cms_WV
Data source: Big Local News · About: big-local-datasette
11,539 rows sorted by inspection_text
This data as json, copyable, CSV (advanced)
| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text ▼ | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7472 | 7472 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 490 | E | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ' Based on record review and staff interview, the administration failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical, mental, and psychosocial well-being of more than a limited number of residents. In the area of resident behavior and facility practices, the facility failed to investigate and report allegations of abuse, neglect, and misappropriation of resident property. In the areas of resident quality of life practices, the facility failed to ensure resident dignity was maintained during the dining experience; failed to maintain a resident's privacy during a physician's visit; failed to ensure resident choices in regard to bathing was upheld; and, failed to ensure the physical environment of the facility was in good repair. In the area of quality of care practices, the facility failed to ensure care and services were provided for the highest well being of a resident; care and treatment was provided to prevent pressure ulcers and the drug regimen of a resident was free from unnecessary medications. In addition, there were system issues in the areas of resident funds, timely physician visits, revision of resident care plans for change of condition, and assistance in scheduling dental appointments in a timely manner. As well, pharmacy recommendations were not addressed by the physician in a timely manner, medications were not available in an emergency, staff were unaware of infection control practices, physicians were not notified of laboratory results, and medical records were not complete and accurate. These isues were identified during the survey from [DATE] through [DATE]. Facility census: 113. Findings include: a) The facility failed to ensure personal funds were available at all times. Resident funds were not accessible to the residents in the evenings or on the weekends. b) The facility failed to ensure the personal privacy of a resident during a physician's v… | 2017-04-01 |
| 8168 | 8168 | SPRINGFIELD CENTER | 515188 | ROUTE 1 BOX 101-A | LINDSIDE | WV | 24951 | 2012-11-15 | 502 | D | 0 | 1 | M8CD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** , Based on interviews and record review, the facility failed to obtain a physician ordered lab test for 1 resident (#35) out of 10 residents reviewed for unnecessary medications. Findings include: Resident #35 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent recapitulation of physician orders, signed by the physician on November 1, 2012, included orders for a lipid panel every six months in February and in August. Review of the clinical record failed to reveal results for the lipid panel that was ordered to be obtained in August 2012. Staff interviews were conducted with the Director of Nurses, staff #2, on November 14, 2012. Staff #2 claimed that the lab was not obtained in August because the physician had intended to discontinue the lab test in September 2011, however, the current physician orders did not reflect this. Staff #2 verified that the lipid panel still appeared as a current order on the most recent recapitulation of physician orders. | 2016-09-01 |
| 876 | 876 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2019-07-02 | 842 | E | 0 | 1 | LUON11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** , Based on record review, resident interview and staff interview the facility failed to ensure that each residents record was complete and accurate. Resident #56's record was inaccurate in regards to location his blood pressure was obtained. For resident #78 the facility failed to document in the record about the residents fall. And for Resident #211 the facility did not complete Activities of Daily Living Documentation for multiple days after their admission to the facility. This was true for three (3) for 41 sampled residents. Resident Identifiers: #56, #78, and #211. Facility Census: 117. Findings Include: a) Resident #56 A review of Residents #56 medical record beginning at 3:11 p.m. on 07/01/19 found Resident #56 has an AV Fistula to his left arm and a physicians order for no blood pressures to be obtained in the left arm. An review of Resident #56's recorded blood pressures in the electronic medical record from 04/01/19 through present found on the following the facility documented Resident #56's blood pressure was obtained in his left arm: 04/01/19 at 8:31 p.m. 04/02/19 at 1:04 p.m. 04/03/19 at 8:27 p.m. 04/04/19 at 9:30 a.m. and 1:04 p.m. 04/05/19 at 4:12 p.m. 04/06/19 at 1:18 p.m. 04/07/19 at 1:13 p.m. 04/09/19 at 6:10 a.m. 04/18/19 at 8:41 p.m. 04/19/19 at 9:12 a.m. 04/20/19 at 2:20 p.m. 04/23/19 at 1:45 p.m. 04/25/19 at 5:03 p.m. 04/26/19 at 5:36 p.m. 04/27/19 at 3:18 p.m. 04/28/19 at 3:26 p.m. 04/30/19 at 3:05 p.m. and 8:32 p.m. 05/01/19 at 8:07 p.m. 05/02/19 at 8:14 p.m. 05/04/19 at 1:16 p.m. 05/07/19 at 8:41 p.m. 05/09/19 at 8:20 p.m. 05/13/19 at 9:46 a.m. 05/14/19 at 10:11 a.m. and 8:35 p.m. 05/17/19 at 8:09 p.m. 05/19/19 at 10:30 a.m. 05/21/19 at 8:11 p.m. 05/28/19 at 5:19 p.m. 05/31/19 at 7:31 a.m. 06/02/19 at 8:53 p.m. 06/03/19 at 8:46 p.m. 06/04/19 at 8:34 p.m. 06/07/19 at 9:13 a.m. 06/08/19 at 5:50 a.m. and 9:08 a.m. 06/22/19 at 5:30 a.m. and 10:25 p.m. 06/28/19 6:01 a.m. 06/30/19 at 12:35 a.m. An interview with Resident #… | 2020-09-01 |
| 9881 | 9881 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-05-09 | 203 | D | 1 | 0 | SZNR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a closed medical record review and staff interview, the facility failed to ensure two (2) of five (5) residents were provided with a written discharge notice thirty (30) days prior to their discharge date s. This notice must include the reason for discharge, the effective date, the location to which the resident was being discharged , the right to appeal, how to notify the ombudsman, and how to notify appropriate protection and advocacy agencies. Resident identifiers: #57 and #85. Facility census: 77. Findings include: a) Resident #57 The medical record review for Resident #57, conducted on 05/08/12, at approximately 1:00 p.m., revealed this eighty seven (87) year resident was admitted to the facility on [DATE]. The resident left the faciity on [DATE]. According to the medical record, she now resides in a personal care home. Medical record review revealed several social service and nursing notes, dating back to November 2011, reflecting the resident's desire to return home. The facility completed a pre admission screening (PAS) on the resident. A progress note, dated 05/01/12, stated, "Resident is in process of discharge planning. She no longer qualifies for nursing home care. At this point plans will be for her to go to (name of personal care home). The ombudsman will be here on Wednesday 05/02/12 to meet with res. and her family. The son who is health care surrogate will not transport to new facility. He wants her transferred by ambulance. " Another progress note, dated 05/04/12, stated, "Resident d/c (discharged ) to a personal care home due to no longer being eligible for nursing home level of care. Her son has made all the financial needs for the transfer. " On 05/09/12, at approximately 11:00 a.m., the former business office manager (Employee #65) and the medical records clerk (Employee #14) reviewed the resident's closed record. The record did not contain information indicating the health care surrogate was provided a thirty… | 2015-08-01 |
| 10359 | 10359 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-01-17 | 514 | D | 1 | 0 | CNU711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a record review and staff interview, the facility failed to ensure a resident's medical record was complete and accurately documented. The nursing notes for Resident #22 indicated this resident was complaining of wrist pain. Her left wrist was [MEDICAL CONDITION] and tender to touch. According to the nursing note, the resident "Stated getting arm stuck in SR (side rail) yesterday evening." The nursing notes were not accurately documented to reflect the details of this incident. This resident was not able to speak and she used gestures with her eyes and head nodding to communicate. The resident occasionally mouthed or whispered one (1) word but could not speak in sentences. Also, her ability to move was very limited. This note was inconstant with the resident's physical abilities. The note did not accurately describe how this resident exhibited pain in her hand (i.e. facial grimacing, crying, frowning, flinching, etc.). The nurse who worked the shift, after the resident's hand was observed injured, recorded someone else's information in her nursing notes. This nurse documented what the other nurse told her and not what she had assessed herself. Inaccurate and incomplete documentation in the medical record had the potential to result inadequate treatment. This was true for one (1) of five (5) sampled residents. Resident identifier: #22. Facility Census: 63. Findings include: a) Resident #22 A nursing note, dated 10/04/11 at 04:30 a.m., reflected this resident had pain in her left wrist. Her left wrist was [MEDICAL CONDITION] and tender to touch. According to the nursing note, "The resident stated getting arm stuck in SR (side rail) yesterday evening. Medicated with Tylenol as ordered and per resident request for left wrist pain." This note was not consistent with the resident's condition and abilities to speak, move, or request pain medication. Review of the medical record indicated this resident required total assistance of two (2) … | 2015-05-01 |
| 10148 | 10148 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-05-05 | 327 | D | 0 | 1 | MKQ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a record review, observation, and staff interview, the facility failed to assure one (1) of thirty (30) Stage II sample residents received care and services to maintain proper hydration and health. The facility failed to adequately assess / monitor and implement interventions to ensure Resident #143, who had poor food and fluid intake, experienced a severe weight loss, and was having diarrhea, was well hydrated. Resident identifier: #143. Facility census: 101. Findings include: a) Resident #143 1. Resident #143 was admitted to this facility from the hospital on [DATE], after falling and sustaining a fracture of his knee. He was being treated for [REDACTED]. diff), which caused him to have repeated bouts of diarrhea. His wife was already a resident at this facility, and he would come in daily to visit her prior being admitted himself. His admission weight, on 03/25/10, was 200#. The second time his weight was measured, on 04/01/10, it was 190#. He had lost 10# in one (1) week. His next weight, on 04/07/10, was 178#. On 4/15/2010, he weighed 171#. On 04/19/10, he complained abdominal pain, nausea, and anorexia and was transferred, then admitted to, the hospital. His weight, upon from the hospital on [DATE], was 171#. The minimum data set assessment, with an assessment reference date of 03/29/10, noted he was leaving greater than twenty-five percent (25%) of his meals uneaten. He was also receiving a therapeutic diet. The resident assessment protocol (RAP) for nutritional status, dated 04/05/10, contained the following recommended interventions: "RD evaluation and Speech Therapy evaluation as needed." Documentation on the dehydration RAP noted the resident was taking a daily diuretic and was at risk for inadequate fluid intake. However, the interdisciplinary team (IDT) decided to NOT proceed with addressing dehydration on his care plan, stating, "No special interventions needed. Average daily intake is good at 1560 cc." 2. An IDT weig… | 2015-06-01 |
| 10154 | 10154 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-05-05 | 492 | C | 0 | 1 | MKQ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of dietary employees' food handler certificates and staff interview, the facility failed to assure all of dietary employees had current food handler certificates as required by their County health department. One (1) of thirteen (13) dietary employees reviewed did not have a current certificate. This practice had the potential to affect all residents receiving on an oral diet. Employee identifier: #47. Facility census: 101. Findings include: a) Employee #47 Review of the dietary employees' food handler certificates, on [DATE], found Employee #47's food handler certificate had expired in [DATE]. The dietary manager (Employee #149), when interviewed regarding this finding, stated she was aware this employee's food handler certificate had expired. She stated she would ensure this employee attended the County health department's next available class. Employee #149 confirmed that Employee #47 worked on full-time on a regular basis. She stated they "must have missed her". This employee repeated the food handlers class during the survey on [DATE], and she was issued a current certificate at that time. . | 2015-06-01 |
| 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 | ||
| 10742 | 10742 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2011-08-25 | 166 | E | 1 | 0 | 36XK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's grievance / complaint reports, family interview, resident interview, and staff interview, the facility failed to make prompt efforts resolve grievances. There was no evidence of a thorough investigation into grievances filed by (or on behalf of) two (2) of six (6) sampled residents and four (4) random residents identified through a review of twenty-two (22) grievance reports reviewed. Resident identifiers: #136, #7, #158, #106, #24, #31, and #137. Facility census: 154. Findings include: a) Resident #136 Review of grievance / complaint reports found a report filed by a family member dated 07/05/11, stating (quoted as written): "Daughter reported concerns of the resident in the room next to her mother and her screaming all of the time. ..." Under the heading "Documentation of Facility Follow-up", and in response to the question "What other action was taken to resolve this concern (be specific)?", the author wrote: "Informed (name of family member filing complaint) we were working /c (with) (name of Resident #155) & collaboration /c Admin, DON (director of nursing),Soc Serv & myself." Under the heading "Resolution of Grievance / Complaint", in response to the question "Was the grievance /complaint resolved?", the person completing the form checked "Yes" and noted (quoted as written): "... 3) (name of family member filing complaint) was advised of above re (regarding) (name of Resident #155)." The author also noted she had a one-to-one conversation with the persona filing the complaint about this resolution on 07/08/11. An interview was conducted with the family member on 08/24/11 at 2:00 p.m., she stated the grievance regarding the resident in the next room (#155) was still an issue, that there had been no resolution of this issue, and that the residents in the vicinity of the room of this resident were complaining. According to the family member, this has been an on-going unresolved issued for the past six … | 2014-12-01 |
| 9931 | 9931 | GOLDEN LIVINGCENTER - GLASGOW | 515118 | PO BOX 350 | GLASGOW | WV | 25086 | 2012-07-25 | 241 | D | 1 | 0 | QRD411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's investigation reports and staff interview, the facility failed to treat Resident #91 in a manner to maintain her dignity. She was dressed in an inappropriate manner for staff convenience and without respect for this total care resident who was unable to verbalize her wishes. This was true for one (1) of seven (7) sampled residents. Resident identifier: #91. Facility Census: 90. Findings Include: a) Resident #91 During a review of the facility's abuse reporting, it was noted there was an investigation of an injury of unknown origin for Resident #91. This resident had a femur fracture and the facility conducted an investigation to identify the cause and facts surrounding this fracture. According to an interview documentation form, completed by Employee #69, on 06/15/2012, this employee was asked whether she had taken Resident #91's pants off. She stated that she "pulled them down below her knees". There was a statement written on her interview form that stated "educated on dignity". The Director of Nursing was ask for written verification on dignity education with Employee #69. The written verification was not provided. During an interview with Employee #65, she was questioned about Resident #91. She related she went and changed this resident at 3:30 p.m. and she did not see an injury. She stated the resident's pants were around her calves and she had changed her. She verified that she did not pull the resident's pants up after she changed them because they would just leave them down. She explained how this was easier because this resident was total care and had contracted knees. She said this resident also had a history of [REDACTED]. The nursing assistant stated that the resident does not move or anything and they were always putting her up and down - it was easier. Employee #34 was questioned about this practice. She stated she was not aware staff were doing this. It was identified that two (2) nursing a… | 2015-08-01 |
| 11000 | 11000 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 250 | E | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed provide medically-related social services, in accordance with facility policy, to eight (8) residents who were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them combinations of laxatives that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices and in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The facility did not provide medically-related social services to these residents after learning they had been named as subjects of mistreatment / abuse / neglect. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and "X". Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #61, #62, and "X" 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mist… | 2014-10-01 |
| 10999 | 10999 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 226 | E | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to develop and operationalize policies and procedures for training employees; protection of residents; and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property, for the purpose of assuring the facility is doing all that is within its control to prevent such occurrences. The facility failed to: (1) ensure all allegations of resident mistreatment / abuse / neglect were immediately reported to the facility's administrator; (2) ensure all allegations of abuse / neglect were immediately reported to all State agencies as required; (3) thoroughly investigate all such allegations (to include efforts to identify as many affected residents as possible) and draw the appropriate conclusions based on the information available to them; and (4) develop and implement measures to ensure staff immediately reported their knowledge related to allegations of resident mistreatment / abuse / neglect without fear of reprisal. The facility, once becoming aware of these allegations, did not immediately report the allegations to the State survey agency (within no greater than twenty-four (24) hours of receiving this information). Not all allegations reported to the administrator by staff were, in turn, reported to the State survey agency. The facility did not thoroughly investigate all allegations of abuse / neglect. Not all residents who received care from Employee #81 were interviewed in an effort to identify other persons who may have been subject to mistreatment abuse / neglect. The facility did not substantiated allegations against the alleged perpetrator even when the events were witnessed by two (2) other staff members, and no reasons for making these … | 2014-10-01 |
| 10997 | 10997 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 223 | G | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to ensure residents were free from abuse. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices and in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others (beyond Resident #12), and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy and procedures. Resident identifiers: #12,… | 2014-10-01 |
| 11003 | 11003 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 157 | E | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to notify the attending physician and the responsible parties of eight (8) residents as having experienced mistreatment / abuse / neglect by Employee #81, as witnessed by staff. Resident identifiers: #12, #15, #30, #59, #60, #62, #61, and an unidentified resident who was no longer at the facility ("X"). Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #62, #61, and X 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed the following allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency: - Employee #81 was alleged to have audio-taped Resident #12 on her cell phone as she cursed (Reported to State survey agency on 01/25/10; date of incident was not known) - Employee #81 was alleged to have squirted water on Resident #62 (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have pushed Resident #15 quickly down the hallway in her wheelchair (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have encouraged Resident #12 to "yell and cuss" and to have given medications to this resident in an "inappropriate manner" (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have encouraged Resident #61 to "yell and cuss" (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have tied Resident #30's wheelchair to a side… | 2014-10-01 |
| 10998 | 10998 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 225 | E | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to: (1) ensure all allegations of resident mistreatment / abuse / neglect were immediately reported to the facility's administrator; (2) ensure all allegations of abuse / neglect were immediately reported to all State agencies as required; (3) thoroughly investigate all such allegations and draw the appropriate conclusions based on the information available to them; and (4) report to all State agencies those individuals who had knowledge of the abuse / neglect by Employee #81 and both failed to intervene to protect the residents from further abuse / neglect and failed to fulfill their roles as mandatory reporters. Eleven (11) employees had knowledge of mistreatment / abuse / neglect occurring to residents in the facility and did not report this to their supervisor, to their administrator, or to any outside agency responsible for receiving reports of abuse / neglect in nursing homes. The facility, once becoming aware of these allegations, did not immediately report the allegations to the State survey agency (within no greater than twenty-four (24) hours of receiving this information). Not all allegations reported to the administrator by staff were, in turn, reported to the State survey agency. The facility did not thoroughly investigate all allegations of abuse / neglect. Not all residents who received care from Employee #81 were interviewed in an effort to identify other persons who may have been subject to mistreatment abuse / neglect. The facility did not substantiated allegations against the alleged perpetrator even when the events were witnessed by two (2) other staff members, and no reasons for making these determinations were documented. After receiving statements from eleven (11) employees revealing th… | 2014-10-01 |
| 11001 | 11001 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 490 | F | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report contributed to a systemic failure of the facility's abuse prohibition program. The administrator, director of nursing (DON), and social worker, who were involved in the facility's internal investigation of Employee #81's actions, were made aware, through witness statements, that employees failed to immediately report Employee #81's actions due to their fear of Employee #81. They failed, however, identify this as a root cause of the failure of the abuse prohibition program, and no measures were developed and implemented to ensure employees, going forward, would not delay reporting of abuse / neglect out of fear of reprisal. The facility also failed to fully implement other components of its policy and procedures related to abuse prohibition, to include thorough investigation of alleged abuse / neglect, notification of the physician and responsible party of affected residents, and the provision of medically-related social services to affected residents. The facility's failure to identify / address root causes of its failure to operationalize policy and procedu… | 2014-10-01 |
| 11002 | 11002 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2011-06-09 | 520 | F | 1 | 0 | 2TQ311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility's quality assessment and assurance (QAA) committee failed to develop and implement action plans to correct quality deficiencies of which the committee should have known with respect to implementation of the facility's abuse prohibition program. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report contributed to a systemic failure of the facility's abuse prohibition program. Members of the QAA committee who were involved in the facility's internal investigation of Employee #81's actions (the administrator, director of nursing, and social worker) were made aware, through witness statements, that employees failed to immediately report Employee #81's actions due to their fear of Employee #81. The QAA committee did not, however, identify this as a root cause of the failure of the abuse prohibition program and did not develop and implement measures to ensure employees, going forward, would not delay reporting of abuse / neglect out of fear of reprisal. The facility also failed to fully implement other components of its policy and procedures related to abuse prohibition of which the QAA committee should have been aware, to include thorough investigation of alleged abuse / neglect, notification of the physician and responsible party of affected residents, and the provision of medically-related social services to affected … | 2014-10-01 |
| 10241 | 10241 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2010-06-04 | 249 | F | 0 | 1 | 5XSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the key personnel worksheet, review of personnel files, review of the activity program documentation, observation, resident interview, and staff interview, the facility failed to involve the activity director in the assessment, development, implementation and/or revision of an individualized activity program for individual residents. The individual identified by the facility as being the activity director of record was only a consultant who visited the facility on a monthly basis to review the activity calendar and residents' activity plans. There was no evidence to reflect this individual's involvement in assessing the activity needs and interests of individual residents, developing and/or revising programs based on the assessed needs and interests for each resident, and/or implementing a schedule of activities for individuals and groups. The individual identified by the facility as being responsible for implementing the facility's activity program on a day-to-day basis (who had completed a State-approved activity director training course but was not the activity director of record) was Employee #1. There was no evidence Employee #1 assessed / recorded each resident's activity interests and needs, developed an individualized program of ongoing activities designed to appeal to each resident's interests and to enhance each resident's highest practicable level of physical, mental, and psychosocial well-being, and/or revised each resident's program of activities when changes occurred in the resident's overall plan of care (such as when a resident was confined to her room due to an infectious process). Additionally, on occasion, Employee #1 was not available to implement activities programming due to being pulled to work as a nursing assistant when a staffing shortage occurred. This practice had the potential to affect all residents in the facility. Resident identifiers: #45, #49, #52, #4, and #16. Facility census: 48. Find… | 2015-06-01 |
| 9946 | 9946 | WELLSBURG CENTER LLC | 515123 | 70 VALLEY HAVEN DR | WELLSBURG | WV | 26070 | 2010-07-08 | 329 | D | 0 | 1 | GJYW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the medical record and staff interview, the facility failed to ensure the medication regimens of three (3) residents of twenty-three (23) Stage II sample residents were free of unnecessary drugs, used in excessive dose, without adequate monitoring, without adequate indications for use, and/or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Resident identifiers: #58, #8, and #28. Facility census: 49. Findings include: a) Resident #58 Review of Resident #58's medical record revealed this [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her physician's orders [REDACTED]. 12/10/09). Review of the resident's comprehensive admission assessment, with an ARD of 12/15/09 again found the assessor noted the resident did not exhibit any indicators of depression, anxiety, and/or sad mood in the preceding thirty (30) day period. The assessor did note the resident exhibited the following behavioral symptoms during the preceding seven (7) day period: wandering (daily), verbally abusive (1-3 days), physically abusive (1-3), and resists care (1-3 days). Further record review revealed her most recent assessment was a comprehensive significant change in status assessment with an assessment reference (ARD) 03/30/10. In Section E of this assessment addressing mood and behavior patterns, the assessor noted the resident did not exhibit any indicators of depression, anxiety, and/or sad mood in the preceding thirty (30) day period and did not exhibit any behavioral symptoms in the preceding seven (7) day period. The assessor also noted the resident's behavioral symptoms had improved over the preceding ninety (90) day period. An interview with the assessment coordinator (Employee #20), on 07/01/10 at 11:00 a.m., revealed the resident had been very ill and her behaviors had decreased, but now they had increased. A review of the resident's care plan revealed, … | 2015-08-01 |
| 10218 | 10218 | PRINCETON HEALTH CARE CENTER | 515187 | 315 COURTHOUSE RD. | PRINCETON | WV | 24740 | 2010-04-15 | 281 | D | 0 | 1 | WIXO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the medical record, observation, and staff interview, the facility failed to assure that services provided to the residents met professional standards of quality for two (2) of fifty (50) sampled residents. For Resident #128, weights were not recorded in a manner to allow the accurate assessment of the resident's nutritional status, and there was no evidence to reflect staff followed the facility's policy and procedure to assure weight loss was promptly addressed. For Resident #18, observation found eye drops were not administered as ordered by the physician. Facility census: 118. Findings include: a) Resident #128 Review of Resident #128's medical record revealed the weight record consisted of a form that provided, for each month, multiple spaces to record weights and the dates on which they were obtained. At the top of Resident #128's weight record, staff recorded his admission weight as 116.4 pounds (#) on 03/01/10. Also recorded in the month of March 2010 was a weight of 116.4# with no date noted as to when this weight was obtained. Upon reviewing the form, the medical records staff member (Employee #42) confirmed the resident's admission weight was written in the March 2010 column and verified this was only one (1) weight recorded on that form as of 04/13/10. The registered nurse (RN) case manager (Employee #142), when questioned as to why no further weights were recorded on this form for Resident #128 since his date of admission, informed this surveyor the resident's weights were recorded in the computer and she would have to print them off. At 10:00 a.m. on 04/13/10, Employee #142 provided a print out of all weights recorded in the computer for Resident #128. Review of the weights from the computer found the resident's admission "base weight" was recorded as 125#. When the resident was weighed on 03/23/10, his weight was 117#. According to this documentation, the resident lost 8.6# from 03/01/10 to 03/23/10. Acco… | 2015-06-01 |
| 9983 | 9983 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2012-04-20 | 280 | D | 1 | 0 | ZXC511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on care plan review and medical record review, the facility failed to ensure one (1) of five (5) residents had a care plan that was updated to reflect their current medical status. Resident #82 had a physician's orders [REDACTED]. The care plan revealed the facility had care planned the resident's risk of elopement but had not included the watchlet bracelet as an intervention to help alleviate the problem. Resident identifier: #82. Facility census: 84. Findings include a) Resident #82 On 04/20/12, at approximately 11:00 a.m., the medical record for Resident #82 revealed she had a physician's orders [REDACTED]. The order stated the bracelet would be worn at all times for the resident's safety. The care plan review, conducted on 04/20/12, at approximately 11:15 a.m., revealed the resident had a care plan in place for being at risk of elopement. The care plan stated "Resident #82 is an elopement risk, according to staff on unit, Resident #82 has expressed a desire to leave and has in the past sent all of her belongings out with one of her visitors. Resident #82 has also recently began stating a certain day on which she would be leaving this facility." The interventions were listed as "Elopement precaution per facility protocol: observe closely for wandering and attempts to exit. Photograph resident and place photo in elopement book and on elopement board ASAP. Write up physical description of resident include any outstanding traits. Apply sweatband per protocol. Assess for need to move to the secure unit." The care plan did not list the watchlet device as an intervention. On 04/20/12, at approximately 11:45 a.m., Employee #33 (registered nurse/program services) indicated this intervention was left off the resident's care plan. She amended the care plan and added the watchlet device as an intervention. . | 2015-08-01 |
| 10971 | 10971 | WORTHINGTON NURSING AND REHABILITATION CENTER, LLC | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2011-06-02 | 157 | D | 1 | 0 | 9FE011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, facility record review, and staff interview, the facility failed to notify the family member / legal representative of one (1) of five (5) sampled residents (who recently passed away), when a significant change in a resident's physical condition occurred and a new and/or altered treatment was ordered by the physician. Resident identifier: #102. Facility census: 100. Findings include: a) Resident #102 Review of Resident #102's closed record found a nursing note, dated [DATE] at 6:50 p.m., stating Resident #102 developed a fever of 101.3 degrees Fahrenheit, his oxygen saturation level was low at ,[DATE]%, and his lung sounds were diminished. The physician was notified by the registered nurse (RN - Employee #54), but there was no evidence the resident's medical power of attorney representative (MPOA) had been notified. In a telephone interview with Employee #54 on [DATE] at 11:30 a.m., the RN revealed that Resident #102 experienced a change of condition on [DATE] at 6:50 p.m., whereby he developed a fever and his lungs sounded congested. She said she notified the physician via fax at 6:50 p.m., and then got busy while awaiting the physician's response. Then it got late, so she did not call the MPOA. Her shift ended at 10:00 p.m., and she gave a report of his condition change to the night shift RN (Employee #69). The physician faxed orders to the facility at 10:30 p.m., after her shift had ended. Review of a physician order [REDACTED]. In an interview on [DATE] at 2:30 p.m., Employee #69 confirmed she was on duty at 10:30 p.m. on [DATE] when the physician's orders [REDACTED]. When asked if she called the MPOA of the new order for the chest x-ray to be done the following morning, she stated that she normally does not call people late at night unless something really bad is going on, and she did not want to alarm the family, so she did not call the MPOA about the new order. She said she was completely shocke… | 2014-10-01 |
| 10741 | 10741 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | PO BOX 6316 | WHEELING | WV | 26003 | 2011-08-11 | 224 | G | 1 | 0 | H2M211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, hospital record review, and staff interview, the facility failed, for one (1) of thirteen (13) residents reviewed, to provide care and services, as determined necessary by a comprehensive assessment and plan of care and/or in accordance with accepted standards of practice, to avoid physical harm. Resident #105 did not receive adequate care related to her diabetes as outlined in her plan of care, and abnormal lab values were not appropriately communicated to her attending physician. This lack of care resulted in a critically high abnormal blood sugar level, rendering the resident unconscious and requiring hospitalization . Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 revealed this 89-year ol female had been admitted to the facility' neighboring acute care hospital on [DATE], when she fell at home, where she lived alone, and fractured her left wrist. According to the hospital "history and physical examination [REDACTED]. This document also stated that the resident had additional medical [DIAGNOSES REDACTED]. The resident was admitted to the hospital and underwent a "closed reduction and casting of the left wrist" the following day. A "Progress Notes" document from the acute care hospital, signed by a hospital physician and dated 03/25/11, stated: "Afebrile, doing well, OK for transfer." The resident was admitted to BJHCCC on 03/25/11 at 15:30 (3:30 p.m.). Her [DIAGNOSES REDACTED]. The resident was ordered no diabetic medication or monitoring when admitted to the nursing home. -- Documentation on the admission nursing assessment noted, on Page 4 of 5 in the area that describes level of consciousness, that the resident had clear speech, made her self understood, was able to express ideas and wants, and was able to understand verbal content. Nurses notes at the nursing home immediately began describing the resident as "alert w… | 2014-12-01 |
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 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 | ||
| 11194 | 11194 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2010-12-22 | 225 | D | 1 | 0 | IX4U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, review of self-reported allegations of abuse / neglect, and staff interview, the facility failed to immediately report to all applicable State officials, as required by law, all nurse aides who were identified by the facility as having failed to provide goods and services to avoid physical harm to 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 [MEDICAL CONDITION] 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. Three (3) nurse aides were identified, through the facility's internal investigation into cause of the fracture, as having transferred Resident #147 manually on 09/02/10; however, the facility only reported two (2) of the three (3) aides to the State's Nurse Aide Program (NAP) for neglect. Employee identifiers: #141, #152, and #170. 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… | 2014-07-01 |
| 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 | ||
| 10085 | 10085 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 203 | E | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, the facility failed to provide correct contact information on its uniform transfer / discharge notice for the State long-term care ombudsman and the single State agency responsible for the protection and advocacy of persons with [DIAGNOSES REDACTED]. This had the potential to affect any resident who might need to contact these organizations. Facility census: 112. Finding include: a) Resident #114 Closed record review of Resident #114 revealed she was given a uniform transfer / discharge notice which contained inaccurate information. The notice she received directed persons with a developmental disability or mental illness to contact the "West Virginia Developmental Disabilities Council" for assistance. However, the single agency designated in West Virginia to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is "West Virginia Advocates, Inc." (not West Virginia Developmental Disabilities Council). Also, the appeals notice lacked the name of the State long-term care ombudsman, although it did list the name of the regional ombudsman. . | 2015-07-01 |
| 10012 | 10012 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2010-03-04 | 312 | E | 0 | 1 | 6XNG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on confidential resident group interview, observation, review of resident bathing information, and staff interview, the facility failed to assure twelve (12) of fifty-three (53) facility residents, with physician's orders [REDACTED]. Resident identifiers: #37, #14, #15, #9, #18, #20, #23, #27, #38, #44, #47, and #50. Facility census: 53. Findings include: a) Confidential Resident Group Meeting (resident identifiers withheld to maintain resident privacy) During the confidential resident group meeting held on the afternoon of 03/03/10, residents stated they wanted to take showers. When asked why they couldn't take showers, they stated the shower bed they had to use for taking showers was broken. b) Resident #37 Following the complaints concerning the lack of showering equipment, Resident #37 was observed in his wheelchair in the resident hallway. Observation found the resident had white scaly patches crusted in and around his ears and hairline. Flakes of skin were noted to be hanging from his eyebrows and the tufts of hair growing from his ears. Review of the medical record found the resident was ordered specialized shampoo and lotions to be applied on shower days. Staff members present in the hallway noted the surveyor looking at the resident. An observation the following morning, at 7:30 a.m., noted the resident's dried, crusty, scaly patches were no longer in evidence. c) The unit charge nurse (Employee #65), was interviewed at 4:45 p.m. on 03/03/10. When asked why the residents did not have a shower bed, she stated it needed a new part. When asked which residents this would affect, she stated all residents who used a mechanical lift for transfers would also need to use the shower bed for showers. On 03/04/10 at 8:00 a.m., nursing assistant Employee #62 was interviewed. She stated that staff had been unable to shower residents who use a mechanical lift for about ten (10) days. d) The director of nursing (DON - Employee #96) was asked… | 2015-07-01 |
| 10092 | 10092 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2010-03-04 | 248 | E | 0 | 1 | FFCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on confidential resident group interview, resident interview, and staff interview, the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being of each resident. This was evident by six (6) of eight (8) residents in attendance at a confidential group meeting who reported they were unable to participate in outings as a group and for one (1) of twenty (20) sampled residents (#6) who reported being unable to participate in outings as desired. Facility census: 112. Findings include: a) During a confidential resident group meeting on 03/02/10 at 10:30 a.m., six (6) of eight (8) residents in attendance reported they had never been able to attend outings as a group outside the facility as they desired. When asked, several of the residents reported they would like to visit the local Senior Center but noted transporting more than one (1) or two (2) residents in wheelchairs on the transit bus would be a problem. Group members stated the facility had no van of its own. During a confidential interview with an employee on 03/03/10 at approximately 3:00 p.m., this employee confirmed no group outings had been held for residents for at least the past two (2) years. Interview with the assistant activity director (Employee #6), on 03/04/10 at 11:15 a.m. revealed, only a few residents over the past few years have asked her about having a group outing. She stated the activities department has contacted the Marion County Transit Authority to transport individual residents for such things as shopping at Wal-Mart when requested, but the facility has not requested the Transit Authority to transport a group of residents at the same time. Interview with the activity director (Employee #10), on 03/04/10 at 2:45 p.m., revealed there have been no group outings since she has been working at the facility in July 2009. She recalled last year, in August or September, residents mentioned wanting group outin… | 2015-07-01 |
| 10448 | 10448 | NELLA'S NURSING HOME, INC. | 5.1e+35 | 200 WHITMAN AVENUE, CRYSTAL SPRINGS | ELKINS | WV | 26241 | 2011-03-16 | 492 | D | 0 | 1 | JSOV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on employee record review and staff interview, the facility failed to ensure one (1) of thirteen (13) dietary employees complied with the local health department's requirement to have a valid food handler's permit. Employee identifier: #80. Facility census: 66. Findings include: a) Employee #80 Review of Employee #80's food service worker's permit, issued in accordance with Legislative Rules 64 CSR 7 Section 17 by the Barbour County Health Department, expired [DATE]. During interview with the dietary manager on [DATE] at 1:20 p.m., he acknowledged the lapsed food service worker's permit, sent Employee #80 home from work, and made arrangements for this employee to be recertified the following week and to make application for a temporary food service worker's permit in the interim before being allowed to return to work in the kitchen. . | 2015-04-01 |
| 10074 | 10074 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2012-03-01 | 225 | D | 1 | 0 | 0TSC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility document review and staff interview, the facility failed to ensure all allegations of neglect were reported to state agencies as required, and were thoroughly investigated. This deficient practice affected one (1) of nine (9) sampled residents. The resident's daughter made an allegation of neglect which was not investigated or reported by the facility. Resident identifier: #73. Facility census: 71. Findings include: a) Resident #73 Review of a facility document, dated 02/13/12, entitled "Record of Customer and Family Concerns," found the social worker, Employee #79, contacted the resident's daughter after the resident's admission to the hospital on [DATE]. Employee #79 documented the daughter "had some concerns about resident's condition prior to admission to hospital (sic)". Employee #79 further documented the nursing home administrator and director of nursing were informed. Employee #79 documented the daughter reported Resident #73 had bilateral pneumonia. Employee #79 further documented the daughter was upset with the facility "...because we did not check on her often because if we did this wouldn't have happened." Employee #79 documented the daughter stated, "...she came in on Wed. 01/31/12 and her mother appeared dehydrated, (her mouth was dry and tongue sticking to roof of mouth). (The Daughter) notified a nurse (couldn't recall name or identify), however nurse shrugged it off. (The daughter) gave her mother water and she seemed better. Monday 2/6/12, (the daughter) came to see (Resident #73) again (around end of dinner) and found her shaking and appearing dehydrated. (The daughter) also reports that her tube feed was dated for 2/4/12 and crusted around opening at stomach. (The daughter) reports that her mother was not talking or acknowledging her presence. (The daughter) went to get a nurse, but felt the nurse shrugged it off and ignored her concerns. (The daughter) continued to express concerns to nurse. (The daugh… | 2015-07-01 |
| 10982 | 10982 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2011-06-02 | 312 | D | 1 | 0 | TI3G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility record review, family interview, resident interview, observation, and staff interview, the facility failed to provide assistance with oral hygiene to one (1) of eight (8) sampled residents who was not independent in performing this activity. Resident identifier: #109. Facility census: 109. Findings include: a) Resident 109# Review of Resident #109's medical record revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her minimum data set assessment, with an assessment reference date of 05/11/11, indicated she had no cognitive impairment and she required the extensive assistance of staff for personal hygiene including brushing teeth. A care plan, initiated by the resident assessment coordinator (Employee #102) on 05/03/11, contained the following intervention: "Assist with daily hygiene, grooming, dressing, oral care and eating as needed." In an interview on 06/01/2011 at 9:30 a.m., Resident #109's family member said she had complained that her mouth was sore approximately ten (10) days after her admission to the facility. The family member inspected the resident's mouth and stated, "It made me sick." Mouth care products brought to the facility by the family on admission had not been used. On 06/01/11 at 4:30 p.m., an interview with Resident #109 revealed no oral or denture care had been provided. When asked if her dentures had been cleaned today, she replied, "No." When asked how many times, over the last five (5) days, staffed cleaned her dentures, she stated "twice". Her dentures were observed to contain food particles. During this interview, the resident repeatedly put her hand over her mouth. On 06/02/11 at 10:00 a.m., the director of nursing (DON - Employee #18) was asked for a copy of the activity of daily living (ADL) documentation for Resident #109, on which direct care staff were to record the provision of ADL assistance given to the resident. The ADL sheet… | 2014-10-01 |
| 9832 | 9832 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2012-05-24 | 327 | G | 1 | 0 | 4S5211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on facility record review, hospital record review, staff interview, and anonymous information received during a complaint investigation, the facility failed to provide adequate amounts of fluid to maintain proper hydration for one (1) of ten (10) sampled residents. The resident experience a change in health status and was subsequently hospitalized . An admitting [DIAGNOSES REDACTED]. Resident identifier: #105. Facility census 103. Findings include: a) Resident #105 A review of the medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He had a Foley catheter placed to facilitate healing of the pressure ulcers. At 4:00 p.m. on 03/03/12, after transferring himself from the wheelchair into bed, Resident #103 complained to nursing that his Foley catheter was hurting him. He had 200 cc of amber urine in his drainage bag. At 9:00 p.m. the nurse's note, written by Nurse #4, stated, "...resident was c/o (complaining of) pain upon exam. It was noted cath (catheter) was clamped - and there was some blood in the cath bag." The physician was notified and the catheter was discontinued at the resident's request. The nurse also noted, "Resident voided X 3 lg amts of cl (large amounts of clear) amber urine since." The nurse's note by Employee #115 (Registered Nurse) stated at 2:00 p.m. on 03/04/12, "Resident c/o burning with urination. Will obtain clean catch UA (urinalysis) with resident's next void." There was no evidence a urine specimen was obtained or sent for testing. The medical record contained no entries for 03/05/12 or 03/06/12. The last nurse's note which contained any reference to intake or output was 03/03/12. There were no further entries in the nurse's notes indicating either intake or output until four (4) days later, on 03/07/12 at 11:00 p.m. Nursing notes, dated 03/07/12 at 11:25 a.m., described the resident had an unwitnessed fall in the bathroom. He sustained a two (2) i… | 2015-08-01 |
| 11432 | 11432 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 327 | G | 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 to provide the necessary care and services to ensure one (1) of eleven (11) sampled residents to maintain proper hydration and health. Resident #45 had a history of [REDACTED]. She was also identified as being at risk for weight loss related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus, and her diet order and care plan both addressed the need for staff to encourage fluid intake. On [DATE], Resident #45 received a Fleets enema on [DATE], after having no BMs for four (4) consecutive days. 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, continued to administer her routine laxatives except when the resident refused, 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]. Staff also did not identify and report to the physician a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. 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. F… | 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 | ||
| 11437 | 11437 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 224 | G | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . 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 goods and services necessary to avoid physical harm and 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, and failed to collect / record, monitor, and report to the physician and the resident's legal representative 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]. 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 (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. 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… | 2014-03-01 | ||
| 11436 | 11436 | BOONE HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-11-11 | 514 | E | IP7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed 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 ensure the clinical record of one (1) of eleven (11) sampled residents was maintained in accordance with accepted professional standards and practices that are complete and accurately documented. Review of the closed record of Resident #45, who was transferred to the hospital on [DATE], found incomplete and/or inaccurate documentation including but not limited to: no entries in the nursing notes describing significant changes in her health status that started on [DATE]; no entries at all after [DATE] (to include no entry related to her transfer); multiple blanks where licensed nurses were to have initialed as having administered ordered medications; multiple instances where the nurses' initials were circled (indicating medication doses were not administered) with no corresponding documentation to explain why; and documentation on the resident's [DATE] activities of daily living (ADL) flowsheet for ADL performance said to have occurred on shifts after the resident had left the faciity on [DATE]. These reflected at pattern of deficient practices affecting a single resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. No documentation related to the resident's change in condition 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 re… | 2014-03-01 | ||
| 11461 | 11461 | MCDOWELL NURSING AND REHABILITATION CENTER, LLC | 515162 | PO BOX 220 | GARY | WV | 24836 | 2010-11-18 | 240 | G | FROJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, ambulance personnel interviews, and staff interview, the facility failed to promote care for one (1) of nine (9) sampled residents in an environment that enhanced each resident's quality of life. A facility staff member forced Resident #49 to attend an appointment with a psychiatrist against her will, despite the resident's repeated and vocal statements that she did not want to go. The resident was placed on a gurney, loaded into an ambulance, and subjected to a two-hour trip to attend an appointment which she expressly did not want to attend. It was determined the resident arrived at the appointment in extreme emotional and physical distress. Resident identifier: #49. Facility census: 104. Findings include: a) Resident #49 An interview with Resident #49's daughter, on 11/15/10 at 7:42 p.m., found the daughter was present at a psychiatrist's office on 11/02/10 when her mother arrived by ambulance for a scheduled appointment. The daughter stated her mother was very upset, crying, and extremely short of breath. She relayed that her mother reported to her "they had thrown her out and made her go". She stated her mother was so upset that she was unable to interact with the psychiatrist and that she (the daughter) had to answer the questions posed to her mother by the psychiatrist due to her mother's emotional distress. She stated that both ambulance personnel told her that her mother had refused to go, but the nurse made them take her. An interview was conducted with the resident's son and medical power of attorney representative (MPOA) at 8:10 p.m. on 11/15/10. He stated that he visited the facility on 11/01/10, and was informed that his mother had an appointment with the psychiatrist the following day. He stated he informed Employee #98 (a licensed practical nurse - LPN), "If there was any way possible, I would like her to go, but she probably won't." He stated his mother had regularly refused… | 2014-03-01 | ||
| 11312 | 11312 | NELLA'S NURSING HOME, INC. | 5.1e+35 | 200 WHITMAN AVENUE, CRYSTAL SPRINGS | ELKINS | WV | 26241 | 2010-08-25 | 279 | D | 1 | 0 | I0YS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, it was determined the facility failed, for one (1) of five (5) sampled residents, to develop a comprehensive care plan that described bathing / shower services to be provided in a manner that accommodated his personal preference to be bathed in the evenings as noted. Resident identifier: #43. Facility census: 73. Findings include: a) Resident #43 During an interview on 08/24/10 at 11:30 a.m., the family of Resident #43 reported this resident was not a "morning person" and that he had a history of [REDACTED]. The family member also noted the resident had been receiving showers / baths in the morning and was becoming aggressive with staff, receiving injuries as a result. Review of the resident's annual comprehensive MDS, with an assessment reference date of 05/05/10, revealed in Section AC (Customary routines) that the resident preferred bathing in the evening. On 08/25/10 at 12:00 p.m., the DON was asked for a resident shower schedule that would indicate this resident was receiving showers in the evenings. The DON reported the facility did not have any schedules to indicate on what day or at what time each resident received a shower or bath. In a subsequent interview on 08/25/10 at 1:45 p.m., the DON confirmed there was no care plan developed to ensure this resident's preference of baths / showers in the evenings was communicated to direct care staff. | 2014-07-01 |
| 11311 | 11311 | NELLA'S NURSING HOME, INC. | 5.1e+35 | 200 WHITMAN AVENUE, CRYSTAL SPRINGS | ELKINS | WV | 26241 | 2010-08-25 | 246 | E | 1 | 0 | I0YS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to ensure the individual preferences were accommodated for one (1) of five (5) sampled residents. Resident #43 was aggressive and combative with staff during morning care when given baths / shower. Review of the most recent minimum data set assessment (MDS) found the resident preferred to be bathed / showered in the evening. Interview with the facility's director of nursing (DON) revealed there was no schedule to identify which residents were to receive baths / showers in the mornings versus evenings. The DON indicated residents received showers whenever they were needed. There was no evidence to indicate individual bathing preferences of this (or any other resident) was being accommodated. This practice had the potential to affect any residents who had expressed a preference to be bathed / showered at a particular time of day. Resident identifier: #43. Facility census: 73. Findings include: a) Resident #43 During an interview on 08/24/10 at 11:30 a.m., the family of Resident #43 reported this resident was not a "morning person" and that he had a history of [REDACTED]. The family member also noted the resident had been receiving showers / baths in the morning and was becoming aggressive with staff, receiving injuries as a result. Review of the resident's annual comprehensive MDS, with an assessment reference date of 05/05/10, revealed in Section AC (Customary routines) that the resident preferred bathing in the evening. On 08/25/10 at 12:00 p.m., the DON was asked for a resident shower schedule that would indicate this resident was receiving showers in the evenings. The DON reported the facility did not have any schedules to indicate on what day or at what time each resident received a shower or bath. In a subsequent interview on 08/25/10 at 1:45 p.m., the DON was unable to provide any further information on how any individual resident's bathing prefe… | 2014-07-01 |
| 11473 | 11473 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2010-10-21 | 309 | D | 6HW411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to monitor the effectiveness of treatment after administration of Tylenol for a new development of fever and in the presence of other symptoms and complaints; the facility also failed to monitor the temperature of a dependent resident with a history of repeated urinary tract infections after a new onset of fever early in the morning. This was evident for one (1) of six (6) sampled residents. Resident identifier: #51. Facility census: 120. Findings include: a) Resident #51 During an interview via telephone on 10/18/10, Resident #51's family member stated that, on 01/10/10 Resident #51 developed a high fever and was medicated with a fever-reducing medication, and five (5) hours elapsed before his temperature was re-checked by staff. By this time, he was totally unresponsive and the fever had elevated even more. Subsequently, he was transported to the hospital for a twelve (12) day stay. Upon his return to the facility, the pressure ulcer on his coccyx had worsened to a Stage IV wound, and he required a wound VAC after the area was surgically debrided during the hospitalization . Medical record review revealed Resident #51's temperature was 100.9 degrees Fahrenheit (F) on 01/10/10 at 3:30 p.m., and he was medicated with [MEDICATION NAME]. The physician was notified, and new orders were received for a urinalysis and culture to be obtained the following day. Further medical record review revealed that, at 5:30 p.m. on 01/01/10, he refused dinner and complained of not feeling well. The nurse documented his refusal to go to the emergency room . There was no evidence that his temperature was monitored at this time, to ascertain whether the [MEDICATION NAME] was effective in reducing his temperature, and there was not evidence to reflect the family was notified of the fever. It was not until 8:00 p.m. on 01/01/10 that the nurse again assessed him again; she do… | 2014-02-01 | ||
| 9898 | 9898 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-06-21 | 280 | D | 1 | 0 | MNCH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, and staff interview, the facility failed to revise the care plan to meet the needs of one (1) of five (5) sampled residents. Resident #92 was hospitalized , intubated, and placed on a respirator due to a possible allergic or toxic reaction to cleaning materials causing respiratory [MEDICAL CONDITION]. The facility failed to revise the care plan to reflect this potential complication related to chemical products. Resident identifier: #92. Facility census: 117. Findings include: a) Resident #92 During an interview with the spouse of this incapacited resident, on 06/21/12 at 2:00 p.m., she stated housekeeping staff sprayed deodorizer on her husband's bedside curtains and made him so sick he was put in the hospital on a ventilator. Review of the medical record found the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. The resident was intubated and placed on a ventilator. He was readmitted to the facility on [DATE]. Review of the current care plan, with a target date of 09/12/12, noted no interventions to refrain from utilizing cleaning or deodorizing chemicals in Resident #92's room. The minimum data set (MDS) nursing staff, Employee #47 and Employee #36 were interviewed on 06/21/12 at 3:45 p.m. Employee #36 stated she was aware of the emergency department report documenting a possible allergic or toxic reaction to cleaning materials causing respiratory [MEDICAL CONDITION]. She reviewed the care plan related to the resident's risk for respiratory impairment due to [DIAGNOSES REDACTED]. The goals developed included, "Will experience effective symptom management". MDS nurse, Employee #36 was asked why, if she was aware of the emergency department report, the care plan did not include interventions to prevent staff from utilizing these products in the resident's room. Employee #36 stated she was only responsible for scheduled care plans. She stated if something happens between those t… | 2015-08-01 |
| 11186 | 11186 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2010-11-12 | 225 | D | 1 | 0 | OP3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, staff interview, review of personnel records, and policy review, the facility failed to ensure all allegations of abuse / neglect were immediately reported (in accordance with facility policy and State law) and thoroughly investigated for two (2) of two (2) allegations reviewed. Resident identifiers: #100 and #34. Facility census: 62. Findings include: a) Resident #100 A family interview, conducted on 11/11/10 at 9:45 a.m., revealed Resident #100 was not turned for two (2) days. The family member stated that, on 09/18/10 and 09/19/10, family sat with the resident and noted no staff members coming into the room to turn the resident. The family member stated that a turning schedule posted on the inside of the closet door was left blank for both dates when reviewed on 09/20/10. The family member stated she reported the failure to turn the resident to the licensed practical nurse (LPN - Employee #9) on the morning of 09/20/10. Review of the medical record found Resident #100 was admitted to the facility on [DATE] with three (3) Stage II wounds and one (1) unstageable wound to her coccyx. The facility instituted treatment to the areas which required debridement and resulted in one (1) Stage IV wound. Review of the care plan in effect during this time period found the resident was to be assisted to turn and reposition every two (2) hours and as needed. Review of facility policy titled "1.0 Abuse Prohibition" found that all allegations were to be reported to the supervisor immediately. An interview with Employee #9, on 11/12/10 at 1:00 p.m., confirmed the family member reported to this nurse that her mother had not been turned for two (2) days. The nurse could provide no evidence this allegation of neglect had been reported to supervisory staff in accordance with facility policy, nor was there any evidence to reflect this allegation of neglect was immediately reported to State agencies as required … | 2014-07-01 |
| 10513 | 10513 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-10-27 | 312 | E | 1 | 0 | 2JCC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, observation, medical record review, and staff interview, the facility failed to assure dependent residents received the necessary services to maintain good grooming and personal hygiene. Review of facility documentation of residents who were to receive showers on Tuesdays found that seventeen (17) of twenty-seven (27) residents had not received showers for up to twenty-four (24) days during the month of October 2011. Additionally, observation found the fingernails of one (1) of thirteen (13) sampled resident were long, jagged, and packed with brownish-colored debris. Resident identifiers: #23, #51, #91, #41, #9, #90, #11, #97, #26, #105, #30, #103, #64, #14, #100, #1, #61, and #99. Facility census: 102. Findings include: a) Showers 1. Resident #23 During the observation of the medication pass on 10/25/11 at 10:10 a.m., a family member of Resident #23 approached the medication cart and expressed to the licensed practical nurse (LPN - Employee #68) his concern that his mother had not had a shower. Review of Resident #23's medical record for the month of October 2011 found the Resident Functional Performance Record (RFPR), on which staff was to document on a daily basis how a resident received bathing - whether a bed bath or a shower - and how much staff assistance with bathing the resident required. According to documentation on Resident #23's RFPR, the resident had not received a shower since 10/10/11, a time period of fourteen (14) days. A follow-up interview with the concerned family member was conducted at 11:00 a.m. on 10/25/11. The family member stated he noticed that his mother had an odor and he had been trying since yesterday (10/24/11) to find out when she had last received a shower. - 2. Residents #51, #91, #41, #9, #90, #11, #97, #26, #105, #30, #103, #64, #14, #100, #1, and #61 A review of all residents scheduled to receive showers on Tuesdays was conducted with the director of nursing (DON - Employee #… | 2015-02-01 |
| 10916 | 10916 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2011-07-13 | 309 | D | 1 | 0 | YYWA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, observation, medical record review, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being in accordance with the plan of care for one (1) of eight (8) residents observed who had orders for [MEDICATION NAME] medication patches. Resident #33 had a physician's orders [REDACTED]. Observations with a licensed practical nurse (LPN - Employee #99) - the LPN responsible for medication pass this day, on 07/12/11 at 8:30 a.m., found Resident #33 had a Nitro-Dur patch on her chest that was dated 07/11/11. Employee #99 stated the patch on the resident's chest dated 07/11/11 should have been removed in the evening on 07/11/11. The failure of nursing staff to remove the Nitro-Dur patch as ordered resulted in the resident receiving an excessive dose of this medication. Resident identifier: #33. Facility census: 97. Findings include: a) Resident #33 During a random interview on 07/11/11 at 3:00 p.m., a family member expressed a concern regarding how the facility was providing care for residents who received medication via patches that were applied externally. During this interview, the family member expressed a concern about finding excess patches on her resident. On 07/12/11 at 8:30 a.m., observations were made of eight (8) residents who were identified by the medication nurses as having [MEDICATION NAME] medication patches. Observations with the medication nurse (Employee #99) found Resident #33 had a Nitro-Dur patch in place on the chest upon examination. The medication nurse reported this patch should not have been found on the resident this morning, as the patch should have been removed the previous evening. Further observation of the medication patch found it was dated for 07/11/11; the medication nurse stated this patch had been applied on the morning of on 07/11/11 and should have been removed by the medication nurse on the evening of 07… | 2014-11-01 |
| 11251 | 11251 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2010-03-18 | 165 | D | 1 | 0 | 8Q6O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interview, the facility failed to assure one (1) of four (4) sampled residents was afforded the right to voice grievances via their legal representative without reprisal. Resident identifier: #2 Facility census: 118. Findings include: a) Resident #2 During an interview with Resident #2's legal representative / family member conducted on 03/17/10 at 12:00 p.m., the legal representative stated that, when she had previously expressed concern to the facility about Resident #2's care, she was told that if she was not happy with the care the resident received, the facility would assist her in finding alternate placement. The legal representative stated she no longer brings complaints or concerns to the attention of the facility out of fear the resident would be forced to move to another facility. A review of the facility's grievance / complaint reports found Resident #2's family met with staff members on 02/03/10 at 3:10 p.m., related to concerns that the resident received a double dose of [MEDICATION NAME]. The hand-written record of the meeting contained the following: "Family has been given option of replacement if they are not satisfy (sic) w/ (with) resident's care & there (sic) response was we don' t want him replaced it is to (sic) convienced (sic) for their mother to visit." In ann interview was conducted with the administrator (Employee #1) on the morning of 03/18/10, he stated he attended the 02/03/10 meeting and did offer to assist the family in finding alternate placement if they were not satisfied with the care provided by the facility. | 2014-07-01 |
| 11537 | 11537 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2010-09-16 | 204 | D | WF8P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interview, the facility failed to provide sufficient preparation at discharge of one (1) of six (6) sampled residents to ensure an orderly transfer from the facility, by failing to safeguard and return timely to the resident and/or responsible party important personal documents left in the facility's possession on admission which could not be produced at the time of the resident's discharge. Resident identifier: #96. Facility census: 94. Findings include: a) Resident #94 During an interview at 3:15 p.m. on 09/13/10, Resident #96's responsible party reported she had not yet received the resident's Medicare benefits card, social security card, or her driver's license, which she had given to staff at the time of the resident's admission to the facility on [DATE]. Resident #96 was discharged from the facility on 08/20/10. The responsible party stated these identification cards were necessary for obtaining health care services for the resident. Review of the resident's closed record revealed a copy of the resident's Medicare benefits card, confirming it had been presented to the facility. There was no mention in the record of the location of the original card. During an interview with the social worker (Employee #8) at 10:40 a.m. on 09/16/10, she acknowledged the cards had not been returned and, in fact, could not be located. She stated she had met with the resident's daughter shortly before her mother's discharge and returned jewelry that had been held for the resident in the facility's safe. At that time, the daughter asked her about the cards. Employee #8 had no knowledge of the cards and had assured the daughter she would locate them and have them returned. She stated this duty had been given to the admissions clerk, who reported she had them in her possession and volunteered to return them. A week ago, the social worker had been contacted again by the resident's daughter, who had again req… | 2014-01-01 | ||
| 11219 | 11219 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2011-03-16 | 309 | D | 1 | 0 | 81RJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interviews, the facility did not ensure one (1) of five (5) sampled residents received care and services to attain or maintain the highest practicable physical well being. Resident #112 received two (2) doses of a short-acting benzodiazepine ([MEDICATION NAME] 0.25 mg), contrary to the physician's orders [REDACTED]. At 4:00 p.m. on the same day, she received a dose of a short-to-intermediate acting benzodiazepine ([MEDICATION NAME] 0.5 mg). Both [MEDICATION NAME] and [MEDICATION NAME] have sedative / hypnotic side effects, and the resident's sons reported she experienced a decrease in her level of consciousness, which was not addressed until they brought it to the staff's attention. Facility census: 116. Findings include: a) Resident #112 In an interview on 03/15/11 at 11:30 a.m., Resident #112's two (2) sons reported the resident received two (2) doses of [MEDICATION NAME] and a dose of [MEDICATION NAME] on the same day (on 02/26/11). The next day (on 02/27/11), their mother's level of consciousness changed. According to her sons, she was sedated, could not eat or drink, and was very stiff and not moving in her bed. She could not open her mouth, and they were having difficulty getting her awake. They asked the nurse if the [MEDICATION NAME] was maybe too strong for their mother, and they wanted the physician notified. When the physician was called, he discontinued the [MEDICATION NAME]. - Record review revealed an order, dated 12/29/10, for: "[MEDICATION NAME] 0.25 mg QD (daily) and [MEDICATION NAME] 0.25 mg PRN (as needed) for increased anxiety." On 02/15/11, the physician discontinued the [MEDICATION NAME] 0.25 mg QD. (The remaining order for [MEDICATION NAME] allowed staff to administered one (1) 0.25 mg tab by mouth every day as needed for anxiety.) On 02/26/11 at 2:30 p.m., the physician discontinued the [MEDICATION NAME] 0.25 mg PRN and ordered [MEDICATION NAME] 0.5 mg every six (6)… | 2014-07-01 |
| 10449 | 10449 | NELLA'S NURSING HOME, INC. | 5.1e+35 | 200 WHITMAN AVENUE, CRYSTAL SPRINGS | ELKINS | WV | 26241 | 2011-03-16 | 514 | E | 0 | 1 | JSOV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, staff interview, observation, and resident interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. This was found for four (4) of forty-four (44) Stage II sample residents. Resident identifiers: #12, #26, #78, and #66. Facility census: 66. Findings include: a) Resident #12 1. During an interview with Resident #12's husband on 03/07/11 at 4:06 p.m., he expressed concern with her decline in skin condition. He stated staff told him it was due to poor circulation. He had asked staff about resumption of physical therapy but had been told she was not a candidate for physical therapy, because she could not follow commands. He stated then asked them to at least move her arms and legs, because he felt that would help poor circulation, but they were not doing it. He expressed she had now lost a leg due to this and had a staph infection. He was afraid that, if they did not move her arms and leg, she would get worse. He pointed out she now had a sore on her hip, about which he was greatly concerned. He said he asked facility staff to resume moving her arms and leg since she returned from the hospital (01/07/11), but he could not recall who he talked to. 2. Resident #12's care plan, when reviewed on 03/09/11 at 9:00 a.m., contained the following problem statement dated 01/20/11: "Risk for skin breakdown due to bowel / bladder incontinence and immobility. Contractures of both hips and right knee. History of stage I area on coccyx. Infusaport left chest wall. Stage IV area right foot. Stage I area left buttock. Left above knee amputation. Red areas behind knees / abdominal folds / groin / buttocks / back." The goal associated with this problem statement was: "Skin will not demonstrate further breakdown." Eighteen (18) approaches were ident… | 2015-04-01 |
| 9914 | 9914 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 246 | D | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, resident interview, observation, staff interview, and medical record review, the facility failed to obtain necessary equipment which would enable one (1) of six (6) sampled residents to safely occupy and utilize a wheelchair. Resident #124 was confined to his bed for approximately five (5) days when the seatbelt on his wheelchair malfunctioned. The facility did not obtain a replacement seatbelt in a timely manner to enable this resident to be out of bed. Resident identifier: #124. Facility census: 123. Findings include: a) Resident #124 A family interview was conducted with Resident #124's spouse on 06/05/12 at 1:50 p.m. The resident's spouse stated the resident had been confined to his bed for approximately five (5) days due to the seatbelt on his wheelchair being broken. She stated staff refused to get him up without the seatbelt for fear of the resident falling from his chair. She stated she had asked staff that day to get him up and no one had attempted to assist her husband to his chair. She stated someone was supposed to order a replacement seatbelt last week, but no one appeared to know about the replacement belt being ordered. It was noted Resident #124 was awake, alert, and appeared aware of his surroundings. The resident's spouse stated the resident enjoyed getting out of bed and visiting with her. An interview with Resident #124's alert and oriented roommate confirmed that the resident's seatbelt had been broken and he had not been allowed out of the bed for days. Observation of Resident #124's wheelchair noted the buckle of the seatbelt attached to his wheelchair was broken. An interview was conducted with the licensed practical nurse (LPN), Employee #98, at 2:10 p.m. She verified she was the nurse assigned to the resident and agreed that the resident's spouse had asked her to get the resident up before lunch. Employee #98 stated the resident could not get up due to the seatbelt in his chair being brok… | 2015-08-01 |
| 11188 | 11188 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2010-11-12 | 314 | D | 1 | 0 | OP3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, resident interview, staff interview, review of manufacturer's information for the Stat 4000 air mattress, and medical record review, the facility failed to provide care and services to promote healing of pressure ulcers for two (2) of four (4) sampled residents. Resident identifiers: #100 and #18. Facility census: 62. Findings include: a) Resident #100 A family interview, conducted on 11/11/10 at 9:45 a.m., revealed Resident #100 was not turned for two (2) days. The family member stated that, on 09/18/10 and 09/19/10, family sat with the resident and noted no staff members coming into the room to turn the resident. The family member stated that a turning schedule posted on the inside of the closet door was left blank for both dates when reviewed on 09/20/10. The family member stated she reported the failure to turn the resident to the licensed practical nurse (LPN - Employee #9) on the morning of 09/20/10. Review of the medical record found Resident #100 was admitted to the facility on [DATE] with three (3) Stage II wounds and one (1) unstageable wound to her coccyx. The facility instituted treatment to the areas which required debridement and resulted in one (1) Stage IV wound. An interview with Employee #9, on 11/12/10 at 1:00 p.m., revealed Resident #100 was to be turned every two (2) hours for treatment of [REDACTED]. She confirmed the family member reported to her that the resident had not been turned for two (2) days. She further stated she viewed the turning schedule with the family member, and two (2) days had been left blank. Review of the medical record found the care plan instructed staff members to turn and reposition the resident every two (2) hours. -- b) Resident #18 An interview with the resident, on 11/10/10 at 5:30 p.m., revealed staff was not turning her since she got her new bed. The resident stated she was told that the new bed took care of it. Interviews with the assigned LPN (Employee #35) a… | 2014-07-01 |
| 9899 | 9899 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2012-06-21 | 323 | D | 1 | 0 | MNCH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, staff interview, and medical record review, the facility failed to ensure the environment remained free from environmental hazards which potentially caused a severe respiratory reaction in one (1) of five (5) sampled residents. Resident #92 was intubated and placed on a respirator with one of the emergency physician's impression being "Possible allergic or toxic reaction to cleaning materials causing respiratory edema". The facility failed to ensure housekeeping staff were instructed to refrain from spraying chemical deodorizers in the resident's room. Resident identifier: #92. Facility census: 117. Findings include: a) Resident #92 During an interview with the spouse of this incapacitated resident, on 06/21/12 at 2:00 p.m., she stated housekeeping staff sprayed deodorizer on her husband's bedside curtains and made him so sick he was put in the hospital on a ventilator. Review of the medical record found the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. The resident was intubated and placed on a ventilator. He was readmitted to the facility on [DATE]. An interview with housekeeping aide, Employee #62, was conducted at 2:30 p.m. on 06/21/12. He was pushing a housekeeping cart up the 100 hallway. He verified he worked for housekeeping and had worked in that position for approximately 2 years. He was asked if there was deodorizer on the housekeeping cart for use in the resident rooms. He opened the door of the cart and indicated a spray bottle labeled "fabric freshener". When asked if he had been instructed to not use the spray in rooms of residents with breathing problems, he stated he had not been instructed to not use it. An interview was conducted with Employee #153 on 06/21/12 at 2:45 p.m. He stated he had been the head of housekeeping for 1 year and supervised about eight (8) housekeeping staff members. According to Employee #153, the facility had switched to a fabric freshener spray to get away… | 2015-08-01 |
| 11189 | 11189 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2010-11-12 | 514 | D | 1 | 0 | OP3T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, staff interview, and medical record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one (1) of four (4) records reviewed. Resident identifier: #100. Facility census: 62. Findings include: a) Resident #100 A family interview, conducted on 11/11/10 at 9:45 a.m., revealed Resident #100 was to be turned every two (2) hours for treatment of [REDACTED]. The family member stated the facility maintained a turning schedule on the inside of the closet door on which staff was to document when they had turned the resident. Review of the medical record found no turning schedule. An interview with the wound care nurse (Employee #9), on 11/12/10 at 1:00 p.m., revealed a turning schedule had been posted in the resident's closet. The facility was unable to locate the turning schedule in the medical record. . | 2014-07-01 |
| 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 | ||
| 10266 | 10266 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-09-26 | 431 | E | 0 | 1 | FJI611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on inspection of the medication storage areas and staff interview, the facility failed to properly store medications. Observation of the medication room found opened injectable medications that had not been dated when opened to ensure use within the appropriate time frames for the medication. Facility census: 109. Findings include: a) Observation of the medication storage room, on 09/24/12, at approximately 3:29 p.m., found one (1) open vial of purified protein derivative (PPD - a test for [DIAGNOSES REDACTED]) and one (1) open vial of Novolin R insulin. Neither vial had been dated when opened to ensure the medication was not used beyond 28 days for Novolin or 30 days for the PPD, as recommended by the manufacturer. Observation of the medication room was conducted with Employee #48 (licensed practical nurse) on 09/24/12, at approximately 3:20 p.m. Employee #48 immediately disposed of the open medications. . | 2015-05-01 |
| 11320 | 11320 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-02-04 | 279 | D | 1 | 0 | NKDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and facility staff interview, the facility failed to develop a comprehensive care plan to meet the nursing needs of one (1) of five (5) sampled residents. Resident identifier: #120. Facility census: 113. Findings include: a) Resident #120 1. Review of Resident #120's medical record found the resident was ordered by the attending physician to receive no foods or fluids by mouth (NPO) on [DATE]. Further review found Resident #120 exhibited food-seeking behaviors and frequently asked staff for food. A staff member gave the resident ice cream on the evening of [DATE]. Review of the care plan found no plan in place to address this resident's food-seeking behaviors. The care plan contained no interventions for staff members to utilize to redirect the resident when displaying these behaviors. An interview with the minimum data set (MDS) nurse (Employee #16), on the afternoon of [DATE], confirmed Resident #120's care plan did not contain interventions for nursing staff to utilize when the resident displayed food-seeking behaviors. 2. Review of the resident's medical record found a Physician order [REDACTED]. The POST form ordered that the resident did not desire cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. Review of the care plan in effect during the resident's stay at the facility found that nursing staff was instructed to initiate CPR should the resident be found with no apical pulse, respirations, and/or blood pressure, contrary to information found on the resident's POST form. . | 2014-06-01 |
| 10672 | 10672 | CRESTVIEW MANOR NURSING & REHABILITATION | 515160 | P.O. BOX 967 | JANE LEW | WV | 26378 | 2010-10-04 | 428 | D | 0 | 1 | K6RU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and review of the drug insert for Primidone found on the Food and Drug Administration (FDA) website (www.fda.gov), the facility failed to assure the consultant pharmacist identified and reported all drug irregularities to the attending physician and the director of nursing for one (1) of twenty-seven (27) Stage II sample resident. Resident identifier: #12. Facility census: 68. Findings include: a) Resident #12 Review of Resident #12's medical record found that Phenobarbital was documented on the resident's list of known allergies [REDACTED]. The medical record contained documentation to reflect the resident had been ordered and received Primidone 250 mg twice-a-day (BID). Review of the manufacturer's information for Primidone, found on the FDA's website, revealed Primidone is metabolized by the body into Phenobarbital and Phenylethylmalonamide (PEMA). Under "Contraindications", the manufacturer stated: "... Primidone is contraindicated in... 2) patients who are hypersensitive to Phenobarbital." The physician was notified on the afternoon of 09/30/10, and ordered the Primidone tapered and discontinued. The medical record contained no evidence to reflect the consulting pharmacist notified the physician or director of nursing of this irregularity in the resident's medication regimen. . | 2015-01-01 |
| 10671 | 10671 | CRESTVIEW MANOR NURSING & REHABILITATION | 515160 | P.O. BOX 967 | JANE LEW | WV | 26378 | 2010-10-04 | 329 | D | 0 | 1 | K6RU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and review of the drug insert for [MEDICATION NAME] found on the Food and Drug Administration (FDA) website (www.fda.gov), the facility failed to assure the medication regimen of one (1) of twenty-seven (27) Stage II sample residents free from drugs for which the resident had a known allergy. Resident identifier: #12. Facility census: 68. Findings include: a) Resident #12 Review of Resident #12's medical record found that [MEDICATION NAME] was documented on the resident's list of known allergies [REDACTED]. The medical record contained documentation to reflect the resident had been ordered and received [MEDICATION NAME] 250 mg twice-a-day (BID). Review of the manufacturer's information for [MEDICATION NAME], found on the FDA's website, revealed [MEDICATION NAME] is metabolized by the body into [MEDICATION NAME] and Phenylethylmalonamide (PEMA). Under "Contraindications", the manufacturer stated: "... [MEDICATION NAME] is contraindicated in... 2) patients who are hypersensitive to [MEDICATION NAME]." The physician was notified on the afternoon of 09/30/10, and ordered the [MEDICATION NAME] tapered and discontinued. . | 2015-01-01 |
| 9980 | 9980 | SPRINGFIELD CENTER | 515188 | ROUTE 1 BOX 101-A | LINDSIDE | WV | 24951 | 2012-06-14 | 428 | D | 1 | 0 | 18U511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility did not ensure the physician provided a rationale for the decision to decline a reduction in an antipsychotic medication recommended by the pharmacist. One (1) of five (5) residents on the sample had a drug regimen review in which the pharmacist recommended a gradual dose reduction for Risperdal. The physician declined the gradual dose reduction, but did not provide any rationale as to why she declined the reduction. Resident identifier: #24. Facility census: 52. Findings include: a) Resident #24 Medical record review for this resident, conducted on 06/13/12, at approximately 3:00 p.m., revealed the pharmacist had identified an irregularity for an antipsychotic medication. A communication from the pharmacist to the attending physician, dated 03/20/12, indicated a request for a reduction of Risperdal. The pharmacist recommended attempting a gradual dose reduction (GDR) for the antipsychotic medication, Risperdal 0.5 mg hs (at night). The physician had disagreed with the pharmacist and signed the "note to the attending physician/prescriber" on 04/07/11. The physician provided no clinical rationale stating why she did not wish to reduce the dosage of Risperdal. On 06/13/12, at approximately 4:00 p.m., Employee #8 (licensed practical nurse) indicated the physician normally documented the information related to her rejection of a pharmacist's recommendation on the "note to the attending physician/prescriber" or in the physician progress notes [REDACTED]. . | 2015-08-01 |
| 10608 | 10608 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 151 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to allow one (1) of eight (8) sampled residents the right to exercise her rights as a resident of the facility. This resident was not permitted to choose how she wished to live her everyday life and receive care. The facility cleaned the resident's room without permission and did not allow the resident to refuse a medication when she clearly stated she did not want the medication. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. This was an infringement on the resident's rights which led to the following infringement on the resident's rights: - On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. - On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for "[MEDICATION NAME] 1 mg IM now". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, "You're not giving me no shot." The resident was walked to her room, all the while screaming "No, no… | 2015-01-01 |
| 10517 | 10517 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2011-10-31 | 309 | G | 1 | 0 | 4SLS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assess and monitor a resident with a history of [MEDICAL CONDITION] and an indwelling Foley urinary catheter, to prevent complications associated with this invasive intervention. Resident #157 had an indwelling urinary catheter inserted on 07/18/11 to treat [MEDICAL CONDITION]. Fluid output records completed by the nursing assistants noted there had been only 50 cc of urinary output from this indwelling catheter during the three-day period prior to her acute hospitalization on [DATE], with 0 cc recorded on 08/17/11 and 08/18/11, and only 50 cc recorded on 08/19/11. The fluid output records further reflected a urinary output of only 425 cc during the entire five-day period prior to her acute hospitalization on [DATE], while the nursing notes for this same time frame documented that the urinary catheter was "patent" (unobstructed) and draining yellow urine into the bedside drainage bag. There was no evidence the resident's decreased urinary output was communicated to a licensed nurse, nor was there evidence that a licensed nurse assessed the resident related to this decreased urinary output until 9:30 p.m. on 08/19/11. There was also no evidence the resident's daily fluid intake had been compared to her daily urinary output to identify a fluid imbalance, nor was there evidence to show staff notified the physician of the resident's poor urinary output over the five-day period preceding her acute hospitalization . The resident was transferred to the hospital emergency room (ER) on 08/19/11, where the ER physician noted on the early morning of 08/20/11 (quoted as typed): "... this is the worst looking foley cath i have ever seen. with the tip of the catheter was almost completely occluded causing the patient [MEDICAL CONDITION] and causing pus to leak out around the foley filling the patients diaper. Pt (patient) smelt horrible. 1400 cc obtained after the Foley was change… | 2015-02-01 |
| 10609 | 10609 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 222 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure one (1) of eight (8) sampled residents had the right to be free from chemical restraints. This resident was given a medication to control behaviors for staff convenience and not to treat identified medical symptoms. The medication was used without assessing possible causes for the resident's behavior and/or without first attempting non-pharmacological interventions. The medication was used as a means of managing the resident's behaviors with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for "[MEDICATION NAME] 1 mg IM now". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, "You're not giving me no shot." The… | 2015-01-01 |
| 11517 | 11517 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2011-01-07 | 387 | D | XJ0U13 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure one (1) of ten (10) sample residents received a physician visit in the facility at least once every thirty (30) days for the first ninety (90) days after admission. This resident, who resided in the facility from [DATE] until 12/17/10, had no face-to-face visits with his attending physician. Resident #143. Facility census: 142. Findings include: a) Resident #143 Medical record review, on 01/05/11, revealed this resident was admitted to the facility on [DATE], and was discharged on [DATE]. There was no evidence this resident had a face-to-face contact, in the facility, with his attending physician between 09/06/10 and 12/17/10. On 01/05/11 at 4:30 p.m., this situation was brought to the attention of the director of nursing (DON). The DON was asked to locate any physician's progress notes which might be available. On 01/06/11, the DON reported nursing personnel was unable to produce any physician's progress notes for the resident. When this situation was brought to the attention of the facility's administrator on 01/06/10, she provided a copy of a letter written to the resident's attending physician on 10/07/09 which stated, "This is your official notice that you have ten days to come in and complete the physician progress notes [REDACTED]. If you fail to comply with this notice it will be placed in your file." . | 2014-01-01 | ||
| 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 | ||
| 10929 | 10929 | MCDOWELL NURSING AND REHABILITATION CENTER, LLC | 515162 | PO BOX 220 | GARY | WV | 24836 | 2011-09-08 | 425 | D | 1 | 0 | 34ZP12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure that medications were available to meet the needs of the residents. Resident #68 did not receive insulin to treat her diabetes due to this medication not being available in the facility when it was time for her to have it. This practice affected one (1) of seventeen (17) sampled residents. Resident identifier: #68. Facility census: 98. Findings include: a) Resident #68 According to the nursing notes, this resident was admitted on [DATE] and arrived at the facility at 11:15 p.m. Her [DIAGNOSES REDACTED]. It was noted (on 09/06/11) that this medication was not recorded on the medication administration record until 09/06/11 at 1630 (4:30 p.m.). The hospital records indicated that, prior to this resident being discharged , she received her insulin at 5:00 p.m. on 09/05/11. There was no evidence the resident received the morning dose of 20 units of Novolin 70/30 Insulin as ordered at 0630 (6:30 a.m.) on 09/06/11. The resident's fingerstick at 1130 (11:30 a.m.) on 09/06/11 was 215 mg/dl. This was then repeated at 4:30 p.m., and her fingerstick blood sugar was 132 mg/dl. She then received her Novolin 70/30 insulin as ordered at 4:30 p.m. During an interview with the administrator on 09/07/11 at 3:15 p.m., she was questioned about this medication. She called the nurse at home at that time and verified that this medication was not administered that morning at 6:30 a.m. on 09/06/11, because it had not arrived from the pharmacy. The director of nursing, when interviewed on 09/08/11 at 11:00 a.m., was about the facility's procedure for obtaining medications when a resident is admitted late at night . She provided a copy of the facility's procedure for obtaining medications after hours. She verified the nurse should have called the on-call pharmacist's pager number. | 2014-11-01 |
| 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 | ||
| 10518 | 10518 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2011-10-31 | 386 | D | 1 | 0 | 4SLS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure the attending physician signed and dated orders with each visit. Resident #157's medical record contained multiple physician telephone orders that had not been reviewed and signed by the physician. There were orders in the medical record from 07/20/11 that were not reviewed and signed as of 10/24/11. This was found to be true in one (1) of one (6) records reviewed. Resident identifier: #157. Facility census: 156. Findings include: a) Resident #157 Review of Resident #157's closed medical record, on 10/24/11, found several pages flagged for the physician to sign. Further review of this record found the resident was admitted [DATE] and discharged from the facility on 08/30/11. There were multiple physician telephone orders receive in July and August 2011 not were signed by the physician, as well as orders for therapy that were written on 07/20/11 and signed and dated by the physician as required. This was a period of three (3) months since these orders had been written. The director of nursing (DON - Employee #127), when interviewed on 10/24/11, verified these orders had not been signed and dated and agreed that this should have been completed by now. She also verified physician followed other residents in the facility and had been in the facility on multiple occasions since Resident #157's discharged on [DATE]. . | 2015-02-01 |
| 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 | ||
| 6801 | 6801 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2015-10-22 | 272 | D | 0 | 1 | 291G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of twelve (12) residents reviewed. The assessments were coded inaccurately related to [DIAGNOSES REDACTED].#7. Facility census: 6. Findings include: a) Resident #7 Review of the resident's medical record, on 10/22/15 at 8:27 a.m., revealed an admission wound evaluation dated 05/08/15. The evaluation indicated Resident #7 had an abrasion on her medial back, pink in color, with a scant amount of serous drainage (normal drainage from a healing wound or incision). Another assessment, dated 05/19/15, identified the abrasion as a Stage 3 pressure ulcer with yellow/white necrotic tissue (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either softer or firmer than surrounding skin), that measured 1 centimeter (cm) wide by one centimeter long (1 cm L x 1 cm W). The surrounding tissue was noted as macerated (skin that is moist, soft and in a state of deterioration). A history and physical, dated 05/19/15 indicated Resident #7 had a [DIAGNOSES REDACTED]. Review of the comprehensive minimum data set (MDS), with an assessment reference date (ARD) of 05/26/15, noted in Section M, the most severe type of tissue as [MEDICATION NAME] (new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface), not necrotic. Additionally, impaired renal function was not identified as a diagnosis. An interview, with the MDS coordinator, on 10/22/15 at 10:15 a.m., confirmed the MDS was inaccurately coded related to the pressure ulcer and [MEDICAL CONDITION]. | 2017-11-01 |
| 10237 | 10237 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2010-06-04 | 272 | D | 0 | 1 | 5XSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to conduct a comprehensive assessment which identified activity needs for one (1) of twenty-nine (29) Stage II sample residents. There was no evidence the facility utilized resident observations, communication with nursing personnel, or family members to obtain an accurate assessment of the resident's activity needs. Resident identifier: #16. Facility census: 48. Findings include: a) Resident #16 Medical record review, on 06/03/10, revealed this resident had a [DIAGNOSES REDACTED]. She was non-verbal and unable to communicate. At 12:00 p.m. on 06/03/10, the resident was observed in her room with a nurse. When the nurse spoke or touched the resident, the resident smiled and laughed. According to the nurse, the resident always responded in this manner when spoken to and touched. Record review revealed the resident had a brother who was active in the resident's care. The resident was cared for in the home for many years prior to requiring nursing home care. There was no evidence the facility interviewed the brother regarding the resident's preferences and needs. review of the resident's medical record revealed [REDACTED]. This note did not indicate any type of initial or ongoing assessments of the resident's activity needs. Review of the resident's assessments and care plans revealed no plans to provide activities for this resident to include talking with her and touching her. There was no evidence the facility identified this resident's interests and needs in an effort to develop an ongoing individualized program of activities to enhance this resident's highest level of mental and psychosocial well-being. There was no evidence the facility utilized resident observations, communication with nursing personnel, or family members to assure an accurate assessment of the resident's activity needs. On 06/03/10 at 11:30 a.m., interviews were conducted with a licensed practical nu… | 2015-06-01 |
| 11009 | 11009 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-05-24 | 279 | D | 1 | 0 | BC7Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for each resident to meet his / her medical, nursing, and mental and psychosocial needs, for one (1) of eight (8) sampled residents. Resident #6's right and left elbows were assessed as having Stage 2 pressure ulcers, but the resident's care plan did not include the treatment for [REDACTED]. Resident identifier: #6. Facility census: 113. Findings include: a) Resident #6 Review of Resident #6's admission nursing assessment revealed he was admitted to the facility on [DATE]. According to notations on the body diagram on page 3 of this assessment, the following wounds were present on admission: a Stage 2 pressure ulcer to the coccyx / buttocks (measuring 12 cm x 10 cm), a Stage 1 pressure ulcer (with a question mark next to it) to the left elbow (measuring 3 cm x 3 cm), and a Stage 1 pressure ulcer (with a question mark next to it) to the right elbow (measuring 7 cm x 0.5 cm). Review of the pressure ulcer documentation forms (PUDFs) for the wounds on the resident's right and left elbows found both were assessed as being Stage 2 pressure ulcers on 05/04/11. Both the admission nursing assessment and the entries dated 05/04/11 on the PUDFs were completed by the same registered nurse (RN - Employee #62). When re-assessed on 05/11/11, the wound on the right elbow remained at Stage 2, and the wound on the left elbow improved to Stage 1. Both wounds were resolved when re-assessed on 05/17/11. admission orders [REDACTED]. Another order directed staff to "Keep Bilateral Elbows elevated off bed to prevent skin breakdown". Review of the resident's care plan revealed the care plan addressed all the wounds present on the resident's admission, but the areas on the elbows were identified as Stage 1 (reddened areas), and the intervention on the care plan to treat these areas was to elevate the elbows. Review of the facility's skin treatment protocol re… | 2014-09-01 |
| 10924 | 10924 | MCDOWELL NURSING AND REHABILITATION CENTER, LLC | 515162 | PO BOX 220 | GARY | WV | 24836 | 2011-07-08 | 279 | D | 1 | 0 | 34ZP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan which included measurable objectives and timetables to meet the medical and nursing needs of one (1) of five (5) sampled residents. Due to the failure to accurately complete the minimum data set (MDS), the care plan for Resident #200 was devoid of interventions related to the use of an indwelling urinary catheter. (See F278 for further details). Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 Review of the medical record found Resident #200 was admitted to the facility on [DATE] with an indwelling urinary catheter. Review of the admission MDS, with an assessment reference date of 11/16/10, found Section H was marked as "none of the above" and did not identify that Resident #200 had an indwelling catheter. Review of the care plan found no mention of the resident's catheter, nor any instructions for the care, assessment, and monitoring of the patency of the catheter or assessment of the color, consistency, and amount or urine excreted by the resident on a daily basis. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. Review of the intake / output records found the section for catheter output had been left blank by facility staff. Further review of the medical record found the resident was found nonresponsive on 12/06/10. He was transported to an acute care facility where he was diagnosed with [REDACTED]. . | 2014-11-01 |
| 10696 | 10696 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 309 | E | 1 | 0 | UBFP12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure (1) of thirteen (13) sampled residents, whose physician gave orders on 10/11/11 for intravenous (IV) antibiotic therapy ([MEDICATION NAME] 1 Gm daily for seven (7) days) to treat a urinary tract infection [MEDICAL CONDITION], received the first dose of [MEDICATION NAME] as scheduled on 10/11/11 due to lack of availability of the medication from the pharmacy. Resident identifier: #16. Facility census: 102. Findings include: a) Resident #16 Medical record review for Resident #16, on 10/25/11, found this [AGE] year old female was admitted to the facility on [DATE] after a four-day hospital stay. The hospital discharge summary revealed the resident had the following Diagnoses: [REDACTED]. The discharge summary also stated: "She was treated with intravenous [MEDICATION NAME]. Urine culture grew proteus mirabilis, sensitive to [MEDICATION NAME]." On 10/25/11 at approximately 1:00 p.m., review of Resident #16's medical record review revealed a physician's orders [REDACTED]." A nursing note dated 10/11/11 at 11:30 a.m. stated, "Resident admitted previous shift to Room (number) under Dr. (name) services. MD in to see Resident today clarification orders obtained as follows: (Symbol for change) [MEDICATION NAME] to 1 grm (gram) IV q (every) 24 hr x 7 days, [MEDICATION NAME] 600 mg PO (by mouth) BID (twice a day) x 10 days r/t (related to) VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) on left heel wound. MD to write order for referral to (name) upon family request. MPOA (medical power of attorney) wants resident to continue wound care with Dr. (name) next appt (appointment) is 10/14/11 @ 3:00 pm. Resp (respirations) even and nonlabored. Abdomen soft and nontender. BS (bowel sounds) (+) (positive) all quads (quadrants). Denies pain @ this time. Will continue to monitor. ABT (antibiotic therapy) ongoing UTI and VRE to left heel wound contact precautions maintained QS … | 2014-12-01 |
| 3118 | 3118 | BRAXTON HEALTH CARE CENTER | 515180 | 859 DAYS DRIVE | SUTTON | WV | 26601 | 2020-02-05 | 842 | D | 0 | 1 | VYLD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. The facility had a conflicting [DIAGNOSES REDACTED]. This practice affected one (1) of sixteen (16), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #11. Facility census: 58. Findings included: a) Resident #11 A medical record review, on 02/05/20, revealed two (2) different physician's orders [REDACTED]. One (1) physician order [REDACTED]. Resident #11's current care plan dated 11/22/19 and pharmacy reviews on 10/02/19 and 11/05/19 revealed, Resident #11's [MEDICATION NAME] orders was for use of the diagnosed condition of muscle spasms. In an interview on 02/05/20at 8:20 AM, the Director of Nursing Services (DON) was made aware of the physician's orders [REDACTED]. During a second interview on 02/05/20 at 08:56 AM, with the DON verified, the HS order for [MEDICATION NAME] with a [DIAGNOSES REDACTED]. She stated that there was no information on why the order noted a [DIAGNOSES REDACTED]. | 2020-09-01 |
| 9851 | 9851 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2013-04-01 | 514 | D | 0 | 1 | KU9T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a complete, accurately documented clinical record for two (2) of thirty-six (36) Stage 2 sample residents. There was no documentation Resident #87 was receiving showers daily. Additionally, there was no documentation Resident #122 was receiving assistance with a bowel and bladder program. Resident identifier: #122 and #87. Facility census: 92. Findings include: a) Resident #122 Medical record review, on 04/08/13 at 2:00 p.m., revealed a physician's orders [REDACTED]. The order also included the resident was to be provided incontinence care every shift and whenever needed. Interview with Employee #54, a nursing supervisor, on 04/08/13 at 5:14 p.m., revealed she placed the resident on the bowel and bladder program on 02/04/13, due to the resident's incontinence. Review of the resident's continence by shift report, on 04/08/13 at 5:30 p.m., revealed the resident was incontinent of urine on a daily basis from 01/15/13 through 04/03/13. The resident's nursing assistant flow sheet, for taking the resident to the toilet, was reviewed on 04/09/13 at 9:00 a.m. There was no documented evidence staff took the resident to the toilet before meals and at bedtime, providing incontinence care every shift and whenever needed. There was also no documentation on the nursing assistant flow sheet, from the start date of 02/04/13 through 03/31/13. The nursing assistant flow sheet had initials of nursing staff only on 04/01/13 through 04/03/13. The resident was discharged on [DATE]. On 04/09/13 at 2:15 p.m., Employee #54, nurse supervisor, and Employee #20, the coordinator of health information (CHI) were interviewed. When asked about nursing assistant flow sheets from 02/04/13 through 03/31/13, regarding documentation of toileting Resident #122, they confirmed the flow sheets could not be found for Resident #122. They stated they had no documented evidence Resident #122 received th… | 2015-08-01 |
| 10123 | 10123 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-02-09 | 312 | D | 1 | 0 | KTFG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a dependant resident received showers as directed. This was true for one (1) of three (3) residents reviewed who were on the sample. Resident identifier: #94. Facility census: 92. Findings include: a) Resident #94 An interview with the director of nursing (DON), on 02/08/12 at 8:30 a.m., found the resident was scheduled to receive showers on Tuesdays and Fridays. Further review of the shower schedule for December 2011, and January 2012, with the DON, revealed the resident should have received five (5) showers in December, before her discharge to the hospital on [DATE]. The resident received two (2) showers, refused two (2) showers, leaving the fifth shower unaccounted for. The resident was re-admitted to the facility on [DATE]. She should have received six (6) showers before her discharge from the facility on 01/21/12. She received four (4) of the six (6) showers scheduled. The DON stated she thought the resident had refused the showers, but was unable to produce information to substantiate the showers were offered and refused by the resident. . | 2015-06-01 |
| 10265 | 10265 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-09-26 | 428 | D | 0 | 1 | FJI611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a gradual dose reduction was attempted after recommended by the consultant pharmacist and agreed upon by the resident's physician. Resident identifier: #145. Facility census: 109. Findings include: a) Resident #145 Review of the medical record revealed this [AGE] year old resident with dementia was admitted to the facility on [DATE], and was ordered Ativan (an anti-anxiety medication) one (1) milligram (mg.) twice daily for anxiety, on 09/21/11. Approximately two (2) weeks later, the dosage was increased to one (1) mg. three (3) times daily, where it has since remained. Review of the medical record found only one pharmacy request, on 07/03/12, for a Gradual Dose Reduction (GDR) of the Ativan, since the initiation of this medication. On 07/03/12 a gradual dose reduction (GDR) was recommended by the consultant pharmacist, to consider reducing the Ativan dosage to 0.5 mg. three (3) times daily, with the eventual goal of discontinuation of the medication, if possible. However, the physician declined to decrease the dose at that time. Review of a hand-written physician's progress note, dated 07/03/12, revealed the resident had a "nervous tremor," and the physician's intent was to continue the Ativan and observe. During interview with the director of nursing on 09/19/12, at approximately 4:00 p.m., she said she thought this resident had two (2) attempts at a GDR of the Ativan in the past year. No information was provided to support this statement was provided prior to exit. | 2015-05-01 |
| 9794 | 9794 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2010-06-01 | 315 | D | 0 | 1 | 2XEX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a resident, who was initially admitted to the facility without an indwelling catheter, was not catheterized unless the resident's clinical condition demonstrated the catheter was medically necessary. This occurred for one (1) of thirty-three (33) Stage II sample residents. Resident identifier #155. Facility census: 57. Findings include: a) Resident #155 Record review revealed Resident #155's initial admission to the facility occurred on 03/12/10. The resident's past medical history included [DIAGNOSES REDACTED]. The resident's discharge diagnoses, from the hospital on [DATE], included large left middle cerebral artery stroke and status [REDACTED]. Review of the resident's comprehensive admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/19/10, found, in Section H, the assessor encoded 4 for both bladder and bowel elimination, indicating total incontinence. No appliances or programs were documented. The resident assessment protocol (RAP) summary triggered for urinary incontinence. Documentation on the urinary incontinence RAP stated, Resident is incontinent of urine. Care plan will be directed towards preventing complications of incontinence via incontinence care. Will proceed with careplanning incontinence status. On 3/23/10, the facility completed a Urinary Incontinence Management Program Evaluation Admission Assessment; the facility's actions, per this assessment, were to monitor the care plan for effectiveness of interventions and to continue to manage the resident's incontinence with protective absorbent products. The care plan also contained these same interventions. The resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. The resident's readmission orders [REDACTED]. At this time, the resident had an order for [REDACTED]. Review of the Medicare 5-Day MDS, with an ARD of 4/23/10, foun… | 2015-09-01 |
| 9887 | 9887 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-01-08 | 514 | E | 1 | 0 | 0RE212 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure accurate documentation for seven (7) of thirteen (13) residents who required bed and/or chair alarms for safety precautions. These residents had no directives on the Treatment Administration Records (TAR) to check the functionality of the alarms. Instead, the TAR directed that alarms were to be used, or nurses "may utilize"alarms. This had the potential to endanger those seven (7) residents by not ensuring clear directives to nursing staff to check and document the functionality of the alarm equipment. Resident identifiers: #55, #18, #35, #85, #62, #26, and #32. Facility census: 87. Findings include: a) Resident #55 An incident and accident report was reviewed on 01/08/14 at 12:00 p.m. This review revealed that on 01/04/14 at 7:45 a.m., Resident #55 was found on the floor by staff. The resident had removed her alarm prior to the fall. The report did not indicate whether it was alarming at or before the time of the fall. Another incident report, dated 01/04/14 at 9:00 a.m., revealed she was again discovered by staff lying on the floor beside her bed. According to the incident report, the alarm did not sound. Staff replaced the alarm at that time. The treatment administration record (TAR) was reviewed on on 01/08/14 at 1:00 p.m.. It directed that staff "may utilize sensor pad alarm to bed at al limes, to alert staff to resident's attempts to transfer unassisted, to minimize falls risk". The start date for this intervention was 12/24/13. Nurses initialed the TAR at 10:00 a.m. and 10:00 p.m. daily from 01/01/14 through 01/08/14. An interview was conducted with licensed nurse Employee #44 at 1:30 p.m. on 01/08/14. She first checked the TAR, then said there is no order on the TAR for staff to check the functionality of the bed alarm. She said there was someone assigned to check the functionality via daily audits. On 01/08/14 at 1:45 p.m., the administrator was asked… | 2015-08-01 |
| 9923 | 9923 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-10-05 | 514 | D | 0 | 1 | TTVD12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure an accurate medical record for two (2) of twenty (20) residents in the sample. The monthly recapitulation orders did not contain revisions and changes made from one month to the next. Resident identifiers: #53 and# 42. Facility census 49. Findings include: a) Resident #53 A review of the medical record revealed the physician's orders [REDACTED]. During an interview with the director of nurses (DON), at 8:50 a.m. on 10/4/12, she stated the resident no longer had pressure ulcers. She said they were healed in August and treatment was discontinued. She located evidence of this in the record. Upon review of the record, she agreed the orders for treatment had not been deleted from the record. . b) Resident #42 Review of the resident's medical record, at 10:00 a.m. on 10/03/12, revealed the October 2012 recapitulation orders contained five (5) orders that had been discontinued. The orders on the recapitulation were indicated accurate by the director of nursing services (DON), Employee #20, on 09/28/12. Additionally, the physician approved the orders, by signature, on 10/01/12. An order was present for monitoring an incision site on the resident's back for signs and symptoms of infection due to status [REDACTED]. Review of the treatment administration record (TAR) revealed this treatment was discontinued on 09/28/12. Interview with the treatment nurse (Employee #48) at 10:15 a.m. on 10//03/12 confirmed this area was healed on the date indicated on the TAR. There was an order for [REDACTED].#20, on 10/04/12 at 12:00 p.m., she clarified the resident went to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The resident's physician's orders [REDACTED]. According to the TAR, the stage II pressure ulcer was healed on 08/23/12. During the interview with Employee #48, at 10:15 a.m. on 10/03/12, she confirmed the pressure ulcer was healed on the date indicated on the TAR.… | 2015-08-01 |
| 10699 | 10699 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2011-08-09 | 425 | E | 1 | 0 | UBFP12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure an intravenous (IV) antibiotic was available for administration as ordered for (1) of thirteen (13) sampled residents (#16), whose physician gave orders on 10/11/11 for IV Rocephin 1 Gm daily for seven (7) days to treat a urinary tract infection (UTI). Additionally, staff failed to obtain from the facility's emergency drug box and administer a dose of Lovenox to Resident #59 when that medication was not available from the pharmacy. Resident identifiers: #16 and #59. Facility census: 102. Findings include: a) Resident #16 Medical record review for Resident #16, on 10/25/11, found this [AGE] year old female was admitted to the facility on [DATE] after a four-day hospital stay. The hospital discharge summary revealed the resident had the following Diagnoses: [REDACTED]. The discharge summary also stated: "She was treated with intravenous Rocephin. Urine culture grew proteus mirabilis, sensitive to Rocephin." On 10/25/11 at approximately 1:00 p.m., review of Resident #16's medical record review revealed a physician's orders [REDACTED]." A nursing note dated 10/11/11 at 11:30 a.m. stated, "Resident admitted previous shift to Room (number) under Dr. (name) services. MD in to see Resident today clarification orders obtained as follows: (Symbol for change) Rocephin to 1 grm (gram) IV q (every) 24 hr x 7 days, Zyvox 600 mg PO (by mouth) BID (twice a day) x 10 days r/t (related to) VRE (Vancomycin-resistant Enterococcus) on left heel wound. MD to write order for referral to (name) upon family request. MPOA (medical power of attorney) wants resident to continue wound care with Dr. (name) next appt (appointment) is 10/14/11 @ 3:00 pm. Resp (respirations) even and nonlabored. Abdomen soft and nontender. BS (bowel sounds) (+) (positive) all quads (quadrants). Denies pain @ this time. Will continue to monitor. ABT (antibiotic therapy) ongoing UTI and VRE to left heel wound c… | 2014-12-01 |
| 10816 | 10816 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2011-08-17 | 309 | E | 1 | 0 | YCK011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure each resident received medications as ordered by the physician, failed to promptly notify the physician when a resident frequently refused one (1) or more medications, failed to notify the responsible party when the resident did not received scheduled doses of medications for an extended period of time, and failed to establish a care plan to address either the resident's refusal of medications or to address the need to monitor those health conditions for which the medications were not have been administered (but were not). This affected ten (10) of (10) sampled residents. Resident identifiers: #4, #8, #41, #44, #57, #62, #75, #78, #79, and #80. Facility census: 77. Findings include: a) Resident #78 1. Review of the resident's medication administration records (MARs) from October 2010 found the resident had a history of [REDACTED]. - [MEDICATION NAME] 100 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 13 doses and missed 1 additional dose (reason unspecified); med discontinued on 10/14/10 - [MEDICATION NAME] 2 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 15 doses and missed 4 additional doses (reason unspecified); order changed on 10/16/10 - [MEDICATION NAME] 10 mg 1 tablet by mouth twice daily for dementia with behavior disturbances - refused 12 of 62 doses and missed 6 additional doses (reason unspecified) - [MEDICATION NAME] 2 mg 1 tablet by mouth for hypertension - refused 3 of 31 doses - [MEDICATION NAME] XL 300 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 - [MEDICATION NAME] sodium 200 mg 1 by mouth at bedtime for constipation - refused 12 of 31 doses and missed 3 additional doses (reason unspecified) - [MEDICATION NAME] 25/200 1 tablet by mouth twice daily for hypertension - refused 14 of 62 doses and missed 5 additional… | 2014-12-01 |
| 10328 | 10328 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-01-13 | 329 | D | 0 | 1 | I28Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. Two (2) of ten (10) residents selected by the ASE-Q software for unnecessary drug review were found to have a lack of documentation of the resident-specific rationale for continuation of the use of psychopharmacological medications. Resident identifiers: #72 and #65. Facility census: 113. Findings include: a) Resident #72 Record review revealed this [AGE] year old male resident had [DIAGNOSES REDACTED]. Review of the medication changes since 01/01/10 to present found the dosage for Klonopin (a benzodiazepine) had remained the same. Review of the current physician's orders [REDACTED]. The medication had been ordered for behaviors manifested by verbal outbursts and / or hitting. He was noted to have dementia with behavioral disturbances. On 03/14/10, the pharmacist had issued a consultation report that included, "(Resident's name) behavior medications are up for annual review for dosage reduction. He is on: [MEDICATION NAME] 20 mg daily Klonopin 0.5 mg TID (three (3) times a day)." The recommendation from the pharmacist was: "Please consider a gradual dose reduction, perhaps decreasing the Klonopin to BID (two (2) times a day) while concurrently monitoring for re-emergence of target and / or withdrawal symptoms. If therapy is to continue at the current dose, please provide rationale describing a dose reduction as clinically contraindicated." For "Rationale for Recommendation", the report had: "Federal nursing facility regulations require that a gradual dosage reduction (GDR) be attempted in two separate quarters within the first year in which and individual is admitted on a psychopharmacologic medication or after the facility has initiated such medication, and then annually UNLESS CLINICALLY CONTRAINDICATED." The physician checked that he "declined" the recommendation beside the statement "Continued u… | 2015-05-01 |
| 10161 | 10161 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-02-23 | 318 | E | 1 | 0 | X35X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure four (4) of nine (9) sample residents received treatment and services to increase range of motion and/to prevent further decrease in range of motion. Three (3) residents were not ambulated as ordered and one (1) resident did not have knee braces applied as ordered. Resident identifiers: #56, #53, #24, and #02. Facility census: 55. Findings include: a) Resident #56 This resident had physician's orders [REDACTED]. This restorative service was ordered every day, and as needed, for strength and endurance. Review of the restorative nursing documentation, for the month of January 2012 to 02/23/12, revealed no evidence this service was done daily as ordered by the physician. b) Resident # 53 This resident had a physician's orders [REDACTED]. Review of documentation revealed no evidence the knee braces were applied as ordered every night. This resident also had an order, dated 01/24/12, for passive range of motion to each leg three (3) to five (5) times every week. During a review of the restorative nursing assistant documentation, on 02/22/12, it was discovered there was evidence of only two (2) days this service was provided between 01/24/12 and 02/22/12. The dates of service were 01/26/12 and 02/09/12. c) Resident # 24 This resident had physician orders [REDACTED]. During a review of the restorative documentation, from 01/01/12 through 02/22/12, it was discovered there was no evidence this service was done daily as ordered. Restorative documentation indicated the resident was walked only three (3) times between 01/01/12 through 02/22/12. d) Resident #2 This resident had a physician's orders [REDACTED]. The order noted the resident was to ambulate with a front wheeled walker. Staff members were to use a gait belt and to follow the resident with a wheelchair. Review of restorative documentation, from 01/01/12 through 02/22/12, revealed no evidence this service was do… | 2015-06-01 |
| 9826 | 9826 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2012-04-04 | 507 | D | 1 | 0 | L6DT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure laboratory results were available for clinical management for one (1) of four (4) residents. On 04/03/12, the resident's medical record did not contain the results of a laboratory test that was performed on 03/09/12. Resident identifier: #98. Facility census: 115. Findings include: a) Resident #98 On 04/03/12, at approximately 1:00 p.m., medical record review for Resident #98 revealed a physician's orders [REDACTED]. The test was completed on 03/09/12. Further review of the medical record revealed the results of the test were not in the record. Employee #68 (licensed practical nurse) looked through the facility's laboratory book and could not locate the results. The director of nursing (Employee #46) provided a copy of the test results on 04/03/12, at approximately 3:00 p.m. By not having the results of the test on the resident's clinical record, the facility could not ensure this information was available if needed for clinical management of the resident. . | 2015-08-01 |
| 10129 | 10129 | MERCER NURSING AND REHABILITATION CENTER, LLC | 515052 | PO BOX 410 | BLUEFIELD | WV | 24701 | 2012-02-09 | 250 | D | 1 | 0 | MC4611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure medically-related social services were provided to one (1) of four (4) residents on the sample. Resident #55 left the facility against medical advice (AMA) with his family on 10/28/12. The resident experienced aggressive behaviors related to a [DIAGNOSES REDACTED]. The facility had planned to transfer him to an inpatient psychiatric unit. The resident's family did not want the facility to seek this type of medical intervention to try and stabilize these behaviors. The family at one time asked to come to the facility and restrain the resident. The facility did not contact adult protective services to make them aware of the situation. Resident identifier: #55. Facility census: 52. Findings include: a) Resident #55 The medical record review for Resident #55 revealed he came to the facility from home on 09/28/11. He had a [DIAGNOSES REDACTED].). The resident's care plan addressed issues such as impaired cognitive function and impaired thought processes due to the dementia. It also addressed the resident's physical behaviors (kicking, hitting, scratching) related to dementia. The following progress notes related to the resident's behaviors and the family's resistance to inpatient psychiatric care. -10/01/11 2:45 p.m. "Resident has been at nurses station with staff; has had 1:1 all day without success. As staff attempted to reposition resident in his wheelchair to keep him from falling, he punched the nurse in the stomach, pulled back his fist and said (cursing) 'I'll punch your nose' resident then grabbed nurses arm and twisted it tightly. Haldol 5 mg po (by mouth) x 1 dose now and Ativan 1 mg IM x 1 dose now. Daughter notified that if behavior continues resident will most likely be transferred OOF (out of facility) for eval (evaluation) of behaviors. She replied 'oh try to hold off, we could come see him but it probably wouldn't do any good ... he's done me like t… | 2015-06-01 |
| 9890 | 9890 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-08-25 | 278 | D | 0 | 1 | MZQB12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure minimum data set assessments (MDSs) accurately reflected the health and functional status of two (2) of fourteen (14) sampled records. Resident identifiers: #141 and #21. Facility census: 140. Findings include: a) Resident #141 Record review revealed Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's discharge MDS, with assessment reference date (ARD) of 08/04/11, found the assessor noted the number of falls since the prior assessment (which was a quarterly MDS with an ARD of 07/13/11) as follows: - Fall with no injury - none - Fall with injury (except major) - none - Fall with major injury - 1 - A review of the incident reports, nursing notes, and the significant event reporting in the computer revealed that Resident #141 had sustained falls as follows: - On 07/20/11 at 5:00 p.m., he was found on the floor and had sustained a scratch to his right hand measuring approximately 5 cm long. - On 07/22/11 at 7:30 p.m., he slid down the side of a chair after missing the seat, and an assessment found no apparent injuries. - On 07/24/11 at 10:45 a.m., he fell , hitting his left arm and the left side of his head against a door frame; he subsequently was found to have sustained a fractured humerus and a subdural hematoma. - The above assessment was inaccurate with respect to the numbers and types of falls that had occurred since his prior MDS with an ARD of 07/13/11. -- b) Resident #21 A review of a significant change in status MDS with an ARD of 05/02/11 found the assessor indicated, in Item M0300F, that Resident #21 had one (1) unstageable pressure ulcer. In a quarterly MDS with ARD of 07/27/11, the assessor again indicated the presence of one (1) unstageable pressure ulcer (measuring 0.4 cm x 0.5 cm) in Item M0300F. - Review of the resident's nursing notes revealed an entry, at 9:50 a.m. on 06/21/11, stating: "Note necrotic tissue to L (l… | 2015-08-01 |
| 11258 | 11258 | MONTGOMERY GEN. ELDERLY CARE | 515152 | 501 ADAMS STREET | MONTGOMERY | WV | 25136 | 2010-06-17 | 514 | D | 1 | 0 | Q89G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure one (1) of eleven (11) residents had an accurate and complete medical record. A comparison of documentation of the resident's bowel movements (BMs), recorded in the plan of care kardex (kardex) and the bowel and bladder elimination pattern evaluation (B&B evaluation form) for the period of 03/01/10 through 03/31/10, found significantly conflicting information about the frequency at which she was having BMs, calling into question the accuracy of the BM monitoring upon which the facility staff based a determination of whether to administer medications to treat constipation. Resident identifier: #23. Facility census: 49. Findings include: a) Resident #23 Resident #23's medical record, when reviewed on 06/14/10 at approximately 2:00 p.m. and again on 06/15/10, disclosed this [AGE] year old female was admitted to the facility from a local hospital on [DATE], with [DIAGNOSES REDACTED]. A nursing note completed by the director of nursing (DON) on 02/24/10 at 4:25 p.m. stated, "(Arrow pointing upward) in geri chair @ (at) bedside states 'pain in stomach goes to back.' Unable to quantify or describe specifically in response to questions. Denies burning, stabbing, knife-like twisting pain. Abd (abdomen) flat, non-distended, normoactive BS (bowel sounds) x 3 quadrants /c (with) hyperactive sounds upper left quad on auscultation. Non-tender to palpation. Denies nausea. Reviewed BM record. Appetite good. Remains calm during assessment. Instructed med (medication) nurse to administer pain med. Skin warm and dry." Record review revealed the nursing assistants recorded each resident's bowel elimination action on a monthly kardex. The instructions on the kardex directed staff to record both bowel and bladder elimination in the same section of the form for each shift daily; staff was supposed to record each BM by noting the size of the BM as follows: S = Small, M = Medium, L = … | 2014-07-01 |
| 9915 | 9915 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2012-06-08 | 327 | G | 1 | 0 | D9VT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents received sufficient fluid intake to maintain proper hydration. Resident #202 suffered from a [MEDICAL CONDITIONS] infection with multiple watery stools and an inadequate intake of fluids necessary to maintain health. Additionally, nursing staff members failed to ensure intravenous (IV) fluids were administered in accordance with physician's orders [REDACTED]. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found the resident was admitted to the facility on [DATE] for treatment of [REDACTED]. The resident was determined to lack the capacity to make medical decisions by the treating physician on 04/25/12 with adult protective services (APS) appointed as the resident's health care surrogate. On 05/10/12, laboratory results were positive for a [MEDICAL CONDITIONS] infection. The resident was ordered, and began receiving, [MEDICATION NAME] 500 mg tid (3 times a day) on 05/10/12. The nursing notes document loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12 and 05/14/12. treatment for [REDACTED]. Review of the 04/26/12 nutritional assessment, completed by the dietitian, found the resident required a daily fluid intake of 2550 cc. Review of the resident's documented intake of fluids, beginning with his treatment for [REDACTED]. -- 05/10/12 - 240 cc, -- 05/11/12 - 360 cc, -- 05/12/12 - 180 cc, -- 05/13/12 - no intake On 05/14/12, the resident was visited by the nurse practitioner who documented the resident to be lethargic and hypotensive. The nurse practitioner ordered 2000 cc of normal saline to be administered intravenously (IV). The order written at 10:20 a.m. on 05/14/12 specified a bolus of 1000 cc of normal saline for the first liter then 85 cc/hr for the second liter of fluids. Review of the nursing notes found IV access was obtained at 12:23… | 2015-08-01 |
| 10829 | 10829 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-08-16 | 222 | D | 1 | 0 | XG6O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure one (1) of six (6) sampled residents was free of chemical restraints. Staff administered to Resident #67 an antipsychotic medication ([MEDICATION NAME]) via intramuscular injection (IM) for agitation without evidence of having first ruled out causal factors (e.g., pain, other sources of discomfort, environmental factors, etc.). [MEDICATION NAME] 5 mg IM was given on 03/26/11 at 12:58 a.m. for being uncooperative with staff and cursing. [MEDICATION NAME] 5 mg IM was given again on 03/26/11 at 11:42 p.m. for yelling "Help", cursing, and being physically abusive toward staff. The resident had physician's orders [REDACTED]. The [MEDICATION NAME] IM was used to control the resident's behavior, which required a lesser amount of effort by the staff and was not in the resident's best interest. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Medical record review disclosed this [AGE] year old male resident, who was initially admitted to this facility on 02/21/11, had medical diagnoses that included multiple [MEDICAL CONDITION] with [MEDICAL CONDITIONS], diabetes, hypertension, [MEDICAL CONDITION] of the prostate with metastasis, dementia, gangrenous changes in his extremities, Stage 2 pressure ulcer on the coccyx, and recent bouts with pneumonia. Review of the multidisciplinary notes disclosed the resident had been sent out to the hospital for acute medical problems and returned to the facility on [DATE]. The notes revealed that, shortly after returning to the facility, the resident began exhibiting behaviors of verbal and physical abuse toward staff and other residents at times. The notes also disclosed the resident was confused, non-ambulatory, and required assistance for most activities of daily living. Review of physician's orders [REDACTED]. In addition, [MEDICATION NAME] 0.5 mg PO (by mouth)/IM BID (twice daily) had been given on … | 2014-12-01 |
| 10380 | 10380 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2011-12-13 | 312 | D | 1 | 0 | DPP211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living unassisted, received showers as scheduled. This was true for two (2) of fourteen (14) sampled residents. Resident identifiers: #117 and #118. Facility census: 116. Findings include: a) Resident #117 Review of the medical record revealed this eighty-nine (89) year old female resident was admitted to the facility on [DATE]. She was discharged to home on 10/17/11. The resident's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/04/11, found the resident required physical help with bathing. During an interview with the director of nursing (DON), on 12/12/11 at 2:30 p.m., she verified the resident was to receive her showers two (2) times a week on Tuesdays and Fridays. Review of the resident's functional performance record revealed the resident did not receive any showers in July 2011. Review of the August 2011 performance record found the resident was showered on 08/01/11, 08/16/11, 08/24/11 and 08/26/11. If the resident had received showers as scheduled, she should have received nine (9) showers in August. The director of nursing was unable to explain why the resident did not receive showers as scheduled. _____________________ b) Resident #118 Review of the medical record found the resident was admitted to the facility on [DATE] and discharged to home on 11/30/11. The resident's shower schedule was reviewed with the DON, at approximately 2:30 p.m., on 12/12/11. She confirmed the resident was to receive showers two (2) times a week, on Tuesdays and Fridays, with staff assistance. According to the document "Residents Functional Performance Record" used by nursing assistants to document daily bathing activity, the resident received only one (1) shower during a twelve (12) day time frame in October 2011. If showered according to the shower schedule, the resident should ha… | 2015-04-01 |
Advanced export
JSON shape: default, array, newline-delimited
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 );