this was the resident's scheduled shower night. The medical record, reviewed on 03/21/17, noted a [DIAGNOSES REDACTED]. The minimum data set (MDS) with an assessment reference date (ARD) of 01/02/17, indicated Resident #99 had a significant change in condition, from independent to extensive assistance with toileting, transferring, and bed mobility. During a discussion with the center nurse executive (CNE) at 11:45 p.m., she said staff should have checked the resident at least every two (2) hours and should not have left her wet for 45 minutes before offering to provide care and toileting. The CNE reviewed the ADL sheets and confirmed they were documented inaccurately.",2020-09-01
959,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,315,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation, staff interview and medical record review, the facility failed to identify a resident who was incontinent of urine and assess and provide appropriate treatment and services to achieve as much normal urinary function as possible, for one (1) of three (3) residents reviewed for activity of daily living (ADL). Resident identifier: #99. Facility census: 117. Findings include: a) Resident #99 On 03/12/17, during the initial tour, observation revealed an odor of urine from the doorway Resident #99's room. A subsequent observation, on 03/20/17 at 12:55 p.m., again revealed a strong odor of urine. A follow-up observation at 2:54 p.m., with Licensed Practical Nurse (LPN) #55, confirmed the odor of urine was present. The sheets appeared without wrinkles as though recently placed on the bed. During a random observation on 03/21/17 at 9:16 p.m., a strong odor of urine/ammonia was present into the hallway. Resident #99's bed was visible from the doorway and the covers were pulled up from the side of the bed. The fitted sheet appeared wet with a brown border along the edge. While observing, family members exited the facility via the hallway. Multiple staff members walked past the door and did not enter to provide care. The staff passed ice, entered in and out of other resident's rooms, and stopped to converse with the nurse. Upon inquiry, at 10:03 p.m., LPN #17 confirmed a strong odor of urine into the hallway, and Resident #99's sheet discolored with a wet appearance outlined with a brown border. Nurse Aide (NA) #114 asked Resident #99 if she wanted to take a shower and the resident said yes. Without explaining, the NA removed the resident's covers and pulled her legs toward the side of the bed. The resident changed her mind, tried to pull the covers back over her and when NA #114 attempted to intervene, Resident #99 struck at her. NA #114 said the resident was sometimes incontinent, but toileted herself, and was last checked around dinner time. The medical record, reviewed on 03/21/17, noted a [DIAGNOSES REDACTED]. The minimum data set (MDS) with an assessment reference date (ARD) of 01/02/17, indicated Resident #99 had a significant change in condition, from independent to extensive assistance with toileting, transferring, and bed mobility. The activities of daily living (ADL) record, reviewed for (MONTH) (YEAR) indicated Resident #99 had zero (0) episodes of incontinence, but assistance varied from independent to extensive assistance. During another discussion with LPN #17, at 10:51 p.m., the nurse verbalized Resident #99 was incontinent every day, about two (2) times a night and confirmed the shift as 11:00 p.m. to 7:00 a.m. Nurse Aide (NA) #165, interviewed at 10:51 p.m. voiced Resident #99's incontinence cycle had not been figured out. The NA said the resident had been a health care professional, and would hide her soiled brief, as though she might be embarrassed. The nurse aide reported the resident had become more incontinent recently on evening shift (3:00 p.m. to 11:00 p.m.) NA #165 said the increase in incontinence episodes had been ongoing for about a month. During a discussion with the center nurse executive (CNE) at 11:45 p.m., she said staff should have checked the resident at least every two (2) hours and should not have left her wet for 45 minutes before offering to provide care and toileting. The CNE reviewed the ADL sheets and confirmed they were documented inaccurately. During an interview with assistant director of nursing (ADON) #61, on the morning of 03/22/17, the nurse reviewed the medical record and said a urinary incontinence assessment had not been completed due to the resident was continent of urine. She acknowledged the facility had not assessed for underlying conditions impacting the incontinence episodes.",2020-09-01
960,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,353,D,0,1,SWUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, and staff interview, the facility failed to deploy staff to ensure resident care needs were met. This practice affected one (1) resident but had the potential to affect more than a limited number of residents. Facility census: 117. Resident identifier: Resident #99 b) Resident #99 During a random observation on 03/21/17 at 9:16 p.m., a strong odor of urine/ammonia was present into the hallway. Resident #99's bed was visible from the doorway and the covers were pulled up from the side of the bed. The fitted sheet appeared wet with a brown border along the edge. Multiple staff members walked past the door and did not enter the room to provide care. Staff passed ice, entered in and out of other resident's rooms, and stopped to converse with the nurse who was administering medications. Upon inquiry, at 10:03 p.m., LPN #17 confirmed a strong odor of urine into the hallway, and Resident #99's sheet discolored with a wet appearance outlined with a brown border. The nurse said the resident should be checked at least every two (2) hours. The medical record, reviewed on 03/21/17, noted a [DIAGNOSES REDACTED]. The minimum data set (MDS) with an assessment reference date (ARD) of 01/02/17 indicated Resident #99 required extensive (weight bearing) support for bed mobility, transfers, dressing, and toilet use. Licensed Practical Nurse #17, interviewed at 10:51 p.m. on 03/21/17, verbalized Resident #99 is incontinent about twice a night. Nurse Aide (NA) #165 voiced Resident #99 had been incontinent for a while, but had not been able to figure out a cycle. The Kardex, reviewed at 10:58 p.m. with the center nurse executive (CNE) indicated Resident #99 required assistance with toileting upon rising, before and after meals and at bedtime. The CNE said that was when staff should offer toileting, but should be checked every two (2) hours. During a follow-up discussion at 11:45 p.m., the CNE verbalized staff should have checked the resident at least every two (2) hours and should not have left her wet for over 45 minutes before offering to provide incontinence care and/or toileting. The CNE acknowledged staff had not been deployed in a manner to provide timely incontinence care.",2020-09-01
965,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2017-03-22,516,D,0,1,SWUR11,"Based on a random observation and staff interview, the facility failed to safeguard the medical record of a resident by leaving his Medication Administration Record [REDACTED]. Resident identifier: #4. Facility census: 117. Findings include: a) Resident #4 On 03/21/17 at 8:32 a.m., licensed practical nurse (LPN) #71 was observed leaving her unit on the south back hall while her MAR indicated [REDACTED]. Further examination found the MAR indicated [REDACTED]. During the absence of LPN #71, two (2) staff members and one (1) resident passed by the open MAR indicated [REDACTED]. LPN #71 returned to her unit and medication cart on 03/21/17 at 8:38 a.m. The concern was discussed with the director of nursing on 03/21/17 at 3:00 p.m. and she said that MARs are not supposed to be left open and uncovered.",2020-09-01
966,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2018-05-24,550,D,0,1,TNYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, policy review, and resident, family and staff interview, the facility failed to treat residents with respect and dignity by providing incontinence care when requested. This affected one (#30) of one sampled residents who required extensive assistance with toileting and personal hygiene care. Resident identifier: #30. Facility census: 119. Findings included: a) Resident #30 Review of the admission record revealed Resident #30 was admitted to the facility on with [DIAGNOSES REDACTED]. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted at approximately 3:00 PM on 05/21/18. The MDS assessment revealed that Resident #30 usually understands others and is also usually understood. Additionally, the resident was coded as having a Brief Interview for Mental Status (BIMS) score of 15; thereby indicating Resident #30 was cognitively intact. The MDS assessment further revealed the resident required extensive physical assistance with toilet use of two persons. The MDS further documented Resident #30 was incontinent of bladder and bowel. During an interview which began on 05/21/18 at 1:56 PM, Resident #30 indicated that she often had to wait for the staff to change her. The resident said sometimes she has had to wait for several hours. Resident #30 recalled an incident where she laid wet in bed from 12:30 PM to 3:30 PM. She said this occurred about two months ago. She said she put on her call light and the staff would come and turn off the light and just wouldn't come back to change her. The resident also expressed, They ignore me. The nurse aides ignore me. There's about three that are mean. Resident #30 said that CNA#4 is rude and hateful and doesn't treat her with respect. The resident conveyed feeling humiliated. She said that CNA #4 throws things on her bed and says No I can't have a snack. An interview was conducted with a family member of Resident #30 on 05/22/18 at 7:02 PM. The family member shared that Resident #30 had also informed this family member about how CNA #4 had treated her, and that CNA #4 was hateful to her. The family member recalled the resident saying that she had laid in her own waste from 12:30-3:30 PM on one occasion and said that the staff member told her that they were busy passing lunch trays and could not change Resident #30 until they were finished passing the lunch trays. The family member reports having shared these concerns with the resident's nurse but could not recall the nurse's name. The family member conveyed that whenever you report a concern to the facility staff they always say the same thing, that they are understaffed. An interview was conducted with CNA #4 on 05/23/18 at 5:20 PM. The CNA acknowledged having worked with Resident #30 in the past and says she last worked with Resident #30 about 3-4 weeks ago. CNA#4 stated that she straightens up the resident's table. When asked if she responds to the resident's call lights timely, CNA #4 responded, I acknowledge the light, and tell her that I will be back as soon as I finish with the other person. When asked if she had been rude or hateful to Resident #30 she said I try not to be rude. I don't think so. During an interview with the facility Administrator and Director of Nursing (DON) on 05/24/18 at approximately 1:50 PM, both indicated that their expectation was for all staff to answer call bells timely and provide the care needed when the resident's call for assistance. Both the Administrator and the DON conveyed that it was their expectation that the facility staff bring these issues to their attention whenever they are reported to them by the residents or by family members. The DON conveyed that it was her expectation that all staff treat all residents with respect and dignity. The DON said she had just conducted an in-service with staff regarding being mindful of what they are saying and where we are saying it. CNE #71 said the in-service was in response to complaints coming from the resident council meeting in (MONTH) (YEAR) about hateful staff. A review of the facility's policy and procedure for Considerate and Respectful treatment was reviewed on 05/21/18 at approximately 4:15 PM. The effective date of the policy was 6/01/1996 and was revised on 9/01/2013. The policy outlined that Dignity means that in their interactions with patients, staff carry out activities that assist the patient to maintain and enhance his/her self-esteem and self-worth. Under the section entitled Process, item #1 stated: Staff will show respect when communicating with, caring for, or talking about patients. and under section entitled Demeaning Practices stated, Staff will refrain from practices that are demeaning to patients such as: Refusing to comply with a patient's request for toileting assistance during meal times .",2020-09-01
967,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2018-05-24,552,D,0,1,TNYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and psychologist interview, the facility failed to ensure each resident had the right to be informed and make treatment decisions before obtaining psychological consultation services. This affected one of one sampled resident for whom a psychological consult was carried out without knowledge of the resident. Resident identifier: #30. Facility census: 119. Findings included: a) Resident #30 Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #30's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 usually understands others and is also usually understood. Additionally, the resident was coded as having a Brief Interview for Mental Status (BIMS) score of 15; thereby indicating both short and long-term memory were intact. A review of a 5-day abuse investigation file was conducted on 05/24/18 at approximately 10:15 AM. Within the abuse investigation file was a report of psychological consultation services for Resident #30. The report was dated 05/23/18 and revealed that Psychologist #132 carried out consultative services for Resident #30. The report findings indicated that her Dementia is progressing, but she also manipulates a situation The report further conveyed that Resident #30 claimed that she could not hear (which she can). An interview was conducted with Resident #30 on 05/24/18 at 10:45 AM. Resident #30 stated that she did not give the facility permission to conduct a psychological consultation nor did she know that she needed one. An interview was conducted with the Director of Nursing (DON) and Administrator on 05/24/18 at approximately 1:30 PM. Both the administrator and the DON denied requesting the psychological consultation for Resident #30. Both the Administrator and the DON denied having gained permission for the psychological consultation from Resident #30 or from her family members prior to the consultative visit on 05/23/18. An interview was conducted with Social Services Specialist #56 on 05/24/18 at 1:59 PM. The social services specialist stated that she was the one that requested the psychological consult for Resident #30 after speaking with a nurse on the unit that shared that Resident #30 seeks attention by coughing and that she only has a dry cough. The Social Services Specialist said there are times when you walk into the resident's room and she would act like she is coughing to get attention. The social services specialist stated that she did not obtain permission for the psychological consult from either Resident #30 nor from the family members of Resident #30 before requesting the psychological consult. An interview was conducted with Psychologist #132 via telephone call on 05/24/18 at approximately 7:15 PM. Psychologist #132 conveyed that his services were requested by the facility to see Resident #30. Psychologist #132 conveyed that the facility requested his services on behalf of Resident #30 for attention seeking behaviors. The psychologist stated that he had never seen Resident #30 on his case load before; therefore, reviewed the resident's medical record before going in to see Resident # 30. Psychologist #132 said he went in to the room and spent about 10 minutes with Resident #30. A review of the clinical record failed to indicate that anyone had informed Resident #30 that a psychological consultation was requested nor gained her permission to do so.",2020-09-01
968,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2018-05-24,583,D,1,1,TNYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review and staff interviews, the facility failed to ensure the timely provision of requested medical records for one of 3 sampled residents. Resident identifier: #116. Facility census: 119. Findings included: a) Resident #116 On 05/23/18 at approximately 10:45 AM, Resident #116's electronic health record (EHR) was reviewed. The Admission Record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 02/14/17 to her home. The Admission Record indicated the resident's son was her responsible party. Further review on 05/23/18 at approximately 10:45 AM revealed a Request for Release of Medical Records form dated 06/01/17. The form requesting the medical records was signed by the responsible part of Resident #116. The form clearly indicated both a telephone number and an address where the resident's responsible party was to be reached. Continued review of the EHR on 05/23/18 at approximately 10:45 AM revealed a second Request for Release of Medical Records form. The form was signed by the Resident #116's responsible party and dated 11/15/17. The form clearly indicated both a telephone number and an address where the resident's responsible party was to be reached. The request form specifically indicated the resident's responsible party wanted the records sent to him via mail. Nothing could be found in records to indicate the medical records of Resident #117 were ever provided to the responsible party as requested. During an interview conducted with the Health Information Management Coordinator on 05/23/18 at 10:21 AM, she stated Resident #116's responsible party requested the resident's medical records twice. She stated the responsible party had come into the facility personally the first time and wanted to know if she would copy the records. She stated a request was filled out at that time and sent the request to the corporate office for review and approval. She stated corporate approved the request within a day or two after the records were requested. The Health Information Management Coordinator stated the resident's responsible party returned to the facility two days later. The requested records were not yet copied because she had been too busy with other duties to copy them. When she did get the requested records copied, she tried to reach out to the resident's responsible party by phone, but the phone was out of service. She acknowledged the attempts to reach the resident's responsible party were not documented and no attempt was made, according to the Health Information Management Coordinator, to reach him by mail to indicate the records were ready to be picked up. She stated she understood the facility policy indicated the records should have been ready when the resident's responsible party returned to the facility two days after the initial request. During a subsequent interview with the Health Information Management Coordinator on 05/23/18 at 12:20 PM, she stated a second request for Resident #116's medical records was faxed to the facility on [DATE] from the resident's responsible party. She stated, I immediately tried to call him back to let him know we had the documents waiting for him from the initial request. The number was not a working number. There was an address on the form, but I did not send anything by mail to let him know the records were ready. He has never called or attempted to contact us again. The records are still there in my office. During an interview with the Health Information Management Coordinator on 05/23/18 at 12:49 PM, she acknowledged attempts should have been made to reach the resident's responsible party by mail. She also indicated attempts to reach the responsible party by phone should have been documented in the record. On 05/23/18 at approximately 3:30 PM, the facility's Release of Information Policy revised on 03/10/17 read, in pertinent part, Requests (for medical records) from patients/residents or their legal representative (should be available) within two working days advance notice.",2020-09-01
969,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2018-05-24,584,D,0,1,TNYE11,"Based on observation, staff interview and facility policy review, the facility failed to ensure wheel chairs, geri chairs (large padded chairs with wheeled base) seat cushions were kept clean and free of stains. This affected 15 of 23 resident mobility devices located on one (South) of two units. Facility census: 119. Findings included: Observation on 05/22/18 at 9:00 AM revealed 23 resident mobility devices lined in a row against a wall in the back hallway of the South unit. The devices included wheel chairs, electric scooters, geri chair and seated rolling walkers. Fifteen of the seat cushions were unclean and heavily stained with a white and/or brown substance on the top surface. During an interview with Certified Nursing Aide (CNA) #78 on 5/22/18 at 10:00 AM, she was not sure who was responsible for cleaning the wheel chairs but had thought it was done on night shift. When asked who would clean the seat cushion if it were soiled, she stated, If I can clean it then I would, but if I can't, then I would let someone know. On 05/23/18 at 4:00 PM, an interview was conducted with the Director of Nursing (DON) and the Administrator. They stated they were unaware the seat cushions on the mobility devices were unclean or stained. They stated they felt the mobility devices had just been cleaned per the cleaning schedule. They revealed no one had reported there were any unclean or stained cushions on wheel chairs, Geri chairs or seat rolling walkers. Immediately after the interview, the DON and Administrator observed and verified the seat cushions were stained. On 05/24/18 at 9:00 AM, the policy and procedure and the cleaning schedule was provided by and reviewed with the DON. The DON revealed the nursing night shift staff were responsible for cleaning the resident mobility devices according to the cleaning schedule posted on each unit. She stated the nursing staff were to take the mobility devices to the shower rooms and use the water wand to clean them. She stated Environmental Services were responsible for detailed or as needed pressure wash cleaning. She stated the nursing department was responsible for monitoring; however, the facility did not do any type of formal audits documented. On 05/24/18 at 11:00 AM, an interview with the Housekeeping Services Director was conducted. She stated Environmental Services was not responsible for any type of cleaning of the resident mobility devices such as the wheel chairs, geri chairs or seated rolling walkers. She stated if the Administrator would ask her to pressure wash the devices she would, but there was no schedule or policy stating she was responsible for cleaning resident mobility devices. Review of the facility's policy titled, Detailed Cleaning dated revision 11/28/16, revealed Both resident/patient and non-resident/patient areas are detailed cleaned on a scheduled cycle at least annually.To ensure an optimal level of cleanliness of resident/patient rooms and to enhance the overall appearance of their environment.1. Environmental Services Director completes the Detailed Room Cleaning Schedule.3. Detailed cleaning is accomplished by using the Seven-Step Cleaning Procedure plus: 3.2. Geri-chair and wheelchair cleaning.",2020-09-01
970,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2018-05-24,656,D,0,1,TNYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interview, the facility failed to implement interventions for oxygen therapy according to the comprehensive plan of care. This affected one of two sampled residents. Resident identifier: #40. Facility census: 119. Findings included a) Resident #40 On 05/22/18 at 3:22 PM, the medical record was reviewed. The nurse's notes revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medicare (14 day) Minimum Data Set (MDS) assessment dated [DATE] stated the resident required assistance of one to two with activities of daily living (ADLs) and required oxygen therapy. The (MONTH) (YEAR) physician's orders [REDACTED]. Check for placement every shift. The original physician order [REDACTED]. Continued review of the medical record on 05/22/18 at 3:22 PM revealed the most recent plan of care dated 03/16/18 stated the resident was at risk for respiratory complications related to [DIAGNOSES REDACTED]. Interventions included: Oxygen via nasal cannula as ordered by the physician. The care plan did not include the specific oxygen setting as ordered by the physician. On 05/22/18 at 2:55 PM, Resident #40 was observed sitting in her wheelchair outside her room in the hallway with a portable oxygen tank attached to her wheelchair. The oxygen tubing that was used via nasal cannula was observed on top of the resident's head. The portable oxygen tank's dial was set to 0.5 liters per minute of oxygen. On 05/22/18 at 3:42 PM, Resident #40 was observed lying in bed with oxygen on via nasal cannula. The oxygen concentrator was set on 1 liter per minute. No respiratory distress was noted. On 05/22/18 at 4:46 PM, Resident #40 the resident was observed lying in bed with oxygen on via nasal cannula. The oxygen concentrator was set at 1 liter per minute. Registered Nurse (RN) #100 entered the room and verified the oxygen setting was set on 1 liter per minute. The resident's wheelchair was observed at the bedside. RN #100 verified the portable oxygen tank was still on the setting of 0.5 liters of oxygen. RN #100 verified the nurses were responsible for ensuring the oxygen settings were at the proper levels. RN #100 stated she did not realize the oxygen settings were at those levels and should be set on 3 liters of oxygen per minute. RN #100 verified the physician's orders [REDACTED]. On 05/24/18 at 4:40 PM, observations were made of the resident lying in bed with oxygen set at 2 liters per minute via nasal cannula. RN #100 stated she wasn't sure why the oxygen was not on 3 liters per minute via nasal cannula and verified the oxygen was on the wrong setting.",2020-09-01
971,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2018-05-24,689,D,0,1,TNYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observations, and staff interviews, the facility failed to ensure a safe smoking environment for one (#33) of 4 sampled residents reviewed for smoking. Resident identifier: #33. Facility census: 119. Findings included: a) Resident #33 The electronic health record (EHR) for Resident #33 was comprehensively reviewed on 05/22/18 at 3:28 PM. Review of the admission record revealed admitted s of 03/08/18 and 04/30/18 with [DIAGNOSES REDACTED]. An untitled agreement form, signed by the Resident #33 dated 03/09/18 read, in pertinent part, Based on our discussion and notification, our smoking policy changed (MONTH) 15, (YEAR). You are signing this form in recognition of our smoking rules outlined below and given a copy: 1. Smoking not permitted within 25 feet of the building; 2. Must be able to smoke independently without any assistance. If at any time staff/family feels you are not safe to smoke independently, you will be re-assessed and privileges taken away if you do not pass the assessment to determine this; 3. Only allowed to smoke in the courtyard at the designated smoking session times which are posted on the activities board in the main hallway; and 4. Employees and/or family members are not allowed to smoke in the courtyard. This is for residents only. The most recent Minimum Data Set (MDS) admission assessment dated [DATE] indicated Resident #33 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15/15. In addition, the assessment indicated the resident required extensive assistance from one to two staff members to complete all of activities of daily living (ADLs). A Progress Note dated 04/12/18 read, in pertinent part, Resident noted to be outside in the courtyard smoking with friends. Resident educated regarding smoke free facility rules and smoking after teeth extraction risks. Resident voices understanding. Continued record review on 05/22/18 at 3:28 PM revealed the Smoking Evaluation dated 05/20/18 indicated the resident required supervision with smoking due to unsafe smoking habits. The Smoking Care Plan dated 05/20/18 read, in pertinent part, Patient may (smoke) with supervision per smoking assessment. Interventions included educate patient on the facility's smoking policy, Inform and remind patient of location of smoking areas and times, reassess patient's ability to smoke independently with any change of condition, ensure that there is no oxygen in smoking area(s), provide smoking apron if indicated, and ensure the appropriate smoking receptacles are available in all smoking areas. Resident #33 was observed on 05/21/18 at approximately 10:30 AM and then again at approximately 2:15 PM outside in front of the facility. The resident was seated in his wheelchair and was smoking a cigarette. Certified Nurse Aide (CNA) #58 was observed to be present in the area while the resident was smoking on both occasions. The resident was seated in front of a handicapped parking spot at the edge of the facility parking lot. A smoking blanket and a cigarette butt receptacle were located on the lawn approximately 50 feet from where the resident was smoking. There was not a fire extinguisher observed anywhere in the area. Resident #33 was again observed on 05/22/18 at 3:30 PM outside in front of building smoking with CNA #33 near the handicapped parking spaces in the parking lot. It was raining outside. Resident #33 appeared to have bed sheet over his head to protect himself from the rain while smoking his cigarette. During an interview with the Administrator on 05/22/18 at 6:18 PM, he stated, There are four smokers in the facility. Two are grandfathered in from prior to the policy implementation. One is an independent smoker. One, (Resident #33) was independent prior to Sunday (05/20/18) and then changed to supervised due to unsafe smoking behaviors such as falling asleep in his wheelchair while smoking. The Administrator stated the facility smoking areas were in the facility courtyard and in front of building by the handicapped parking spaces, although he indicated the formal smoking area was in the facility courtyard. During an interview with the Director of Nursing (DON) on 05/22/18 at 4:40 PM, she confirmed Resident #33 was to be supervised with smoking as of 05/20/18 due to the fact that she had been informed that he was falling asleep while smoking by nursing staff. She stated, For a supervised smoker, the rules are they can smoke at 1:00 PM and 4:00 PM in the courtyard. (Resident #33) must have the smoking apron on now when he smokes. When asked how the resident's changed smoking status had been communicated to staff, the DON stated, Verbal education was given to staff in the building on Sunday that staff could go out (with Resident #33 to smoke) if they had time. She stated staff were told to have the resident wear a smoking apron when smoking. The DON acknowledged the facility was not following unsupervised or supervised rules/policies/procedures for Resident #33. She stated, He is supervised smoker, but we are not following the supervised smoking rules for him. Smoking times were observed posted next to the activities room on 05/23/18 at approximately 9:00 AM. The posting indicated supervised smoking times were scheduled in the smoking area in the facility courtyard twice daily at 1 PM and 4 PM. During an interview with CNA #58 on 05/24/18 at 10:57 AM, she stated, They changed his smoking (status) on Sunday and they told me he had to sign out and needed to be supervised. I was also supposed to make sure he was wearing his apron. He frequently goes outside to smoke. He wasn't having to follow the rules the same as the other supervised smokers. They didn't explain why .just that he needed to be supervised by someone. We went out front to smoke .not to the courtyard. I was told no-one is supposed to smoke out there in the courtyard because other families like to be out there unless it is at 1:00 or 4:00 (the supervised smoking times). I took him out the one time on Tuesday. He requests to smoke and we take him when he wants to go if we have time several times a day usually. The facility's Smoking Policy most recently dated 06/15/17 read, in pertinent part, Purpose: To ensure that patients who choose to smoke will do so safely; and For centers that allow smoking: Smoking will only be allowed in designated areas; and The patient's smoking status- independent, supervised, or not permitted to smoke- will be documented in the care plan; and If there is a willful disregard for safety to others or the Center is jeopardized by a patient's disregard for the smoking policy, termination of smoking privileges or initiation of a discharge plan may occur. The facility's undated Center Rules of Living and Conduct read, in pertinent part, Smoking: Some centers are smoke free while others allow smoking per the following guidelines. You will be informed if the center is smoke free prior to your admission and will be asked to sign and acknowledgement form. If you refuse to sign the form, your admission to the center may be denied. If you are admitted to a center that allows smoking, you will be assessed for smoking safety. Smoking will be permitted only in designated areas. If you are deemed unsafe based on your assessments, smoking supplies will be maintained by staff, and families and visitors are prohibited from giving smoking materials to you. Staff will assist you at specified times throughout the day.",2020-09-01
972,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2018-05-24,695,D,0,1,TNYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interview, the facility failed to ensure equipment settings for oxygen therapy were set at the proper setting. This affected one of two sampled residents. Resident identifier: #40. Facility census: 119. Findings included: On 05/22/18 at 3:22 PM, the medical record was reviewed. The nurse's notes revealed Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Medicare (14 day) Minimum Data Set (MDS) assessment dated [DATE] stated the resident required assistance of one to two with activities of daily living (ADLs) and required oxygen therapy. The (MONTH) (YEAR) physician's orders [REDACTED]. Check for placement every shift. The original physician order [REDACTED]. Continued review of the medical record on 05/22/18 at 3:22 PM revealed the most recent plan of care dated 03/16/18 stated Resident #40 was at risk for respiratory complications related to [DIAGNOSES REDACTED]. Interventions included: Oxygen via nasal cannula as ordered by the physician. On 05/22/18 at 2:55 PM, Resident #40 was observed sitting in her wheelchair outside her room in the hallway with a portable oxygen tank attached to her wheelchair. The oxygen tubing that was used via nasal cannula was observed on top of the resident's head. The portable oxygen tank's dial was set to 0.5 liters per minute of oxygen as opposed to the 3.0 liters ordered by the physician. On 05/22/18 at 3:42 PM, Resident #40 was observed in her room lying in bed with oxygen on via nasal cannula. The oxygen concentrator was set on 1 liter per minute as opposed to the 3 liters per minute ordered by the physician. On 05/22/18 at 4:46 PM, Resident #40 was observed lying in bed with oxygen on via nasal cannula. The oxygen concentrator was on at 1 liter per minute. Registered Nurse (RN) #100 entered the room and verified the oxygen setting was set at 1 liter per minute. The resident's wheelchair was observed at the bedside. RN #100 verified the portable oxygen tank was still on the setting of 0.5 liters of oxygen. RN #100 verified the nurses were responsible for ensuring the oxygen settings were at the proper levels. RN #100 stated she did not realize the oxygen settings were at those levels and should be set on 3 liters of oxygen per minute. RN #100 verified the physician's orders [REDACTED]. On 05/24/18 at 4:40 PM, observations were made of the resident lying in bed with oxygen set at 2 liters per minute via nasal cannula. RN #100 stated she wasn't sure why the oxygen was not on 3 liters per minute via nasal cannula and verified the oxygen was on the wrong setting.",2020-09-01
974,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2018-05-24,880,D,0,1,TNYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to ensure the infection prevention and control program was carried out to maintain a safe, sanitary and comfortable environment to help prevent the spread of infection. This affected two of three residents (#39 and #81) observed receiving blood sugar checks during medication pass observations. The glucometer device was not appropriately sanitized prior to use for these residents. Resident identifier: #39 and #81. Facility census: 119. Findings included: a) Resident #39 On 05/24/18 at approximately 2:00 PM, the electronic health record (EHR) Resident #39's was reviewed. The Admission Sheet dated 05/24/18 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Summary Order Report dated for (MONTH) (YEAR) revealed the resident had an order for [REDACTED]. Licensed Practical Nurse (LPN) #79 was observed using the EVENCARE G3 Blood Glucose Monitor to check Resident #39's blood sugar on 05/23/18 at 4:23 PM. LPN #79 did not clean the glucometer prior to obtaining Resident #39's blood sugar. After using the monitor to obtain the resident's blood sugar, LPN #79 wiped the monitor off with an alcohol prep pad for approximately 5 seconds and then placed the glucometer back into the medication cart for storage. During an interview with LPN #79 on 05/24/18 at 12:01 PM, she stated, I thought we were supposed to use the alcohol to clean the meters. This morning we were talking about it (cleaning the blood glucose meters) and they told me I'm supposed to use the bleach wipes in the bottom of the cart. b) Resident #81 On 05/24/18 at approximately 2:15 PM, the electronic health record for Resident #81 was reviewed. The Admission Record dated 05/24/18 revealed the resident was admitted with [DIAGNOSES REDACTED]. The Order Summary Report dated for (MONTH) (YEAR) revealed the resident had an order for [REDACTED]. Licensed Practical Nurse (LPN) #24 was observed using the EVENCARE G3 Blood Glucose Monitor to check Resident #81's blood sugar on 05/24/18 at 11:19 AM. LPN #24 did not clean the glucometer prior to obtaining Resident # 81's blood sugar. After using the monitor to obtain the resident's blood sugar, LPN #24 wiped the monitor off with an alcohol prep pad for approximately 5 seconds and then placed the glucometer back into the medication cart for storage. During an interview with LPN #6 on 05/24/18 at 11:27 AM, she stated, I Normally clean (the glucometer) with alcohol. We have the bleach wipes in the bottom of the med cart, too. We can use either, but I usually use the alcohol because it's more convenient. During an interview with the Director of Nursing (DON) on 5/24/18 at approximately 2:04 PM, she stated, Staff should be using sani-wipes (bleach wipes) in the med carts to clean the glucometers, and they should be following directions on wipe container related to kill time. On 05/24/18 at approximately 1:45 PM, the undated Medline EVENCARE G3 Blood Glucose Monitoring System Operations Manual was reviewed and read, in pertinent part, Cleaning and Disinfecting: Materials Needed: A validated disinfecting wipe. The following products have been approved for cleaning and disinfecting the EVENCARE G3 Meter: Dispatch Hospital Cleaner Disinfectant Towels with Bleach; Medline Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol; Clorox Healthcare Bleach Germicidal and Disinfectant Wipes; Medline Micro-Kill Bleach Germicidal Bleach Wipes; and The EVENCARE G3 Meter should be cleaned and disinfected between each patient. On 05/24/18 at approximately 11:20 AM, the Medline Micro-Kill Bleach Germicidal Wipes used by the facility to disinfect equipment was observed. The Wet/Kill Time (the time a device needs to remain wet for 99.9% of the microbes on its surface to be killed) on the side of the Medline Micro-Kill Bleach Germicidal Wipes including blood glucose monitors, indicated a Wet/Kill time of 3 minutes.",2020-09-01
975,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,558,D,0,1,VCKW11,"Based on observation, staff interview, and resident interview the facility failed to ensure call light was in reach and accessible to resident. This was a random opportunity for discovery. Resident identifier: #44. Facility census: 118. Findings included: a) Resident #44 On 07/15/19 at 11:24 AM during the initial screening process, Resident #44's call light was found to be in the floor under Resident's bed. Resident stated, that is where it (call light) stays most of the time is in the floor. When Resident was asked how she got help if needed, Resident stated, I yell at my room mate and she helps me. Resident stated she had very poor vision and could only see silhouettes and most of the time she can not locate the call light. The Resident also stated, If my room mate is not in here, I just wait for someone to come by to help me. At 11:30 AM on 07/15/19, Certified Nurse Aid (CNA) #75 came into Resident room and verified call light to be under bed out of reach of Resident. CNA #75 retrieved call light from floor and placed it within Resident's reach on the right side of bed and stated, I have no idea how long it's (call light) been in the floor. On 07/16/19 at 11:45 AM during an interview with Activities Director (AD) #93 in Resident's room, Resident was unable to find call light that was hanging on right bed rail when prompted and Resident asked AD # 93 for assistance. Resident stated it would be helpful of call light could be Velcro to right bed rail so she could easily locate it, and it had to be on the right side to accommodate her left sided paralysis deficit causes from a previous stroke. Record review revealed the Resident was deemed by a physician to have capacity to make her own medical decisions. The Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating the Resident had little or no impairment in cognitive ability.",2020-09-01
976,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,580,D,0,1,VCKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician when Resident #61's blood sugars were outside of physician ordered parameter and for Resident #12 family was not notified of an accident which resulted in an injury and required physician intervention. This deficient practice was true for one (1) of one (1) reviewed for change in condition and one (1) of five (5) reviewed for care area of unnecessary medication. Resident identifiers: #61 and #12. Facility census: 118. Findings included: a) Resident #61 Review of Resident #61's medical records found a physician's orders [REDACTED]. Resident #61's Medication Administration Record [REDACTED]. Further review of Resident #61's medical records found no progress note indicating the physician had been notified on 07/03/19 and 07/05/19. During an interview with the Director of Nursing (DON) on 07/17/19 at 10:05 am, Resident #61's medical records were reviewed. She confirmed the physician had not been notified on 07/03/19 and 07/05/19. b) Resident #12 Medical record review for Resident #12, found an incident report for 03/15/19 at 8:30 pm, which read: Resident yelled out that she had fell . Walked into room and she was laying on right side. Complaint of right shoulder pain. Incident was blank under resident representative notified. Review of Resident #12's progress note for 03/19/19 found the family/representative was not notified. Physician had been notified and new order for x-ray of the right shoulder. Additionally, a progress note on 03/16/19 at 11:50 pm, read, X-ray of right shoulder shows an acute fracture involving distal clavicle with mild displacement . Medical Power of Attorney (MPOA) notified. Interview with the DON on 07/17/19 at 1:05 pm, confirmed the resident's representative/family was not notified of the incident which occurred on 03/15/19 until after the x-ray results were received on 03/16/19",2020-09-01
977,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,623,D,0,1,VCKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to provide the long-term care ombudsman with prompt notification of facility-initiated transfers to the hospital for Residents #13 and #27. This deficient practice was found for two (2) of two (2) residents reviewed for hospitalization . Resident identifiers: #13 and #27. Facility census: 118. Findings included: a) Resident #13 On 07/15/19 at 2:25 PM, Resident #13 stated that she had been to the hospital approximately a month ago. Record review during the survey found that Resident #13 was transferred to the hospital on [DATE]. On 07/17/19 at 9:23 AM, the facility's Director of Nursing (DoN) was asked if the facility had any documentation that they had notified the long-term care ombudsman of Resident #13's transfer to the hospital on [DATE]. The DoN stated, No. No further information was provided prior to exit. b) Resident #27 Record review on 07/16/19 at 12:24 PM, revealed the resident was discharged to the hospital on [DATE] at 3:25 AM, for chest pain. On 7/16/19 at 12:58 PM , the surveyor asked the social worker, employee #122, who handles Ombudsman notifications. Employee #122 stated the administrator sends facility initiated discharge information to the Ombudsman. On 7/16/19 at 12:58 PM, the surveyor asked employee #122 for documentation showing the Ombudsman notification of the facility-imitated transfer for Resident #27. At 12:59 PM on 7/16/19, employee #122 said she was going to contact the administrator to locate the Ombudsman notification binder. On 7/16/19 at 1:28 PM, employee #122 was unable to provide any verification of information being sent to the Ombudsman after 5/10/19. Employee #122 was unable to provide any verification the ombudsman was notified of Resident #122's discharge to the hospital on [DATE]. On 7/16/19 at 1:35 PM, the DON and employee #122 confirmed the fax dated (MONTH) 10, 2019, was the only notification to the Ombudsman. No further documentation was provided.",2020-09-01
978,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,625,D,0,1,VCKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to provide the resident/resident representative notice of the bed hold policy when Resident #27 was transferred to a local hospital. This was true for one (1) of two (2) residents reviewed for hospital transfers. Resident identifier: #27. Facility census 117. Findings included: a) Resident #27 During a medical record review, on 7/16/19, it was discovered that Resident #27 was transferred to a local hospital on [DATE] at 3:25 AM. There was no evidence the resident or the residents representative received a copy of the bed hold policy at the time of transfer. In addition there was no documentation in the medical record of contacting the resident / resident representative regarding the bed hold policy. In an interview with the Director of Nursing (DON) on 7/16/19 at 1:01 PM, the DON confirmed that there was no documentation regarding staff notifying the resident / resident representative of the bed hold policy for the hospital transfer on 7/10/19.",2020-09-01
979,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,655,D,0,1,VCKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to include information regarding a resident's risk for falls when the resident had a known history of falls. This deficient practice was found for one (1) of nine (9) residents reviewed for the care area of accidents. Resident identifier: #110. Facility census: 118. Findings included: a) Resident #110 On 07/15/19 at 11:53 AM Resident #110 was observed to have numerous bruises on her forehead, cheeks, and the bridge of her nose, suggesting that she had fallen recently. Record review during the survey found that Resident #110 had been admitted to the facility on [DATE]. A review of Resident #110's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/01/19 found that section J was coded Yes for a fall in the last month prior to admission and coded Yes for a fall in the last two (2) to six (6) months prior to admission. A review of Resident #110's care plan on 07/16/19 at 9:08 AM found that falls had not been addressed in the care plan until 07/02/19, more than 48 hours after Resident #110's admission to the facility. During an interview on 07/17/19 at 12:23 PM, the facility's Director of Nursing (DoN) agreed that based upon the admission MDS assessment, Resident #110 had a history of [REDACTED]. When asked if falls should have been addressed on the baseline care plan within 48 hours of Resident #110's admission since Resident #110 had a known history of falls, the DoN stated, Yes. No further information was provided prior to exit.",2020-09-01
983,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,686,D,0,1,VCKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to implement physician orders [REDACTED].#42. The resident's pressure ulcer was located on the right heel. The facility provided the pressure ulcer treatment to the left heel. In addition, the resident did not have bilateral heel protectors in place as ordered by the physician. This was true for one (1) of three (3) reviewed for the care area of pressure ulcers. Resident identifier: #42. Facility census 117. Findings included: a) Resident #42 Record review on 7/15/19 at 1:50 PM, revealed a current care plan, revised on 03/12/19. A focus problem on the care plan noted the resident has a stage 3 pressure ulcer to the right heel. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/19, noted that the resident has a stage 3 pressure ulcer. A nurses note, dated 4/10/19, confirmed the resident has a stage 3 pressure ulcer to the right heel and venous ulcers to the left second and third toes. Review of the physician orders [REDACTED]. The order is dated 02/25/19. In addition, the resident has a physician's orders [REDACTED]. On 07/16/19 09:50 AM, the resident was observed in his room, laying in bed, resting. No staff were present. The resident did not have heel protectors on while in bed. During a staff interview on 7/16/19 at 9:51 AM, Employee #88, the Registered Nurse (RN) Unit Manager confirmed that the resident did not have bilateral heel protectors on as directed by physician's orders [REDACTED].#42 should have bilateral heel protectors on at all times. On 7/16/19 at 9:53 AM, the RN surveyor observed Resident #42's pressure ulcer treatment with RN #88. RN #88 told the RN surveyor the resident had a pressure ulcer on the left heel. RN #88 provided wound care to the left heel by cleansing the left heel with skin integrity wound cleanser. RN #88 patted the left heel dry and applied sure prep covering with gauze cahgne. On 7/16/19 at 10:39 AM, RN #88 stated that the resident was getting a treatment to the left heel, not the right heel. RN #88 provided a copy of the skin integrity report. RN #88 stated on 7/15/19, she measure the left heel not the right heel. RN #88 further noted that the skin integrity report stated that the treatment was for the right heel, but RN #88 stated that the location was incorrect, it was the left heel with the pressure ulcer. RN #88 stated the documentation on the skin integrity report, should say the left heel not the right heel. Should be an L instead of R. At 11:09 AM on 7/16/19, observation of the resident with the Director of Nursing (DON) confirmed that the resident was not wearing the bilateral heel protectors. At 11:24 AM on 7/6/19, the DON confirmed the resident's left heel was treated and gauze was placed. The DON verified this treatment should be on the right heel, not the left heel. Review of a progress note dated 7/3/19, completed by the Nurse Practioner, noted the resident has a right heel pressure ulcer. At 12:03 PM on 7/16/19, the RN surveyor notified the DON that the pressure ulcer treatment was provided to the left heel instead of the right heel. At 12:30 PM on 7/16/19, RN #88 entered the conference room, where surveyors were working, and said, I'm coming to you with my head hung down. I guess you already know what I did. RN #88 confirmed she treated the wrong heel. On 7/17/19 at 2:32 PM, the nurse practioner confirmed the resident has a pressure ulcer on the right heel, not the left heel.",2020-09-01
984,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,687,D,0,1,VCKW11,"Based on observation, resident interview, and staff interview the facility failed to provide foot care and treatment, in accordance with professional standards of practice. Resident #69 was observed to have very long toe nails and there was no evidence the facility had provided appropriate nail hygiene to ensure the residents nails were trimmed and cleaned. This was random opportunity for discovery. Resident identifier: #69. Facility census: 118. Findings include: a) Resident #69 Observations of Resident #69's left foot at 11:43 a.m. on 07/15/19, found her toe nails to be long and sticking out past the end of her toes. Please note Resident #69 has a right above knee amputation. An additional observation of the Residents left foot at 11:00 a.m. on 07/17/19 with the Director of Nursing (DON) confirmed the residents toe nails were long and needed trimmed. During an interview with Resident #69 at 11:00 a.m. on 07/17/19 she stated, My nails need trimmed but it is hard for me to get down there to cut them. An interview with the DON at 12:01 p.m. on 07/17/19 confirmed Resident #69 had not been seen by the podiatrist and she would put her on the list to be seen. She stated, I am going to have the nurses to try to trim her nails but they looked kind of thick so she is not sure if nursing can trim them. The DON indicated resident nail care is to be performed when resident's have their shower. She agreed Resident #69's toe nails should have been trimmed prior to our observations.",2020-09-01
986,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,690,D,0,1,VCKW11,"Based on observation, staff interview, resident interview, the facility failed to provide appropriate treatment and services for care of a resident with an indwelling catheter. Resident #29's indwelling catheter was not properly secured. This was a random opportunity for discovery. Resident identifier: #29. Facility census: 118. Findings included: a) Resident #29 On 7/15/19 at 11:37 observation of an Indwelling Foley Catheter attached to Resident's right lower bedrail was made. Certified Nurse Aide (CNA) #102 was asked to verify the Indwelling Foley Catheter was being properly maintained. Upon inspection, the Indwelling Foley Catheter was found to be improperly anchored and not secured in a way to prevent excess tension or kinking of the tubing. Resident stated she would like to have a strap for her leg to properly secure the Indwelling foley catheter and keep it from pulling so much. During an interview on 07/17/19 at 10:41 AM the Assistant Director of Nursing (ADON) stated the facility does not have an anchoring device appropriate for Resident to utilize that will fit the Resident's leg due to her size; however, they (the facility) have ordered a special catheter securement device specific for this Resident.",2020-09-01
992,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,756,D,0,1,VCKW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the pharmacist recognized an incomplete medication order for administering insulin. The order did not detail how many times a day the medication could be administered and did not specify what the resident's blood glucose reading should be before giving the medication. This was true for one (1) of five (5) residents reviewed for unnecessary medication. Resident identifier: #87. Facility census: 117. Findings include: a) Resident #87 Record review found the resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The resident had three physician's orders [REDACTED].>1. Insulin [MEDICATION NAME] 100 units, inject 60 units subcutaneous before meals and at bedtime for Diabetes Mellitus. 2. Insulin [MEDICATION NAME] Solution 100 units, inject as per sliding scale for Diabetes Mellitus. 3. Insulin [MEDICATION NAME] Solution 100 units, inject 30 units subcutaneous as needed (PRN)for Diabetes mellitus with snacks, ordered on [DATE]. (This order had never been administered but remained on the Medication Administration Record [REDACTED].) The order did not specify what the residents blood glucose reading should be before administering the 30 units. In addition, the order did not specify how many times a day the insulin could be administered. On 07/17/19 at 2:06 PM, the Director of Nursing (DON) was asked how staff would know when to administer the PRN insulin [MEDICATION NAME] solution? The DON said the order was confusing as the order had no parameters. She said she would talk to the physician and see what he wanted to do. At 8:51 AM on 07/18/19, the DON provided a copy of the corrected physician's orders [REDACTED].>Insulin [MEDICATION NAME] Solution 100 units. Inject 30 units subcutaneous as needed for DM with snacks up to three times a day for an accu check greater than 300. On 07/17/19 at 2:06 PM, the DON was asked if the pharmacist had reviewed the residents medications and recognized the incomplete order. On the morning of 07/18/19, the DON provided a copy of the consulting pharmacist report, dated 06/17/19. The DON verified the pharmacist failed to recognize the incomplete order for the resident's insulin.",2020-09-01
997,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2019-07-18,921,D,0,1,VCKW11,"Based on observation and staff interview, the facility failed to ensure a safe and homelike environment. The air conditioning/heating unit was broken, leaving a sharp edge exposed. A urine socked brief was uncovered in the resident's trash can creating an odor. This was found during a random opportunity for discovery. Resident identifier: #33. Facility census: 117. Findings include: a) Resident #33 Observation of the resident's room at 11:51 AM on 07/15/19 found a razor laying by the sink. In addition, a soiled, open, urine soaked brief was in the trash can beside the sink. A strong odor of urine could be detected in the resident's room. Review of the resident's most recent quarterly minimum data set (MDS) with a reference date (ARD) date of 5/10/19, noted the resident requires total assistance with activities of daily living (ADL's), requiring two-person assistance with toileting. The resident is incontinent of bowel and bladder. Moreover, the resident's cognition is severely impaired. On 7/15/19 at 11:51 AM , observation with Employee #115, Clinical Reimbursement Coordinator, confirmed that the razor should not be in the resident's room. Also, Employee #115 confirmed that the brief needed to be removed from the trash. Both items were removed from the resident's room at this time. In addition, the heating and cooling unit in resident #33's room had a front unit cover broken, leaving rough, sharp plastic edges exposed. Debris was present in the heating and cooling system. On 7/16/19 at 4:33 PM, the surveyor along with the Maintenance Supervisor, Employee #45, went in the resident's room. When the surveyor pointed out the broken heating and cooling unit cover, Employee #45 stated that he didn't even know it was broken. Employee #45 confirmed the broken, sharp, and jagged edge. On 7/16/19 at 4:33 PM, Employee #45 also confirmed the presence of debris in the heating and cooling unit. Employee #45 stated that cover would be replaced and unit would be clear of debris in just a few minutes.",2020-09-01
998,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2018-01-18,584,D,1,0,CYMZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon observation, review of facility documentation and staff interview, the facility failed to provide maintenance services to ensure a safe environment. This was found for one (1) resident's room which was identified by a review of maintenance request logs for (MONTH) (YEAR) and (MONTH) (YEAR) to 1/16/18. Resident identifier: #29. Facility census: 70. Findings include: a) The Facility's Maintenance Request Logs for (MONTH) 1, (YEAR) through (MONTH) 16, (YEAR) were reviewed on 1/17/18 at 9:30 AM. Some requests submitted by staff, but with no correction, comments, or resolution noted from maintenance were selected for further investigation. There was a Maintenance service request from Licensed Practical Nurse (LPN) #45 on 12/4/17 regarding room [ROOM NUMBER] that stated (typed as written): strip gone on floor and tile coming up. Pt. almost fell . Then, another request by the Director of the Therapy Department, #42 on 12/9/17 that the threshold to room [ROOM NUMBER] was gone. She documented it was a tripping hazard. b) Observation of the threshold between the bathroom and room [ROOM NUMBER] on 1/17/18 at 11:20 AM on 1/17/18 found the threshold was still missing. There was damage to the floor creating an uneven surface. c) Maintenance Assistant, employee #14, was interviewed in the doorway to room [ROOM NUMBER] on 1/17/18 at 11:25 AM. He confirmed the area had never been repaired. He said there used to be a sign on the door to alert people to be careful, but someone must have taken it down. d) Facility Administrator, employee #95, was interviewed on 1/17/18 at 11:40 AM. She agreed the floor damage in room [ROOM NUMBER] was a safety hazard and should have been repaired when the service requests were made. e) Resident #29, who resides in room [ROOM NUMBER] is [AGE] years of age. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. f) Incident report logs for (MONTH) 1, (YEAR) through 1/16/18 were reviewed on 1/17/18 at 12:00 PM. Resident #29 suffered a fall documented on 12/13/17. She had a fall in her room on 12/13/17 at 2:30 PM. The incident report stated she was found on the floor beside her nightstand. The fall was not witnessed, so there is not sufficient evidence to suggest a connection with the floor damage as a contributing factor. g) The investigation found sufficient evidence to substantiate deferred maintenance and repairs which resulted in a safety hazard.",2020-09-01
999,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2018-01-18,689,D,1,0,CYMZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon observation, review of facility documents, and staff interview, the facility failed to maintain an environment as free of accident hazards as is possible. This was found for one (1) resident's room which was identified from review of maintenance request logs for (MONTH) (YEAR) and (MONTH) (YEAR) to 1/16/18. Resident identifier: #29. Facility census: 70. Findings include: a) The Facility's Maintenance Request Logs for (MONTH) 1, (YEAR) through (MONTH) 16, (YEAR) were reviewed on 1/17/18 at 9:30 AM. Some requests submitted by staff, but with no correction, comments, or resolution noted from maintenance were selected for further investigation. There was a Maintenance service request from Licensed Practical Nurse (LPN) #45 on 12/4/17 regarding room [ROOM NUMBER] that stated (typed as written): strip gone on floor and tile coming up. Pt. almost fell . Then, another request by the Director of the Therapy Department, #42 on 12/9/17 that the threshold to room [ROOM NUMBER] was gone. She documented it was a tripping hazard. b) Observation of the threshold between the bathroom and room [ROOM NUMBER] on 1/17/18 at 11:20 AM on 1/17/18 found the threshold was still missing. There was damage to the floor creating an uneven surface. c) Maintenance Assistant, employee #14, was interviewed in the doorway to room [ROOM NUMBER] on 1/17/18 at 11:25 AM. He confirmed the area had never been repaired. He said there used to be a sign on the door to alert people to be careful, but someone must have taken it down. d) Facility Administrator, employee #95, was interviewed on 1/17/18 at 11:40 AM. She agreed the floor damage in room [ROOM NUMBER] was a safety hazard and should have been repaired when the service requests were made. e) Resident #29, who resides in room [ROOM NUMBER] is [AGE] years of age. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. f) Incident report logs for (MONTH) 1, (YEAR) through 1/16/18 were reviewed on 1/17/18 at 12:00 PM. Resident #29 suffered a fall documented on 12/13/17. She had a fall in her room on 12/13/17 at 2:30 PM. The incident report stated she was found on the floor beside her nightstand. The fall was not witnessed, so there is not sufficient evidence to suggest a connection with the floor damage as a contributing factor. g) The investigation found sufficient evidence to substantiate deferred maintenance and repairs which resulted in a safety hazard.",2020-09-01
1001,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,241,D,0,1,1Y9Q11,"Based on resident interview, staff interview and review of grievance form completed on 01/25/17,the facility failed to promote care for Resident #10 in a manner that maintained or enhanced the resident's dignity. The facility staff (licensed nurses and nurse aides) addressed her in a undignified manner by addressing her as honey, dear and sweetheart. This was evident for one (1) of two (2) residents reviewed during stage II of the survey for the care area of dignity. Resident identifier: #10. Facility Census: 82. Findings include: a) Resident #10 An interview with Resident #10, on 01/24/17 at 2:56 p.m., revealed the nursing staff (licensed nurses and nurse aides) were rude. She stated, They call you honey, dear and sweetheart but they don't mean that. They are just being sarcastic and they really don't want to assist you to the bathroom. When asked if she had told anyone at the facility of this behavior by the nursing staff, she said, No. On the morning of 01/25/17, the Social Service Director (SSD) was notified of Resident #10's concerns with the nursing staff calling her honey, dear and sweetheart. Review of the grievance/concern form completed on 01/25/17, found the SSD had spoke with Resident #10 on 01/25/17 and the resident stated, Nurses and nurse aides call her honey, dear and sweetheart and she knows they are being sarcastic with her because they are mean. She further stated, I know they are being mean and sarcastic because she had an Aunt[NAME] who was a mean woman (her mother's sister). I don't want anyone to call me honey, sweetheart or anything like that. I feel it is disrespectful. Interview with the SSD, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 01/30/17 at 1:15 p.m., revealed the nursing staff should address the resident's by their names unless the resident requests the staff to address them another way. They all agreed the staff should address Resident #10 by her name due to she feels when they call her honey, sweetheart and dear, the staff is being mean and disrespectful to her. They also stated all the nursing staff has been educated.",2020-09-01
1002,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,242,D,0,1,1Y9Q11,"Based on resident interview and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of choices, received personal care consistent with past interests important to the resident. The facility failed to seek information regard the resident's preference for a bathing schedule. Resident identifier: #105. Facility census: 82. Findings include: a) Resident #105 At 8:50 a.m. on 01/25/17, the resident said she did not get to choose how many times a week she could take a shower. Showers are only given two (2) times a week. She said she would like more showers but figured the staff were too busy to give her more showers. The resident said she did not ask for more showers because, I thought it was the rules. On 01/25/17 at 2:32 p.m., the director of nursing (DON) said shower schedules are set by the resident's room number. The DON said all residents are given two (2) showers/baths per week but could have more if they requested. The DON was unable to provide information the resident was interviewed upon admission regarding her preferences for bathing. The resident was interviewed with the DON at 3:00 p.m. on 01/25/2017. The DON asked the resident if she would like a daily shower. The resident replied, I would hate to trouble them to do it every day, if they could just do it every other day that would be OK. The DON told the resident she would arrange a shower for her every other day. The admission, minimum data set (MDS), with an assessment reference date (ARD) of 01/06/17, found the resident obtained a score of 15 on the brief interview for mental status (BIMS). A score of 15 is the highest score obtainable and indicates the resident is cognitively intact.",2020-09-01
1004,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,272,D,0,1,1Y9Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #95's admission minimum data set (MDS) with an assessment reference date (ARD) of 05/06/16 was accurately completed to reflect Resident #95's dental status. This was true for one (1) of three (3) residents reviewed for the care area of dental during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #95. Facility census: 82. Findings include: a) Resident #95 A review of Resident #95's medical record, at 2:11 p.m. on 01/30/17, found she was admitted to the facility (MONTH) of (YEAR). Further review of the record found an initial nursing admission assessment completed on 04/30/16. This assessment indicated Resident #95 had an obvious or likely cavity or broken natural teeth. On 05/06/16 nursing completed another nursing assessment which indicated Resident #95 had no problems with her teeth. A review of the admission MDS with an ARD of 05/06/16 found Section [MI] Dental contained the following choices with a yes and no under each choice: [NAME] Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose). B. No natural teeth or tooth fragment(s) (edentulous). C. Abnormal mouth tissue (ulcers, masses, oral [MEDICAL CONDITION], including under denture or partial if one is worn). D. Obvious or likely cavity or broken natural teeth. E. Inflamed or bleeding gums or loose natural teeth. F. Mouth or facial pain, discomfort or difficulty with chewing. [NAME] Unable to examine. Z. None of the above. The MDS was completed with a no for A - G, and was marked with a Yes for Z. During an interview with Registered Nurse Clinical Reimbursement Coordinator (CRC) #30 at 9:59 a.m. on 01/31/17, she confirmed she completed Resident #95's admission MDS with an ARD of 05/06/16. She was asked to explain her steps for assessment when completing Section L for Dental of the MDS. She stated, I will go and talk with the resident, will examine the resident if they will let me, and I look at the nutrition assessment completed by the dietician to see if she has identified any dental problems. She then reviewed Resident #95's nutrition assessment completed by the Licensed Dietician (LD). The LD did not note any dental problems in her assessment. CRC #30 indicated that is why she coded her as not having any dental problems. CRC #30 was then asked to review the admission assessment completed by nursing on 04/30/16 which indicated the resident had obvious or likely cavity or broken natural teeth. Upon review of that assessment CRC #30 indicated that assessment was not completed within the seven (7) day look back period and that she would have used the nursing assessment completed on 05/06/16 which indicated the resident did not have any problems with her teeth. CRC #30 never confirmed if she looked at Resident #95's teeth herself or not she just kept referring to assessments completed by other staff members as the basis of her determination on how to mark Section [MI] At 11:40 a.m. on 01/31/17 the Director of Nursing (DON) performed an oral assessment of Resident #95's oral cavity. The DON stated the Resident had two missing teeth, one broken tooth, and some obvious cavities. She indicated she would contact the resident's daughter to see if she wanted her to have a dental appointment. At the time of the assessment Resident #95 denied pain in her mouth and indicated she did not have any pain when eating. In a later interview with the DON, at approximately 12:00 p.m. on 01/31/17, she confirmed Resident #95 had not seen a dentist since her admission to the facility in (MONTH) of (YEAR). Review of Resident Assessment Instrument (RAI) manual for the completion of Section [MI] Dental at 11:00 a.m. on 01/31/17 found the following instructions for the completion of this section: . Steps for assessment. 1. Ask the resident about the presence of chewing problems or mouth or facial pain/discomfort. 2. Ask the resident, family, or significant other whether the resident has or recently had dentures or partials. (If resident or family/significant other reports that the resident recently had dentures or partials, but they do not have them at the facility, ask for a reason. 3. If the resident has dentures or partials, examine for loose fit. Ask Him or her to remove, and examine for chips, cracks, and cleanliness. Removal of dentures and/or partials is necessary for adequate assessment. 4. Conduct exam of the resident's lips and oral cavity with dentures or partial removed, if applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved finger to adequately feel for masses or loose teeth. 5. If resident is unable to self report, then observe him or her while eating with dentures or partials, if indicated, to determine if chewing problems or mouth pain are present. 6. Oral examination of resident or are uncooperative and do not allow for a thorough oral exam may result in medical conditions being missed. Referral for dental evaluation should be considered for these residents and any resident who exhibits dental or oral issues. . Coding Instructions . Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken teeth is seen.",2020-09-01
1005,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,278,D,0,1,1Y9Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Resident Assessment Instrument (RAI) version 3.0 manual, and staff interview, the facility failed to ensure Resident #95's quarterly Minimum Data Sets (MDS) with assessment reference date (ARD) of 11/01/16 was accurately completed to reflect what types of medications Resident #95 received during the seven (7) day look back period. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #95. Facility census: 82. Findings include: a) Resident #95 A review of Resident #95's medical record at 4:15 p.m. on 01/30/17, found a Quarterly MDS with an ARD of 11/01/16. Review of the MDS found Section N0410. Medication Received marked with a zero (0) to indicate Resident #95 received no antipsychotic medication during the seven (7) day look back period. Review of Resident #95's medication administration records (MAR) for the look back period of 10/26/16 through 11/01/16 found Resident #95 received [MEDICATION NAME] the generic for [MEDICATION NAME], an antipsychotic medication, five (5) milligrams (mg) seven (7) of the seven (7) days during the look back period. A review of the RAI manual at 11:30 a.m. on 01/31/17 found the following coding instructions pertaining to Section N0410 A, Antipsychotic: Record the number of day an antispsychotic medication was received by the resident at any time during the 7- day look back period. (or since admission/entry if less than 7 days). An interview with Registered Nurse (RN) Clinical Reimbursement Coordinator (CRC) #30, at 10:08 a.m. on 01/31/17, confirmed the quarterly MDS with the ARD of 11/01/16 was inaccurate in the area of medications. She reviewed the MDS and the MAR for the look back period and stated it should have been coded with a seven (7). She indicated she did not complete this MDS that a traveling CRC had completed it, but did confirm it was inaccurate.",2020-09-01
1006,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,279,D,0,1,1Y9Q11,"**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 measurable goals and interventions for two (2) of twenty (20) Stage II residents whose care plans were reviewed. Resident #106's care plan contained no measurable goals or interventions related to her [DIAGNOSES REDACTED].#33's care plan contained an inaccurate, non-individualized intervention for this resident who was allowed nothing to eat or to drink by mouth. Resident identifiers: #106, #33. Facility census: 82. Findings include: a) Resident #106 The medical record was reviewed on 01/26/17. The initial minimum data set (MDS), with assessment reference date (ARD) of 01/13/17 assessed a mood score of 6 (six). [DIAGNOSES REDACTED]. Review of the care plan found a focus for this resident at risk for distressed/fluctuating mood symptoms related to anxiety and fear. The care planned goal stated this resident would exhibit decreased episodes of fear and anxiety by the next review. The care plan interventions included to give medication as ordered, observe for pain and attempt non-pharmacological interventions as listed, and to observe for signs/symptoms of worsening sadness/depression. The care plan was silent for non-pharmacological interventions to treat the resident's symptoms of fear and anxiety. An interview was completed with the director of nursing (DON) on 01/26/17 at 1:57 p.m. She said initially the facility keyed in on pain as a trigger for her distressed moods, but since then the pain issue has been adequately addressed. She said the resident has other interpersonal and health issues that impacts her level of anxiety and depression. She agreed that the care plan was silent for any individualized interventions staff might utilize to help the resident decrease her episodes of fear and anxiety. b) Resident #33 The medical record was reviewed on 01/26/17. The initial minimum data set (MDS) with assessment reference date (ARD) of 12/08/16, revealed this resident's nutrition was comprised of tube feedings every day during the seven (7) day look back period. Further medical record review revealed this resident sustained [REDACTED]. The purpose of this procedure was to place a tube for which to administer feedings via the enteral route. Review of physician's admission orders [REDACTED]. His only other intake was medication and water through the gastrostomy tube. [DIAGNOSES REDACTED]. Other pertinent [DIAGNOSES REDACTED]. Review of the care plan revealed an intervention to encourage this resident to attend meals in the dining room. The initiation date of this intervention was 12/13/16. An interview was conducted with the DON on 01/26/16 at 2:00 p.m. She reviewed the care plan intervention initiated on 12/13/16 to encourage the resident to attend meals in the dining room. She said that was obviously incorrect and there was no explanation for the error. She said this resident was NPO (nothing by mouth), with feedings and water per gastrostomy tube as his only intake. She said that was an incorrect care plan intervention not tailored to his needs at that time.",2020-09-01
1007,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,282,D,0,1,1Y9Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement the care plan for one (1) of twenty (20) Stage II sample residents whose care plans were reviewed. The facility failed to implement Resident #33's care planned interventions to ensure he passed a soft formed stool at least every three (3) days. Resident identifier: #33. Facility census: 82. Findings include: a) Resident #33 Review of the medical record, on 01/26/17, revealed this resident came to the facility with enteral tube feeding orders, and was allowed nothing to eat or drink by mouth. [DIAGNOSES REDACTED]. Review of the resident's care plan on 01/26/17 found a care plan focus that the resident exhibited, or was at risk for, gastrointestinal symptoms or complications related to constipation. The care planned goal related to that focus was for the resident to pass a soft formed stool at least every three (3) days. One care planned intervention was to observe and report signs and symptoms of decrease in bowel movements. Another care plan intervention included to observe for and record bowel movements. Also, another care planned intervention included (typed as written) provide bowel regimen, utilize pharmacological agents as appropriate i.e. stool softeners, laxatives, etc. document effectiveness. Review of the activities of daily living record (ADL) record for (MONTH) (YEAR) found three (3) separate instances where the resident went greater than three (3) days with no evidence of having passed a bowel movement. According to the ADL record, this resident had a bowel movement on 12/05/16, and none again until five (5) days later on 12/10/16. Also according to the ADL record, this resident had a bowel movement on 12/15/16, and none again until seven (7) days later on 12/22/16. Again according to the ADL record, this resident had a bowel movement on 12/23/16, and none again until five (5) days later on 12/28/16. Review of the facility's standing orders/bowel protocol found orders to administer medications and/or treatments if the resident went three (3) days with no bowel movement as follows: On the third day of no bowel movement, administer Milk of Magnesia 30 milliliters (ml). On the fourth day of no bowel movement, administer [MEDICATION NAME] 10 milligrams (mg) suppository rectally. On the fifth day of no bowel movement, administer a Fleets enema rectally. If no results from the Fleet's enema, notify the physician for further orders. These orders were were signed by the medical director. Review of the Medication Administration Record [REDACTED]. Also, review of the (MONTH) nurse progress notes provided no evidence of treatment for [REDACTED]. An interview was conducted with the director of nursing (DON) on 01/26/17 at 4:00 p.m. She reviewed the (MONTH) ADL bowel movement record, and agreed on three (3) different stretches of time in (MONTH) that he had no bowel movements recorded for three (3) or more consecutive days. She then reviewed the MAR for December, and the (MONTH) nursing progress notes. She agreed there were no notations about laxatives or bowel treatments administered, or of physician notification of no bowel movements. She did not dispute that the facility failed to follow all of his care planned interventions to ensure he met his care planned goal of passing a soft formed stool at least every three (3) days.",2020-09-01
1009,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,323,D,0,1,1Y9Q11,"Based on observation during the initial tour and staff interview, the facility failed to ensure Resident #75's environment over which it had control was as free from accident hazards as possible. The facility failed to prevent accident hazards by storing care equipment (reclining Geri-chair) in the Quiet Room in which Resident #75 prefers to sit. This deficient practice has a potential to affect only a minimal residents whom uses the Quiet Room. Resident identifier: #75. Facility Census: 82. Findings include: a) Resident #75 An initial tour conducted on 01/24/17 at 9:45 a.m., found, Resident #75 ambulating using a rollator walker into the Quiet Room. Further observation on 01/24/17 at 9:50 a.m., this surveyor stopped to speak with Resident #75; at this time it was noted the Quiet Room was a small room (nine (9) feet by eight (8) feet as provided by the maintenance supervisor). In the room were two (2) straight back wing chairs, an end table placed between the chairs and a reclining Geri-chair placed in front of the one wing chair and protruding in front of the other wing chair in the room. This Geri-chair limited Resident #75's ability to get safely to the wing chairs. At 9:51 a.m. on 01/24/17, an interview with Assistant Director of Nursing (ADON) #44 verified the Geri-chair in the Quiet Room did create an unsafe environment for Resident #75, whom ambulates with a rollator walker and prefers to sit in the Quiet Room with the lights out. The ADON agreed the Geri-chair was an accident risks for Resident #75. She immediately removed the Geri-chair from the room. On 01/24/17 at 10:20 a.m., the Director of Nursing (DON) and Nursing Home Administrator (NHA) were informed of the findings. No further information provided.",2020-09-01
1010,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,329,D,0,1,1Y9Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for the care area of unnecessary medications was considered for non-pharmacological interventions before resuming an antianxiety medication after a gradual dose reduction (GDR). In addition, the facility failed to provide documentation of an increase in behaviors to warrant starting the medication after the GDR. Resident identifier: #75. Facility census: 82 Findings include: a) Resident #75 On 03/07/16, the pharmacist reviewed the resident's medications and made the following recommendation: --(Name of resident's) [MEDICATION NAME] 10 milligrams (mg) HS (at bedtime) is due for annual GDR review in the first year .Please consider a gradual dose reduction (5 mg. HS x 2 weeks?) while concurrently monitoring for re-emergence of target and/or withdrawal symptoms The physician reviewed the recommendation on 03/24/16 and agreed with the pharmacist's recommendation. Review of the Medication Administration Record [REDACTED]. The resident did not receive [MEDICATION NAME] from 04/07/16 through 05/03/16. On 05/03/16, an order was written to resume the [MEDICATION NAME] 10 mg in the evening. The resident received the first dose of [MEDICATION NAME] 10 mg on 05/04/16. Review of the nurses notes found no documentation of any behaviors from 03/24/16 through 05/02/16. Record review found a nurses note at 3:50 p.m. on 05/03/16 that indicated the resident was having increased agitation and yelling out, and an order was received to increase the [MEDICATION NAME] back to 10 mg in the evening. Review of the behavior monitoring and interventions document for (MONTH) (YEAR), found the resident was being monitored for exhibiting the behaviors of yelling, screaming at others and paranoia (thinks others are talking about her). During the reduction of the [MEDICATION NAME] from 10 mg to 5 mg (03/24/16 through 04/07/16), the resident had one (1) episode of paranoia on 03/25/16. The non-pharmacological interventions provided was to familiarize with belongings and surroundings. On 03/26/16, the resident exhibited 3 episodes of paranoia. The non-pharmacological interventions provided were re-direction. On both occasions the nurse noted the behavior was unchanged. Review of the behavior monitoring and interventions document for (MONTH) (YEAR), found the resident exhibited no behaviors until 04/23/16, when the resident was yelling at others. The resident was re-directed and escorted to her room for reduced stimuli. The behavior was unchanged. On 05/03/16, the physician completed a, visit note. The physician's note directed staff to start [MEDICATION NAME] 10 mg in the evening. The physician noted the resident had a failed GDR and an increase in behavior. The physician noted in the assessment/plan to discontinue [MEDICATION NAME] 5 mg in the evening; however, the resident was not receiving [MEDICATION NAME] 5 mg at the time he completed his visit notes on 05/03/16. At 1:05 p.m. on 01/25/17 the director of nursing (DON) was interviewed. The DON reviewed the facility's documentation and confirmed the documented behaviors. The DON was unable to locate the behavior monitoring document for (MONTH) (YEAR). She said the document was missing. She was also unable to find documentation of any additional behaviors other than the behaviors detailed above on the behaviors monitoring and interventions documentation. At 1:25 p.m. on 01/25/17, the DON was asked where the physician would have obtained information the resident behaviors had increased when he ordered the [MEDICATION NAME] 10 mg on 05/03/16. The DON said, The doctor knew because the nurses probably told him that. The DON was unable to find documentation the staff considered and used non-pharmacological interventions before re-starting the [MEDICATION NAME]. After resuming the [MEDICATION NAME] 10 mg on 05/04/16, the behavior monitoring and interventions document for June, (YEAR), was reviewed. The resident exhibited yelling out behaviors on five (5) days (06/04/16, 06/06/16, 06/07/16, 06/08/16 and 06/10/16). On four (4) days (06/06/16, 06/07/16, 06/08/16 and 06/09/16) the resident exhibited paranoid behaviors. According to the behavior monitoring and interventions document for (MONTH) (YEAR), the resident experienced yelling out on eleven (11) days in (MONTH) (YEAR) (07/11/16, 07/12/16, 07/13/16, 07/14/16, 07/16/16, 07/17/16, 07/24/16, 07/26/16, 07/27/16, 07/29/16 and 07/30/16). The resident experienced paranoid behaviors on ten (10) days in July, (YEAR), (07/11/16, 07/12/16, 07/13/16, 07/14/16, 07/16/16, 07/17/16, 07/18/16, 07/19/16, 07/24/16, and 07/29/16.) Review of the behavior monitoring and interventions documents for (MONTH) and (MONTH) (YEAR), found the resident exhibited behaviors on five (5) days in (MONTH) and ten (10) days in (MONTH) as compared to exhibiting behaviors on two (2) days during the two (2) week tapering of the [MEDICATION NAME] and one (1) behavior during the time the [MEDICATION NAME] was discontinued. The resident continued to receive the [MEDICATION NAME] 10 mg in the evening and received the medication at the time of the review on 01/25/17.",2020-09-01
1011,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,371,D,0,1,1Y9Q11,"Based on observation and staff interview, the facility failed to serve food under sanitary conditions. This was a random opportunity for discovery during dining observations. Resident identifiers: #43 and #13. Facility census: 82. Findings include: a) Meal service At 12:24 p.m. on 01/24/2017, staff were observed serving the noon meal on the [NAME]ide hallway. Activities Assistant (AA) #43 removed Resident #24's tray from a covered food cart. AA #43 knocked on the resident's door and entered the room with the tray. Shortly thereafter, AA #43 exited the resident's room with the resident's tray and placed the tray inside the covered food cart. The food cart contained the remaining trays of Resident's #42 and #13. When asked about placing a contaminated tray on a clean cart, AA #43 said, The resident didn't eat it. She didn't want the tray because she has something else to eat. Staff continued to deliver the trays from the food cart to Resident's #42 and #13. The meal service was not stopped and clean trays were not ordered for Resident's #42 and #13. At 12:30 p.m. on 01/24/17, the DON said she was getting new trays for residents #42 and #13; however, the residents were already eating the contaminated trays.",2020-09-01
1012,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,428,D,0,1,1Y9Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure nursing responded to a pharmacy recommendation to clarify the diagnosis/indication for use for Resident #95's antipsychotic and mood stabilizing medication. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey. Resident identifier: #95. Facility census: 82. Findings include: a) Resident #95 A review of Resident #95's medical record, at 2:11 p.m. on 01/30/17, found the following orders contained on the (MONTH) (YEAR) monthly recapitulation orders: --Olanzapine Tablet 5 milligrams (mg) by mouth at bedtime related to vascular dementia without behavioral disturbance. --Divalproex Sodium Tablet Delayed Release 250 mg by mouth at bedtime for atypical psychosis and agitations related to vascular dementia without behavioral disturbance. Further review of the medical record found a pharmacy recommendation dated 07/06/16 which read as follows: . Nursing: please discuss any documented harmful behaviors with physician during the last quarter. Also, please update the indication on the Zyprexa (olanzapine) order to dementia with behaviors. Please change the indication on the Depakote (Divalproex) order to dementia with behaviors. During and interview with the Director of Nursing (DON) at 9:31 a.m. on 01/31/2017, she indicated she thought the original order for both medications had the correct [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. She further stated, I gave direction for them to fix the [DIAGNOSES REDACTED].",2020-09-01
1017,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2018-03-22,756,D,0,1,ER7J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the pharmacist failed to identify the facility's failure to monitor a resident's medication regimen for potential adverse consequences. The pharmacist failed to identify and report the use of [MEDICAL CONDITION] medications without evidence of adequate monitoring during monthly reviews. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #67. Facility census: 67. Findings included: a) Resident #67 Review of the medical record on 03/20/18, revealed Resident #67 has a [DIAGNOSES REDACTED]. He was transferred unexpectedly to acute care on 01/02/18 and 03/19/18 for a decreased level of consciousness. Current medications include: [MEDICATION NAME] 100 micrograms (mcg) / hour times 72 hours, Quetiapine (antidepressant) 100 milligrams (mg) at bed time, Quetiapine 50 mg every morning, [MEDICATION NAME] HCL (antidepressant) 150 mg every morning, [MEDICATION NAME] (mood stabilizer) 250 mg twice a day, and [MEDICATION NAME] (antianxiety) 0.5 mg twice a day. The monthly pharmacy review records include a Potential Drug Interaction form for Resident #67, dated 03/03/18. This record identifies the combinations of the [MEDICATION NAME] with [MEDICATION NAME] HCL, and/or the [MEDICATION NAME] with Duloxetine HCL. The section titled Patient Management states: .Monitor patients on multiple serotonergic agents for symptoms of serotonin toxicity. Patients in whom serotoni[DIAGNOSES REDACTED] is suspected should receive immediate medical attention. The Patient Management section under the [MEDICATION NAME] with [MEDICATION NAME] states: .Monitor patients receiving concurrent therapy for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. Irregularities and/or recommendations were noted on the following dates: --01/09/18 the pharmacist requested clarification related to orders for the [MEDICATION NAME] capsule and [MEDICATION NAME] and a recommendation to discontinue the [MEDICATION NAME] (antidepressant) as needed order. -- 02/12/18 the pharmacist requested Duloxetine HCL be replaced because it should not be opened or crushed prior to administration. In addition, clarifications were requested for orders related to [MEDICATION NAME], and the [MEDICATION NAME]. The monthly medication regimen reviews lacks any notations regarding staff's failure to monitor Resident #67 for adverse consequences of [MEDICAL CONDITION] drugs. The form titled Suspected Medication Side Effects dated (MONTH) (YEAR), notes Resident #67 is receiving Duloxetine HCL (antidepressant), [MEDICATION NAME] HCL (antidepressant), [MEDICATION NAME] (antianxiety), and Quetiapine (antidepressant). The [DIAGNOSES REDACTED]. The form lacks any other documentation indicating staff assessed the resident for potential adverse consequences. Licensed Practical Nurse (LPN) #68 reported a residents medication side effects are documented on the form titled Suspected Medication Side Effects, during an interview on 03/21/18 at 10:00 AM. She reviewed Resident #67's form and acknowledged it was blank. When asked what the side effects were for the medications Resident #67 is receiving she stated: I would have to look them up, they are probably the usual fatigue, headache, drowsiness, and dizziness. During an interview on 03/20/18 at 3:00 PM, The Director of Nursing (DON) acknowledged Resident #67's medical record lacks any information related to staff monitoring him for side effects of [MEDICAL CONDITION] meds.",2020-09-01
1018,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2018-03-22,758,D,0,1,ER7J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to monitor a resident's medication regimen for potential adverse consequences to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. Nursing staff failed to assess Resident #67 for side effects of [MEDICAL CONDITION] medications. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #67. Facility census: 67. Findings included: a) Resident #67 Review of the medical record on 03/20/18, revealed Resident #67 has a [DIAGNOSES REDACTED]. He was transferred unexpectedly to acute care on 01/02/18 and 03/19/18 for a decreased level of consciousness. Current medications include: [MEDICATION NAME] 100 micrograms (mcg) / hour times 72 hours, Quetiapine (antidepressant) 100 milligrams (mg) at bed time, Quetiapine 50 mg every morning, [MEDICATION NAME] HCL (antidepressant) 150 mg every morning, [MEDICATION NAME] (mood stabilizer) 250 mg twice a day, and [MEDICATION NAME] (antianxiety) 0.5 mg twice a day. The monthly pharmacy review records include a Potential Drug Interaction form for Resident #67, dated 03/03/18. This record identifies the combinations of the [MEDICATION NAME] with [MEDICATION NAME] HCL, and/or the [MEDICATION NAME] with Duloxetine HCL. The section titled Patient Management states: .Monitor patients on multiple serotonergic agents for symptoms of serotonin toxicity. Patients in whom serotoni[DIAGNOSES REDACTED] is suspected should receive immediate medical attention. The Patient Management section under the [MEDICATION NAME] with [MEDICATION NAME] states: .Monitor patients receiving concurrent therapy for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness. The form titled Suspected Medication Side Effects dated (MONTH) (YEAR), notes Resident #67 is receiving Duloxetine HCL (antidepressant), [MEDICATION NAME] HCL (antidepressant), [MEDICATION NAME] (antianxiety), and Quetiapine (antidepressant). The [DIAGNOSES REDACTED]. The form lacks any other documentation indicating staff assessed the resident for potential adverse consequences. Licensed Practical Nurse (LPN) #68 reported a residents medication side effects are documented on the form titled Suspected Medication Side Effects, during an interview on 03/21/18 at 10:00 AM. She reviewed Resident #67's form and acknowledged it was blank. When asked what the side effects were for the medications Resident #67 is receiving she stated: I would have to look them up, they are probably the usual fatigue, headache, drowsiness, and dizziness. During an interview on 03/20/18 at 3:00 PM, The Director of Nursing (DON) acknowledged Resident #67's medical record lacks any information related to staff monitoring him for side effects of [MEDICAL CONDITION] meds.",2020-09-01
1023,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2018-03-22,908,D,0,1,ER7J11,"Based on observation and staff interview the facility failed to maintain resident equipment in a safe sanitary condition. An oxygen concentrator exterior filter was soiled with built up dust. Facility census: 67. a) Observed on 03/19/18 at 11:35 AM while observing dining, an oxygen concentrator sit beside the wall in the dining room. The filter on the concentrator had build up dust on the exterior filter. At 9:35 AM on 03/20/18 the oxygen concentrator exterior filter remained soiled. The maintenance supervisor stated the oxygen concentrator is used by residents, explained the filter are cleaned on a schedule and agreed the filter was soiled.",2020-09-01
1024,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,550,D,0,1,HCZ012,"Based on observation and staff interview the facility failed to provide dignity to a resident. The facility failed to assist a resident for over an hour and a half when pants were visibly wet. This was a random opportunity for discovery. Resident identifier: #66. Facility census: 75 Findings included: a) Resident #66 An observation of Resident #66, fully viewable from hallway, on 05/28/19 at 12:00 PM, revealed Resident #66 stood at the foot of the bed with visible wet jeans. An additional observation of Resident #66, fully viewable from hallway, on 05/28/19 at 12:30 PM, revealed Resident #66 stood at the foot of the bed with visible wet jeans. An interview with Licensed Practical Nurse (LPN) #25, on 05/28/19 at 12:30 PM, revealed He doesn't usually do that and I will get it taken care of. An observation of Resident #66, fully viewable from hallway, on 05/28/19 at 1:30 PM, revealed Resident #66 continued to stand at the foot of the bed with visible wet jeans. An interview with LPN #25, 05/28/19 at 1:30 PM, revealed that They are getting ready to take him to the shower.",2020-09-01
1025,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,558,D,0,1,HCZ011,"Based on observation, record review, and staff interview, the facility failed to provide services with reasonable accommodation for a resident. A Resident's call light was out of reach. This practice affected one (1) of twenty one (21) residents observed during the Long Term Care Survey Process (LTCSP). Resident identifier: #19. Facility census 80. Findings include: a) Resident #19 An observation of the Resident, on 03/25/19 at 1:55 PM, revealed the Resident was in bed. The Resident's call light was on the floor under the bed. The Resident could not see or reach the call light. An interview with the Licensed Practical Nurse (LPN) #15, on 03/25/19 at 2:00 PM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/25/19 at 2:30 PM. The Care Plan, with a revision date of 02/05/19, had a focus of Resident is at risk for injury related to falls, cognitive, and history of multiple falls with the intervention Keep call bell within easy reach. Remind resident to use call light prior to transfers.",2020-09-01
1026,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,578,D,0,1,HCZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all residents had formulated advanced directives, which included their wishes for cardiopulmonary resuscitation. This was evident for two (2) of twenty-one (21) residents. Resident identifiers: #28, #71. Facility census: 80. Findings include: a) Resident #28 Review of the medical record on [DATE] found this resident first came to the facility in (MONTH) 2019. The medical record contained an incomplete Physician order [REDACTED]. In the space provided for the physician/nurse practitioner/physician's assistant it contained an illegible signature which was dated [DATE]. In the space provided for the resident/guardian/medical power of attorney/surrogate there was no signature or date to attest to whether or not the resident's power of attorney (MPOA) agreed or disagreed with the POST directives. An interview was conducted with the licensed social worker (LSW) on [DATE] at 11:43 AM. She said she will take care of getting the POST signed by the resident's spouse (MPOA), as the resident's spouse is in the facility often to visit. A copy of the resident's POST form was provided by the administrator on [DATE] at 2:20 PM. On [DATE] at 3 PM the acting director of nursing (DON) provided a copy of the the resident's current recapitulation of physician's orders [REDACTED]. On [DATE], facility staff provided a copy of the current medication administration record (MAR). In the section allotted for Advance Directive at the top of each page of the MAR, it stated the resident was a full code status with full interventions, intravenous fluids as long as necessary, and feeding tube long-term. In parenthesis, it stated this was discontinued as of [DATE] at 14:52. An interview was conducted with the administrator and the acting DON on [DATE] at 12 PM. They provided no further information at this time related to the lack of representative's signature on the POST form, and the lack of directives in the physician's recapitulation of (MONTH) orders and on the (MONTH) MAR related as to whether or not to perform CPR in the event of a cardiopulmonary arrest. b) Resident #71 The medical record was reviewed on [DATE]. This resident first came to the facility in (MONTH) 2019. found no evidence of the resident's wishes for cardiopulmonary resuscitation (CPR) in the event of a cardiopulmonary arrest. The current recapitulation of physician's orders [REDACTED]. The current medication administration record (MAR) contained a space at the top of each page for advanced directives, but on each page this section was left blank. Review of the current care plan contained no directives about end of life decisions which would include whether or not to perform CPR. Review of the hard copy medical record found it contained a plastic sleeve which contained a sticker stating Advanced Directives. This sleeve was empty. The face sheet listed the name of the resident's surrogate. The resident was deemed to lack capacity on [DATE], as signed by the physician. An interview was conducted with the licensed social worker (LSW) on [DATE] at 11:21 AM. She said the facility should have obtained the resident's and/or surrogate's wishes for CPR during the admission process in November, but this was not done. She said the health care surrogate lives in another county and has not been in to visit since the admission. The LSW said she will now take care of obtaining advanced directives. The DON provided a copy of the resident's current physician's orders [REDACTED]. She acknowledged it contained no orders related as to whether or not to perform CPR in the event of a cardiopulmonary resuscitation. An interview was conducted with the administrator and the acting DON on [DATE] at 12 PM. They provided no further information at this time related to the lack of directives in the physician's recapitulation of (MONTH) orders and on the (MONTH) MAR and on the care plan related as to whether or not to perform CPR in the event of a cardiopulmonary arrest.",2020-09-01
1029,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,602,D,0,1,HCZ011,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure the resident's right to be free from misappropriation of property. This was evident for one (1) of twenty-one (21) sampled residents. Resident identifier: #71. Facility census: 80. Findings include: a) Resident #71 During an interview with the resident on 03/25/19 at 2:59 PM, he said his wallet was stolen soon after his admission to the facility in (MONTH) (YEAR). He said the wallet contained some cash and some personal identification (ID) cards such as his social security card, food stamp card, and an insurance paper. He said he kept the wallet in the top drawer of his bedside table which is beside his bed. He said the wallet would had to have been stolen, because someone would had to have opened the drawer to remove it. He said upon discovery of the missing wallet from his bedside table, that he went out to the nurses's station and reported the theft to the day shift staff who were at the station. When asked the outcome, he said no one did anything about it. He said he never heard anything back from anyone about replacing the cash or its contents. An interview was conducted with the acting director of nursing (DON) on 03/28/19 at 10:15 AM. After requesting an inventory list of personal possessions the resident had at the time he first came to the facility, the acting DON said she searched the medical record and could find no inventory list. An interview was conducted with the licensed social worker (LSW) on 03/28/19 at 11:30 AM. She said she recalled that at first housekeeping or someone said that he lost his wallet, but then later said he found it. She said this happened in (MONTH) (YEAR). She said she did not complete a grievance form. On 03/28/19 at noon an interview was conducted with the acting DON and the administrator 03/28/19 about the missing wallet and its contents. The latter said said she thought the LSW completed a grievance on it when it first occurred. Another interview was conducted with the LSW on 03/28/19 at 12:30 PM. She said she did not make out a grievance form back in (MONTH) at the time of the incident. She said she recalls that the lost wallet was discussed in a morning meeting soon after the alleged loss occurred. She said later that day, or perhaps the following day, someone she cannot recall who told her that he found his wallet, when in actuality he got a replacement wallet. She said she just completed a grievance form with him. She said the resident told her that his ID was missing (driver's license, social security card)along with thirty (30) or forty (40) dollars cash for snack money that was missing from his wallet since (MONTH) (YEAR). She said she did not know until today of the allegation that the wallet and contents were stolen She said they will replace his ID cards. She said she will talk to the administrator about the cash and she figures they will reimburse him the cash. She said that since an inventory form was not done, there is no proof that he did not have a wallet with thirty (30) or forty (40) dollars in it.",2020-09-01
1031,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,610,D,0,1,HCZ011,"Based on resident interview, staff interview, and medical record review, the facility failed to thoroughly investigate an allegation of theft/misappropriation. This was evident for one (1) of twenty-one (21) sampled residents. Resident identifier: #71. Facility census: 80. Findings include: a) Resident #71 During an interview with the resident on 03/25/19 at 02:59 PM, he said his wallet, cash, and some identification cards were stolen from the top drawer of his bedside table in (MONTH) (YEAR) not long after he first came to the facility. He said he told day shift nursing staff that his wallet was stolen as soon as he found it was gone. He said he has not yet heard anything back from the facility and he does not know if they are still looking for it. An interview was conducted with the acting director of nursing (DON) on 03/28/19 at 10:15 AM. She said she was unable to find an inventory list of his possessions upon or after his admission to the facility. On 03/28/19 at 11:30 AM an interview was conducted with the licensed social worker (LSW). She said she recalls that someone, perhaps housekeeping, reported soon after his admission in (MONTH) (YEAR) that he had lost his wallet, but then someone later said he had found it. She said she did not talk with the resident about the wallet because she was under the impression that it had been found. She said she did not make out a grievance form in November. She said she is going back now to talk to him about the lost wallet and file a grievance report. She said no other staff members completed a grievance form on the alleged missing wallet, so therefore there was no follow-up. An Interview was conducted with the acting DON and the administrator on 03/28/19 at noon. The administrator said she recalls once hearing about his missing wallet a good while ago. She said she thought the LSW had previously completed a grievance on it. During an interview with the LSW on 03/28/19 at 12:30 PM, she said she just completed a grievance report with the resident. She said he told her that his wallet went missing in (MONTH) (YEAR), and that the wallet contained thirty (30) or forty (40) dollars cash, his driver's license, and his social security card. She said the facility will help him to obtain replacement identification cards. She spoke of plans to speak with the administrator about the cash, and she believes the facility will reimburse the cash. She said an inventory of possessions was not completed when he first came to the facility, so it cannot be proven that he did not have a wallet with the contents he described.",2020-09-01
1032,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,623,D,0,1,HCZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to give written notice to the resident's representative, and a copy of the notice to a representative of the Office of the State Long-Term Care ombudsman when a resident was transferred to an acute care facility This was evident for one (1) of three (3) residents reviewed for discharges. Resident identifier: #28. Facility census: 80. Findings include: a) Resident #28 Medical record review on 03/28/19 found this resident transferred to an acute care facility on 03/04/19, where the resident was subsequently admitted for inpatient services. Further review of the medical record found no evidence of a written notice of the transfer/discharge to the resident's legal representative and/or to the Office of the State Long-Term Care Ombudsman. At the time of the transfer there was also no evidence that the resident's representative received written notice of appeal rights including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the forms and submitting the appeal hearing request; the name, address and telephone number of the Office of the State Long-Term Care Ombudsman. An interview was completed with the licensed social worker (LSW) on 03/28/19 at 12:30 PM. She said she would look for a copy of bed hold and appeals information and written notice of transfer which may have been given to the resident and/or the resident's representative related to the transfer for hospitalization . At 3:15 PM on 04/01/19 an interview was conducted with the director of nursing (DON). She said there was no written transfer notice, or bed hold or appeals information conveyed to the resident's representative related to the (MONTH) hospitalization . She said they began inservice education on this topic on 03/29/19. An interview was conducted with the DON, the Corporate Clinical Quality Specialist, and the administrator on 04/01/19 at 4:00 PM. Discussed the absence of a written transfer notice, bed hold, appeals information, and Ombudsman's contact information when the resident was admitted to the hospital on [DATE]. The administrator said she did not know if the State Long-Term Care Ombudsman's office was notified at the time of the resident's transfer to a hospital. She said either the LSW or admissions would perform that task. On 04/01/19 at 4:10 PM an interview was conducted with the admissions coordinator Employee #87. She said she was not aware that the Ombudsman's office was supposed to be notified of transfer/discharges to the hospital. She said the LSW might be in charge of notifying the Ombudsman's office of transfers/ discharges to the hospital. She said she did not know if the LSW or anyone had notified the Ombudsman of the (MONTH) hospitalization . On 04/02/19 at 8:45 AM the administrator provided their policy on discharge and transfer. She said she assumes the LSW notifies the State Long-Term Care Ombudsman's office in a batch once per month of all residents' transfers for hospitalization . Review of this policy found that the facility must immediately inform the patient/resident representative, consult with the patient's physician, and notify, consistent with below, when there is a decision to transfer or discharge the patient from the Center. The patient and resident representative must be notified in writing and in a language and manner they understand. Item 5.1 addressed residents who are transferred to a hospital, as follows: For unplanned, acute transfers where it is planned for the patient to return to the Center, the patient and/or resident representative will be notified verbally followed by written notification using the Notice of Hospital Transfer or other state specific transfer form. Section 5.1.1 stated Copies of notices for emergency transfers must also be sent to the Ombudsman, but they may be sent when practicable, such as in a list of patients on a monthly basis or per state requirements. During an interview with the DON on 04/02/19 at 11:00 AM, she said she did not have a copy of the Notice of Hospital Transfer or a similar form. She said the business office would have that form. At 11:05 am on 04/02/19 the business office staff said their department does not have Notice of Hospital Transfer forms. On 04/02/19 at noon an interview was conducted with the licensed social worker (LSW). She said she never sends notice to the State Long-Term Care Ombudsman's office when residents go to the hospital. Upon inquiry as to whether she batches them and sends the notices once per month to the State Long-Term Care Ombudsman's office, she replied in the negative. The LSW said she sends the Ombudsman's office notice of discharge only when the discharge is permanent and the resident will not return to the facility.",2020-09-01
1033,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,625,D,0,1,HCZ011,"Based on medical record review and staff interview, the facility failed to provide written information to the resident's representative which specified the duration of the bed-hold when a resident was transferred for a hospitalization . This was evident for one (1) of three (3) residents reviewed for discharges. Resident identifier: #28. Facility census: 80. Findings include: a) Resident #28 Medical record review on 03/28/19 found this resident transferred to an acute care facility on 03/04/19, where the resident was subsequently admitted for inpatient services. Further review of the medical record found no evidence that written bed-hold information was provided to the resident's representative at the time of the hospitalization . An interview was conducted with the licensed social worker (LSW) on 03/28/19 at 12:30 PM. She said she would look for a copy of bed-hold and appeals information, and written notice of transfer, which may have been given to the resident and/or the resident's representative related to the transfer for hospitalization . At 3:15 PM on 04/01/19 an interview was conducted with the director of nursing (DON). She said there was no written transfer notice, or bed-hold, or appeals information conveyed to the resident's representative related to the (MONTH) hospitalization . She said they began inservice education on this topic on 03/29/19. An interview with the administrator was completed on 04/02/19 at noon. She provided no further information.",2020-09-01
1034,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,641,D,0,1,HCZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, the facility failed to ensure the accuracy of the comprehensive assessments for two (2) of twenty-one (21) sampled residents. Resident identifiers: #37, #50. Facility census: 80. Findings include: a) Resident #37 Medical record review on 03/26/19 found this resident enrolled into a hospice program in (MONTH) (YEAR), and has remained a hospice patient since that time. Review of the minimum data set (MDS) with assessment reference date 02/04/19 found that she was incorrectly assessed as not receiving hospice services. An interview was conducted with the acting director of nursing and the administrator on 03/28/19 at noon about the inaccuracies of the 02/04/19 as it pertained to hospice services. No further information was provided prior to exit. b) Resident #50 A resident interview, on 03/25/19 at 2:07 PM, Resident #50 stated I receive [MEDICAL TREATMENT]. I go Tuesday, Thursday and Saturday. Resident #50 denied participation in hospice. A review of resident records, on 03/27/19 at 03:00 PM, revealed the care plan and physician orders for [MEDICAL TREATMENT]. The physician order stated, [MEDICAL TREATMENT] center phone number is: Fresenius [MEDICAL TREATMENT] [PHONE NUMBER] days: on Tuesday, Thursday, Saturday. Time for Pick up: 0530 for [MEDICAL TREATMENT] at 0640, (must be there by 0620) Transport to: Fresenius Nephrologists' name: Dr. Adeniyi. There was no physician order or care plan focus for hospice care. Further medical record review, on 03/27/19 at 3:17 PM, revealed a NO marked for [MEDICAL TREATMENT] on Resident #50's minimum data sheet (MDS.) The MDS revealed a NO to [MEDICAL TREATMENT] indicating Resident #50 does not receive [MEDICAL TREATMENT] in section O of the MDS. The MDS was marked Yes to Hospice indicating Resident #50 does participate in hospice care in section O of the MDS. A staff interview with the Support Director of Nursing (S-DON) #100, on 03/27/19 at 3:25 PM, revealed the MDS was marked wrong for both the [MEDICAL TREATMENT] and hospice questions in section O of the MDS. S-DON #100 confirmed Resident #50 does receive [MEDICAL TREATMENT]. S-DON #100 confirmed the MDS marked No to [MEDICAL TREATMENT] is incorrect. SDON #100 confirmed Resident #50 does not participate in hospice care. S-DON confirmed the MDS marked Yes to Hospice is wrong.",2020-09-01
1035,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,655,D,0,1,HCZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to develop and implement a baseline care plan related to nutritional needs. This is true for one (1) of twenty-one (21) reviewed. Resident identifier: 229. Facility census: 80. Findings include: a) Resident #229 Resident #229's admission to the facility occurred on 03/22/19. While in the hospital the resident underwent [REDACTED]. Resident #229 primary hospital discharge diagnosis, includes a principle problem [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED].>Tobacco use disorder [MEDICATION NAME] Depression Recent unintentional weight loss over several months Normocytic [MEDICAL CONDITION] Vitamin B 12 deficiency [MEDICAL CONDITIONS] Pelvic mass in female [DIAGNOSES REDACTED] The initial care plan with a date of 03/22/19 does not include dietary needs of Resident #229. The Kardex report includes, Encourage resident to consume all fluids of choice daily and during meals. On 04/01/19 at 12:19 PM this information was shared with the DON whom had no comment.",2020-09-01
1038,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,677,D,0,1,HCZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the facility failed to provide nail care to a resident unable to carry out activities of daily living. Resident: #16. Facility census: 80. Findings include: a) Resident #16 A change in condition note with a date of 10/09/18 reveals the resident had a loose toenail. The specific toenail is not identified on the evaluation. Medical record reveal a podiatry assessment completed on 10/12/18. The results reveal Resident #16 has: difficulty walking, pain in feet/toes, and, to continue monitoring vascular status of the resident. A change in condition note with a date of 12/31/18 reveals a right great toe pressure ulcer. The physician/nurse practitioner ordered to cleanse the area and apply [MEDICATION NAME] ointment for three (3) days. Neither the (MONTH) of (YEAR) or (MONTH) of 2019 medication administration records has evidence the [MEDICATION NAME] ointment was applied to the right great toe. A change in condition note with a date of 03/17/19 reveals the resident to have a skin wound or ulcer on the right great toe with the base of the nail being brittle and cracking. On 03/17/19 the resident began taking Bactrim tablet 800-160 milligrams (mg), two (2) tablets twice a day for infection of the right great toe. After thirteen (13) doses of this medication the resident developed a rash. The medication was changed to, Keflex 500 mg every eight (8) hours, for five (5) days. Given for infection in the right great toe related to local infection of the skin and subcutaneous tissue. On 03/28/19 the medication administration was completed. A skin integrity report on 04/01/19 reveals the right great toe to be healed. On 04/02/19 at 8:45 AM observation, found the right great toe nail to be very long. The additional toe nails were also too long. Licensed nurse (LPN) #44 agreed the nail needed trimmed. On 04/02/19 8:50 AM the DON explained there is no referral for the podiatry to assess the resident, but will make one for the next visit by the podiatrist.",2020-09-01
1040,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,686,D,0,1,HCZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, the facility failed to ensure physician ordered heel protectors were in place at all times on a resident with a newly acquired pressure ulcer on her ankle. Resident identifier: #37. Facility census: 80. Findings include: a) Resident #37 Observation on 03/26/19 at 02:30 PM, while accompanied by wound care nurse/licensed practical nurse (LPN) #76, found this resident had a small pressure wound on the right lateral ankle. LPN #76 said this pressure wound was discovered yesterday and assessed as a deep tissue injury. Observed at this time also were two (2) heel protectors lying at the foot of her bed on top of the covers. LPN #76 said the really thick padded boot was a Level two (2) device the resident wears on her right ankle. LPN #76 said the smaller, less thick one which lay alongside it on top of the covers was termed a regular heel protector. She said the latter was used on the left foot/heel which has no pressure wound. Upon inquiry as to why the resident was not wearing the heel protectors, LPN #76 said the nursing assistants probably removed them when they were in the room positioning the resident or providing toileting care in the bed. The resident was alert and oriented. She said she did not recall who removed the heel protectors, or when they were removed. LPN #76 applied the heel protectors to both feet. She said she will speak to the nursing assistants to remember to use the heel protectors when the resident is in the bed. At 2:35 PM on 03/26/19 LPN #76 said that she spoke with the resident's aide about the heel protectors the resident had orders for. Review of the medical record on 03/26/19 revealed a new physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the wound measurement flow sheet on 03/26/19 found the first measurement occurred on the day of discovery of the deep tissue injury on 03/25/19. The measurement on that date was 0.5 by 0.5 centimeters, with no depth. On 03/27/19 at 3:00 PM the acting director of nursing provided copies of the current care plan and the current recapitulation of physician's orders [REDACTED]. Care plan review on 03/27/19 found on page twenty-two (22) a care plan revision dated 03/25/19 for a healing goal for the deep tissue injury to the right lateral ankle as evidenced by history of pressure ulcer, incontinence, limited mobility, and impaired circulation. An interview was conducted with the acting DON and the administrator on 03/28/19 at noon. No further evidence was provided related to the emergence of the newly acquired deep tissue injury of the right lateral ankle.",2020-09-01
1042,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,692,D,0,1,HCZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview the facility failed to develop and implement a baseline care plan related to nutritional needs. Resident identifier: 229. Facility census: 80. Findings included: a) Resident #229 Resident #229 admission occurred on 03/22/19. While in the hospital the resident underwent [REDACTED]. Resident #229 primary hospital discharge diagnosis, includes a principle problem [MEDICAL CONDITION]. Other [DIAGNOSES REDACTED].>Tobacco use disorder [MEDICATION NAME] Depression Recent unintentional weight loss over several months Normocytic [MEDICAL CONDITION] Vitamin B 12 deficiency [MEDICAL CONDITIONS] Pelvic mass in female [DIAGNOSES REDACTED] The initial care plan with a date of 03/22/19 does not have information related to dietary needs of Resident #229. The Kardex report includes, Encourage resident to consume all fluids of choice daily and during meals. Upon admission to the facility Resident #229 had a surgical wound, peripherally inserted central catheter (PICC) and a drain line placed in the abdomen. Medications upon admission to the facility includes [MEDICATION NAME] 750 milligrams (mg) in normal saline 7.5 milliliters (ml) infusion, every twelve (12) hours. [MEDICATION NAME] an antibiotic given for infection. Also, prescribed, Cefeprime two (2) grams/100 ml intravenous every eight (8) hours. Cefeprime is an antibiotic given for infection. Both the [MEDICATION NAME] and Cefeprime orders were completed on 03/30/19. A nursing note on 03/25/19 reveals the resident feels nauseous at times and appetite is poor. During initial tour of the facility on 03/25/19 at 3:32 PM the resident explained she is not eating well, and she does not like the food brought to her. States the day before this interview she requested soup but it was not delivered to her. The resident received [MEDICATION NAME] four (4) mg on, 03/26/19 and on 03/28/19 for nausea and vomiting. On 03/27/19 the resident received, normal saline 0.9% at seventy-five (75) ml per hour for dehydration. On 03/27/19 a nursing notes reveals the resident asked for bottled water due to not liking the tap water. Meal intake documentation obtained on 04/01/19 includes: 03/22/19 Refused lunch and dinner 03/23/19 50% of breakfast, 25% of lunch and 50% of dinner 03/24/19 Refused breakfast, refused lunch, with no documentation for dinner 03/25/19 Refused all meals 03/26/19 Refused all meals 03/27/19 Refused all meals 03/28/19 Refused all meals 03/29/19 Refused all meals 03/30/19 Refused breakfast, refused lunch, with no documentation for dinner 03/31/19 Refused breakfast, with no documentation for lunch and dinner. Observation on 04/01/19 at 10:47 AM found the resident to appear very underweight and pale in color. The dietary manager on 04/01/19 at 11:45 AM presented a meal ticket form for breakfast, lunch and dinner, for Resident #229. The meal ticket reveals the resident is to receive regular/liberalized diet with no listed likes, dislikes, requests or special needs. At 3:40 PM on 04/01/19 the dietary manager voiced there is not a process in which a notice is sent to dietary after a resident refuses a certain number of meals. He explained he is notified when a significant change weight loss occurs. He was notified on this day by reading a note by the dietitian. Notes reveal a dietitian assessment on 03/28/19. The note explains Resident #229 was very emotional and the interview was stopped. Also a contact with the dietary manager will be made to recommend a house supplement. This note was documented as a late note completed on 03/28/19 but not documented in the system until 04/01/19, at which time the dietary manager received the information. Weight documentation on: 03/22/10 131.6 pounds standing 03/25/19 123.4 pounds standing 03/31/19 105.4 pounds standing 04/01/19 104.6 pounds standing Admission includes a [DIAGNOSES REDACTED]. On 04/01/19 at 12:19 PM this information was shared with the DON whom had no comment.",2020-09-01
1043,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,695,D,0,1,HCZ011,"Based on observation, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen therapy was not being administered as ordered by the physician. These practices affected three (3) of six (6) residents reviewed for respiratory care during the Long Term Care Survey Process (LTCSP). Resident identifiers: #14, #47, and #279. Facility census: 80. Findings include: a) Resident #14 An observation of the Resident, on 03/25/19 at 12:30 PM, revealed the Resident was in her wheelchair in her room. The Resident had an oxygen concentrator in the room and was receiving 2.5 liters of oxygen via nasal cannula. A review of the physician orders, on 03/25/19 at 12:40 PM, revealed the Resident was ordered Oxygen at 4 Liters per minute via nasal cannula continuously for shortness of breath. The order had a start date of 06/14/18. An interview with Licensed Practical Nurse (LPN) #15, on 03/25/19 at 12:45 PM, revealed the Resident should be receiving oxygen continuously at 4 liters and not 2.5 liters. b) Resident #47 An observation of the Resident, on 03/25/19 at 1:05 PM, revealed the Resident was in bed in her room. The Resident had an oxygen concentrator in the room and was receiving 4 liters of oxygen via nasal cannula. A review of the physician orders, on 03/25/19 at 1:15 PM, revealed the Resident was ordered Oxygen at 2 liters per minute via nasal cannula continuously. The order had a start date of 11/29/18. An interview with Licensed Practical Nurse (LPN) #15, on 03/25/19 at 1:20 PM, revealed the Resident should be receiving oxygen continuously at 2 liters and not 4 liters. The LPN stated sometimes the residents will change the oxygen levels themselves. c) Resident #279 An observation of the Resident, on 03/25/19 at 1:40 PM, revealed the Resident was in bed in her room. The Resident had an oxygen concentrator in the room and was receiving 2.5 liters of oxygen via nasal cannula. A review of the physician orders, on 03/25/19 at 1:45 PM, revealed the Resident was ordered Oxygen at 3 liters per minute via nasal cannula continuously. The order had a start date of 02/25/19. An interview with Licensed Practical Nurse (LPN) #15, on 03/25/19 at 1:50 PM, revealed the Resident should be receiving oxygen continuously at 3 liters and not 2.5 liters.",2020-09-01
1044,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2019-03-29,697,D,0,1,HCZ011,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure pain management was provided to a Resident consistent with professional standards of practice and the person centered care plan. Non-pharmacological interventions were not provided and the effectiveness of pharmacological interventions were not assessed for Resident #69. This practice affected one (1) of two (2) residents reviewed for pain management during the Long Term Care Survey Process (LTCSP). Facility census: 80. Findings include: a) Resident #69 An interview with the Resident, on 04/02/19 at 9:30 AM, revealed the staff does not attempt any non-pharmacological interventions for pain. The Resident stated they just give me medication. The Resident stated the staff sometimes asks what his pain level is and rather the pain medication was effective. An interview with LPN #250, on 04/02/19 at 9:35 AM, revealed she does not attempt any non-pharmacological interventions before giving the resident his pain medications. The LPN stated she will ask the Resident what his pain is before giving pain medications but does not follow-up for the effectiveness of the medication. A review of the Resident's Care Plan was conducted on 04/02/19 at 10:15 AM. The Care Plan, with a review date of 03/21/19, had a focus of Resident exhibits or is at risk for alterations in comfort with the goal of pain relief with non-pharmacological interventions for mild pain and pharmacological interventions for unrelieved moderate to severe pain. The Care Plan included the interventions, Evaluate pain characteristics, quality of pain, severity of pain, location of pain, and precipitating and relieving factors of the pain and medicate the Resident as ordered and monitor for effectiveness. Further review of the Resident's medical record, on 04/02/19 at 10:30 AM, revealed no documentation the Resident was receiving non-pharmacological interventions or assessment of the effectiveness of pharmacological interventions. An interview with the Director of Nursing, on 04/02/19 at 10:45 AM, revealed the nursing staff should be implementing non-pharmacological interventions for pain as well as assessing the effectiveness and pain levels after pharmacological interventions are attempted.",2020-09-01