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| Link | rowid | facility_name | facility_id | address | city | state | zip ▼ | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 498 | 498 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 578 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's advance directives, communicated via the Physician order [REDACTED]. Resident identifier: #38. Facility census: 100. Findings included: a) Resident #38 Review of the medical record found the Resident lacked capacity to make medical decisions, and her son was her legal representative. Review of the current POST form noted the Resident did not wish to be resuscitated, have comfort measures, a feeding tube, or IV fluids for a trial period of no longer than 3-5 days. Under the heading, signature of Patient/Resident, the form noted verbal consent was obtained from (Name of son) via phone on 09/29/19. The physician signed the POST form on 08/01/19, although the POST form indicated the Resident's son did not complete the form until 09/29/19. The date the form was prepared by a facility nurse was 07/29/19. The resident's electronic medical record as well as the current care plan directed, do not attempt resuscitation, or comfort measures. Review of the instructions for the 2016 edition entitled, Using the POST form, section D, found: The patient or representative/surrogate and physician/APRN (Advanced Practice Registered Nurse) must sign the form in this section. These signatures are mandatory. A form lacking these signatures is NOT valid. The physician/APRN then prints his/her name, phone number, and the date and time the orders were written. On 01/29/20 at 10:10 AM, the facility social worker (SW) #81 verified the Resident's son did not sign the POST form. SW #81 said she did not know anything about the POST form because she was not present when the POST form was completed. The POST form was discussed with the administrator at 8:06 AM on [DATE]. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 499 | 499 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 580 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record interview and interview, the facility failed to notify the physician when medications were held for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found the resident was ordered to receive [MEDICATION NAME] 5/325 milligrams (mg) via the feeding tube three times daily for pain and [MEDICATION NAME] 0.25 mg via feeding tube three times a day for anxiety. Review of Resident #98's nurses progress notes found on 10/31/19 at 6:55 PM, a Licensed Practical Nurse (LPN) #138 held the [MEDICATION NAME] and [MEDICATION NAME]. Note attached to the holding of [MEDICATION NAME] and [MEDICATION NAME] as follows: Medication held due to drowsiness, spoke with son and he was also in agreement to hold the medication. There was no documentation the physician was notified of the withholding of the medication. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:15 PM, they verified after reviewing the medical records for Resident #98, the physician had not been notified of the withholding of [MEDICATION NAME] and [MEDICATION NAME] on 10/31/19. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 500 | 500 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 584 | D | 0 | 1 | CN2N11 | Based on record review and interview, the facility failed to ensure reasonable care for the protection of resident's personal property from loss or theft for one (1) of one (1) resident reviewed for the care area of personal property. Resident identifier: #58. Facility census: 100. Findings included: a) Resident #58 On 0[DATE] 03:01 PM, the Resident's son said he had no problems with the facility other than, They lose clothes in laundry sometimes they find them, sometimes not. It's just aggravating not a big problem. I have been labeling them myself. Sometimes they don't label them, and I think that is what causes the problem. Review of the notes in the electronic medical record found a progress note, dated 06/27/19 at 9:14 AM, during a care conference for the resident, his son raised his concern that his mother had some articles of clothing that are missing. At 11:44 AM on 01/28/20, the Social Worker (SW) #33 confirmed she could not find information to indicate the investigation into the allegation of missing clothing. SW #33 said someone at the facility should have completed a complaint form, then this allegation would have been assigned to someone in environmental services. She said if an item is missing and we can confirm the Resident had the item, the facility would reimburse the family member or replace the missing item. At 8:06 AM on [DATE], the Administrator was informed of the above information. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 501 | 501 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 623 | D | 0 | 1 | CN2N11 | Based on record review and staff interview, the facility failed to provide the Ombudsman with notification of a resident's transfer to the hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Resident #[AGE] A record review for Resident #[AGE] on 01/28/20, revealed two (2) Minimum Data Sets dated [DATE] and 12/24/20 for transfer to an acute care hospital. Further review indicated there had been no notifications of these hospitalization s sent to the Ombudsman. On 02/03/20 at 1:52 PM, the Nursing Home Administrator (NHA) verified there were no notices sent to the Ombudsman for hospitalization s on [DATE] and 12/24/19. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 502 | 502 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 641 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for three of 20 residents. Resident identifiers: #99, #38, #98. Facility census: 100. Findings included: a) Resident #99 Review of Resident #99's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/12/20, stated the resident had two (2) Stage 2 pressure ulcers. Resident #99's Pressure Ulcer Reassessment dated [DATE], documented a Stage 4 pressure ulcer on the left buttock. An initial Pressure Ulcer Assessment also performed on 01/07/20 documented a new unstageable pressure ulcer on Resident #99's sacrum. Resident #99's Pressure Ulcer Reassessments dated 01/14/20 documented a Stage 4 pressure ulcer on the left buttock and a Stage 3 pressure ulcer on the left buttock. During an interview on 02/03/20 at 11:46 AM, the Regional Director of Operations stated Resident #99's MDS with ARD 1/12/20 was incorrect. She stated Resident #99 did not have two (2) Stage 2 pressure ulcers at that time. No further information was provided through the completion of the survey. b) Resident #38 Review of Resident's quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19, coded the resident as receiving an anticoagulant for 2 days during the assessment period. Review of the Medication Administration Record [REDACTED]. At 2:26 PM on 01/29/20, during an interview with the nursing coordinator #139, it was confirmed the MDS was incorrectly coded, and the resident did not receive an anticoagulant. c) Resident #98 Review of the Resident's medical record found a comprehensive (5-day) minimum data set (MDS) with an assessment reference date (ARD) of [DATE], coded as the Resident received a hypnotic medication. Review of the November 2019, physician orders [REDACTED]. At 01/31/20 at 12:54 pm, the MDS registered nurse employee #139, confirmed the MDS was incorrect. In addition, E #139 confirmed the resident… | 2020-09-01 |
| 503 | 503 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 656 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a person-centered comprehensive care plan for one of twenty (20) residents reviewed. The care plan for Resident #57 was not developed for the [DIAGNOSES REDACTED].#57. Facility census: 100. Findings included: a) Resident #57 A record review on 01/29/20, revealed the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/20, indicated the Resident had a [DIAGNOSES REDACTED]. During an interview on 01/29/20 at 11:15 AM, the Director of Nursing (DON) verified the care plan had not been developed for the [DIAGNOSES REDACTED].#57. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 504 | 504 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 657 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan for one of 20 residents reviewed. Resident identifier: #17. Facility census: 100. Findings included: a) Resident #17 Review of Resident #17's comprehensive care plan revealed the following focus, (Resident's name) has an ADL Self Care Performance Deficit r/t (related to) stroke, left [MEDICAL CONDITION]. Interventions included, Bathing: The resident requires 1 staff participation with bathing.Resident receives a shower on Monday/Thursday and a bed bath the remaining days. Review of Resident #17's task report for January 2020, revealed she received showers on Tuesdays and Fridays. During an interview on 01/29/20 at 9:49 AM, the Director of Nursing (DON) verified Resident #17 received showers on Tuesdays and Fridays, but her care plan stated she received showers on Mondays and Thursdays. The DON stated she would update the care plan to reflect Resident #17 received showers on Tuesdays and Fridays. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 505 | 505 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 684 | E | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one (1) of five (5) residents discharged from the facility received treatment and care in accordance with professional standards of practice. Nursing staff failed to follow physician's orders [REDACTED]. Resident identifier: #103. Facility census: 100. Findings included: a) Resident #103 Record review found the Resident was admitted to the facility on [DATE]. The Resident was discharged to home on 07/12/19. On 06/25/19 the physician wrote an order for [REDACTED].>Accu-Check ac and hs; notify FNP (family nurse practioner) or MD ( if greater than 350 or less than [AGE]. before meals and at bedtime. This order remained in effect until the Resident was discharged on [DATE]. Review of the Medication Administration Record [REDACTED]. On the following dates and times, the Resident's blood sugar (BS) was over 350 and the physician was not notified: --06/25/19 at 9:00 PM, BS- 392 --06/26/19 at 11:30 AM, BS - 399 --06/26/19 at 5:30 PM, BS - 387 --06/26/19 at 9:00 PM, BS - 400 --06/27/19 at 11:30 AM, BS 396 --06/27/19 at 5:30 PM, BS - 3[AGE] --06/28/19 at 11:30 AM, BS - 371 --07/01/19 at 5:30 PM, BS - 390 --07/02/19 at 9:00 PM, BS - 392 --07/03/19 at 5:30 PM, BS - 389 --07/03/19 at 9:00 PM, BS - 399 --07/06/19 at 9:00 PM, BS - 370 --07/07/19 at 9:00 PM, BS - 367 --07/09/19 at 11:30 AM, BS - 366 --07/11/19 at 9:00 PM, BS - 394 On 15 occasions during the resident's 19 day stay at the facility the Resident's BS was over 350 and the physician was not notified. In addition the Resident's blood sugar was over 400 on two (2) occasions when the physician was contacted. On 06/25/19 the physician was contacted for a blood sugar reading of 404 at 5:30 PM. New orders were written to start sliding scale [MED] ([MEDICATION NAME]) for 7 days and give 10 units of [MEDICATION NAME] at this time. Sliding scale [MED] was to be administered per sliding scale at 7:30 AM, 11:30 AM, 5:30 PM and 9:00 AM. There… | 2020-09-01 |
| 506 | 506 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 690 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received the appropriate treatment for [REDACTED]. In addition, this placed the resident at risk for developing antibiotic-resistance. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100,000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. A review of the Medication Administration Record [REDACTED]. Review of the C&S report found [MEDICATION NAME] (Cipro) is Resistant (R) to E coli and not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM, the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 507 | 507 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 693 | E | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure water flushes, for a resident with a feeding tube, were provided as directed by the physician. This was true for one (1) of two (2) residents reviewed for the care area of feeding tube. Resident identifier: #98. Facility Census: 100. Findings included: a) Resident #98 Review of Resident #98's, record found she was admitted to the facility on [DATE]. Record review also revealed, the resident was to have nothing by mouth (NPO) and received all of her nutrition and fluids through the feeding tube due to a prior [MEDICAL CONDITIONS]. Physician order [REDACTED]. --10/07/19 through 10/11/19- Water flushes via the tube feeding- 90 cubic centimeters (cc) every six (6) hours-12 am- 6 am- 12 pm- 6 pm. --10/12/19 through current - Water flushes via the tube feeding- 1[AGE] cc every four (4) hours-12 am- 4 am- 8 am- 11 am- 5 pm and 8pm. Review of Resident #98's Medication Administration Record [REDACTED] --10/07/19 at 6 pm. --10/11/19 at 4 pm. --10/14/19 at 4 pm. --10/16/19 at 4 pm. --10/23/19 at 12 pm. --11/01/19 at 8 am. --11/04/19 at 8 am. --11/25/19 at 8 am. --[DATE] at 4 pm. --12/04/19 at 8 am. --12/06/19 at 11 am. --12/09/19 at 5 pm. --12/13/19 at 5 pm. --[DATE] at 5 pm. --12/22/19 at 8 am. --12/24/19 at 8 am and 11 am. --[DATE] at 11 am. --12/29/19 at 8 am and 11 am. --01/03/20 at 8 am and 11 am. --01/06/20 at 11 am. --0[DATE] at 11 am and 5 pm. --01/13/20 at 5 pm. --[DATE] at 5 pm. --01/20/20 at 11 am and 5 pm. --01/24/20 at 11 am. On 02/03/20 at 1:15 pm, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) verified, after review of the medical records for Resident #98, the water flushes as mentioned above had not been given due to [MEDICAL TREATMENT] treatments. The physician/registered dietician had not been notified to arrange water flushes to accommodate her [MEDICAL TREATMENT] treatments to ensure the proper hydration was maintained. No further inform… | 2020-09-01 |
| 508 | 508 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 697 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to manage the resident's pain in accordance with facility policy and physician order. This was true for one (1) of three (3) of residents reviewed for the care area of pain. Resident identifier: #17. Facility census: 100. Findings included: a) Policy Review According to the facility's policy entitled, Medication Administration - general guidelines with effective date 1/1/17 When PRN medications are administered, the following documentation is provided: .Complaints or symptoms for which the medication was given, including any nonpharmacologic interventions attempted by the nursing staff prior to administration of the PRN medication. b) Resident #17 Review of Resident #17's physician's orders [REDACTED]. Resident #17 also had an order initiated 03/01/19 to evaluate for signs and symptoms of pain every four (4) hours. This pain assessment was performed daily at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. From January 1, 2020, through January 14, 2020, Resident #17's pain was assessed as 0 on a scale from 1-10. A score of 0 indicates the absence of pain. On 01/13/20 Resident #17's [MED] with [MEDICATION NAME] order was changed from a scheduled order three times per day to one tablet by mouth every six hours as needed for pain. For this medication, the MAR indicated [REDACTED]. On 01/14/20, Resident #17's pain assessment order was changed to evaluate for signs and symptoms of pain every six (6) hours. This pain assessment was performed daily at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Resident #17's pain was assessed as 0 on a scale from 1-10 at each assessment from 01/14/20 through 01/28/20. On 01/14/20 at 6:55 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 6, on a scale from 1-10. The medication was documented as effective. On [DATE] at 8:07 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as… | 2020-09-01 |
| 509 | 509 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 698 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received Phosphorus supplements as requested. This failed practice had the potential to affect a limited numer of residents. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical record found on [DATE] at 10:23 AM, the [MEDICAL TREATMENT] center physician requested a phosphorus supplement due to the resident's phosphorus level being low at 2. The facility Nurse Practitioner (NP) was notified on [DATE] at 2:17 PM, and said, The nephrologist needs to recommend what phosphorus supplement he wants. On 01/02/20 at 12:16 pm, the [MEDICAL TREATMENT] center was notified concerning what phosphorus supplement the nephrologist wanted. The [MEDICAL TREATMENT] center responded with, (Nephrologist Name) is out of town and will not return till 01/13/20. The Resident's medical record contained no documentation the attending physician was consulted for a phosphorus supplement. In addition, no further communication between the [MEDICAL TREATMENT] center and the facility concerning the phosphorus could be found. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:30 pm, they confirmed there was no documentation to indicate the attending physician was notified concerning a phosphorus supplement. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 510 | 510 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 726 | F | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure nursing staff possess the competencies and skills sets to recognize proper antibiotic use to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifer: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/2… | 2020-09-01 |
| 511 | 511 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 758 | E | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's [MEDICAL CONDITION] medication regimen was managed and monitored to promote or maintain the resident's highest level of mental, physical, and psychosocial well-being for four (4) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #40, #38, #98, #57. Facility census: 100. Findings included: a) Resident (R) #40 Record review indicated the facility's physician did not appropriately respond to the Gradual Dose Reduction (GDR) for [MEDICATION NAME] ([MEDICAL CONDITION] medication, selective serotonin reuptake inhibitor used to treat anxiety and depression) recommended by the pharmacist on the on the Medication Regimen Review (MRR) for 01/16/2020. The MRR completed on 01/16/2020 by the pharmacist noted the last GDR evaluation for [MEDICATION NAME] was on 0[DATE] was contraindicated by the physician. The last dose adjustment was on 12/09/19 at which time the physician increased the [MEDICATION NAME] dose from 10mg to 15mg at bedtime (HS). The pharmacist indicated, Residents [MEDICATION NAME] 15 mg HS is due for GDR evaluation which must be attempted unless clinically contraindicated. The physician signed the MRR on 1/20/20 and left the form blank without providing any further comments to indicate his response to the GDR, or any further action to be taken. Review of the Resident's Mediation Administration Record on 02/03/2020 at 10:00 AM, revealed R #40 had been receiving [MEDICATION NAME] 15mg at bedtime for major [MEDICAL CONDITION] since [DATE] through current with no decrease in dose. On 01/29/20 at 12:25 PM, during an interview Regional Director of Operations #129 reviewed and verified the GDR recommendation dated 01/16/2020 was not appropriately acknowledged or completed by the physician. During an interview on 01/29/2020 at 12:35 PM, the Director of Nursing (DON) reviewed the GDR on the MRR dated 01/16/2020, and ag… | 2020-09-01 |
| 512 | 512 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 761 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled in accordance with facility policay for one (1) of eight (8) [MED]'s stored in the B-hallway medication cart. Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Policy Review The facility's policy entitled, Vials and [MEDICATION NAME] of Injectable Medications with effective date 01/01/2017 stated, When a vial is opened, the licensed nurse records the opened date on the vial. b) Resident #[AGE] On 01/28/20 at 9:08 AM, the B-hall medication cart was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Resident #[AGE]'s [MEDICATION NAME] Solution Pen-injector ([MED] [MEDICATION NAME]) was not dated when opened. LPN #[AGE] confirmed Resident #[AGE]'s [MED] pen-injector was not dated when opened. The facility's Administrator was informed of the above findings on 01/28/20 at 9:34 AM. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 513 | 513 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 773 | D | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the ordering physician of laboratory results outside of the clinical reference range for Resident #98. Additionally, the facility failed to obtain laboratory testing for Resident #57, as directed per physician's orders [REDACTED]. Resident identifiers: #98 and #57. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found an order to obtain an ammonia level. This level was obtained on [DATE] at 3:31 pm. The ammonia level was [AGE] which was critically high. Normal ammonia level is 9-35. Review of the progress notes found the attending physician was not notified of the labortory results until 10/21/19 at 5:11 pm. An interview with the Director of Nursing, on 01/30/20 at 1:10 pm, confirmed, after the review of Resident #98's medical record, there was a delay in notifying the physician of a critical lab. b) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician had ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100.000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. Review of the Medication Administration Record [REDACTED]. Review of the C& S, [MEDICATION NAME] (Cipro) is Resistant (R) to E coli an not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 514 | 514 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 812 | F | 0 | 1 | CN2N11 | Based on observation and interview, the facility failed to store, prepare, distribute and serve food in a manner to protect for food service safety. During the kitchen tour it was discovered the floor of the reach-in refrigerator had food particles and cardboard stuck to the floor. This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 100. Findings included: a) Kitchen tour During the kitchen tour on 0[DATE] at 11:24 AM, it was discovered the reach-in refrigerator to be unclean, with food particles and cardboard stuck to the floor. This failed practice provided for unsanitary storage for refrigerated foods. In an interview on 0[DATE] at 11:24 AM with the Dietary Manager (DM), she verified the refrigerator was dirty and needed to be cleaned. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 515 | 515 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 868 | F | 0 | 1 | CN2N11 | Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee consisted of the required members. The medical director (MD) or his/her designee did not attend quarterly QAA meetings. This had the potential to affect all residents. Facility census: 100. Findings included: a) QAA Review of the signatures on the attendance sheets for QAA meetings found the medical director only attended 2 quarterly QAA meetings from January 2019 - January 2020. The MD attended meetings held on 10/24/19 and a meeting dated July 2019. The actual date of the meeting was not included on the signature sheet. On [DATE] at 8:07 AM, the Administrator confirmed signature sheets showed the MD only attended 2 quarterly QAA meetings for the year. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 516 | 516 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 880 | F | 0 | 1 | CN2N11 | Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 100. Findings included: a) B-hallway medication room On 01/28/20 at 9:08 AM, the B-hallway medication room was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Under the sink were stored two (2) cartons with six (6) cups of applesauce in each carton. LPN #[AGE] removed the applesauce from under the sink. On 01/28/20 at 9:34 AM, the facility's Administrator was informed that applesauce was stored in an unsanitary area under the medication room sink. No further information was provided at the close of the survey at 12:30 PM on [DATE]. | 2020-09-01 |
| 517 | 517 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 881 | K | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].) In addition, this placed the resident at risk for developing antibiotic-resistance. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. Due to the facility's failure to implement an antibiotic stewardship protocol the State Agency (SA) determined there was an immediate jeopardy (IJ) present for more than a limited number of residents residing in the facility. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. The following details the timeline of the IJ situation. --The IJ started on 01/04/20. --The facility Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) at 12:22 PM on 01/30/20. --The facility submitted their first abatement Plan of Correction (POC) at 1:55 PM on 01/30/20. --The SA requested changes to the abatement POC. --At 2:08 PM and a second abatement POC was submitted by the facility on 01/30/20. --This POC was accepted by the SA at 2:10 PM on 01/30/20. --The IJ was abated at 11:40 AM on 02/03/20 when the SA observed Resident #57's urine culture and sens… | 2020-09-01 |
| 518 | 518 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 583 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to safeguard, ensure, and maintain the privacy and confidentiality of a resident's clinical record. An unauthorized disclosure of Resident#6's clinical record, without Resident#6's consent or knowledge, was given by accident to another resident's family member to take to a consulting physician's appointment. This is true for one (1) of one (1) resident reviewed for privacy and confidentiality. This practice had the potential to affect more than a limited number of residents. Resident identifier: #6. Census: 85. Findings included: a) Resident #6 On 04/16/18 at 1:05 PM, an interview with the Ombudsman information concerning issues that had been brought to the Ombudsman's attention. The Ombudsman stated it was revealed a resident's family member had mistakenly been given another resident's clinical records to take with them to a doctor's appointment. On 04/16/18 at 2:38 PM, an interview with Resident#3's daughter-in-law revealed, upon arriving with Resident #3 at a doctor's appointment in another city, it was discovered she had mistakenly been given Resident #3's roommates medical records to take to the appointment. The daughter-in-law had requested Resident#3 records, but by mistake was given Resident#6's medical records. The daughter-in-law said she returned the records back to the facility, when she returned the resident (Resident #3) back to the facility. Resident#3's daughter-in-law said, she was asked by the facility to not tell Resident #6 (the roommate of Resident #3) what had occurred. The daughter-in-law, also a nurse, said she was very upset about the incident and told the facility she was concerned her mother-in-laws records could also be compromised. On 04/18/18 at 9:30 AM, review of all Resident Council meeting minutes; all Incident/Accident logs; all Grievances/Complaint/Concern logs and reports; and all Reportable incidents with related investigations for the past six (6) months, revealed no incidents or grievances co… | 2020-09-01 |
| 519 | 519 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 585 | E | 1 | 0 | DQUX11 | > Based on staff interview, family interview, and record review, the facility failed to promptly address complaints/grievances to resolution and keep the residents appropriately apprised of progress toward resolution of complaints/grievances. This was evident by the lack of documentation of any follow up regarding resident council grievances and concerns; lack of a grievance filed concerning a staff member hanging up on a resident's family member where disciplinary action was taken against the staff member; and failure to promptly address a complaint of finding several feces soiled items stored in a resident's room. This practice had the potential to affect more than a limited number of residents. Resident identifier: #1, and #9. Census: 85. Findings included: a) Resident #9 On 04/16/18 at 3:10 PM, review of Resident Council meeting minutes for the past six (6) months, revealed a lack of documentation and/or evidence as to whether issues and concerns expressed during Resident Council meetings were addressed and followed up on. An interview with Social Worker (SW#90) revealed she does not write down resolutions or outcomes to issues discussed. SW#90 said, We talk about any concerns and, if say it is about food, I'll get someone from the kitchen to come and talk to the residents. I do not write anything down. SW#90 after looking over Resident Council meeting minutes confirmed the minutes did not reflect follow up or outcomes to issues. On 04/17/18 at 3:59 PM, Social Worker (SW#124), requested the surveyors speak with the resident council president, so that the resident council president could tell the surveyors the council's internal process for dealing with issues and concerns. SW#124 said They do it different here, they bring up issues and deal with it right then and there at the meeting. SW#124 left the room to get the Resident Council President, Resident #9. Resident #9 entered the room alone. SW#124 did not return. The Resident Council President was asked by this surveyor, If there is anything you would like t… | 2020-09-01 |
| 520 | 520 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 609 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required. | 2020-09-01 |
| 521 | 521 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 610 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required. | 2020-09-01 |
| 522 | 522 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 745 | E | 1 | 0 | DQUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, family interview, and record review, the facility failed to provide medically related social services regarding timely notification of care plan meetings to ensure attendance and participation of residents and/or resident's family members responsible for making decisions concerning resident care. The facility also failed to provide medically related social services to assist residents and/or resident's family members responsible for making decisions in voicing and obtaining resolution to complaints and grievances. This practice had the potential to affect more than a limited number of residents. Resident identifier: #1, #4, #5, and #6. Census: 85. Findings included: Both surveyors on the investigative team conducted an interview, on 04/17/18 at 1:10 PM, with two (2) of the joint Medical Power of Attorneys (MPOAs) for Resident #1. The interview revealed they do get letters notifying them of care plan meetings. The MPOAs issues and concerns where they were not being notified in enough time to make any arrangements at work, so they could attend the care plan meetings. They said they might get a letter on Friday, for a meeting scheduled for the following Monday. They both confirmed it is just too hard to get off work and make any arrangements with such a short notice. The MPOAs revealed an incident where they arrived on the date and time the letter indicated, and as they sat waiting for the meeting, they were informed the meeting had already taken place on a different day. The MPOAs said the facility did go ahead and meet with them that day, because they refused to leave until they did. The MPOAs said they have shared these concerns about timely care plan meeting notices with staff before. Review of grievance and concern records did not reveal any of these issues or concerns had been identified, filed, and/or addressed. On 04/17/18 at 5:10 PM, an interview with Social Worker (SW#62), revealed the following. SW#62 said,… | 2020-09-01 |
| 523 | 523 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 804 | E | 1 | 0 | DQUX11 | > Based on observation, staff interview, family interview and record review, the facility failed to serve foods that are at proper temperature and palatable. This practice has the potential to affect more than a limited number of residents are consume foods served from this central location. Census: 85. Findings included: a) Review of resident council minutes on 04/18/18 revealed the residents had expressed concern with the food being cold. Such things as coffee being cold was listed in the 03/02/18 meeting and then food being cold if you ate in the room. Chicken noodle soup was described as being poured staight out of the can and not heated. b) Confidential family interview on 04/16/18 after lunch revealed the food does not always look appealing or appetizing. Sandwiches will often be a piece of bread with a slice of lunch meat on it. Did not have condiments or anythisg else on the sandwich. c) This was reviewed with the dietary manager on 04/18 /18 in the morning. She verified the residents had expressed concern about cold foods in resident council meetings and they have been attempting to resolve the issue. d) These issues were discussed with the director of nursing and the corporate regional director of operations on 04/18 /18 in the afternoon. e) Random confidential resident interviews During the initial tour on 04/16/18 at 12:45 PM, observations and interviews with several randomly chosen residents having lunch in their rooms revealed complaints of food being served cold. One resident stated, Lunch is warm today, but it is not always. Another resident said, Sometimes it's cold, the meals were sometimes cold on a few days last week. A different resident shared, Most of the time it (meals) is cold. On 04/17/18 at 3:59 PM, an interview with the Resident Council President revealed a recurring problem about food being served cold, that was supposed to be served hot. The Resident Council President said, The food was cold just the other day, and one day last week, everyone in the dining hall was talking about it. | 2020-09-01 |
| 524 | 524 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 880 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to implement proper infection control monitoring. Soiled clothing was left in Resident #1's drawers and closets creating an infection control concern. This was evident for one (1) of four (4) sampled residents currently in the faciilty. Census: 85. Findings included: a) Resident #1 During the investigation confidential interviews were conducted with family members on 04/16/18 in the afternoon. It was found that Resident #1 was known to remove soiled clothing and place them in the drawer or closet in their room. This issue was known to staff and the care plan interventions required staff to monitor the draweres and closets in the room every shift for soiled clothing and perform visual checks of the area. This was not being implemented and soiled cloting is still being left in these areas and family will come in and notice odors which are coming from the soiled clothing. This procendure could lead to an infection control issue and soiled clothing is not being handled using proper infection control techniques. The issue was discussed with the director of nursing on 04/17/18 in the afternoon. An inservice was conducted on 12/24/17 but this has still not corrected the problem. | 2020-09-01 |
| 525 | 525 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-10 | 241 | D | 0 | 1 | FJSP11 | Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one randomly observed resident, during a dinner time meal. One (1) nurse aid (NA) approached Resident #149 to set the resident up for the meal without speaking to the resident or letting the resident know what the NA was about to do. Resident identifier: #149 and #99. Facility census: 87. Findings include: a) Resident #149 Random observation during the dinner time meal, on 11/06/17 at 5:12 p.m., revealed Resident #149 was reclining in a geri chair beside a dinner table. Nurse Aide (NA) #44 came up behind Resident #149, and without saying anything to the resident or explaining what he was about to do changed the geri chair from a reclining position to a sitting position. The sudden quick movement from a reclining to a sitting position jarred the resident and caused the resident to scream out. b) Resident #99 Random observation during the dinner time meal, on 11/06/17 at 5:22 p.m., revealed NA #44 was feeding Resident #99 as she was leaning to the right side in her gerri-chair, with her head leaning forward. LPN #26 also in the dining room at the time and after observing NA #44 feeding Resident #99 agreed Resident #99 was not in good body alignment to promote feeding. LPN #26 proceeded to reposition the resident and prop the resident with folded blankets, after surveyor intervention, and instruct NA #44 on proper body alignment to promote feeding. | 2020-09-01 |
| 526 | 526 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-10 | 279 | D | 0 | 1 | FJSP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan had measurable and/or individualized objectives for a resident on anti-anxiety medication. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of fifteen (15) Stage II sampled residents. Resident identifier: #88. Facility census: 87. Findings include: a) Resident #88 The medical record was reviewed on 11/09/17. Physician orders [REDACTED]. at bedtime daily for anxiety. Review of the care plan found it lacked individualized, measurable goals for the use of anti--anxiety medications. The care plan did not identify the behaviors the facility intended to treat with the anti-anxiety medication. The care plan did not include measurable goals set for the resident's emotional and/or behavioral condition. Rather, the care plan focus stated (name of resident) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) anxiety disorder. The goals stated Patient will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Their only non-pharmacological interventions were to encourage him to vent his feelings, and listen to his concerns. On 11/09/17 at 9:58 a.m. an interview was conducted with the director of nursing (DON). She said this resident does have targeted behaviors, but they were not listed on the care plan. She acknowledged that there was no focus on the behaviors that caused him to need the [MEDICATION NAME]. She acknowledged that there were no individualized or measurable goals for any targeted behaviors they were treating. She said she would correct these issues right away. | 2020-09-01 |
| 527 | 527 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-10 | 371 | E | 0 | 1 | FJSP11 | Based on observation and staff interview, the facility failed to maintain kitchen equipment in a sanitary manner. This practice has the potential to affect more than limited number Residents. Staff Identifiers: #66. Facility Census: 87. Findings include: On 11/06/17 at 2:40 p.m., inspection of the kitchen with the dietary assistant #66, revealed an observation of the food lid to hot bar was dirty. The dietary assistant #66 agreed the food lid to hot bar was dirty and should not have been. | 2020-09-01 |
| 528 | 528 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2017-11-10 | 431 | D | 0 | 1 | FJSP11 | Based on observation and staff interview the facility failed to store and label medications. Resident: #48, #81 and #88. 11/08/2017 11:05:14 AM in medication room B and 2 medication carts, LPN #72 Levemir multi vail use wasn't labeled with opened date on vial for Resident #48, LPN #56 11/08/2017 11:15:31 AM Medication Room A and 2 medication carts, LPN #23 pens LPN #4 Humalog pen not labeled with opened date, Resident #81 Novolog pen not labeled with opened date, Resident #88 Based on observations and staff interview, the facility failed to collaborate with the pharmacist, to ensure safety and effective use of medications. An opened and partially used insulin vial was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication. This was evident for three (3) of thirty one (31) opened insulin vials and pens stored in two (2) of four (4) carts. Resident identifiers: #48, #81, #80. Findings include: a) Resident # 48 Observation on 11/08/2017 at 11:05 a.m., found a Levermir vial which belonged to resident # 48 was opened and partially used. There was no date indicating when the vial was intially opened, or the date it should be discarded. The Licensed Practical Nurse (LPN) #72 agreed the date that it was opened should have been on the vial. b) Resident #81 and #80 Observation on 11/08/2017 at 11:15 a.m. found a Humalog pen which belong to Resident # 81 was opened and partially used. There was no date indicating when the pen was was intially opened, or the date to discard. A novolog pen belonging to Resident #80 was opened and partially used. There was no date indicating when the pen was intially opened, or the date to discard. The LPN # 4 agreed that it should have been labeled when it was intially opened. There was a place on the pens to put the opened dates that were blank. Interveiw with the Director of Nursing was completed on 11/09/2017 at 10:30 a.m. she was aware of the findings of the insulin not being dated of when the medication was intially opened… | 2020-09-01 |
| 529 | 529 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 574 | E | 0 | 1 | J9FW11 | Based on observation, staff interview and information from the resident council meeting, the facility failed to provide information on how to contact the local ombudsman. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) Resident council meeting During the resident council meeting on 11/28/18 at 10:27 AM, the residents in attendance did not know how to contact the ombudsman if they would choose to do so. The facility's Social Worker (SW) #28, was also in attendance at the council meeting. SW #28 told the resident's the name and contact information of the local ombudsman was posted at the nurses station. After the meeting was adjourned, at 10:52 AM on 11/28/18, the SW and the surveyor reviewed the information posted at the nurses station. The name and contact information of the local ombudsman was not available. On 11/28/18 at 03:03 PM, the administrator said the contact information of the local ombudsman, Was posted but someone removed it, we have put it back. | 2020-09-01 |
| 530 | 530 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 583 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure Resident #245's medical record was kept confidential. Resident #245's medication orders were observed to be hanging on the magnetic bulletin board in the residents room. This was a random opportunity for discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 Observation of Resident #245's room at 12:34 p.m. on 11/26/18 found her medication list placed on her magnetic bulletin board with a magnet. The list had been printed by the facility and it appeared Resident #245's daughter had placed it on the board with a hand written note which read, Mom's Medications, and No [MEDICATION NAME]. An additional observation with the Director of Nursing (DON) at 1:05 p.m. on 11/27/18, found the medication list was still on the magnetic bulletin board in Resident #245's room. The DON removed the list and indicated it looked like Resident #245's daughter had placed the list there and she would call and talk to them about it. She agreed the medication should not have been posted in the residents room. | 2020-09-01 |
| 531 | 531 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 584 | D | 0 | 1 | J9FW11 | Based on observation and staff interview the facility failed to ensure Resident #245's wheelchair was in good prepare. The wheelchair was missing an arm rest on one side and the other arm rest was loose. This was a random opportunity of discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 An observation of Resident #245's wheelchair at 9:40 a.m. with the Director of Nursing (DON) found the arm rest on the left side of her wheelchair was missing and the residents right arm rest on her wheelchair was loose. The DON stated, I will have (name of Maintenance Director) to fix it right away. | 2020-09-01 |
| 532 | 532 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 622 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to convey all required transfer information to the receiving hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #43. Facility census: 97. Findings include: a) Resident #43 On 09/17/18 at 5:18 am, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. The Acute Care Transfer form provided to the receiving hospital did not include information regarding usual mental status, ambulation status, skin condition at time of transfer, devices and special treatments. The Acute Care Transfer form contained sections to provide this information. However, the sections were blank. During an interview on11/27/18 at 12:20 PM, the Director of Nursing agreed the information had not been completed on Resident #43's Acute Care Transfer form dated 09/17/18. | 2020-09-01 |
| 533 | 533 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 641 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview the facility failed to ensure the Minimum Data Sets (MDS)s accurately reflected the resident's status. This was true for six (6) of twenty-six (26) resident's MDSs reviewed during the Long Term Survey Process (LTCSP). Resident #96's MDS was inaccurate in the area of death in the facility. Resident #14 MDS was inaccurate in area of pressure ulcers. Resident #9's MDS was inaccurate in area of falls. Resident #95's MDS was inaccurate in the area of nutrition. Resident #62's MDS was inaccurate in the area of positioning/mobility. Resident #84's MDS was inaccurate in area of unnecessary medications. Resident identifiers: #96, #14, #9, #95, #62 and #84. Facility census 97. Findings include: a) Resident #96 Resident #96 was admitted to the facility on [DATE] from an acute care hospital due to multiple falls at home. Resident's [DIAGNOSES REDACTED]. Further review of nurse's notes found on [DATE] at 8:05 am, the resident was found unresponsive. Cardiopulmonary resuscitation was initiated due to resident's wishes to be Full Code. Resident #96 was transported to local hospital and expired at the hospital. Review of the MDS with an assessment reference date (ARD) of [DATE] was marked, Death in Facility. During the review of the attending physician's discharge summary found: Patient died at (Name of local hospital. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE] at 3:00 pm, confirmed the resident did not die in the facility and the MDS with ARD of [DATE] was inaccurately coded. They both agreed the MDS should have been coded, Discharge with assessment return not anticipated. b)Resident #14 Medical record review found a Wound Assessment-Pressure Ulcer Assessment, dated [DATE] read: Right and left buttocks, 9.6 centimeters (cm) in length, 9 cm in width and 0.1 cm in depth, stage II. Area less red and not as firm, now with three (3) open areas. Further re… | 2020-09-01 |
| 534 | 534 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 656 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop/and or implement care plans for 4 of 23 residents whose care plans were reviewed. Resident #44's care plan was not developed to include how the facility would provide care to a Dementia resident. Resident #45's care plan was not was implemented for Dementia care. Residents #6 and #70's care plans were not implemented to anchor catheters. Resident identifiers: #44, #45, #6, and #70. Facility census: 97. Findings include: a) Resident #44 Review of the current care plan, revised on 07/20/17, found the problem: (Name of Resident ) has impaired cognitive function related to Dementia. The goal associated with the problem was: Patient will maintain current level of cognitive function through the review date. Interventions included: Administer Meds ([MEDICATION NAME]) as ordered Document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Engage patient in simple, structured activities that avoid overly demanding tasks. A second care plan problem addressed the resident was receiving [MEDICATION NAME] for delusions and hallucinations. The goal of this care plan was: The resident will be/remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions From the guidance to surveyors: Residents living with dementia require specialized services and supports, (e.g., specialized activities, nutrition, and environmental modifications) that vary, based on the individual's abilities and challenges related to their condition. Dementia causes significant intellectual functioning i… | 2020-09-01 |
| 535 | 535 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 657 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise care plans when residents had changes in their care related to advance directives, position and mobility, and [MEDICAL TREATMENT] schedule. This was found to be true for three (3) of 23 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifiers: #395, #62, #16. Facility census: 97. Findings included: a) Resident #395 On [DATE] at 1:32 PM it was noted through the screening portion of the Long-Term Care Survey Process that the code status marked on Resident #395's profile in the electronic medical record did not match the code status indicated on the care plan. The code status on the profile in the electronic medical record stated, Resuscitate (CPR); Feeding Tube Long-Term; Patient has a completed POST form dated: [DATE]; Limited Additional Interventions; IV Fluids for a trial period of no longer than: ,[DATE] days. A review of the current Physician order [REDACTED].#395's representative on [DATE], stated to Attempt Resuscitation/CPR and to provide Limited Additional Interventions, IV fluids for a trial period of no longer than ,[DATE]d(ays), and Feeding tube long-term. A previous POST form, signed by Resident #395's representative on [DATE], indicated to provide full interventions as well as IV fluids for a trial period of no longer than ,[DATE]d(ays). It was marked VOID. Resident #395's physician orders [REDACTED]. However, the advance directives documented on the care plan stated, Full interventions, IV fluids for a trial period of no longer than ,[DATE] days, Feeding tube long term. According to date stamps on the care plan, this information was last revised on [DATE] by Registered Nurse Assessment Coordinator (RNAC) #47. During an interview on [DATE] at 2:20 PM, RNAC #47 acknowledged that the advance directive information on the POST form and the care plan did not match and stated she would fix the problem immediately. On … | 2020-09-01 |
| 536 | 536 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 660 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a plan was in place to address the the residents expressed desire to talk to someone about in-home and community agencies available before her discharge to home. This was true for one (1) resident reviewed for the care area of discharge to the community. Resident identifier: #95. Facility census: 97. Findings include: a) Resident #95 Record review at 9:20 AM on 11/27/18, found the resident was admitted to the facility on [DATE]. The resident was discharged to her home on 08/31/18. Review of the minimum data set (MDS), a 5 day Medicare Part A Stay, with an assessment reference date (ARD) of 06/19/18, found the resident participated in completing the MDS. The resident expected to be discharged to the community. When asked the question on the MDS, Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The residents response was, yes. The Resident Assessment Instrument (RAI) manual provides the following direction when answering yes to the above question on the MDS: The goal of follow-up action is to initiate and maintain collaboration between the nursing home and the local contact agency to support the resident's expressed interest in talking to someone about the possibility of leaving the facility and returning to live and receive services in the community. This includes the nursing home supporting the resident in achieving his or her highest level of functioning and the local contact agency providing informed choices for community living and assisting the resident in transitioning to community living if it is the resident's desire. The underlying intention of the return to the community item is to insure that all individuals have the opportunity to learn about home and community based services and have an opportunity to receive long term services and supports in the least restrictive sett… | 2020-09-01 |
| 537 | 537 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 684 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, resident interview, and the National Pressure Ulcer Advisory Panel's (NPUAP), the facility failed to provide quality treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. This was true for six (6) of twenty-three (23) residents reviewed. For Residents #37, #14, #345, and #9 had wounds not assess, monitor and treat wounds as indicated. Resident #43 did not have a follow appointment as directed by the discharging physician. Additionally, Resident #59's bowel and bladder incontinence was not accurately assessed. Resident identifiers: #37, #14, #345, #9, #43, and #59. Facility census: 97. Findings include: a) Resident #37 Medical record review found Resident #37 was admitted to the facility on [DATE]. Additionally, Resident #37 had a facility acquired pressure ulcer to the Matrix. Review of Resident #37 nursing assessment and wound assessments: Nursing assessments for 01/09/18, 04/10/18, and 04/10/18- No pressure ulcers noted. --10/02/18- Initial wound assessment dated [DATE]: coccyx- Stage II- measured 0.9 centimeter (cm) in length (l) and 0.6 cm in width (w) and 0.1 cm depth (d). --10/05/18 - Nursing assessment- Coccyx- dressing intact, see detailed initial pressure ulcer assessment (dated 10/02/18). Right inner foot - see detailed non-pressure wound evaluation. (None could be found). --10/08/18- Coccyx- Stage II- measured 0.8 cm l and 0.4 cm w. and 0.1 cm in depth. --10/09/18-Initial assessment-right inner heel- Stage II- blister which had ruptured and measured 3.0 cm in l and 3.5 cm in w and 0.1 cm in d. --10/17/18- cocc… | 2020-09-01 |
| 538 | 538 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 690 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review the facility failed to ensure residents, with an indwelling catheter, received the appropriate care based upon current professional standards of practice and services to prevent urinary tract infections to the extent possible. Also failed to ensure the indwelling Foley catheter was secured to the leg was used to prevent injury, accidental removal. This was true for two (2) of two (2) reviewed for catheter care. Identified Residents were Resident #70 and #6. Facility Census 97. Findings included: a) Resident #70 During an interview on 11/26/18 at 11:39 AM, Resident's husband said that she has ESBL in urine she has a catheter. On 11/28/18 at 9:23 AM, Indwelling Foley Catheter care observation with Nursing Assistant (NA) #40, it was noted the catheter anchor was not on the resident's leg. NA#40 wiped once down the sides of the inner legs (groin area), one down stroke over the outside of the vagina. She then emptied the water basin and left room. When she returned with clean wash cloth and water she wiped the catheter tubing but not at the insertion site, only a section of the tubing about 3 inches from the vagina. Licensed Practical Nurse (LPN) #27 brought in a thigh strip to secure the Foley catheter to the leg. NA #85 wiped the buttock crevices toward the vagina, not away from the vagina to prevent Infections. After the two (2) NAs had finished and put the supplies away they were asked the following; - How often are they in-serviced on catheter care? They both said the last time was in (MONTH) this year. - How do they believe they did? NA # 85 said that, she knew that she should not have wiped towards the vagina and NA #40 said she normally does a better job. Both NAs agreed they did not use proper technic for catheter care. During an interview on 11/28/18 at 10:04 AM, DoN was notified of findings that were observed. She stated that she was disappointed. The Facility Policy, Catheter Care… | 2020-09-01 |
| 539 | 539 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 698 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure Resident #16 a [MEDICAL TREATMENT] patient received care and services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #16 reported that she is late to [MEDICAL TREATMENT] frequently because the ambulance is always late to get her. Also, Resident #16 had an order for [REDACTED]. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the long term care survey process. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 1. Transportation to [MEDICAL TREATMENT] During an interview with Resident #16 at 12:00 p.m. on 11/26/18, she stated, I am late for [MEDICAL TREATMENT] on a regular basis. She indicated her appointment was set for 12:00 p.m. and the ambulance often times picked her up after her scheduled appointment time. She stated, I am supposed to be on the machine all ready and I am still sitting her waiting for them to come and get me. She stated, This happens at least once or twice a week. At 12:16 p.m. on 11/26/18, the ambulance company was observed arriving to pick up resident #16 for her [MEDICAL TREATMENT] appointment which was scheduled at 12:00 p.m. A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found the following physician order [REDACTED].>Further review of the record found the following dates which Resident #16 was picked up for her [MEDICAL TREATMENT] appointment after her scheduled appointment time: All notes are entered by nursing and are appointment/outing notes. The times used are the effective times of the note which would be the time Resident #16 left the building in route to her [MEDICAL TREATMENT] treatment: 07/18/18 at 12:45 p.m. 08/01/18 at 12:55 p.m. 08/27/18 at 12:03 p.m. 09/04/18 at 1:32 p.m. 09/14/18 at 12:19 p.m. 09/24/18 at 12:51… | 2020-09-01 |
| 540 | 540 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 744 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents diagnosed with [REDACTED]. This was true for three (3) of three (3) residents reviewed for the care area of Dementia. Resident identifiers: #44, #45, and #92. Facility census: 97. Findings include: a) Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:3… | 2020-09-01 |
| 541 | 541 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 757 | D | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #16's drug regimen was free from unnecessary medications. Resident #16's [MEDICATION NAME] was ordered to be held at certain times on [MEDICAL TREATMENT] days and it was not held as ordered. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered. | 2020-09-01 |
| 542 | 542 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 758 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents where not placed on [MEDICAL CONDITION] medication before the facility utilized individualized non-pharmacological approaches to care. Therefore these residents medication could not be proven to necessary. This was true for four (4) of five (5) residents reviewed for the care area of unnecessary medications during the Long term care survey process. Resident identifiers: #92, #45, #44, and #84. Facility census: 97. Findings Include: a) Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and any non pharmacological interventions they had put into place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on… | 2020-09-01 |
| 543 | 543 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 812 | F | 0 | 1 | J9FW11 | Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner. Bowls and tray covers were not stored inverted and foods that had passed their use by/best by/expiration dates were found in a refrigerator, a food serving area, and the dry storage area. This had the potential to affect all residents in the facility. Facility census: 97. Findings included: a) Kitchen Tour An initial tour of the facility kitchen began on 11/26/18 at 10:23 AM with Dietary Services Supervisor (DSS) #122. During this tour, one (1) individual bowl of prepared salad with a use by date of 11/22/18 was found in a refrigerator containing resident food across from the tray line. DSS #122 removed the salad at the time of the finding. On shelves underneath the tray line, a box labeled Orange Pekoe and Pekoe Cut Black Tea containing 41 loose tea bags was found to have a best by date of 07/12/15. On the same shelves underneath the tray line, stacks of bowls were found facing up, potentially exposing the insides of the bowls to dust, debris, and/or splatter. Numerous tray covers were found on top of the tray line also facing up, potentially exposing the insides to dust, debris, and/or splatters. Once notified of the above issues, DSS #122 removed the box of loose tea bags. She stated that she did not feel that the bowls and tray covers needed to be stored inverted since they were dry. DSS #122 confirmed that the bowls and tray covers were used in serving resident food. She was then asked for a facility policy indicating that it was acceptable not to invert bowls and tray covers to be used in serving resident food. DSS #122 stated she was not aware of any such policy. In the dry storage room, 11 more boxes of Orange Pekoe and Pekoe Cut Black Tea were found. Each box had a best by date of (MONTH) (YEAR) and contained 100 tea bags. One (1) 11-pound container of vanilla creme icing with a use by date of 11/10/18 was also found in the dry storage area. At 10:37 AM, DSS #122 was notified of the findin… | 2020-09-01 |
| 544 | 544 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-11-29 | 865 | E | 0 | 1 | J9FW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the Quality Assessment and Assurance committee made good faith attempts to correct quality deficiencies which it did have or should have had knowledge of. The facility failed to identify the fact that three (3) of three (3) residents reviewed for the care area of dementia management was started on antipsychotic medications when no non pharmacological interventions and been put in place prior to the starting of the medication. This practice has the potential to effect more than an isolated number of residents currently residing in the facility. Resident Identifiers: #92, #44, and #45 Facility Census: 97. Findings Include: a) Treatment/Services for Dementia 1. Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medicatio… | 2020-09-01 |
| 3271 | 3271 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 157 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party when one (1) of seventeen (17) residents reviewed, experienced changes in medical conditions. The responsible party was not notified when Resident #86 experienced a fall at the facility, and when changes to medication were made due to an irregular laboratory value. Resident identifier: #86. Facility census: 58. Findings include: a) Resident #86 Record review found the resident was admitted to the facility on [DATE]. The medical record contained a copy of a guardian/conservation court appointment dated 08/21/08. The resident's facility physician deemed the resident to lack capacity to make medical decisions on 11/01/16. Review of the nurses notes found the resident had a fall on 02/04/17. The nursing note dated 02/04/17 at 4:07 p.m. revealed she, Heard resident calling for help, when entering room saw resident in floor sitting on buttocks beside w/c (wheelchair) able to move all extremities, unwitnessed and Neuro checks started. Assisted via 2 assist back to w/c. A nursing note dated 02/04/17 at 7:10 p.m. read, Notified DHHR (Department of Health and Human Services) via voice mail. A nursing note dated 02/06/17 read, d/c (discontinue) potassium 20 meq, (milliequivalent) BID (twice a day) PO (by mouth), start potassium 20 meq daily PO, DX (diagnosis), potassium 5.3. DHHR made aware via voice mail. (A normal potassium level is 3.6 to 5.2). The facility social worker (SW) #62, verified at 1:00 p.m. on 02/07/17, the resident's guardian/ conservation, was the resident's brother. She stated, the appointment of the brother in 2008 continues to be in effect and the DHHR is not the resident's responsible party. At 1:29 p.m. on 02/07/17, the director of nursing said, she did not know why the nurse would have contacted DHHR and not the legal representative. She also confirmed the DHHR is not the resident's medical decision maker and should not have been notifi… | 2020-09-01 |
| 3272 | 3272 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 164 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility provided confidential medical information to an entity who was not the resident's responsible party. This was true for one (1) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #86. Facility census: 58. Findings include: a) Resident #86 Record review found the resident was admitted to the facility on [DATE]. The medical record contained a copy of a guardian/conservation court appointment dated 08/21/08. The resident's facility physician deemed the resident to lack capacity to make medical decisions on 11/01/16. Review of the nurses notes found the resident had a fall on 02/04/17. The nursing note dated 02/04/17 at 4:07 p.m. revealed she, Heard resident calling for help, when entering room saw resident in floor sitting on buttocks beside w/c (wheelchair) able to move all extremities, unwitnessed and Neuro checks started. Assisted via 2 assist back to w/c. A nursing note dated 02/04/17 at 7:10 p.m. read, Notified DHHR (Department of Health and Human Services) via voice mail. A nursing note dated 02/06/17 read, d/c (discontinue) potassium 20 meq, (milliequivalent) BID (twice a day) PO (by mouth), start potassium 20 meq daily PO, DX (diagnosis), potassium 5.3. DHHR made aware via voice mail. (A normal potassium level is 3.6 to 5.2). The facility social worker (SW) #62, verified at 1:00 p.m. on 02/07/17, the resident's guardian/ conservation, was the resident's brother. She stated, the appointment of the brother in 2008 continues to be in effect and the DHHR is not the resident's responsible party. At 1:29 p.m. on 02/07/17, the director of nursing said, she did not know why the nurse would have contacted DHHR and not the legal representative. She also confirmed the DHHR is not the resident's medical decision maker and should not have been notified of changes in condition. . | 2020-09-01 |
| 3273 | 3273 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 241 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to carry out activities to assist the resident to maintain his self-esteem and self -worth. This was true for one (1) of one (1)resident reviewed for the care area of dignity. Resident #29 had a persistent urine odor. Resident identifier: #29. Facility census: 58. Findings include: a) Resident #29 Observation of the resident in Stage 1 of the Quality Indicator Survey (QIS) at 4:54 p.m. on 02/06/17 found the resident was in his room, in bed and under the covers. Upon entrance to the room, a strong urine odor was detected. The odor was permeating from the area where the resident was located. Review of the resident's current care plan found no information to indicate the resident refused personal care. The care plan addressed the resident's activities of daily living (ADL's) and directed the resident's bathing required the assistance of one (1) staff member for bathing on Tuesday's, Thursday's and Saturday's. Observation of the resident at 9:45 a.m. on 02/08/17, found the odor was still persistent. Review of the resident's shower schedule with Employee #88, the unit secretary, at 10:00 a.m. on 02/08/17, found documentation the resident had received a shower on 02/07/17. At 10:10 a.m. on 02/08/17, Registered Nurse (RN), #8, working on the resident's unit, said the resident usually has a urine odor. She stated sometimes he refuses care. At 10:20 a.m., on 02/08/17, the resident was observed in his bed. The director of nursing (DON) was present for the observation. The DON acknowledged the odor and said it could be his mattress and sometimes the resident hides his briefs. Observation of the room, found no indication the resident had hid his briefs on this day. The DON said she would have the sheets and blankets stripped and his mattress cleaned. She said the facility had recently purchased a new mattress for the resident. She said the resident is known to dribble urine on h… | 2020-09-01 |
| 3274 | 3274 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 272 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to complete an accurate comprehensive assessment for two (2) of seventeen (17) Stage 2 sampled residents whose comprehensive assessments were reviewed. Resident #42 sustained a fall with injury which was not assessed on her annual comprehensive assessment. Resident #43's comprehensive assessment was incorrect in the areas of falls and prognosis. Resident identifiers: #42 and #43. Facility census: 58. Findings include: a) Resident #42 The medical record was reviewed on 02/08/17. According to nurse progress notes, she sustained a fall with injury on 10/31/16, which consisted of a nickel sized bruise to the right knee, and complaints of pain to that area. Nursing notified the physician of the incident, and received new orders for x-rays of the right knee. Nursing administered a scheduled pain medication at that time. Review of this resident's annual minimum data set (MDS) with assessment reference date (ARD) of 12/15/16, incorrectly assessed this resident sustained [REDACTED]. An interview was conducted with MDS registered nurse #26 on 02/08/17 at 2:00 p.m. After she reviewed the 10/31/16 nursing progress note and the 10/31/16 incident report, she said the resident's annual MDS with ARD 12/15/16 should have assessed she sustained one (1) fall with injury since the previous MDS, and it did not. This information was shared with the director of nursing on 02/09/17 at 1:10 p.m. She provided no further information prior to exit. b) Resident #43 1. Falls A review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed an admission date of [DATE]. A significant change MDS, with an assessment reference date (ARD) of 09/10/16, indicated Resident #43 had no falls since admission, entry or reentry or prior assessment, whichever is more recent. Review of Resident #43 incident reports for the period of time since the last MDS and the significant change MDS with… | 2020-09-01 |
| 3275 | 3275 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 278 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete Resident #43's quarterly Minimum Data Set (MDS), in the areas of prognosis and falls. Resident #51's thirty (30) day MDS was inaccurate in the area of weight loss. This was true for two (2) of seventeen (17) Stage 2 residents MDS's reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #43 and #51. Facility census: 58. Findings include: a) Resident #43 1. Falls A review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed a quarterly MDS, with an assessment reference date (ARD) of 02/05/17, which indicated Resident #43 had one (1) fall since the prior assessment. Review of Resident #43's incident reports for the period of time since the last MDS, found Resident #43 had three (3) fall during this period: --On 11/09/16 at 11:30 a.m., Leaned over from his wheelchair to pick something up from the floor and fell to the floor. No injuries. --On 01/05/17 at 2:15 a.m., fell when attempting to get out of bed to check on his wife (roommate). No injuries noted. --On 01/05/17 at 9:00 a.m., Slid out of bed to floor. Resident had a lump on right side of forehead and complained of knee pain. 2. Prognosis Further review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed a quarterly MDS, with an assessment reference date (ARD) of 02/05/17, which indicated Resident #43 did not have a life expectancy of six (6) months or less. Review of the physician progress notes [REDACTED]. 3. Interview During an interview on 02/09/17 at 9:15 a.m., MDS Coordinator #24 said Resident #43 had three (3) falls since the last MDS assessment, inlcuding one (1) fall on 11/09/16, and two (2) falls on 01/05/17. She further verified this should have been noted on the quarterly MDS with ARD of 02/05/17. In addition, she verified the resident had a decline in condition and was restarted on hospice services on 10/24/16. The MDS Coordinator confirmed t… | 2020-09-01 |
| 3276 | 3276 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 279 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) one (1) resident reviewed for the care area of hydration during Stage 2 of the Quality Indicator Survey (QIS). The care plan failed to address how the physician ordered fluid restriction would be implemented and monitored by each discipline, including dietary, nursing and activities. Resident identifier: #40. Facility census: 58. Findings include: a) Resident #40 During Stage 1 of the QIS survey, at 12:17 p.m. on 02/06/17, an interview with Resident #40 found he said he did not receive the fluids he wanted between his meals. He said he thought it was due to a kidney problem. Record review at 4:43 p.m. on 2/07/17, found the resident had a physician's orders [REDACTED]. Further record review found a care plan addressing dehydration/fluid maintenance with a potential for dehydration due to fluid restriction and a [DIAGNOSES REDACTED]. The goal was the resident would remain free of signs/symptoms of dehydration through next review date. The care plan was updated on 02/02/17. The care plan approaches did not detail how much fluid the resident would receive from dietary and how much fluid from the nursing staff. An interview with Registered Nurse (RN) #26, author of the care plan, at 8:23 a.m. on 02/08/17, confirmed the fluid restriction was not detailed in the resident's care plan. At 8:51 a.m. on 02/08/17, the resident's Licensed Practical Nurse (LPN) #11 said the resident is not on a fluid restriction and she verified the resident had a pitcher with water in his room with a straw for drinking. At 8:56 a.m. on 02/08/17, the dietary manager (DM) #23, provided a copy of the tray card for the resident's noon meal on 02/08/17. The tray card directed the resident to receive 4 ounces (oz) of coffee or hot tea and 8 oz's of milk. She was asked how to convert ounces to cubic centimeters. She said she wasn't sure, but would … | 2020-09-01 |
| 3277 | 3277 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 280 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to revise the care plans for Residents #30, #9 and Resident #43's when there was a change in their treatment. Resident #30 and #43 did not have their care plans revised when changes were made to their medication regimen. Resident #9's care plan was not revised when her pressure ulcer interventions changed. For Resident #97 the facility failed to involve him in his care planning process as it related to his preference to have meat for breakfast. This was true for four (4) of seventeen (17) stage 2 sampled residents. Resident Identifiers: #30, #97, #9 and #43. Facility census: 58. Findings include: a) Resident #30 A review of Resident #30's medical record, at 9:22 a.m. on 02/08/17, found a physician's orders [REDACTED]. This order had a discontinue date of 07/08/16. A review of Resident #30's care plan found the following intervention related to her nutritional status problem statement, Administer medications as ordered and monitor for side effects. Med Pass and sliding scale insulin. This intervention had a start date of 03/16/16. An interview with the Director of Nursing (DON) on 02/09/17 at 10:02 a.m., confirmed Resident #30 no longer received sliding scale insulin and the care plan was not revised when this medication was discontinued. b) Resident #97 The medical record was reviewed on 02/07/17 at 11:53 a.m. which revealed a diet order dated 2/01/17 for the resident to receive, double meat/egg portions on trays. On 02/08/17 at 7:54 a.m. Staff #94 stated the resident discussed food preferences with the Registered Dietician on 02/07/17 and because the resident receives [MEDICAL TREATMENT], cannot receive meats served at breakfast. Observed Resident #97 breakfast tray on 02/08/17 at 8:17 a.m., no meat observed on tray. Resident stated understanding of diet recommendations. Resident does not want meat all the time but would like meat sometimes at breakfast but has not received meat … | 2020-09-01 |
| 3278 | 3278 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 282 | E | 0 | 1 | UXFJ11 | Based on resident interview, resident observation, record review and staff interview the facility failed to implement Resident #30's activities of daily living (ADL) care plan on multiple occasions by not providing her showers three times weekly and by not cleaning her glasses every shift as directed by her care plan. This was true for one (1) of three (3) residents reviewed for the care area of ADL's during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #30. Facility census: 58. Findings include: a) Resident #30 1. Showers During a Stage 1interview with Resident #30, at 3:00 p.m. on 02/06/17, when asked if she received the number of showers in a week she would like she stated, No, I am supposed to be showered three (3) times a week and they only shower me once a week or once every two weeks. A review of Resident #30's medical record at 8:29 a.m. on 02/09/17 found the following care plan related to Resident #30's ADL care: --Problem statement with a start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. --The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. --The interventions associated with this problem statement and goal included: Bathing PM (evening) Shower assist of 1 Days Monday, Wednesday, and Friday. This intervention was added to the care plan on 03/16/16. Review of the Resident #30's shower documentation from 06/20/16 through present found the following: --For 06/20/16 through 06/30/16, Resident #30 was scheduled to receive five (5) showers and only received two (2) on 06/25/16 and 06/28/16. She did not receive her shower as scheduled on 06/21/16, 06/23/16, and 06/30/16. --For the month of (MONTH) (YEAR) (07/01/16 through 07/31/16), Resident #30 was schedul… | 2020-09-01 |
| 3279 | 3279 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 309 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, resident interview and staff interview, the facility failed to ensure medication was administered as ordered by the physician, failed to coordinate hospice services and failed on multiple occasions when neurological checks directed by the facility's standing orders for Resident #43. For Resident #97, the facility failed to coordinate [MEDICAL TREATMENT] treatments. For Resident #30 and 42, the facility failed to complete neurological checks as directed by the facility's standing orders. For Resident #40, the facility failed to follow a physician ordered fluid restriction. This was true for five (5) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #43, #97, #30, #42 and #40. Facility census: 58. Findings include: a) Resident #43 1. Medication Administration A review of Resident #43's medical record at 10:19 a.m. on 02/08/17, found a physician's orders [REDACTED]. Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. 2. Hospice Services A medical record review for Resident #43 on 02/08/17 at 1:00 p.m., found the resident received hospice services since 10/24/16. Review of Resident #43's care plan for hospice services found no indication of when and who would be involved in the coordination and implementation of the resident's hospice care. Interview with register nurse (RN) # 52 on 02/09/17 at 8:25 a.m., found the facility staff was unable to provide information for when the hospice personnel were scheduled and who was responsible for the coordination of hospice care with the facility and hospice staff. 3. Neurological checks Review of Resident #43's incident reports found on 08/29/16, 10/19/16, 11/09/16 and 01/05/17 he… | 2020-09-01 |
| 3280 | 3280 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 312 | E | 0 | 1 | UXFJ11 | Based on resident interview, resident observation, record review and staff interview the facility failed to provide Resident #30 who is not able to carry out her own Activities of Daily Living (ADL) care with the necessary ADL care for her to maintain good grooming, and personal hygiene. This was true for one (1) of three (3) residents reviewed for the care area of ADL's during stage 2 of the quality indicator survey (QIS). Resident Identifiers: #30. Facility Census: 58. Findings include: a) Resident #30 1. Showers During a Stage one (1) interview with Resident #30 at 3:00 p.m. on 02/06/17 when asked if she received the number of showers in a week she would like she stated, No I am supposed to be showered three (3) times a week and they only shower me once a week or once every two weeks. A review of Resident #30's medical record at 08:29 a.m. on 02/09/17 found the following care plan related to Resident #30's ADL care: Problem Statement with a problem start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. The goals associated with this problem statement and goals included: Bathing PM (evening) Shower assist of 1 Days Monday, Wednesday, and Friday. This intervention was added to the care plan on 03/16/16. Review of the Resident #30's shower documentation from 06/20/16 through present found the following: 06/20/16 through 06/30/16: Resident #30 was scheduled to receive five (5) showers and only received two (2) on 06/25/16 and 06/28/16. She did not receive her shower scheduled on 06/21/16, 06/23/16, and 06/30/16. For the month of (MONTH) (YEAR) (07/01/16 through 07/31/16) Resident #30 was scheduled to receive 12 showers. She received a sh… | 2020-09-01 |
| 3281 | 3281 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 353 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation, the facility failed to ensure qualified nursing staff provided day to day care to meet the resident's needs in an environment which promoted each resident's physical, mental, and psychosocial well-being, to enhance their quality of life. Resident #43 was not administered a breathing ([MEDICATION NAME]) medication as ordered by the physician, failed to ensure the care of a hospice resident was correlate his hospice provider and failed on multiple occasions when neurological checks were indicated to complete as directed by the facility's standing orders. For Resident #97 the facility failed to ensure the care of a [MEDICAL TREATMENT] resident was correlated with the [MEDICAL TREATMENT] center. For Resident #30 and 42, the facility failed to complete neurological checks as directed by the facility's standing orders. For Resident #40, the facility failed to follow a physician ordered fluid restriction. This was true for five (5) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #43, #97, #30, #42 and #40. Facility census: 58. Findings include: a) Resident #43 1. Medication Administration A review of Resident #43's medical record at 10:19 a.m. on 02/08/17, found a physician's orders [REDACTED]. Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. 2. Hospice Services A medical record review for Resident #43 on 02/08/17 at 1:00 p.m., found the resident received hospice services since 10/24/16. Review of Resident #43's care plan for hospice services found no indication of when and who would be involved in the coordination and implementation of the resident's hospice care. Interview wit… | 2020-09-01 |
| 3282 | 3282 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 356 | B | 0 | 1 | UXFJ11 | Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date; the current resident census; the total number and actual hours worked by registered nurses, licensed nurses, and nurse aides per shift. This had the potential to affect more than an isolated number of residents and/or visitors residing or visiting the facility. Facility census: 58. Findings include: a) Observation of the staff posting on the 2nd floor, during the initial tour of the facility, at 10:34 a.m. on 02/06/17, found the facility staff posting was dated 02/02/17. An interview with the director of nursing, at 10:35 a.m. on 02/06/17, confirmed the facility had not displayed the staff posting information for 02/03/17 through 02/06/17. . | 2020-09-01 |
| 3283 | 3283 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 371 | F | 0 | 1 | UXFJ11 | Based on observation and staff interview, the facility failed to prepare, store and serve food in a safe and sanitary manner. The kitchen walk-in refrigerator had solid matter where floor and wall meet, undated dry goods, un-intact packaged frozen food observed in walk-in freezer and perishable food stored at room temperature. Resident refrigerators on first and second floor contained unlabeled and/or undated food, and soiled food carts were observed. These findings had the potential to affect all residents. Census: 58. a) The Kitchen Observations made on 02/06/17 and 02/08/17 found the following: --02/06/17 at 10:46 a.m. observed non securely packaged pancakes and chicken patties exposed to air inside walk-in freezer. --02/06/17 at 10:53 a.m. observed solid matter in areas of walk-in refrigerator where floor and wall meet. --02/06/17 at 12:44 p.m. observed single serve milk cartons set out at room temp for the duration of meal tray assembly. --02/06/17 at 12:49 Staff #94 states that once a week the refrigerator floor should be cleaned out and that it is a good idea to put the milk on ice if milk will be setting out for a while. --02/08/17 at 10:22 a.m. observed the following opened, undated food items stored on a shelf, bulk Italian seasoning, molasses, cream of wheat, 2 (two) cans of food thickener and 2 (two) jars of chicken base seasoning. The label on the jars of chicken base seasoning reads, refrigeration after opening is required. --02/08/17 at 10:30 a.m. interview with Staff #94 states that items need to be dated when opened and stored in the proper place. b) Observation of the resident's food pantry refrigerator During the tour of the facility at 10:30 a.m. on 2/6/17, observation of the resident's personal refrigerator, located in the medication administration room, on the 1st floor of the facility found 2 packs of sliced, soft, American, cheese. The cheese was not individually wrapped. One package was dated 1/29/17 with discard date of 2/5/16. The second package of cheese was dated 01/20/17 with a disca… | 2020-09-01 |
| 3284 | 3284 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 428 | D | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, medical record reviews, and review of the consultant pharmacist's recommendations, the facility failed to ensure the pharmacist's recommendations which were approved by the attending physician were acted upon. For Resident #43, the consultant pharmacist recommended Theophylline be given twice daily with meals to reduce gastrointestinal (GI) distress and the attending physician approved this recommendation, but nursing failed to implement the recommendation. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Recommendation. Resident identifier: #43. Facility census: 58. Findings include: a) Resident #43 A review of Resident #43's medical record, at 10:19 a.m. on 02/08/17, found the following a consultant pharmacist recommendation the attending physician agreed to follow on 08/18/16, Theophylline Extended Release (ER) one tablet by mouth twice daily with meals to reduce gastrointestinal (GI) distress Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing, at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. She confirmed the consultant pharmacist recommendation was agreed to by the attending physician on 08/18/16 and was not administered as directed. | 2020-09-01 |
| 3285 | 3285 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 431 | E | 0 | 1 | UXFJ11 | Based on observation, staff interview, and policy review, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. Two (2) multi-dose vials of insulin which belonged to Residents #77 and #27 were open and had no date, and/or legible date to indicate when the vials were initially opened. Use of medication from multi-dose vials open for a time period greater than recommended by the manufacturer had the potential to negatively impact the safety and/or potency of the medication. Observation of the first floor medication room refrigerator found it was not at the appropriate temperature. This had the potential to affect more than a limited number of residents. Resident identifiers: #77 and #27. Facility census: 58. Findings include: a) Resident #77 Observation on 02/07/17 at 9:07 a.m., found an opened, partially used, ten (10) milliliter (ml) vial of Humulin R insulin. The vial contained no date indicating when it was initially opened. Licensed practical nurse (LPN) #22 said nurses discard vials of Humulin-R insulin thirty (30) days after the date they are opened. She agreed the vial was not marked with the date it was initially used or opened . She discarded the opened vial, and obtained a new, unopened vial of Humulin-R insulin for this resident's use. During an interview with the director of nursing on 02/08/17 at 4:15 p.m., she said nursing staff are supposed to date all multi-dose vials of insulin when they are first opened. b) Resident #27 Observation on 02/08/17 at 4:15 p.m., found an opened, nearly empty, ten (10) ml vial of Levemir insulin. The vial contained an illegible inscription of the date when it was initially opened. The director of nursing (DON) was present at this time, and said she would dispose of this vial since it cannot be accurately determined when it was initially opened. She said nursing staff is supposed to date all multi-dose vials of insulin when they are first opened. She said the opened date on this vial was smudged and illegible. Sh… | 2020-09-01 |
| 3286 | 3286 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 441 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and manual for glucometer care, the facility failed to ensure an effective infection control program designed to prevent the development and/or transmission of disease and infection to the extent possible. Potential for cross-contamination was observed when nursing staff placed reusable patient care supplies directly onto residents' overbed trays without any type of barrier; nursing staff demonstrated improper cleaning and/or disinfection of a resident-shared glucometer after use; nursing staff touched inanimate objects in a resident's semi-private room without first removing disposable latex gloves previously used while cleaning an incontinent resident; nursing staff soaked washcloths in a resident sink prior to use for incontinence care. These practices had the potential to affect more than a limited number of residents on the first floor long hall, but most directly involved Residents #50, #95, #29. Resident identifiers: #50, #95, #29. Facility census: 58. Findings include: a) Resident #50 During observation on 02/07/17 at 7:22 a.m., licensed practical nurse (LPN) #22 placed a glucometer (small machine used to obtain blood glucose tests) directly onto this resident's overbed tray without the use of any type of barrier. After the test was completed, LPN #22 placed the glucometer directly onto the top of the medication cart. This act contaminated the top of the medication cart, which is where a nurse would pour medications for other residents. She then obtained a wipe from a canister and proceeded to wipe off the glucometer before returning the glucometer to the drawer of the medication cart. Observation of the canister found its only active ingredient was a seventy percent (70%) alcohol solution. She did not clean and/or disinfect the top of the medication cart where the glucometer had been placed. During interview with the director of nursing (DON) on 02/08/2017 9:06 a.m., she said there is no need to… | 2020-09-01 |
| 3287 | 3287 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 514 | E | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the medical record was complete and accurate for Resident #1 and Resident #43 . The medical record did not contain any documentation concerning the change in legal representative for Resident #1 and the delay completing the required process for making such a change. Resident #43 had a bleeding alert on his physician's orders [REDACTED]. However, the order for [MEDICATION NAME] was discontinued over one (1) year ago. Resident identifiers: #1 and #43. Facility census: 58. Findings include : a) Resident #1 A review of Resident #1's medical record at 1:00 p.m. on 02/07/17 found the resident was admitted to the facility in 2005. Upon her admission to the facility the sheriff of the previous county she resided in was her guardian and conservator. This appointment was made in 1988. This guardian remained in effect until 07/15/16 at which time the[NAME]County Department of Health and Human Resources (DHHR) was appointed to serve at the residents Health Care Surrogate (HCS). This HCS remained in effect until 12/15/16 when the physician appointed Resident #1's cousin to serve as her HCS. Further review of the appointment of the cousin to the position of HCS found the resident was notified of this on 10/19/16 at 3:30 p.m. and was happy the her cousin would be making her decisions, and gestured that she loves her cousin. The form however was not signed by the attending physician until 12/15/16 which is the date the form went into effect. A HCS cannot go into effect until the date the physician signs the form. At 2:15 p.m. on 02/07/17, the facility's Licensed Social Worker (LSW) was interviewed. When asked how the resident's cousin came to be her HCS she stated, (Name of Resident) was under an old committee and the Sheriff of (Name of neighboring county) was making her medical and financial decisions. She indicated, she had started looking into this and did not realize the resident h… | 2020-09-01 |
| 3288 | 3288 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 520 | F | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, review of water temperatures, staff interviews, and resident interviews, the quality assessment and assurance (QA & A) committee failed to identify and address quality deficiencies of which they were aware, or should have been aware. Deficient practices related to quality of life and quality of care were identified during the Quality Indicator Survey (QIS). The issues identified were results of systemic breakdowns in the manner in which the facility staff administered care and services to their residents. The issues had been ongoing for multiple months giving the QA & A committee ample time to identify and correct the deficient practices prior to its QIS survey which began on 02/06/17 and ended on 02/09/17. Quality of Life: The facility failed to maintain an environment which was clean, sanitary, and in good repair. Walls were marred and scratched, door frames and doors were rusted, floor tile was cracked, resident equipment was dirty and/or rusted, shower room floors were dirty, blinds were bent and broken, and facility floors in resident rooms and common areas were dirty. Quality of Care: The facility was notified on 02/08/17 at 6:22 p.m. of an immediate jeopardy (IJ) situation due to elevated water temperatures. It was noted the facility had been monitoring the water temperature and on 02/07/17 had the hot water shut off to room [ROOM NUMBER] and 105 for a period of time. However, on 02/08/17 at 2:21 p.m. the hot water temperature in room [ROOM NUMBER] was 144 degrees and was not turned off, not had the hot water been turned off to the front public restrooms which had also had elevated temperatures. Furthermore, the hot water tank and the mixing valve in question serviced the entire first floor of the facility and no other actions had been taken by the facility to ensure resident safety until the problem is resolved. These deficient practices had to potential to affect all residents resid… | 2020-09-01 |
| 3289 | 3289 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 550 | D | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to ensure Resident #32 was treated with dignity and respect. Nurse Aide #5 (NA), turned her back to the resident and made grumbling sounds and moved shoulders in a rotating motion twice. This was true for one (1) of sixteen (16) residents reviewed for dignity and respect. Resident identifier: #32. Facility census: 46. Findings included: a) Resident #32 An observation on 04/02/18 at 11:30 AM revealed Resident #32 requested a wet paper towel to wash her hands prior to eating her meal from NA #5. NA #5 turned her back on Resident #5 and made a Blaha sound while moving her shoulders in a rotating motion. Resident #32 asked NA #5 for additional paper towels to dry her hands. NA #5 again with back turned from this resident, made the Blaha sound and made rotating motions with her shoulders. Resident #32, who was hard of hearing, did not hear or see NA #5. During an interview on 04/02/18 at 1:59 PM, the Director of Nursing agreed NA #5's actions were disrespectful to Resident #32. | 2020-09-01 |
| 3290 | 3290 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 558 | E | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to provide services with reasonable accommodations for residents. A bathroom in the hallway near the activity room was available for resident use without a safety call light in working condition. This practice had the potential to affect more than a limited number of residents. Facility census: 46. Findings included: a) Observations on 04/04/18 at 10:50 AM, noted a resident using the bathroom near the activity room on the first floor. Observation of this bathroom found no pull string attached to the alarm which would alert staff to provide care if needed. At 3:33 PM on 04/04/18 Maintenance Staff #31 explained the bathroom was for staff and visitors, but was told not to disallow residents to use the bathroom. On 04/04/18 at 3:35 PM, the maintenance supervisor verbalized the residents did use that bathroom. The switch in which a pull string could be attached was tested by the maintenance supervisor and would not work. The bathroom door knob was replaced with a key entry to prevent residents from using the bathroom. | 2020-09-01 |
| 3291 | 3291 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 561 | D | 0 | 1 | NWDF11 | Based on observations, resident interview, staff interview, and record review, the facility failed to provide a resident with her diet of choice. This is true for one (1) of sixteen (16) residents reviewed. Resident identifier: #1. Facility census: 46. Findings include: a) Resident #1 During the initial tour on 04/02/18 at 11:55 AM, observation of Resident #1's lunch tray found it did not include cranberry juice. The tray ticket noted cranberry juice should be on the tray. Resident #1 stated she requested cranberry juice, but I don't often get it. Observation of the lunch tray on 04/03/18 at 12:15 PM, again revealed there was no cranberry juice on the resident's tray. Resident commented, I did have it Sunday. Again on 04/04/18 at 11:45 AM, Resident #1's lunch tray had no cranberry juice. The tray ticket also listed coffee as a request. Resident #1 stated she also did not get coffee on this date, and went on to state she does not make the facility aware of food that is not on her tray unless she does not have chicken noodle soup. On 04/04/18 at 3:10 PM, the dietary manager explained the trays had been checked by dietary staff as food was put on the trays and the cranberry juice should have been on the resident's lunch tray. | 2020-09-01 |
| 3292 | 3292 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 578 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, electronic record review, hard copy (paper) medical record review, and staff interview, the facility failed to ensure a resident's code status was accurate, available, consistent, and communicated to staff. Staff were unable to locate Resident #18 code status in the electronic medical record. In addition, staff found conflicting code statuses when reviewing the hard copy in the resident's medical record. This failed practice was true for one (1) 16 residents reviewed for code status. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 On 04/02/18 at 3:00 PM, a review of the electronic medical record (EMR) for Resident #18 revealed a DO NOT RESUSCITATE (DNR) order. An additional review of the paper medical record on 04/03/18 found conflicting orders for Resident #18's code status. The hard copy medical record was labeled to read FULL CODE. Continuing review of the both the EMR and hard copy medical record found the following: --State of West Virginia Medical Power of Attorney (MPOA) stated FULL CODE dated 08/14/1998 --the Physician order [REDACTED]. --the Face Sheet dated admitted : 08/27/13 (latest return) and 06/01/12 Current as a DNR; --admission orders [REDACTED] --physician's orders [REDACTED]. --physician's orders [REDACTED]. --admission orders [REDACTED] --Advanced Directives and code Status Report dated 4/2/18 stated DNR. During an interview on 04/04/18 at 2:00 PM, Nurse Aides (NAs) #46 and #84, and Licensed Practical Nurse (LPN) #72 were asked to demonstrate how to find a resident code status. NAs #46 and #84, and LPN #72, stated that staff were not informed of the code status during shift change, but were sure it was in the computer in the hallway. After searching for about 15 minutes, the NAs and LPN had to be shown were to find a resident's code status on the computer system. When asked to show the code status for Resident #18, they pointed to the screen for Resident #18 that show… | 2020-09-01 |
| 3293 | 3293 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 584 | E | 0 | 1 | NWDF11 | Based on observation, resident interview, and staff interview, the facility failed to maintain a comfortable and homelike environment for three (3) of sixteen (16) sampled residents. There were holes in the fitted sheet on Resident #21's bed. Residents #32 and #19 felt the water temperature during showers was too cool. Resident identifiers: #32, #19, and #21. Facility census: 46. Findings included: a) Resident #21 On 04/04/18 at 4:46 PM, an observation of the fitted sheet on Resident #21's bed revealed the sheet had holes. After showing the sheet to Nurse Aide (NA) #46 and NA #16, they changed the sheet. On 04/04/18 at 5:03 PM, an observation with Licensed Practical Nurse (LPN) #72 revealed the sheet NA #46 and NA #16 put on the bed also had holes. LPN #72 said the facility expected staff to discard linens with holes. b) Resident #19 On 04/02/18 at 4:02 PM, an interview with Resident #19 revealed she often got a shower where the water was too cold, and there did not ever seem be enough hot water. The resident said a nurse aid (could not remember the name) told her the maintenance said she was taking a shower at the wrong time of day because the kitchen used the water for dishes. The resident said the ombudsman even came into the facility and met with the administrator about the cold showers and other issues. When asked about the result of the meeting, the resident said, The administrator said that it takes too long for me to take a shower. I now have a designated time to take a shower, but sometimes the water still gets cold. c) Resident #32 During an interview on 04/02/18 at 11:34 AM, Resident #32 stated while getting a shower the water was too cold. On 04/02/18 at 01:40 PM, in Shower Room A, Nursing Aide (NA) #54 was assisting with checking water temperatures. NA #54 said, It takes a while for the water to heat up. After running the shower for 10 minutes, the water temperature for the left shower reached 96 degrees Fahrenheit (F) and the shower on the right reached 88 degrees F. On 04/02/18 at 1:55 PM, the Dire… | 2020-09-01 |
| 3294 | 3294 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 623 | D | 0 | 1 | NWDF11 | **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) resident who was discharged to the community received a discharge notice. Resident #40 left the faciity on therapeutic leave and did not return. The facility discharged him, but did not ensure he received a notice. This affected one (1) of two (2) residents reviewed for discharge notices. Resident identifier: #40. Facility census: 46. Findings included: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his cousins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daughter of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medications for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated, resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated, SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. During an interview with the Social Worker (SW), on 04/04/08 at 9:48 AM, SW said Resident #40 left t… | 2020-09-01 |
| 3295 | 3295 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 625 | D | 0 | 1 | NWDF11 | **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 left the building on therapeutic leave received written notice of the facility's bed-hold policy. Although the resident did not return to the facility, there was no evidence the facility attempted to provide its bed-hold policy to the resident. This was found for one (1) of one (1) resident reviewed for notice of the facility's bed-hold policy when going on therapeutic leave. Resident identifier: #40. Facility census: 46. Findings included: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his counsins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daughter of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medications for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated, resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated, SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. Dur… | 2020-09-01 |
| 3296 | 3296 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 641 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review, staff interview, policy review the facility failed to ensure accurate assessments were completed for one (1) of 16 residents. Resident #40's assessment did not have an accurate assessment related to discharge. Resident identifier: #40. Facility census: 46. Findings include: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his counsins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daught of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medicaitons for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. During an interview with the Social Worker (SW), on 04/04/08 at 9:48 AM, SW said Resident #40 left the faciity on [DATE] and did not return. The facility completed a prosepective payment system (PPS) 5 day Minimum Data Set (MDS) assessmen… | 2020-09-01 |
| 3297 | 3297 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 655 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement an accurate baseline care plan for Resident #98. The resident's baseline care plan did not include fall risk or care for a wound on the foot, both present at the time of admission. This was true for one (1) of sixteen (16) records reviewed. Resident identifier: #98. Facility census: 46. Findings included: a) Resident #98 Medical records review revealed Resident #98 was admitted to the facility on [DATE]. Review of discharge summary from the hospital where Resident #98 was treated prior to being admitted to the facility, revealed the reason for admission to the hospital was a subtrochanteric fracture (a [MEDICAL CONDITION] bone near the hip) of left hip on 03/03/18. Review of the baseline care plan, with a date of 03/16/18, was absent of any evidence Resident #98 had a risk for falls. physician's orders [REDACTED]. Review of nursing admission assessment with a date of 03/17/18 revealed Resident #98, .was admitted to (initials) Nursing after sustaining a fall in previous nursing home facility. The fall evaluation completed on admission also revealed a high fall risk. Fall risk was not included in the base line care plan. The nursing assessment dated [DATE] identified Resident #98 had a, blister like area on the left heel that has a protective dressing intact. The baseline care plan with a date of 03/16/18 did not include actual skin breakdown or treatment for [REDACTED]. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed indicating full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed, the resident's risk of falls and the wound observation on the nursing admission were not identified on the baseline care plan. | 2020-09-01 |
| 3298 | 3298 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 656 | D | 0 | 1 | NWDF11 | Based on record review and staff interview, the facility failed to develop a care plan for care of an indwelling catheter when Resident #18 returned to the facility with an indwelling catheter. This affected one (1) of sixteen (16) from the sample. Facility census: 46. Finding included: a) Resident #18 On 04/02/18 a record review revealed Resident #18 returned to the facility from a local hospital with an indwelling Foley catheter on 03/30/18. The indwelling catheter was not care planned at that time. On review of records on 04/03/18 a care plan was on record showed a date created on 04/03/18. The indwelling catheter was not care planned for four (4 ) days. On 04/02/18 at 4:30 PM, the Director of Nursing (DoN) was asked for a paper copy of the care plan. On 04/03/18 at 4:45 PM, DoN the DoN provided a paper copy of the resident's care plan. At that time, the DoN was informed no care plan was developed for the indwelling catheter until four (4) days after Resident #18 returned from the hospital. | 2020-09-01 |
| 3299 | 3299 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 677 | D | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to provide care and services to maintain good grooming/personal hygiene to one (1) randomly observed resident. Resident #12's fingernails were long and jagged. Several of the resident's fingernails also had a black/brown substance underneath them. Resident identifier: #12. Facility census: 46. Findings included: a) Resident #12 On 04/04/18 at 5:13 PM, an observation of Resident #40's nails revealed they were long, jagged, and had a brown/black substance underneath them. Licensed Practical Nurse (LPN) #72 observed Resident #40's nails on 04/04/18 at 5:20 PM and said she would trim and clean them. On 04/05/18 at 8:12 AM LPN #72 said it took her several times of going back to the resident, but she did get them trimmed and cleaned. On 04/05/18 at 11:00 AM, the administrator and director of nursing said the resident was resistant to care. His care plan revealed he did not like to be shaved and would often wear dirty clothing. The minimum data set (MDS) completed on 01/15/18 reflected the resident needed extensive assistance with personal hygiene. A review of the progress notes revealed a note dated 02/13/18 by Registered Nurse (RN) #43. The note stated the resident allowed his nails trimmed without difficulty, but did not want them cleaned. No further notes showed follow up attempts to clean the resident's nails. | 2020-09-01 |
| 3300 | 3300 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 686 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and staff interview, the facility failed to identify and provide care related to Pressure Ulcers. Resident #18 was found to have six (6) pressure ulcers, some of which may have developed in-house. In addition, the facility failed to provide care for an unstageable pressure ulcer for Resident #98 for three (3) days. These failed practices were true for two (2) of four (4) residents reviewed for pressure ulcers. Resident identifiers: #18 and #98. Facility census: 46. Findings included: a) Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 stated that Resident #18 was admitted on [DATE] and had no pressure ulcers in the past year. Registered Nurse (RN) #44 showed LPN #39 a nursing note stating that a pressure ulcer on the left heel 1/2018 was a deep tissue injury but had since healed. On 04/03/18 a review of the evi… | 2020-09-01 |
| 3301 | 3301 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 690 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observation and staff interview, the facility failed to provide care in accordance with its policy and physician orders, regarding securing an indwelling catheter. A random observation of Resident #18 noted no device to secure the resident's catheter was in place. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 Review of the facility's policy titled, Catheter Care, with a reviewed date of (MONTH) 207, found it included that a leg strap must be used to prevent accidental injury and/or removal. An observation of wound care for Resident #18 on 04/03/18 at 3:00 PM, found this resident had an indwelling urinary catheter (Foley catheter). Further observation revealed the catheter was not secured to prevent accidental removal or to reduce the risk of trauma. This was verified with Registered Nurse #44 and Licensed Practical Nurse #39, who agreed the resident should have a stabilization method for the catheter. The physician's orders [REDACTED]. | 2020-09-01 |
| 3302 | 3302 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 692 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to provide therapeutic diets in accordance with physician orders [REDACTED].#25. Both residents received foods that were not of the correct consistency. This was true for two (2) of seven (7) residents reviewed for the care area of Nutrition/Hydration Status. This practice had the potential to affect a limited number of residents. Resident identifiers: #22 and #25. Facility census: 46 Findings included: a) Resident #22 Review of records revealed Resident #22 had a [MEDICAL CONDITION] (TBI), was a quadriplegic (one affected with partial or complete paralysis of both the arms and legs), had [MEDICAL CONDITION] (an inability to comprehend and formulate language because of damage to specific brain regions). Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/19/18, at 09:58 AM on 04/05/18, revealed the resident's Brief Interview for Mental Status (BIMS) score was zero (0), indicating the resident was severely cognitively impaired. The resident was assessed as totally dependent with all activities of daily living (ADLs). Medical record review found Resident #22 had a swallowing disorder that was demonstrated by loss of liquids and solids from his mouth when eating or drinking, and coughing or choking during meals. The resident required a mechanically altered diet that required change in the texture of food and liquids (pureed food and thickened liquids). The physician's orders [REDACTED]. Diet order puree with honey thickened liquids. Observations on 04/03/18 at 11:49 AM, revealed a bowl of thin tomato soup on the resident's lunch tray. Nurse aide (NA) #34 was preparing to feed the resident his lunch. According to the resident's lunch ticket, the resident was to receive pureed vegetable soup honey consistency. When asked what was in the bowl sitting in front of the resident, NA#34 said it looked like toma… | 2020-09-01 |
| 3303 | 3303 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 710 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility Physician failed to evaluate and assess medical issues related to the residents skin status for one (1) of four (4) in the care area Pressure Ulcers. Resident identifier #18. Facility census 46. Findings included: a) Resident #18 Review of records revealed Resident #18 was readmitted on [DATE]. There was no mention or description of any pressure ulcers until 04/2/18. During an interview on 04/05/18 at 9:08 AM, Resident #18's physician he stated he had not looked at the pressure ulcers on Resident #18. He stated, that was on him, because he took the nurses' charting and notes at face value and failed to look at the resident himself. He also agreed that the nursing documentation was not consistent or accurate. The progress note he wrote on 04/04/18, reinforced his statement that he had not examined this resident himself. | 2020-09-01 |
| 3304 | 3304 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 726 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, staff interview, and family interview the facility failed to have nursing staff with the appropriate competencies and skills set to provide nursing and related services to attain or maintain the highest practicable physical mental and psychosocial well-being of each resident. Resident identifiers: #18 and #98. Facility census: 46. Findings included: a) Pressure ulcers Resident #18 was found to have six (6) pressure ulcers, some of which may have developed in-house. The facility failed to ensure Resident #18's pressure areas were assessed and when assessed, that they were assessed correctly and timely, and failed to implement timely interventions. The facility also failed to provide care for an unstageable pressure ulcer for Resident #98 for three (3) days. 1. Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 sta… | 2020-09-01 |
| 3305 | 3305 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 761 | E | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy and procedures review, the facility failed to adequately store and dispose of expired medications. Nine (9) oral medications and three (3) vials 0.9% Sodium Chloride Irrigation were not returned to the pharmacy and/or destroyed in a timely manner as per pharmacy policy and procedure. Additionally, the facility failed to ensure all prescription medications were labeled. This practice had the potential to affect more than an isolated number of residents. Findings includes: a) On 04/03/18 at 09:43 AM, Licensed Practical Nurses (LPNs) #39 and #42 were present during the inspection of the facility's medication room and the long hall medication cart. When asked, neither LPN could explain the facility's policy and/or process for identifying a medication's expiration date, or the record keeping and disposing of expired medications. The facility's stock medications included those labeled and dispensed by (name of pharmacy) as well as two (2) stock medications, which were not labeled. The medications dispensed by the pharmacy included the medication's expiration date on each label: 1. Therems-M (Multivitamin with iron and other minerals): expiration date 11/17/17 2. Vitamin C 500 mg: expiration date 01/23/18 3. [MEDICATION NAME] Coated ASA 81 mg: expiration date 11/17/17 4. Zinc Sulfate 200 mg (50 mg): expiration date 11/29/17 5. ASA 81 mg Chewable: expiration date 01/23/18 6. ASA 325 mg: expiration date 02/08/18 7. [MEDICATION NAME][MEDICATION NAME] 25 mg: expiration date 01/06/18 8. [MEDICATION NAME]-HC 25 mg suppositories: expiration date 04/2018 (no pharmacy label) 9. Fast Acting Mi-Acid Regular Strength Antacid/[MEDICATION NAME] Original: expiration 1/18 (January (YEAR)) 10. 0.9% Sodium Chloride Irrigation, USP 3 vials: expiration date 03/06/18 During the inspection of the medication cart, two (2) unlabeled medications, [MEDICATION NAME] 2.5 mcg (micrograms) (Opened 2/12/18) and [MEDICATION NAME] 160/4… | 2020-09-01 |
| 3306 | 3306 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 838 | E | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility assessment, medical record review and staff interview the facility failed to ensure they conducted a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. Nursing staff did not receive training that equipped them with the competencies necessary to provide the level of care needed by the residents. Resident #18 did not receive care and treatment necessary for the prevention of and treatment for [REDACTED].#18. Facility census: 46. Findings include: a) Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 stated that Resident #18 was admitted on [DATE] and had no pressure ulcers in the past year. Registered Nurse (RN) #44 showed LPN #39 a nursing note stating that a pressure ulcer on the left heel 1/2018 was a deep tissue injury but h… | 2020-09-01 |
| 3307 | 3307 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 842 | D | 0 | 1 | NWDF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, electronic record review, hard copy (paper) medical record review, and staff interview, the facility failed to ensure the accuracy of a resident's code status, and to ensure it was readily available, consistent, and communicated to staff. Staff were unable to locate Resident #18 code status in the electronic medical record. In addition, staff found conflicting code statuses when reviewing the hard copy of the medical record. This failed practice was true for one (1) of sixteen (16) residents reviewed for code status. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 On 04/02/18 at 3:00 PM, a review of the electronic medical record (EMR) for Resident #18 revealed a DO NOT RESUSCITATE (DNR) order. An additional review of the hard copy (paper) medical record conflicting orders were found on 04/3/18 for Resident #18's code status. The hard copy medical record was labeled to read FULL CODE. Continuing review of the both the EMR and hard copy medical record found the following: - State of West Virginia Medical Power of Attorney (MPOA) stated FULL CODE dated 08/14/1998 - the Physician order [REDACTED]. - the Face Sheet dated admitted : 08/27/13 (latest return) and 06/01/12 Current as a DNR; - admission orders [REDACTED] - physician's orders [REDACTED]. - physician's orders [REDACTED]. - admission orders [REDACTED] - Advanced Directives and code Status Report dated 4/2/18 stated DNR. During an interview on 04/04/18 at 2:00 PM, Nursing Aides (NAs) #46 and #84, and Licensed Practical Nurse (LPN) #72 were asked to demonstrate how to find a resident code status. The NAs and LPN stated that staff were not informed of the code status during shift change, but were sure it was in the computer in the hallway. After searching for about 15 minutes, the NAs and LPN had to be shown were to find a resident's code status on the computer system. When asked to show the code status for Resident #18, they pointed to… | 2020-09-01 |
| 3308 | 3308 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 880 | D | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of diseases and infection to the extent possible. During random observations, Resident #98's nasal cannula tubing was laying inside a garbage can and Resident #32's nebulizer mouthpiece was lying unprotected on the floor. Resident identifiers: #98 and #32. Facility census: 46. Findings included: a) Resident #98 Observations at 11:12 AM on 04/04/18 found Resident #98's nasal cannula tubing laying in a garbage can. The tubing was still attached to the oxygen concentrator and the was concentrator running. Nursing assistant #66 explained I was in a hurry, and put it in the garbage can because it had bowel movement on it. Because of being in a hurry the tubing was not detached from the oxygen concentrator. At 11:30 AM on 04/04/18, the director of nursing (DON) observed the tubing in the garbage can and agreed it should have been detached from the concentrator. b) Resident #32 An observation on 04/02/18 at 11:19 AM, revealed the resident's nebulizer mouth piece (used to administer breathing treatments) lying unprotected on the floor. This finding was verified with Nurse Aide #5 and Licensed Practical Nurse (LPN) #42. During an interview on 04/02/18 at 11:26 AM, LPN #42 agreed the nebulizer mouth piece should have been stored in a clean bag. | 2020-09-01 |
| 3309 | 3309 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2018-04-05 | 921 | E | 0 | 1 | NWDF11 | Based on observation and staff interview, the facility failed to provide a safe environment for residents. A container of disinfectant wipes were left unsecured on the back of a commode in shower room B. This practice has the potential to affect more than a limited number of residents. Facility census: 46. Findings included: a) At 11:55 AM on 04/02/18, during the initial tour of the facility, the unlocked shower room B was found to have a container of disinfectant wipes sitting on the commode tank. The safety data sheet (SDS) for this disinfectant included a warning about acute toxicity for eye contact and skin contact. Eye contact first aid should include, immediately flushing the eye with large amounts of water. Skin contact first aid includes immediately flush skin with plenty of water while removing clothing. At 3:00 PM on 04/02/18, the disinfectant wipes remained on the commode tank in shower room B and the facility administrator entered the room and removed the disinfectant wipes. At 9:00 AM on 04/05/18, the facility administrator agreed the disinfectant wipes should not have been in shower room B where residents had easy access. | 2020-09-01 |
| 3310 | 3310 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 574 | E | 0 | 1 | KGJN11 | Based on Resident Council meeting and observation, the facility failed to display the Resident Rights poster easily accessible to all residents wanting to review these rights. This was reported during the Resident Council meeting regarding the posters being too high for residents in wheelchairs to review. This had the potential to affect all residents wishing to review their Resident Rights from a seated position. Facility census: 57. Findings included: a) Resident Rights poster During a Resident Council meeting on 04/09/19 at 11:45 AM, this group of residents reported the Resident Rights poster located on the wall by the Dining Room and on 100 Hallway were too high for any residents in a wheel chair to be able to read. An observation on 04/09/19 at 12:15 PM of the Resident Rights posters located on the wall by the Dining Room and the 100 hallway could be lowered to be more accessible to any residents in a wheel chair. In an interview with the Interim Nursing Home Administrator on 04/09/19 at 12:45 PM, was informed of the Resident Council concern regarding the height of the Resident Rights poster being displayed too high for residents in a wheel chair to review. | 2020-09-01 |
| 3311 | 3311 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 600 | K | 0 | 1 | KGJN11 | Based on observation, record review, resident interview and staff interview, the facility failed to ensure Resident #33 was free from neglect. Resident #33 went 9 and 16 days without a shower. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #33. Facility census: 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. He stated he asked the Social Worker to please report her to the state. The resident said the Social Worker told him it would just be her word against his and would not do any good. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. A review of records revealed there was not a reportable completed by the facility for the allegation of verbal/mental abuse and neglect … | 2020-09-01 |
| 3312 | 3312 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 607 | E | 0 | 1 | KGJN12 | Based on record review, policy review and staff interview the facility failed to implement their Abuse Policy as it pertained to the reporting and investigating of allegations of abuse. This practice has the potential to effect all residents currently residing in the facility. Resident #13 on multiple occasions was sexually abusive toward six (6) different female residents. These allegations were not reported and/or investigated thoroughly as directed by the facility's policy. Resident identifiers: #13, #55, #40, #2, #25, #61 and #15. Facility census: 56 Findings Include: a) Resident #13 A review of the reportable incidents from 05/29/19 through current found an Immediate Fax Reporting of allegations - Nursing Home Program. This form was completed by the facility's social worker on 06/04/19 and faxed to the Office Health Facility Licensure and Certification (OHFLAC) on 06/04/19 at 1:25 p.m. The date of the incident was listed as 06/03/19 and the brief description of the incident read as follows, (First and Last name of Resident #13), resident at the (Name of facility), approached 3 female residents trying to rub his private area against them and put his penis in their mouth. Staff immediately intervened and diffused the situation. Review of the Five Day follow up form found the following under the section titled outcome/results of investigation: (First and Last name of Resident #13), resident at the (Name of Nursing Facility) approached 3 female resident trying to rub private area against them and put his penis in their mouth. Staff intervened immediately and diffused the situations. Families were notified of the incident. Under the section Corrective Action by the facility the following was noted, (First and Last name of Resident #13) was sent out of facility for psychiatric treatment/evaluation. Addressed behavior in care plan to avoid any further incidences. Resident will be assessed upon return for mental status and any further behaviors. A review of the investigation or this incident found only one statement… | 2020-09-01 |
| 3313 | 3313 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 609 | D | 0 | 1 | KGJN11 | Based on record review, resident interview and staff interview, the facility failed to report suspected abuse and neglect to the required state agencies. This failed practice had the potential to affect a limited number of residents. Resident identifier: #48. Facility census 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. He stated he asked the Social Worker to please report her to the state. The resident said the Social Worker told him it would just be her word against his and would not do any good. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. A review of records revealed there was not a reportable completed by the facility for the allegation of verbal/mental abuse and neglect to the required state agencies. During an… | 2020-09-01 |
| 3314 | 3314 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 610 | D | 0 | 1 | KGJN11 | Based on record review, resident interview and staff interview, the facility failed to investigate allegations of suspected abuse and neglect. Resident #48 reported an allegation of abuse and neglect and the facility failed to complete a thorough his was a random opportunity for discovery. Facility census 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. The Grievance and Concern form did not note any protections put into place to safeguard the resident from the alleged perpetrator. The form did not mention any information concerning an investigation. A review of records revealed there was not an investigation completed by the facility for the allegation of verbal/mental abuse… | 2020-09-01 |
| 3315 | 3315 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 641 | D | 0 | 1 | KGJN11 | **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 medium data set (MDS) assessment of one (1) of sixteen (16) MDS assessments reviewed during the investigation process of the survey. The Restraint section of the MDS assessment for R8 was not coded to include a wander/elopement alarm. Resident identifier: R9. Facility census: 57. Findings included: a) R9 During a medical record review on 04/08/19 of the comprehensive MDS assessment for R9 with an assessment reference date (ARD) of 01/14/19 revealed the section for Restraints and Alarms had not been coded to include the use of a wander/elopement alarm. Further review revealed a physician's orders [REDACTED]. In an interview on 04/09/19 at 11:15 AM with E74, registered nurse (RN) verified the MDS section for Restraints and Alarms did not include the wander/elopement alarm for R9. | 2020-09-01 |
| 3316 | 3316 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 655 | D | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure accurate completion of a 48 hour care plan for one (1) of one (1) resident reviewed for discharge planning. The Resident's 48 hour care plan failed to address the resident wanted to be discharged to the community. Resident identifier: #60. Facility census: 57. Findings included: a) Resident #60 Review of the medical record found the Resident was admitted to the facility on [DATE]. He was discharged to his home on 01/26/19. Review of the 48 hour baseline care plan noted the resident wished to remain in long term care. Record review found a progress note, completed by the social worker: 01/09/2019 01:14 PM This [AGE] year old white male resident is transferred to the care facility yesterday from (name of hospital). He is admitted for rehabilitation following a hospital stay. He is alert and able to verbalize needs and wants to staff. He is pleasant and interacts with staff without difficulty. He has good support from his brother and sister-in-law, with whom he lives. He reports that he often stays up until 12 or 1 am and chats with his brother and will get up around 9 or 10 am. He states his days consist of sitting around and watching TV and playing with the dog and cats. He says he usually only leaves the house for Medical appointments, and occasionally goes out to eat on those days with his brother, who transports him. He hopes to regain ability to walk and toilet himself and eventually return home with his brother. The social worker completed a discharge plan assessment on 01/09/19. The resident's short term goal was described as, To begin therapy and regain ability to walk and toilet self. The long term goal was, To return home with brother and community based services as indicated. At 4:06 PM on 04/09/19, the Registered Nurse care plan coordinator (RN) #74, acknowledged the resident's 48 hours care plan did not reflect the resident's desire to return home. In additio… | 2020-09-01 |
| 3317 | 3317 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 656 | E | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement and/or develop resident care plans. For Resident #12 and Resident #56 the facility failed to implement their Diabetes Mellitus (DM). For Resident #9 the facility failed to develop a care plan in area of behaviors. Finally, for Resident #54 the facility failed to implement the residents care plan in regards to a smoking cessation program. This was trued for four (4) of 21 care plans reviewed. Resident identifiers: #12, #56, #9 and #54. Facility census: 57. Findings included: a) Resident #12 A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: --Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. --Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44 a.m. blood sugar was 223. --10/31/18 - 5:34 p.m. blood sugar was 379. --11/02/18 - 5:52 p.m. blood sugar was 324. --11/05/18 - 9:09 p.m. blood sugar was 232. --11/12/18 - 5:54 a.m. blood sugar was 230. --11/12/18 - 8:00 p.m. blood sugar was 286… | 2020-09-01 |
| 3318 | 3318 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 657 | D | 0 | 1 | KGJN11 | Based on resident interview and staff interview, the facility failed to ensure Resident # 48 was in attendance and /or included in his care plan meeting. This true for one (1) of one (1) reviewed for care planning. Resident identifier: #48. Facility census: 57. Findings included: During an interview, on 04/08/19 at 12:05 PM, Resident #48 stated that he always attends his care planning meeting, but for whatever reason no one came to take him to his last meeting. He stated that he got up and ready, but they must have had it without him. He stated that the letter said it was schedule for 04/04/19. He received a letter requesting him to attend. During an interview on 04/08/19 at 12:17 PM, Registered Nurse (RN) #74 said, that they had his care plan meeting on 3/14/19 in his room. She further stated he did not attend the one held on 04/04/19. The RN stated she did not know he wanted to attend the one for last week. She stated that normally he does attend. She said it may have slipped though the cracks because they have a new Social Worker and she is not sure she knows how they do it yet. She also stated that they would reschedule one for next week for him. | 2020-09-01 |
| 3319 | 3319 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 677 | E | 0 | 1 | KGJN11 | Based on observation, resident interview, staff interview, facility policy and record review, the facility failed to provide a resident with necessary services to maintain grooming and personal hygiene. This was true for two (2) of three (3) residents reviewed in the care area of Activities of Daily Living (ADL). Resdient identifiers: #33 and #5. Facility census 57. Findings included: a) Resident #33 During an interview on 04/08/19 at 12:47 PM, Resident #33 stated that she went two weeks without a shower. Resident # 33 also stated that she did not refuse a shower during this time. A review of the shower log verified Resident # 33 did not receive a shower from 2/11/19 to 02/20/19 which was nine (9) days between showers, and she also did not receive a shower from 02/22/19 to 03/09/19 which was 16 days without a shower. During an interview on 04/10/19 at 12:34 PM, DoN verified the resident went nine (9) and then 16 days without a shower. Her response was, I thought you said a week not two weeks. No other shower records were provided before the end of the survey. b) Resident #5 During an observation of wound care on 04/10/19 at 2:08 PM, Licensed Practical Nurse (LPN) #55 and Nurse Aide (NA) #17 removed the adult brief on Resident #5 and revealed she had had a bowel movement. There was fecal matter on the front and back of this resident. Review of the facility policy titled, Perineal Care with revision date 2005 listed the following: The following equipment and supplies are necessary when performing this procedure: 1. Wash basin 2. Towels 3. Washcloths 4. Soap 5. Gloves --Place wash basin and supplies at bedside for easy access. --Fill the wash basin 1/2 full --For female residents wash perineal area from front to back --Separate the labia and wash area downward --Wash from inside to out including thighs --Do not reuse the same washcloth NA#17 left the room and returned with one wash cloth and one towel. She did not use a basin she wet the wash cloth in the sink and sprayed peri cleaner on the wash cloth. She smeared … | 2020-09-01 |
| 3320 | 3320 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 684 | K | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to administer Resident #12's and Resident #56's sliding scale insulin in accordance with the physician's orders [REDACTED].#12's blood sugar was recorded as 57. Resident #12 did not receive her sliding scale insulin coverage on 76 occasions when her blood sugar was in excess of 200 which required sliding scale coverage. This was during the time frame of 10/08/18 through current. Also on 01/25/19 the residents blood sugar was 57 and there was no evidence the facility implemented the hypoglycemic protocol. Resident #56 did not receive her sliding scale coverage on four (4) occasions when her blood sugar was in excess of 201 which required sliding scale coverage. This was from 02/09/19 through current. It was determined by the state agency (SA) that these failures place Resident #12 and Resident #56 at an immediate risk for serious harm and/or death placing Resident #12 and Resident #56 in an immediate jeopardy situation. At 12:30 p.m. on 04/09/19 the Nursing Home Administrator (NHA) and Director of Nursing (DON) was notified of the immediate jeopardy. The facility submitted a plan of correction (P[NAME]) at 1:29 p.m. on 04/09/19. The SA requested changes and new P[NAME] was submitted at 2:00 p.m The SA again requested changes and the final P[NAME] was submitted at 2:19 p.m. and was accepted by the SA at 2:27 p.m. The SA observed for implementation of the P[NAME] and determined it had been implemented. The IJ was abated at 4:50 p.m. on 04/09/19. This was true for two (2) of two (2) residents who receive sliding scale insulin coverage. After the IJ was abated a deficient practice remained therefore the scope and severity was decreased from a K to E. A deficient practice remained for Resid… | 2020-09-01 |
| 3321 | 3321 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 697 | D | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to provide appropriate pharmacological interventions in accordance with physician's orders [REDACTED]. Resident identifier: #27. Facility census: 57. Findings included: During initial resident screening on 04/08/19 at 12:49 PM, Resident #27 stated My tail bone hurts me when I am up in my wheelchair for a long time, and sometimes my neck hurts. I used to take Tylenol at home, and it helped. Not sure if I am getting it here. Resident has been deemed by the facilily's attending physician to have capacity to make her own decisions, and a Brief Interview for Mental Status (evaluation aimed at evaluating aspects of cognition in elderly patients) score of 15(highest score possible) out of 15 indicating intact cognitive response. Review of Medication Administration Record [REDACTED]. Progress note dated 03/01/19 by Registered Nurse (RN) #38 documented the following (typed as written): Resident up in bed watching TV. C/o (complain of) pain to right side of neck states she slept wrong. States there is a knot there. This nurse could not feel a knot in this area. Long LPN informed of need for pain medication. She states she [MEDICATION NAME] home to sleep and hasn't been sleeping well here. Will put on doctors board (observation book for facility's provider) . On 04/09/19 at 11:27 AM, review of med record revealed resident does not have any current pharmacological orders for pain. Resident's care plan was silent for pain managment interventions. On 04/09/19 at 4:45 PM Licensed Practical Nurse (LPN) #30 verified that the Resident (MONTH) #27 does not have an order for [REDACTED]. Review of medial record on 04/09/19 at 4:42 PM revealed progress note dated 03/01/19 entered by Registered Nurse (RN) #38 that documented the following (typed as written): Resident up in bed watching TV. C/o (complain of) pain to right side of neck states she slept wrong. States there… | 2020-09-01 |
| 3322 | 3322 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 730 | E | 0 | 1 | KGJN11 | Based on record review and staff interview, the facility failed to provide evidence of 12 contact hours for 3 of 5 sampled nurse aides. The facility failed to perform performace reviews for 3 of 5 sampled record reviews. Staff identifiers: #73, #69 and #52. Facility census 57. Findings included: a) NA #73 was hired on 09/20/10. Her records did not contain contact hours for inservice training done for (YEAR). The record provided no performance appraisal. b) NA #69 was hired on 09/12/17. Her record contained no inservice contact hours for (YEAR). The record contained no performance appraisal. c) NA #52 was hired on 06/05/18. Her record did not contain contact hours for inservice training done for (YEAR). The record contained no performance appraisal. d) During an interview, on 04/10/19 at 9:30 am, the Director of nursing (DON) stated she was unable to provide the contact hours for NA #73, #69 and #52. The DON stated she had been in the role of staff educator since the previous educator had left several weeks prior to the survey. The administrator was unable to provide explanation of the lack of performance appraisals. | 2020-09-01 |
| 3323 | 3323 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 732 | E | 0 | 1 | KGJN11 | Based on review of facility records assignment sheets, staff postings and timecards, the facility failed to provide accurate staff posting for 04/05/19 and 04/06/19. Facility census 57. Findings included: a) Review of staff posting for 04/05/19 for the 2:00 PM to 10:00 PM shift indicated 4 nurse aides worked. Review of time cards indicated 3 nurse aides worked the entire shift. During an interview, on 04/09/19 at 4:34 pm, the DON stated the staffing assignment sheets and time cards were accurate not the staff posting. b) Review of staff posting for 04/06/19 for the 6:00 AM to 2:00 PM indicated 3 nurse aides worked. Review of the time cards indicated 2 nurse aides left the building during the shift. The DON and administrator both confirmed with the timecards that one NA was in the building from 9:20 AM until 2:22 PM. Both the the DON and administrator were aware of the staffing issue on 04/06/19. | 2020-09-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );