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| Link | rowid | facility_name | facility_id | address | city ▼ | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2147 | 2147 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2019-09-24 | 580 | E | 1 | 0 | 9CH711 | **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 medications were not administered. This is true for two (2) out of five (5) residents Medication Administration Record [REDACTED]. Facility census: 59. Findings included: a) Resident #2 A review of Resident #2's MAR indicated [REDACTED]. --Apixaban 5 milligrams (mg) twice a day at 9:00 AM and 9:00 PM --Aspirin 81 mg daily at 9:00 AM --[MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg twice a day at 9:00 AM and 9:00 PM - [MEDICATION NAME], a schedule IV medication, was signed off on the controlled substance book indicating the nurse had taken the medication out of the pack, but Nurse #1 signed her initial on the dates and times on the MAR indicated [REDACTED]. The medication [MEDICATION NAME] was not sign off with another nurse on the controlled substance book that the medication was wasted. This means the medication was not observed by another nurse the medication was disposed of properly. --Carvedilol 3.125 mg twice a day at 9:00 AM and 9:00 PM --[MEDICATION NAME] 25 mg daily at 9:00 AM --[MEDICATION NAME] 20 mg daily at 9:00 AM --[MEDICATION NAME] 10 mg daily at 9:00 AM --[MEDICATION NAME] 7.5 mg at 9:00 PM --[MEDICATION NAME] Chloride extended release 15 mg daily at 9:00 AM --[MEDICATION NAME] 20 mg daily for at 9:00 AM --Vitamin B 12 100 microgram (mcg) daily at 9:00 AM The Director of Nursing (DoN) stated the nurse who did not administer Resident #2's medication on 09/03/19 was Nurse #1. She further stated when a nurse circles her initals on the dates and times on the MAR, this indicates the nurse did not administer medication to the resident. Nurse #1 did not notify the physician why the medication were not administer to Resident #2. b) Resident #5 A review of Resident #5's MAR indicated [REDACTED]. When a nurse circles her initals on the date and times, this indicates the nurse did not administer these medication to the Resident #5. The Nu… | 2020-09-01 |
| 2148 | 2148 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2019-10-23 | 583 | D | 0 | 1 | 8VRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a Resident's Medication Administration Record (MAR) and a Nurse Report Sheet were secured in a manner that protected personal, medical, and health information. Personal identifiers including resident's names, room numbers, code status, medications, medical interventions, allergies [REDACTED]. This was a random observation. This practice affected a limited number of residents. Facility census: 59. Findings included: a) Observation An observation of the 100 Hall, on 10/22/19 at 9:30 AM, revealed the medication cart was in the hall. The Medication Administration Record (MAR) and a Nurse Report Sheet were on top of the medication cart open and visibly available for anyone to view. No staff members were at the medication cart at the time of the observation. The MAR and the Nurse Report Sheet contained the following resident information: -Names -Room numbers -Code Status -Medications -Medical interventions -allergies [REDACTED]. b) Interview An interview with Licensed Practical Nurse (LPN) #16, on 10/22/19 at 9:35 AM, revealed the MAR and Nurse Report Sheet are supposed to be covered before she leaves the medication cart unattended. The LPN stated she forgot to do so. | 2020-09-01 |
| 2149 | 2149 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2019-10-23 | 623 | D | 0 | 1 | 8VRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the ombudsman of the Resident's transfer to the hospital. This deficient practice was found for 1 of 4 residents reviewed in the care area of hospitalization . Resident identifiers: #59. Facility census: 59. Findings included: a) Resident #59 Record review indicated Resident #59 was transported to local hospital on [DATE] at 8:14 AM for an unplanned transfer and never returned the facility. Notification to the Ombudsman for this transfer was not documented. During an interview on 10/22/19 at 2:37 PM Social Services Specialist #54 verified the facility did not notify the ombudsman of the transfer or discharge and the reasons for the move in writing. Social Service Specialist #54 stated, I was not aware I should be sending those notifications to the ombudsman until recently when corporate questioned me about it. Review of the facility's Discharge and Transfer Policy, subtitled OPS404 Discharge and Transfer, effective date 06/01/96 Review date 01/16/10, revision date 02/01/19 stated - For patients transferred to a hospital 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. | 2020-09-01 |
| 2150 | 2150 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2019-10-23 | 625 | D | 0 | 1 | 8VRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Resident with Bed Hold Notice upon transfer. This deficient practice was found for one (1) of four (4) Residents reviewed in the care area of hospitalization . Resident identifier: #59. Facility census: 59. Findings included: a) Resident #59 Record review indicated Resident #59 was transported to local hospital on [DATE] at 8:14 AM for an unplanned transfer. Evidence that documented a Bed Hold Notice was provided to the Resident or Resident's legal representative was not found. During an interview on 10/22/19 at 2:37 PM Social Services Specialist #54 verified the facility did not provide the Resident or the Resident's legal representative with a Bed Hold Notice. Social Services Specialist #54 stated, Unless nursing done it, it wasn't done because when she left on the 9/14/19 it was a Saturday and I was not here. On 10/22/19 at 2:55 PM, Social Services Specialist #54 confirmed the facility did not have any documentation anywhere within medical records that a Bed Hold Notice had been provided for Resident #59's transfer on 09/14/19. Review of the facility's Accounts Receivable Policies and Procedures Policy subtitled: AR102 Bed Holds - effective date 03/15/00, review date 04/15/16, revision date 05/01/16 stated when a resident is transferred out of the service location to a hospital or on therapeutic leave, the designee will provide the resident/family member the written Bed Hold Policy Notice & Authorization form regardless of the payer. | 2020-09-01 |
| 2151 | 2151 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2019-10-23 | 657 | D | 0 | 1 | 8VRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's care plan was revised based on the results of a comprehensive assessment. This failed practice had the potential to affect one (1) of 19 residents whose care plans were reviewed during the long term care survey process. Resident identifier: #53. Facility census: 59. Findings included: A record review for Resident #53 noted the resident was re-admitted to the facility on [DATE] with an order for [REDACTED]. A review of the comprehensive care plan dated 10/08/19, noted no problem or modality utilizing the oxygen therapy ordered to be administered to Resident #53. An interview, on 10/22/19 at 10:55 AM, with the Clinical Reimbursement Coordinator (CRC), revealed the oxygen therapy had been noted on the comprehensive assessment but not carried through to the care planning process. The CRC verified the oxygen should have been care planned but the facility missed that. | 2020-09-01 |
| 2152 | 2152 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2019-10-23 | 695 | D | 0 | 1 | 8VRQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The failed practice had the potential to affect one (1) of seven (7) residents receiving oxygen therapy. Resident identifier: Resident #53. Census: 59 Findings included: A review of the policy, Oxygen Concentrator, revision date: 12/01/18. showed when oxygen was to be administered, the oxygen flow rate would-be set-in accordance with the physician's orders [REDACTED].>An observation, on 10/21/19 at 01:02 PM, revealed Resident #53 was receiving oxygen (O2) via nasal cannula at 2 liters per minute. An additional observation, on 10/22/19 at 08:15 AM revealed Resident #53 was receiving O2 at 1.5 liters per minute via nasal cannula. Medical record review for Resident #53 noted a physician's orders [REDACTED]. An interview, on 10/22/19 at 08:27 AM, with RN#7, verified Resident #53's O2 was set on 1.5 liters per minute but verified the order was for 3 liters per minute. An interview was conducted on 10/22/19 at 09:31 AM, with the Center Nursing Executive (CNE). When informed of the oxygen settings observed on 10/21/19 and 10/22/19, the CNE verified the oxygen was to be set at 3 liters per minute and verbalized understanding they were not set in accordance with physician's orders [REDACTED]. | 2020-09-01 |
| 2153 | 2153 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2019-10-23 | 842 | D | 0 | 1 | 8VRQ11 | Based on record review and interview, the facility failed to maintain medical records on each resident that are complete and accurate. Resident #43's Nurses Notes included a fall with injury that occurred for Resident #11. This practice affected two (2) of nineteen (19) resident records reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #11 and #43. Facility census: 59. Findings included: a) Record Review A review of the Nurses Notes for Resident #43, on 10/22/19 at 11:17 AM, revealed the notes included a fall with injury that occurred on 09/03/19. No other indication of a fall could be found in Resident #43's record. b) Interview An interview with the Center Nurse Executive (CNE), on 10/22/19 at 11:30 AM, revealed Resident #43 did not have a fall on 09/03/19 with injury. The CNE stated a nurse mistakenly charted Resident #11's fall in Resident #43's Nurses Notes by mistake. The CNE stated she would ensure the mistake was corrected in both of the Resident's medical records. | 2020-09-01 |
| 2154 | 2154 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2019-10-23 | 925 | E | 0 | 1 | 8VRQ11 | Based on observation and interview, the facility failed to maintain an environment free from pests. The resident Dining Room and the 100 Hall was observed to have flies on multiple occasions. This practice affected a limited number of residents. Facility Census: 59. Findings included: a) Observations Multiple observations during the LTCSP on 10/21/19, 10/22/19, and 10/23/19, revealed flies in the Resident Dining Room and 100 Hall. b) Interviews Interviews with Resident #26 and #36, on 10/22/19 at 1:45 PM, revealed there are flies in the dining room daily. The Resident's stated they need fly swatters during meals. An interview with Administrator, on 10/23/19 at 8:15 AM, revealed the facility has a pest control company come monthly. The Administrator stated they noticed an increase in flies last week and had contacted the pest control company to come out and take care of the issue. The Administrator stated they have not showed up yet. | 2020-09-01 |
| 2155 | 2155 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2018-11-08 | 561 | D | 0 | 1 | I3US11 | Based on medical record review and staff interview, the facility failed to ensure the resident's right to make choices about aspects of his/her life that are significant to the resident. Resident #38 said she was not offered the opportunity to vote in the mid-term election. This was evident for one (1) of fifteen (15) sampled residents. Resident identifier: #38. Facility census: 58. Findings included: a) Resident #38 An interview was conducted with the resident on 11/05/18 at 11:48 AM. She said she votes in every election. She said no one at the facility offered her the option of an absentee ballot and/or an on-site polling voting option for the 11/06/18 mid-term election. The medical record was reviewed on 11/07/18. The most recent minimum data set (MDS), with assessment reference date (ARD) 09/09/18, assessed her with a Brief Interview for Mental Status (BIMS) score of fourteen (14). A score of thirteen (13) to fifteen (15) indicates intact cognition. On 11/08/18 at 8:49 AM the licensed social worker (LSW) was interviewed. Upon inquiry, she said that the activities department takes care of finding out which residents wish to vote, and then assists them with voting. She said she has worked here only since April, and this is the first election since her hire date. She spoke awareness that one male resident went to the polls and voted in this week's mid-term election. An interview was conducted with the activity director on 11/08/18 at 8:52 AM. She said facility staff transported one (1) male resident to the polls to vote in the early voting period. She said no other residents in the facility voted this election either in person or by absentee ballot. Upon inquiry as to whether Resident #38 was given the option to exercise her right to vote in this year's election, she said they sometimes talk about the election in current events, but she could not recall if or when she spoke with this resident about her voting preference. She was asked if anyone canvassed the residents last month to see if anyone wanted an absent… | 2020-09-01 |
| 2156 | 2156 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2018-11-08 | 641 | D | 0 | 1 | I3US11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview and staff interview the facility failed to ensure one (1) of fifteen (15) residents, had an assessment completed that accurately reflected their status. Resident #4's assessment did not reflect the resident's status concerning speech. This had the potential to affect more than a limited number of residents. Resident identifiers: #4 Facility census: 58 Findings included: a) Resident #4 On 11/05/18 at 02:30 PM during the initial interview with the resident this surveyor had difficulty understanding the resident at times due to the resident's speech abilities. The resident was slow to form some words at times and had to repeat herself to help this surveyor understand what she was trying to communicate. Review of Resident #4's quarterly minimum data set (MDS) with an assessment reference date (ARD) 11/04/18, on 11/06/18 at 11:51 AM, revealed the MDS was marked the resident had clear speech. Pertinent [DIAGNOSES REDACTED].) On 11/07/18 at 09:20 AM, observation of Licensed Practical Nurse (LPN#61) providing Pressure ulcer wound care to Resident #4, revealed LPN#61 had some difficulty communicating with and understanding Resident #4 due to the resident's speech abilities. LPN#61 had to ask the resident various times to repeat herself so the LPN could understand the resident. The same observations were made, on 11/07/18 at 10:10 AM, when LPN#61 provided supra pubic catheter to Resident #4. Interview with the back-up clinical reimbursement coordinator (CRC, the nurse responsible for completing the resident's MDS), on 11/07/18 at 01:16 PM, revealed 'clear speech' being marked on the MDS was inaccurate. The back-up CRC said, The resident has been here a while. I am familiar with the resident, and she does not have clear speech. The MDS is not accurate. | 2020-09-01 |
| 2157 | 2157 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2018-11-08 | 655 | D | 0 | 1 | I3US11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a baseline care plan for one (1) of one (1) closed record reviewed for death. Resident identifier: #58. Facility census: 58. Findings included: a) Resident #58 Resident #58 was admitted to the facility on [DATE]. A copy of Resident #58's baseline care plan was requested and reviewed on 11/07/18 during the Long Term Care Survey Process. The baseline care plan included problems, goals, and interventions related to nutrition and skin breakdown only. The initial nursing assessment completed on 09/22/18 revealed that Resident #58 had a urinary tract infection [MEDICAL CONDITION], urinary and bowel incontinence, recent falls, moderate hearing difficulty with need for a hearing aid, and limited mobility with wheelchair use. Per his admission orders [REDACTED]. On 11/07/18 at 4:00 PM, Clinical Reimbursement Coordinator (CRC) #8 stated that a baseline care plan should include, at a minimum, information related to nutrition, activities of daily living, skin integrity, and advance directives. She reviewed Resident #58's baseline care plan and agreed that it was incomplete. She said she did not know where the rest of the care plan was. | 2020-09-01 |
| 2158 | 2158 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2018-11-08 | 656 | D | 0 | 1 | I3US11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation the facility failed to develop and/or implement a comprehensive care plan related to psychosocial needs, the use of medication for [MEDICAL CONDITION], nutrition and activities. Resident identifiers: #40 and #48. Facility census: 58. a) Resident #40 Intermittent observations of his room on 11/05/18 found it devoid of any personal effects. The room had no music or television. He wore a hospital gown at every observation. The medical record was reviewed on 11/06/18. This resident first came to the facility the preceding month. He and/or his guardian elected hospice services on 10/04/18. Review of the care plan found it was not person-specific in the care area of things that formerly brought him comfort/pleasure, or past interests. The care plan contained a focus which was initiated on 10/05/18, that he was at risk for alterations in comfort related to chronic pain. Interventions included to Evaluate resident's past coping mechanism to determine what measures work best (relaxation, diversional activities, visualization). However, his past coping mechanisms were not included in the care plan. An interview was conducted with the licensed social worker (LSW) on 11/06/18 at 2:42 PM. We discussed that the care plan was not person-centered in that it did not include things that brought him comfort/pleasure or past interests. Also, his room was absent of any personal memorabilia or connections to his past life that might bring him comfort. The LSW said that mostly he likes for people to talk to him, although that was not included on the care plan. She said he has two (2) grandchildren who visit sometimes. Upon inquiry as to whether they were involved in care planning things that have brought him comfort/pleasure in the past such as favorite pets, type of music preferred, hobbies, pictures from his home, past employment, religious preference, she said she did not know. She added that activities us… | 2020-09-01 |
| 2159 | 2159 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2018-11-08 | 657 | D | 0 | 1 | I3US11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to revise a careplan for two (2) of fifteen (15) sampled residents. Resident #108's care plan was not revised when isolation was discontinued. Resident #5's care plan was not revised related to diet and nutritional supplements. Resident identifiers: #108 and #5. Facility census: 58. Findings included: a) Resident #108 The medical record was reviewed on 11/07/18. This resident was hospitalized for [REDACTED]. She returned to the facility on [DATE] and was placed on contact precautions. Review of the care plan provided by the facility found a focus for being at risk for complications of infection related to pneumonia. One of the interventions included Droplet Precautions, which was initiated on the current care plan with the date of 09/13/18, as it remains today. Observations found no evidence of any type of isolation set up for her room. On 11/07/18 at 4:00 PM an interview was conducted with the director of nursing (DON). She clarified that this resident is no longer on droplet precautions, nor has she been in droplet precautions for at least the past month. She said the care plan should have been revised to reflect that change, and it was not. b) Resident #5 During an interview on 11/06/18 at 3:16 PM, Resident #5 said he thought he was on a renal diet, but he was not sure because no one had explained his diet to him. He also stated that he was given a nutritional supplement via his feeding tube. A review of Resident #5's physician's orders [REDACTED]. Low sodium diet due to fluid overload. Another physician's orders [REDACTED]. A review of Resident #5's care plan revealed instructions to provide a pureed, no added salt (NAS) diet with a sugar substitute and no oranges, OJ, bananas, or tomatoes. Additionally, care plan diet instructions stated to provide double eggs at breakfast, double meats at lunch and dinner, and diet as ordered. Page seven… | 2020-09-01 |
| 2160 | 2160 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2018-11-08 | 684 | D | 0 | 1 | I3US11 | Based on medical record review and staff interview, the facility failed to follow physician's orders for one (1) of fifteen (15) sampled residents. Resident identifier: #108. Facility census: 58. Findings included: a) Resident #108 On 11/07/18 the medical record was reviewed. On 09/19/18 the physician ordered an increase in supplements (house shake) from once daily at 10:00 AM to twice daily at 10:00 AM and 2:00 PM. A verbal order from (name of doctor) to licensed practical nurse #71 (LPN #71) was dated 09/19/18 stated House supplements BID (twice daily) at 10 a and 2 p. Review of the treatment administration record (TAR) found the supplement was offered and/or given only one time per day on 09/20/18, 09/21/18, 09/22/18, 09/23/18, 09/24/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/29/18, and 09/30/18. The (MONTH) TAR contained directive for supplement twice daily as the physician ordered. On 11/07/18 at 4:00 PM the director of nursing (DON) agreed the physician's order for twice daily supplements was not placed on the TAR until 10/01/18, and that the twice daily supplements were not offered to her in September. She said the order was not transcribed on the (MONTH) TAR correctly as it should have been, and this error was not found until changeover of the monthly TAR occurred the beginning of October. | 2020-09-01 |
| 2161 | 2161 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2018-11-08 | 693 | D | 0 | 1 | I3US11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review, resident interview, and staff interview, the facility failed to ensure the administration of enteral nutrition is consistent with the physician orders. This was true for one (1) of one (1) residents reviewed for the care area of tube feeding status. This had the potential to affect more than a limited number of residents. Resident identifiers: #4 Facility census: 58 Findings included: a) Resident #4 On 11/05/18 at 02:31 PM the enteral feeding container of [MEDICATION NAME] HN was found hanging in the resident's room with no information filled out on the label as required. The 2000cal (calorie)/1000 ml. (milliliter) container had a considerable amount of residual sediment from the enteral feeding deposited on the inside top of the container, indicating the container had not been properly shook prior to being hung. Instructions on the container read, Shake well before each use. Hang product up to 48 hours after initial connection when clean technique and only when one new feeding set are used. Otherwise, hang no longer than 24 hours. On 11/05/18 the enteral feeding container had 900 ml. of [MEDICATION NAME] left in the container that had not been administered. The resident said she gets her feedings between 6:00 PM to 6:00 AM, but according to the resident the nurse hung the container now hanging at 3:00 AM that morning. There was nothing on the label to indicate the time it was hung. Review of Resident #4's quarterly minimum data set (MDS) with an assessment reference date (ARD) 11/04/18, on 11/06/18 at 11:51 AM, revealed the resident's Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident is cognitively intact. The resident is dependent for all activities of daily living. The resident has impairment in range of motion (ROM) in both sides upper and lower extremities. Resident #4 has a supra pubic catheter and is always incontinent of bowel. Pertinent [… | 2020-09-01 |
| 2162 | 2162 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2018-11-08 | 838 | E | 0 | 1 | I3US11 | Based on record review, activity calendar review, facility assessment and staff interview the facility failed to ensure facility wide assessment was conducted to thoroughly assess the needs of residents and to determine the required resources needed to provide activity programing. This issue has the potential to affect more than an isolated number of residents. Resident identifiers: Facility census: 58. Findings included: Review of the activity calendar for the month of (MONTH) (YEAR) revealed the following: Thursday 11/01/18 9:30 Meal choice (activity staff gets meal choice from each resident) 10:30 Sensory 11:30 News and Views (right before lunch while waiting in the dining room) 1:00 Meal choice 2:30 Missing Letter 4:30 TV Land ( a channel with old shows the residents are familiar with) Friday 11/03/18 9:30 Meal choice 10:00 One to One 11:30 News View a:00 Meal choice 2:30 Let's get physical 4:30 TV Land Saturday 11/03/18 9:30 Meal choice 10:00 One to One 11:30 News & Views 1:00 Meal choice 2:30 Bingo 4:30 Pre-meal social Sunday 11/04/18 9:30 Meal choice 10:30 Sensory 11:30 News and Views 1:00 Meal choice 2:30 Church 4:30 Pre meal social Monday 11/05/18 9:30 Meal choice 10:00 One to One 11:30 News and Views 1:00 Meal choice 2:30 Baptist Ladies group 4:30 TV Land Tuesday 11/06/18 9:30 Meal choice 10:30 Sensory 11:30 News & Views 1:00 Meal choice 2:30 Bingo 6:00 Singing with the Perry's (volunteer group) Wednesday 11/07/18 9:30 Meal choice 10:00 One to One 11:30 News & Views 1:00 Meal choice 2:30 Creative time 4:30 TV Land The activity calendar continues with the same pattern, with a few changes for the remainder of (MONTH) (YEAR). During the month of October, September, (MONTH) of (YEAR) there was only one scheduled evening activity each month Singing with the Perry's. The month of (MONTH) (YEAR) had no scheduled evening activities. The activity calendars did not have weekend activities outside of the activity listings mentioned. A request was made to the activity director on 11/08/18 at 11:40 AM concerning the… | 2020-09-01 |
| 2163 | 2163 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2017-12-06 | 583 | E | 0 | 1 | BX2G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to protect the personal privacy of residents including medical and health information. A resident's medication box and a nurse report sheet was left unattended on medication cart in the hallway. Personal identifiers including residents' names, medications, and other health information were viewable by any person in the hall. This practice affected nine (9) residents. Resident identifiers: #14, #17, #19, #38, #39, #42, #47, #53, and #205. Facility census: 60. Findings include: a) Medication Box An observation during medication administration on 12/05/17 at 9:35 a.m., on the 200 Hall, revealed Resident #53's medication box for eye drops was left on top of the medication cart in the hallway. The medication cart was unattended. The medication box for Resident #53 contained the following information: --Resident's name --Medication prescribed --Physician's name b) Nurse Report Sheet An observation during medication administration on 12/05/17 at 9:35 a.m., on the 200 Hall, revealed a Nurse Report Sheet was left on top of the medication cart. The Nurse Report Sheet contained the following: --Resident #14-Resident's name, room number, and [MEDICATION NAME] 4:15 am. --Resident #17-Resident's name, room number, and fall, evening, witness. --Resident #19-Resident's name, room number, and no caffeine. --Resident #38-Resident's name, room number, and increased [MEDICATION NAME]-redraw-Thursday. --Resident #39-Resident's name, room number, and 3:30 am-Tylenol. --Resident #42-Resident's name, room number, and 2:15 Neb tx. --Resident #47-Resident's name, room number, and change R heel-skin prep. --Resident #205-Resident's name, room number, and Dr. Safely, p/u 12. An interview with Licensed Practical Nurse (LPN) #18 on 12/05/17 at 9:45 a.m. revealed the LPN should have not left the Nurse Report Sheet and medication box unattended on the medication cart. The LPN stated she knows bette… | 2020-09-01 |
| 2164 | 2164 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2017-12-06 | 584 | D | 0 | 1 | BX2G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide maintenance services for one (1) of twenty seven (27) rooms observed during the Long Term Care Survey Process. The issue identified included a resident's bathroom with paint missing and hanging from the ceiling. Room identifier: #103. Facility census: 60. Findings include: a) room [ROOM NUMBER] The following observation was made on 12/04/17: --room [ROOM NUMBER]-The bathroom ceiling above the sink had paint missing as well as several large paint chips hanging from the ceiling. An interview with the facility's Administrator on 12/06/17 at 9:30 a.m. revealed the Administrator was not aware of the paint falling from the bathroom ceiling. The Administrator stated he would ensure that maintenance fixed the ceiling immediately. | 2020-09-01 |
| 2165 | 2165 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2017-12-06 | 689 | E | 0 | 1 | BX2G11 | Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Chemical substances, shaving razors, and skin treatments, were unsecured and accessible to residents in the 100 and 200 Hall Shower Rooms. This practice had the potential to affect more than a limited number of residents. Facility census: 60. Findings include: a) 100 Hall Shower Room A tour of the 100 Hall, on 12/04/17 at 11:15 a.m., revealed the Shower Room did not have a lock on the door. The room contained the following items: --Two (2) containers of Medspa Shave Cream with the warning Keep out of reach of children. --One (1) container of Gold Bond Body Powder with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center. b) 200 Hall Shower Room A tour of the 200 Hall Shower Room, on 12/04/17 at 11:25 a.m., revealed the Shower Room did not have a lock on the door. The room contained the following items: --One (1)-container of Soothe and Cool Inzo Barrier Cream with 5% Dimethicone with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center. --One (1)-container of Medline Remedy Phytoplex Z Guard Paste with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Contact Center. --Two (2) containers of Medspa Shave Cream with the warning Keep out of reach of children. --Fifteen (15) uncapped razors in an unlocked biohazard infectious waste container. --Eight (8) capped razors in a bucket. An interview with the Director of Nursing (DON) on 12/04/17 at 11:30 a.m. revealed the shower rooms are never locked. The DON stated the razors and other care products should be secured away from the residents. The DON stated I had no idea the items in the shower rooms were there. | 2020-09-01 |
| 2166 | 2166 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2017-12-06 | 761 | E | 0 | 1 | BX2G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure expired medication and enteral feedings were removed after the expiration date. Twenty-two cans of enteral feeding supplies and a bottle of multivitamins were found expired on the shelves in the medication storage room. This had the potential to affect more than an isolated number of residents. Facility census: 60. Findings include: a) On [DATE] at 2:32 p.m. observations of the medication storage room revealed one bottle of stock multivitamins (Ondra One daily) had an expiration of date of (MONTH) (YEAR). The storage room also contained 20 cans of Glucerna and two (2) cans of Two Cal which had an expiration date of (MONTH) (YEAR). On [DATE] at 12:00 p.m. Center Nursing Executive Sr #13 confirmed the enteral feeding and multivitamins should have been discarded at the time they expired. | 2020-09-01 |
| 2167 | 2167 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2017-12-06 | 880 | E | 0 | 1 | BX2G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 to the extent possible. During a random observation, a nurse was observed placing a bottle of lancets and a resident-shared glucometer directly onto a resident's overbed tray with no barrier, and in so doing contaminated the surface of the lancet bottle and glucometer. Prior to surveyor intervention, the nurse failed to disinfect the contaminated bottle of unused lancets before attempting to place the bottle back into the medication cart where some residents' medications were stored. Also, the nurse contaminated the clean surface of the medication cart by placing the contaminated glucometer and bottle of unused lancets directly onto the work area surface of the medication cart. This had the potential to affect more than a limited number of residents on the 100 hall. Facility census: 60. Findings include: a) On 12/04/17 at 12:24 p.m., Licensed Nurse #18 checked the blood sugar of a resident who received [MEDICAL TREATMENT] treatments three (3) times weekly. During the process, she laid the glucometer and a small bottle of unused lancets directly onto the resident's overbed tray without providing a barrier of any type. This contaminated the surface of the bottom of the glucometer and the outside of the bottle of unused lancets. After the blood sugar was completed, the nurse wiped the glucometer with an alcohol wipe, then left the resident's room. The nurse was asked if all of the residents used the same glucometer, and if all the residents used lancets from the bottle she held in her hand. The nurse replied that all of the diabetic residents on the 100 hall shared the same glucometer and the same bottle of unused lancets. She said they disinfect the glucometer with Micro-Kill bleach wipes after every patient use. She then entered the medicati… | 2020-09-01 |
| 4390 | 4390 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-11-09 | 241 | D | 0 | 1 | B8Y111 | Based on observation and staff interview, the facility failed to ensure the dignity of residents during the dining experience. This was evident for two (2) random observations. Resident #27 was fed by nursing staff while the staff member stood over her. The same was true for resident #52. Both residents were cognitively and physically impaired, and unable to feed themselves. Resident identifiers: #27, #52. Facility census: 59. Findings include: a) Resident #27 On 10/31/16 at 12:22 a.m., an observation revealed Resident #52 lying in her bed. Nurse Aide (NA) #76 stood by the resident's bed, and spoon fed her pureed meal. She stood over the resident through the entire meal. The resident was unable to be interviewed due to cognitive impairment. Review of the quarterly minimum data set (MDS), with assessment reference date (ARD) 08/03/16, revealed moderate cognitive impairment. She required extensive assistance of two (2) for bed mobility, and extensive assistance for eating. b) Resident #52 On 11/01/16 at 12:25 p.m., Registered Nurse #35 stood by the resident's bed, and spoon fed her meal. She stood over the resident while she fed her, rather than obtaining a chair and sitting down by the resident in a more dignified manner. The resident was unable to be interviewed due to cognitive impairment. Review of the quarterly minimum data set, (MDS) with assessment reference date (ARD) of 10/03/16, revealed severe cognitive impairment. She was totally dependent on staff for eating her mechanically altered diet. On 11/01/16 at 5:15 p.m., an interview was conducted with the director of nursing (DON) to ascertain if she felt the practice of standing over residents while feeding them was an acceptable standard at this facility. She replied in the negative. She said it is their practice at the facility to sit down beside the residents while feeding them, rather than standing over them. She said that standing over a resident while feeding them is undignified. She said she would speak to nursing staff about this finding. On 11/01/1… | 2019-11-01 |
| 4391 | 4391 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-11-09 | 246 | D | 0 | 1 | B8Y111 | Based on observation, staff and resident interview, it was determined the facility failed to provide Resident #24 an alternative to call for assistance due to the inability to always push the call light button. This practice affected one (1) of thirty (30) Stage 1 sampled residents for reasonable accommodation of individual needs. Resident identifier: #24. Facility census: 59. Findings include: a) Resident #24 When Resident #24 was asked, during Stage one (1) of the Quality Indicator Survey(QIS), to push the call bell button to test to see if it was functioning properly, Resident #24 replied, If I can. When asked what she meant by, If I can, the resident replied, I can't always push the button to make the call light work. Sometimes I just can't. The resident was asked what she did when she was unable to push the call light button. The resident replied, I get my roommate to push her call light. During the time of the interview the resident was alone in her room, the roommate was not present. The resident was then asked, What do you do when your roommate is not here? The resident replied, I holler for staff or just wait until somebody comes by. When asked if the resident had ever told any staff she had a problem pushing the call light button, the resident replied, Yes, several times. Resident #24 was unable to give any names of the staff she had told. An interview with Licensed Practical Nurse (LPN) #52, on 10/31/16 at 4:25 p.m., revealed Resident #24 had talked her about having difficulties pushing her call light button. LPN #52 stated, It has been a while ago since she talked to me about it. I did not know it was still a recent problem. The Director of Nursing (DON) was notified about the issue and was informed that the resident had informed the facility staff that she was unable at times to push the call light. The facility promptly provided a touch pad call bell for the resident. This occurred after surveyor intervention and after the facility confirmed the problem with Resident #24. | 2019-11-01 |
| 4392 | 4392 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-11-09 | 280 | D | 0 | 1 | B8Y111 | Based on observation, record review, and staff interview the facility failed to revise the care plan to reflect the resident's current status. This failed practice had the potential to affect one (1) of twenty one (21) sampled residents. Resident identifier: # 57. Facility census: 59. Findings include: a) Resident #57 Interview with Nurse Aide (NA #50), on 11/02/16 at 11:05 a.m., revealed Resident #57 required total care and was dependent for activities of daily living (ADL). NA #50 said, We reposition her (Resident #57) every two (2) hours and check her briefs and change her. We use to get her up to the toilet, but not for a good while, she's not able. On 11/02/16 at 1:04 p.m., review of quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/16/16 revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe mental status impairment. Resident #57's MDS showed Resident #57 was dependent for care, including toileting, bathing, personal hygiene, and is always incontinent of bowel and bladder and is not on a toileting program. Review of the care plan, on 11/07/16 at 3:47 p.m., revealed a focus area which stated, Resident requires a limited assist to extensive at times with ADLs. She does have cognitive loss secondary to dementia. Resident does transfer and toilet herself independently at times . Other focus areas noted were, Resident is occasional incontinent of urine with potential for improved control or management of urinary elimination, and, Resident is occasional incontinent of bowel with potential for improved control or management of bowel elimination. Interventions included: --Assist resident to toilet at scheduled times --Discuss and plan voiding schedule with resident --Maximize physical activity to enhance general muscle tone, functioning of lower GI (gastrointestinal) tract, and ability to mobilize to bathroom in response to urge to defecate On 11/07/16 at 4:29 p.m., an interview with Registered Nurse (RN ) #38, revealed resident was dependent for care. RN #38 a… | 2019-11-01 |
| 4393 | 4393 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-11-09 | 309 | D | 0 | 1 | B8Y111 | Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to ensure residents attained or maintained good body alignment and comfortable positioning while the resident was lying in bed. This was true for one (1) of twenty one (21) sampled residents. Resident identifier: #57. Facility census: 59 Findings include: a) Resident #57 Observation of Resident #57, on 11/02/16 at 11:05 a.m., revealed she was lying on her bed in poor body alignment. After Nurse Aide (NA) #50 completed her peri-care, she assisted and positioned Resident #57 to lie on the resident's back. Both of the resident's legs were observed with the knees bent in an upright position perpendicular to the bed, with the soles of both feet laying flush on the bed. The resident stated she was cold, and NA #50 covered Resident #57 with a blanket. When the blanket was placed on the resident, her bent upright legs started to tilt to the right and the resident grimaced. NA #50 started to leave, the surveyor asked NA #50 if she would look at the resident and see if there were any issues. NA #50 acknowledged, after surveyor intervention, that Resident #57 needed a pillow to support her legs, and proceeded to reposition the resident with a pillow supporting both legs. On 11/02/16 at 1:04 p.m., review of quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/16/16 revealed a Brief Interview for Mental Status (BIMs) score of 3 indicating severe mental status impairment. Resident #57's current MDS showed resident was dependent for care, including toileting, bathing, and personal hygiene. Review of the care plan, on 11/07/16 at 3:47 p.m., revealed she was to maintain good body alignment and she was at risk for alterations in comfort with an intervention to assist resident to a position of comfort, utilizing pillows as appropriate positioning device. | 2019-11-01 |
| 4394 | 4394 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-11-09 | 431 | E | 0 | 1 | B8Y111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of purified protein derivative (PPD), a medication injected beneath the skin to aid in the detection of exposure to [DIAGNOSES REDACTED], was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication, and had the potential to affect any resident who might receive an injection of medication/serum from this vial. Facility census: 59. Findings include: a) On 11/01/16 at 1:52 p.m., the facility's only medication room refrigerator was observed, accompanied by licensed practical nurse #41. An opened and partially used multi-dose vial of Aplisol purified protein derivative (PPD) was stored in the medication room refrigerator. When full, this vial held ten (10) doses. The vial was about half full, indicating that approximately five (5) doses remained. The vial contained no date to indicate the time interval since it was first opened. Nurse #41 said she believed the vial could only be used for thirty (30) days after opening it. She said since the vial was undated, it could not be determined when it was first opened, or when the thirty (30) day period was over. She disposed of the vial immediately. Review of the facility's policy entitled 3.8 Accessing a Multi-Dose Vial, with revision date 07/01/12, stated under section 7 that multi-dose vials are to be discarded if open and undated. It also stated that multi-dose vials are to be discarded within twenty-eight (28) days of opening, or as specified by the manufacturer for an open vial. On 11/01/16 at 5:15 p.m., the director of nursing (DON) was interviewed. She said that licensed nurses are supposed to date multi-dose vials when initially opened, then dispose of the vial thirty (30) days after first opened. She agreed that their policy was not followed in th… | 2019-11-01 |
| 4395 | 4395 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-11-09 | 441 | E | 0 | 1 | B8Y111 | Based on observation and staff interview the facility failed to provide a safe and sanitary environment, to help prevent the development and transmission of disease and infection. Resident care equipment was stored improperly in two (2) separate instances. Two (2) hoyer lift cloth slings were observed lying directly on an unclean surface, and a plastic cart used to store resident's personal care items inside its storage drawers, was observed under a sink resting directly on the floor. A breach in infection control principal and practices was also observed while staff was providing peri-care for Resident #57. These practices had the potential effect more than a limited number of residents in the facility. Resident identifier: #57. Facility census: 59 Findings include: a) Hoyer lift slings On Unit 1, during the initial tour on 10/31/16, hoyer lift cloth slings were observed hanging on hooks mounted to the wall beside the hoyer lifts. Each cloth sling was meant to be hung by the sling's strap and buckles on both sides of the sling, leaving the slings hanging half way down the wall. Two (2) hoyer lift cloth slings were observed with only one side of the slings hung on a hook. The two (2) slings hung by only one side, dangled all the way down the wall, leaving their other side's buckles, straps, and area of the cloth lying directly on the floor. On 10/31/16 at 11:40 a.m., Registered Nurse Unit 1 Manager (RN) #38, accompanied this surveyor and observed the two (2) hoyer lift cloth slings resting on the floor. RN #38 agreed this was an infection control issue, and the slings were not supposed to be on the floor. RN #38 stated, I will have them removed, and have to have them washed. b) Storage drawers On 11/02/16 at 11:05 a.m., a plastic cart, used to store resident's personal care items inside its storage drawers, was observed under a sink resting directly on the floor in Resident #57 room. An interview with Registered Nurse/Nurse Practice Educator/Infection Control (RN #29), on 11/02/16 at 11:18 a.m., verified the plas… | 2019-11-01 |
| 5005 | 5005 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 165 | D | 1 | 0 | 06GH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, family interview, staff interview, medical record review, and facility record review, the facility failed to ensure the rights of one (1) of six (6) sample residents to voice grievances without reprisal. Resident #33 related a Licensed Practical Nurse (LPN) and a Nurse Aide (NA) retaliated against the resident after a complaint was initiated over the administration of a medication. The nurse confronted the resident and the nurse aide did not assist with a transfer from chair to bed, and required the resident remain in his chair for over two (2) hours after dinner. Resident identifier: #33. Facility census: 57. Findings include: a) Resident #33 During an interview with Resident #33 and his wife on 04/18/16 from 4:04 p.m. to 4:45 p.m., Resident #33's wife said a complaint had been initiated about the administration of [MEDICATION NAME], but it was a misunderstanding. According to the resident's wife, the resident thought he received Tylenol instead of [MEDICATION NAME]. Resident #33 agreed with his wife's statement. Resident #33's wife related Licensed Practical Nurse (LPN) #20 came to the resident's room, and said they needed to talk. The nurse told Resident #33 She did not appreciate him reporting her to the administrator. The resident's wife indicated the nurse had said they had gotten her in trouble. Resident #33 and his wife also related LPN #20 had said to him that she had her medication cart at his door every day at 4:00 p.m. They also stated she asked him, Do you know what this is? and he had answered, Tylenol?, and the nurse had responded, No, it's (it is) your [MEDICATION NAME]. Resident #33's wife related the Center Nurse Executive (CNE) had entered the room and spoken with LPN #20, and they exited the room. Resident #33 related she had apologized to the nurse for the misunderstanding, and had called the facility and offered her apologies. Resident #33 related the day after the incident, he was in his c… | 2019-04-01 |
| 5006 | 5006 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 225 | D | 1 | 0 | 06GH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, family interview, staff interview, facility record review, review of facility policies, and medical record review, the facility failed to ensure all alleged violations concerning mistreatment, abuse, and neglect were reported immediately to the administrator and/or to State agencies. Additionally, the facility failed to provide sufficient evidence that all alleged violations were thoroughly and/or investigated timely, and failed to prevent further potential abuse while the investigation was in progress. This practice affected two (2) of three (3) sample residents. Resident identifiers: #33 and #27. Facility census: 57. Findings include: a) Resident #33 During an interview with Resident #33 and his wife, on 04/18/16 from 4:04 p.m. to 4:45 p.m., an inquiry as to whether the resident had experienced abuse or neglect revealed an incident involving the administration of [MEDICATION NAME]. Resident #33's wife recounted an incident on 04/05/16 concerning the administration of [MEDICATION NAME], and how it was actually a misunderstanding. His wife said Resident #33 thought he was receiving Tylenol, but was actually receiving [MEDICATION NAME]. She related Licensed Practical Nurse (LPN) #60 came to the room and said, We need to talk. Resident #33 and his wife related the nurse told the resident that she did not appreciate him reporting her to the administrator. His wife indicated the nurse spoke in an angry and confrontational manner and that LPN #60 thought Resident #33 should have known what he was receiving. She said the nurse came in again the next evening and asked, Do you know what this is? The resident had replied, Tylenol? and the nurse responded, No it's (it is) your [MEDICATION NAME]. The resident related his wife had apologized to LPN #60 for the misunderstanding. During the interview on 04/18/16, Resident #33's wife said she called her husband on 04/06/16, the evening after the confrontation with LPN #60. She… | 2019-04-01 |
| 5007 | 5007 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 226 | D | 1 | 0 | 06GH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, facility record review, and policy review, the facility failed to implement its written policies prohibiting mistreatment, neglect, and abuse of residents. The facility failed to conduct a thorough investigation, failed to report occurrences, and failed to ensure residents were protected from harm during an investigation. This affected two (2) of three (3) residents reviewed for allegations of abuse. Resident identifiers: #33 and #27. Facility census: 57 Findings include: a) Resident #33 During an interview with Resident #33 and his wife, on 04/18/16 from 4:04 p.m. to 4:45 p.m., an inquiry as to whether the resident had experienced abuse or neglect, revealed an incident involving the administration of [MEDICATION NAME]. Resident #33's wife recounted an incident on 04/05/16, concerning the administration of [MEDICATION NAME], and how it was actually a misunderstanding. His wife said Resident #33 thought he was receiving Tylenol, but was actually receiving [MEDICATION NAME]. She related Licensed Practical Nurse (LPN) #60 came to the room and said, We need to talk. Resident #33 and his wife related the nurse told the resident that she did not appreciate him reporting her to the administrator. His wife indicated the nurse spoke in an angry and confrontational manner and that LPN #60 thought Resident #33 should have known what he was receiving. She said the nurse came in again the next evening and asked, Do you know what this is? The resident had replied, Tylenol? and the nurse responded, No it's (it is) your [MEDICATION NAME]. The resident related his wife had apologized to LPN #60 for the misunderstanding. During the interview, on 04/18/16, Resident #33's wife said she called her husband on 04/06/16, the evening after the confrontation with LPN #60. She related the resident informed her that he was up in his chair and they would not put him to bed. The resident had told her LPN #60's husband, Nurse… | 2019-04-01 |
| 5008 | 5008 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 253 | E | 1 | 0 | 06GH11 | > Based on observation, resident interview, staff interview, family interview, facility record review, and policy review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior. Curtain tracks were coated with dust/grime, garbage was overflowing on to the resident's floor, and floors were dirty. This practice affected eight (8) residents. Resident identifier: #33. Rooms: 200, 201, 204, and 208. Facility census: 57. Findings include: a) Resident #33 1. During an interview and observation on 04/18/16 at 4:04 p.m., Resident #33 related the curtain track over his bed was filthy. Observation revealed a layer of dust/grime along the track. The resident and his wife pointed to a dark pink mark on the wall/window border about midway down the window area. Resident #33 also related the floor on the right side of his bed, between the bed and the window was dirty, and pointed to dark brown/black areas. The resident said the areas had been there for at least three (3) days. Resident #33 and his wife stated staff only mopped every two (2) to three (3) days. She related staff buffed, but only from the entry across the room and bathroom. Another observation on 04/19/16 at 9:05 a.m., revealed the dark areas on the floor on the far side of the bed by the window remained. An interview with the housekeeping supervisor, on 04/19/16 at 10:50 a.m., revealed she only had two (2) housekeeping staff, one (1) from 8:00 a.m. to 4:00 p.m. and one (1) from 11:00 a.m. to 7:00 p.m. She said the housekeeper who came on duty at 11:00 a.m., was the one who completed the detailed cleaning of the rooms, and upon completion, she assisted with cleaning other rooms. During rounds with the supervisor she confirmed the floor area on the right side of Resident #33's bed was dirty, and the curtain guide over the bed was coated with grime and dust balls. 2. While reviewing information about the admission process and residents rights with Resident #33 and his wife on 04/20/16 at 1:30 p.m., his… | 2019-04-01 |
| 5388 | 5388 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 272 | D | 0 | 1 | ZG3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to conduct accurate comprehensive assessments for one (1) of twenty-three (23) Stage 2 sample residents. The comprehensive assessment for Resident #47 did not accurately reflect the resident's dental status. Resident identifiers: #47. Facility census: 53. Findings include: a) Resident #47 On 08/25/15 at 8:47 a.m., an observation of Resident #47 revealed most of the residents teeth were missing and the remaining teeth were carious. A review of the medical record, on 08/27/15 at 11:18 a.m., revealed Resident #47 was admitted on [DATE]. [DIAGNOSES REDACTED]. A review of the annual minimum data set (MDS) on 08/27/15 at 1:07 p.m., with an assessment review date (ARD) of 03/18/15, revealed, Section L0200 (Oral/Dental Status) (Z), had been marked as none of the above. Section L0200 (D) stated (obvious or likely cavity or broken natural teeth), which accurately reflected the oral/dental status for Resident #47. However, this selection was not marked. The concurrent review of the significant change MDS, with an ARD of 04/15/15, revealed Section L0200 (Z) marked as none of the above. This again was an inaccurate assessment of Resident #47. In an interview with the MDS coordinator and director of nursing (DON), on 08/27/15 at 1:44 p.m., revealed they were in agreement the oral/dental status, on the 03/18/15 and 04/15/15 MDSs, were incorrectly coded and would submit an immediate correction. | 2019-01-01 |
| 5389 | 5389 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 278 | D | 0 | 1 | ZG3O11 | **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 23 residents, had an assessment completed that accurately reflected their status. Resident #18's assessment did not reflect a diganosis of [MEDICAL CONDITION] disorder. Resident identifier: #18. Facility census: 53. Findings include: a) Resident #18 On 09/01/15 at 10:21 a.m., a review, of the medical record for Resident #18, revealed this resident was readmitted from an acute psychiatric admission on 07/16/15. An new [DIAGNOSES REDACTED]. A concurrent review of the five (5) day MDS, with an ARD of 07/23/15, the fourteen (14) day MDS, with an ARD of 07/28/15 and the quarterly MDS, with an ARD of 08/01/15 did not reflect the [DIAGNOSES REDACTED]. An interview with the MDS coordinator, on 09/01/15 at 10:48 a.m., revealed she was in agreement the MDSs had not been coded to reflect the [DIAGNOSES REDACTED]. | 2019-01-01 |
| 5390 | 5390 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 279 | D | 0 | 1 | ZG3O11 | **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 to meet the needs for one (1) of twenty-three (23) Stage 2 residents. Resident #9, a [MEDICAL TREATMENT] patient did not have a care plan that described the services or interventions needed to attain or maintain the resident's highest practicable physical needs. Resident identifier: #9. Facility census: 53. Findings include: a) Resident #9 Review of the medical record, on 08/27/15 at 12:00 p.m., revealed this [AGE] year old resident came to the facility on [DATE]. She received [MEDICAL TREATMENT] treatments at a [MEDICAL TREATMENT] center three (3) times per week. Review of the care plan at this time found a focus on complications related to [MEDICAL TREATMENT]. One (1) intervention directed to monitor blood pressure and pulses, and report to the physician as indicated. However, the care plan did not offer directives as to when and how often to check vital signs, nor the parameter the facility desired for the vital signs. On 08/27/15 at 3:00 p.m., during an interview the director of nursing (DON) revealed it was her expectation that residents receiving [MEDICAL TREATMENT] treatments have their vital signs assessed before going out to [MEDICAL TREATMENT], and immediately upon their return to the facility following a [MEDICAL TREATMENT] treatment. She agreed that the care plan did not contain those directives, and it did not include parameters for the vital signs. | 2019-01-01 |
| 5391 | 5391 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 280 | D | 0 | 1 | ZG3O11 | Based on observation, resident interview, medical record review and staff interview the facility failed to revise the care plan for one (1) of 23 residents. Resident #59 ' s care plan was not revised to reflect the resident's status regarding the use of a hand splint. Resident identifier: #59. Facility census: 53. Findings include: a) Resident #59 On 08/25/15 at 12:51 p.m., an observation of Resident #59 revealed he had a bed control remote in his left hand. Medical record review, on 08/25/15 at 1:00 p.m., a care plan intervention with an initiated date of 04/28/14 of Left hand splint from morning ADL's (activities of daily living) and remove by evening meal. At 1:45 p.m., on 08/26/15 during an interview, Resident #59 stated he does not wear the left hand splint during the day or night. Instead, he demonstrated how he holds the remote in the palm of his left hand, which he stated he has done for several months. | 2019-01-01 |
| 5392 | 5392 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 282 | D | 0 | 1 | ZG3O11 | **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-three (23) Stage 2 sampled residents. The care plan directed nursing staff to administer a medicated rectal suppository every night at bedtime, and after each bowel movement. Nursing staff failed to follow the care plan, by not administering the rectal suppository as ordered by the physician. Resident identifier: #36. Facility census: 53. Findings include: a) Resident #36 Review of the medical record, on 08/25/15 at 4:00 p.m., found [DIAGNOSES REDACTED]. A signed physician's orders [REDACTED]. The revised care plan, dated 08/11/15, read the same. The Medication Administration Record [REDACTED]. The activities of daily living (ADL) and medical record review found the resident did not receive a rectal suppository, or have a documented refusal, following twenty-five (25) bowel movements between 08/7/15 and 08/25/15. On 08/25/15 at 5:00 p.m., the director of nursing agreed that the signed physician's orders [REDACTED]. She acknowledged the care plan was not followed, as the resident received only one (1) rectal suppository and had only two (2) documented refusals between 08/07/15 and 08/24/15. | 2019-01-01 |
| 5393 | 5393 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 309 | D | 0 | 1 | ZG3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of twenty-three (23) Stage 2 sampled residents. Resident #36 did not receive medicated rectal suppositories as ordered by the physician. Resident #9 did not receive vital signs assessment timely upon her return to the facility following a [MEDICAL TREATMENT] treatment. Resident identifiers: #36 and #9. Facility census: 53. Findings include: a) Resident #36 Review of the medical record, on 08/25/15 at 4:00 p.m., found [DIAGNOSES REDACTED]. A signed physician's orders [REDACTED]. Nursing staff documented family notification of this new physician's orders [REDACTED].>The Medication Administration Record [REDACTED]. Review of the medical record and the activities of daily living (ADL) record, found the resident did not receive a rectal suppository, or have a documented refusal, following any of the twenty-five (25) documented bowel movements between 08/07/15 and 08/25/15. During an interview with the director of nursing (DON) on 08/25/15 at 5:00 p.m., she acknowledged that the signed physician's orders [REDACTED]. She agreed that it appeared the resident received only one (1) rectal suppository and had only two (2) documented refusals of the rectal suppository between 08/07/15 and 08/24/15. The DON acknowledged that the order was written in a confusing manner on the MAR, which caused the resident not to receive the prescribed medication. On 08/26/15 at 8:30 a.m., the DON said she spoke with the nurse who wrote the original order for the [MEDICATION NAME] suppositories. The DON said the nurse did not mean to write it that way. The DON said nursing staff contacted the physician this morning, and received a clarification for the [MEDICATION NAME] order. The physician's orders [REDACTED]. b) Resident #9 Review of th… | 2019-01-01 |
| 5394 | 5394 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 332 | D | 0 | 1 | ZG3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, medical record review, manufacturer's instructions, and policy and procedure review, the facility failed to ensure it had a medication error rate of less than five percent (5%). Resident #61 was administered two (2) different inhalers without waiting at least one (1) minute between the different inhalers. Resident #18 was administered an inhaler without waiting between puffs. Medication errors were identified for two (2) of six (6) residents observed for medication pass. There were three (3) medication errors in forty-two (42) opportunities for error, resulting in a medication error rate of 7.14% (per cent). Resident identifiers: #61 and #18. Facility census: 53. Findings include: a) Resident #61 On 08/26/15 at 8:57 a.m., during a medication observation with a Licensed Practical Nurse (LPN)#23 revealed this employee prepared [MEDICATION NAME] Diskus and [MEDICATION NAME] hand held inhaler for Resident #61. These medications were ordered for [MEDICAL CONDITION]. LPN #23 placed each inhaler on the overbed table, Resident #61 picked up the [MEDICATION NAME] inhaler and inhaled one (1) puff and proceeded to pick up the [MEDICATION NAME] Diskus and inhale one (1) puff. LPN #23 then gave Resident #61 a plastic medication cup which contained multiple medications. After exiting Resident #61's room, in a discussion with LPN #23 regarding Resident #61 administering the inhalers, she stated this is the way she always does it. When asked about the pharmacy instructions on both inhaler boxes stating, Wait at least 1 minute between different inhaled medications. Rinse mouth after each use. she stated she did not know this and had not read the instructions on the boxes, and this is the way she does this. A review of the physician orders, on 08/26/15 at 1:33 p.m., revealed orders, dated 06/18/15, for [MEDICATION NAME] Diskus Aerosol Powder Breath Activated 250-50 mcg/dose ([MEDICATION NAME]-Salmeterol ( 1 inhalation in… | 2019-01-01 |
| 5395 | 5395 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 441 | F | 0 | 1 | ZG3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, policy and procedure review, and infection control surveillance record review; the facility failed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of disease and infection. The infection- control surveillance records were not completed and maintained in their entirety. A bedpan was stored improperly in a bathroom shared by two (2) residents. Nursing staff administered medication to a resident after the medication fell on the top of an unclean medication cart. In addition, two (2) of two (2) medication carts were observed to be dirty with dust and debris. These practices had the potential to affect all residents in the facility. Resident identifiers: #93, #100, #61. Facility census: 53. Findings include: a) Infection control log surveillance records Review of the infection control surveillance records was completed on 08/31/15 at 2:00 p.m. (Surveillance refers to the ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks to try to reduce morbidity and mortality and to improve resident health status.) Findings were as follows: 1. The (MONTH) (YEAR) infection control monthly line listing contained the names of twelve (12) residents with newly developed infections. None of the twelve residents with newly developed infections were documented as having had resolution of the infections. Nine (9) residents lacked an admitted . Eight (8) residents had no recorded dates of onset of the infections. Nine (9) residents had no room numbers recorded. Eleven (11) infections were not differentiated as to whether they were healthcare acquired or community acquired. Eight (8) cultures did not include the dates of the cultures. All five (5) of the urine cultures lacked the results of the organisms, which grew. In addition, the start dates for eight (8) of the antibiotics p… | 2019-01-01 |
| 5396 | 5396 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2015-09-02 | 520 | F | 0 | 1 | ZG3O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, policy and procedure review, infection control program review; the quality assessment and assurance (QAA) committee failed to identify and or act upon a quality deficiency within the facility's operations of which it did have or should have had knowledge. Infection Control: The QA & A committee failed to identify the need to develop and implement processes to implement an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infections within the facility. This had the potentital to affect all residents in the facility. Facility census: 53. Findings include: a) Infection control log surveillance records Review of the infection control surveillance records was completed on 08/31/15 at 2:00 p.m. (Surveillance refers to the ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks to try to reduce morbidity and mortality and to improve resident health status.) Findings were as follows: 1. The (MONTH) (YEAR) infection control monthly line listing contained the names of twelve (12) residents with newly developed infections. None of the twelve residents with newly developed infections was documented as having had resolution of the infections. Nine (9) residents lacked an admitted . Eight (8) residents had no recorded dates of onset of the infections. Nine (9) residents had no room numbers recorded. Eleven (11) infections were not differentiated as to whether they were healthcare acquired or community acquired. Eight (8) cultures did not include the dates of the cultures. All five (5) of the urine cultures lacked the results of the organisms, which grew. In addition the start dates for eight (8) of the antibiotics prescribed were not documented. 2. Review of the infection control monthly line listings for (MONTH) through (MONTH) found similar results. Many… | 2019-01-01 |
| 6530 | 6530 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2014-06-04 | 253 | E | 0 | 1 | N2BW11 | Based on observation and staff interview, it was determined the facility failed to ensure effective maintenance services. The physical environment was not in good repair. The walls had holes, the cove base was loose and hanging from the walls in resident's rooms, and a toilet seat was missing a seat bumper in a resident's bathroom. This practice affected seven (7) of twenty (20) rooms observed. This practice had the potential to affect more than an isolated number of residents. Room numbers of affected rooms: #105, #107, #109, #114, #206, #213, and #215. Facility census: 54. Findings include: a) Observations of the facility during Stage I and Stage II of the Quality Indicator Survey revealed the following rooms had environmental concerns: 1) Room #105 - The wall under the television had several holes. 2) Room #107 - The cove base was loose and hanging from the wall. 3) Room #109 - The cove base was loose and hanging from the wall. 4) Room #114 - The wall behind bed B had several holes. 5) Room #206 - The cove base was loose and hanging from the wall. 6) Room #213 - The toilet seat in the bathroom was missing a seat bumper. 7) Room #215 - The cove base was loose and hanging from the wall. | 2018-02-01 |
| 6531 | 6531 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2014-06-04 | 323 | E | 0 | 1 | N2BW11 | Based on observation and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control. The soiled utility closet on the 100 Hall was unlocked on several occasions. The closet contained cleaning supplies, soiled linens, sharps containers, laboratory supplies, and trash. This practice had the potential to affect more than an isolated number of residents. Facility census: 54. Findings include: a) During the initial tour of the facility on 05/27/14 at 11:30 a.m., the soiled utility room on the 100 Hall was observed unlocked. Employee #53 (Nursing Assistant-NA) witnessed the door unlocked and stated the door should be locked at all times. The NA stated she would ensure the door was locked. The room contained cleaning supplies, soiled linens, sharps containers, laboratory supplies, and trash. An observation on 05/27/14 at 12:15 p.m. revealed the soiled utility room on the 100 Hall was again unlocked. Employee #53 (NA) witnessed the door unlocked and stated she was not sure why the door was not locking, but had informed the maintenance department to look at the door. An interview with Employee #79 (Maintenance Director), on 06/04/14 at 10:00 a.m., revealed the soiled utility room doors were to be locked at all times. The maintenance director stated the door was unlocked on 05/27/14 because someone had accidentally unlocked the door causing it not to lock when shut. | 2018-02-01 |
| 6532 | 6532 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2014-06-04 | 431 | E | 0 | 1 | N2BW11 | Based on observation, staff interview, policy review, and information obtained from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure the safe administration of medications. Opened vials of medications were not labeled with the dates they were opened for use. This date is essential to ensure the medications were not used beyond their safe and/or effective dates after opening. This practice had the potential to affect more than an isolated number of residents. Facility census: 54. Findings include: a) On 06/02/14 at 1:10 p.m., observation of the medication storage area behind the nursing desk was completed with Employee #33, the Director of Nursing (DON), and Employee #43, a Licensed Practical Nurse. Novolog 70/30, Lantus, and two (2) vials of Tuberculin purified protein had no dates indicating when they were opened. b) During an interview with the DON, at 11:15 a.m. on 06/04/14, she agreed medications were to be labeled and dated according to common nursing and pharmacy standards of practice. Facility policies were provided by the DON on 06/04/14 at 12:55 p.m. The facility used the consulting pharmacy recommendations which stated, All vials should be dated when opened and discarded 28 days after opening (except for Levemir (insulin detemir), Novolin R, Novolin N, and Novolin 70/30 which can be used up to 42 days after opening and Humulin which can be used up to 31 days after opening). Other multiple-dose vials for injection should be dated when opened and discarded after 28 days or in accordance with the manufacturer's recommendation. On 06/04/14 at 11:15 a.m. the DON confirmed medications were to be labeled and dated in accordance with the consulting pharmacy's recommendations. c) According to the Centers for Disease Control and Prevention(CDC), multi-dose vials of medications which have been opened or accessed should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. | 2018-02-01 |
| 6533 | 6533 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2014-06-04 | 441 | D | 0 | 1 | N2BW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview, the facility failed to provide a safe and sanitary environment. The shower rooms on the 100 and 200 Halls contained soiled linens, gloves on the floor, unlabeled clothing, unlabeled grooming products, soiled toilet seats, and a pool of emesis was on the floor. Resident #19's catheter bag was touching the floor, and intravenous (IV) tubing was hanging from the pump and touching the floor in a resident's room. These practices affected four (4) rooms of twenty (20) rooms observed and had the potential to affect more than an isolated number of residents. Affected room identifiers: Shower room-100 Hall, Shower room-200 Hall, #209, #211. Resident identifier: #19. Facility census: 54. Findings include: a) Observations of the facility on 06/02/14 revealed the following infection control concerns: 1) Shower room-100 Hall - The shower room was observed on 06/02/14 at 10:40 a.m. The toilet seat was covered in a brown, foul smelling, substance. There were two gloves, inside-out, on the floor. An unlabeled container of body wash was on the shower chair. 2) Shower room-200 Hall - The shower room was observed on 06/02/14 at 10:50 a.m. There was emesis with intact food (noodles) on the floor. A wet soiled washcloth was on the floor. A pair of unlabeled shoes were in a wheelchair. Employee #32 (Registered Nurse-RN) witnessed both shower rooms on 06/02/14 at 10:50 a.m. The RN stated the shower rooms should never be in their current condition and she would see they were attended to immediately. 3) room [ROOM NUMBER] - An observation of this room was completed on 06/02/14 at 10:55 a.m. Resident #19's catheter bag was touching the floor. Employee #48(Licensed Practical Nurse-LPN) verified this observation. The LPN stated the catheter bags should never be on the floor. 4) room [ROOM NUMBER] - The room was observed on 06/02/14 at 11:00 a.m. The Intravenous (IV) pump in the room had tubing touching the floor. Employee #48… | 2018-02-01 |
| 6534 | 6534 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2014-06-04 | 514 | D | 0 | 1 | N2BW11 | Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure the accuracy of the medical record for one (1) of one (1) resident reviewed for notification of room change. Resident identifier: #77. Facility census: 54. Findings Include: a) Resident #77 While conducting the Stage 1 interview with Resident #77, she stated she had not been informed she would have a new roommate. On 05/28/14 at 11:00 a.m., registered nurse, Employee #35 stated on 05/24/14 she had informed Resident #77 she would receive a new roommate sometime within the next twenty-four hours. Resident #77 received a new roommate on 05/25/14. Review of the medical records found no evidence Resident #77 or Resident #77's medical power of attorney (MPOA) were informed Resident #77 would receive a new roommate. After interviewing Employee #35, she stated she would create a late entry note concerning notification of a new roommate. The note was created. The facility policy and procedures concerning room transfers was received from Employee #35 at 9:50 a.m. on 06/04/14. Section 10 included, All room changes will be documented in a progress note or on the Room Transfer Form and placed in the medical records. | 2018-02-01 |
| 7929 | 7929 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 253 | E | 0 | 1 | K06L11 | Based on observation and staff interview, the facility failed to provide a sanitary, orderly and comfortable environment in resident rooms and facility hallways. Hallways and resident rooms were in poor repair. There were scuffed floors, scraped walls with peeling paint, damaged furniture and curtains were incorrectly hung, creating an unkempt appearance. This had the potential to affect more than a minimal number of residents who resided in the facility. Facility Census: 60. Findings include: a) During the initial tour of the facility, on 12/03/12, at approximately 11:30 a.m., and with further observations during the course of the survey, it was noted the facility hallways and resident rooms were in need of numerous repairs. The following maintenance/housekeeping issues were observed: 1) The hallways on both units in resident living areas were observed to have dark marks running along the walls. 2) Numerous interior and exterior door jams, both entrance doors and bathroom doors, were observed with damage beginning at the floor and proceeding up to approximately eighteen (18) inches from the floor. This damage included multiple dark scratched areas and chipped paint. 3) Dark marks were observed on the floor covering under several resident beds. 4) Many of the walls behind resident beds had peeling drywall and chipped paint. Also, the paint on the walls in resident bathrooms had dark marks. 5) A few bathrooms had towel rack hooks (no rack attached) remaining on the wall and painted over. This left dangerously sharp protrusions from the walls. 6) Many bathroom floor coverings had separation cracks along the walls, making the area unable to be thoroughly cleaned. 7) A large portion of the baseboards in both the resident rooms and resident bathrooms were soiled. 8) Curtains in many resident rooms were not correctly fastened to the rod causing the curtain to hang in an unkempt manner. b) During observation of specific rooms the following were observed: 1) Room 100 had a wall lighting fixture hanging to one side. 2) Ro… | 2016-12-01 |
| 7930 | 7930 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 279 | E | 0 | 1 | K06L11 | **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 develop a comprehensive care plan for five (5) of thirty-one (31) Stage 2 sample residents. The facility failed to develop a care plan related to the use of antidepressants, prevention of contractures, care of pressure ulcers, measurement of urinary output, nausea and vomiting, [MEDICAL CONDITION] reflux disease, and insulin usage. Resident identifiers: #61, #10, #26, #19, and #62. Facility census: 60. Findings include: a) Resident #61 Review of the medical record identified Resident #61 received the antidepressant [MEDICATION NAME] for a [DIAGNOSES REDACTED]. No interventions were in place for staff to follow related to the use of this medication. Additionally, no side effects were identified for staff awareness and observation. This information was confirmed with Employee #36, the director of nursing (DON), on 12/06/12 at 9:14 a.m. b) Resident #62 Medical record review found the resident had a Foley catheter for a [DIAGNOSES REDACTED]. Further review of the physician's orders [REDACTED]. Review of the resident's current care plan, dated 03/30/12, found a problem: Resident requires indwelling Foley catheter due to: stage 3/4 pressure ulcer and quadriparesis at risk for infection. The care plan failed to address measuring urinary output on each shift. The DON was interviewed on 12/06/12 at 10:00 a.m. She acknowledged the care plan did not address the physician's orders [REDACTED]. c) Resident #10 During a stage one interview, on 12/03/12 at 2:53 p.m., the nurse stated Resident #10 had a contracture of the left hand. She related the resident did not wear a splint, and did not receive range of motion services. An observation and interview was completed with Resident #10 on 12/04/12 at 2:18 p.m. Observation of the resident revealed a contracture of her left hand. She stated services were not performed to maintain range of motion. She… | 2016-12-01 |
| 7931 | 7931 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 280 | E | 0 | 1 | K06L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to revise the care plans for four (4) of thirty-one (31) Stage 2 sample residents. The care plans were not revised to reflect changes in lift transfer status, contact precautions, wound status, dental needs, feeding tube removal, and constipation. Resident identifiers: #26, #47, #54 and #66. Facility census: 60 Findings include: a) Resident #26 1) The current care plan was reviewed on 12/04/12 at 3:19 p.m., and again on 12/12/12 at 10:00 a.m. It indicated Resident #26 had decreased ability to self perform activities of daily living (ADLs) secondary to recent hospitalization for repair of a right [MEDICAL CONDITION]. Additionally, the care plan noted she required the assistance of a Total Lift 450/FB/Green sling to get out of bed. Review of the medical record, on 12/05/12, at approximately 4:00 p.m., revealed a physician's orders [REDACTED]. Employee #53, a nursing assistant (NA), was interviewed on 12/06/12 at 8:40 a.m. She stated the resident utilized the sit to stand lift for transfers. The care plan had not been revised to accurately reflect the resident's current needs. 2) A physician's orders [REDACTED]. Additionally, an order dated 12/01/12 was written to maintain contact precautions. The care plan did not contain this information Employee #7, a registered nurse (RN), was interviewed on 12/11/12. She stated the care plan was updated daily utilizing the pink slips from the physician's telephone orders. She reviewed the medical record and compared it to the care plan. The employee acknowledged the care plan did not accurately reflect the physician's orders [REDACTED]. 3) The residents's skin integrity report was reviewed on 12/05/1/2 at approximately 2:00 p.m. The resident had a pressure ulcer which was noted as a deep tissue injury (DTI). The information on the skin integrity reports, dated 11/23/12 and 11/30/12, noted a scab in the center of the woun… | 2016-12-01 |
| 7932 | 7932 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 282 | D | 0 | 1 | K06L11 | **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 related to behavioral flow sheets for one (1) of thirty-one (31) Stage 2 sample residents. Resident identifier: #57. Facility census: 60. Findings Include: a) Resident #57 Review of the resident's current care plan, with a review date of 10/31/12, revealed the problem, Resident at risk for complications related to the use of [MEDICAL CONDITION] drugs antianxiety and antidepressant medications, with a goal of complete behavior monitoring flow sheet. Review of physician orders [REDACTED]. On 12/06/12, at approximately 3:00 p.m., the director of nursing, Employee #36, was interviewed concerning the completion of behavioral flow sheets for Resident #57. Employee #36 stated a behavioral flow sheet was not completed when a resident is on antidepressants. A behavioral flow sheet was not implemented and/or completed as directed by the current care plan. | 2016-12-01 |
| 7933 | 7933 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 309 | E | 0 | 1 | K06L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, staff interview, and policy and procedure review, the facility failed to follow their protocol/policy and procedure for care of a resident receiving [MEDICAL TREATMENT]; failed to follow physician's orders to monitor the urinary output for two (2) residents with indwelling catheters; and failed to provide individualized interventions for one (1) resident with continuing constipation. This was identified for four (4) of thirty-one (31) stage 2 residents during the quality indicator survey (QIS). Resident identifiers: #45, #62, #66, and #74. Facility census: 60. Findings include: a) Resident #45 Medical record review found the resident was diagnosed with [REDACTED]. Review of the facility policy and procedure for [MEDICAL TREATMENT]: Graft and Fistula Care, dated 11/01/07, found the following: .Perform routine observation of access site daily and on return from [MEDICAL TREATMENT] center. Observe for signs of complications including, but not limited to: 2.1 Pain, swelling, redness, odor, hardness, bleeding or drainage at site: 2.2 Color, temperature of extremity; 2.3 Presence of pain or numbness in extremity; 2.4 Pulses distal to access site (fistula/graft); 2.5 Presence of bruit on auscultation with stethoscope; 2.6 Presence of thrill (vibration) by palpation The director of nursing (DON) was interviewed at 12:15 p.m. on 12/10/12. She stated the facility used a weekly [MEDICAL TREATMENT] evaluation tool to document the resident's condition before and after return from the [MEDICAL TREATMENT] center. The weekly [MEDICAL TREATMENT] evaluation tool was reviewed for the months of October and November 2012. Documentation (pre and post [MEDICAL TREATMENT]) was missing from the tool on the following days: 10/06/12 no pre-[MEDICAL TREATMENT] documentation, 10/11/12 no post-[MEDICAL TREATMENT] documentation, 10/18/12 no pre-[MEDICAL TREATMENT] documentation, 10/20/12 no documentation pre or post [MED… | 2016-12-01 |
| 7934 | 7934 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 318 | D | 0 | 1 | K06L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, resident observation, staff interview, and record review, the facility failed to ensure one (1) of three (3) residents sampled for range of motion during Stage two (2) of the survey, received appropriate treatment to increase range of motion or prevent further decrease in range of motion. A resident with a contracture did not receive range of motion services. Resident identifier: #10. Facility census: 60. Findings include: a) Resident #10 A stage one staff interview, on 12/03/12 at 2:53 p.m., revealed Resident #10 had a contracture of the left hand. Additionally, it revealed the resident did not wear a splint, nor receive range of motion services. An observation and interview was completed with Resident #10 on 12/04/12 at 2:18 p.m. Observation revealed a contracture of her left hand. She stated services were not performed to maintain range of motion. The resident stated her contracture was related to a stroke. Review of the medical record, on 12/05/12, revealed a [DIAGNOSES REDACTED]. The minimum data set (MDS) was reviewed on 12/11/12 at 9:00 a.m. The assessment, dated 10/03/12, indicated the resident had an impairment of one (1) of her upper extremities. Section S of the comprehensive assessment, dated 04/02/12, indicated the resident had a contracture of the left hand. Employee #57 (a nursing assistant) was interviewed on 12/11/12 at 10:10 a.m. She stated the resident did not receive therapy or range of motion services for the contracture of her left hand. The resident was interviewed again on 12/11/12 at 10:15 a.m. She was alert, verbal and coherent. She said her hand had been this way since my stroke. She again stated the staff did not provide range of motion, nor encourage her to perform range of motion of her left hand. Employee #35, a registered nurse care plan coordinator (RN CPC) was interviewed on 12/11/12 at 3:00 p.m. She acknowledged the contracture was not addressed on the care plan and no routine pr… | 2016-12-01 |
| 7935 | 7935 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 329 | D | 0 | 1 | K06L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, and staff interview, the facility failed to ensure two (2) of ten (10) sample residents' medication regimens were free from unnecessary medications. One (1) resident received multiple doses of laxatives, including invasive laxatives, and the antipsychotic [MEDICATION NAME] with no indication for its use. Another resident received [MEDICATION NAME] without adequate indication for its use and without an attempt at a gradual dose reduction. Resident identifiers: #66 and #11. Facility census: 60. Findings include: a) Resident #66 (Laxatives) 1) Medical record review identified Resident #66 had a diagnoses of constipation. Further review of the medical record identified this resident did not have an individualized medication regimen for the constipation. According to the medical record, the resident had frequently been given medications from the facility's standing orders for constipation. No interventions, other than frequent use of laxatives, were put in place to relieve the resident of constipation. The facility continued the use of the standing orders for constipation. There was no evidence the physician was notified of any issues of constipation with this resident. The following laxatives were given to the resident for constipation. This included giving an invasive suppository on a regular basis. -- 08/25/12 - Milk of Magnesia given -- 09/15/12 - [MEDICATION NAME] suppository given -- 09/26/12 - Milk of Magnesia -- 10/03/12 - Milk of Magnesia -- 10/09/12 - Milk of Magnesia -- 10/13/12 - Milk of Magnesia Review of the medical record identified an order dated 10/23/12, by the attending physician, for the resident to have Senna S two (2) capsules at bedtime. During an interview with the DON, on 12/06/12 at 1:30 p.m., it was confirmed this resident was never ordered routine medication for constipation until 10/23/12. Further review of the medical record identified the Senna was ineffective, and… | 2016-12-01 |
| 7936 | 7936 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 428 | D | 0 | 1 | K06L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, and staff interview, the pharmacist failed to recognize and report the excessive use of laxatives for one (1) of ten (10) sample residents. Resident #66 received frequent doses of laxatives, including invasive laxatives, for constipation. The facility was using standing orders for this resident's constipation, and did not implement an individualized plan for the resident who had frequent episodes of constipation. The pharmacist did not identify this irregularity. Additionally, the pharmacist did not identify and report the resident was prescribed an iron supplement which contributes to constipation. Resident identifier: #66. Facility census: 60. Findings include: a) Resident #66 Medical record review identified Resident #66 had a [DIAGNOSES REDACTED]. According to the medical record, the resident had frequently been given medications from the facility's standing orders for constipation. No interventions, other than frequent use of laxatives, were put in place to relieve the resident of constipation. The facility continued the use of the standing orders for constipation. There was no evidence the physician was notified of any issues of constipation with this resident. The following laxatives were given to the resident for constipation. This included giving an invasive suppository on a regular basis. -- 08/25/12 - Milk of Magnesia given -- 09/15/12 - Dulcolax suppository given -- 09/26/12 - Milk of Magnesia -- 10/03/12 - Milk of Magnesia -- 10/09/12 - Milk of Magnesia -- 10/13/12 - Milk of Magnesia Review of the medical record identified an order dated 10/23/12, by the attending physician, for the resident to have Senna S two (2) capsules at bedtime. Further review of the medical record identified the Senna was ineffective, and the facility continued to use the standing orders. No evidence was found the facility identified the Senna was not working and/or notified the physician. The facility … | 2016-12-01 |
| 7937 | 7937 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 431 | E | 0 | 1 | K06L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of manufacturer's package inserts, review of CDC guidelines for storage of flu vaccine, and staff interview, the facility failed to maintain and/or label medications in a manner which ensured safe usage. Observation of the medication room found expired stock medications, and observation of medication Cart Two revealed open medications with no date to indicate when the medications were opened. These practices had the potential to affect more than a limited number of residents. Facility census: 60. Findings include: a) Observation of the medication storage area, on [DATE] at 11:06 a.m., found three (3) bottles of 325 mg aspirin with an expiration date of ,[DATE]. This finding was confirmed with Employee #36 (director of nursing) at the time of discovery. b) Inspection of medication Cart Two, with Employee #69, a licensed practical nurse, revealed an open vial of Lantus insulin which contained no date indicating when it was opened, to ensure the medication was still safe for use. (The manufacturer's package insert includes Open vials, whether or not refrigerated, must be used within 28 days after the first use. They must be discarded if not used within 28 days . Also, Cart Two contained an open vial of influenza vaccine. It had no date indicating when it was opened. This finding was also confirmed with Employee #36 at 11:06 a.m. (The Centers for Disease Control guidelines note multidose vials should be discarded after 28 days.) | 2016-12-01 |
| 7938 | 7938 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 441 | E | 0 | 1 | K06L11 | **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 maintain an infection control program to help prevent the development and spread of infection. Linens were handled improperly, gloves were not changed during a dressing change, floor coverings in bathrooms were cracked, gloves were not worn in an isolation room when removing a water pitcher from the room, and a potentially contaminated water pitcher was placed on a cart with other items. This affected one (1) resident and had the potential to affect more than a limited number of residents. Resident identifier: #26. Facility census: 60 Findings Include: a) An ice pass was observed on 12/03/12 at 11:35 a.m. Employee #45, a nursing assistant (NA), touched the inside surface of the ice receptacle with her fingers. An interview with Employee #36, the director of nursing (DON), on 12/03/12, confirmed this was an infection control issue. b) During observations on 12/03/12, the floor covering was noted to be cracked in three (3) of eight (8) bathrooms observed. This impeded proper sanitation. During an interview with Employee #5 (executive director), on 12/06/12, she acknowledged the floor covering was in disrepair and would be replaced. c) Employee #45 (NA) was again observed passing ice on 12/05/12 at 1:30 p.m. She removed two (2) pitchers from the room of a resident on contact precautions related to a [DIAGNOSES REDACTED]. Additionally, she did not wear gloves when touching the water pitchers, and she did not wash her hands. Employee #76, a licensed practical nurse (LPN) was present and acknowledged the nursing assistant violated acceptable infection control practices. d) Resident #26 This resident's wound dressing change was observed on 12/05/12 at 1:45 p.m. Resident #26 was on contact precautions related to clostridium difficile. Employee #76 (LPN) removed the soiled dressing, cleansed the wound, and applied a new dressing without changing glo… | 2016-12-01 |
| 7939 | 7939 | ANSTED CENTER | 515133 | 96 TYREE STREET | ANSTED | WV | 25812 | 2012-12-11 | 514 | D | 0 | 1 | K06L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure medical records were accurate for two (2) residents. Nursing staff continued to document a resident was receiving medication via her gastrostomy tube ([DEVICE]), after the tube had been removed. Another resident was ordered medications to be administered via [DEVICE], but the order read administer via mouth. Resident identifiers: #54 and #74. Facility census: 60. Finding include: a) Resident #54 Medical record review found this resident removed her [DEVICE] on 11/22/12. Nursing staff continued to document, on the Medication Administration Record [REDACTED]. A clarification order was written on 11/26/12 for the resident to receive her medications by mouth. An interview with the director of nursing, on 12/05/12 at 2:00 p.m., confirmed the facility should have clarified the route the resident's medications would be administered on 11/22/12 when the [DEVICE] was removed. b) Resident #74 Review of the medical record for Resident #74 identified this resident was admitted to the facility on [DATE]. Resident #74 had an order in place to be NPO (nothing by mouth). Review of the Medication Administration Record [REDACTED]. The nurses signed the Medication Administration Record [REDACTED]. During an interview with Employee #36 (director of nursing) on 12/11/12, at 10:45 a.m., it was verified the medications were given via the [DEVICE], but the Medication Administration Record [REDACTED]. It was confirmed the Medication Administration Record [REDACTED]. | 2016-12-01 |
| 9652 | 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 |
| 9653 | 9653 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 279 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan for the use of an antipsychotic medication for one (1) of twenty-eight (28) Stage II sample residents. Resident #56 was prescribed [MEDICATION NAME] on 10/11/10 for a [DIAGNOSES REDACTED].#56. The facility must develop a comprehensive care plan for each resident that includes measurable objectives to meet a residents medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITION], schizo-affective disorder, and mood disorders (e.g. mania, [MEDICAL CONDITION] disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of [MEDICATION NAME] to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the [MEDICATION NAME] was increased to 1 mg at bedtime. Review of the medical record revealed no comprehensive care plan to identify the use of the [MEDICATION NAME]. This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11. | 2015-10-01 |
| 9654 | 9654 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 281 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses (Delegation Guidelines), the facility failed to provide services in accordance with accepted standards of clinical practice. Review of Resident #26's medication administration records (MARs) revealed the orders that offered the option to the licensed practical nurse (LPN) of administering by mouth or via enteral tube, with no parameters to guide the LPN's decision-making process. This practice allows an LPN to act outside his or her scope of practice as established by the WV Boards of Nursing. Resident identifier: #26. Facility census: 59. Findings include: a) Review of Resident #26's MARs found orders that offered the option to the LPNs of administering medications by mouth or through the resident's enteral feeding tube, with no parameters to guide a LPN's decision-making process. Review of the Delegation Guidelines, revised by the West Virginia Board of Examiners for Registered Professional Nurses and the West Virginia State Board of Examiners for Licensed Practical Nurses on 06/17/09, found the following information on Page 13: ACTIVITIES THAT MAY BE DELEGATED TO THE LPN Activities appropriate for delegation to the LPN should be those that, after careful evaluation by the supervising RN, are expected to contain only one option. That is, the LPN is expected to be able to proceed through the established steps or an activity without encountering an unexpected response or reaction and competence in performance of the activity has been demonstrated. ACTIVITIES THAT SHOULD NOT BE DELEGATED TO THE LPN Activities that are NOT appropriate for delegation to an LPN are those that are likely to present decision making options, requiring in depth assessment and professional judgment in determining the next step to take as the provider proceeds throu… | 2015-10-01 |
| 9655 | 9655 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 329 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen of one (1) of twenty-eight (28) Stage II sample residents was free from unnecessary drugs. Resident #56 was ordered [MEDICATION NAME] (an antipsychotic medication) on 10/11/10 for the [DIAGNOSES REDACTED].#56 had an appropriate [DIAGNOSES REDACTED]. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITION], schizo-affective disorder, and mood disorders (e.g. mania, [MEDICAL CONDITION] disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of [MEDICATION NAME] to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the [MEDICATION NAME] was increased to 1 mg at bedtime. Further review of the medical record found the consulting pharmacist had reported to the physician and the facility, on 10/18/10, that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. In addition, the clinical condition being treated did not meet the criteria for the use of [MEDICATION NAME]. The physician responded to the pharmacist's recommendation by stating, Still (symbol for 'with') repetitive health related complaints. GDR (gradual dose recommendation) not appropriate. This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11. | 2015-10-01 |
| 9656 | 9656 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 425 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medications as prescribed for one (1) of twenty-eight (28) Stage II sample residents. Resident #80 was admitted to the facility on [DATE], for rehabilitation after surgery requiring cemented left triathlon total knee arthroplasty. A dose of routine pain medication was not given as prescribed at 9:00 a.m. on 10/30/10. According to staff interview, the medication was not available for administration at that time. Resident identifier: #80. Facility census: 59. Findings include: a) Resident #80 Record review revealed Resident #80 was admitted to the facility on [DATE], for rehabilitation services related to a total knee replacement. The resident was ordered Morphine Sulfate ER 30 mg twice a day for pain related to the knee surgery. Review of the Medication Administration Record [REDACTED]. During a telephone interview with a nurse (Employee #16) confirmed the medication was not available to give to the resident that morning. She further stated she called the physician at approximately 10:30 a.m. on 10/30/10 to report the medication was not in the facility. The physician discontinued the morphine at this time. During an interview with the director of nursing (DON - Employee #15 on 02/01/11 at 12:35 p.m., she verified the medication was not available for administration to Resident #80 at that time. | 2015-10-01 |
| 9657 | 9657 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 428 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of twenty-eight (28) Stage II sample residents, to ensure the physician acted upon reports of irregularities in a resident's medication regimen. Resident #56 was ordered Risperdal (an antipsychotic medication) on 10/11/10 for the [DIAGNOSES REDACTED].#56 had an appropriate [DIAGNOSES REDACTED]. The consulting pharmacist identified and reported to the facility and the physician that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. Risperdal is an antipsychotic used to treat schizophrenia, schizo-affective disorder, and mood disorders (e.g. mania, bipolar disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of Risperdal to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the Risperdal was increased to 1 mg at bedtime. Further review of the medical record found the consulting pharmacist had reported to the physician and the facility, on 10/18/10, that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. In addition, he reported the clinical condition being treated did not meet the criteria for the use of Risperdal. The physician responded to the pharmacist's recommendation on 11/05/10, by stating, Still (symbol for 'with') repetitive health related complaints. GDR (gradual dose recommendation) not appropriate. However, the physician did not provide documentation of the clinical rationale for using this antipsychotic medication to treat this behavior (repetitive health complaints). This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11. | 2015-10-01 |
| 9658 | 9658 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2011-02-02 | 441 | D | 0 | 1 | 860Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's listing of residents with histories of Methicillin-resistant Staphylococcus aureus (MRSA), observation, and staff interview, the facility failed to assure Resident #49 was appropriately cohorted with roommates to prevent the potential spread of infection. The facility placed Resident #74 in a four-bed ward with Resident #49, when Resident #74 was receiving treatment for [REDACTED].#74 at risk of contracting a MRSA infection to her open wounds. This deficient practice affected one (1) of twenty-eight (28) residents in the Stage II sample. Resident identifiers: #74. Facility census: 59. Findings include: a) Resident #74 Review of the facility's listing of residents with a history of MRSA infection, on 01/27/11, found Resident #49 had a history of [REDACTED]. Review of Resident #74's medical record found she was receiving treatment for [REDACTED]. Observation of the facility found Resident #74 had been placed in the same room as Resident #49. When this issue was brought to the facility's attention, Resident #49 was moved to a private room. An interview with the director of nursing (DON - Employee #15), on the afternoon of 02/02/11, revealed Resident #49 was moved to a private room for infection control purposes on 01/31/11. | 2015-10-01 |
| 11225 | 11225 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-09-24 | 250 | E | 1 | 0 | 0T3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's policy and procedure titled "4.1 Social Service Progress Notes" and staff interview, the facility failed to assure the residents were assessed for unmet social service needs. The facility did not complete assessments to identify the need for social services and to promote actions by staff to enhance each resident's individuality. There was no evidence the facility assessed the current mental / psychological status, education level, prior living arrangements, and pertinent events affecting each resident's condition to assure his/her social service needs were met. This was found for four (4) of nine (9) sampled residents. Resident identifiers: #58, #38, #23, and #19. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58, a [AGE] year old female, was admitted to the facility from the hospital with chronic health problems. Prior to admission, her husband had been caring for her at home. The physician determined this resident had the capacity to understand and make her own health care decisions. It was also noted that her diabetes was very unstable and required close monitoring and frequent changes to her insulin. She experienced blood pressure elevations, and her medications were frequently changed. She received dialysis three (3) times a week. She had severe peripheral vascular disease (PVD), and her skin condition was very poor. She was admitted to the facility with extensive skin treatments. Further documentation in her record revealed she verbalized frequently that she wanted to go home. There was evidence in the progress notes that the Medicaid aged and disabled waiver program had told the facility the resident was a danger to herself due to her unsafe medical decisions. There was also evidence that the adult protective service worker (APS) had stated the husband could not care for her at home. Review of the resident's social history found no assessment t… | 2014-07-01 |
| 11226 | 11226 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-09-24 | 309 | D | 1 | 0 | 0T3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure staff routinely monitored the bowel habits of residents and monitored / recorded interventions that were initiated in accordance with the physician's standing orders when a resident was experiencing problems with constipation. According to the medical record, Resident #58 went five (5) days without a bowel movement before interventions were initiated in accordance with the standing orders. Resident #31 went four (4) days without a bowel movement, and the physician's standing orders were not initiated until Day 5, contrary to the established bowel protocol. The bowel protocol was not followed for two (2) of nine (9) sampled residents. Resident identifiers: #58 and #31. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58 had experienced problems with constipation. In May 2009, the resident's bowel records indicated there was no bowel movements from 05/15/09 through 05/19/09. The facility's bowel protocol was requested for review. The director of nursing (DON) provided a "standing orders template" and indicated the interventions listed under the section titled "constipation" were what they do if there is not a bowel movement. According to these orders for constipation, if there is no bowel movement in three (3) days, staff is to give the resident one (1) dose of 30 cc Milk of Magnesia or [MEDICATION NAME] tablets. If there is still no bowel movement on Day 4, staff is to give the resident a [MEDICATION NAME] rectal suppository PRN x 1. If there is no bowel movement on Day 5, staff is to give the resident a Fleets enema. If there are no results from the enema, staff is to call the doctor for further orders. These standing orders were not followed for Resident #58. According to the resident's nurse aide flow sheet, she did not have a bowel movement on 05/15/09, 05/16/09, 05/17/09, 05/18/09, and 05/19/09. On Day 6, staff administ… | 2014-07-01 |
| 11227 | 11227 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-09-24 | 514 | D | 1 | 0 | 0T3Z11 | Based on a review of the medical record and staff interview, the facility failed to assure residents' bowel records were complete and accurate. Without accurate records of a resident's bowel movements, the facility could not assure interventions were initiated when needed to prevent complications. Residents' bowel movements were recorded on two (2) different places, and a comparison of these forms revealed the documentation did not match. The nurses kept track of each resident's bowel movements on a bowel sheet which was not part of the resident's medical record, and the information on the bowel sheets did not match the records kept by the nursing assistants which was part of the medical record. Bowel elimination records were not complete for two (2) of nine (9) sampled residents. Resident #58, and #31. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58 had experienced problems with constipation. In May 2009, documentation of the resident's bowel movements on the nurse aide flow sheet indicated there were no bowel movements from 05/15/09 through 05/19/09. During this five (5) day period, the form for recording bowel movements had blanks, and it could not be determined whether the resident had a bowel movement or not. The director of nursing (DON), when interviewed on 09/22/09 at 3:00 p.m., reported the information recorded on the nurse aide flow sheet in the resident's medical record was not used to monitor the resident's bowel elimination patterns. Instead, the nurses used information recorded on a separate bowel sheet to guide the administration of the standing orders for constipation. She confirmed these bowel sheets were not part of the resident's medical record, and they did not keep these sheets for more than a couple of months, after which they threw them away. The facility did not have bowel sheets for the time frame being reviewed for this resident, and the information in her medical record related to bowel elimination was incomplete. b) Resident #31 Record review … | 2014-07-01 |
| 11228 | 11228 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-11-13 | 323 | E | 1 | 0 | 0T3Z12 | Based on observation, staff interview, and record review, the facility failed to assure the resident environment remained as free of accident hazards as is possible. Staff disabled the alarming system and propped the front door open at 10:00 p.m. on the night of 11/10/09. This deficient practice placed all residents at risk should an unauthorized individual with nefarious intentions enter the facility undetected, or a confused resident not equipped with a WanderGuard device exit the facility undetected. Facility census: 54. Findings include: a) Upon arrival at the facility to conduct an unannounced follow-up survey at 10:00 p.m. on 11/10/09, observation found the front interior entrance doors were propped open with the use of the survey results notebook. When the door was pulled opened, no alarm sounded to alert staff members that someone had either entered or exited the facility. When inquiry was made of the registered nurse (RN) supervisor as to the practice of propping open the front door and turning off the alarm, the RN stated it was shift change and they did not want to have to keep getting up, unlocking the door, and turning off the alarm to let in staff members. An interview was conducted with the administrator at 12:15 a.m. on 11/11/09. He stated the doors were to be locked and the alarm turned on prior to the 9:00 p.m. medication pass. He stated the alarm that had been turned off was recently installed to provide added security, and it required a key to turn it on and off. He stated it was not acceptable for the doors to be propped open and the alarm disabled. The administrator was asked, on the afternoon of 11/11/09, to assist in a test of the front door under the conditions found upon entrance to the facility. The interior front doors were propped open with the survey results notebook, and the administrator utilized a key to disable the alarm. Observation and performance testing found the facility could be entered and exited without audible detection. A WanderGuard device was obtained and tested with … | 2014-07-01 |
| 11229 | 11229 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-11-13 | 492 | E | 1 | 0 | 0T3Z12 | Based on record review, review of West Virginia State Codes 9-6-1(2) and 9-6-11(c) and West Virginia Administrative Rule 19CSR3-14.1bb, and staff interview, the facility failed to assure allegations of abuse and/or neglect were reported to the State or Regional Ombudsman and the West Virginia State Board of Examiners for Licensed Practical Nurses (LPNs) in accordance with State law for two (2) of two (2) allegations reviewed. This deficient practice involved two (2) of five (5) sampled residents and had the potential to affect more than an isolated number of facility residents. Resident identifiers: #40 and #33. Facility census: 54. Findings include: a) Resident #40 Review of facility documents found that. on 08/11/09 at 8:30 a.m., a licensed practical nurse (LPN) was informed that Resident #40 was complaining of not feeling well and experiencing pain. A registered nurse (RN) reported to the social worker the LPN made the statement that the resident "needs a pillow over her face". Review of West Virginia State Code 9-6-1(2) found the definition of abuse to be the following: "Abuse means the infliction or threat to inflict physical pain or injury on or the imprisonment of any incapacitated adult or facility resident." Further review of West Virginia State Code 9-6-11(c) found the following language: "If the person who is alleged to be abused or neglected is a resident of a nursing home or other residential facility, a copy of the report shall also be filed with the state or regional ombudsman and the administrator of the nursing home or facility". Review of West Virginia Administrative Rule 19CSR3-14.1.bb found that the RN who reported the abusive statement was required to report this act of abuse to the West Virginia State Board of Examiners for Licensed Practical Nurses. The following language was found: "14.1.bb. failed to report through proper channels a violation of any applicable state law or rule, any applicable federal law or regulation or the incompetent, unethical, illegal, or impaired practice of anothe… | 2014-07-01 |
| 11230 | 11230 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-11-13 | 371 | D | 1 | 0 | 0T3Z12 | Based on random observation, the facility failed to assure food was distributed under sanitary conditions for residents electing to remain in their rooms for meals. Facility census: 54. Findings include: a) Random observations of the noon meal food service, on 11/13/09 at 12:10 p.m., found meal trays intended for residents to eat in their rooms were stacked on shelves on an open cart. Further observation found two (2) trays on the cart for the 200 hallway and one (1) tray on the cart for the 100 hallway were not adequately covered to prevent contamination of the residents' food. Closer inspection of the pellet system noted, in each case, the top lid had slid off the bottom portion of the pellet system, exposing a small bowl and other food items to potential contamination. . | 2014-07-01 |
| 11231 | 11231 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2010-11-05 | 225 | D | 1 | 0 | OEKS11 | . Based on review of facility documents, medical record review, and staff interview,the facility failed to assure one (1) of three (3) allegations of abuse / neglect was reported immediately to State officials in accordance with State law, and failed to thoroughly investigate this allegation of abuse / neglect. This deficient practice affected one (1) of three (3) sampled residents. Resident identifier: #60. Facility census: 57. Findings include: a) Resident #60 Review of facility documents found that, on 07/03/10, Resident #60 sustained lacerations to his face which required transport to an acute care facility for placement of thirty-four (34) stiches to close the wounds. Review of the medical record found a nursing note, written at 11:41 a.m. on 07/02/10, stating, "Nursing assistant pushing resident in w/c (wheelchair) when his foot dropped onto floor, he fell forward onto floor, laceration noted above and below left eye, resident remained alert at all times, denies pain anywhere else, able to move all other extremities... pressure applied as well as ice pack, notified POA (power of attorney) and (name of physician), transferred to (name of hospital) for eval (evaluation) and treatment." Review of facility documentation found a summary of the incident signed by the director of nursing (DON - Employee #14). Review of the summary found that, on 07/11/10, the resident's spouse spoke with the facility's physician concerning the 07/03/10 incident. The summary documented that the spouse stated, "This is neglect and abuse and you know it." Review of other facility documents found the facility did not report the incident until 07/21/10. Further review found that, following the delayed reporting, the facility did not complete a thorough investigation to determine if the resident's injuries were the result of abuse / neglect on the part of the staff member who was transporting the resident. The facility determined which employees were working at the time of the incident, but did not interview or collect statements from t… | 2014-07-01 |
| 11232 | 11232 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2010-11-05 | 323 | E | 1 | 0 | OEKS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, observations, and staff interview, the facility failed to assure nursing staff followed the practice instituted by the facility for the safe transport of residents in wheelchairs, after a male resident was injured after falling forward out of his wheelchair while being transported. Additionally, the facility failed to assure licensed nursing staff secured a stocked medication cart against unauthorized access prior to leaving the cart unattended in the resident hallway. These practices affected four (4) randomly observed residents being transported in wheelchairs without leg rests, and had the potential to affect any wandering and/or confused resident with the potential to access the medications in the cart. Resident identifiers: #46, #28, #54, and #17. Facility census: 52. Findings include: a) Residents #46, #18, #54, and #17 Review of facility documents found a male resident (Resident #60) fell forward from his wheelchair while being propelled by staff on 07/03/10. The resident sustained [REDACTED]. On 07/05/10, the facility instituted a practice to ensure leg rests were placed on the wheelchairs of all residents before being transported more that three (3) feet by staff. Random observations of the evening meal on 11/05/10, between the hours of 4:15 p.m. and 4:45 p.m., found four (4) staff members transporting four (4) residents in wheelchairs without leg rests. 1. Resident #36 A nursing assistant (Employee #19) transported Resident #46 from her room to the dining room at 4:05 p.m.; the resident was seated in a wheelchair with no leg rests. 2. Resident #28 The activities director (Employee #11) transported Resident #28 from her room to the dining room at 4:22 p.m.; the resident was seated in a wheelchair with no leg rests. 3. Resident #54 A nursing assistant (Employee #7) transported Resident #54 from her room to the dining room at 4:30 p.m.; the resident was seated in a wheelchair with no leg rests. … | 2014-07-01 |
| 11233 | 11233 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-08-05 | 241 | E | 0 | 1 | Q61611 | Based on an observation and staff interview, the facility did not provide care in an environment that maintained or enhanced dignity and respect for five (5) residents of a random observation. Residents were parked in wheelchairs and a reclining chair, lined up against a wall in the hallway awaiting transportation to the dining room for a meal. Resident identifiers: #1, #2, #14, #27, and #34. Facility census: 55. Findings include: a) On the mid-morning of 07/28/09, observation revealed five (5) residents (#1, #2, #14, #27, and #34) lined up in the 100 hallway. Four (4) residents were sitting in wheelchairs, and one (1) resident was in a reclining chair. The residents were parked in a line against the right side of the hallway. Interview with the activity director, on 07/28/09 at 12:00 p.m., revealed the nursing staff brought the residents out of their rooms and placed them in the hallway to await transportation to the dining room. She could not give a reason for why they were lined up against the wall. Interview with the director of nursing, on 07/28/09 at 4:00 p.m., revealed the residents should not be placed in a line in the hallway. She confirmed the residents were waiting to go to lunch. . | 2014-07-01 |
| 11234 | 11234 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-08-05 | 309 | D | 1 | 0 | Q61612 | Based on a review of the medical record and staff interview, the facility failed to assure residents' bowel records were complete and accurate. Without accurate records of a resident's bowel movements, the facility could not assure interventions were initiated when needed to prevent complications. Residents' bowel movements were recorded on two (2) different places, and a comparison of these forms revealed the documentation did not match. The nurses kept track of each resident's bowel movements on a bowel sheet which was not part of the resident's medical record, and the information on the bowel sheets did not match the records kept by the nursing assistants which was part of the medical record. Bowel elimination records were not complete for two (2) of nine (9) sampled residents. Resident #58, and #31. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58 had experienced problems with constipation. In May 2009, documentation of the resident's bowel movements on the nurse aide flow sheet indicated there were no bowel movements from 05/15/09 through 05/19/09. During this five (5) day period, the form for recording bowel movements had blanks, and it could not be determined whether the resident had a bowel movement or not. The director of nursing (DON), when interviewed on 09/22/09 at 3:00 p.m., reported the information recorded on the nurse aide flow sheet in the resident's medical record was not used to monitor the resident's bowel elimination patterns. Instead, the nurses used information recorded on a separate bowel sheet to guide the administration of the standing orders for constipation. She confirmed these bowel sheets were not part of the resident's medical record, and they did not keep these sheets for more than a couple of months, after which they threw them away. The facility did not have bowel sheets for the time frame being reviewed for this resident, and the information in her medical record related to bowel elimination was incomplete. b) Resident #31 Record review … | 2014-07-01 |
| 11235 | 11235 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-08-05 | 314 | G | 1 | 0 | Q61611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor / assess and obtain timely medical intervention for one (1) of twelve (12) residents of the sample selection with an infected pressure sore. Resident #40 exhibited sign and symptoms of an infected pressure sore and did not receive physician intervention; the resident was taken to a [MEDICAL TREATMENT] center for treatment and was immediately transferred by the [MEDICAL TREATMENT] center to the hospital [MEDICAL CONDITION]. Facility census: 55. Findings include: a) Resident #40 A review of Resident #40's medical record revealed a skin integrity report, dated 07/02/09, which indicated the resident's Stage IV pressure ulcer had purulent drainage. There was no corresponding entry in the nursing notes to reflect the resident's physician was notified of this finding. Nursing notes, dated 07/03/09 at 7:15 p.m., recorded, "New order noted for Tylenol 650 mg every 4 hours for elevated temp. Temperature 100.8 F." At 10:30 p.m., the resident's temperature was 99 F. On 07/06/09 at 6:30 a.m., a nursing note indicated, "Temperature 99.2 F and 99.4 F. ... Ambulance to take resident to [MEDICAL TREATMENT] treatment per family's request. Family wants resident to have an extra treatment." Later on 07/06/09 (no time given), a nursing note recorded, "[MEDICAL TREATMENT] center called to inform me resident's temp was 102 F and the resident is septic and unresponsive and was sent to the hospital." A discharge summary from the hospital, dated 07/08/09, revealed a [DIAGNOSES REDACTED]. The resident's pressure ulcer was necrotic and was debrided at the hospital. A wound VAC was placed, and resident was given [MEDICATION NAME] (an antibiotic) after [MEDICAL TREATMENT] and received two (2) units of blood. In an interview on 07/28/09 at 2:00 p.m., the director of nursing related that the nurses had called the physician on 07/02/09, when the resident was exhibiting purulent drainage and an elevate… | 2014-07-01 |
| 11236 | 11236 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-08-05 | 310 | D | 0 | 1 | Q61611 | Based on an observation and staff interview, the facility did not ensure one (1) resident of a random sample received proper positioning for meals to promote self-feeding. Observation found Resident #34 in the dining area attempting to drink a cup of coffee before the lunch meal was served. The resident was seated at a table that was elevated to the level of the resident's chin. Facility census 55. Findings include: a) Resident #34 Observation, on 07/28/09 at 12:30 p.m., found Resident #34 seated at a table in the dining room. The table was elevated to the level of the resident's chin. The resident was attempting to drink a cup of coffee that was served before lunch. The resident was stating to a staff person that she wanted to be placed at another table, because the table was too high. Interview with the activity director, on 07/28/09 at 12:35 p.m., revealed the resident was able to help herself with drinking and eating, and she related that the table at that height helped her to move the cup over to her mouth. Interview with the director of nursing, on 07/28/09 at 12:37 p.m., revealed the resident needed to be placed at a table with an appropriate height; she acknowledged the table at which Resident #34 was seated was too high for her to eat and drink and the resident had requested to be moved to another table. . | 2014-07-01 |
| 11237 | 11237 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-08-05 | 371 | F | 0 | 1 | Q61611 | Based on record review and staff interview, the facility failed to serve food under sanitary conditions; dietary staff failed to routinely monitor the concentration of sanitizing solution and the water temperatures of the wash and final rinse cycles in the dishwasher, to ensure they were maintained within the proper range to effectively sanitize dishware between uses. This practice has the potential to affect all residents in the facility. Facility census: 55. Findings include: a) On 07/28/09, review of the facility's July 2009 dishwasher temperature and sanitizer check log revealed places to record the concentration of sanitizing solution, wash temperature, and final rinse temperature of the dishwasher three (3) times each day, for the breakfast, lunch, and dinner meals; each of these items would have been measured and recorded eighty-one (81) times from 07/01/09 through 07/27/09. The concentration of the sanitizing solution was omitted forty-six (46) times, with no recordings during any meal time on 07/02/09, 07/12/09, 07/13/09, and 07/14/09, and no recordings during any lunch meal on any day. The wash and final rinse temperatures were omitted a total of forty-eight (48) times, with most of the omissions occurring during the dinner meal. During an interview on 07/28/09 at 11:30 a.m., the dietary manager agreed the dietary staff needed to keep up better with temperature and chemical recordings in the washing area. She noted the kitchen had a lot of temporary employees working in the kitchen lately and she would re-inservice them. Readings taken at this time, of the sanitizer concentration and the water temperatures of the wash and final rinse cycles, were found to be acceptable limits. . | 2014-07-01 |
| 11238 | 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 e… | 2014-07-01 |
| 11239 | 11239 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-08-05 | 280 | D | 0 | 1 | Q61611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plans for two (2) of twelve (12) sampled residents when they exhibited signs and symptoms of infections. Facility census: 55. Findings include: a) Resident #17 On 07/16/09, Resident #17 tested positive for [MEDICAL CONDITIONS] Toxins A and B. Subsequently, the physician ordered an antibiotic ([MEDICATION NAME] 500 mg) every eight (8) hours for ten (10) days beginning 07/16/09. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON) reported contact precautions were no longer employed, since Resident #17 no longer had diarrhea and had completed the ten (10) day course of antibiotics. A copy of the care plan, produced by the DON on 07/28/09 at approximately 5:00 p.m., contained no mention of the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The lack of care planning for this issue was shared with the DON during the exit conference with no additional information provided. b) Resident #40 Record review revealed a skin integrity report, dated 07/02/09, which documented a Stage IV pressure ulcer with purulent drainage. On 07/03/09, a nursing note recorded Resident #40 had an elevated temperature which was treated with Tylenol 650 mg. The interdisciplinary care team did not revise the resident's care plan when signs and symptoms of an active infection were exhibited. The resident was subsequently hospitalized for [REDACTED]. . | 2014-07-01 |
| 11240 | 11240 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-08-05 | 225 | D | 0 | 1 | Q61611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to screen applicants for employment for findings entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Employee identifiers: #84 and #88. Facility census: 55. Findings include: a) Employees #84 and #88 On 07/28/09, review of the personnel files of a random sample of five (5) recently hired employees and five (5) employees hired greater than one (1) year ago revealed a registered nurse (Employee #84) was hired in May 2009, and a licensed practical nurse (Employee #88) was hired in June 2009. Neither employee's personnel file contained evidence to reflect the facility had screened them for adverse findings on the WV Nursing Assistant Abuse Registry. Facility staff in charge of personnel files and health records was unable to produce evidence of checks against the Abuse Registry for these two (2) employees. After surveyor inquiry, staff ran checks of these employees on the afternoon 07/28/09; no adverse results were found, and copies of these checks were placed in the employees' records for future reference. . | 2014-07-01 |
| 11241 | 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 |
| 2898 | 2898 | E.A. HAWSE NURSING AND REHABILITATION CENTER | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2019-02-14 | 758 | D | 0 | 1 | SV8C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed in collaboration with the pharmacist, to consult the physician for an annual evaluation for gradual dose reduction of psychoactive medications. This was evident for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #15, #25. Facility census: 53. Findings included: a) Resident #15 Medical record review on 02/13/19 found this resident received [MEDICATION NAME] 75 milligrams (mg) twice daily. [MEDICATION NAME] is a psychoactive medication used for the treatment of [REDACTED]. Further review of the medical record found the most recent pharmacy recommendation to consider a gradual dose reduction (GDR) occurred sixteen (16) months ago on 10/22/17. The pharmacist at that time addressed that this resident has been taking [MEDICATION NAME] 75 mg. twice daily since 01/30/14. The pharmacist requested the physician to evaluate for the lowest effective dose. The physician declined the option of a dose reduction at that time, with instructions to see his progress notes for the rationale. Review of the medical record found no evidence that the pharmacist made any requests in (YEAR) or through the current date, for the physician to again evaluate for the lowest effective dose of this medication. An interview was conducted with the administrator and the director of nursing on 02/14/19 at 8:45 AM. They said there was no other pharmacy irregularity report/consult to the physician for a consideration for dose reduction of the [MEDICATION NAME] since 10/22/17. They said the physician did not order contraindications for future considerations for GDR of the [MEDICATION NAME], or note previous failures of a GDR. b) Resident #25 A review of the pharmacist recommendation for Resident #25, revealed the pharmacist made a recommendation for a GDR for the medication [MEDICATION NAME] 0.5 milligram (mg) at night for Dementia with Lewy Bodies. Resident #25 has be… | 2020-09-01 |
| 6350 | 6350 | E.A. HAWSE NURSING AND REHABILITATION CENTER | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2014-04-15 | 161 | E | 0 | 1 | D8L411 | Based on record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover all of the funds. This had the potential to affect all 57 residents with a resident trust fund account. Facility census: 70. Findings Include: a) A review of resident funds on deposit with the facility at 10:30 a.m., on 04/15/14, found the facility's current surety bond was for a sum of $19,000.00 with the term beginning 07/26/13 and ending 07/26/14. Review of the resident fund accounts beginning 07/26/13 and ending 03/31/14 revealed the following months beginning balance being greater than the $19,000.00 surety bond: September 2013 with a beginning balance of $22,229.82, November 2013 with a beginning balance of $23,432.96, February 2014 with a beginning balance of $20,943.12, and March 2014 beginning balance of $22,306.25. On 04/15/14 at 11:50 a.m. during an interview with the business office supervisor, (Employee #33), she acknowledged the amount of money in the resident trust account was higher than the surety bond's coverage. | 2018-04-01 |
| 6593 | 6593 | E.A. HAWSE NURSING AND REHABILITATION CENTER | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2016-09-14 | 272 | D | 0 | 1 | ZHIW11 | Deficiency Text Not Available | 2018-01-01 |
| 8009 | 8009 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2012-10-23 | 280 | D | 0 | 1 | R9MR11 | Based on staff interview and medical record review, the facility failed to revise a resident's care plan when there was a progressive decline in functional range of motion. One (1) of eight (8) residents reviewed for range of motion (ROM) was affected. Resident identifier: #10. Facility census: 56. Findings include: a) Resident #10 Review of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/08/12, revealed the resident had no functional impairment of the upper extremities and had impairment on one (1) side of the lower extremities, according to Section G0400 - Functional Limitation in Range of Motion. Review of the MDS, with an ARD of 04/01/12, found no decline in the resident's baseline from the previous assessment. The resident continued to be coded as having no functional impairment of the upper extremities, and impairment of one (1) side of the lower extremities. Record review also revealed the resident received physical therapy (PT) from 02/24/12 through 04/04/12. The MDS, with an ARD of 07/01/12, indicated the resident had experienced a decline in functional range of motion (ROM). The assessment indicated the resident had impairment of both upper extremities (where previously there was none), and of one (1) side of the lower extremities. Record review found no new care plan revisions to address the ROM decline. Review of the MDS, with an ARD of 09/30/12, revealed further decline in the resident's functional ROM to include impairment of both upper extremities and both lower extremities. Record review found no care plan revisions had been made to address the resident's progressive declines in ROM. During an interview, on 10/23/12 at 10:00 a.m., the Administrator stated she could see where there were no care plan revisions to address the declines. | 2016-11-01 |
| 8010 | 8010 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2012-10-23 | 282 | D | 0 | 1 | R9MR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility did not provide in accordance with a resident's written care plan. The facility failed to implement the care plan related to pain for one (1) of twenty-eight (28) residents on the sample. Resident identifier: #4. Facility census: 56. Findings include: a) Resident #4 During an interview with Resident #4, on 10/16/12 at 9:23 a.m., he stated he had pain in his legs all of the time and medication did not help. On 10/17/12 at 2:30 p.m., in a follow up interview with Resident #4, he confirmed the pain in his legs. He rated it as a ten (10) on a zero (0) to ten (10) pain scale. He stated his pain affected his ability to perform activities of his choice and his sleep. (Note: for the numerical pain scale from 1 to 10, a rating of 1 is mild pain, and the pain severity increases up to a rating of 10, which is severe pain.) A medical record review was performed on 10/17/12. Resident #4 had a [DIAGNOSES REDACTED]. His most recent care plan listed Acute Pain as a focus problem. The goal was . will state relief in pain within 1 hour of receiving pain medication. An intervention was, Document patient's response to pain and medications or therapeutics aimed at abolishing or relieving pain. The medication administration report listed Tylenol 650 milligrams (mg) as a medication given every evening at 9:00 p.m. On 10/17/12 at 12:25 p.m., Employee #28, the Unit Charge Nurse/Licensed Practical Nurse (LPN), was interviewed. S he confirmed that Resident #4 did receive a scheduled Tylenol every evening. She was unable to produce evidence that follow up evaluation was performed after administration of Resident #4's Tylenol. This was discussed with the Director of Nursing (DON) on 10/17/12 at 3:00 p.m. The DON was unable to produce evidence of an evaluation/reassessment of Resident #4 in regards to pain in accordance with the care plan. On the Medication Administration Report (MAR), t… | 2016-11-01 |
| 8011 | 8011 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2012-10-23 | 309 | G | 0 | 1 | R9MR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, 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. The facility failed to provide effective pain relief, resulting in actual harm due to ineffective pain management, for one (1) of three (3) Stage 2 residents reviewed for the care area of pain. Resident identifier: #4. Facility census: 56. Findings include: a) Resident #4 During an interview with Resident #4, on 10/16/12 at 9:23 a.m., he stated he had pain in his legs all of the time and medication did not help. On 10/17/12 at 2:30 p.m., a follow up interview was conducted at which time Resident #4 stated his pain was in his legs. He rated his pain as a ten (10) on a zero (0) to ten (10) pain scale, with zero (0) being no pain and ten (10) being the highest pain level. He stated his pain affected his ability to perform activities of his choice and affected his sleep. An interview with Employee #28, a Unit Charge Nurse/Licensed Practical Nurse (LPN) was conducted on 10/17/12 at 12:45 p.m. She stated Resident #4 received a scheduled Tylenol every evening and had an as needed (PRN) Tylenol order as well, although the resident had not received the PRN Tylenol since last month (09/20/12). She was unable to produce evidence of any follow up evaluations for Resident #4 regarding the effectiveness of his scheduled pain medication. When asked if the resident was assessed for pain, she stated the registered nurses performed pain assessments on residents at weekly intervals, but it was unrelated to the administration of pain medication. This situation was discussed with the Director of Nursing (DON) on 10/17/12 at 3:00 p.m. She was unable to produce any additional information regarding assessment and reassessment of Resident #4's pain and his response to the medic… | 2016-11-01 |
| 8012 | 8012 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2012-10-23 | 318 | G | 0 | 1 | R9MR11 | Based on record review, staff interview, and review of the facility's policy for therapy screening, the facility failed to ensure a resident with a decline in functional range of motion received timely care and services to prevent further declines. This resulted in actual harm to the resident due to loss of functional range or motion. The resident was assessed as having declines in functional range of motion on two (2) consecutive assessments with no measures implemented in an attempt to prevent further decline. This was evident for one (1) of five (5) sampled residents reviewed for the care area of range of motion. Resident identifier: #10. Facility census: 56. Findings include: a) Resident #10 Review of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/08/12, revealed the resident had no functional impairment of the upper extremities and impairment on only one (1) side of the lower extremities. The MDS, with an ARD of 04/01/12, indicated there had been no decline in the resident's baseline since the prior assessment. The resident continued to have no functional impairment of the upper extremities and impairment of one (1) side of the lower extremities. Record review also revealed the resident received Physical Therapy (PT) from 02/24/12 through 04/04/12. Review of the MDS, with an ARD of 07/01/12, found the resident had experienced a decline in her functional ROM to include impairment of both upper extremities and of one (1) side of the lower extremities. Record review found no interventions to the resident's care plan to address this decline. The MDS, with an ARD of 09/30/12, revealed the resident had experienced further decline in functional ROM to include impairment of both upper extremities and both lower extremities. Record review found no new interventions to address this decline. Further review of the resident's care plan found no new interventions had been established to address the resident's decline in functional ROM abilities that had been identified on the 07/01/12… | 2016-11-01 |
| 8013 | 8013 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2012-10-23 | 323 | E | 0 | 1 | R9MR11 | Based on observation, staff interview, and policy review, the facility failed to ensure water temperatures in the resident rooms and/or common use rooms were adequately and/or accurately monitored. Following an observation of an extremely hot water sample from the sink in the training toilet room, the facility provided three (3) different thermometers that obtained three (3) different temperature readings when water temperatures were assessed simultaneously. Failing to ensure accurate assessment of water temperatures had the potential to affect more than a limited number of residents. Facility census: 56. Findings include: a) Measurement of the water temperature of the sink in the common toilet room on 10/22/12 at 3:30 p.m. found the water so hot that one could only keep a hand placed beneath the faucet comfortably for less than two (2) seconds. The Maintenance Supervisor, Employee #10, obtained a digital thermometer and found the water temperature to be 122 degrees. The water from the first shower in the same room was then checked by Employee #10, and was found to be 118 degrees. When asked, Employee #10 said the water should be between 110 and 120 degrees, and surmised the water was hotter than usual due to a resident having just completed a shower. He said he would make an adjustment and lower the water temperature right away. According to Table 1 in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur at 120 degrees with exposure of five (5) minutes, noting that burns can occur even at temperatures below that level depending on an individual's condition and the length of exposure. On 10/22/12 at 4:50 p.m., Employee #10 said he determined that his thermometer was broken, as he obtained a lower reading of the water in the shower and toilet room sink when using a thermometer obtained from the dietary department that was not digital. He said he had most recently checked water temperatures on Friday 10/19/12 with the digital thermomet… | 2016-11-01 |
| 8014 | 8014 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2012-10-23 | 329 | D | 0 | 1 | R9MR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of manufacturer's labels, interview with the consultant pharmacist, staff interview, review of an excerpt from the State Operations Manual (SOM),and review of an action plan provided by the administrator, the facility failed to ensure residents were administered a potassium chloride (KCl) supplement with a sufficient amount of liquids. This had the potential to cause gastrointestinal irritation and a laxative effect. During the observation of medication pass, of the 10 residents observed, two (2) residents received KCl. Resident identifiers: Resident #21 and #48. Facility census: 56. Findings include: a) Resident #21 On 10/17/12 at 8:56 a.m., medications were observed being given to Resident #21 by a licensed practical nurse (LPN), Employee #28. The resident's medications included liquid KCl. After pouring 15 cc of the KCl into a cup, Employee #28 added approximately 30 ml of grape juice to the KCl. Upon taking the first sip of the medication, and with each subsequent sip, the resident grimaced and shook her head. Employee #28 did not offer or encourage the resident to drink more water or juice. A review of Resident #21's physician's orders, on 10/17/12 at 10:00 a.m., revealed the following order: Potassium Chloride 20 MEQ (milliequivalents)/15 ML (10%) Oral (By mouth) - 1x (times) Everyday, 0900 (9:00 a.m.). The physician's order did not contain any information regarding additional fluids with this medication. On 10/24/12 at 9:00 a.m., observation of the pharmacy label revealed no directions regarding giving additional fluids with the KCl. The manufacturer's label on the side of the bottle included, DIRECTION: To minimize gastrointestinal irritation, patients must follow direction regarding dilution. Each tablespoonful (15 mL) should be diluted with three (3) fluid ounce or more of water or other liquid. Three (3) fluid ounces would equal approximately 90 cc of fluid - three (3) times the … | 2016-11-01 |
| 8015 | 8015 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2012-10-23 | 431 | D | 0 | 1 | R9MR11 | Based on observation and staff interview, the facility failed to provide a permanently affixed compartment for storage of medications for which there is a potential for abuse. The medication refrigerator contained the medication Ativan, a medication with abuse potential, in an box that was not permanently affixed. Findings include: a) Observation, on 10/17/12 at 3:30 p.m., revealed the medication refrigerator contained one (1) plastic box containing two (2) vials of liquid Ativan and one injectable tubex of Ativan, a drug with potential for abuse. The box had a key lock and was locked, however the box was not permanently affixed to the refrigerator. Present during this observation was licensed practical nurse (LPN) Employee #34. She affirmed the box containing the Ativan was not affixed to the refrigerator. | 2016-11-01 |
| 9465 | 9465 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | P.O BOX 70 | BAKER | WV | 26801 | 2009-12-02 | 279 | D | 0 | 1 | 7R6711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to develop appropriate plans of care, including measurable goals and nursing interventions aimed at attaining these goals, for three (3) of twelve (12) sampled residents with problems that had been identified in their comprehensive assessments. Resident identifiers: #1, #42, and #6. Facility census: 55. Findings include: a) Resident #1 A review of the medical record revealed Resident #1 was an [AGE] year old female with [DIAGNOSES REDACTED]. She received this medication almost nightly since her admission on 09/14/09, and the resident assessment protocol (RAP) summary, dated 10/02/09, indicated her care plan would address the use of psychoactive medications. At 3:00 p.m. on 11/30/09, a review of the resident's active care plan (which had been revised with a significant change on 10/02/09) revealed neither the establishment of a measurable goal for her identified problem of [MEDICAL CONDITION], nor any nursing interventions aimed at the resolution of her [MEDICAL CONDITION], although the nurses' notes documented almost nightly administration [MEDICATION NAME] with her pain medication; the nurses' also notes failed to reveal any documentation of intervention attempts other than the administration of medications. The care plan also did not address the potential problems associated with the resident receiving [MEDICAL CONDITION] medications. This was pointed out to the director of nurses (DON) at 12:00 noon on 12/01/09. The DON returned at 3:00 p.m. on 12/01/09 with a copy of a page from the resident's initial care plan which did include a plan, established on 09/16/09, for the problem of: Resident receiving [MEDICAL CONDITION] mg po qHS prn for [MEDICAL CONDITION] and is at risk for side effects. She stated this page had accidentally been omitted when the care plan was revised, but she acknowledged that neither care plan addressed the problem of [MEDICAL CONDITION]. b) … | 2015-11-01 |
| 9466 | 9466 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | P.O BOX 70 | BAKER | WV | 26801 | 2009-12-02 | 309 | D | 0 | 1 | 7R6711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure staff, for one (1) of twelve (12) sampled residents who received as needed antianxiety and pain medications, consistently administered medications in accordance with clear parameters for their use. Resident identifier: #42. Facility census: 55 Findings include: a) Resident #42 Resident #42, when observed in the afternoon on 11/30/09, was seated in a cardiac chair in her room with her feet elevated. The resident was yelling out and moaning. When an attempt at interviewing the resident was made, the resident responded that she was hurting but could not indicate where. An interview at this time with a licensed practical nurse (LPN - Employee #47) found the resident did not like being in bed and would not stay there if put into bed. She related that the resident mostly was up in her wheelchair, and when she needed to rest, she was most comfortable in the cardiac chair. She also related that Resident #42 exhibited intermittent crying spells that included loud repetitious verbalizations of distress, often refused to go to bed, and was placed into a cardiac chair. The resident, when observed intermittently throughout the day on 12/01/09, was in a wheelchair with a self-release lap buddy. The resident was asleep by the nurse's station during the lunch observation on 12/01/09, and was asleep during most of the afternoon in the wheelchair by the nurse's station. On 12/02/09 at 9:00 a.m., the resident was observed going through the hallways of the facility yelling and chanting out without any meaningful purpose or direction. Review of the physician's orders [REDACTED]. The resident was also ordered Tylenol #3 with [MEDICATION NAME] every four (4) hours as needed Dx: DJD / Pain on 09/16/09 and Tylenol 650 mg every four (4) hours as needed - Not to exceed 4gr in 24 hrs. Not to be given within 4 hrs of Tylenol #3. Dx: Mild pain on 10/26/09. The resident was also… | 2015-11-01 |
| 10418 | 10418 | E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC | 515173 | P.O BOX 70 | BAKER | WV | 26801 | 2011-12-06 | 157 | D | 1 | 0 | H3SV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility failed to notify the resident's legal representative, a family member, and/or the resident's physician when there was a deterioration in the health status of one (1) of six (6) sampled residents until the resident became unresponsive and required hospitalization . Resident identifier: #60. Facility census: 56. Findings include: a) Resident #60 A review of the closed medical record revealed that Resident #60 was an [AGE] year-old female who was admitted to the facility on [DATE], and discharged to an acute care facility on 09/13/11. Her [DIAGNOSES REDACTED]. A review of the nurse's notes revealed the following: -- 08/30/11 at 12:34: Multidisciplinary Care Conference held. The notes state, ". . . met goal for cognition . . . continues to make needs known . . . intake is less than 25% . . . . Patient visits with family, and staff. She watches the birds outside, strolls throughout the building in her wheelchair, eat chocolate and just people watch." -- A second note, at 11:44, stated only that due to a pulse of "47", the resident's [MEDICATION NAME] was held. -- 08/31/11 at 10:56: "(Resident's physician) in to see resident new orders to D/C (discontinue) [MEDICATION NAME] Give Tylenol 650 mg po q 4hrs (by mouth every 4 hours) while awake.". . . "Daughter (health care surrogate's name) notified of new orders." It was also noted the resident's blood pressure medications were held due to pulse rate of "47". -- 09/01/11 at 23:18: It was again noted the resident's blood pressure (BP) medications were held due to low BP of 137/62 and pulse rate of 46. The notes contained no additional nursing assessment or observations. -- 09/02/11 at 14:34: "Physical Evaluation: lethargic, weak. MD (physician) made aware." The entry did note the physician and the responsible party had been notified. It is also noted the resident had been determined to have a significant weight loss (9 pounds… | 2015-04-01 |
| 1 | 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 … | 2020-09-01 |
| 2 | 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 f… | 2020-09-01 |
| 3 | 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 ad… | 2020-09-01 |
| 4 | 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 … | 2020-09-01 |
| 5 | 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 physicia… | 2020-09-01 |
| 6 | 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 |
| 7 | 7 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 241 | E | 0 | 1 | ELSQ11 | Based on observation and staff interview, the facility failed to maintain residents' dignity during the dining experience for seven (7) of twenty-seven (27) residents in the main dining room. A random observation revealed obviously soiled linens were not changed in a timely fashion for Resident #25. Facility census: 116. Resident identifiers: Resident #25, #124, #77, #71, #21, #49, #192 and #68. Findings include: a) Resident #25 During a random observation on 05/17/17 at 6:20 a.m., Nurse Aide (NA) #36 placed a sheet over Resident #25's blanket. Observation revealed a brown stain covering an area of approximately two feet by two feet (2 ft x 2 ft). The nurse aide looked at the area and verbalized, Oh, Lord. Another observation at 9:20 a.m., revealed Resident #25 sitting at the bedside eating his breakfast. The stained blanket was again visible from the doorway. Upon request, the Center Nurse Executive (CNE) completed an observation and interview. Resident #25, interviewed at 9:22 a.m., said he was sitting at his bedside the night before and had spilled his coffee, making a big mess. The resident said the accident occurred about 10:00 p.m. on 05/16/16. At 9:24 a.m., the CNE acknowledged the blanket should have been changed at the time of the spill, and as the resident sat at the bedside for breakfast, staff had additional opportunity to change the blanket. b) Residents #124, #77, #71, #21, #49, #192, and #68. A dining observation on 05/16/17 from 11:10 a.m. and 12:45 p.m., revealed Residents #124, #77, and #21 sat in the dining room and did not converse with other residents or staff during the pre-meal interim or during mealtime. Staff asked residents meal preferences, but did not converse in a social manner. Resident #71, sat at a table alone. She verbalized she had no friends, and felt lonely. At another table, Resident #21 did not have a tablemate. She looked around the room at other residents, but neither staff nor residents spoke to her throughout the course of the dining experience. Resident #77 and #125 requ… | 2020-09-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );