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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11332 | 11332 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 152 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to verify that a surrogate decision-maker had the necessary authority to act on behalf of a resident who had been determined to lack the capacity to make healthcare decisions, for one (1) of six (6) sampled residents. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of Resident #23's medical record revealed a [AGE] year old female who was originally admitted to the facility on [DATE], and who had been determined to lack the capacity to make healthcare decisions by her attending physician on 08/21/08. The face sheet in the resident's record indicated the resident had designated an individual to serve as her medical power of attorney representative (MPOA), but there was no copy of this document in the record. Social service notes, dated 12/13/10, stated the resident's sister had been appointed to serve as her health care surrogate (HCS), and documentation elsewhere in the record indicated this HCS was making healthcare decisions for the resident. No record of the appointment of a HCS by the resident's attending physician was located in the record. During an interview with the social worker (Employee #5) at 10:40 a.m. on 12/28/10, she verified, after review of the resident's medical record and her office records, that there was no record of a legal representative. She speculated it had been misplaced at some point. . | 2014-04-01 | ||
| 11333 | 11333 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 225 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to report allegations involving mistreatment and/or neglect to the appropriate agencies in accordance with State law for three (3) of six (6) sampled residents. Resident identifiers: #37, #38, and #67. Facility census: 89. Findings include: a) Resident #37 A review of the medical record revealed Resident #37 was an [AGE] year old male who has been determined to lack the capacity to form healthcare decisions, and his minimum data set and care plan indicated he was totally dependent upon staff for hygiene. A review of a grievance form revealed that, on 11/16/10, the resident's wife / healthcare surrogate (HCS) reported to a nurse (Employee #7) that the resident's nails were dirty at times and that she always had to cut his nails herself. The nurses' notes indicated this allegation of neglect was investigated and being followed up by Employee #7 and a nursing assistant and, when checked on 11/17/10, his nails were clean. Daily monitoring of the resident's nails was ordered by the physician and added to the care plan. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- b) Resident #38 A review of the clinical record for Resident #38 revealed an [AGE] year old male with [DIAGNOSES REDACTED]. He had been determined by the attending physician to lack the capacity to form healthcare decisions, and his niece was his medical power of attorney representative (MPOA). A grievance form was filed on 11/08/10, after the facility received a letter from the MPOA stating she had spoken to a staff member two (2) weeks prior and complained that the resident had become unable to physically lift his arm enough to feed himself, but nothing had been done and he was still having his tray set up and being left to feed himself. During an interview w… | 2014-04-01 | ||
| 11334 | 11334 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 323 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to ensure one (1) of six (6) sampled residents was free from accident hazards over which the facility had control, and the facility failed to provide adequate supervision and/or assistive devices by failing to put preventive interventions into place after an identified accident. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of the medical record revealed Resident #23 was a [AGE] year old female, who was alert and oriented, but whose sister who had been appointed to serve as her health care surrogate (HCS) per the social worker, to assist her with healthcare decisions. A facility investigation report indicated that, on 12/15/10, the resident was found with her right foot caught in the siderail of her bed in her bedroom resulting in redness of the entrapped area. The resident had a physician's orders [REDACTED]. A Side Rail Evaluation Screen was completed on 12/27/10, and the decision was made to add padded coverings to the siderails. The assessment nurse (Employee #6) presented a copy of the care plan at 2:00 p.m. on 12/28/10, with an added intervention (hand-written) dated 11/22/10 which read: "Bilateral 1/2 SR padded for T & R (turning and repositioning)." An observation of the resident was made at 10:45 a.m. on 12/27/10, while she was lying in bed in her room. Both 1/2 siderails were raised and appeared to have a satisfactory fit to the bed, but there was no padding on the rails. In an interview with the resident at that time, she stated she did like having the rails to use when she moved about in bed. She remembered getting her foot caught in the rail and said she was being careful not to do it again. During a staff interview with the interim director of nurses at 11:15 a.m. on 12/28/10, she acknowledged the padding had not been added until the evening of 12/27/10, when she realized that her instru… | 2014-04-01 | ||
| 11335 | 11335 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 514 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the accuracy of the medical record by continuing to indicate, in the physician's progress notes, that two (2) of six (6) sampled residents were on medications and/or dosages that had been changed and/or discontinued. Resident identifiers:#37 and #87. Facility census: 89. Findings include: a) Resident #37 A review of the medical record found Resident #37 presently had physician's orders [REDACTED].@ bedtime" (with a start date of 09/13/10) and "[MEDICATION NAME] (insulin [MEDICATION NAME]) 100 unit/ml solution subcutaneous - once daily Everyday: 4 units" (with a start date of 07/07/10). A review of the physician's progress notes revealed the physician's assistant (Employee #4) had documented on all entries back to 06/15/10 that the resident was receiving the following drug therapy for treatment of [REDACTED]. DM II (diabetes mellitus type II): [MEDICATION NAME] 20U qhs (each night). Presently taking [MEDICATION NAME] 2U with supper and continue 4U with breakfast and lunch. Will continue to monitor qid (four-times-a-day)." During an interview with Employee #4 at 11:50 a.m. on 12/28/10, he acknowledged, after checking the orders, that the notes were inaccurate, but he commented "the nurses know not to go by (his) notes." The medical director, who was present at exit, stated that corrections would be made. -- b) Resident #87 A review of the physician's progress notes written by the physician's assistant (Employee #4), on 12/09/10, 10/19/10, 09/21/10, and 08/24/10, all stated Resident #87 was being treated with the following: "1. [MEDICAL CONDITION]'s chorea: Klonopin 1 mg bid (twice daily). [MEDICATION NAME] mg qhs for [MEDICAL CONDITION]. [MEDICATION NAME] 7.5 mg 1 po (by mouth) qhs." A review of the record found the [MEDICATION NAME] was discontinued on 07/22/10 and [MEDICATION NAME] discontinued in August 2009. During an interview with Employee #4 at 11:50 a.m. on 12/2… | 2014-04-01 | ||
| 11336 | 11336 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-01-11 | 318 | E | CVPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to provide a continuity of restorative nursing services as ordered by the physician to maintain and/or increase strength and/or range of motion (ROM). Thirty-six (36) residents had physician orders [REDACTED]. Resident identifiers: #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77. Facility census: 76. Findings include: a) Residents #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77 On 01/10/11, a review of the facility's "Restorative Nursing and Progress Summary" for the months of January 2011 and December 2010 was completed to determine whether residents were receiving restorative nursing services at the frequency ordered by their attending physician Month-to-date in January 2011, twenty-four (24) residents did not receive restorative nursing services for active / passive ROM, therapeutic / strengthening exercises, and/or the application of splints on five (5) of ten (10) days. These were Residents #2, #5, #7, #8, #10, #12, #15, #24, #25, #33, #35, #42, #43, #44, #50, #57, #60, #61, #63, #64, #67, #68, #73, and #76. During the month of December 2010, thirty-six (36) residents did not receive restorative nursing services for active / passive ROM, therapeutic / strengthening exercises, and/or the application of splints on anywhere between three (3) and eight (8) days of this month. These were Residents #1, #2, #5, #7, #8, #10, #11, #12, #14, #15, #17, #18, #23, #24, #25, #32, #33, #35, #42, #43, #44, #48, #50, #53, #57, #60, #61, #62, #63, #64, #67, #68, #70, #73, #76, and #77. Each resident had one (1) or more physician orders [REDACTED]. Restorative nursing services were ordered for seven (7) days a week with two (2) restora… | 2014-04-01 | ||
| 11337 | 11337 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-01-11 | 311 | E | CVPG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interviews, the facility failed to provide a continuity of restorative nursing services as ordered by the physician to maintain and/or increase self-performance of transfer / ambulation and/or eating activities. Twenty-four (24) residents had physician orders [REDACTED]. Resident identifiers: #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77. Facility census: 76. Findings include: a) Residents #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77 On 01/10/11, a review of the facility's "Restorative Nursing and Progress Summary" for the months of January 2011 and December 2010 was completed to determine whether residents were receiving restorative nursing services at the frequency ordered by their attending physician Month-to-date in January 2011, fourteen (14) residents did not receive restorative nursing services for transfer / ambulation or activities to improve eating on five (5) of ten (10) days. These were Residents #2, #5, #7, #12, #15, #24, #33, #41, #52, #57, #61, #68, #74, and #76. During the month of December 2010, thirty-six (36) residents did not receive restorative nursing services for transfer / ambulation or activities to improve eating on anywhere between three (3) and eight (8) days of this month. These were Residents #2, #5, #7, #11, #12, #15, #17, #18, #21, #23, #24, #33, #41, #48, #52, #53, #57, #61, #62, #68, #70, #74, #76, and #77. Each resident had a physician orders [REDACTED]. Restorative nursing services were ordered for seven (7) days a week with two (2) restorative aides providing the restorative services. A licensed practical nurse (LPN) was currently in charge of the program, and a registered professional nurse (RN) had been hired to assume the supervision of the restorative nursing program. An interview with a restorative aide (Employee #60), o… | 2014-04-01 | ||
| 11338 | 11338 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2010-12-09 | 225 | D | 9K0R11 | . Based on review of abuse / neglect policies, review of employees' personnel files, and staff interview, the facility failed make reasonable efforts to uncover information about any past criminal prosecutions to assure that individuals are not employed who have been potentially found guilty of abusing, neglecting, or mistreating residents by a court of law for one (1) of seven (7) employee personnel records reviewed. Facility census: 115. Findings include: a) The facility was entered at 12:15 p.m. on 12/09/10, to conduct an unannounced complaint investigation alleging that the facility did not perform necessary screening for potential employees to rule out criminal convictions that would make them unfit for service in a nursing facility. Review of the facility's policy addressing the prevention of resident abuse / neglect "1.0-WV Abuse Prohibition" (revised 11/01/09) found the following under the section entitled "Process": "2. The Center will screen potential employees for a history of abuse, neglect, or mistreating residents... "2.1.2.1 Knowledge of actions by a court of law against an employee, which would indicate unfitness for service...". Review of the personnel file for nursing assistant (NA) #1 found she had previously worked in the Commonwealth of Virginia. The personnel file contained no evidence to reflect the facility made a reasonable effort to determine whether this individual had criminal convictions in Virginia which would render him / her unfit to work in a long term care facility. An interview with the administrator, on 12/09/10 at 3:10 p.m., confirmed the facility had no evidence that NA #1 had been screened for criminal convictions in Virginia. | 2014-04-01 | ||
| 11339 | 11339 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 157 | D | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to notify a resident's legal representative when they commenced a new form of treatment. One (1) of six (6) sampled residents was initiated into the fine dining program and the walk-to-dine program (during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts), with no evidence of family notification of this change in treatment or what it involved. The resident, who was seated in a regular chair at a table in the dining room without safety devices, got up from the chair by herself and fell to the floor, sustaining significant injury. The family of the resident was not informed that the use of these safety devices would not be permitted during fine dining and/or the walk-to-dine program. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. The was also revealed no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chai… | 2014-04-01 | ||
| 11340 | 11340 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 280 | D | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents when she was initiated into the facility's newly established walk-to-dine and fine dining programs, during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts. Resident #111, who had an order for [REDACTED]. needs while in the walk-to-dine / fine dining program. Resident identifier: #111. Facility census: 110. Findingd include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. There was also no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safet… | 2014-04-01 | ||
| 11341 | 11341 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 323 | G | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to develop and implement written policies and procedures to ensure that residents receive care and services necessary to prevent avoidable accidents This was evident for one (1) of six (6) sampled residents whose treatment was changed without a physician's orders [REDACTED]. There was no evidence this resident (who had been identified as being at risk for falls) was first assessed to see if she was a candidate for removal of safety devices while in the dining program and no evidence of care planning for safety interventions to prevent accidents while participating in these programs. Additionally, there were no written guidelines or interventions for staff to follow to assure the resident's safety needs were met. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... "Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)." Review of the care plan revealed no evidence of plans to walk the resident to the dining room for th… | 2014-04-01 | ||
| 11342 | 11342 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 155 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure one (1) of seven (7) sampled residents (who had the capacity to understand and make a health care decision) was fully informed in advance of the nature of a surgical procedure (incision and drainage of a large hematoma); understood the possible consequences of the procedure; and was asked for a written consent prior to the undertaking of the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her re… | 2014-04-01 | ||
| 11343 | 11343 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 157 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure, for one (1) of seven (7) sampled residents, the physician was notified of an acute change of condition (the presence of a large hematoma), and failed to consult the physician and notify an interested family member prior to a significant alteration in treatment. Resident #118 (who had multiple comorbidities and was on anticoagulation therapy) developed a large hematoma on her left lower extremity, and the facility failed to notify the attending physician of the hematoma. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage) on the hematoma without consulting with the attending physician and without informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. The physician and the MPOA were contacted after the procedure resulted in significant bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her… | 2014-04-01 | ||
| 11344 | 11344 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 224 | G | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to assure one (1) of seven (7) sampled residents received appropriate services necessary to avoid physical harm. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a large hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on [DATE], she verified Resident #118 had capacity, a… | 2014-04-01 | ||
| 11345 | 11345 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 225 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to immediately report to State agencies and/or thoroughly investigate an incident involving the neglect of one (1) of seven (7) sampled residents. The facility's certified nurse practitioner (CNP) performed an invasive surgical procedure (incision and drainage of a hematoma) on a high-risk resident with multiple comorbidities and on anticoagulation therapy, without evidence of having obtained informed consent from the resident, consulting with the resident's attending physician, and informing an interested family member (whom the resident designated to serve as her medical power of attorney representative - MPOA) prior to performing the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures and which may have been a factor in her death less than seventy-two (72) hours later. This event was reported to the State survey and certification agency as an "unusual occurrence" without evidence of a thorough investigation. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being … | 2014-04-01 | ||
| 11346 | 11346 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-01-13 | 157 | D | I28Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, family interview, and staff interview, the facility failed to provide prompt notification, to the responsible party of one (1) of forty-two (42) Stage II sample residents, after the resident experienced a change in condition. Resident #120 became agitated while in the dining room on 11/12/10, and the nurse aides had to carry the resident back to her room due to her increased agitation, resistance of care, and physically aggressive behaviors. The resident's medical power of attorney representative (MPOA) did not learn of these events until 11/16/10. Resident identifier: #120. Facility census: 113. Findings include: a) Resident #120 On the night of 11/12/10, Resident #120 exhibited agitated behaviors that were atypical for her. According to documentation recorded by a licensed practical nurse (LPN - Employee #114), the resident was in the dining room by herself when she became agitated and started carrying around a wet floor sign, hitting the window of the dining room with the wet floor sign. The resident was soiled also due to incontinence. When nurse aides approached her and tried to get her to her room (in order to provide incontinence care), she became more agitated, hitting and kicking the nurse aides. Nurse aides eventually had to carry the resident from the dining room to her room, in order to change her out of her soiled clothes. On 01/06/11 at approximately 2:00 p.m., the social worker (Employee #134) provided a copy of documentation she had collected on 11/16/10. The documentation stated, "(Name), daughter and MPOA for (Resident #120), came into the office about 1:25 PM this date and stated that (name of Employee #73), CNA (certified nursing assistant), told her there was a rumor that 3 CNA's (sic) on south side turned in 3 CNAs from north side for abuse of (Resident #120). The story is that Friday, 11/12/10, night (Resident #120) was hitting and combative with staff. In an attempt to get her calmed t… | 2014-04-01 | ||
| 11347 | 11347 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 309 | D | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, staff interview, and resident interview, the facility failed to provide necessary care and services for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was receiving blood thinners and was observed with excessive bruising to bilateral upper extremities. There was no documentation that the use of blood thinners was being monitored for this resident. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of recent laboratory results, dated 09/09/10 and 11/08/10, found no laboratory results used for monitoring the effectiveness of the blood thinner to regulate clotting. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 4:00 p.m., Resident #15 reported, "I can barely just touch or scratch myself and I bruise. I am on blood thinners, and I think it needs to be checked. I was going to talk to my doctor about it, but I haven't seen him." In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, "We know we have a problem with documentation, and we are working on it." Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. Interview with the licensed practical nurse (LPN) assigned to Resident #15 (Employee #159), on 12/22/10 at 5:20 p.m., revealed he was not aware of any bruising to Resident #15's bilateral upper extremities. . | 2014-04-01 | ||
| 11348 | 11348 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 514 | D | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident observation, and staff interview, the facility failed to maintain a complete clinical record for one (1) of a hundred and forty-four (144) residents on the sample. Resident #15 was observed with excessive bruising to bilateral upper extremities, and there was no documentation that two (2) of three (3) weekly body audits had been completed in the month of December 2010. Resident identifier: #15. Facility census: 144. Findings include: a) Resident #15 Observation, on 12/21/10 at 10:20 a.m., found Resident #15 sitting on her bed with excessive bruising to her bilateral upper extremities. An interview with Resident #15 revealed she was on blood thinners. Review of the physician's orders [REDACTED]. Review of the resident's treatment administration record (TAR) for December 2010 revealed weekly body audits had not been documented for 12/09/10 and 12/16/10. In an interview on 12/22/10 at 5:15 p.m., the director of nursing (DON - Employee #169) reported, "We know we have a problem with documentation, and we are working on it." Employee #169 stated the facility had no documentation regarding the bruising on Resident #15's arms. (See also citation at F309.) | 2014-04-01 | ||
| 11349 | 11349 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 323 | G | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, review of the facility's self-reported injuries of unknown source and allegations of resident abuse / neglect, and staff interview, the facility failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents with injury for one (1) of eleven (11) sampled residents. Resident #147, who had partial loss of voluntary movement with limitations to range of motion in both legs and feet and who was totally dependent on staff for bed mobility, transfers, and locomotion, was assessed as needing the physical assistance of two (2) persons and a mechanical lift for safe transfers between surfaces. On 09/02/10, Resident #147 was manually transferred on three (3) separate occasions (from wheelchair to shower chair; from shower chair back to wheelchair; and from wheelchair to bed); she complained of leg pain during the second and third manual transfers. In response to her complaints of leg pain during the third manual transfer, the aides notified the nurse; the nurse contacted the physician, who ordered a stat x-ray. The x-ray revealed a displaced acute fracture of the fibula with no indication that the fracture was clinically avoidable, and the resident was subsequently transferred to the hospital on the early morning of 09/03/10. Resident identifier: #147. Facility census: 144. Findings include: a) Resident #147 1. Closed record review, on 12/21/10, revealed this [AGE] year old female was originally admitted to the facility in 2004; her most recent readmission / return to the facility occurred following a hospital stay from 12/03/08 to 12/17/08. - Her most recent comprehensive assessment was an annual assessment with an assessment reference date (ARD) of 02/24/10, in which the assessor recorded the resident as having both short and long-term memory problems with moderately impaired cognitive skills for daily decision-making, and she was able to make herself understood to others and usually un… | 2014-04-01 | ||
| 11350 | 11350 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2010-12-16 | 225 | D | 17LC11 | . Based on record review, staff interview, and confidential staff interview, the facility failed to report an allegation of resident neglect by a nursing assistant to the appropriate State officials agencies when the identity of the alleged perpetrator was known. This was evident for one (1) of five (5) sampled residents. Resident identifier: #32. Facility census: 65. Findings include: a) Resident #32 Record review revealed Resident #32 received a head injury of unknown origin. Subsequently, this resident was transported to the emergency room for evaluation, then returned to the facility the same day. Record review revealed the facility reported this injury of unknown source to the appropriate State agencies, because the source of the injury was not observed by any person, it could not be explained by the resident (who was cognitively impaired due to a disease process), and the injury was suspicious because of the location and extent of the injury. Further record review revealed a licensed practical nurse (LPN - Employee #32) completed an incident report on the date and time of the discovery of the injury and documented an allegation that a nursing assistant caused the injury during turning and failed to notify the nurse of what she had done. -- Interview with the administrator, director of nursing, and the licensed social worker, on 12/14/10 at 3:00 p.m., revealed their belief that it would have been physically impossible for Resident #32's head to hit the bedside stand while being turned; they reported the aides "speculated" about what might have happened, and a former employee (Employee #84, a nursing assistant who was terminated last week) and other staff who were working the evening of the incident, when interviewed, admitted having no knowledge of how the injury happened. Subsequently, the administrator felt the allegation was hearsay, and the facility did not substantiate abuse or neglect in their investigation of the incident. -- Interview with Employee #32, on 12/14/10 at 3:25 p.m., revealed that the ide… | 2014-04-01 | ||
| 11351 | 11351 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2010-12-16 | 281 | D | 17LC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to follow physician's orders to perform monthly laboratory testing for one (1) of five (5) sampled residents. One (1) resident in the sample did not receive a monthly complete blood count (CBC) per physician's orders, as evidenced by one (1) CBC lab test omission in March 2010. A CBC drawn a month after the omitted lab test, in April 2010, revealed abnormal findings resulting in the resident's hospitalization Resident identifier: #67. Facility census: 65. Findings include: a) Resident #67 Record review revealed Resident #67 was diagnosed with [REDACTED]. A hospice encounter occurred in September 2009 but was declined by the family. Review of a facility's Encounter Sheet, dated 12/10/09, revealed the physician was to be consulted regarding increasing the [MEDICATION NAME] dosage, as this resident with multiple contractures and "pain expressed (symbol for with) even slightest movement". -- Record review revealed Resident #67's physician orders included orders for a basic metabolic profile (BMP) every three (3) months and CBC every month. Review of physicians orders effective from 03/01/10 through 03/31/10 revealed both the BMP and the CBC were both due on 03/10/10 and all CBCs were to be sent to Hospital #1. The BMP, requested and completed on 03/19/10 by the contracted lab service at Hospital #2, yielded results similar to the previous quarterly BMPs; however, there was no evidence to reflect the monthly CBC was requested and/or completed in March 2010. A CBC, requested and completed by the contracted lab service at Hospital #2 on 04/23/10, contained the following abnormal laboratory results: - WBC (white blood cell count) 1.2 (normal reference range 4.9 - 10.8); - RBC (red blood cell count) 1.98 (normal reference range 4.20 - 5.4); - HGB (hemoglobin) 5.9 (normal reference range 12.0 - 16.0); - HCT (Hematocrit) 18.3 (normal reference range 36 - 48%); and - PLT (Platelet) 44 (nor… | 2014-04-01 | ||
| 11352 | 11352 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2009-08-21 | 279 | D | I2SV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to develop care plans, for one (1) of thirteen (13) sampled residents and one (1) resident of random opportunity, to reflect each resident's needs and the services being furnished to attain or maintain the resident's highest practicable physical well-being. One (1) resident had a physician's orders [REDACTED]. Another resident had sustained an injury when she spilled hot chocolate on herself, and no mention of this was made on the care plan in order to prevent another such incident. Resident identifiers: #8 and #13. Facility census: 54. Findings include: a) Resident #8 During a random tour of the facility on 08/18/09 at 2:00 p.m., observation found Resident #8 in her bed with side rails up on both sides. Review of the resident's medical record disclosed that, although the resident did have a physician's orders [REDACTED]. b) Resident #13 A review of the accident / incident reports and nursing notes found, on 06/08/09, Resident #13 "fell asleep before breakfast in dining room with hot chocolate in her hand and spilled hot chocolate in her lap." The resident's upper and inner thighs were red, with [MEDICATION NAME][MEDICAL CONDITION] the resident's upper inner bilateral thighs. When interviewed on 08/19/09 at 10:00 a.m., the resident related she was not sure whether she fell asleep or her fingers / hands were not good at holding things as well as before, and she was not sure exactly how the incident happened. She did not think the staff was doing anything differently since the incident occurred related to how she received hot liquids. A review of the resident's current care plan failed to find anything addressing how to promote resident safety with respect to drinking hot liquids without becoming burned. . | 2014-04-01 | ||
| 11353 | 11353 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2009-08-21 | 309 | E | I2SV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for three (3) of thirteen (13) sampled residents and three (3) residents of random opportunity. One (1) resident was hospitalized with a toxic level of medication, and no follow-up labs were completed after the resident's return to the facility. Five (5) residents were observed with side rails up and had no physician's orders for the use of side rails and no mention of their use in the plan of care. Resident identifiers: #40, #43, #15, #52, #30, and #41. Facility census: 54. Findings include: a) Resident #40 The medical record of Resident #40, when reviewed on 08/17/09, disclosed the resident was admitted to the facility on [DATE] from Health South following a [MEDICAL CONDITION] hip. At the time of admission, the resident was receiving the medication [MEDICATION NAME] 0.25 mg every day for the [DIAGNOSES REDACTED]. On 07/12/09, the resident was noted in nursing notes to be nauseous and having an episode of vomiting. The resident's son insisted she be transferred to the emergency room , from which she was admitted to the hospital with [REDACTED]. The resident returned to the facility on a decreased dose of [MEDICATION NAME] (0.0625 mg) and a potassium supplement on 07/20/09. A document entitled "Physician's Orders", received from the hospital, displayed an order which stated: "Dig ([MEDICATION NAME]) level next week at The Madison." The hospital discharge summary referenced above stated, "Check her [MEDICATION NAME] level within one week and then do it every month thereafter until she is stable and then she can do it once or twice per year." Further review of the record, on 08/17/09, divulged no evidence that a [MEDICATION NAME] level had been obtained since the resident's return to the facility. The facility's director of nurses (DON), when interviewed on 08/… | 2014-04-01 | ||
| 11354 | 11354 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2009-08-21 | 159 | D | I2SV11 | Based on record review and staff interview, the facility disclosed information regarding a resident's personal funds account to individuals who did not have the legal authority to receive this information. This was evident for two (2) of four (4) residents whose personal funds were reviewed. Residents #7 and #57. Facility census: 54. Findings include: a) Residents #7 and #57 A review of the financial information for Residents #7 and #57 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal funds records with the business office manager, on 08/20/09 at 10:00 a.m., found quarterly financial statements were sent to unauthorized representatives for both residents. . | 2014-04-01 | ||
| 11355 | 11355 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26505 | 2009-08-21 | 371 | F | I2SV11 | Based on observation and staff interview, the facility failed to store foods under sanitary conditions. Cold temperatures for milk at 41 degrees F or less were not maintained. Milk from the milk machine temperatures were observed at 42 -50 degrees Fahrenheit (F). This had the potential to affect all residents who drank milk. Facility census: 54. Findings include: a) Observation of preparation of the noon meal, in the dietary department on 08/19/09, found milk in small glasses on a tray in the kitchen. A request was made for one (1) of the cooks (Employee #3) to take the milk temperatures. The first temperature read 50 degrees F, and the second read 45 degrees F. A request was made to take the temperature of milk just after it came from the milk dispenser; this was 45 degrees F, while the external thermometer on the dispenser read 42 degrees F. The temperature of milk dispensed from the machine was measured another thermometer, which read 43 degrees F, while the internal thermometer inside the dispenser read 30 degrees F. Employee #3 and the dietary supervisor were both present. A request was made to review the temperature logs for the milk dispenser. The employee reported she recorded temperatures for both the cooler and the milk dispenser, and it could not be determined whether the temperature logs were for the cooler or the milk dispenser. The temperatures varied from 38 degrees F to 40 degrees F, according to the log, and were listed as measuring the temperature of the refrigerator. . | 2014-04-01 | ||
| 11356 | 11356 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-08-26 | 323 | G | 3L9811 | . Based on observations, the facility failed to ensure the resident environment remained as free of accident hazards as possible. A treatment cart was found unlocked and unattended on the Blue Ridge hall in the presence of mobile residents. The cart contained items that had the potential to be harmful if ingested or used in a manner other than they were intended to be used. All mobile residents on the Blue Ridge hall had the potential to be affected. Facility census: 114. Findings include: a) Treatment cart - unlocked and unattended During random observations of the facility on 08/24/10 at 7:30 a.m., the treatment cart of Blue Ridge was found sitting outside of the Blue Ridge nurses' station. The cart was not locked, and no staff was in line of sight of the cart. The cart contained a variety of treatment supplies, i.e., a container of Greer's Goo (composed of nystatin (Mycostatin) powder 4 million U, hydrocortisone powder 1.2 g, and zinc oxide paste), Nystop (an antifungal), and a large bottle of 100% Acetone. There would be a potential for adverse reactions should a resident who was sensitive / allergic to Mycostatin or Nystop have contact with the Greer's Goo and / or Nystop. Acetone (http://www.drugs.com/enc/acetone-poisoning.html) has the potential to cause cardiovascular problems (hypotension), gastrointestinal problems (nausea, abdominal pain, vomiting), the nervous system may be affected (seem as though drunk, coma), as might the respiratory system . | 2014-04-01 | ||
| 11357 | 11357 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-09-10 | 323 | G | 9G3Y12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibi… | 2014-04-01 | ||
| 11358 | 11358 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-12-09 | 323 | G | 777711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on medical record review, review of facility records, staff interview, and family interview, the facility failed to provide adequate supervision and/or appropriate assistive devices, based on a comprehensive assessment of the resident, to promote the safety of one (1) of three (3) residents whose closed records were reviewed. Resident #114 sustained a total of five (5) falls between his admission date of [DATE] and [DATE], when the resident expired at the facility. A fall from the bed on [DATE] resulted in a fractured nasal bone. A fall from the bed on [DATE] resulted in a complaint of shoulder and back pain; the resident was transported to the hospital, but x-rays were negative for fractures. On [DATE], the resident had three (3) falls from a wheelchair with no injury noted. The last fall occurred on [DATE], when the resident was found on the floor by the pharmacy delivery man at 8:30 p.m. that night, having fallen out of a reclined geri-chair located at the nurses' station. The resident sustained [REDACTED]. Medical record review and an interview with the rehabilitative therapy program manager disclosed this resident had been identified as being at risk for falls upon his admission to the facility, and staff was aware the resident was constantly attempting to get out of chairs and bed. There was no evidence in his medical record to reflect the use of the reclining geri-chair with this resident had been evaluated by physical therapy, ordered by the physician, or addressed in his care plan. Interviews with nursing staff present on [DATE] confirmed the resident had been left unsupervised in a reclining geri-chair for an unknown length of time prior to his fall. Resident identifier: #114. Facility census: 113. Findings include: a) Resident #114 1. Medical record review disclosed this [AGE] year old resident was admitted to the facility from the hospital on [DATE] for skilled services and rehabilitative therapy with the possibi… | 2014-04-01 | ||
| 11359 | 11359 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 250 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and interview with a hospital social, the facility failed to provide medically-related social services for two (2) of thirty-two (32) Stage II sample residents. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors and no planned medically-related social service interventions to address the behaviors. Resident #31 missed a medical appointment, because the facility did not remind him so that he was prepared in advance. Resident identifiers: #35 and #31. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of … | 2014-04-01 | ||
| 11360 | 11360 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 201 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and interview with the social worker at the hospital, the facility failed to attempt to meet the needs of one (1) of six (6) sampled residents prior to planning his discharge from the facility. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. There was evidence the facility had no plans to readmit the resident after the evaluation. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causal factors and no planned intervention to address the behaviors. Evidence revealed the facility had prearranged for the resident to be transferred to a local hospital then be transferred to another facility out of state. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. O… | 2014-04-01 | ||
| 11361 | 11361 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 279 | E | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, staff interview, family interview, and resident interview, the facility failed to develop comprehensive care plans and/or interventions for four (4) of thirty-two (32) Stage II sample residents. There was no care plan for intentional weight loss for Resident #43; no care plan for foot care for Resident #5; no interventions for behaviors for Resident #35; and no restorative care plan for Resident #115. Resident identifiers: #43, #5, #35, and #115. Facility census: 83. Findings include: a) Resident #43 During an interview with the resident on 12/08/10 at 3:15 p.m., the resident revealed she was trying to lose weight, stating, "I really want to get rid of my belly." Review of the dietary progress notes, dated 08/26/10 and 09/29/10, revealed the registered dietician had noted the resident was trying to lose weight. Review of the dietary progress notes, dated 10/26/10, revealed the dietary supervisor (Employee #68) also noted: "Resident wants to lose wt (weight)." Review of the dietary progress notes, dated 11/30/10, revealed the dietary supervisor noted: "Resident wants to continue to lose wt per her choice due to history of diabetes." An interview on 12/08/10 at 2:15 p.m., with a registered nurse (RN - Employee #77), revealed the resident frequently requested junk food and had yet to mention to her (Employee #77) that she wanted to lose weight. Review of the resident's care plan found no mention of a plan to assist the resident in achieving intentional weight loss. b) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During the interviewed, the sister expressed concern that the resident's feet were not routinely cleaned by facility staff. She stated the resident's feet were often dry and flaky, and that she (the sister) often soaked and cleaned them herself. Interview with the resident, at 1:00 p.m. on 12/07/10, revealed her feet were always cold, so she wore soc… | 2014-04-01 | ||
| 11362 | 11362 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 319 | D | GCMN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide appropriate treatment and services to assist one (1) of thirty-two (32) Stage II sample residents related to behavioral problems. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors for the behaviors. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for "definite long-term stay". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from … | 2014-04-01 | ||
| 11363 | 11363 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 364 | F | GCMN12 | . Based on observation, test tray temperatures, and staff interview, the facility failed to assure foods were attractive, appetizing, and at the proper temperature when received by the residents. Pureed foods were thin and ran into each other on the plate for twenty (20) residents who were provided pureed diets. Additionally, the temperature of coleslaw was too warm for palatability, at the point of service, for all residents. These practices affected all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) On 02/24/11 during the noon meal, observations were made of residents eating in the activity room. The pureed foods (pinto beans, sauerkraut, and polish sausage) ran together touching each other on the plates. This created an unappetizing presentation for the twenty (20) residents who required pureed foods. There was no form to the foods at all. The foods on the plates were touching each other, edge to edge, with color being the only distinguishing factor from one food to the other. This was shown to the administrator (NHA - Employee #117) and the director of nursing (DON - Employee #118) at the time of the observation. The NHA confirmed the meals served to residents on pureed diets were not appetizing or attractive. -- b) At noon on 03/02/11, pureed meals were observed with the dietary manager (DM - Employee #63). The pureed broccoli mix and pureed ranch style beans were thin, without form, and ran into each other on the plates. At that time, the DM confirmed the foods should have form and not spread into each other. -- c) On 03/02/11 at 12:55 p.m., a test tray was requested to be placed on the cart immediately following the last resident to be served at the noon meal. There was a misunderstanding, and the cart on which the test tray was placed was not the last cart to be served. In addition, it contained only three (3) trays. The meals on this cart had no wait time for service; however, the foods were tested anyway, with the DM. The hot foods were… | 2014-04-01 | ||
| 11364 | 11364 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 246 | D | MWZ111 | Based on observation, staff interview, and record review, the facility failed to ensure proper positioning of one (1) randomly observed resident in restorative dining. A resident in a scoot chair was observed eating lunch while the back of his scoot chair was in a reclined position. The reclined position of the chair back interfered with the resident's ability to reach his food. Resident identifier: #189. Facility census: 102. Findings include: a) On 06/29/09 at 12:25 p.m., observation found Resident #189 eating in the restorative dining room. The resident was seated in a scoot chair. The scoot chair's seat was low to the ground, and the backrest was observed to be in a reclined position. The table height was too high for the resident to comfortably reach his food. The resident, who was attempting to feed himself, was having difficulty reaching the food on the table and was spilling some food onto his chest. The resident, when observed on 07/02/09 at 12:30 p.m. in the restorative dining room., was again in the scoot chair seated at the table. The backrest to the chair was observed in a reclined position. The resident was observed having difficulty reaching the food on the table. When interviewed on 07/02/09 at 12:45 p.m., the speech language pathologist (SPL - Employee #17) stated the backrest to the scoot chair was "all the way up". She further stated, "I sometimes put pillows behind his back." The SPL walked over to the chair and raised up the backrest. The resident's medical record, when reviewed at 1:30 p.m. on 07/02/09, revealed a physician's for the scoot chair. A dietary note, dated 06/12/09, reported the resident consumes 59% of meals and requires supervision with meals. . | 2014-04-01 | ||
| 11365 | 11365 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 240 | B | MWZ111 | Based on resident interview, observation, and staff interview, the facility failed to ensure residents received fresh ice and water every shift. This was evident for four (4) of four (4) sampled residents, three (3) of whom were located on the same hall. Resident identifiers: #57, #108, #6, and #31. Facility census: 102. Findings include: a) Resident #31 During an interview on 06/30/09, Resident #31 voiced a complaint of not having ice for his pitcher. He said he could not stand to drink the water that was not cold and elaborated that he will awaken from sleep and crave a cold drink, but many times there was no ice in his pitcher. He said he had not voiced complaints about this to anyone. He felt the facility should know to provide ice water to people who cannot easily get their own. He said there have been many times he had to get cold water from the bathroom in order to have a cold drink, and this may happen by day or by night. At 8:55 a.m. on 07/01/09, observation of his water pitcher found it contained only water, no ice. His pitcher was checked for ice again at 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., and no ice was present on any of these observations. Observations of every water pitcher on the same hall found none of the residents on that hall had ice in their pitchers. During an interview on 07/01/09 at 4:30 p.m., a nurse (Employee #139) stated ice was supplied to residents every shift. When informed that sampled residents had received no ice in their pitchers on day shift today, and currently none of the residents on the hall in question had ice, she stated she would take care of it immediately. b) Resident #6 Record review revealed Resident #6 was dependent on staff for all activities of daily living (ADLs) except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. c) Resident #108 Record review revealed Resid… | 2014-04-01 | ||
| 11366 | 11366 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 252 | D | MWZ111 | Based on observation and staff interview, the facility failed to provide a clean environment free from unpleasant odors as evidenced by the presence of a persistent odor of urine in a room shared by two (2) incontinent residents. This was evident for two (2) of four (4) sampled residents. Resident identifiers: #6 and #108. Facility census: 102. Findings include: a) Residents #6 and #108 share a room. Observations of the residents' shared room on 06/30/09, at 8:05 a.m., 1:42 p.m., and 2:15 p.m., revealed an unpleasant odor of urine that could be detected immediately upon entering the room. At 8:05 a.m., the odor seemed to be the strongest from Resident #6. At 1:42 p.m., the odor seemed to be coming from an afghan on the bed and the curtain separating the two (2) residents. At 2:15 p.m., the odor of urine was noted also from the wheelchair pad belonging to Resident #108, who had been sitting in the wheelchair. On all three (3) instances, the smell of urine was easily noticeable and could be detected immediately upon entering the room. On 07/01/09 at 11:45 a.m., the distinct odor of urine was detected immediately upon entering the room. During an interview at this time, a nursing assistant (Employee #93) stated she and other aides had noticed a bad smell in the room yesterday and, subsequently, Resident #108's mattress was changed. After the floor was mopped and the resident was showered, they still noticed the odor. She stated she did not believe the odor was coming from the pad in Resident #108's wheelchair, but she agreed she could smell the odor of urine in the curtain separating the residents. She immediately notified housekeeping. The housekeeping, upon arrival, smelled the curtain and also agreed it smelled like urine. She said they do terminal cleaning once every month, which includes taking down the curtains and washing them. She said Resident #6 will yell and throw things when that curtain is removed, as she always wants it pulled. She related she would use the second curtain in the room as a divider betwe… | 2014-04-01 | ||
| 11367 | 11367 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 242 | D | MWZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, policy review, staff interview and record review, the facility failed to ensure one (1) of twenty-eight (28) Stage II sampled residents receive bi-weekly showers per resident request. Resident #133, who had an intestinal infection, reported she did not receive bi-weekly showers as requested, due to facility's infection control policy regarding [MEDICAL CONDITIONS] infection. Resident identifier: #133. Facility census: 102. Findings: a) Resident #133 Resident #133, when interviewed on 06/30/09 at 10:00 a.m., reported she has not been able to take a shower and get her hair washed for the past two (2) weeks. The resident stated she has an intestinal infection, and staff told her she could not take a shower due to the infection. Resident #133 stated, "This makes me feel dirty and my hair looks terrible." The director of nurses (DON - Employee #20) provided a copy of the facility's policy titled "[MEDICAL CONDITION] Protocol" on 07/01/09. Review of this, at 1:45 p.m. on 07/01/09, found no limitations on a resident's shower schedule during active infection. On 06/30/09 at 11:00 a.m., a licensed practical nurse (LPN - Employee #127), when interviewed, stated, "Residents with [MEDICAL CONDITION] do not get showers due to loose stools." On 07/01/09 at 2:45 p.m., the DON stated residents with [MEDICAL CONDITION] infection can have showers, and it is not the facility's policy to hold showers for residents with [MEDICAL CONDITION] infection. The DON further stated she needed to educate her staff regarding the current policy. Resident #133's medical record, when reviewed on 07/01/09 at 3:00 p.m., revealed a care plan for diarrhea dated 06/09/09. The interventions listed did not include withholding showers until the intestinal infection resolved. . | 2014-04-01 | ||
| 11368 | 11368 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 431 | E | IFJQ11 | Based on an observation and staff interview, the facility did not ensure that two (2) of two (2) treatment carts were entered only by authorized personnel. A nursing assistant was permitted to have a key to open both treatment carts, which contained supplies and topical medications prescribed to residents by the physician. Facility census: 53. Findings include: a) An observation, on 03/18/09 at 10:00 a.m., revealed a nursing assistant (NA) was assisting the treatment nurse with resident treatments on 200 hall of the facility. The NA was observed using a key to enter the treatment cart and remove treatment supplies. An interview the NA, on 03/18/09 at 10:30 a.m., revealed she assisted the treatment nurse and was permitted to have a key to open both treatment carts. She also stated she would retrieve the necessary supplies and treatments (which would include physician-ordered topical medications) for the nurse. . | 2014-04-01 | ||
| 11369 | 11369 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 225 | D | IFJQ11 | Based on facility record review and staff interview, the facility failed to make reasonable efforts to uncover criminal histories of two (2) sampled employees, by failing to conduct criminal background checks in all States in which these employees had previously worked. Employee identifiers: #1 and #4. Facility census: 53. Findings include: a) Employee #1 A review of the personnel file of Employee #1, who was hired on 01/21/08, revealed she possessed a nursing license from the Commonwealth of Pennsylvania, and information on her her employment application indicated prior work history in that State. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. b) Employee #4 A review of the personnel file of Employee #4, who was hired on 12/23/08, revealed prior work history in the State of Ohio. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. . | 2014-04-01 | ||
| 11370 | 11370 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 314 | G | IFJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation,and staff interview, the facility failed to provide the necessary care and services to prevent new pressure sores from developing for one (1) of three (3) residents whose medical records were reviewed for pressure ulcers. Resident #16 had been assessed as being at low risk for development of pressure ulcers. Medical record review revealed the resident developed a pressure ulcer, which was treated, healed, and then re-opened, because the facility failed to provide a pressure relieving device for chairs in which the resident spent most of the day sitting. Resident identifier: #16. Facility census: 53. Findings include: a) Resident #16 Medical record review revealed Resident #16 developed a pressure ulcer on 01/08/09. The resident was treated, and staff recorded the wound was healed on 02/16/09, after which preventive treatment was used. Review of the resident's Braden Scale, used to predicting pressure sore risk, revealed the resident was rated as being at mild risk for the development of pressure sores. During a treatment on 03/17/09 at 10:00 a.m., observation revealed the resident had a red area on the lower coccyx at the cleft of the buttocks. When the treatment nurse cleansed the red area, observation revealed two (2) small areas open areas which measured 0.2 x 0.2. Interview with the treatment nurse (Employee #80) during this observation revealed the area had been healed and these two (2) areas had just re-opened. When the treatment nurse was questioned as to why the resident had developed a pressure ulcer and why the area had re-opened, the nurse indicated the resident spent a large part of her day sitting in a chair at the nurse's station, and she stated the resident probably needed a pressure relieving cushion. On 03/17/09, observations found the resident moved independently in bed and was ambulatory with a walker and staff assistance. Observations beginning at 11:00 a.m. found the resident si… | 2014-04-01 | ||
| 11371 | 11371 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 329 | D | IFJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure the medication regimen of one (1) of ten (10) sampled residents was free of unnecessary drugs. Resident #21, who was receiving 2 mg a day of [MEDICATION NAME] (greater than the maximum daily dosage recommended for geriatric residents), was exhibiting no behaviors for which the medication was originally ordered, had the medication held on several occasions due to sleeping, and had no attempted gradual dose reduction for ten (10) months. Resident identifier: #21. Facility census: 53. Findings include: a) Resident #21 A review of the resident's medical record indicated this [AGE] year old female was admitted to the nursing facility on 05/07/08, with a physician's orders [REDACTED]." The resident continued to the present to receive the original dose [MEDICATION NAME] 0.5 mg four (4) times a day, for a total of 2 mg a day. A review of the facility's behavior record indicated that, for the months of February 2009, January 2009, December 2008 , November 2008, and October 2008, the resident did not exhibit any behaviors. The behaviors identified on this record for monitoring included agitation over need to leave and exit-seeking behavior. A review of the physician's progress notes revealed that only one (1) entry addressing the [MEDICATION NAME], dated 11/25/08, in which the physician indicated, "Continue [MEDICATION NAME] less overall anxiety and less of a fall risk at present." Observations of the resident, on 03/11/09 at 3:30 p.m. and 03/12/09 at 11:00 a.m., revealed the resident sitting in a wheelchair with the staff moving the resident to other locations in the facility. An observation of the resident, on 03/16/09 at 10:30 a.m.. revealed the resident lying in bed sleeping. Later at 2:30 p.m., the resident was again observed lying in bed sleeping. A nursing note, dated 02/26/09 (no time was documented), indicated the resident was lethargic related to not slee… | 2014-04-01 | ||
| 11372 | 11372 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2010-12-11 | 371 | F | RUPW11 | . Based on observation and staff interview, the facility failed to assure that two (2) male dietary aides wore effective hair restraints to prevent potential contamination of food by facial hair. This unsanitary practice had the potential to affect all residents receiving an oral diet. Facility census: 80. Findings include: a) An inspection of the dietary department, during the noon meal on 12/11/10 at 12:20 p.m., noted one (1) male dietary aide (Employee #3) was assisting with the service of the noon meal. Observation found Employee #3 had approximately 1/2 inch hair growth on his lip and chin with no beard guard in use to prevent his facial hair from potentially contaminating the food being served. Further observation found another male dietary employee (Employee #4) making peanut butter and jelly sandwiches in an adjacent room. Observation found Employee #4 had facial hair on his lip, chin, and along his jaw with no beard guard in place. When asked why he was not wearing a hair restraint on his beard and mustache, he stated that he had only worked there about three (3) weeks and had never been told he needed to wear anything on his face. | 2014-04-01 | ||
| 11373 | 11373 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2011-01-13 | 441 | E | JK1V11 | . Based on observation, staff interview, and a review of the facility's handwashing policy and procedures, the facility failed to ensure four (4) of nine (9) nursing employees observed washed their hand in accordance with acceptable hand hygiene practices per the facility's handwashing policy. Employees #102, #27, #71, and #155 were observed to turn off the faucet with their hands before drying their hands and without obtaining a clean paper towel to turn off the water. This had the potential to affect any resident receiving care from these employees after their hands became recontaminated from contact with the water faucet. Resident identifiers; #39, #115, #36, and #22. Facility census: 132 Findings included: a) Employee #102 During observations made on 01/12/11 at 1:30 p.m., a registered nurse (RN - Employee #102) was observed while washing her hands and after providing perineal care to Resident #39. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for two (2) of three (3) handwashing observations for this employee. -- b) Employee #27 During observations made on 01/12/11 at 1:45 p.m., a nursing assistant (Employee #27) was observed while washing her hands and after providing perineal care to Resident #115. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for one (1) of two (2) handwashing observations for this employee. -- c) Employee #71 During observations made on 01/12/11 at 1:45 p.m., a licensed practical nurse (LPN - Employee #71) was observed while washing her hands and after providing perineal care to Resident #115. She turned off the water faucet after washing her hands without obtaining a paper towel to dry her hands and to turn off the water faucet. This occurred for one (1) observation for this employee. -- d) Employee #155 During observations of incontinence care on 01/12/11 between 3:10 p.m. an… | 2014-04-01 | ||
| 11374 | 11374 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-01-05 | 257 | E | TDRO11 | . Based on observation, confidential family interview, confidential resident interviews, and staff interview, the facility failed to maintain an environment with temperatures that were comfortable for the residents. Residents expressed that it was often cold in the front hallway area of the facility that leads to the outside. This was an area frequented by residents and visitors, and persons had to pass through this area to access the activity room, the dining area, and the therapy room. The uncomfortably cold temperature of this area had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) During a tour of the facility on 01/03/11 beginning at 1:00 p.m., the temperatures in different areas of the facility were measures, and all areas were found to be above 72 degrees Fahrenheit (F) except the front lobby. The maintenance supervisor (Employee #3) was asked to place a thermometer in this area, so the temperature could be monitored in the hall. Using the facility's own thermometer, the temperature in that hallway at that time was 68 degrees F. Observation also found the heater on the hall in that area was not turned on at that time. - A confidential family interview, conducted on the afternoon of 01/03/11, revealed the facility's temperatures fluctuated a lot, and it was often very cold in this hallway. She stated her mother, who often sites in the hallway, gets very cold, and staff does put a blanket on her, but she would feel the end of her mother's nose and find it to be "cold as ice". - Confidential interviews with alert and oriented residents identified six (6) residents who felt the ambient temperature of this area was uncomfortably cold. One (1) resident stated, "When it is real cold outside, you can not hardly stand to come through that area, but you have to go through it to get to the dining room. Then you are cold when you get in the dining room, because you came through that cold air." Another resident commented that it was very cold in the area whe… | 2014-04-01 | ||
| 11375 | 11375 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-01-05 | 323 | D | TDRO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure the resident environment was free of accident hazards, by applying elevated half side rails to the bed of one (1) of seven (7) residents without first determining these half rails were necessary and safe for use. The facility assessed Resident #43 for the need for side rails on his bed, and his most recent assessment revealed the use of side rails was not indicated. The resident was observed, on 01/05/11, to have half side rails up. This resident was confused, he required staff assistance with transfers and mobility, and he had a history of [REDACTED]. Resident identifier: #43. Facility census: 57. Findings include: a) Resident #43 Observation of Resident #43, on 01/05/11 at 10:00 a.m., found him in bed with a half side rail in the elevated position. The nursing assistant (NA - Employee #29) caring for Resident #43 was interviewed at 10:05 a.m. on 01/05/11, regarding the use of side rails on this resident's bed. This employee stated Resident #43 used side rails to turn and reposition himself in bed. When asked how she determines who was suppose to use bed rails, she stated that the rails were secured down and could not be raised on the beds of residents who were not to use the rails. Review of Resident #43's medical record found a side rail assessment completed on 11/01/11. This assessment indicated the resident did not meet the criteria for the use side rails. Further review of the medical record revealed his [DIAGNOSES REDACTED]. In an interview at 1:00 p.m. on 01/05/11, the director of nursing (DON - Employee #70) identified that Resident #43 should not have side rails used on his bed. She stated that he was confused and he was not supposed to have side rails. She verified the assessment completed on this resident showed that side rails were not indicated for this resident and, therefore, the side rails should not be used. | 2014-04-01 | ||
| 11376 | 11376 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 157 | D | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the electronic medical record, staff interview, family interview, and incident report review, the facility failed to immediately inform the legal representative when one (1) of nine (9) sampled residents was involved in an incident requiring physician intervention. Resident #100, who had a history of [REDACTED]. After the son intervened, staff contacted the physician and Resident #100 was subsequently sent to the hospital where she was diagnosed with [REDACTED]. Facility census: 115. Findings include: a) Resident #100 On 11/16/10 at approximately 9:00 a.m., a family interview revealed Resident #100's son, who was also her legal representative, did not receive notification that his mother fell on [DATE] until he came to the facility on [DATE] and found a bruise on her shoulder. - Documentation on an incident report dated 10/16/10, when reviewed on 11/16/10 at approximately 1:00 p.m., revealed the nurse wrote, "As I was starting up the hallway, to do my med pass heard resident in (room #) yelling out. When entered the room and walked to her side (sic) she already started out of the bed on her arms before I got to her; the bottom half slithered out. Asked resident if she could get up and she attempted but went down on her right side." Documentation on the report related to notification of the resident's responsible party found the son was not notified of the fall until 5:00 p.m. on 10/17/10. - Review of Resident #100's electronic medical record, on 11/16/10 at approximately 2:00 p.m., revealed a nursing progress note identified as a "late entry" and dated 10/16/10 at 21:00 (9:00 p.m.) which stated, "As I was walking up the hallway to do my med pass. Writer heard resident yelling out. When entered the room and walked to her side. She already started out of the bed on her arms before I could get to her; the bottom half slithered out and onto the mat. Asked resident if she could get up and she attempted but went down onto her… | 2014-04-01 | ||
| 11377 | 11377 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 441 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the facility failed to fully implement appropriate measures to control the spread of scabies and to prevent possible re-exposure and re-infestation, in accordance with the facility's infection control policies and procedures and accepted standards of professional practice. These practices had the potential to result in more than minimal harm to all residents. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the handling of an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled "4.12 Scabies" (last revised on 02/01/10), the following process was to be implemented: "5 - Implement procedures to eliminate infestation and prevent transmissio… | 2014-04-01 | ||
| 11378 | 11378 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 490 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's policies and procedures, staff interview, and review of information published on the Internet by the Mayo Clinic and the American Academy of Family Physicians on the topic of scabies, the governing body failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical well-being of all residents and others. The facility's administration failed to oversee and ensure the infection control policies and procedures were implemented as written to manage an outbreak of scabies and prevent transmission to others inside and outside the facility. This practice has the potential to cause more than minimal harm to all residents, staff, and visitors. This is a REPEAT DEFICIENCY, as the facility was cited for non-compliance with this requirement related to the governing body's failure to ensure the facility responded appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. Resident identifiers: #36, #98, #13, and #40. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents ' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were… | 2014-04-01 | ||
| 11379 | 11379 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 520 | F | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of the facility's infection control policies and procedures related to scabies, review of other facility documentation, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to implement appropriate plans of action to prevent the spread and re-infestation of scabies when a resident was diagnosed with [REDACTED]. The facility was aware of potential quality deficiencies associated with the implementation of policies and procedures to prevent the spread of scabies, as the facility was previously cited for non-compliance related to the facility's failure to respond appropriately to an outbreak of scabies during a complaint investigation completed on 06/16/10. These practices had the potential to result in more than minimal harm to all residents. Facility census: 115. Findings include: a) Observations, during a tour of the facility beginning on 11/15/10 at 7:15 p.m., found several open clear plastic bags in residents' rooms throughout the facility. In an interview on 11/15/10 at 7:15 p.m., a nursing assistant (Employee #145) confirmed the facility had an outbreak of scabies. Employee #145 stated, "We are to leave all the residents' personal items that cannot be washed in a sealed plastic bag for 7 days. November 19th will be the last day." The bags, when examined, were not labeled to instruct staff, residents, and/or visitors to not open them until a certain date had come to pass, nor was there any way to determine whether the items in the bags had remained contained for a period of at least seven (7) days. The nursing assistants, when questioned about these bags, confirmed they had to remain sealed until seven (7) days after they were originally bagged. - According to the facility's policy titled "4.12 Scabies" (last revised on 02/01/10), the following process was to be implemented: "5 - Implement procedures to eliminate infestation and prevent transmission to others. "5.1 - Use… | 2014-04-01 | ||
| 11380 | 11380 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 309 | G | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on incident report review, medical record review, staff interview, and family interview, the facility failed to ensure one (1) of nine (9) sampled residents received prompt medical attention following a fall from bed. The facility failed to contemporaneously collect and record physical assessment data following a fall (to identify possible injuries), failed to immediately notify the resident's family and physician of the fall, failed to communicate the fall to oncoming shifts so that staff would know to monitor the resident for possible sequelae of the fall, and failed to assess / monitor the resident after the fall to identify the need for, and obtain, medical intervention until after a family member intervened. On 10/16/10 at approximately 9:00 p.m., Resident #100 was said to have "slithered" out of her bed and onto the floor unassisted. The licensed practical nurse (LPN) who observed the incident (Employee #128) did not complete an incident report or document anything about the event in the resident's medical record at the time of the occurrence. She generated a "late entry" nursing note and an incident report (both dated 10/16/10), stating Resident #100 had no apparent injury related to the fall and no complaints of pain. When interviewed, Employee #128 admitted to not having completed a thorough assessment after the fall occurred on 10/16/10, and she admitted to not having documented anything about this fall (on either an incident report or in the nursing notes) until after the family's visit, which occurred on the evening of 10/17/10. No contemporaneous entries were made in the resident's nursing notes about Resident #100 having an injury until 6:20 p.m. on 10/17/10, when the nurse on duty at that time (Employee #34) recorded that the resident's son found a bruise on the resident's right shoulder that was dark purple in color; when interviewed, Employee #34 reported she had not been aware of the fall on 10/16/10 at the bruising … | 2014-04-01 | ||
| 11381 | 11381 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2010-12-09 | 514 | D | 3ZOF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to ensure the medical record of one (1) of nine (9) sampled residents was maintained in accordance with accepted standards of professional practice. Resident #100 was observed by a licensed practical nurse (LPN) having "slithered" out of her bed and onto the floor on the evening of 10/16/10. The LPN who witnessed this occurrence (Employee #128), when interviewed on 12/09/10, reported that she did not record an entry in the resident's nursing notes when the event occurred; rather, she recorded an entry in the nursing notes after the family noticed extensive bruising on the resident's shoulder during a visit on the evening of 10/17/10. The note, which was identified as a "late entry" and dated 10/16/10 at 21:00 (9:00 p.m.), did not contain any information to alert the reader that it was actually recorded after the fact, at a later date and time. Additionally, review of the resident's activities of daily living (ADL) flowsheet for October 2010 revealed blanks where the assigned nursing assistant should have recorded the amount of ADL assistance provided to the resident on the day shift (7:00 a.m. to 3:00 p.m.) on 10/17/10, and staff recorded "OOF" (out of facility) for the evening shift (3:00 p.m. to 11:00 p.m.) on 10/17/10, even though she did not leave the facility until 6:20 p.m. on that date. According to this resident's most recent minimum data set assessment, she was totally dependent on staff for all ADLs. Resident identifier: #100. Facility census: 115. Findings include: a) Resident #100 1. Review of facility records, conducted on 11/16/10 at approximately 11:00 a.m., revealed an incident report dated 10/16/10 for an event said to have occurred at 9:00 p.m. on 10/16/10 involving Resident #100. The report stated, "A… | 2014-04-01 | ||
| 11382 | 11382 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 327 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to: (1) ensure a resident with a gastrostomy feeding tube received all 275 cc free water flushes in accordance with physician orders; (2) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although el… | 2014-04-01 | ||
| 11383 | 11383 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 224 | G | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, review of information published on the Internet related to the topics of "fever" and "axillary temperature", and staff interview, the facility failed to provide goods and services necessary to avoid physical harm to one (1) of five (5) residents (#28). The facility failed to: (1) obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. Tylenol in accordance with physician orders [REDACTED]. line insertion site and ostomy sites for signs of irritation or infection; (6) change the resident's central line dressing weekly in accordance with facility protocol; (7) ensure the resident received all 275 cc free water flushes in accordance with physician orders; (8) monitor the resident to ensure he was having adequate urinary output each shift and irrigate the resident's suprapubic catheter if his urinary output was less than 200 cc in an 8-hour shift in accordance with physician's orders [REDACTED]. the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a UTI. This failure to provide necessary goods and services resulted in physical harm to Resident #28, who was transferred to a hospital on [DATE] and was subsequently diagnosed with [REDACTED]. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facilit… | 2014-04-01 | ||
| 11384 | 11384 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 157 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, review of facility policies and procedures, and review of information published on the Internet related to the topics of "fever" and "axillary temperature facility failed, for one (1) of five (5) sampled residents, to promptly notify the physician when the resident exhibited intermittent elevated temperatures beginning two (2) days after having completed a 3-day course of antibiotic for a urinary tract infection [MEDICAL CONDITION]. Resident #28 completed his antibiotic therapy on 11/07/10 and began having intermittent fevers on 11/09/10. Staff did not notify the physician of this until 11/16/10. The resident, who was transferred to a hospital on [DATE], was subsequently diagnosed with [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff memb… | 2014-04-01 | ||
| 11385 | 11385 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 514 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, the facility failed to maintain clinical records for one (1) of five (5) residents (#28) in accordance with accepted professional standards and practices that are completed, accurately documented, readily accessible, and systematically organized. The facility failed to obtain and consistently record in the same place in the electronic medical record Resident #28's vital signs (e.g., temperature) every shift in accordance with his care plan related to antibiotic administration via his central line for the treatment of [REDACTED]. readings for analysis, tracking, and trending of abnormal findings. The facility also failed to record on the medication administration record (MAR) each time Tylenol was given from an elevated temperature and failed to record on the reverse side of the MAR whether the medication was effective in reducing his temperature. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his minimum data set assessment (MDS 3.0), an abbreviated quarterly assessment with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10. Further review of assessment data revealed he was transferred (with return anticipated) to an acute care hospital on [DATE], and he returned to the facility on [DATE]. -- 2. A review of the resident's electronic medical record at the nursing facility revealed a weights and vitals summary report (VSR) for the period of 10/16/10 to 11/17/10 revealed the following consecutive entries: - 10/16/10 at 3:55 a.m. - 97.4 (axilla) - 11/05/10 at 10:51 p.m. - 99.2 (axilla) - High of 99.0 exceeded - 11/05/10 at 11:30 p.m. - 101.10 (axilla) - High of 99.0 exceeded - 11/06/10 at 12:51 a.m. - 98.1 (axilla) - 11/08/10 at 3:29 a.m. - 98.7 (axilla) - 11… | 2014-04-01 | ||
| 11386 | 11386 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 282 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, policy review, and staff interview, the facility failed to provide services to one (1) of five (5) sampled residents in accordance with the resident's comprehensive plan of care including physician orders, with respect to: monitoring vital signs; providing free water flushes as ordered; monitoring the resident's urinary output to ascertain whether it was necessary to irrigate the resident's suprapubic catheter; monitoring central line and ostomy sites for signs of infection; and providing dressing changes to the central line site as ordered. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did not receive any nutri… | 2014-04-01 | ||
| 11387 | 11387 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 279 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of records from two (2) hospitals, and staff interview, the facility failed, for one (1) of five (5) sampled residents, to develop a care plan to ensure a resident with a gastrostomy feeding tube and a suprapubic catheter, who had a history of [REDACTED]. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Resident Assessment Data Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According to the State-specific section of this MDS, the resident had NOT acquired any MDRO infections since his last assessment, to include [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The assessor noted Resident #28 was alert, rarely / never able to make self understood or to understand others, with impaired short and long term memory and severely impaired cognitive skills for daily decision making. He required the extensive physical assistance of two (2) or more staff members for bed mobility, transferring, locomotion, dressing, toilet use, and personal hygiene, he was totally dependent on one (1) staff member for eating, he did NOT receive any nutrition through tube feeding (although elsewhere in his record was noted that he received feedings through a gastrostomy - "PEG tube" or "[DEVICE]"), and he was frequently incontinent of bowel and had in place an indwelling urinary catheter (elsewhere in his record, it was noted to … | 2014-04-01 | ||
| 11388 | 11388 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 281 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, review of information published on the Internet related to the topics of "fever" and "axillary temperature", and policy review, the facility failed to provide services that meet professional standards of quality for one (1) of five (5) sampled residents (#28). Resident #28, who had a gastrostomy feeding tube and a suprapubic catheter and who had a personal history of urinary tract infections, exhibited an elevated temperature beginning on 11/04/10. On 11/05/10, staff contacted the physician, who ordered a 3-day course of antibiotics ([MEDICATION NAME]) via intramuscular injection (IM). Two (2) days after this first course of antibiotics ended, the resident began (on 11/09/10) to exhibit intermittent elevated temperatures; however, the staff did not promptly notify the physician of this. These temperatures were taken via axilla, which is usually 1 degree Fahrenheit (F) below a temperature taken orally; the temperatures were not monitored at the frequency specified in the resident's care plan; they were not consistently recorded in the same place in the medical record for ready access for analysis, tracking, and trending; and the staff did not always medicate with Tylenol when indicated. Resident identifier: #28. Facility census: 68. Findings include: a) Resident #28 1. Review of Resident #28's electronic medical record revealed a [AGE] year old male who was originally admitted to the facility in 2004. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. Although the assessor noted the resident had infection with a multi-drug resistant organism (MDRO), the assessor did NOT place checkmarks in the assessment to indicate the resident's active [DIAGNOSES REDACTED]. According t… | 2014-04-01 | ||
| 11389 | 11389 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2010-12-21 | 278 | D | NKSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of resident assessment data and physician orders, the facility failed, for one (1) of five (5) sampled residents, to ensure each resident assessment accurately reflected each resident's health status and condition. Resident #28's primary source of nutrition was received via a gastrostomy tube, but his most recent abbreviated quarterly assessment did not identify the presence of this feeding tube. Facility census: 68. Findings include: a) Resident #28 Record review, on 12/20/10 and 12/21/10, included a review of the resident's assessments and physician orders. According to his most recent minimum data set assessment (MDS v 3.0) - an abbreviated quarterly MDS with an assessment reference date (ARD) of 10/04/10, his most recent re-entry to the facility as of the ARD occurred on 01/17/10, and his active [DIAGNOSES REDACTED]. In Section G, the assessor noted Resident #28 was totally dependent on one (1) staff member for eating. In Section K, the assessor noted he did NOT receive any nutrition through tube feeding. Review of the physician's orders [REDACTED]. - "Peg tube: Magna ports 20 Fr. 10cc - FYI - Change when dysfunctional. May use 18 fr 10cc or 20 fr 10cc." This order was originally given on 07/29/09 - "[MEDICATION NAME] 1.5 at 85 cc (sic) hour for 20 hour cycle with 4 hours down time (sic) off at 6am (sic) on at 10 am (sic) continue with h2o (sic) flushes of 275cc (sic) every 4 hours for additional 1650ml (sic) a day. Hold if residual (sic) 100ml or over." This order was originally given on 05/18/09. Review of the resident's most recent comprehensive assessment (MDS 2.0) with an ARD of 01/28/10 revealed, in Section K, the assessor did note the presence of a feeding tube, which was used to provide 76-100% of the resident's total daily calories and 2001 or more cc of fluid intake daily. . | 2014-04-01 | ||
| 11390 | 11390 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2010-12-29 | 329 | D | CYQN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of five (5) residents reviewed, to assure the resident's drug regimen was free of unnecessary drugs. A resident receiving a medication that had the ability to affect her level of consciousness, and which was ordered to treat the symptom of anxiety, was awakened by the nurse by having her face bathed with a cold cloth in order to receive an additional dose of that same medication. Resident identifier: #65. Facility census: 61. Findings include: a) Resident #65 When reviewed on 12/28/10, the closed medical record of Resident #65 divulged the resident had been admitted to the facility in February 2001 and was 80-years old at that time. When transferred to the hospital from the facility on 12/11/10, the resident's weight was noted to be 70 pounds. The resident was noted to have [DIAGNOSES REDACTED]. The resident's record further revealed she suffered with severe breathing problems and frequent episodes of anxiety, possibly associated with the inability to breathe without difficulty. The resident had been receiving the medication Klonopin for anxiety, in varying dosages since the time of admission to the facility. On 12/10/10, a physician's orders [REDACTED]. According to the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to http://www.fda.gov/downloads/Drugs/DrugSafety, the patient medication guide for the medication Klonopin indicated the most common side of the medication is drowsiness. Facility nurse's notes, on 12/11/10 at 10:50:57 a.m., stated, "Klonopin 0.5mg given this am (morning) and resident very hard to awaken. Cold wash cloth applied to forehead and to resident's face. Resident aroused long enough to give meds. Also was unable to feed resident breakfast or to give am (morning) snack..." The resident was not exhibiting the symptom of anxiety for which it was ordered, and she was actually experiencin… | 2014-04-01 | ||
| 11391 | 11391 | NELLA'S INC. | 51A010 | 399 FERGUSON ROAD | ELKINS | WV | 26241 | 2010-03-17 | 225 | D | N9NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, family interview, and staff interview, the facility failed to immediate report and/or thoroughly investigate allegations of abuse and/or neglect to the appropriate State agencies. This affected two (2) of three (3) sampled residents whose closed records were reviewed. Resident identifiers: #94 and #96. Facility census: 92. Findings include: a) The facility was entered at 1:00 p.m. on 03/15/10. At 1:15 p.m., a request was made of the social worker for records including all incident / accident reports, internal complaints, and allegations of abuse / neglect reported and investigated by the facility from 01/01/10 to the present. Within the hour, the incident / accident reports were submitted to this surveyor, but the social worker stated there had been no complaints or allegations received by the facility since 01/01/10. b) Resident #94 Review of Resident #94's closed medical record revealed a [AGE] year old male who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reflected he refused to communicate most of the time and isolated himself from others. This behavior was not new and was related by family in his admission history. He had been determined by physician to lack capacity, and a family member was appointed to serve as his health care surrogate (HCS), although he was alert, could make his needs known, and understood what was said to him. He was discharged on [DATE], because of aggressive behaviors (both physical and verbal), after the nursing home stated they were unable to provide the care he needs. In an interview with the resident's HCS at 10:00 a.m. on 03/17/10, she stated she was relieved that he was no longer at the facility, because none of her complaints was ever addressed. She stated that, after his readmission from the hospital in January 2010, she was notified he was stockpiling razors in his room. She complained to the nursing home that, bec… | 2014-04-01 | ||
| 11392 | 11392 | NELLA'S INC. | 51A010 | 399 FERGUSON ROAD | ELKINS | WV | 26241 | 2010-03-17 | 165 | D | N9NH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, family interview, and staff interview, the facility failed to support each resident's right to voice grievances and failed, after receiving a complaint or grievance, to actively seek a resolution and keep the resident or his or her representative appropriately apprised of the facility's progress toward resolution. This affected three (3) of three (3) sampled residents whose closed records were reviewed. Resident identifiers: #94, #95, and #96. Facility census: 92. Findings include: a) The facility was entered at 1:00 p.m. on 03/15/10. At 1:15 p.m., a request was made of the social worker for records including all incident / accident reports, internal complaints, and allegations of abuse / neglect reported and investigated by the facility from 01/01/10 to the present. Within the hour, the incident / accident reports were submitted to this surveyor, but the social worker stated there had been no complaints or allegations received by the facility since 01/01/10. A review of the facility's complaint policy, provided by the social worker on 03/16/10, revealed the following: "ALL COMPLAINTS RECEIVED BY THE FACILITY MUST BE DOCUMENTED IN THE COMPLAINT LOG, KEPT AT THE CHART DESK ON THE A-SIDE." "ALL COMPLAINTS AND SOLUTIONS SHOULD BE MAINTAINED IN A FILE FOR FUTURE REFERENCES, AFTER A COPY HAS BEEN SUBMITTED TO THE ADMINISTRATOR." b) Resident #94 Review of Resident #94's closed medical record revealed a [AGE] year old male who was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Documentation reflected he refused to communicate most of the time and isolated himself from others. This behavior was not new and was related by family in his admission history. He had been determined by physician to lack capacity, and a family member was appointed to serve as his health care surrogate (HCS), although he was alert, could make his needs known, and understood what was said to him. He was di… | 2014-04-01 | ||
| 11393 | 11393 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2010-12-07 | 323 | G | EBZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to provide an environment that is free from accident hazards over which the facility has control and failed to provide adequate supervision and/or assistive devices to prevent avoidable accidents. Three (3) residents, who were known to wander, sustained injuries during this unsupervised wandering, and the facility failed to review / revise their care plans and implement new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Residents #19, #20, and #36 wandered unsupervised throughout the facility. Although incident / accident reports disclosed these residents had sustained numerous injuries while wandering, the facility failed to evaluate and analyze hazards and failed to attempt to revise or implement additional measures that would prevent injury during the wandering episodes. Resident #19 had repeated falls, was slapped and shaken by other residents, and placed in her mouth items she had removed from the trash. Resident #20 had repeated falls, sustained a head laceration that required closure with staples as a result of one (1) fall and a dislocated shoulder following another fall. Resident #36 was known to have aggressive behaviors and to wander unsupervised about the facility; no attempt was made to manage these behaviors, which resulted in an altercation with another resident ending with a head laceration that required closure with sutures. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, h… | 2014-04-01 | ||
| 11394 | 11394 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2010-12-07 | 280 | D | EBZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of facility incident / accident reports, observation, staff interview, and resident interview, the facility failed, for three (3) of five (5) residents reviewed, to review / revise their care plans with new interventions to promote their safety when the existing care plan interventions were ineffective in preventing further injury. Resident identifiers: #19, #20, and #36. Facility census: 44. Findings include: a) Resident #19 1. The medical record of Resident #19, when reviewed on 12/06/10, revealed the resident had been admitted to the facility on [DATE], with medical [DIAGNOSES REDACTED]. This [AGE] year old female resident spoke very little English and was hard of hearing. At the time of admission, her physician determined she lacked the capacity to understand and make informed health care decisions. - 2. Review, on 12/06/10, of the facility's incident / accident reports for the months of October and November 2010 disclosed the following: - On 11/14/10 at 11:30 p.m., staff found Resident #19 on the floor in another resident's room, when they responded to Resident #19's yelling. On 11/17/10, the resident was noted to have "bruising each side of her nose" which was attributed to the 11/14/10 incident. - On 11/23/10 at 9:15 p.m., a report stated the resident was "slapped across the L (left) side of her face when resident (#19) tried to climb into bed with resident # (another resident)." - On 11/25/10 at 8:30 p.m., a report stated, "Resident at med cart taking something out of trash and appeared to have put dirty spoon in mouth from the trash." - On 11/27/10 at 5:00 p.m., another report stated, "CNA (certified nursing assistant) called my attention to a 3 cm round bruise on resident's L (left) hip. No pain noted." No explanation was offered as to the cause of this injury. - 3. Review of the resident's nursing notes revealed the following: - On 07/09/10 at 11:00 p.m., "CNA walking past room (#) she saw resident … | 2014-04-01 | ||
| 11395 | 11395 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 281 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, staff interview, and review of the Criteria for Determining Scope of Practice for Licensed Nurses published by the State licensing boards for registered professional nurses and licensed practical nurses (LPNs), the facility failed to provide services that meet professional standards of quality, as evidenced by the facility allowing an unknown employee to obtain intravenous access through an improper access site. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report dated 07/28/10 revealed an unknown employee had obtained intravenous access through Resident #109's port-a-cath without a physician's orders [REDACTED]. Review of the nurses note revealed no documentation of the incident and no clarification of the physician's orders. Review of the physician's orders [REDACTED]." Another hand-written entry, with no date, stating access port-a-cath times three (3) weeks after the following order: "[MEDICATION NAME] HCl 1 gram Intravenous (IV) - Q12H Everyday, 0900 2100: 1 gram Q12 [MEDICAL CONDITION]." An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 3:00 p.m., revealed the DON agreed that a port-a-cath should never be used as an intravenous access site without a physician's orders [REDACTED]. Review of the Criteria for Determining Scope of Practice for Licensed Nurses, revised in 2009, revealed a Scope of Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse. Review of the Practice Model for the Advanced Practice Nurse, Registered Nurse, and Licensed Practical Nurse revealed a guideline stating: "Is there a written order from a licensed Physician, Physician's Assistant, or Advanced Practice Nurse or is there a signed written protocol? If No, report / defer to qualifi… | 2014-03-01 | ||
| 11396 | 11396 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 309 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility incident / accident reports, and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, as evidenced by the facility allowed an employee to provide care to a resident without a physician's directive. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #109. Facility census: 108. Findings include: a) Resident #109 Review of an incident / accident report, dated 07/28/10, revealed a registered nurse (RN - Employee #111) went into resident's room to unhook intravenous access, and when she unhooked the intravenous access device, she realized that access had been obtained through a [MEDICAL TREATMENT] port-a-cath. Employee #111 stated she then unhooked the intravenous access device and flushed the [MEDICAL TREATMENT] port-a-cath. Review of the alleged abuse interview questionnaire, which was attached to the incident / accident report dated 07/28/10, revealed a statement from an unknown employee stating the oncoming RN found the antibiotic hanging and flushed the line (port-a-cath) with normal saline and [MEDICATION NAME] flush, and the physician was notified. Review of the nurses' notes, dated 07/28/10, revealed the physician was notified, but no directives from the physician to flush intravenous site (port-a-cath) were found. Review of the physician's orders [REDACTED]. On 11/03/10 at 3:00 p.m., an interview with the director of nursing (DON - Employee #106) revealed he agreed the port-a-cath should not have been flushed without a physician's orders [REDACTED]. . | 2014-03-01 | ||
| 11397 | 11397 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2010-11-03 | 441 | D | 3TTH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's infection control policies / procedures, review of the daily census report, and staff interview, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection, as evidenced by improper cohorting of a resident with Methicillin-resistant Staphylococcus aureus (MRSA) with a compromised resident. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #13. Facility census: 108. Findings include: a) Resident #13 Review of Resident #13's medical record revealed she had been cohorted in a room with Resident #82, who was positive for MRSA since 10/29/10. Review of the daily census report revealed Resident #13 was moved to another room on 11/01/10. Review of the physician's orders [REDACTED]. Resident #13 was receiving the following treatments: "Cleanse left lower leg with soap and water. Apply [MEDICATION NAME] cream, [MEDICATION NAME], and netting 2x per day on 7-3 and 11-7. Check placement QS. - NS, DS Everyday." and "Cleanse right lower leg with soap and water. Apply [MEDICATION NAME], and netting 1 time per day 7-3. Check placement QS. - DS Everyday." Review of the facility's infection control policies / procedures revealed a resident with MRSA "may be placed with a 'low risk' individual. Low risk means that the resident would not be clinically compromised. Definition of non-compromised resident is one who does not have surgical or other wound / open area." An interview with the director of nursing (DON - Employee #106), on 11/03/10 at 1:20 p.m., revealed he did not feel that Resident #13 was "low risk",and he further stated the proper protocol would have been to place Resident #82 on contact precautions, remove Resident #13 from that room, and contact the physician. | 2014-03-01 | ||
| 11398 | 11398 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2010-11-23 | 333 | D | D3L711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure residents were free of significant medication errors, when a resident's [MEDICATION NAME] (an anticoagulant) was not administered in accordance with physician's orders [REDACTED]. This was found for one (1) of six (6) records reviewed. Resident identifier: #99. Facility census: 128. Findings include: a) Resident #99 The medical record of Resident #99, when reviewed on 11/22/10 at 2:00 p.m., revealed this [AGE] year old woman had resided in the facility since 07/24/09 and was receiving [MEDICATION NAME] therapy for [MEDICAL CONDITION]. ([MEDICATION NAME] dosage is regulated based upon laboratory testing results designed to measure the blood clotting time and blood clotting factor.) Resident #99 was ordered a dosage of [MEDICATION NAME] for 1.5 mg by mouth every other day, alternating with [MEDICATION NAME] 3.0 mg by mouth every other day on 09/01/10. She was found to be stable on this dosage until lab results, dated 10/25/10, were elevated. A new order was written on 10/27/10, for [MEDICATION NAME] 3.0 mg by mouth on Day 1, then 1.5 mg by mouth on Days 2 and 3 on a repeating cycle, thus lowering the overall dosage. Documentation on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 11/01/10, the monthly recapitulation (recap) of physician's orders [REDACTED]. Consequently, the [MEDICATION NAME] orders on the November 2010 MAR indicated [REDACTED]. The physician had ordered on [DATE] (when the dosage was lowered) that a repeat lab test be conducted in two (2) weeks, because of the elevated results observed on the 10/25/10 test. When the lab results were obtained on 11/10/10, they were still elevated, and the error was apparently recognized. The dosage was subsequently changed back to conform with the physician's orders [REDACTED]. The MAR for November 2010 confirmed Resident #99 received [MEDICATION NAME] per the 10/2… | 2014-03-01 | ||
| 11399 | 11399 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 278 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, and staff interview, the facility failed to ensure resident assessment information was accurate for one (1) of fifteen (15) sampled residents. Resident #61's medical record indicated a history of [MEDICAL CONDITIONS] with right-sided [MEDICAL CONDITION]. An abbreviated quarterly minimum data set assessment (MDS), with an assessment reference date of 09/10/08, indicated the resident did not have any limitations in range of motion or voluntary movement to his right arm and hand. Resident identifier: #61. Facility census: 89. Findings include : a) Resident #61 Resident #61 was observed and interviewed at 2:45 p.m. on 01/21/09, at which time he was noted to have a contracture and paralysis of the right hand. Resident #61 reported he had a stroke several years ago and did not have function of his right arm and hand. Medical record review, on 01/22/09 at 10:45 a.m., revealed the resident had a history of [REDACTED]. On 01/21/09 at 10:45 a.m., the MDS coordinator (Employee #98) was interviewed. The MDS coordinator provided the resident's most recent quarterly MDS, a significant change in status MDS, and the current care plan. Review of Section G4 of the MDS dated [DATE], revealed the information contained in this section was incorrect; the assessment indicated the resident had no limitation in function and voluntary movement to his arm or hand. The resident did have functional limitations of his right arm and hand due to post-[MEDICAL CONDITION] paralysis. . | 2014-03-01 | ||
| 11400 | 11400 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 241 | D | FRRZ11 | Based on observation and staff interview, the facility failed to ensure care was promoted in a manner and in an environment that maintained the dignity of two (2) of fifteen (15) sampled residents. Resident #78 was observed in bed prior to having received morning care, while the maintenance man was painting the wall in the resident's room and was not interacting with the resident. Resident #86 was observed in a public area of the facility, crying and begging for help, and the resident's dentures were laying on her chest. Resident identifiers: #78 and #86. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room; the maintenance man was not engaging the resident in any conversation. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. This resident should have been moved to another area of the facility after providing morning care and breakfast, and prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed maintenance should not have painted in the resident's room at that time. b) Resident #86 On 01/20/09 at 2:10 p.m., observation found this resident was sitting in a wheelchair in the front lobby at the nurse's station. The resident was crying and begging this surveyor to help her, and her dentures were laying on her chest. Further observation found staff at the nurse's station and walking past the resident, paying no attention to the condition the resident was in. During an interview on 01/21/09 at 3:30 p.m., the DON agreed the resident should have been removed from the public area and the resident's discomfort assessed. . | 2014-03-01 | ||
| 11401 | 11401 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 279 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans to include hospice services and review and revise a care plan for three (3) of fifteen (15) sampled residents. Residents #78 and #28 were receiving hospice services and the comprehensive care plan failed to include the services to be provided by hospice. A care plan had been developed for Resident #42 which did not accurately describe the resident's pain and had not been revised when reviewed. Resident identifiers: #78, #28, and #42. Facility census: 89. Findings include: a) Resident #78 Medical record review, on 01/20/09, revealed this resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan, revised in November 2008, revealed the care plan did not include the services to be provided by hospice. The resident's comprehensive care plan failed to have an integrated care plan with hospice which included the services provided by hospice with interventions describing who would do them and when they would be done. During an interview on 01/22/09 at 2:00 p.m., the minimum data set assessment (MDS) coordinator confirmed the comprehensive care plan and the hospice care plan was not integrated ensuring continuity of care by both facility and hospice staff. b) Resident #42 Medical record review, on 01/20/09, and a review of the comprehensive care plan it was revealed during the review of the activity care plan this resident indicated she could not leave her room due to pain. During further review of the activity care plan dated September, 2008, under the heading of Problems / Strengths was a quote "I want something to do, but I can't leave my room due to pain and need to be comfortable. I lie in bed most of the day." During a review of the estimated date of the goals it was discovered this activity plan had been reviewed on 01/19/09 with no changes made. During interviews on 01/21/09 at 4:00 p.m., the director of nursing (DON) an… | 2014-03-01 | ||
| 11402 | 11402 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 309 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure care and services were provided in a manner to maintain the highest practicable physical well-being for one (1) of fifteen (15) sampled residents. Resident #78 had a medical history of [REDACTED]. Resident identifier: #78. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. The room smelled strongly of paint. Medical record review revealed Resident #78's [DIAGNOSES REDACTED]. This practice put the resident at risk for respiratory distress and can contribute to a poor appetite. This resident should have been moved to another area of the facility prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed the room should not have been painted while the resident was in the room. . | 2014-03-01 | ||
| 11403 | 11403 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 441 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a sanitary environment to prevent the spread of infections in the facility during treatments provided to residents with known infections. Observation of the treatment nurse (Employee #2) during a treatment found her kneeling beside the resident's bed while applying a dressing to Resident #86's wound; she contaminated her uniform by kneeling on the floor, as she wore no protective clothing during this dressing change. This resident (#86) had a history of [REDACTED]. Resident identifier: #86. Facility census: 89. Findings include: a) Employee #2 During treatment administration on 01/21/09 at 1:10 p.m., observation found the treatment nurse changing a dressing to a pressure sore on Resident #86's coccyx. The treatment nurse knelt on the floor beside the resident's bed while applying the dressing. Although the nurse used universal precautions during the procedure, she did not don protective clothing. By kneeling on the floor, the contaminated her uniform. Medical record review revealed the resident had a history of [REDACTED]. Observation found, upon entering the resident's room, a sign advised visitors of the need for contact isolation and to see the nurse before entering the room. During an interview on 01/21/09 at 4:15 p.m., the director of nursing (DON) agreed the treatment nurse should not have been on the floor of this resident's room while changing the dressing. . | 2014-03-01 | ||
| 11404 | 11404 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 225 | D | FRRZ11 | Based on review of the facility's complaint / grievance log and staff interview, the facility did not ensure two (2) of twenty (20) sampled complaints / grievances containing allegations of neglect were immediately reported to the appropriate State agencies. Resident identifiers: #22 and #96. Facility census: 95. Findings include: a) Resident #22 On 01/01/09, Resident #22 alleged, "he did not have a pad for his bed. CNA (named by resident) was asked to get one for his bed. The CNA told him no, that they took them out of the building. He reported that he had to sleep on a bath blanket which wrinkled and caused a sore to his buttocks." The facility's investigation revealed cloth pads were to be available for this resident, and the nurse had assessed the resident after he was placed on the bath blanket and found the resident's buttocks were more red and irritated. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. b) Resident #96 On 11/19/08, Resident #96 alleged, "Resident had call light on for 50 minutes and roommate also call light on also and that fresh water on the 2:00 p.m. to 10:00 p.m. shift was not provided." The facility's investigation revealed the nursing assistant involved was identified and education would be provided for answering call lights and providing fresh water to residents. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. . | 2014-03-01 | ||
| 11405 | 11405 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2010-11-02 | 279 | E | QWDA11 | . Based on observation, record review, and staff interview, the facility did not develop care plans for six (6) of seven sampled residents to provide justification for the residents to sit in the facility hallways in front of the nursing station to eat their meals. Resident identifiers: #19, #6, #26, #46, #45, and #44. Facility census: 75. Findings include: a) Residents #19, #6, #26, #46, #45, and #44 Observations, on 11/01/10 beginning at 12:15 p.m., found the above-identified six (6) residents sitting in front of the nursing stations in the hallways eating their lunch. Some of the residents were able to eat without assistance, and others were being fed by the staff. Four (4) residents (#6, #26, #46, and #45) were observed on the South hall, and two (2) residents (#19 and #44) were observed on the North hall. An interview with the director of nursing (DON), on 11/01/10 at 12:15 p.m., revealed the residents wanted to eat in the hallway in front of each nursing station. She further stated that some of the residents were unable to make the decision to eat in the hallway and the legal representative requested that the resident eat in the hallway in front of the nursing station. The DON also stated all of these residents had a care plan identifying the reason for each resident eating meals in this location. A review of the care plans these residents found no mention of eating their meals in the hallways. . | 2014-03-01 | ||
| 11406 | 11406 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2010-11-02 | 309 | D | QWDA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not ensure one (1) of seven (7) sampled residents did not receive the influenza vaccine in accordance with the legal representative's wish to decline the vaccine due to an allergy. Resident identifier: #19. Facility census: 75. Findings include: a) Resident #19 Record review revealed a facility consent form titled "Vaccine Administration Authorization", upon which was recorded either acceptance or refusal to receiving the influenza vaccine, indicated that Resident #19's legal representative declined administration of the influenza vaccine, because the resident was allergic to it. On 10/21/10 at approximately 6:30 a.m., a nurse administered the influenza vaccine to the resident contrary to the wishes of the legal representative. At 8:00 a.m. on 10/21/10, Resident #19 became unconscious and was transferred to the hospital and admitted . Review of hospital records for Resident #19 revealed, "[AGE] year old female nursing home resident presented to the hospital after having two [MEDICAL CONDITION]. Patient had received [MEDICATION NAME] at the nursing home after getting the flu vaccine which she is allergic to. Patient had recently been taken off [MEDICATION NAME] which she was on for a number of years for agitation. Two weeks prior to having [MEDICAL CONDITION], [MEDICATION NAME] was discontinued abruptly and she was started on [MEDICATION NAME]. Patient was admitted and we restarted [MEDICATION NAME]." The hospital obtained an electrocardiogram (EKG), serial cardiac enzymes, CT of the brain, electroencephalogram (EEG), a chest X-ray, and blood work, and all results were within normal limits. An interview with the assistant director of nursing (ADON - Employee #32), on 11/01/10 at 1:30 p.m., revealed she was called to Resident #19's room after the influenza vaccine was administered to the resident by mistake at approximately 6:30 a.m. on 10/21/10. She immediately told the nurse to ca… | 2014-03-01 | ||
| 11407 | 11407 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2010-11-11 | 244 | E | VERC11 | . Based on review of resident council meeting minutes and staff interview, the facility failed to act upon a grievance made during a resident council meeting. On 09/27/10, residents expressed concerns regarding call lights not being answered during the midnight shift on Unit 4. This concern was not addressed by facility personnel. This practice had the potential to affect twenty-six (26) of twenty-six (26) residents who resided on Unit 4. Facility census: 107. Findings include: a) Review of the facility's 09/27/10 resident council meeting minutes, on 11/11/10, revealed residents expressed a concern regarding call lights not being answered on the midnight shift on Unit 4. Further review of the minutes revealed no evidence this concern had been acted upon by facility personnel. On 11/11/10 at 1:00 p.m., the administrator (Employee #16) was asked to provide evidence this issue had been addressed by the facility. At 1:10 p.m., Employee #16 reported the concern had not been acted upon as required. | 2014-03-01 | ||
| 11408 | 11408 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 157 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to notify the physician of a potential need to alter treatment for one (1) of six (6) sampled residents whose closed record was reviewed. Resident #119 was admitted to the facility on [DATE] following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for acute [MEDICAL CONDITION] (ARF), and her discharge orders from the hospital included [MEDICATION NAME] inhalation treatments every four (4) hours (at regular intervals six (6) times a day). According to documentation on her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record found no documentation reflecting either the physician or the physician extender had been notified of the resident refusing these treatments. This notification would have provided the physician an opportunity to change / modify treatment for this resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for ARF. Her discharge orders from the hospital included the administration of [MEDICATION NAME] inhalation treatments every four (4) hours. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated 2 = Drug Refused"). Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short… | 2014-03-01 | ||
| 11409 | 11409 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 225 | D | 50T311 | . Based on review of information from a criminal background check, staff interview, and review of a 2004 newsletter issued by the Office of Health Facility Licensure and Certification (OHFLAC) to all Medicare / Medicaid nursing facilities, the facility failed to ensure a West Virginia State Police background check was completed prior to hire for one (1) of one (1) background checks reviewed. Employee #123, a certified nurse practitioner (CNP), had been employed at this facility since May 2010, and no criminal background check by the West Virginia State Police had been completed as required by OHFLAC. Employee identifier: #123. Facility census: 118. Findings include: a) Employee #123 During a complaint investigation conducted at the facility between 11/08/10 and 11/11/10, it was discovered the facility had employed Employee #123 as a CNP since May 2010. Review of Employee #123's personnel record revealed the pre-employment screening conducted on this individual did not include a criminal background check by the West Virginia State Police in an effort to uncover a personal history of criminal convictions that may indicate this individual was unsuited for employment in a nursing facility. In an interview on the afternoon of 11/09/10, the facility's administrator (Employee #53) confirmed a criminal background check had not been conducted through the West Virginia State Police prior to hiring Employee #123. Review of a newsletter (dated November 2004), which had been distributed by OHFLAC to all Medicare / Medicaid certified nursing facilities in West Virginia, revealed the following directive: "... Regarding criminal background checks, both the State licensure rule and the Federal Medicare / Medicaid certification requirements mandate screening of applicants for employment in a nursing home or nursing facility. The licensure rule specifically requires nursing homes to conduct a 'criminal conviction investigation' on all applicants; the certification requirements require that nursing facilities 'must not employ indivi… | 2014-03-01 | ||
| 11410 | 11410 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 281 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, licensed nursing staff at the facility failed to follow facility policy regarding the administration of aerosolized medication to one (1) of six (6) sampled residents whose closed record was reviewed. According to her October 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to facility policy, licensed nursing staff was to collect and record physical assessment data regarding the resident's respiratory status prior to and following the administration of an aerosolized medication and the resident's response to each treatment after administration was complete. Review of documentation recorded in the resident's nursing notes and on the medication administration records (MARs) found no evidence that any physical assessment data regarding the resident's respiratory status had been collected and recorded either prior to and after each nebulizer treatment, and there was no documentation recorded describing the resident's response to each treatment. Staff interviews confirmed these assessments were not being done, thus not meeting professional standards of quality. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - Review of the resident's care plan, which had been initiated on 10/07/10, revealed the following problem statement: "Short of breath / difficulty breathing related to: [MEDICAL CONDITION]." Interventions to address this problem included: "Administer medication as ordered. ... Notify physician of increased complaints of difficulty in breathing. Obtain oxygen saturation l… | 2014-03-01 | ||
| 11411 | 11411 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 309 | G | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility policies and procedures, review of records from an area hospital and the ambulance service, and staff interviews, the facility failed to ensure one (1) of six (6) sampled residents received care and services necessary to attain or maintain her highest level of physical well-being and to avoid physical harm. Resident #119, who was admitted to the facility on [DATE] for Medicare-covered skilled nursing and rehabilitation services to include observation and assessment of her care plan, began exhibiting an acute change in condition. The facility's licensed nursing staff failed, in accordance with the facility's policy and procedures, to provide on-going assessment / monitoring, administer interventions when ordered by the physician extender, and/or obtain timely medical intervention as the resident's condition continued to decline. A registered nurse (RN) first recorded in the medical record that Resident #119 was lethargic at 5:10 p.m. on [DATE]; prior to that time, the resident had been noted to be free of signs and symptoms of distress and discomfort. A licensed practical nurse (LPN) first recorded in the medical record, in an entry dated 5:00 a.m. on [DATE], Resident #119 had vomited three (3) times during the 11:00 p.m. to 7:00 a.m. (,[DATE]) shift. After this entry, there was no evidence of any physical assessment data having been contemporaneously collected and recorded in the resident's medical record related to the resident's level of consciousness (LOC), vital signs, respiratory status, and/or vomiting until the certified nurse practitioner (CNP - Employee #123) employed by the facility evaluated the resident and recorded a progress note that was electronically signed at 11:59 a.m. on [DATE]. In addition to the absence of evidence that physical assessment data was being contemporaneously collected and recorded with respect to Resident #119's acute change in condition, routine a… | 2014-03-01 | ||
| 11412 | 11412 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 328 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents, whose closed record was reviewed, received proper care and treatment for [REDACTED]. Resident #119 was [AGE] years old female who was admitted to the facility from the hospital following a surgical procedure for a [MEDICAL CONDITION]. During a prolonged hospital stay, she was also treated for [REDACTED]. Review of Resident #119's medication administration records (MARs) revealed she was frequently noted to refuse her inhalation treatments; these refusals were not communicated to her attending physician. Facility policy required licensed nursing staff to collect and record physical assessment data regarding the resident's respiratory status before and after the administration of each inhalation, as well as the resident's response to each treatment after it was completed. Review of her nursing notes and MARs found no evidence this physical assessment data was being collected and recorded in accordance with facility policy. The resident subsequently exhibited an acute change in condition, which the certified nurse practitioner ultimately considered was attributable to possible pneumonia. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed medical record revealed this [AGE] year old female was admitted to the nursing facility on 09/30/10 following a prolonged hospital stay beginning on 09/09/10 for a surgical repair of a [MEDICAL CONDITION], during which she received treatment for [REDACTED]. Review, on 11/10/10, of Resident #119's October 2010 MAR indicated [REDACTED]. - 2. According to documentation on her October 2010 MAR, between 10/01/10 and 10/11/10, Resident #119 did not receive twenty-five (25) of sixty-six (66) scheduled inhalation treatments. Of these twenty-five (25) missed doses, coding on the MAR indicated [REDACTED]. Medical record… | 2014-03-01 | ||
| 11413 | 11413 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-11-11 | 514 | D | 50T311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to maintain, in accordance with accepted standards of professional practice, the medical record of one (1) of six (6) sampled residents whose closed record was reviewed. Review of the closed record for Resident #119 revealed licensed nursing staff failed to document every change in her condition until her condition was stabilized or the situation was otherwise resolved, in accordance with professional standards of practice. Late entries in Resident #119's nursing notes were not recorded as soon as possible, with one (1) nursing note containing six (6) separate late entries having been recorded seven (7) days after the resident expired, even though the author of that note was working in the facility two (2) days after the resident transferred to the hospital. Additionally, a review of hospital discharge orders from the physician prior to Resident #119's admission on [DATE] found an order for [REDACTED]. The resident's [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This discrepancy in frequency of administration of the inhalation treatments was not identified previously by the facility. These practices did not allow for accurate and complete clinical information about this resident's change in condition and treatments. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 1. Review of Resident #119's closed record revealed this [AGE] year old female was admitted to the facility on [DATE] after a prolonged hospital stay. Review of Resident #119's nursing notes found a contemporaneous entry, dated [DATE] at 3:00 a.m., stating, "Skilled services continue. (Symbol for 'no') S/S (signs / symptoms) of distress or discomfort @ this time. Meds taken /s (without) di… | 2014-03-01 | ||
| 11414 | 11414 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2010-11-18 | 311 | D | 0ZJV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to provide treatment and services to maintain or improve the range of motion in both hands, for one (1) of eight (8) residents who had contractures of both hands and a physician's orders [REDACTED]. Resident identifier: #41. Facility census: 117. Findings include: a) Resident #41 Medical record review, on 11/16/10, revealed this resident had a physician's orders [REDACTED]. The order, dated 09/28/10, was for the protectors to be applied for eight (8) hours daily beginning at 9:00 a.m. each morning. Observations, at 2:00 p.m. on 11/16/10, at 9:30 a.m. on 11/17/10, at 1:00 p.m. on 11/17/10, and at 3:00 p.m. on 11/17/10, revealed neither hand had a palm protector in place. At 3:30 p.m. on 11/17/10, this information was brought to the attention of a licensed practical nurse (LPN - Employee #7), who confirmed the order and confirmed the palm protectors were not being used. | 2014-03-01 | ||
| 11415 | 11415 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 309 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for two (2) of eighteen (18) Stage II sample residents. Resident #153 complained to her family of a sore mouth, tongue, and throat, which the resident's legal representative conveyed to the facility. The facility's licensed nursing staff failed to collect and record physical assessment data related to the condition of the resident's entire oral cavity and related to the attending physician only the presence of a slightly inflamed tongue, for which the physician ordered a medicated [MEDICATION NAME]. The resident's legal representative ultimately made an appointment for the resident to be evaluated and treated by a second physician outside the facility, who diagnosed glossitis, mouth ulcers, and possible candidiasis and ordered five (5) medications for treatment of [REDACTED]. A nurse failed to ensure Resident #73 received all medications ordered by the physician during a medication pass on the morning of 11/10/10. Resident identifiers: #153 and #73. Facility census: 98. Findings include: a) Resident #153 An interview with the Resident #153's daughter, on 11/11/10 at 8:50 a.m., revealed the resident had been in pain from sores in her mouth and the resident's tongue was irritated and swollen. The resident had told the her the inside of her mouth had sores, her tongue was very irritated, and that her throat was also sore. According to the daughter, her brother visited Resident #153 and reported back to her that he had observed sores in the mouth and that her tongue was red. The daughter further stated she called the facility and asked for the physician to look at her mother's mouth. According to the daughter, the facility's physician did not look at her mother's mouth, so she called her mother's previous attending physician (who … | 2014-03-01 | ||
| 11416 | 11416 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 315 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to provide care and services for one (1) resident of five (5) sampled residents with an indwelling Foley urinary catheter who was exhibiting signs and symptoms of a urinary tract infection [MEDICAL CONDITION] and did not receive timely medical intervention. The resident was transferred to the hospital after becoming lethargic on [DATE], four (4) days after she was first symptomatic for a UTI on [DATE] (as evidenced by an elevated temperature and a finding of "very cloudy and dark" urine). The resident subsequently died at the hospital [MEDICAL CONDITION] on [DATE]. Resident identifier: #153. Facility census: 98. Findings include: a) Resident #153 Closed record review revealed Resident #153 was a [AGE] year old female who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #153's comprehensive admission assessment with an assessment reference date (ARD) of [DATE], she had short-term memory problems but no long-term memory problems, she exhibited modified independence with her cognitive skills for daily decision making, she required the extensive physical assistance of two (2) or more persons with bed mobility and transfers, and she was totally dependent on two (2) or more persons with toilet use. She was also incontinent of bowel elimination, continent of bladder elimination with the presence of an indwelling Foley urinary catheter, and had been diagnosed with [REDACTED]. According to her comprehensive annual assessment with an ARD of [DATE], Resident #153's cognitive status remained the same, she required the extensive physical assistance of one (1) person with bed mobility, she was totally dependent on two (2) or more persons for transfers, and she required the extensive physical assistance of two (2) or more persons with toilet use. She was also now continent of bowel elimination and bladder elimination with th… | 2014-03-01 | ||
| 11417 | 11417 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 323 | G | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to ensure one (1) of eighteen (18) sampled residents received adequate supervision and assistance devices to prevent avoidable accidents. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The two (2) nursing assistants who were involved in the transfer did not use the equipment in accordance with the manufacturer's instructions to ensure a safe transfer, by failing to ensure the legs of the lift were in the maximum open position for stability during the transfer. The facility also failed to ensure the lift used for transferring Resident #54 was the most appropriate device in view of the fact that the resident was not always able to bear the majority of her own weight, and the legs of the lift could not be opened to the maximum open position for stability when placed under the resident's electric bed, both of which were required by the manufacturer's instructions. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the re… | 2014-03-01 | ||
| 11418 | 11418 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 520 | E | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility records, resident interview, policy review, and staff interview, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. A resident was transferred inappropriately while using the sit-to-stand lift; the legs of the lift were not placed in the maximum open position for stability prior to lifting the resident to/from an electric bed; the resident fell during this transfer and sustained a [MEDICAL CONDITION]. Following the fall, the facility completed an internal investigation which included obtaining witness statements from various employees. However, the facility did not interview the affected resident, who was alert / oriented, possessed the capacity to understand and make informed health care decisions, and who returned to the facility and was available to be interviewed following the surgical repair of her fracture. In spite of the fact the topics of incident / accident report review and abuse / neglect reporting and investigation were identified as being permanent items on the QAA committee's agenda, existing quality deficiencies were not effectively addressed to ensure resident accidents and/or neglect (related to inappropriate care / services provided) were thoroughly investigated. In addition, the facility's internal investigation contained statements by staff alluding to difficulties using the sit-to-stand lift in conjunction with an electric bed, but the facility's QAA committee failed to explore this concern and implement measures (e.g., staff training) to prevent recurrence. These practices have the potential to result in more than minimal harm to all residents. Facility … | 2014-03-01 | ||
| 11419 | 11419 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2010-11-17 | 225 | D | TRO311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to conduct a thorough investigation, and make a report to the Nurse Aide Registry of two (2) nursing assistants, of neglect involving one (1) of eighteen (18) sampled residents who was injured during an unsafe transfer. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The facility's internal investigation into this fall was not thorough as evidenced by a failure to conduct an interview with the affected resident, who was alert and oriented and available for interview upon her return from the hospital to the facility; when interviewed by a surveyor, the resident related information markedly different from what had been reported by staff involved in the incident. The facility also failed to identify during its investigation that the sit-to-stand lift was not used in accordance with the manufacturer's instructions. The two (2) nursing assistants who were involved in the transfer failed to ensure the legs of the sit-to-stand lift were in the maximum open position for stability prior to attempting to transfer the resident. The facility did not identify this as neglect and/or report the individuals involved to the appropriate State agencies as required. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriente… | 2014-03-01 | ||
| 11420 | 11420 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 242 | E | U2Q611 | . Based on staff interview and record review, the facility failed to identify and communicate to direct caregivers the residents' preferences with respect to what time of day they were to receive showers. This was evident for at least seventeen (17) of twenty-two (22) residents who routinely received showers during the night shift. Resident identifiers: #7, #15, #23, #24, #38, #43, #44, #48, #52, #61, #70, #76, #81, #92, #93, #82, and #50. Facility census: 150. Findings include: a) Residents #7, #15, #23, #24, #38, #43, #44, #48, #52, #61, #70, #76, #81, #92, #93, #82, and #50. Interviews with nursing staff working night shift on 10/24/10 and 10/25/10 revealed residents were being given showers and baths during this shift. A review of shower documentation sheets revealed residents were scheduled and listed as having been given a shower or bath at various times throughout the night shift. Staff stated, in confidential interviews, they showered or bathed anywhere from one (1) to three (3) residents this shift each day except Sunday. There was no evidence, via record review, to reflect the facility staff made efforts to ascertain whether the practice of bathing during the hours of night shift was either a personal preference or customary routine of the residents or whether the practice was acceptable to the residents, as it may require awakening sleeping residents to perform this task. Review of care plans for these residents, on the morning of 11/02/10, found the care plans addressed the need for assistance with bathing, but they did not indicate what time of day each resident preferred to bath or shower. Interview with the administrator, on the morning of 11/02/10, again revealed there was no evidence that permission had been obtained from each of these residents or responsible parties to provide showers or baths to the residents during the night shift. . | 2014-03-01 | ||
| 11421 | 11421 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 279 | E | U2Q612 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure the interdisciplinary care team developed a comprehensive care plan, to include measurable objectives and timetables, to meet each resident's medical and nursing needs for two (2) of ten (10) sampled residents. Resident identifiers: #150 and #151. Facility census: 142. Findings include: a) Resident #150 Review of Resident #150's medical record found a nursing note, written at 3:20 a.m. on 11/27/10, documenting the resident was sent to the emergency room for rectal bleeding with clots. He returned to the facility on [DATE]. Review of the current care plan, on 01/06/11, found no care plan for monitoring and assessment for gastrointestinal (GI) bleeding. An interview with the DON, on 01/06/11 at 11:40 a.m., confirmed the potential for GI bleeding should have been included in the comprehensive care plan. -- b) Resident #151 Review of the medical record found that Resident #151 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission orders [REDACTED]. Review of the current care plan, on 01/06/11 at 4:35 p.m., confirmed the care plan did not include interventions for [MEDICAL CONDITION] precautions. . | 2014-03-01 | ||
| 11422 | 11422 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 425 | E | U2Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on review of medical records, review of reports from the facility's provider pharmacy and consultant pharmacists, staff interviews, review of the facility's pharmacy policy and procedure for adverse drug reactions, review of a list of drugs with the potential to interact with Coumadin, and the manufacturer's sheet for Coumadin, it was determined the facility had not implemented pharmaceutical services procedures to minimize medication-related adverse consequences or events. One (1) resident who was receiving Coumadin was ordered Bactrim DS for an infection. The resident fell and was later hospitalized . She was found to have subarachnoid bleeding. The hospital physician identified this may have occurred due to the resident receiving Bactrim DS and warfarin (Coumadin). The records of thirty (30) residents who were receiving warfarin were reviewed. Thirteen (13) were found to have orders for medications known to have major interactions with warfarin (a blood thinner). There was no evidence the potential for interactions had been identified by the pharmacists. Additionally, the facility's pharmacy manual included a policy which included notification when there was a potential adverse drug reaction (ADR). There was no evidence this policy had been implemented for residents receiving warfarin. Resident identifiers: #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131. Facility census: 150. Findings include: a) Residents #46, #145, #100, #27, #23, #137, #29, #52, #142, #128, #149, #90, #105, and #131 A review of residents receiving the medication warfarin was prompted by a complaint allegation. On the morning of 10/26/10, a request was made for copies of the physicians' orders for residents who were receiving warfarin. A copy of the facility's policy for adverse drug reactions was also requested. Copies of the orders for thirty (30) residents were provided the afternoon of 10/26/10. The ordered medicati… | 2014-03-01 | ||
| 11423 | 11423 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 153 | D | U2Q611 | . Based on a review of the State Board of Review hearing notice, staff interview, family interview, and a review of a Release of Medical Record form, the facility failed to ensure a resident or his / her legal representative had the right, upon an oral or written request, to access all records pertaining to his/her stay at the facility, including current clinical records, within twenty-four (24) hours (excluding weekends and holidays) of receipt of the request. This occurred for one (1) of eleven (11) residents included in the sample. Resident identifier: #162. Facility census: 150. Findings include: a) Resident #162 During a telephone interview on 11/01/10 at 7:30 p.m., Resident #162's legal representative reported the facility did not allow access to the resident's medical record for review prior to an appeal for discharge hearing with the State Board of Review at 1:00 p.m. on 09/27/10. The representative reported having called the facility on 09/23/10 or 09/24/10 and leaving a voice message for the assistant administrator, asking to review the information the facility was going to use in the hearing. She said she was not provided the information prior to the hearing. During an interview on 11/02/10 at 11:00 a.m., the assistant administrator reported the request was made on 09/24/10 (a Friday) and, at that time, the information was being gathered by the facility administrator for the hearing. He said the information was not available for review until the hearing at 1:00 p.m. on 09/27/10. Review of the hearing notice, dated 09/20/10, found a second page with a section titled, "You Have the Right To:" The first item under this title stated, "1. Examine all documents and manual sections to be used at the hearing, both before, during, and after the hearing. Please call the nursing home if you wish to look at the evidence before the hearing." The administrator, who was interviewed on 11/02/10 just after the assistant administrator, stated the resident's legal representative did not ask to review the resident's recor… | 2014-03-01 | ||
| 11424 | 11424 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 309 | G | U2Q611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, staff interview, and review of facility records, policies, and procedures, the facility failed to provide ongoing assessment / monitoring for and failed to obtain timely medical intervention for one (1) of eleven (11) sampled residents who simultaneously received [MEDICATION NAME] (an anticoagulant) and Bactrim DS (an antibiotic that potentiates anticoagulant effects) from 10/11/10 through 10/15/10. Resident #29 was found on the floor in her room (an un-witnessed fall) on the morning of 10/14/10. The day shift nurse on 10/14/10 recorded the fall in the nursing notes, noting no injury was apparent at the time. No further entries were made in the resident's nursing notes until 3:20 p.m. on 10/15/10, when the evening shift nurse noted the presence of bruising with hematoma to the resident's left temple and noted the resident appeared to have difficulty opening her left eye. The evening shift nurse contacted the attending physician, who stated that he had not previously been informed of the resident's fall and ordered that she be sent to the hospital emergency room for evaluation, as she was on a blood thinner. The resident was transported to Hospital #1's ER, where she was noted to have critical lab values related to her anticoagulation therapy and subarachnoid bleeding. The resident was later transferred to Hospital #2, where she was admitted to its neurology intensive care unit. According to the Hospital #2 discharge summary, Resident #29's subarachnoid hemorrhaging was "secondary to over anticoagulation from [MEDICATION NAME] and Bactrim drug interactions as well as increased blood pressure as well as a traumatic fall. ..." Nursing assistants on the early afternoon of 10/14/10 and the morning of 10/15/10 reported to the licensed nursing staff that Resident #29 had a bruise to her left temple, but no on-going neurologic assessments were completed by the licensed nursing staff after … | 2014-03-01 | ||
| 11425 | 11425 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 520 | E | U2Q612 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's quality assessment and assurance committee failed to identify quality deficiencies of which it was (or should have been) aware and develop and implement plans of action to correct these quality deficiencies. This resulted in the facility's continuing non-compliance with the Medicare / Medicaid conditions of participation. During the current survey from 01/03/11 through 01/07/11, the facility failed to correct deficient practices cited during previous survey events that concluded on 09/01/01 and 11/02/10, with respect to the following regulatory requirements: Comprehensive Care Plans (F279), Quality of Care (F309), and Pharmaceutical Services (F425), resulting in repeat deficiencies in these areas. These deficient practices affected three (3) of ten (10) sampled residents and presented the potential for more than minimal harm to more than an isolated number of residents at the facility. Resident identifiers: #150, #151, and #152. Facility census: 142. Findings include: a) Quality of Care 1. The facility demonstrated non-compliance with the Medicare / Medicaid conditions of participation with respect to the provision of Quality of Care (F309) resulting in findings of deficiencies at a level of actual harm to an isolated number of residents during two (2) previous survey events at the facility, which concluded on 09/01/10 and 11/02/10. During this current survey event from 01/04/11 through 01/07/11, based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. 2. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to… | 2014-03-01 | ||
| 11426 | 11426 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-09-01 | 309 | G | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure that necessary care and services were provided to attain or maintain the highest practicable physical and mental well-being for (2) of ten (10) sampled residents. Resident #151 was initially admitted to the facility at 11:00 p.m. on 12/10/10 with [DIAGNOSES REDACTED]. The facility failed to obtain from the pharmacy in a timely manner and administer medication, in accordance with physician orders, to treat the resident's anxiety. Resident #152 was admitted to the facility on [DATE] following a hospitalization for urinary tract infection [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. Nursing staff at the facility failed to appropriately assess and monitor this resident for exacerbation of these conditions. Nursing staff failed to institute neurological assessments for Resident #152 (who was receiving [MEDICATION NAME] therapy which placed her at high risk for bleeding) following a fall sustained on 12/05/10. Nursing staff members did not begin monitoring the resident's neurological status until the evening of 12/07/10, and the director of nursing (DON), when interviewed, stated these neuro-checks should have been initiated immediately after the fall. Additionally, Resident #152, who had a [DIAGNOSES REDACTED]. These practices had the potential to result in more than minimal harm to an isolated number of residents. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of her nursing notes revealed the following consecutive entries: - The admission nursing note, dated 11:00 p.m. on 12/10/10, stated,"... Resident appeared anxious and wanted to call her niece. The Resident (sic) phone was given to Resident and this appeared to have a calming affect (sic). ... VS (vital si… | 2014-03-01 | ||
| 11427 | 11427 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 425 | E | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure pharmaceutical services were provided to meet the needs of two (2) of ten (10) sampled residents, both of whom had a [DIAGNOSES REDACTED]. Resident identifiers: #151 and #152. Facility census: 142. Findings include: a) Resident #151 Review of Resident #151's medical record found this [AGE] year old female was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admitting orders found the resident was prescribed Xanax 1 mg twice daily for anxiety and Doxepin 50 mg at bedtime for depression / anxiety. Review of her nursing notes revealed a note, dated 12/13/10 at 4:30 p.m., stating, "Late entry 12/12/10 12am (sic) went to res (resident's) room to give her meds. res (sic) states 'What's this?' Explained to her that it was her night time meds. Res says 'I don't take any of that sh**! I want my nerve pill and my depression pill.' Explained to her these meds had not arrived from pharmacy. Res became upset, shouting 'What the hell is wrong with this place. The longer I'm here the worse it is.' res (sic) ref (refused) to take any meds. RN supervisor (name) answered res light right after ref meds. He spoke /c me about 'not giving her meds'. I explained situation to him, went in & offered meds again & res cont (continued) to refuse. phoned (sic) pharmacy about Xanax & Sinequan. pharmacy (sic) states that a script is needed for Xanax & Sinequan had been sent. ..." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the back of the MAR found a nurse's initials documented at 10:00 p.m. with the following statement, "Refused all pm (evening) meds (medications) because Xanax & depression med was not available." Further review of the MAR indicated [REDACTED]. She did not receive her first dose of Ativan at the nursing facility until the 9:00 p.m. dose was administered on 12/12/10. An i… | 2014-03-01 | ||
| 11428 | 11428 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-11-11 | 241 | D | 6V1A11 | . Based on observation, resident interview, and staff interview, the facility failed to promote care for one (1) of four (4) residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Observation and interview revealed one (1) resident did not receive prompt assistance with incontinence care during a meal time. Resident identifier: #77. Facility census: 141. Findings include: a) Resident #77 Observation, on 11/11/10 at approximately 8:35 a.m., found Resident #77 turned on his call light. When interviewed, he reported he needed to be cleaned up. The resident said, "I am in a mess." At approximately 8:40 a.m., the resident's call light went off. At approximately 8:45 a.m., Employee #130 (a nurse aide) said she told the resident she would clean him up after she finished picking up the breakfast trays. On 11/11/10 at approximately 10:45 a.m., the interim director of nursing indicated he had spoken with this nurse aide, and Employee #130 did realize she should have provided Resident #77 with the assistance he needed before she finished picking up the breakfast trays. He agreed the resident's needs should have come before picking up trays after the breakfast meal. . | 2014-03-01 | ||
| 11429 | 11429 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 314 | G | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of product information found on the Internet, and staff interview, the facility failed to provide care and services for one (1) of eleven (11) residents reviewed, to prevent the development of new pressure sores for a resident who entered the facility without a pressure sore. Resident #50, who was admitted to the facility on [DATE] with intact skin, was totally dependent upon staff for bed mobility and transferring, and was identified as being at high risk for developing pressure sores. The interdisciplinary team identified her risk for developing skin breakdown in her care plan dated 06/21/10, and approaches to be implemented by staff to prevent skin breakdown included conducting weekly body audits. On 08/13/10, a nursing assistant identified Resident #50 as having a "blackened area" on her left heel. Weekly body audits were not completed in accordance with her plan of care, and the presence of this skin breakdown was not identified and treated at an earlier stage. Facility census: 84. Findings include: a) Resident #50 Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] bladder. The resident's admission nursing assessment, dated as completed on 06/03/10, stated the resident had no skin breakdown present on admission. This document also stated the resident was totally dependent on staff for transfers and she was non-weight bearing. The resident was also incontinent of bowel and had an indwelling Foley catheter at that time (which was removed on 08/15/10). The resident's pressure ulcer risk assessment, completed on 06/03/10, rated her as "10", indicating she was at high risk for developing pressure sores. According to her comprehensive admission assessment with an assessment reference date (ARD) of 06/10/10, she was alert but not oriented, with short and long term memory problems and moderately impaired cognitive … | 2014-03-01 | ||
| 11430 | 11430 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 157 | D | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed, for one (1) of eleven (11) sampled residents, to notify the resident's legal representative or attending physician of a significant change in the resident's health status. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs and failed to collect / record, monitor, and report to the physician or the resident's legal representative any physical assessment data related to this resident's change in condition. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who "pinched" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief tha… | 2014-03-01 | ||
| 11431 | 11431 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 309 | G | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, failed to identify a decrease in fluid intake, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine… | 2014-03-01 |
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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 );