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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 926 | 926 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2017-03-23 | 246 | D | 0 | 1 | 10BJ11 | Based on observation, staff interview and resident interview, the facility failed to ensure a resident received services with reasonable accommodation of their individual needs. This was true for one (1) of thirty five (35) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident #9, who was capable of using the call light, did not have access to their call light. Resident identifier: #9. Facility census: 77. Findings include: a) Resident #9 Observation of Resident #9, during stage one (1) of QIS, on 03/20/17 at 3:32 p.m., revealed the resident's call bell button cord tied to the bed's left side rail. The resident had contractures of the right upper and lower extremities. The resident had impaired mobility of her right arm (elbow and hand). When the resident was asked to push the call light button to see if the call system was functioning properly, the resident attempted to reach for it and was unable to reach the button. The resident said, I can't. The resident was then asked, What do you do when you can't reach the call bell and you need help with something? The resident replied, I just lay here. On 03/20/17 at 3:40 p.m., Nurse Aide (NA) #55 was outside of Resident #9's room in the hall. This surveyor requested NA#55 go into Resident #9's room to have the resident push her call light. NA #55 went in and asked Resident #9 to push her call light. Resident #9 said, I can't. I can't reach it. The resident demonstrated to NA #55 that she could not reach the button. NA#55 unfastened and lengthened the call bell cord so Resident #9 could reach and push the call bell button with her left hand. Interview with NA#55 confirmed Resident #9 could not reach the call bell button prior to NA#55 untying and moving the call bell cord, after surveyor intervention. Interview with DON, on 03/23/17 at 8:35 a.m., revealed the facility would get a call pad for Resident #9 to use, to make it easier for her to access the call system and to accommodate her needs. | 2020-09-01 |
| 927 | 927 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2017-03-23 | 253 | E | 0 | 1 | 10BJ11 | Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services to ensure a sanitary, orderly and comfortable interior for ten (10) of thirty (30) rooms observed during Stage 1 of the Quality Indicator Survey. The cosmetic imperfections included privacy curtains hanging loose from hooks, missing tile, damaged sink tops, torn padding on side rail, and a scrapped wall. Room identifiers: #103, #111, #112, #113, #210, #212, #214, #215, #313, and #314. Facility census: 77. Findings include: a) Cosmetic imperfections: - Room #103 observed on 03/20/17 at 3:59 p.m., had missing tile on the on the wall around the bathtub. - Room #111 observed on 03/21/17 at 10:45 a.m., had a discolored sink top. - Room #112 observed on 03/21/17 at 11:12 a.m., had scrapped walls and a missing sink skirt. - Room #113 observed on 03/21/17 at 10:56 a.m., had a porcelain chip in the sink. - Room #210 observed on 03/21/17 at 11:36 a.m., had privacy curtains hanging loose from the hooks. - Room #212 observed on 03/20/17 at 5:34 p.m., had privacy curtains hanging loose from the hooks. - Room #214 observed on 03/21/17 at 11:14 a.m., had privacy curtains hanging loose from the hooks. - Room #215 observed on 3/21/17 at 10:59 a.m., had privacy curtains hanging loose from the hooks. - Room #313 observed on 03/20/17 at 4:09 p. m., had molding pulled away from sink top, and the padding was torn on the side rail for bed B. - Room #314 was observed on 03/20/17 at 4:05 p.m., had molding missing from the side of the sink top. b) Interview with the Maintenance Supervisor During an interview on 03/22/17 at 9:35 a.m., the Maintenance Supervisor verified the privacy curtains should hang properly, the missing tile, damaged sink tops, torn side rail padding, and the scrapped wall all needed repaired or replaced. | 2020-09-01 |
| 928 | 928 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2017-03-23 | 371 | E | 0 | 1 | 10BJ11 | Based on observations and staff interviews, the facility failed to store foods in a sanitary manner and maintain clean kitchen equipment. The facility also failed to serve Resident #84's food under sanitary conditions. This practice had the potential to affect any resident receiving nourishment from the dietary kitchen and residents being served their food under sanitary conditions. Resident identifier: #84. Facility census: 77. Findings include: a) Kitchen tour During a tour of the kitchen, on 03/20/17 at 2:15 p.m., the following observations were made: --A ten (10) pound bag of fish filets, and a two (2) pound bag of biscuits in the walk-in freezer opened and not dated. --A 10 pound can of mandarin oranges had a two (2) inch dent to the rim and side of the can. The facility failed to ensure these food items were safe for consumption. --A three (3) shelf utility cart used for transferring food was found dirty with dried food particles on the third shelf and a brown colored build up on the handle and shelf supports. The facility failed to ensure the utility cart was sanitary for transporting and serving food. Interviews with the Dietary Manager and the Dietician on 03/20/17 at 2:45 p.m., verified the fish filets and biscuits were not dated after opening, the dented can of mandarin oranges should have been pulled from the rack and the utility cart was dirty and needed cleaned. b) Resident # 84 Observations of the evening meal on 03/20/17, found Resident #84 was served his meal at 5:41 p.m. by Quality Assurance Aide (QAA) #46. Resident #84's urinal, which contained urine, was sitting on his over the bed table. QAA #46 picked up the urinal and moved it to the side of the table, and then proceeded to sit Resident #84's evening meal on the over the bed table beside the urinal. He positioned the over the bed table in front of Resident #84 so that he would be able to eat his meal. QAA #46 then left the room and did not remove the residents urinal from his over the bed table. At 5:45 p.m. Licensed Practical Nurse (LPN) #… | 2020-09-01 |
| 929 | 929 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2018-05-16 | 641 | D | 0 | 1 | 6Z1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of eighteen (18) residents whose records were reviewed had an accurate and complete Minimum Data Set (MDS) which reflected the residents current status. Resident #43's MDS did not reflect the resident had a fall. Resident #70's MDS did not reflect the resident was receiving an antidepressant. Resident identifiers: #43 and #70. Facility census: 80. Findings included: a) Resident #43 Review of an incident/accident report, dated 03/05/18 found the, Resident stood up to pull up her pants and when she went to sit back down, she missed the potty chair and fell on to the floor on her bottom. An x-ray was obtained and no injuries were noted. Review of the MDS, completed after the fall on 03/05/18, a quarterly MDS, with an assessment reference date (ARD) of 03/27/18, coded the resident as having no falls since the last assessment. The last assessment was a significant change MDS with an ARD of 12/26/17. At 1:00 p.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the 03/05/18 MDS was incorrectly coded. At 1:20 p.m. on 05/15/18, the Director of Nursing (DON) was advised of the incorrectly coded MDS. She had no further information to present. b) Resident #70 Review of Resident #70's medical records found a physician order [REDACTED]. Review of the significant change MDS, with an assessment reference date (ARD) of 01/16/18, coded the resident received no antidepressants in the seven day look-back period. At 10:22 a.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the MDS with ARD of 01/16/18 was incorrectly coded. At 11:20 a.m. on 05/15/18, the Director of Nursing (DON) was advised of the incorrectly coded MDS. She had no further information to present. | 2020-09-01 |
| 930 | 930 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2018-05-16 | 656 | D | 0 | 1 | 6Z1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to develop a comprehensive person-centered care plan in the care areas of indwelling catheter and [MEDICAL CONDITION] medication. This was true for two (2) of 18 care plans reviewed. Resident identifiers: #50 and #70. The facility census was 80. Findings included: a) Resident #50 During an observation on 05/14/18 at 12:44 PM, it was noted Resident # 50 had a Foley Catheter and there was no strap securing it to her leg. An observation on 05/15/18 at 8:25 AM, with NA #51, confirmed there was no strap securing Resident #50's catheter to her leg. She was asked if there should be a strap securing the catheter to her leg to prevent injury. NA #51 said, I don't know I don't do that the nurses do. She stated, she would have the nurse to get one. During a review of the comprehensive care plan the only mention of a Foley Catheter was under the focus statement At Risk for Skin breakdown. Without any mention or direction for Foley Catheter care. During an interview on 05/15/18 at 12:36 PM, with RN #36, She agreed she should have care planned the Foley Catheter and would fix it right away. b) Resident #70 A review of Resident #70's medical records found a physician order [REDACTED]. A review of the comprehensive care plan found no mention of the use of an antidepressant. At 10:22 a.m. on 05/15/18, Registered Nurse (RN) #36 confirmed the care plan did not address the use of an antidepressant ([MEDICATION NAME]). | 2020-09-01 |
| 931 | 931 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2018-05-16 | 684 | D | 0 | 1 | 6Z1211 | Based on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Neurological checks were not performed after an unwitnessed fall for one (1) of two (2) residents reviewed for the care area of falls and accident hazards. Resident identifier: #27. Facility census: 80. Findings included: a) Resident #27 An incident report for Resident #27 on 5/10/18 at 1:07 PM stated the following: Incident Description: Was notified that resident was found in the floor on the safe floor mat with no injury when observed. Resident unable to give. The immediate action taken stated, Staff reports that resident was checked for injury and no injury found. Unknown if this was an intentional act due to uncontrollable squirming movements. Will consider a fall at this time due to resident unable to tell us why she was moving. The incident report stated there were no witnesses to the fall. The incident report was completed by Licensed Practical Nurse (LPN) #44. The medical record contained no evidence that neurological checks had been initiated for Resident #27 after her unwitnessed fall on 5/10/18. During an interview on 05/15/18 at 1:45 PM, LPN #44 confirmed Resident #27's fall on 5/10/18 had been unwitnessed. LPN #44 also confirmed neurological checks had not been initiated after the fall. She stated facility practice is to initiate neurological checks for residents who have experienced unwitnessed falls but this was not done for Resident #27 on 5/10/18. | 2020-09-01 |
| 932 | 932 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2018-05-16 | 690 | D | 0 | 1 | 6Z1211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure two (2) of two (2) residents reviewed with indwelling Foley catheters, had catheter tubing securely anchored to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. Resident identifiers: #33 and #50. Facility census: 80. Findings included: a) Resident #33. Review of the medical record found the resident was initially admitted to the facility on [DATE] with an indwelling Foley catheter for a [DIAGNOSES REDACTED]. Observation of the resident at 1:03 p.m. on 05/14/17, revealed the resident was lying in bed. The catheter tubing was running along side the bed into the catheter bag which was hooked to the bed frame. Observation of the resident with the Director on Nursing (DON) at 8:15 a.m. on 05/15/18, confirmed the catheter tubing was not properly secured to prevent removal or tissue injury from dislodging the catheter. b) Resident #50 An observation on 05/14/18 at 12:44 PM, found Resident #50 had a Foley Catheter and there was nothing securing the catheter tubing to her leg. An observation on 05/15/18 at 8:25 AM, with NA #51, confirmed there was nothing securing the catheter to Resident #50's leg. She was asked if the catheter tubing should be secured to Resident #50's leg to prevent injury. She said, I don't know, I don't do that the nurses do. NA #51 stated, she would have a nurse to get one. During an interview with Director of Nursing (DON) on 05/15/18 at 9:07 AM, she was informed about the findings. She indicated she would take care of it. c) Facility Policy A review of the Facility Policy, FOLEY CATHETER CARE dated, 07/2008. Found no mention of the use of any type of an anchoring device to secure the catheter from being pulled or tugged which could cause injury. An interview with the Administrator and the DON was conducted on 05/15/18 at 2:05 PM, in regards to the Policy not containing anything about the use of a secure de… | 2020-09-01 |
| 933 | 933 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2018-05-16 | 812 | E | 0 | 1 | 6Z1211 | Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food safety. Food items in the 400 hallway lounge refrigerator, night pantry cupboard, and the Activities Department refrigerator were not dated when they were opened. Additionally, two items in the activities department refrigerator were past their sell-by date. This failed practice had the potential to affect more than a limited amount of residents. Facility census: 80. Findings included: a) Kitchen On 05/15/18 at 12:52 PM, observations were made of the refrigerator located in the lounge at the end of the 400 hallway. The surveyor was accompanied by the Dietary Manager. The refrigerator was locked. According to the Dietary Manager, the items in the refrigerator were used by the Activities Department staff for resident activities. Upon observation, the following items in the refrigerator had been opened but not dated when opened: - Bottle of Worcestershire sauce - Bottle of lemon juice - Bottle of peach flavored malt beverage - Tub of margarita salt The Dietary Manager confirmed these items in the 400 hall lounge refrigerator had not been dated when opened. She stated the items should have been dated when opened according to facility policy. The Dietary Manager discarded the items. On 05/15/18 at 1:00 PM, observations were made of the night pantry. The surveyor was accompanied by the Dietary Manager. The night pantry was in a locked room. According to the Dietary Manager, the refrigerator was used to obtain food for residents when the kitchen was not open. Food brought in by residents' families was also kept in the night pantry refrigerator. Upon observation, the following items located in a cupboard in the night pantry had been opened but not dated when opened: - Tub of peanut butter - Loaf of bread The Dietary Manager confirmed these items in the night pantry cupboard had not been dated when opened. She stated the items should have been dated when opened according to facility policy. The Di… | 2020-09-01 |
| 934 | 934 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 625 | D | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to provide the second notice for the Bed Hold Policy to the resident representative via in writing or verbally within 24 hours of discharge to an acute care hospital. This was true for one (1) of three (3) residents reviewed for hospitalization s during the survey process. The resident representatives did not receive the Bed Hold notices timely in writing or verbally when R48 was transferred to the hospital. Resident identifiers: R48. Facility censes: 75. Findings included: a) R48 A medical record review for R48 on 05/13/19 revealed the second Bed Hold Notice had not been provided to the resident representative in writing or verbally within 24 hours when R48 was transferred to the hospital on [DATE]. In an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 05/13/19 at 10:30 AM verified R48's resident representative did not receive the second Bed Hold notice in writing or verbally when he was transferred to the hospital. | 2020-09-01 |
| 935 | 935 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 656 | D | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to develop a care plan for a [MEDICAL TREATMENT] resident with interventions addressing complications related to [MEDICAL TREATMENT], pre and/or post [MEDICAL TREATMENT] assessments, blood pressure parameters, and post [MEDICAL TREATMENT] treatment care upon return to the facility from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. An interview with the resident, on 05/14/19 at 09:39 AM, revealed the staff rarely ever takes her blood pressure or ask her anything specific when she returns to the facility from the [MEDICAL TREATMENT] center. R#32 said, They take my blood pressure in the mornings, most of the time. The residents stated the ambulance people that take her helps her back into the bed, and sometimes the nurse comes in and talks to the ambulance people. The resident said she comes back from the [MEDICAL TREATMENT] center with a dressing over her AV access and it is left on till the next day, and sometimes a nurse will look at it when she gets back from [MEDICAL TREATMENT]. An interview with licensed… | 2020-09-01 |
| 936 | 936 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 657 | D | 0 | 1 | 06KF11 | Based on medical record review, care plan review and staff interview, the facility failed to revise Resident #60's care plan to reflect the date of a pacemaker check had been rescheduled. This was found during a random review of the medical record for one of one reviewed for pacemaker care. Resident identifier: 60. Facility census: 75. Findings included: a) A review of the care plan in the medical record for resident #60 revealed the resident did have a pacemaker. The care plan showed a pace maker check was to be completed in April. There was no evidence that a pacemaker check had been done at that time. Discussion with the director of nursing on 5/15/19 in the afternoon verified that she could not find any documentation showing a pacemaker check. She then had nursing staff search for any information regarding the check. Nursing staff did submit evidence later that a pacemaker check had been completed in (MONTH) and at that time was rescheduled for six months which would be July. A new appointment was set for (MONTH) 26, 2019. The change in the appointment date was not changed on the care plan. The current care plan still stated pacemaker check for April, 2019. | 2020-09-01 |
| 937 | 937 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 684 | D | 0 | 1 | 06KF11 | Based on observation, record review, resident interview, and staff interview the facility failed to ensure resident #74 received an accurate skin assessment reflecting the status of the resident's skin. This was true for one of one resident reviewed for skin conditions (non-pressure). This practice has the potential to affect a limited number of residents. Resident identifiers: R#74 . Facility census: 75. Findings included: a) Resident #74 Observations, on 05/13/19 at 3:35 PM, revealed R#74 had a noticeable asymmetric uneven black brownish area of discoloration, almost the size of a dime, with blurred irregular edges on his left cheek. The area on the resident's cheek had the appearance of a flat irregular mole. Also observed was a large area on the residence right lower forearm of faintly reddish pink discoloration. Review of records, on 05/16/19 at 09:58 AM, revealed neither areas were documented on any skin assessments. On 05/16/19 10:08 AM interview and review of records with Assistant Director of Nurses (ADON #50) revealed both skin areas were not documented on the nursing assessments, neither on the admission assessment or any following assessments as they should have been. The ADON acknowledged the areas were present on the resident and should be evaluated. ADON#50 requested the physician to evaluate the skin areas, as the physician was making rounds that day and resident is on list to be seen. An interview with the resident, on 05/16/19 at 10:55 AM, revealed he has always had the moles they had not newly developed but the one on his cheek had changed a little. | 2020-09-01 |
| 938 | 938 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 698 | D | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to consistently perform pre and post [MEDICAL TREATMENT] resident assessments, before going and/or returning from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: a) Resident #32 Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. Review of the [MEDICAL TREATMENT] communication form, on 05/14/19 at 10:45 AM, show the following information was to be provided on the form by the facility before resident went for [MEDICAL TREATMENT] treatment: Resident's name; date; transported by; condition before leaving facility (Lines to write a narrative about the resident's condition); vital signs before [MEDICAL TREATMENT] (blood pressure, pulse, respirations, and temperature); received meal; and sent snack with resident. Information the [MEDICAL TREATMENT] center was to provide on the communication form was as follows: weight before; weight after; date of physicians visits at [MEDICAL TREATMENT]; labs drawn at [MEDICAL TREATMENT]; problems at [MEDICAL TREATMENT]; medications given; new orders; and vital signs before leaving [MEDICAL TREATMENT]. Review of the past month's [ME… | 2020-09-01 |
| 939 | 939 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 812 | E | 0 | 1 | 06KF11 | Based on observation and staff interviews, the facility failed to ensure foods were handled in a manner that promoted safe sanitation techniques. Foods were found stored incorrectly, and staff used the same gloves to handle food and non-food items This practice has the potential to affect more than a limited number of residents who are served from this central location. Facility census: 75. Findings included:a) During the initial tour of the dietary department at 11:00 a.m on 5/13/19 at lunch revealed the following issues. The dietary manager was present at the time of the observations. 1. Sugar was stored with the scoop being in direct contact with the product. Scoops are to be stored in a manner that the serving portion is not in contact with the product. 2. A styrofoam cup was stored directly in a plastic container in the product. The dietary manager identified it as thickened. This also should have the device used to scoop the item from the container not be in direct contact with the product itself. 3 A dietary staff member was noted to be handling fried green tomatoes with her gloved hand. The staff was also seen touching non-food items with those same gloves. This practice could lead to possible cross contamination of the foods. | 2020-09-01 |
| 940 | 940 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 923 | E | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, resident family interview, and staff interview the facility failed to ensure adequate ventilation in a communal resident television lounge room, adjoining hallways, and in nearby resident's room as evidenced by the strong cigarette smoke odor lingering in the facility during and after the resident's smoke breaks. This practice has the potential to affect more than a limited number of residents and more than a limited area is affected. Resident identifiers: R#14 and R#28. Facility census: 75. Findings included: a) Resident #14 and #28 On 05/13/19 at 11:22 AM, this surveyor was walking in the hallway between the two nurses' stations, when encountering an overwhelming strong smell of cigarette smoke. The Assistant Director of Nurses (ADON #50) appeared in the hallway coming from the communal television, the surveyor asked ADON #50 if they allowed the residents to smoke inside the building. ADON #50 replied, No they have to go outside to smoke. Looking through the television lounge doorway, observations revealed three (3) residents in wheelchairs right outside the door smoking in the courtyard and two (2) more residents in wheelchairs in the television lounge opening the door trying to go through the doorway to the outside. Interview with Resident (R#28)'s daughter, on 05/13/19 at 11:26 AM, revealed during the interview the daughter requested to stop the interview long enough for her to get up and close the resident's door to the room. The daughter stated, It must be time for the smokers to start smoking, the only way we can deal with it is if I close the door and turn on the exhaust fan in the bathroom. It helps some. The daughter said the facility took good care of her mother the only issue she has is the smoke smell that comes into the room. When asked if she ever told anyone about the smoke smell, the daughter stated it's been a while ago when a maintenance man came in the room change a filter in the … | 2020-09-01 |
| 4786 | 4786 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 223 | D | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, Centers for Disease Control and Prevention interview, State Epidemiology interview, and policy review the facility did not ensure one (1) of nine (9) residents, reviewed for abuse allegations in Stage 2 of the quality indicator survey (QIS), was free of abuse. Resident #14 was involuntarily secluded due to a history of a multi-drug resistant organism. Resident identifier: #14. Facility census: 81. Findings include: a) Resident #14 During a Stage 1 interview, on 01/11/16 at 12:55 p.m., Resident #14 related he only participated in activities in his room. The resident related he was told he had an infection and could not go outside of his room for activities. A physician's orders [REDACTED]. Review of the care plan, on 01/12/16, at 4:00 p.m. revealed a focus, initiated on 06/19/14 related to isolation precautions due to Resident #14 had a history of [REDACTED]. Interventions indicated gloves would be worn upon entry of the room, and other PPE (personal protective equipment) would only be required if substantial contact with resident expected. The Carbapenem Resistant [MEDICATION NAME] (CRE) policy, reviewed on 01/12/16 at 2:59 p.m., revealed the purpose was to prevent transmission ., and to ensure compliance with federal and state regulations .according to centers for disease control (CDC) guidelines. The policy also indicated isolation would be discontinued after completion of antibiotic therapy, then in thirty (30) days if three (3) consecutive cultures obtained from the source of infection were negative, unless otherwise advised the isolation would remain discontinued. An interview with the infection control preventionist, Licensed Practical Nurse (LPN #106), on 01/13/16 at 10:02 a.m., revealed she utilized the CRE toolkit and the CDC had been contacted when Resident #14 was admitted to the facility. The nurse related one infectious disease specialist indicated the resident … | 2019-07-01 |
| 4787 | 4787 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 225 | F | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, medical record review, policy review, reive of personnel records, and the Affordable Care Act, the facility failed to ensuer they screened one (1) of ten (10) employees by not ensuring they completed crominal background checks. Additionally, they failed to throughly investigate and report allegations of abuse/neglect for three 93) of nine (9) residents reviewed for abuse and neglect. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related that he felt like staff did not want to come to his room at times. He related he believed he had been vervbally abused. The resident related the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionall, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practice nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty 930) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Resident #48 related he told Social Worker (SW #76). The minimum datea set (MDS) with an assessment reference date (ARD) of 10/20/15, reviewed on 01/14/5 at 8:08 a.m., revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #48 was cognitively intact. The highest attainable score was 15. Further review revealed he was totally dependent upon staff for bed mobility, transfer, toileting, personal hygiene and bathing. Concern/complaint/grievance forms, and reportable allegations, reviewed on 01/13/15, revealed no evidence the facaility had filed/reported an allegation … | 2019-07-01 |
| 4788 | 4788 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 226 | F | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, policy review and review of the Affordable Care Act (ACA) guidelines, the facility failed to operationalize abuse/neglect policies and procedures for screening, training, identification, prevention, and investigating allegations of abuse and neglect for three (3) of nine (9) residents reviewed. The facility failed to thoroughly investigate allegations of neglect for Resident #77. The facility failed to identify an allegation of neglect and protect a resident after an allegation of neglect was made by Resident #48. The facility failed to ensure Resident #14 was free from abuse. Resident #14 was involuntarily secluded from other residents and activities. The facility failed to report an allegation of neglect to State agencies for Resident #106. In addition, they failed to operationalize screening policies and procedures to ensure completion of a fingerprint based criminal background check for one (1) of ten (10) employee personnel files reviewed. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #14, #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related he felt like staff did not want to come to his room at times. He related he believed he had been verbally abused. The resident said the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionally, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practical nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty (30) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Residen… | 2019-07-01 |
| 4789 | 4789 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 246 | D | 0 | 1 | V5RK11 | Based on observation, resident interviews, and staff interview, the facility failed to provide reasonable accommodations for one (1) of thirty-five (35) Stage 1 sample residents. Resident #48 was unable to access the pull cord for the over-bed lights. Resident identifier: #48. Facility census: 81. Findings include: a) Resident #48 During Stage 1 room observations for Resident #48, on 01/11/16 at 1:58 p.m., the resident reported he was unable to reach the pull cord for his over-bed light. The pull cord enabled him to turn on his light. Observations at this time revealed the pull cord for the over-bed light was too short for the resident to reach. The observation of the light cord being too short for Resident #48 was discussed with the Director of Maintenance on 01/21/16 at 10:05 a.m. He stated the resident needed to be able to turn his light on. | 2019-07-01 |
| 4790 | 4790 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 253 | E | 0 | 1 | V5RK11 | Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior for eight (8) of twenty nine (29) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). Rooms 104, 305 and 306 had sink tops with rough edges and a white film around the sinks. Rooms 102 and 203 had furniture with damage. Room 204 needed a longer pull cord for the over- bed light and Rooms 300 and 100 had an unpainted bathroom door and cove base pulled away from the wall. This had the potential to affect more than an isolated number of residents. Room identifiers: #100, #102, #104, #203, #204, #300, #305 and #306. Facility census: 81. Findings include: a) Sink tops --Room #104 was observed, on 01/11/16 at 12:47 p.m., to have white film on the sink top. --Room #305 was observed, on 01/12/16 at 9:55 a.m., to have rough edges on the front of the sink base and a white film around the sink. --Room #306 was observed, on 01/12/16 at 8:30 a.m., to have rough edges on the front of the sink base and a white film around the sink. b) Furniture --Room #102 was observed, on 01/11/16 at 1:09 p.m., to have a night stand with missing veneer. --Room #203 was observed, on 01/11/16 at 12:13 p.m. Room #203 had a four (4) drawer chest with missing veneer and drawers that were not closing properly. c) Light pull cord --Room #204 was observed, on 01/11/16 1:58 p.m., to have a short over-bed light pull cord. d) Door and cove base --Room #300 was observed, on 01/12/16 at 9:01 a.m., to have a bathroom door with unpainted areas. --Room #100 was observed, on 01/11/16 at 12:47 p.m. Room #100 had cove base pulling away from the wall. During an interview with the Maintenance Director on 01/21/16 at 9:45 a.m., agreed the sink tops, furniture, light pull cord, bathroom door and cove base all needed repaired. | 2019-07-01 |
| 4791 | 4791 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 278 | D | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the quarterly minimum data set (MDS) assessment accurately reflected the [DIAGNOSES REDACTED].#3 and #47. Section I - Active [DIAGNOSES REDACTED]. Resident identifiers: #3 and #47. Facility census: 81. Findings include: a) Resident #3 A review of the medical record, for Resident #3 on 01/13/16 at 7:50 a.m., revealed the quarterly MDS assessment with the assessment reference date (ARD) of 10/15/15 did not accurately reflect a [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#3 had an order for [REDACTED]. An interview on 01/13/15 at 8:22 a.m., with Registered Nurse (RN) #86, the RN verified Section I - Active [DIAGNOSES REDACTED].#3. b) Resident #47 The MDS assessment review for Resident #47 on 01/19/16 at 11:00 a.m. revealed an MDS with the assessment reference date of 12/26/15. The 14 day PPS MDS Minimum Data Set Assessmt (MDS) with the assessment reference date (ARD) of 12/26/15 indicated the assessment did not include the [DIAGNOSES REDACTED]. Review of the MDS significant change with ARD of 12/15/15 did indicate the resident had a [DIAGNOSES REDACTED]. This [DIAGNOSES REDACTED]. Discussion with the MDS Coordinator on 01/19 /16 at 10:15 a.m. revealed the [DIAGNOSES REDACTED]. Current physician's orders [REDACTED]. | 2019-07-01 |
| 4792 | 4792 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 279 | E | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview it was determined the facility had not included goals for advanced directive specifics or end of life care on resident care plans. This would ensure staff members would provide treatment in accordance with resident wishes. This included seven (7) of seven (7) residents in the Stage 2 sample which were reviewed for advanced directives. Resident identifiers: #17, #95, #42, #100, #3, #98, and #29. Facility census: 81. Findings include: a) Resident #17 Review of the medical record, 01/19/16 at 10:00 a.m., for this resident revealed there were orders for comfort measures only. The current care plan did not address the resident's advanced directives. The Physician order [REDACTED]. The resident's advance directives and specific wishes for end of life were not identified in the care plan. An interview with Registered Nurse (RN) #86 on 01/20/16 at 9:30 a.m revealed that they had not been placing he advanced directive issues as part of the care plan. b) Resident #95 A review of the medical record, on 01/20/16 at 10:30 a.m., revealed the resident had orders for Do Not Resuscitation. The care plan did not include any specifics regarding the advanced directives. The POST form dated 08/24/15 had Do Not Resuscitation indicated. Other directives were IV fluids long term if needed and feeding tube long term. These were not in the current care plan to ensure the staff would implement the resident's wishes. Discussion with nursing staff as listed above. in example a. c) Resident #42 Review of Resident #42's medical record, on 01/20/16 at 10:30 a.m., showed the resident had a POST form, which indicated the following directives should be implemented per his wishes: The POST form revealed that he wanted full measures taken, IV for long term and no tube feeding. However, the care plan stated comfort measures were to be implemented. These directives were not in the current care plan. RN #86 was interviewed on 01/2… | 2019-07-01 |
| 4793 | 4793 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 309 | D | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental or psychosocial well-being for one (1) of five (5) residents reviewed for unnecessary medications. The facility failed to adequately assess and monitor a resident who experienced an exacerbation of [MEDICAL CONDITIONS]. Resident identifier: 96. Facility census: 81. Findings include: a) Resident #96 During a Stage 1 interview, on 01/11/16 at 1:10 p.m., Resident #96 expressed he utilized an inhaler for shortness of breath. The resident related, I had to give my inhaler up. When you need it, you just smother. Here you have to ask for it .I don't (do not) like it at all. Sometimes I go up there and there is no one at the desk at all, and I smother and am uncomfortable, and it makes me mad. I am not mental. Upon inquiry, the resident related he had not discussed it with the physician, but I talk to the nurse all the time. They can't (cannot) do anything unless he tells them. Don't (Does not) make sense to me. Sometimes I go out there and there is two (2) of them, and they are busy doing other things and had to wait. The resident related he always had one on me, wherever I went, I had it, but they took it away from me here. The resident related he had been in the facility about two (2) months. Another interview with Resident #96, on 01/13/16 at 8:31 a.m., revealed his status as I'm (I am) fair. I'd (I would) say I am fair. The resident further added, I just can't (cannot) seem to connect here. The resident related he would go to the hospital, and sometimes had to wait a long time, but would sit and converse with other men. The resident said he was able to talk about his feelings and they would give him nerve pills. The resident related he was unsure of what the facility administered him, but indicated he used inhalers and took a blood thinner medication… | 2019-07-01 |
| 5809 | 5809 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2014-10-22 | 253 | D | 0 | 1 | CW7M11 | Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services to ensure a sanitary, orderly and comfortable interior. Furniture in resident rooms was in need of repair. Bathrooms had scraped doors, missing tiles around the commode, and a sink front needed repair and new caulking. This had the potential to affect more than an isolated number of residents. Facility Census: 78 Findings include: a) Furniture -- Room #100 On 10/15/14 at 9:40 a.m. an observation of Room 100 revealed the wardrobe drawer was missing a knob. -- Room #305 At 10:18 a.m., on 10/15/14, an observation of Room 305 revealed the wardrobe doors were sprung and would not close properly. The bathroom doors and door facings needed painted and there were cracked floor tiles. -- Room #109 At 2:39 p.m., on 10/14/14, an observation of Room 109 revealed the bathroom door had the finish scraped off down to the bare wood. -- Room #309 On 10/15/14, at 10:27 a.m., an observation of Room 309 revealed the bathroom door had the finish scraped off down to the bare wood. -- Room #311 At 9:57 a.m., an observation of Room 311 revealed the bathroom door had the finish scraped off down to the bare wood. -- Room #315 At 4:20 p.m., on 10/14/14, an observation of Room 315 revealed the bathroom door had been damaged and the wood veneer was splintered. -- Room #111 An observation of Room 111 on 10/15/14 at 10:00 a.m. revealed the bathroom door facings had the paint scraped off and the wood was exposed. -- Room #109 On 10/14/14, at 2:39 p.m., an observation of Room 109 revealed the tile around the commode was cracked and separated. c) Vanity sinks -- Room #109 At 2:39 p.m. on 10/14/14 an observation of the vanity sink in Room 109 revealed the front of the sink had a large piece of Formica missing, exposing an unfinished surface. -- Room #105 At 4:14 p.m., on 10/14/14, observation revealed Room 105 had stained caulking around the vanity sinks. The caulking needed replaced. -- Room #315 An observation of the vanity sink in Room… | 2018-07-01 |
| 5810 | 5810 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2014-10-22 | 314 | D | 0 | 1 | CW7M11 | Based on observation, staff interview, Lipincott Nursing Procedure review, and policy review, the facility failed to ensure a resident received the necessary care and services to promote healing and prevent infection. Staff utilized improper technique when cleansing pressure ulcer wounds creating a potential for introducing microorganisms into the resident's wounds. This was found for one (1) of one (1) resident observed with pressure ulcers. Resident identifier: #59. Facility census: 78. Findings include: a) Resident #59 During an observation of wound care, on 10/21/14 at 6:30 a.m., Employee #84, a licensed practical nurse (LPN), completed wound dressing treatments to five (5) pressure ulcer wounds for Resident #59. The nurse first changed the dressing to the left heel. The nurse poured saline over gauze and then dabbed the whole wound bed with the same gauze. She rolled the resident to his left side. Observation revealed the dressing to the right buttock was not intact, and the resident had defecated (bowel movement). When cleaning the wound bed, the LPN cleansed the wound from the center to the outer aspect of the wound bed, wiped the peri wound area, then dabbed the wound bed again with the same gauze. The nurse washed her hands, before applying the clean dressing. Upon inquiry, she related the technique for cleaning wounds included cleaning from the inner to the outer part of the wound. With further inquiry, she related the way she cleansed the wounds posed a potential for cross contamination. She related organisms from the skin could be transmitted to the wound causing infection and delayed healing. Review of the wound care policy, on 10/21/14 at 1:30 p.m., indicated staff cleanse the wound with solution, cleaning area inside out. An interview with the director of nursing, on 10/21/14 at 4:30 p.m., revealed Employee #84 had spoken with her and related she had utilized improper technique. The director of nursing concurred the improper technique created a potential for contamination of the wound bed and did n… | 2018-07-01 |
| 5811 | 5811 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2014-10-22 | 371 | E | 0 | 1 | CW7M11 | Based on observation and staff interview, the facility failed to store foods in the nutrition pantry in a manner to prevent the potential for foodborne illnesses. Uncovered food was stored in the refrigerator in the nutrition pantry. This practice had the potential to affect more than an isolated number of residents. Facility census: 78. Findings include: a) During the initial tour of the facility on 10/07/14 at 1:50 p.m., the nutrition pantry located in the hallway between the east and west wings of the facility was observed. Employee #85, a nursing assistant (NA), unlocked the door of the nutrition pantry. Observation of the contents of the refrigerator, with the NA, revealed an uncovered container of a moist pink substance on the second shelf. The nursing assistant did not know the contents of the uncovered container. At 1:54 p.m., the Director of Nursing (DON) came into the nutrition pantry. The DON agreed the facility had not stored the food in the proper manner. The DON identified the food item as ham salad and said she would find out who made the last ham salad sandwich. The DON discarded the ham salad at that time. | 2018-07-01 |
| 7514 | 7514 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 253 | E | 0 | 1 | NOYK11 | Based on observation and staff interview, the facility failed to provide maintenance services to maintain resident rooms and furnishings in good repair. in seven (7) rooms on the 300 hall. Rooms #302, #304, #305, #307, #312, #313, and #315 all contained wardrobes for resident clothing which were missing knobs. The knobs were necessary to assist residents in opening and closing the drawers. Room #307 also had a hole in the wall where the cable outlet was connected. The outlet cover was hanging on the cable that ran from the wall to the television. This practice had the potential to affect more than an isolated number of residents. Facility Census: 80. Findings Include: a) Room #307 Random observations completed during Stage 1 of the survey, at 4:54 p.m. on 07/15/13, revealed the wardrobes in Room #307 had drawers with missing knobs. Without the knobs it was difficult to open and close the drawers. Also observed was a square hole in the drywall with a black cable. The cable ran from the hole to the television sitting by the window. The black cable had a cream-colored outlet cover hanging on it with the cable running through a small hole in the center of the outlet cover. The outlet cover appeared to have at one time been screwed into the wall covering the hole. Employee #28, a maintenance employee, was interviewed at 1:45 p.m. on 07/17/13. He made an observation of Room #307 and confirmed the cable outlet cover was pulled from the wall exposing the hole, which was made to run a cable to the room for television access. Employee #28 also confirmed the drawers were missing knobs. He stated they would compile a list to get them replaced. b) Rooms #302, #304, #305, #312, #313, and #315. Random observations were made during Stage 2 of the survey, at approximately 1:00 p.m., on 07/17/13. The observations revealed all of these rooms had missing knobs on the drawers of the wardrobes which contained residents' clothes. This made it difficult to open and close the drawers. Employee #28 confirmed there was a problem on this ha… | 2017-04-01 |
| 7515 | 7515 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 272 | D | 0 | 1 | NOYK11 | Based on medical record review and staff interview, it was determined the Minimum Data Set (MDS) assessment for one (1) of twenty-one (21) residents whose medical records were reviewed, contained an assessment which had inaccurate data regarding use of a urinary catheter. Resident #96 had a catheter identified on the current assessment, but this device had been removed months prior to the current assessment being completed. Resident identifier: #96. Facility census: 80. Findings include: a) Resident #96 Review of the quarterly MDS assessment, completed on 06/03/13, indicated the resident had an indwelling Foley catheter. An interview with the director of nursing, Employee #58, at 10:20 a.m. on 07/17/13, revealed the resident did not currently have a catheter and it had been removed back in March 2013. She could not determine why the MDS indicated the resident had a catheter when it had not been used for some time. | 2017-04-01 |
| 7516 | 7516 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 323 | E | 0 | 1 | NOYK11 | Based on observation and staff interview, the facility failed to maintain an environment free from accident hazards. During a random observation of the facility's shower room, an electric hairdryer was observed hanging unattended and plugged into an electrical outlet near a water source. This had the potential to affect more than a minimal number of residents. Facility Census: 80. Findings Include: a) During a random observation, at 2:15 p.m. on 07/18/13, an electric hairdryer was observed hanging on a towel hook in the facility shower room. The hairdryer was plugged into the electrical outlet and was located near the sink in the shower room. At 2:20 p.m. on 07/18/13, Employee #79, a Licensed Practical Nurse (LPN), accompanied the surveyor to the shower room. When Employee #79 saw the hairdryer she stated, They know better than this. She unplugged the hairdryer and stated the hairdryer was to be kept in the locked cabinet on the wall across from the sink. She stated when the hairdryer was not in use, the staff should put the hairdryer in the cabinet, and should not leave the hairdryer plugged in unattended. | 2017-04-01 |
| 7517 | 7517 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 431 | E | 0 | 1 | NOYK11 | Based on observation, policy review, and staff interview, the facility failed to ensure the safe and secure storage of controlled medications. The refrigerated controlled substances were not stored in a permanently affixed locked compartment. This practice had the potential to affect a limited number of residents. Facility census: 80. Findings include: a) During the visual check of the West wing medication storage room, on 07/17/13 at 2:45 p.m., the medication storage refrigerator was noted to have a clear locked box containing four (4) vials of Lorazepam 2 mg/ml injectable. The box was not secured inside of the refrigerator and the refrigerator was not locked to secure the controlled substances. The facility did not maintain a separately locked, permanently affixed compartment for the storage of controlled medications. During an interview with the director of nursing (DON), on 07/17/13 at 2:50 p.m., she was made aware the vials of Lorazepam were not in a secure box. She asked how this could be done. She stated she felt the medications being in the box that was locked and the medication room door was locked, the medications were secured. She stated she was going to notify the pharmacy to get the box secured inside of the refrigerator. Review of the facility's policy, on 07/18/13 at 10:00 a.m., entitled 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles number twelve (12) Controlled Substances Storage included, Number 12.1 Facility should ensure that Schedule II-IV controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by the Facility. Number 12.2 was After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-IV controlled substances are immediately placed in a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law). | 2017-04-01 |
| 7518 | 7518 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-07-19 | 514 | D | 0 | 1 | NOYK11 | Based on medical record review, facility policy review, and staff interview, the facility failed to ensure the completeness and accuracy of two (2) of twenty-one (21) medical records. Resident #27's medical record did not contain complete documentation pertaining to social services provided by the social worker. Resident #66's medical record did not contain complete documentation for pressure ulcers. Resident identifiers: #27 and #66. Facility census: 80. Findings include: a) Resident #27 On 07/18/13 at 2:00 p.m., the social worker (Employee #50) said she had files for residents she had talked with in her office in a file cabinet. She said these records were secure in her office in the locked cabinet. She said they contained sensitive information and she did not believe she should put that type of information in the resident's electronic medical record. She said she had a file for Resident #27. She explained some of the conversations she had with Resident #27 and did not feel she should put these conversations and their content in the electronic medical record for all staff to view. According to AHIMA (American Health Information Management Association) long-term care guidelines (06/09) a complete medical record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual has adequate plans of care and provides sufficient documentation of the effects of the care provided. Documentation should provide a picture of the resident, including what resident said or did, observations and/or assessments by staff, communications with practitioners and legal representative, response to interventions/treatment. Good practice indicates that for functional and behavioral objectives the clinical record should document change toward achieving care plan goals. The social worker verified Resident #27 had episodes of verbal aggression toward staff and other residents. She said the facilit… | 2017-04-01 |
| 7707 | 7707 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2014-02-19 | 253 | D | 1 | 0 | 70SM11 | Based on random observation and staff interview the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior. The facility failed to clean a table before serving a resident food on that table. Resident Identifier: #40. Facility census: 83. Findings Include: a) Resident #40 During initial tour of the facility on 02/17/14 at 1:00 p.m., a dining table in the east dining room had a soiled area approximately the size of a dinner plate. The area had a dried dark brown appearance. On 02/17/14 at 5:15 p.m., the same soiled area remained on the east dining room table. At 5:30 p.m., Resident #40 went into the dining room to wait for her dinner tray. Resident #40 motioned for this surveyor to come to the dining room. She pointed at the soiled table and made hand motions to suggest she wanted the table cleaned. At 6:00 p.m., on 02/17/14, Resident #40 ' s dinner was served in the east dining room. Employee #14 (nurse aide) placed the tray on the table on top of the soiled area. At the same time, Employee #14 stated she did not notice the soiled area and would clean the area. On 02/19/14 at 1:30 p.m., nursing assistant supervisor, Employee #19 agreed the facility should have cleaned the table prior to serving a resident dinner, on the table. | 2017-02-01 |
| 7708 | 7708 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2014-02-19 | 280 | D | 1 | 0 | 70SM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and incidents/accidents report review, the facility failed to revise and implement a care plan for one (1) of nine (9) residents. The facility did not utilize the care plan when Resident #14 had an exacerbation of aggressive behaviors. Additionally, the facility did not revise the care plan to include effective interventions for staff to utilize regarding the resident's pain during ambulation. Resident identifier: #14. Facility census: 83 Findings include: a) Resident #14 1) The incident/accident reports reviewed, on 02/17/14 at 2:00 p.m., revealed Resident #14 had a history of [REDACTED]. A review of behaviors revealed the resident had hallucinations, delusions, and exhibited both verbal and physical behaviors during the assessment period. Resident #14's [DIAGNOSES REDACTED]. The care plan, dated 01/29/14, and reviewed on 02/17/14 at 3:50 p.m., noted a focus related to psychosocial well-being related to distractibility/inability to concentrate. It also described impaired cognitive function/dementia or impaired thought processes related to impaired decision making (has short attention span). The interventions for this focus area included: engage in simple, structured activities that avoid overly demanding task, verbal praise, play a variety of music when she is upset to try to calm her, invite and assist resident to social activities such as parties, church, sing-a-longs and socials. The medical record review provided no evidence the facility implemented these interventions during acts of aggression from 01/22/14 through 01/27/14. Random observations were made during the survey. Throughout the day on 02/17/14, from 11:45 a.m. to 7:15 p.m. the resident was observed sitting in a small dining area across from the nurse's station or in her room. This was also observed on 02/18/14 from 9:00 a.m. to 7:15 p.m. and on 02/19/14 from 9:00 a.m. to 4:00 p.m. There was no evidence present indic… | 2017-02-01 |
| 7709 | 7709 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2014-02-19 | 514 | D | 1 | 0 | 70SM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical records to reflect resident status for two (2) of nine (9) residents whose medical records were reviewed. The care plan for Resident #28 did not correlate with physicians orders. The behavior monitoring sheets for Resident #14 did not accurately reflect the resident's behaviors. Resident identifiers: #14 and #28. Facility census: 83. Findings include: a) Resident #28 Review of Resident #28's medical record revealed a physician order [REDACTED]. An additional physician order [REDACTED]. The resident's care plan, with a revision date of 02/12/14, revealed interventions which stated: Resident to go for [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays . and Remove dressing from right arm [MEDICAL TREATMENT] fistula on Wednesdays, Fridays, and Sundays . The care plan interventions did not reflect the physician orders. On 02/18/14 at 2:00 p.m., Employee #81, a registered nurse, agreed the records revealed a discrepancy between the physician orders [REDACTED]. b) Resident #14 Incidents/accident reports were reviewed on 02/17/14 at 2:00 p.m. According to the reports, Resident #14 engaged in five (5) acts of aggression in January 2014. The resident engaged in acts of aggression on 01/22/14 at 4:13 p.m., 01/24/14 at 7:25 p.m., 01/25/14 at 4:00 p.m., 01/27/14 at 5:53 p.m. and on 01/28/14 at 11:18 a.m. On 02/18/14 at 3:00 p.m., a review of the behavior monitoring sheets revealed no behaviors were noted for four (4) of the five (5) incidents: 01/22/14, 01/24/14, 01/25/14, and 01/27/14. Registered nurse #92 reviewed the forms at 4:15 p.m., and confirmed they did not portray an accurate clinical record. The director of nursing also reviewed the behavior monitoring reports on 02/18/14 at 5:30 p.m., and confirmed the behavior monitoring sheets did not accurately reflect the resident's status. | 2017-02-01 |
| 7710 | 7710 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2014-02-19 | 520 | D | 1 | 0 | 70SM11 | Based on medical record review and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to identify quality deficiencies of which they had, or should have had knowledge. A resident had an exacerbation of resident-to-resident altercations which were not addressed by the QAA committee. The committee failed to develop and implement a plan of action to correct the problem. Resident identifier: Resident #14. Facility census: 83. Findings include: a) Resident #14 The incidents/accident reports were reviewed on 02/17/14 at 2:00 p.m., related to a complaint of resident-to-resident altercations. According to the reports, Resident #14 engaged in multiple acts of aggression in January as follows: -- On 01/22/14 at 4:13 p.m., Resident #14 entered another resident's room and slapped a resident on the chest, while the resident was lying in bed. -- At 7:25 p.m., on 01/24/14 after hearing a call for help, a nurse observed Resident #14 grabbing another resident by the shirt and hands. Resident #14 squeezed the resident's hand causing a reddened area. -- Resident #14 entered the dining room on 01/25/14 at 4:00 p.m., and started hitting another resident on the left shoulder. -- On 01/27/14 at 5:53 p.m., Resident #14 entered another resident's room and began smacking her in the face. The incident report noted she smacked the resident 2-3 times. -- At 6:29 a.m., on 01/28/14, staff observed Resident #14 holding onto another resident's wheel chair. Staff observed Resident #14 scratching the resident on the face. -- Again, on 01/28/14, at 11:18 a.m., after hearing a resident yell, staff observed Resident #14 twisting the right hand of a resident. During an interview with the assistant administrator, on 02/18/14 at 5:00 p.m., he said the facility had not identified a pattern related to the resident-to-resident altercations. He said the QAA committee met in February 2014, but did not address the exacerbation of behaviors exhibited by Resident #14. He acknowledged the facility had not identified that the … | 2017-02-01 |
| 8660 | 8660 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 156 | C | 0 | 1 | 46GB11 | Based on interview and review of documentation, the facility was not using the correct Centers for Medicare and Medicaid Services (CMS) form when notifying residents of changes in the services being provided them under the plan. Residents are to be notified when they no longer are going to receive Medicare skilled services using form CMS . The facility was using a a form entitled C-4. This was evident for three (3) of three (3) residents whose records for denial of payment for services were reviewed. This practice had the potential to affect any resident who was discharged from Medicare services. Resident identifiers: #40, #26 and #70. Facility census: 76. Findings include: a) Residents #40, #26, and #70 Review of documentation given these residents, when they no longer qualified for Medicare services, revealed the facility was using a form entitled C-4. This was not the required form as specified by CMS. The form specified by CMS is form CMS . This is the form to be given at the time residents are no longer eligible for skilled services. Such reasons include: when a resident has used all their days, has reached his/her potential, and/or for any reasons, as set forth by CMS, in which Medicare services are discontinued. This was discussed, on 01/09/12 at mid-morning, with the business office manager(Employee #63) who was responsible for providing these notices. Employee #63 stated he was not aware of form CMS , and would begin using it immediately. | 2016-04-01 |
| 8661 | 8661 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 157 | D | 0 | 1 | 46GB11 | **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 and physician of a resident's continued refusal to allow staff to obtain laboratory specimens. This practice affected one (1) of forty-two (42) sampled residents. Resident identifier: #10. Facility census: 76. Findings include: a) Resident #10 Review of this resident's physician's orders [REDACTED].#10 was ordered a basic metabolic profile (BMP) every four (4) months and a complete blood count (CBC) every six (6) months. Review of the medical record found no laboratory services. Further review of the medical record found the following nursing documentation entries: -- 06/08/11 at 536 -- Resident cont (continues) to refuse to let staff obtain routine schedule labs after several attempts made. Will continue to keep trying to obtain. -- 06/22/11 at 14:20 -- Resident refuses to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 07/22/11 at 12:39 -- Resident refuses to let staff obtain routine labs after several attempts made per staff. Will continue to keep trying to obtain. -- 07/27/11 at 13:27 -- Resident cont to refuse to let staff obtain routine schedule labs after several attempts made per staff. Resident states 'you are not getting any of my blood'. -- 07/29/11 at 09:34 -- Resident cont to refuse to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 08/04/11 at 13:12 -- Resident continues to refuse to let staff obtain labs after several attempts made per staff. will continue to keep trying to obtain. -- 08/12/11 at 12:13 -- Resident continues to refuse to let staff obtain routine labs after several attempt made per staff. Will cont to keep trying to obtain. -- 08/22/11 at 13:56 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. -- 09/08/11 at 11:37 -- Resident c… | 2016-04-01 |
| 8662 | 8662 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 160 | B | 0 | 1 | 46GB11 | Based on review of residents' personal funds and staff interview, the facility failed to convey residents' funds, and to provide a final accounting of those funds, to the individual or probate jurisdiction administering the residents' estates. Instead, the facility paid the residents' funds to the funeral home and did not provide a final accounting of the residents' funds to a legally authorized individual or probate jurisdiction administering the estate. This practice affected three (3) of three (3) sampled residents. Resident identifiers: #2, #9, and #100. Facility census: 76. Findings include: a) Residents #2, #9, and #100 Review of the facility's personal funds accounting records found these three (3) residents' final accounts were paid directly to a funeral home. During an interview, on the afternoon of 01/11/12, a business office manager, Employee #63, confirmed when a resident passed away the facility did provide a final accounting of the residents' funds, and did not send the funds to the individual or probate jurisdiction administering the resident's estate. Employee #63 stated, All funds go directly to the funeral home. | 2016-04-01 |
| 8663 | 8663 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 241 | D | 0 | 1 | 46GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to promote care which enhanced the dignity for one (1) of forty-two (42) residents. This resident's fingernails were not groomed as he wanted them groomed. The resident's fingernails were long, jagged and had debris underneath. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On 01/05/12 at 9:30 a.m., observation of Resident #78 revealed he had long, jagged, and dirty fingernails. He said a physician came in to trim his toenails, but no one had trimmed his fingernails lately. The resident had right sided [MEDICAL CONDITION] which affected his right hand and arm. This made him dependent upon staff for things such as nail care. On 01/09/12, at approximately 11:30 a.m., Employee #92 (a licensed practical nurse) was informed the resident's fingernails needed trimmed. On 01/10/12 the resident's fingernails were observed and appeared clean and trimmed. | 2016-04-01 |
| 8664 | 8664 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 242 | D | 0 | 1 | 46GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview and staff interview, the facility failed to assure one (1) of forty-two (42) residents was afforded the opportunity to make choices about an aspect of his life that was significant to him. The resident complained about not having any personal spending money to buy things such as soda. He indicated he had informed the facility that he had no money and that this made him upset and angry. The resident had capacity to make decisions and had informed the facility he wanted access to his personal needs allowance which was allotted by Medicaid. The facility did not act upon the resident's request, or provide the resident assistance in getting his money. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 Medical record review, conducted on the morning of 01/05/12, revealed this resident was admitted to the facility on [DATE]. On the afternoon of 01/05/12, during an interview with the resident, he indicated his brother handled all of his financial affairs. He said this worked out ok except his brother did not bring any money to him for personal needs. He indicated he had to call his brother and request items such as snacks. He said this bothered him and he would like to have his own money so he did not always have to call and ask his brother for things. On 01/05/12, at approximately 3:00 p.m., the business office manager (Employee #63) verified Resident #78 did not have a trust account set up by the facility. He produced a document showing the resident had declined to have a savings / trust account set up at the time of admission. Employee #63 also provided a copy of the resident's determination of medical capacity. This document, dated 04/21/10, revealed the resident had capacity to make medical decisions. Employee #63 said the facility did not have a copy of the financial power of attorney document. Employee #63 stated the resident had asked him to contact his brother i… | 2016-04-01 |
| 8665 | 8665 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 246 | D | 0 | 1 | 46GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to assure personal toiletry items were kept within reach for independent use for one (1) of forty-two (42) residents. Resident #78 did not have sufficient oral hygiene supplies for brushing his teeth. Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On the morning of 01/04/12, during an interview, Resident #78 said he did not have a toothbrush or toothpaste. He said he had some bottom teeth, but they were not brushed every day. He said staff normally assisted him with oral hygiene about once a week. The resident had [MEDICAL CONDITION] affecting his right side. His night stand was next to his bed on his left side. He was able to access the night stand with his left hand. On 01/10/12, at approximately 2:00 p.m., a nursing assistant (NA), Employee #6, came into the resident's room and looked for his oral hygiene supplies. A tube of unopened toothpaste was in the drawer of the night stand. Employee #6 looked in other areas of the room and could not find any other supplies, such as a toothbrush or an emesis basin. Employee #70, a QA came in later with a toothbrush and emesis basin, and asked where he should put them. The resident requested Employee #70 put the supplies in the night stand drawer. He said he could brush his own teeth if the supplies were kept in the night stand. | 2016-04-01 |
| 8666 | 8666 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 253 | E | 0 | 1 | 46GB11 | Based on observations and staff interview, it was determined the facility had not assured the environment and condition of the furnishings were maintained in a sanitary and orderly manner. There were doors to resident bathrooms that had scuffs and scratches, furniture in common dining areas was in need of repair, a bathroom sink leaking, paint was peeling and chipped, and doors to the lounge area and central bath had deep scrapes and gouges in the wood. These environmental issues made the areas unsightly, as well as not easily cleanable. These issues were evident in twenty-two (22) resident rooms, doors to the central bath, and the resident lounge between the 100 and 200 hallways. Room numbers included: 102, 300, 315, 207, 212, 206, 313, 203, 113, 308, 314, 209, 305, 100, 215, 110, 204, 112, 208, 213, 200, and 212. This practice had the potential to affect more than an isolated number of residents. Facility Census: 76 Findings include: a) Rooms 102, 300, 315, 207, 212, 206, 313, 203, 113, 308, 314, 209, 305, 100, 215, 110, 204, 112, 208, 213, 200, and 212 Observations during the stage I interviews and tour of the facility revealed doors to resident rooms and bathrooms had scratches and gouges. Rooms had peeling paint, walls had holes in them, and chipped paint was observed on doorframes. b) Observations, on 01/11/12 at mid-morning, revealed there were chairs in the dining rooms with ripped and / or torn upholstery. The wooden legs of the chairs were scratched and / or in other disrepair. In the central shower area, a shower bed had a vinyl cover that was torn around the button areas. c) Room 308 had a leaking sink and a strong urine odor d) During the afternoon of 01/18/12, these environmental concerns were discussed with the administrator. . | 2016-04-01 |
| 8667 | 8667 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 279 | E | 0 | 1 | 46GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to develop a comprehensive care plan to address problems and needs for four (4) of forty-two (42) Stage II sampled residents. Resident #29 did not have a care plan to address her contractures and services needed to prevent further complications. Resident #73 did not have a care plan to address her dental needs. Resident #19 did not have a care plan to address the special care needed for her [DIAGNOSES REDACTED]. (Mayo Clinic April 9, 2011)). Resident #10 did not have a care plan to address her refusal of laboratory services. Failure to identify the needs and services to be furnished through the care planning process had the potential to result in a failure to provide optimum resident care. Resident identifiers: #29, #73, #19, and #10. Facility Census: 76. Findings Include: a) Resident #29 Resident #29 was admitted to the facility on [DATE] with severe joint contractures to all extremities. She received occupational therapy (OT) for management of her contractures. When she was discharged from OT, on 02/25/11, she was referred to the restorative nursing program for bilateral upper extremity and lower extremity passive range of motion exercises for fifteen (15) minutes a day six (6) days a week. This resident was transferred to the hospital, on 04/02/11, and was readmitted to the nursing home on 04/12/11. She was screened by therapy when she returned. It was determined she had an existing deficit, but there had not been a change in function, so she was not treated at that time in therapy. There was no evidence her care plan, which was established prior to her hospitalization , provided for the passive range of motion exercises to be continued after she was readmitted from the hospital. During an interview with the minimum data set (MDS) coordinator, Employee #19, on 01/10/12 at 3:30 p.m., it was verified the resident did not have a care plan to address her positioning… | 2016-04-01 |
| 8668 | 8668 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 280 | D | 0 | 1 | 46GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review, medical record review, and staff interview, the facility failed to assure three (3) of forty-two (42) residents had care plans that were evaluated and updated as the residents' needs changed. Resident #78's care plan had not been revised to reflect his ability to remove his personal alarm which was used as a way to alert staff the resident had gotten up and could potentially fall. Resident #47's care plan was not updated after he received dentures. Resident #29's care plan was not updated after a urinary catheter was removed. Resident identifiers: #87, #47, and #29. Facility census: 76. Findings include: a) Resident #87 Care plan review for Resident #87, conducted on 01/09/12 at approximately 1:00 p.m., revealed the following problem, Potential for injury/falls R/T (related to) - History of falls- poor safety awareness - Attempts to transfer without assistance- [MEDICAL CONDITION] drug use. The care plan was initiated on 03/30/11. The interventions listed did not mention the resident's ability to dismantle/turn off his personal tab alarm. The tab alarm was placed on the resident's bed for safety. This intervention section had been revised on 08/05/11. Medical record review revealed Resident #87 sustained a fall, on 12/19/11 at 5:14 p.m. The documentation stated, His alarm was sounding in room, sat on floor on buttocks; hit his head, laceration to back of head. Went out to hospital and they put staples in his head. W/C (wheelchair) alarm noted to not be intact. Resident states he removed the alarm. On 01/10/12 at 10:22 a.m.,. the director of nursing (Employee #55) agreed the resident did have tendencies to remove or turn off his alarm. She agreed this element needed added to the resident's care plan. b) Resident #47 Review of the care plan for Resident #47 revealed the problem, Alteration in nutritional status r/t (related to) edentulous. The interventions included: -Appetite stimulants per orders - Diet: Regular - M… | 2016-04-01 |
| 8669 | 8669 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 313 | D | 0 | 1 | 46GB11 | Based on resident interview, observation, medical record review, and staff interview, the facility failed to assure one (1) of forty-two (42) sampled residents received assistance with her hearing devices. The resident had hearing aids, but staff failed to ensure the hearing aids were operational, and failed to provide the resident assistance in using them. Resident identifier: #19. Facility census: 76. Findings include: a) Resident #19 During an interview with Resident #19, the evening of 01/03/12, it was identified the resident had difficulty hearing the interview questions. Resident #19 stated, I cannot hear anything you are saying. On the morning of 01/04/12, an unidentified nursing assistant (NA) was asked if the resident had hearing aids. The NA stated, She had them, but I think something was wrong with the batteries. Resident #19 was observed on three (3) other occasions, after 01/03/12, without her hearing devices in place. Review of the care plan for Resident #19 found an intervention regarding the hearing aid, Assure resident is wearing hearing aid before engaging in conversation. This intervention was dated 11/23/11. The observation of the resident's difficulty in hearing was reported to the director of nursing, Employee #55, at 8:30 a.m. on 01/10/12. During the afternoon of 01/10/12, the DON reported, She has hearing aids - they were in her drawer. | 2016-04-01 |
| 8670 | 8670 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 318 | D | 0 | 1 | 46GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide appropriate treatment and services for a resident with severe contractures to prevent further decline in range of motion (ROM). Resident #29 received occupational therapy (OT) services, which included passive range of motion and joint mobility, to her extremities. After she completed her treatment with OT, she was referred to restorative nursing for passive range of motion (PROM). The resident experienced was hospitalized for [REDACTED]. When she returned from the hospital, there was no evidence the resident received range of motion services or treatment for [REDACTED]. Resident identifier: #29. Facility Census: 76. Findings Include: a) Resident # 29 Resident #29 was admitted to the facility on [DATE] with severe joint contractures to all extremities. She was provided OT for management of these contractures. When she was discharged from therapy on 02/25/2011, she was referred to the restorative nursing program for bilateral upper extremity and lower extremity passive range of motion exercises for fifteen (15) minutes a day six (6) days a week. This resident was transferred to the hospital on [DATE], and was readmitted to the facility on [DATE]. She was screened by therapy when she returned. It was determined she had an existing deficit, but there had not been a change in function. She was not treated again at that time by therapy. There was no evidence her care plan, which was established prior to her hospitalization , ensured the passive range of motion exercises were continued after she was readmitted . The restorative nursing assistant (Employee #15) was interviewed at 2:00 p.m. on 01/10/2012. Employee #15 verified she was treating this resident and providing passive range of motion to her extremities prior to the resident's hospitalization . Employee #15 stated when the resident returned from the hospital, on 04/12/2011, she did not receive an order t… | 2016-04-01 |
| 8671 | 8671 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 329 | D | 0 | 1 | 46GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** unecessary drug regimen review revealed drug regimen's were missing from the following months (September, October, November and December 2011. The medication review also revealed the resident was suppose to have a lipid panel in 09/12 no communication from pharmacist for drug regimen review conducted on 12/27/11 & 11/28/11. #35 Michale Coleman - Had not recieved a reduction of his [MEDICATION NAME] for a year. #78 Paul Blackburn Pharmacy review not done. No labs could be found related to liver function testing and accurate [MEDICATION NAME] levels. There was only one pharmacy review on [MEDICATION NAME] and that was in January of 2011. labs were not obtained as orderd. | 2016-04-01 |
| 8672 | 8672 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 356 | B | 0 | 1 | 46GB11 | Based on observations, review of the nurse staff posting and staff interview, the facility failed to ensure they were in compliance with the requirements set forth by the Center for Medicare and Medicaid Services (CMS) in relation to nurse staffing information. The facility was completing the staff posting in advance, rather than at the beginning of each shift as required. This practice had the potential to affect more than an isolated number of both residents and other interested individuals such as family members or visitors. Facility census: 76. Findings include: a) On 01/03/12, at approximately 4:30 p.m., an observation of the daily staffing sheet revealed the facility had the number of licensed practical nurses and registered nurses for night shift already filled in and counted. On 01/09/12, at approximately 11:00 a.m., a second observation of the daily staffing sheet revealed it had the wrong date listed and had the number of licensed and registered nurses had been filled in for day, evening, and night shifts. On 01/09/12, at approximately 12:00 p.m., the director of nursing (Employee #55) said Employee #89 (licensed practical nurse) took care of the daily staffing post and would answer any questions related to the issue. On 01/09/12, at approximately 1:00 p.m., Employee #89 confirmed she was responsible for the daily staffing posting. She stated she assigned another staff member to fill in the number and hours scheduled for licensed and registered nurses each day. Employee #89 indicated she would discontinue having staff fill out the sheet for the entire day, and instead, fill in the numbers at the beginning of each shift. b) The posting of staff was observed on 01/10/12. Noted on the bottom of this posting was Required staffing is 2.25 hours. This statement was misleading to the public because this is not the required staffing level, but the minimal staffing level required by the State licensure rule. The required staffing is the amount of staff necessary to meet the needs of the residents as described in… | 2016-04-01 |
| 8673 | 8673 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 371 | F | 0 | 1 | 46GB11 | Based on dietary observations and staff interview, dishware was not stored in a manner that promoted sanitary conditions. Stored plates were discovered to have water between them when food was being served on the tray line. This practice created a medium for bacterial growth resulting in a potential contamination of the dishware. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 76 Findings include: a) While observing meal service, at lunch on 01/09/12, plates were observed stored wet with moisture between them. As these were retrieved from the lowerator for use at the meal, some plates were observed wet. This practice had the potential to allow bacterial grow in the moist environment. The consultant dietitian was present at the time of the observation and verified wet dishes were present. The Food Code, section 4-901.11, requires equipment and utensils, after cleaning and sanitizing, be air dried or used after adequate draining. Wet storage, particularly when items are stacked on top of each other while wet, creates a medium for bacterial growth. | 2016-04-01 |
| 8674 | 8674 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 428 | D | 0 | 1 | 46GB11 | Based on record review and staff interview, the facility failed to ensure a drug regimen review was completed monthly by the consultant pharmacist for one (1) of forty-two (42) Stage 2 sampled residents. This resident had a monthly review on 01/24/11, but no reviews for the remaining months in 2011. Resident identifier: #35. Facility census: 76 a) Resident #35 Review of the facility's drug regimen reviews for Resident #35 revealed a drug regimen review dated 01/24/11. No other drug regimen reviews were found for this resident for the eleven (11) other months in 2011. During an interview, on 01/11/12, Employee #74 verified the facility could find no evidence the pharmacist conducted a drug regimen review for this resident after 01/24/11. unecessary drug regimen review revealed drug regimen's were missing from the following months (September, October, November and December 2011. The medication review also revealed the resident was suppose to have a lipid panel in 09/12 no communication from pharmacist for drug regimen review conducted on 12/27/11 & 11/28/11. | 2016-04-01 |
| 8675 | 8675 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 441 | E | 0 | 1 | 46GB11 | Based on review of the facility's infection control program, medical record review of residents with Escherichia coli (E-coli), and staff interview, the facility failed to implement an effective infection control program which identified the probable cause of a number of E-coli infections, and failed to develop a plan to prevent the spread of E-coli infections in the facility. This practice had the potential to affect more than a limited number of residents. Facility census: 76. Findings include: a) Review of the facility's infection control tracking form revealed nineteen (19) residents for which E-coli had been identified as the cause of urinary tract infections from 07/2011 through 12/28/11. The list included four (4) residents with indwelling Foley catheters and one (1) resident with a suprapubic catheter. Review of the infection control program found no in-service records related to the prevention of urinary tract infections associated with E-coli. On 01/10/12 at 3:09 p.m., the infection control nurse, Employee #93, stated, I did not focus on E-coli. I was just looking at what I needed to do for isolation measures. She further stated, I did not realize five (5) of the residents had catheters. When asked if she had provided in-services for nursing personnel related to E-coli infections associated with catheters, she stated, No. The facility failed to develop, implement, and maintain an effective infection prevention and control program, regarding the E-coli, to prevent, recognize, and control, to the extent possible, the onset and spread of this infection within the facility. | 2016-04-01 |
| 8676 | 8676 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 504 | D | 0 | 1 | 46GB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain physician ordered laboratory services for one (1) of forty-two (42) Stage 2 sample residents. A resident was receiving medications for which liver function tests were indicated. The facility had not ensured liver function tests were obtained as ordered by the physician. Resident identifier: #35. Facility census: 76. Findings include: a) Resident #35 Review of this resident's medical record identified Resident #35 was ordered a liver function test every three (3) months. This was because the resident received [MEDICATION NAME] 120 milligrams per day and [MEDICATION NAME] for high cholesterol. Review of the medical record found only one (1) laboratory result for the liver function test, which was obtained on 06/17/11. During an interview with Employee #74, a minimum data set employee, on 01/11/12 at 9:53 a.m., she stated, This is the only one we have. She further stated, It was ordered in September, but we did not obtain it. It was also ordered in November, but we didn't get it then either. A liver function test was obtained for the resident on 01/12/12, after the failure to obtain the ordered test was brought to the facility's attention during the survey. | 2016-04-01 |
| 8677 | 8677 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 514 | D | 0 | 1 | 46GB11 | Based on resident interview, medical record review and staff interview, the facility failed to ensure the clinical record for one (1) of forty-two (42) Stage 2 residents was maintained in accordance with accepted professional standards. The medical record did not contain complete and accurate information for activities of daily living (bathing / showering). Resident identifier: #78. Facility census: 76. Findings include: a) Resident #78 On 01/05/12 at 8:52 a.m., Resident #78 said he had gone for several days without a shower, and he wanted a shower every day. Employee #89 (licensed practical nurse) indicated she supervised the restorative nursing program. She provided a copy of the resident's shower / bathing documentation for the month of December 2011. Employee #89 said the facility's computer system did not allow for the nurse aide to document whether a shower or a bath was given. The system the facility used did not allow for accurate documentation, as it did not allow for identification of whether a shower or a bath had been given. This was of particular concern when the resident stated he did not have a shower for days and he wanted a shower daily. There was no means to evaluate whether, and / or when, the resident was provided a shower as opposed to a bath. | 2016-04-01 |
| 8678 | 8678 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 520 | E | 0 | 1 | 46GB11 | Based on review of the facility's infection control program, quality assurance committee information, and staff interview, the quality assessment and assurance committee failed to identify and correct infection control problems and environmental issues. This practice had the potential to affect more than a limited number of residents. Facility census: 76. Findings include: a) Infection Control Program Review of the facility's infection control tracking form revealed nineteen (19) residents with E-coli identified as the cause of urinary tract infections from 07/2011 through 12/28/11. The list included four (4) residents with indwelling Foley catheters and one (1) with a suprapubic catheter. Review of the infection control program found no in-service records related to the prevention of urinary tract infections associated with E-coli. On 01/10/12 at 3:09 p.m., the infection control nurse, Employee #93, stated, I did not focus on E-Coli. I was just looking at what I needed to do for isolation measures. She further stated, I did not realize five (5) of the residents had catheters. When asked if she had provided in-services for nursing personnel related to E-Coli infections associated with catheters, she stated, No. On 01/11/12 at 2:30 p.m., the director of nursing (Employee #55) was asked if she had any evidence the quality assurance committee had addressed the more current urinary tract infections in the facility. Employee #55 provided information for 01/24/11. This information noted the committee had discussed, in general, urinary tract infections, but not urinary infections with E-coli and /or the E-coli infections which were associated with catheter use. The findings discussed in the meeting, dated 01/24/11, were issues related to October 2010, November 2010, and December 2010. Employee #55 provided no quality assurance information which verified the committee was aware and / or had an action plan regarding the facility's most current nineteen (19) urinary tract infections as described above. b) Environment The f… | 2016-04-01 |
| 8825 | 8825 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-03-12 | 371 | F | 1 | 0 | 8SQC11 | Based on observation and staff interview, it was found sanitation issues were evident in the dietary department. Equipment needed repaired/replaced, walls and doors needed cleaned and repaired, equipment was in need of cleaning and milk cartons were stored covered in ice which was not a sanitary method. This practice had the potential to affect all residents as all residents were served food from this central location. Findings include: Upon observations in the dietary department, on 03/10/13 at 5:00 p.m., the following items were noted: a) A home-type freezer was found to have the interior lining broken with the insulation visible. b) Milk cartons were placed in a pan with ice completely covering the cartons. This could lead to possible cross contamination as the ice may be contaminated and then contaminate the opening of the carton from which an individual would drink. c) The lids of bins which contain flour and sugar had food debris spilled on them and were in need of cleaning d) The hand sink in the dishwashing area had caulking that was chipped and in need of repair. It was not easily cleanable. e) The inside of doors that entered the kitchen from the hallway were noted to have scrapes and gouge in them and therefore not easily cleanable. All of these issues were discussed with the dietary director of the sister facility, Employee #83, who was available for assistance in the absence of the facility's dietary manager. This occurred on 03/11/13 in the afternoon. | 2016-03-01 |
| 8826 | 8826 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2013-03-12 | 372 | F | 1 | 0 | 8SQC11 | Based on observation and staff interview, it was determined the facility had not ensured garbage and refuse were disposed of in a manner to ensure waste was properly contained and to prevent the harborage and feeding of pests. Dumpster lids were found to be left open and food items were exposed which had the potential to attract vermin. This practice had the potential to affect all residents residing in the facility. Findings include: a) Upon entering the facility, on 03/10/13 at 4:45 p.m., it was noted that the dumpster lids were open. This did not ensure waste was properly contained in the dumpster. Birds were observed getting into the exposed bags of garbage and food items that were lying on the ground near the unit. . | 2016-03-01 |
| 9880 | 9880 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-05-09 | 156 | C | 1 | 0 | SZNR11 | . Based on record review and staff interview, the facility failed to ensure three (3) of three (3) resident's received the appropriate discharge notice, as required by the Centers for Medicare and Medicaid Services (CMS), after they were discharged from a Medicare skilled service. Resident #22, Resident #72, and Resident #39 were all discharged from Medicare Part A skilled services in April 2012. The facility did not issue one (1) of two (2) notices at the time Medicare Part A services ended. Facility census: 77. Findings include: a) Resident #22 This resident was discharged from Medicare Part A, on 04/21/12, due to no further skilled services being available for her. b) Resident #72 This resident was discharged from Medicare Part A, on 04/15/12, due to no further skilled services being available for her. c) Resident #39 This resident was discharged from Medicare Part A, on 04/26/12, due to a completion of antibiotic therapy. d) An interview with Employee #10 (business office manager), on 05/09/12 at 1:00 p.m., revealed these three (3) residents had received the Notice of Non Coverage, CMS form ( ). The generic notice (form ) simply informs the resident of their right to an expedited review of the service termination for coverage reasons. The facility must issue the skilled nursing advanced beneficiary notice to address the resident's potential liability for payment if they remain in the facility. The residents had not received the Skilled Nursing Advanced Beneficiary Notice (SNFABN). According to the business office manager, all three (3) residents remained in the facility under another payer source. The facility needed to give the three (3) residents both notices because all Medicare covered services were ending and the center intended to deliver non-covered care. The SNFABN is given because benefit days remain to inform the resident of potential financial liability. . | 2015-08-01 |
| 9881 | 9881 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-05-09 | 203 | D | 1 | 0 | SZNR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a closed medical record review and staff interview, the facility failed to ensure two (2) of five (5) residents were provided with a written discharge notice thirty (30) days prior to their discharge date s. This notice must include the reason for discharge, the effective date, the location to which the resident was being discharged , the right to appeal, how to notify the ombudsman, and how to notify appropriate protection and advocacy agencies. Resident identifiers: #57 and #85. Facility census: 77. Findings include: a) Resident #57 The medical record review for Resident #57, conducted on 05/08/12, at approximately 1:00 p.m., revealed this eighty seven (87) year resident was admitted to the facility on [DATE]. The resident left the faciity on [DATE]. According to the medical record, she now resides in a personal care home. Medical record review revealed several social service and nursing notes, dating back to November 2011, reflecting the resident's desire to return home. The facility completed a pre admission screening (PAS) on the resident. A progress note, dated 05/01/12, stated, "Resident is in process of discharge planning. She no longer qualifies for nursing home care. At this point plans will be for her to go to (name of personal care home). The ombudsman will be here on Wednesday 05/02/12 to meet with res. and her family. The son who is health care surrogate will not transport to new facility. He wants her transferred by ambulance. " Another progress note, dated 05/04/12, stated, "Resident d/c (discharged ) to a personal care home due to no longer being eligible for nursing home level of care. Her son has made all the financial needs for the transfer. " On 05/09/12, at approximately 11:00 a.m., the former business office manager (Employee #65) and the medical records clerk (Employee #14) reviewed the resident's closed record. The record did not contain information indicating the health care surrogate was provided a thirty… | 2015-08-01 |
| 10750 | 10750 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 279 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop a plan of care to address the care and treatment of [REDACTED]. The staff caring for this resident was not aware she had a drug-resistant infection in her eyes and nares. There was no evidence that the facility had a plan to alert staff and visitors of special precautions needed with respect to having contact with the resident's body secretions. This affected one (1) of thirteen (13) sampled residents . Resident identifier: #32. Facility census: 75. Findings include: a) Resident #32 Review of Resident #32's medical record revealed she was admitted to the hospital on [DATE], for an altered level of consciousness. According to her hospital records, she had had a fever and drainage from her eyes, and she tested positive for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in her right eye and her nares. She was receiving antibiotics for her nares and her eyes and was still receiving this treatment when she came back to the nursing home. Observation of this resident revealed she was not in any type of isolation, and her care plan did not identify any special precautions to be taken when interacting with or caring for this resident. During an interview with the infection control nurse (Employee #26) on 06/24/09 at 3:00 p.m., she was made aware of the resident's infections. She confirmed this was missed when the resident returned from the hospital; the resident's infections were not record on the facility's infection control log, and no isolation precautions were initiated when she returned from the hospital. She also confirmed Resident #23 should have been placed in isolation. This resident's room was observed at 9:00 a.m. on 06/25/09. The nursing assistant was observed taking special precautions prior to entering the room to care for this resident. There was a sign placed on the door to see the nurse before entering the room. These precautions were … | 2014-12-01 |
| 10751 | 10751 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 328 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure Resident #72 received the proper respiratory care and treatment. Staff failed to utilize proper technique to administer a nebulizer treatment to a resident with a [MEDICAL CONDITION] (trach). Staff also did not ensure this resident's oxygen was administered in accordance with physician's orders [REDACTED]. Proper respiratory care and treatment was not provided for one (1) of thirteen (13) sampled residents. Resident identifier: #72. Facility census: 75. Findings include: a) Resident #72 1. During an observation of the medication administration for Resident #72 on 06/23/09, this resident was observed to have an order for [REDACTED].# 81) administered this treatment by holding a face mask over the resident's trach. Observation found the medicated aerosol coming out the sides of the mask, with very little actually going into [MEDICAL CONDITION]. The nurse, when questioned about the use of this mask, stated they have special tubing for the trach, but they were out and did not have the right ones available. The assistant director of nursing (ADON), when interviewed on 06/23/09, was asked to provide the facility's policy and procedure for administering a nebulizer treatment to a resident with a trach. The ADON provided a policy for administering hand-held nebulizer treatments but stated they did not have a policy for administering a nebulizer via a trach. The ADON reported they have a respiratory person who comes in and provides them with the equipment they need and shows them how to use it. She stated the facility does have special tubing and [MEDICAL CONDITION] to use for the residents with trachs. 2. Further observations of this resident, throughout the day on 06/23/09 and 06/24/09, revealed this resident did not use her oxygen during those days. The resident's O2 saturation, when checked, was at 98%. A review of the resident's medical record revealed [REDACTED].@ (at) four … | 2014-12-01 |
| 10752 | 10752 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 333 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents were free from significant medication errors. The nurse was preparing to administer 60 mg of the anticoagulant medication [MEDICATION NAME], instead of the 45 mg dose ordered by the physician. Receiving too much of this medication could result in internal hemorrhaging. Significant medication errors were found for one (1) of ten (10) residents observed during medication pass. Resident identifier: #66. Facility census: 75. Finding include: a) Resident #66 During medication administration, observation found a nurse (Employee #81) preparing medications for Resident #66. Review of the labels found a pre-filled syringe of [MEDICATION NAME] 60 mg /0.6 ml. The directions on the medication label stated to administer 0.5 ml (50 mg) sub-Q ( subcutaneously) bid (twice a day). While the nurse was preparing her medications, surveyor observed Resident #66's Medication Administration Record [REDACTED]." The nurse was observed to complete her preparation. As she was preparing to administer the medications to the resident, the surveyor intervened and asked the nurse to stop and double check the label against the MAR. The nurse then verified the dose she was preparing to administer was not correct. The nurse then calculated the correct dose and wasted the excess medication that was in the syringe. The nurse proceeded to tell the surveyor they had discussed this, but the [MEDICATION NAME] did not come from the pharmacy in the dose ordered. . | 2014-12-01 |
| 10753 | 10753 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 441 | F | 0 | 1 | 667111 | Based on a review of the facility's policies and procedures for infection control and isolation for residents with infections, observations of residents with infections, and staff interview, the facility failed to develop and implement an effective infection control program to prevent the potential spread of infections in the facility. The facility's policies and procedures were not periodically reviewed and revised to reflect changes in standards of practice, and the existing procedures were not consistently implemented to prevent the spread of infectious organisms. The facility's did not maintain a record of all residents with infections, including the infectious organism found and/or the type of isolation precaution to be used. The number of residents at the facility with facility-acquired (nosocomial) infections had increased, but there was no evidence to show the facility investigated this increase in nosocomial infections for the causative factors or implemented measures to prevent further incidents of residents contracting nosocomial infections. The absence of an effective infection control program placed all residents residing in the facility at risk of acquiring an infection. Facility census: 75. Findings include: a) Infection Control Program Review of the facility's infection control policies and procedures revealed the policies were not thorough and were not consistently implemented. The infection control policy (which did not contain an effective date) stated the purpose of the policy was to ensure the infection control program was effective for investigating, controlling, and preventing infections in order to provide a safe sanitary, and comfortable environment. The procedure for this stated the following: "1. LPN (Licensed Practical Nurse) on duty will report any signs / symptoms of infection to the physician. Along with any other information requested. "2. Obtain order for treatment. Check ER (emergency) box to see if medication ordered can be obtained. If not STAT medication to facility. "3. Notif… | 2014-12-01 |
| 10754 | 10754 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 226 | C | 0 | 1 | 667111 | Based on a review of the facility's policy titled "reporting abuse" and staff interview, the facility failed to ensure its "reporting abuse" policy addressed the identification, reporting, and prevention of resident neglect. This practice had the potential to affect all facility residents. Facility census: 75. Findings include: a) On 06/23/09 at approximately 10:00 a.m., the facility's policy titled "reporting abuse" was reviewed. The policy did not identify what constituted resident neglect, nor did it address how, when, or who would report such situations within the facility, and to what State agencies they would be reported outside of the facility. The policy also did not explain how the facility would prevent neglect from occurring. The policy basically only gave an understanding on what constituted abuse and how the facility would proceed with identifying, preventing, and reporting allegations involving abuse. The facility social worker and director of nurses both agreed the policy did not address allegations of resident neglect, including identification, reporting, and prevention. . | 2014-12-01 |
| 10755 | 10755 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 152 | E | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure, for three (3) of thirteen (13) sampled residents, a legal surrogate was appointed in accordance with State law for residents lacking the capacity to understand and make their own informed health care decisions. Determinations of incapacity were made solely based on a [DIAGNOSES REDACTED]. Resident identifiers: #50, #33, and #47. Facility census: 75. Findings include: a) Resident #50 On 06/24/09 at approximately 2:00 p.m., review of Resident #50's medical record revealed a physician's determination of capacity form indicating Resident #50 lacked the capacity to understand and make informed health care decisions. However, the cause of the incapacity had not been recorded on the form. b) Resident #47 On 06/23/09, review of Resident #47's medical record revealed a physician's determination of capacity form indicating Resident #47 lacked the capacity to understand and make informed health care decisions due to having a [DIAGNOSES REDACTED]. c) Resident #33 Review of Resident #33's medical record, on 06/23/09, revealed the physician determined she lacked the capacity to understand and make her own health care decisions; however, the cause of her incapacity was not recorded. d) According to '16-30-7. Determination of incapacity., "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a … | 2014-12-01 |
| 10756 | 10756 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 465 | F | 0 | 1 | 667111 | Based on observation and staff interview, the facility failed to maintain an environment for residents that was in good repair. All but one (1) hallway had doors in need of repair, the surface of an isolation table was unclean and in poor repair, and Resident #58's room and nursing equipment were not maintained in a sanitary manner. Facility census: 75. Findings include: a) On 06/25/09 at approximately 10:00 a.m., a tour of the inside of the building revealed the corridor doors of resident rooms were scarred and had some type of substance on them. The administrator said the doors had holes that had been filled (but not finished), and the filler was the substance that had been noted. He agreed the doors were not in good condition and commented that they were replacing the doors one (1) at a time, and he hoped to have all of them replaced soon. b) An isolation table was also observed to be in poor repair on the 200 hallway. The table was beaten and scratched up and appeared dirty. c) Resident #58 Observation, during a tour of the facility on 06/25/09, revealed Resident #58's room contained a suction machine that was not clean. The wall area in this room was also dirty, with splashes that ran down the wall. d) On 06/25/09 at approximately 1:00 p.m., the administrator indicated he was unaware of the dirty equipment and condition of the walls in Resident #58's room as well as the soiled table on the 200 hallway. The administrator indicated the areas and equipment would be cleaned as soon as possible. . | 2014-12-01 |
| 10757 | 10757 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 309 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents received medication in an amount as ordered by the treating physician. Resident identifier: #21. Facility census: 75. Findings include: a) Resident #21 During observations of the medication administration pass on 06/23/09 at 8:50 a.m., the nurse was monitored while preparing Resident #21's medications. The nurse was noted to place a [MEDICATION NAME] 325 mg (Iron) tablet into a plastic medication administration cup with her other medications. Review of the Medication Administration Record [REDACTED]. As the nurse locked her cart and prepared to enter the resident's room, she was asked to review the MAR. She agreed the resident should not be administered the [MEDICATION NAME] and discarded the medication. . | 2014-12-01 |
| 10758 | 10758 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 371 | F | 0 | 1 | 667111 | Based on observations and staff interview, the facility failed to ensure proper sanitation procedures were employed for manual warewashing, freezer units had internal thermometers to ensure food items were being stored at proper temperatures, and food (ice) was being handled with clean utensils when served. These practices have the potential to affect all residents, as all residents who consume food by oral means are served from this central location. Facility census: 75. Findings include: a) During the initial tour of the kitchen on the afternoon of 06/23/09, observation found the walk-in freezer did not contain an internal thermometer to ensure correct temperature levels were being maintained for safe storage of frozen foods. b) Also during the tour, observation found dietary staff had placed a sanitizer tablet in the water of the three-compartment sink for manual warewashing; the tablet had not dissolved. The surveyor questioned staff about the method used to sanitize, and the dietary staff indicated they used tablets that would dissolve in the water to the make the right concentration of sanitizer. Review of the manufacturer's directions for use of the tablets revealed staff needed to increase the amount of water in the sanitizing compartment of the three-compartment sink and use hot water to dissolve the tablets. The dietary manager and the consultant dietitian were present and instructed the staff member to add more water and use two (2) tablets, not one (1). Additionally, they directed the staff member to use hot water, not just warm water from the tap. c) During observations of the medication pass on 06/23/09 at 9:35 a.m., the nurse was observed to pour water (for a resident to take medications) from a clear plastic pitcher. Observation of the water pitcher noted the inner rim beneath the pitcher was coated with a black layer of grime. This same substance was present on the inner portion of the plastic handle. The nurse agreed the pitcher was not clean and stated she had not noticed it. She obtained a cle… | 2014-12-01 |
| 10759 | 10759 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 492 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and review of the West Virginia Health Care Decisions Act, the facility failed to ensure the physician orders [REDACTED]. Resident identifiers: #26 and #77. Facility census: 75. Findings include: a) Resident #26 Review of the medical record found a POST form completed on [DATE]. Section A was documented the resident was to receive cardiopulmonary resuscitation (CPR) should he suffer cardiac or [MEDICAL CONDITION] arrest. Further review noted Section B directed the resident receive comfort measures. This section specifically states: "Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location." The two (2) sections, as completed, conflicted with the resident's wishes to receive treatment to support cardiac and [MEDICAL CONDITION] function. The POST form did not comply with the West Virginia Health Care Decisions Act [DATE](b) which states, "...in accordance with that person's wishes...". b) Resident #77 The medical record of this female resident contained a POST form dated "2/ /09" (date was incomplete), which was not signed by either the resident or the resident's legal surrogate for health care decisions. This was discussed with the office manager on the afternoon of [DATE], who verified the form was incomplete and that there was not way to determine whether the directives otherwise noted on the form reflected the actual wishes of the resident. . | 2014-12-01 |
| 10760 | 10760 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 161 | E | 0 | 1 | 667112 | Based on a review of the facility's surety bond and staff interview, the facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. Facility census: 77. Findings include: a) A review of the facility's surety bond revealed the facility had increased the amount of the bond from $20,000 to $40,000 to assure the security of the residents' personal funds. There was no evidence this new surety bond had been approved by the AG for sufficiency of form and amount, as required. The administrator verified, at 09/07/09 at 4:00 p.m., the bond with the new amount had not been approved by the AG's office. . | 2014-12-01 |
| 10761 | 10761 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 225 | E | 0 | 1 | 667112 | Based on a review of the facility's reported abuse investigations and staff interview, the facility failed to ensure an allegation of neglect was thoroughly investigated. Resident #78's family reported the resident had arrived at 2:00 p.m. on 08/22/09, and they reported to the nurse at 6:00 p.m. that no staff member had been in her room since she arrived. The report also stated an indwelling Foley urinary catheter bag had been put in the bed with the resident. During the investigation, a written statement by the nursing assistant providing care for the resident on 08/22/09 indicated the family told her a "shake" was also thrown in the corner of the sink and not given to the resident. A review of the investigation into allegations of neglect involving this resident revealed no evidence to reflect the allegations related to the nutritional supplement not being given and the Foley catheter bag laying in the resident's bed were further investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. Resident identifier: #78. Facility census: 77. Finding include: a) Resident #78 According to the facility's abuse reporting records, on 08/22/09, Resident #78's son came to the nurse and wanted to see the charge nurse. That nurse told him she was the charge nurse, and he asked her to come in the resident's room. When the nurse went in the room, he told her his mother (Resident #78) had arrived at the facility at 2:00 p.m. that day, and no staff member had turned her since she arrived and that a Foley catheter bag had been put in bed with the resident. This was at 6:00 p.m. on 08/22/09, and he wanted to make sure this did not happen again. This incident was reported to the State agencies including the nurse aide registry for the nursing assistant responsible for providing care to the resident at that time. A review of the facility's investigation found the family member told the nursing assistant there was a "shake" (nutritional supplement) for 2:00 p.m. that was "thrown"… | 2014-12-01 |
| 10762 | 10762 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 508 | D | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain radiology services in a timely manner as ordered by the treating physician for one (1) of thirteen (13) sampled residents. Resident identifier: #60. Facility census: 75. Findings include: a) Resident #60 Review of the medical record found a 02/19/09 physician's orders [REDACTED].-resistant Staphylococcus aureus (MRSA) had cleared. Review of the medical record found no evidence the facility had obtained the ordered radiology service for this resident. The director of nursing (DON) provided information which stated the CT would have been scheduled on 03/03/09. During an interview conducted on 06/25/09 at 9:15 a.m., the DON agreed staff should have either obtained the CT scan or called the physician. . | 2014-12-01 |
| 10763 | 10763 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-09-10 | 332 | E | 0 | 1 | 667112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and a review of the manufacturer's instructions for administration, the facility failed to assure it was free of medication error rates of greater than 5%. The facility had a medication error rate of 12.5 %. Medications not administered in accordance with the physician's orders [REDACTED]. Additionally, a nurse prepared to administer the incorrect vitamins, and a resident was not instructed to rinse his mouth out with water following the administration of the [MEDICATION NAME] Diskus. There were forty (40) opportunities with a total of five (5) medication errors observed. Resident identifiers: #75, #6, #63, and #47. Facility census: 77. Findings include: a) Resident #75 During the medication pass observation on 09/09 2009 at 9:00 a.m., the nurse (Employee #15) administered medications to Resident #75, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. b) Resident #6 During the medication pass observation on 09/09 2009 at 9:15 a.m., Employee #15 administered medications to Resident #6, including a dose of medication from a bottle labeled [MEDICATION NAME] 500 mg. Review of physician orders [REDACTED]. The dose administered did not match the medication ordered by the physician. c) Resident #63 During the medication pass observation on 09/09/09 at 9:20 a.m., the nurse administered medications to Resident #63, including the inhalant [MEDICATION NAME]. The nurse administered the [MEDICATION NAME] discus and then closed the Diskus and put it back in the cart. The nurse failed to instruct the resident to rinse his mouth out with water and spit after the administration of this medication. The nurse, when questioned about rinsing out the resident's mouth, she stated she was not aware that they had to do this. A review of the instruction sheet provided with … | 2014-12-01 |
| 10764 | 10764 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-09-10 | 520 | F | 0 | 1 | 667112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on information gathered on a revisit through observation, record review, and staff interview, the facility failed to implement a plan of action to correct identified quality deficiencies. The facility failed to correct deficient practices in six (6) of the same areas after the facility submitted an acceptable plan of correction indicating these concerns would be resolved prior to the end of August 2009. Repeat deficiencies were found in the areas of protection of residents funds, abuse investigating and reporting, care planning, medication errors, infection control, and isolation. This practice has the potential to affect all of the residents in this facility. Facility census: 77. Findings include: a) The facility's plan of correction for the standard survey completed on 06/25/09 was reviewed; however, deficient practices remained within respect to the following: 1. The facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. See citation at F161. 2. The facility failed to ensure an allegation of neglect was thoroughly investigated. The investigation was not thorough for one (1) of three (3) allegations of neglect that were reported. See citation at F225. 3. The facility failed to develop a plan of care to include the precautions to be taken during the care of residents who had a drug resistant infection. This was true for three (3) of three (3) residents reviewed who had a drug-resistant infection. See citation at F279. 4. The facility failed to administer a medication as ordered by the physician. This was a significant medication error affected one (1) of ten (10) sampled residents. See citation at F333. 5. The facility failed to implement an effective infection control program to prevent the potential spread of infections in the facility. The absence of an effective infect… | 2014-12-01 |
| 10765 | 10765 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-11-18 | 514 | B | 0 | 1 | 667113 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to utilize the correct reporting forms for submitting initial and five (5) day follow-up reports for allegations of resident abuse / neglect to the State survey agency's Nursing Home Program; failed to incorporate all necessary data onto one easy-to-read form for infection control tracking; and failed to ensure a transcription error did not occur for one (1) of forty-three (43) observed medication administrations. Facility census: 73. Findings include: a) Review of the facility's abuse policy, on 11/17/09, revealed, on page 3 Item #5 "Investigation and Reporting", the facility's plan to send immediate fax reportings of allegations and five (5) day follow-up reports to the State survey agency's Nurse Aide Abuse Registry. Review of all the self-reported allegations and their respective investigations for September, October, and November 2009 revealed several were submitted using the Nurse Aide Abuse Registry's reporting forms for instances where a nursing assistant was not involved in the alleged event and the Nursing Home Program's reporting forms (which is a separate program within the same State survey agency) should have been used, as follows: 09/13/09 involving Resident #34; 09/20/09 involving Resident #69; 09/24/09 involving Resident #34; 09/25/09 involving Resident #2; 09/29/09 involving Resident #67; and 10/04/09 involving Resident #25. Five (5) of the above events were related to unknown perpetrators, and one (1) event (dated 09/13/09) was related to a licensed practical nurse. In all of the cases, no allegations of abuse or neglect were substantiated. During interview with the director of nursing on 11/18/09 at 9:00 a.m., the above findings were discussed, and she received a copy of the two-page Table 1 - Abuse / Neglect Reporting Requirements for WV Nursing Homes and Nursing Facilities revised August 2009. She stated the social worker completes and faxes the five (5) day… | 2014-12-01 |
| 11112 | 11112 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2011-04-01 | 157 | D | 1 | 0 | 0DKH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to notify the legal representative of one (1) of three (3) sampled residents when she had been restrained to her bed without a physician's order. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found that, on 03/10/11 at approximately 9:00 p.m., a quality assistant (QA - Employee #0) reported Resident #65's was restrained in her bed by a tightly tucked blanket / sheet. Review of Resident #65's medical record found no physician's order or care plan for the resident to be restrained in her bed by the use of tightly tucked sheets or blankets. Review of the facility's interview investigation, and interviews with facility staff and former staff conducted on 03/30/11, 03/31/11, and 04/01/11, confirmed the blanket / sheet on Resident #65's bed had been tightly tucked beneath her bed to the point that staff had to tear the blanket / sheet in order to free the resident. An interview with the director of nursing (DON), on the afternoon of 03/31/11, elicited that Resident #65's legal representative was not contacted about the incident nor informed that the resident had been restrained without a physician's order, until he came into the facility on [DATE]. The DON stated the legal representative relayed that a woman had called him and told him Resident #65 had been found tied to her bed. . | 2014-08-01 |
| 11113 | 11113 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2011-04-01 | 221 | D | 1 | 0 | 0DKH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, staff interviews, and review of the State Operations Manual (Appendix PP - Guidance to Surveyors), the facility failed to assure one (1) of three (3) sampled residents was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found a former quality aide (QA - Employee #0) reported Resident #65 had been restrained in her bed by the use a of tightly tucked blanket / sheet at approximately 9:00 p.m. on 03/10/11. Review of Resident #65's medical record found no evidence the treating physician ordered the resident to be restrained while in the bed. Further review of the medical record found a minimum data set (MDS) with an assessment reference date (ARD) of 01/17/11. Review of this MDS revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed as having long and short term memory problems and difficulty focusing attention with disorganized thinking, and she displayed moderately impaired cognitive skills for daily decision making with noted delusions. She is always incontinent of bowel and bladder. She required one person physical assistance with bed mobility, transfers, dressing, eating, personal hygiene and total assistance with bathing. -- The following interviews were conducted with former and current staff: 1. Employee #0 (a QA) Employee #0 was interviewed at 9:59 a.m. on 04/01/11. She stated she was working the evening shift on 03/10/11 at approximately 9:00 p.m., when she walked past Resident #65's room and heard her call out "Baby Doll". Employee #0 stated she entered the resident's room to determine if the resident was trying to get up or had fallen. She noticed Resident #65 was lying on her back and was trying to raise her upper body … | 2014-08-01 |
| 11114 | 11114 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2011-04-01 | 225 | D | 1 | 0 | 0DKH11 | . Based on staff interview, review of the facility's abuse / neglect policies, and review of facility documents, the facility failed to ensure all allegations of abuse / neglect were immediately reported in accordance with State law for one (1) of two (2) allegations. Additionally, the facility failed to conduct a thorough investigation into this allegation, which was that a certified nursing assistant (CNA) was giving residents oral medications and an insulin injection. Facility census: 84. Findings include: a) During an interview conducted with a quality aide (QA - Employee #0) on the morning of 03/30/11, she stated she had reported to a licensed practical nurse (LPN - Employee #83) that a CNA (Employee #64) was witnessed giving oral medications and an insulin shot around the first part of February 2011. Review of the facility's reportable files for the previous three (3) months found no evidence the LPN reported this allegation as required. Review of the facility's abuse and neglect policies found the following: "THE INDIVIDUAL WHO OBSERVES AN INCIDENT OF ABUSE OR NEGLECT MUST BE THE ONE WHO REPORTS IT. THIS MUST BE REPORTED IMMEDIATELY TO THE LOCAL DEPARTMENT OF HUMAN SERVICES, ADULT PROTECTIVE SERVICE DIVISION...". When interviewed on the afternoon of 03/31/11, Employee #83 confirmed Employee #0 had reported this alleged abuse / neglect to her. She stated she did not report the allegation, and she could provide no evidence that a thorough investigation had been conducted. | 2014-08-01 |
| 1530 | 1530 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 558 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and resident interview, the facility failed to provide services for reasonable accommodation of resident needs and preferences for two (2) of 20 residents reviewed during the long-term care survey process. The facility failed to install bed rails for mobility in a timely manner for Resident #219. The facility also failed to ensure the call light was in reach for Resident #30. Resident identifiers: #219, #30. Facility census: 62. Findings include: a) Resident #219 On 02/04/19, Resident #219 called the Office of Health Facility Licensure and Certification (OHFLAC)to report complaints about her care at the facility. The complaints included the allegation that bed rails were not installed on her bed in a timely manner to assist her in getting out of bed after she had neck surgery. Resident #219 was not available by telephone during the survey. Review of Resident #219's medical records revealed she had been admitted to the facility following hip replacement surgery. While she was residing in the facility, Resident #219 was developed weakness in her arms. A [DIAGNOSES REDACTED]. Resident #219 returned to the facility after her surgery on 10/03/18. After Resident #219 returned to the facility, a physician order [REDACTED]. The treatment record verifies side rails were placed on Resident #219's bed on 11/27/18. During an interview on 02/14/19 at 8:16 AM, the Director of Nursing (DON) stated, recalled Resident #219 had gone without side rails for a period of time after returning to the facility following her neck surgery. The DON stated, no documentation regarding the matter. She stated the matter had been referred to the facility's corporate compliance program after the bed rails had been installed. b) R #30 On 02/11/19 at 12:14 PM a random observation revealed R #30 lying in her bed with her call light lying on the floor between the bed and the wall. On 02/11/19 at 03:14, observed R #30 struggling… | 2020-09-01 |
| 1531 | 1531 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 578 | F | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure three (3) of three (3) residents had a the right to formulate an advance directive. Physician order [REDACTED]. The trial period was not established. Resident identifiers: #318, #39, and #49. Facility census: 62. Findings included: a) Resident #318 Medical record review for Resident #318 included a POST form. Resident #318's Medical Power of Attorney (MPOA) had signed the POST on 01/21/19. Section C of the POST addressed medically administered fluids and nutrition. Intravenous (IV) fluids for a trial period are part of this section. Resident #318's POST did not include a length of time for the trial period for IV fluids b) Resident #39 Medical record review for Resident #49 included a POST form completed on 11/15/18. Resident #39's MPOA had signed the POST on 11/15/18. Section C of the POST addressed medically administered fluids and nutrition. This section contained a box to check if the MPOA wanted the resident to have IV fluids for a trial period. Resident #49's MPOA had selected this option. The trial period of time had not been addressed on the POST. c) Resident #49 Medical record review for Resident #49 included a POST form completed on 01/09/19. Resident #49 had signed the POST form on 01/09/19. The resident had indicated he did not want to be resuscitated. Section C of the POST addressed medical administered fluids. Resident #49 had selected to have IV fluids for a trial period of time. The length of the trial period had not been selected. A review of the (YEAR) edition of using the POST form guidance for health care professionals revealed the following regarding section C. IV Fluids for a Trial Period of No Longer Than - A patient or representative/surrogate may decide on a defined trial period of fluids to see if this treatment benefits the patient (for example correcting dehydration from a [MEDICAL CONDITION] gastroenteritis). The recommended trial period is … | 2020-09-01 |
| 1532 | 1532 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 585 | D | 0 | 1 | Y5ZN11 | Based on resident interview and staff interview, the facility failed to ensure one (1) randomly interviewed resident who attended the group meeting felt comfortable making complaints about her care. Resident identifier: #17. Facility census: 62. Findings included: a) Resident #17 On 01/12/19 at 1:55 PM Resident #17 who attended the group meeting said she had some concerns about her care the night before. She said that on the night of 01/11/19 her nurse aide had not changed her brief. She explained that she was able to put on pull ups by herself but needed assistance with putting on a brief for the night. At 4:00 PM on 01/12/19 the Center Nurse Executive (CNE) was informed about Resident #17's complaints about her care on 01/11/19. At 4:45 PM on 01/12/19 the Center Executive Director (CED) and CNE both said they would report the allegations made by Resident #17 to the State agencies. At 9:00 PM on 01/12/19 Resident #17 said she felt she had talked too much in the group meeting held earlier in the day. She said, the CNE and CED had came to her after the surveyor had informed them of the complaint. Resident #17 said, CNE and CED both said they wished she had came to them first. She said, the CNE told her she wished she could have told her instead of bringing the issue out in the meeting. Resident #17 said, they (CNE and (CED) both told her she knew she could come to them with anything. Resident #17 said this made her feel like she had done something wrong by not going to the CNE and CED first. She specifically stated, Felt she had tattled. On 01/13/19 at 8:30 AM, the CNE said, helped Resident #17 with some computer issues on the afternoon of 01/12/19. She had and felt it was odd that Resident #17 never mentioned anything to her about the complaints regarding her care on 01/11/19. The CNE never told the resident she wished she had came to her before bringing up the issue in the group meeting. The CNE told the resident that she knew she could come to her with anything. During an interview on 01/13/19 at 8:45 AM, the C… | 2020-09-01 |
| 1533 | 1533 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 656 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview and policy review; the facility failed to develop and/or implement care plans in the care areas of [MEDICAL TREATMENT], oxygen therapy, and communication. This is true for three (3) of seventeen (17) resident's care plan reviewed during the annual Long-Term Care Survey Process (LTCSP). Resident Identifier: #2, #30, and #39. Facility Census: 62. Findings included: a) Resident (R#2) Review of R#2 care plan, on 02/12/19 at 04:01 PM, revealed a Focus area Resident is at risk for impaired renal function and is at risk for complications related to [MEDICAL CONDITION]. The focus area had an intervention stating - [MEDICAL TREATMENT] at (name of [MEDICAL TREATMENT] Center) on . Send double bagged snack with resident to [MEDICAL TREATMENT]. On 02/11/19 at 12:31 PM, R#2 stated, treatment is provided at an outpatient [MEDICAL TREATMENT] center. The facility does not send any food or snacks with him when he goes to [MEDICAL TREATMENT]. An observation at 12:40 PM on 02/11/19 revealed no bagged snack provided upon R #2's transport to the [MEDICAL TREATMENT] Center. b) Resident (R#30) An observation on 02/11/19 at 03:16 PM, revealed R#30 receiving oxygen (O2) via nasal cannula (NC) with the flow meter registering 3 1/2 liters (L) per minute. Upon request, Licensed Practical Nurse (LPN) #15 verified the O2 settings at 3 1/2 [MI] LPN #15 stated, That's wrong she (R#30) is to be on continuous oxygen at 3 liters/minute. LPN #15 immediately adjusted the O2 flow meter to 3 liters/minute. Record review on 02/14/19 at 11:56 AM, revealed an order stating (typed as written), O2 @3 L/min via NC. The care plan included a focus area, Resident at risk for experiencing respiratory distress related to DX of [MEDICAL CONDITION] ([DIAGNOSES REDACTED]. An intervention included Oxygen to be administered as ordered via nasal cannula. c) Resident #39 On 02/11/19 at 2:17 PM an observation of Resident #39 rev… | 2020-09-01 |
| 1534 | 1534 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 657 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to revise the care plans for two (2) of seventeen (17) residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident #62's care plan was not revised in the area of positioning to reflect noncompliance. Resident #80's care plan was not revised to include updated treatment schedule for [MEDICAL TREATMENT]. Resident identifiers: #62 and #80. Facility census: 62. Findings included: a) Resident #62 Review of the care plan on 02/12/19 at 2:00 PM, found a focus/problem of, Resident is at risk for skin breakdown as evidence by limited mobility, recurring MASD (moisture associated skin damage), [DIAGNOSES REDACTED]. The goal (Revised 09/20/18, target date of 05/09/19) associated with the problem were: - Resident will not show signs of skin breakdown through next review. Interventions included: - Float heels while in bed. - Wedge pillow for positioning while in bed. Observation of Resident #62 on 02/12/19 at 4:00 PM and 8:47 PM revealed positioning device wedge pillow not in use, and not positioned with heels floated while in bed. During an interview at 11:40 AM on 02/13/19, Resident #62 stated, Don't like my feet elevated or touched, not comfortable with any kind of pillow under my back and like to lie flat in bed with head slightly elevated. At 11:45 AM on 02/13/19, Nurse Aide (NA) #46 stated, That wedge pillow has not been in her (Resident #62) room for a long time, she doesn't let us use it and she hates for her feet to be touched or elevated. At 11:50 on 02/13/19, Unit Manager, Licensed Practical Nurse (LPN) #5 confirmed Resident #62's care plan still reflected positioning orders of a wedge pillow and floating heels which the resident refuses. LPN #5 agreed the care plan needed updated to reflect Resident #62's refusal/noncompliance. with positioning and devices. b) Resident #2 Review of medical record on 02/12/19 at 12:30 PM, revealed an order dated 02/01… | 2020-09-01 |
| 1535 | 1535 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 676 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview the facility failed to ensure one (1) of one (1) resident reviewed for communication with a [DIAGNOSES REDACTED]. Resident identifier: #39. Facility census: 62. Findings included: a) Resident #39 On 02/11/19 at 2:17 PM an observation of Resident #39 revealed this resident was not easily understood. A review of the speech therapy initial evaluation completed on 12/03/18 reflected the resident had the following Diagnoses: [REDACTED].>Dysarthria and (a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system characterized by poor articulation of phonemes. In other words, it is a condition in which problems effectively occur with the muscles that help produce speech, often making it very difficult to pronounce words) [MEDICAL CONDITION] (an inability to comprehend or formulate language because of damage to specific brain regions). Section B of the quarterly minimum data set (MDS) assessment reference date (ARD) 01/11/19 indicated the resident had unclear speech and sometimes understands and responds adequately to simple direct communication only. The speech therapy initial evaluation short team goal included the following short term goal, Pt (patient) will utilize gestures/pictures/simple communication boards with 90% accuracy with opportunities to communicate when message not understood by listener to increase his effective expression of wants and needs. An observation on 02/11/19 at 2:17 PM revealed the communication book was not located in the resident's room. On 02/11/19 at 2:17 PM Coordinator Clinical Reimbursement (CCR) #51 said, the resident did have a communication book. At 1:31 PM Registered Nurse #35 entered the resident's room to try to locate his communication book. She said, he had gotten upset recently because his family would not take him home and threw the book into the hallway. She located the communication book at th… | 2020-09-01 |
| 1536 | 1536 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 684 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 residents' choices. This practice was found for two (2) of 17 residents reviewed during the long-term care survey process. The facility failed to ensure Resident #23 received laboratory testing according to the physician orders. The facility also failed to ensure Resident #30 was properly aligned and positioned while in bed. Resident identifiers: #23 and #30. Facility census: 62. Findings include: a) Resident #23 Review of Resident #23's medical records revealed a physician order [REDACTED]. A CBC is a laboratory test that gives information about cells that make up the blood. The record lacked CBC testing results for (MONTH) (YEAR). On 02/13/19 at 11:39 AM, the Director of Nursing (DON) presented a laboratory testing log dated 11/05/18. The phlebotomist attempted but was unable to obtain blood for the testing. According to the laboratory testing log, Resident #23's physician was notified and ordered the CBC testing to be canceled at this scheduled time. On 02/13/19 at 11:39 AM, the Director of Nursing (DON) presented a laboratory testing log dated 12/03/18. The DON stated, Resident #23 had a CBC ordered and the blood was going to be drawn by a Registered Nurse (RN), because the resident had a peripheral intravenous line. In (MONTH) the Phlebotomist was unable to obtain the laboratory blood sample. The DON further stated, unable to locate any documentation that Resident #23 had CBC testing in (MONTH) (YEAR). b) Resident (R#30) On 02/11/19 at 03:14 PM, observation of R#30 revealed the resident lying with poor body alignment. The head of the bed was elevated at forty-five (45) degrees, with two (2) pillows placed under the resident's head. The pillows behind her head had her head bent forward with her chin against h… | 2020-09-01 |
| 1537 | 1537 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 689 | D | 0 | 1 | Y5ZN11 | Based on record review and staff interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control. The facility failed to evaluate, analyze hazards and risks to implement fall prevention interventions for one (1) of three (3) residents reviewed for the care area of accidents. Resident identifier: #47. Facility census: 62. Findings included: a) Resident #47 Review of Resident #47's medical records revealed the resident had experienced falls on 06/12/18 and 08/01/18. The facility's Falls Management Policy included the process to conduct interdisciplinary team meeting within 72 hours of the fall. Review of Resident #47's medical records did not demonstrate interdisciplinary team meetings were conducted within 72 hours of her falls on 06/12/18 and 08/01/18. During an interview on 02/13/19 at 12:36 PM, the Director of Nursing (DON) stated the purpose of post-fall interdisciplinary meetings was to determine the root cause of falls and develop interventions to prevent additional falls. The DON stated, post-fall interdisciplinary meetings were not held following Resident #47's falls on 06/12/18 and 08/01/18. | 2020-09-01 |
| 1538 | 1538 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 692 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to accurately assess and record the percentage of food consumed for a [MEDICAL TREATMENT] resident. This was true for one (1) of three (3) residents reviewed for the care area of Nutrition. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #2. Facility Census: 62 Findings included: On 02/11/19 at 12:31 PM, during an interview with R#2, the resident stated he goes out of the facility to a [MEDICAL TREATMENT] center for [MEDICAL TREATMENT] treatment. R#2 said the facility does not send any food or snack with him when he goes to [MEDICAL TREATMENT]. At 12:39 PM on 02/11/19, a lunch tray was delivered to the resident's room. This surveyor stepped out into the hall so that the resident could eat his lunch. R#2 asked staff if he could have unsweet tea, and it was brought to him. At 12:40 PM on 02/11/19 an ambulance arrived to transport R#2 to the [MEDICAL TREATMENT] Center. The ambulance crew went to the resident's room and asked the resident if he was done eating, the ambulance crew stepped back into the hallway when the resident told them he was not done eating. At 12:43 PM, a nurse seeing the ambulance crew outside of the resident's room, hurriedly came down the hall into the Resident's room and asked if he was done eating, at that time the resident said he was done eating. The resident was placed on the ambulance gurney and was transported to [MEDICAL TREATMENT] without a bagged snack being provided by the facility or ample time for the resident to complete his lunch. On 02/11/19 at 12:49 PM, this surveyor viewed R#2 lunch tray, less than one fourth (1/4) of a sandwich had been consumed and a small glass was empty that appeared to have contained unsweet tea, everything else was left untouched on the lunch tray. Review of records provided by the Center Nurse Executive (CNE#27), on 02/13/19 at 11:44 AM, revealed lunc… | 2020-09-01 |
| 1539 | 1539 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 695 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure a resident receiving oxygen therapy was dispensed the prescribed amount. In addition failed to ensure the implementation of the care plan for the administration of oxygen therapy. This practice has the potential to affect a limited number of residents. Resident identifier: #30. Facility census: 62. Finding included: a) Resident (R#30) An observation on 02/11/19 at 03:16 PM, revealed R#30 receiving oxygen (O2) via nasal cannula (NC) with the flow meter registering 3 1/2 liters (L) per minute. Upon request, Licensed Practical Nurse (LPN) #15 verified the O2 settings at 3 1/2 [MI] LPN #15 stated, That's wrong she (R#30) is to be on continuous oxygen at 3 liters/minute. LPN #15 immediately adjusted the O2 flow meter to 3 liters/minute. Record review on 02/14/19 at 11:56 AM, revealed an order for [REDACTED]. The care plan included a focus area, Resident at risk for experiencing respiratory distress related to DX of [MEDICAL CONDITION] ([DIAGNOSES REDACTED]. An intervention included Oxygen to be administered as ordered via nasal cannula. | 2020-09-01 |
| 1540 | 1540 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 697 | E | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to complete the pain management flow sheet for PRN pain medication for one (1) of two (2) residents reviewed for the care area of pain. Resident identifier: #61. Facility census: 62. Findings included: a) Resident #61 Review of Resident #61's Medication Administration Records (MARs) for (MONTH) and (MONTH) 2019 demonstrated she had an order for [REDACTED]. --Pain Management Flow Sheet for (MONTH) 2019 showed no documentation for PRN pain medication given on 01/30/19 and 01/31/19. --Pain Management Flow Sheet for (MONTH) 2019 showed no documentation for PRN pain medication given on 02/02/19, 02/03/19, and 02/08/19. During an interview on 02/14/19 at 9:50 AM, Registered Nurse Unit Manager (RN UM) #62 stated, the PRN Pain Management Flow Sheet should be completed each time a PRN medication is administered to a resident. During an interview on 02/14/19 at 10:14 AM, the Director of Nursing (DON) confirmed the PRN Pain Medication Flow Sheet was not completed when Resident #61 received PRN pain medication on 01/30/19, 01/31/19, 02/02/19, 02/03/19, and 02/08/19. The DON had no further information regarding the matter. | 2020-09-01 |
| 1541 | 1541 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 761 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles in one (1) of two (2) medication carts observed. A multi-dose insulin pen and a multi-dose eye ointment located within the medication carts was not dated with the date of opening. This practice has the potential to affect more than a limited number of residents. Facility census: 62. Findings included: a) Medication Cart 100/300 Hallways On 02/12/19 at 11:15 AM observation of the medication cart for 100/300 hallways discovered the following undated medications: [REDACTED] --One (1) of seven (7) insulin pens ([MEDICATION NAME] Solution 100 UNIT/ML Insulin [MEDICATION NAME]). --One (1) of (1) antibiotic eye ointment ([MEDICATION NAME] Ointment 3.5 GM- -0.1, [MEDICATION NAME]-[MEDICATION NAME]-Dexameth). On 02/12/19 at 11:20 AM, Licensed Practical Nurse (LPN) #16 verified the insulin pen and antibiotic eye ointment lacked the date of opening. LPN #16 stated, they should have been dated, these are administered by previous shift, so I didn't know they were like this. Review of the facility's policy Storage and Expiration Dating of Medications, Biologicals, syringes, and Needles stated, Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. | 2020-09-01 |
| 1542 | 1542 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 810 | D | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, record review and staff interview, the facility failed to provide residents with appropriate adaptive devices for meals and hydration. This practice had the potential to affect more than a limited number of residents. Resident Identifier: #30 and #62. Facility Census: 62. Findings included: a) Resident (R#30) An observation on 02/11/19 at 03:14 PM, revealed R #30 lying in bed struggling to get a drink of water through a straw in a large pitcher located on the overbed table. R#30 eventually took the large plastic pitcher off the table, but still was unable to sip through the straw due to the straw being taller than the level of her mouth. On 02/11/19 at 03:20 PM, upon request Registered Nurse RN#54 entered R #30's room. RN #54 said, R#30 does not like the straw. She proceeded to pour water into the plastic cup and hand it to the resident. R#30 with shaking hands held the plastic cup and immediately drank two thirds (2/3) of the water. The large water pitcher was immediately replaced a more suitable smaller pitcher. b) Resident #62 Review of the care plan on 02/13/19 at 12:00 PM, found a focus/problem of, Resident is at nutritional risk due to elevated BMI (body mass index), [MEDICAL CONDITION] and non-compliance with her therapeutic diets in the past. Weight loss with [MEDICAL CONDITION] changes. The goals (Revised 09/20/18, with target date of 05/09/19) associated with the problem were: - Resident will maintain weight without significant change through the next review period. Interventions (initiated 01/14/19) included: - Kennedy Cup with all meals. - Provide rehab eating devices: Kennedy Cup during meals. At 12:35 PM on 02/13/19 observation of lunch tray for Resident #62 revealed, Assistive device Kennedy Cup was not available for Resident's use during mealtime. Resident #62 stated: I usually get a cup with lid, straw and handle with my tray. At the time of observation, only a clear, short, plastic cup, with no l… | 2020-09-01 |
| 1543 | 1543 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 842 | D | 0 | 1 | Y5ZN11 | Based on observation and staff interview, the facility failed to ensure the medication record information is kept confidential. Resident #49's medication record was left open and visible to anyone passing by the medication cart. In addition failed to ensure Resident #23's nutritional assessment was accurate in the area of pressure ulcers. Resident identifiers: #49 and #23. Facility census: 62. Findings included: a) Resident #49 On 02/13/19 at 10:10 AM an observation revealed the medication record was left open and flipped to Resident #49's record on the medication cart. The medication cart was sitting outside the nurses desk area. Residents as well as visitors passing by could easily read the information in the medication book. Nursing staff were inside the medication storage room behind the nurses station. They were not within eye sight of the medication record. At 10:25 AM on 02/13/19 Licensed Practical Nurse (LPN) #3, was asked to look at the medication book on the medication cart. LPN #3 then asked Registered Nurse #35 to close the book. b) Resident #23 Review of Resident #23's medical records reviewed a Nutritional Assessment was performed on 12/18/18. The question, Are there any pressure ulcers? was answered as no. On 12/18/18 at 9:37 AM, discovered a progress note stating, Dressing changed to sacrum as ordered. During an interview on 02/12/19 at 2:06 PM, the Director of Nursing (DON) stated the Nutritional Assessment performed on 12/18/18 was erroneous in stating Resident #23 did not have a pressure ulcer. | 2020-09-01 |
| 1544 | 1544 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 867 | D | 0 | 1 | Y5ZN11 | **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 (QAA) committee implemented a plan of correction for a quality deficiency which they knew or should have known about. Three (3) of three (3) residents reviewed for advance directives had a physician's orders [REDACTED]. The trial period had not been addressed with the three (3) residents. Resident identifiers: #318, #39, and #49. Facility census: 62. Findings included: a) Resident #318 Medical record review for Resident #318 included a POST form. Resident #318's MPOA had signed the POST on 01/21/19. Section C of the POST addressed medically administered fluids and nutrition. Intravenous (IV) fluids for a trial period are part of this section. Resident #318's POST did not include a length of time for the trial period for IV fluids b) Resident #39 Medical record review for Resident #49 included a POST form completed on 11/15/18. Resident #39's Medical Power of Attorney (MPOA) had signed the POST on 11/15/18. Section C of the POST addressed medically administered fluids and nutrition. This section contained a box to check if the MPOA wanted the resident to have IV fluids for a trial period. Resident #49's MPOA had selected this option. The trial period of time had not been addressed on the POST. c) Resident #49 Medical record review for Resident #49 included a POST form completed on 01/09/19. Resident #49 had signed the POST form on 01/09/19. The resident had indicated he did not want to be resuscitated. Section C of the POST addressed medically administered fluids. Resident #49 had selected to have IV fluids for a trial period of time. The length of the trial period had not been selected. A review of the (YEAR) edition of using the POST form guidance for health care professionals revealed the following regarding section C. IV Fluids for a Trial Period of No Longer Than - A patient or representative/surrogate may decide on a defined tria… | 2020-09-01 |
| 1545 | 1545 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2019-02-14 | 880 | F | 0 | 1 | Y5ZN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review the facility failed to implement infection control practices and processes designed to prevent transmission of disease, infection and/or cross-contamination. This is true for the following issues; failure to maintain negative air flow in the dirty laundry area, improper hand hygiene during wound care, and failing to provide a barrier between a clean and unclean surface. These practices had the potential affect more than a limited number of residents in the facility. Resident identifier: #37, and #62. Census :62 Findings included: a) Laundry room On 02/14/19 at 09:40 AM, inspection of laundry room and interview with the Laundry Director (Staff#76), revealed the exhaust fan was broken and there was not negative air flow in the dirty laundry room since 02/01/19. The dirty laundry room at the time of inspection was extremely hot and stuffy, staff used a window air conditioner to cool the room down when it became too hot. Staff #76 stated maintenance was waiting on the part to fix the fan. An interview with Maintenance Supervisor (Staff #32), on 02/14/19 at 09:54 AM, revealed the exhaust fan was ordered on [DATE]. Staff #32 said, The part came in yesterday (02/13/19). On 02/14/19 at 10:00 AM, an interview revealed the Administrator was not aware the exhaust fan was not working or that parts were ordered to fix it. When asked what his expectations were to have the exhaust fan fixed, the Administrator replied, I know how important it is to keep negative pressure, so my expectation is to fix it as soon as possible, when the part comes in. When informed the parts came in yesterday, The Administrator replied, We'll get on it now. b) #37 On 02/12/19 at 9:18 AM, during medication administration observation, Licensed Practical Nurse (LPN) # 3 removed Resident #37's [MEDICATION NAME] nasal spray, from its box in the medication cart drawer. She placed it on the medication cart while she prepared the r… | 2020-09-01 |
| 1546 | 1546 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2018-02-22 | 641 | D | 0 | 1 | TLOK11 | **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 two (2) of sixteen (16) residents reviewed during the annual long term care survey process. Resident identifiers: #50 and #55. Facility census: 60. Findings include: a) Resident #50 Review of a skin check performed on Resident #50 on 01/01/18 at 10:03 AM revealed the presence of a pressure ulcer on the left posterior thigh. On 01/07/18, Resident #50 was transferred to an outside hospital for evaluation of altered mental status. The Discharge - return anticipated Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/07/18 documented Resident #50 had one (1) stage 2 pressure ulcer. The MDS further documented this pressure ulcer was not present upon admission/entry or reentry. Resident #50 returned to the facility on [DATE]. Review of a skin check performed on Resident #50 on 01/15/18 at 10:37 PM revealed pressure ulcers on the left lower, middle, and upper posterior thigh. The five (5) day MDS with ARD 01/21/18 documented Resident #50 had three (3) stage 2 pressure ulcers. All three (3) of these pressure ulcers were documented as being present upon admission/entry or reentry. On 02/22/18 at 11:52 AM, Coordinator Clinical Reimbursement (CCR) #28 was interviewed. CCR #28 was informed the posterior thigh pressure ulcer should not have been coded on the MDS as present upon admission/entry or reentry because it had been acquired in the facility before transfer to the hospital. CCR #28 stated he was not aware if a resident who has a pressure ulcer that was originally acquired in the facility is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer should not be coded as present on admission because it was present and acquired at the facility prior to the hospitalization . b) Resident #55 Resident #55 had an order for [REDACTED]. Resident #55's MDS with ARD 11/23/17 documen… | 2020-09-01 |
| 1547 | 1547 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2018-02-22 | 655 | D | 0 | 1 | TLOK11 | Based on medical record review and staff interview, the facility failed to develop and implement a baseline care plan within forty-eight (48) hours of admission. The baseline care plan was not developed timely for Resident # 51, to include healthcare information necessary to properly care for this resident's immediate nutritional needs. This was true for one (1) of seven (7) new admission care plans reviewed. Resident identifier: #51. Facility census: 60. Findings include: a) Resident #51 A medical record review on 02/20/18 at 10:07 AM for Resident # 51 revealed the baseline care plan had not been completed within forty-eight (48) hours of her admission on 01/02/18. This baseline care plan is required to be completed timely to reflect necessary nutritional care for this resident's immediate needs. During an interview with the Director of Nursing (DON) on 02/20/18 10:43 AM, verified the nutritional baseline care plan for Resident #51 had not been completed within forty-eight (48) hours of her admitted on 01/02/18. | 2020-09-01 |
| 1548 | 1548 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2018-02-22 | 656 | E | 0 | 1 | TLOK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and/or implement an accurate and complete care plan for five (5) of sixteen (16) resident's whose care plans were reviewed. Resident #12's care plan was not implement for [MEDICAL TREATMENT] treatments and a care plan addressing nutrition for the [MEDICAL TREATMENT] resident was not developed. For Resident #41, the facility did not develop a care plan when the resident lost weight. For Resident #16 and #13 the care plans were not implemented addressing restorative therapy. For Resident #51 a care plan was not developed to address nutrition. Resident identifiers: #12, #41, #16, #13, #51. Facility census: 60. Findings include: a) Resident #12 1. Record review on 02/21/18, at 8:45 a.m., found the resident was receiving outpatient [MEDICAL TREATMENT] services for treatment of [REDACTED]. Review of the resident's current care plan found the following problem: --Resident is at risk for experiencing alterations in comfort level related to resident's impaired mobility, [MEDICAL TREATMENT], history of osteo[DIAGNOSES REDACTED], right lower leg fracture The goal associated with this problem was: --Resident will achieve acceptable level of pain (as determined by resident as four) through to the next review period . Interventions associated with the care plan included: --Emla cream as ordered prior to [MEDICAL TREATMENT]. Review of the treatment administration record found the following treatments ordered by the physician: --Apply EMLA cream to AVF (Arteriovenous fistula) (RUA) 1 hour prior to [MEDICAL TREATMENT], cover with dry dressing, one time a day every Monday, Wednesday, and Friday; (Emla cream is a local anesthetic (numbing medication) Review of the current TAR for February, (YEAR), found the Emla cream was not applied on the following [MEDICAL TREATMENT] days: --02/19/18 and 02/21/18. (On 02/21/18, at 8:45 a.m., the time of the record review, the resident had already left… | 2020-09-01 |
| 1549 | 1549 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2018-02-22 | 657 | D | 0 | 1 | TLOK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise the comprehensive care plan after a change in condition for two (2) of sixteen (16) residents reviewed during the long term care survey process. Resident identifiers: #50 and #48. Facility census: 60. Findings include: a) Resident #50 During observation on 02/20/18 at 1:23 PM, Resident #50 was noted to have a large amount of bilateral [MEDICAL CONDITION] of her feet. Review of the medical records, including a discharge summary from an outside hospital written on 01/14/18, documented the presence of chronic [MEDICAL CONDITION] with skin changes consistent with chronic [MEDICAL CONDITION]. Resident #50's comprehensive care plan included the following focus, Resident with [MEDICAL CONDITION] noted at times. This focus was created on 04/15/14 and revised on 07/31/14. Resident #50's comprehensive care plan included the following goal, Resident will not experience any signs/symptoms of fluid overload as evidenced by the absence of [MEDICAL CONDITION] and dypsnea through to the next review period. This goal was created on 04/15/14 and revised on 01/08/18. During an interview on 02/21/18 at 9:26 AM, Coordinator Clinical Reimbursement (CCR) #28 agreed Resident #50's [MEDICAL CONDITION] was present all the time. He also agreed the goal of absence of [MEDICAL CONDITION] was not realistic for Resident #50 at this time. CCR #28 stated he would correct the comprehensive plan of care for Resident #50. b) Resident #48 Resident #48 had the following foci on her comprehensive care plan: --Resident is at risk for injury or complications related to the use of [MEDICATION NAME]. This focus was initiated on 01/01/18. --Resident is at risk for complications related to the use of anti psychotic (sic), anti anxiety (sic) medication to treat anxiety and anti depressant (sic) medication to treat depression. This focus was initiated on 01/01/18. Review of Resident #48's current medic… | 2020-09-01 |
| 1550 | 1550 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2018-02-22 | 684 | D | 0 | 1 | TLOK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and provide treatment and care needed in accordance with professional standards of practice to meet the physical, mental and psychological needs of residents concerning weights, use of side rails and parameters of insulin. For Resident #51 the facility failed to follow physician orders [REDACTED]. For Resident #12, the facility failed to follow the physician ordered parameters for insulin. Resident identifiers: #51 and #12. Facility census: 60. Findings include: a) Resident #51 Record review found the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Weight record as follows: -- 01/03/18, the resident's weight was 95.6 pounds. -- 01/04/18, the resident's weight was 94.8 pounds. --01/19/18 two (2 weights recorded), the resident's weight was 86.6 pounds both times. Loss of 7.5% change {Comparison weight 01/03/18. 95.6 pounds, -9.4%, -9 pounds}. --01/25/18, resident's weight was 84.1 pounds. Loss 7.5% change {Comparison weight 01/03/18. 95.6 pounds, -12%, -11.5 pounds}. --02/09/18, resident's weight was 85.2 pounds. Loss of 7.5% change {Comparison weight 01/03/18. 95.6 pounds, -10.9%, -10.4 pounds}. Review of the History and Physical completed on 01/04/18 by the attending physician read: . weigh resident weekly foe four (4) weeks and then every two (2) weeks. No side rails . On 02/22/18 at 11:00 a.m., Resident #51's medical records was reviewed with the Director of Nursing (DON), she verified the resident had not been weighed according to the weight policy as well as the physician orders. She also verified the resident had side rails even though the physician ordered no side rails. b) Resident #12 Record review on 02/21/18, at 8:30 AM found a fifty-six (56) year old resident with end stage [MEDICAL CONDITION] receiving [MEDICAL TREATMENT]. The resident has a [DIAGNOSES REDACTED]. On 11/02/17, a physician's orders [REDACTED]. Review of the Medication Administration Recor… | 2020-09-01 |
| 1551 | 1551 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2018-02-22 | 688 | E | 0 | 1 | TLOK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide physician ordered restorative therapy services to maintain, improve or prevent avoidable decline in range of motion and mobility for one (1) of five (5) resident's reviewed for the care area of activities of daily living (ADL's) and one (1) resident reviewed for the care area of rehabilitation services. Resident identifiers: #16 and #13. Facility census: 60. Findings include: a) Resident #16 Review of the resident's medical record on 02/20/18 found two (2) physician's orders [REDACTED]. --Ambulate with assistance of 1 aide, requiring supervision for distance of 800 feet with use of rolling walker 5 days a week for 6 weeks. --Range of Motion all bilateral lower extremities joints-motion all planes with 10 repetitions x 3 sets with 3 pound weight or green thera-band 5 days a week times 6 weeks. Review of the restorative nursing record found: --Therapy began on 01/22/18 and continued to 01/26/18 (5 days). The resident did not receive therapy on 01/27/18 or 01/28/18. The next week of therapy started on 01/29/18 and continued until 01/31/18. (Only 3 days of therapy services.) The resident did not receive therapy for another 4 days, (02/01/18 through 02/04/18). The next week of therapy started on 02/05/18 and continued for 5 days until 02/09/18. The resident did not receive therapy again until 02/12/18. This week of therapy was only three days; 02/12/18, 02/13/18, and 02/14/18. The resident did not receive any therapy for the next four (4) days, (02/15/18 through 02/18/18). The following week of therapy started on 02/19/18. At 9:31 a.m. on 02/21/18, the director of nursing confirmed the resident did not receive restorative therapy 5 days a week as ordered by the physician. b) #13 Resident #13 had [DIAGNOSES REDACTED]. On 01/19/18 at 3:10 PM, Resident #13's attending physician wrote an order for [REDACTED]. On (MONTH) 21, (YEAR), review of Resident #13's Restorative Nursing R… | 2020-09-01 |
| 1552 | 1552 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2018-02-22 | 692 | E | 0 | 1 | TLOK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of nutrition to maintained acceptable parameters of nutritional status. Due to the failure of the registered dietician/ dietary staff to access Resident #51's nutritional needs the resident lost a significant amount of weight. The facility could not ensure the resident received the daily caloric and fluid intake recommended. Resident identifier: #51. Facility census: 60. Findings include: a) Resident #51 Record review found the resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Weight record as follows: -- 01/03/18, the resident's weight was 95.6 pounds. -- 01/04/18, the resident's weight was 94.8 pounds. --01/19/18 two (2 weights recorded), the resident's weight was 86.6 pounds both times. Loss of 7.5% change {Comparison weight 01/03/18. 95.6 pounds, -9.4%, -9 pounds}. --01/25/18, resident's weight was 84.1 pounds. Loss 7.5% change {Comparison weight 01/03/18. 95.6 pounds, -12%, -11.5 pounds}. --02/09/18, resident's weight was 85.2 pounds. Loss of 7.5% change {Comparison weight 01/03/18. 95.6 pounds, -10.9%, -10.4 pounds}. --02/14/18, resident's weight was 84.6 pounds. Loss of 7.5% change {Comparison weight 01/03/18. 95.6 pounds, -11.5%, -11.0 pounds}. Policies Review: --Nutrition Care Process: Each resident will be visited and assessed upon admission and routinely thereafter. Nutritional care process is to assure each resident receives timely, individualized, and consistent nutritional care. Nutritional assessment is completed by the Registered Dietician (RD) completes a comprehensive assessment for resident's determined to of nutritional concern. --Weight Policy: Residents are weighed upon admission and then weekly for four (4) weeks and then monthly. Purpose of policy is to obtain a baseline weight and identify significant weight changes and to determine possible causes of si… | 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 );