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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 600 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, abuse and neglect policy review, staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to provide necessary care and services to Resident #92 in preparation for scheduled appointments outside of the facility, of which the facility was aware of or should have been aware. The facility also failed to provide Resident #92 care and services in the care areas concerning baths and shaving. This was true for one (1) of six (6) sample residents dependent for care. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Scheduled appointments outside of the facility Resident #92 is a paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. He is totally dependent for all care, is legally blind, and newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of records on 02/05/18 at 2:55 PM revealed a significant change minimum data set (MDS) with an assessment reference date (ARD) 01/04/18. The resident had impaired vision (legally blind); had clear speech, was able to understand and make himself understood. The MDS revealed a Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident was cognitively intact. Resident #92 needed extensive assistance with eating and was dependent for all other activities of daily living (ADL) including bed … | 2020-09-01 |
| 2 | 2 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 656 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and Center (VAMC) staff interviews, the facility did not implement interventions in Resident #92's care plan to meet the resident's preferences and address the resident's medical, physical, mental and psychosocial needs. This pertained to the care area of activities of daily living (ADL), concerning shaving Resident #92 daily. This was true for one (1) of three (3) care plans reviewed for resident's totally dependent for ADL care. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Observations, on 02/05/18 at 11:55 AM., revealed Resident #92 appeared clean, without any body odors, Foley catheter was draining to drainage bag on bedside. The resident was lying in his bed, eyes closed with hair stubble noted on resident's chin. The resident has a special needs call light (Blow call light) to accommodate resident due to paralysis and inability to use hands, and it was within reach of the resident. On 02/06/18 at 9:05 AM, review of grievance and concerns revealed on 09/12/17 the resident complained . he was not being shaven adequately to allow f… | 2020-09-01 |
| 3 | 3 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 657 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility did not revise a care plan to meet the resident's medical, physical, mental and psychosocial needs. Resident #92's care plan was not revised with resident specific interventions to address the resident's newly diagnosed fractured neck. This was true for one (1) of three (3) care plans reviewed. This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #92. Facility census: 107. Findings include: a) Resident #92 Resident #92 is a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder. The resident is incontinent of bowel and has a Foley catheter. He is totally dependent for all care, and was newly diagnosed with [REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve produces numbness, paresthesia (pins and needles), and paralysis of the arms. Records show both Resident #92's forearms, wrist, and hands were affected by and show symptoms of the C5 compression. Interview with the Minimum Data Set Registered Nurse (RN#49), on 02/07/18 at 11:55 AM, revealed the resident was found to have cord compression of his cervical spine and a fracture. RN#49 said this was found after the resident was admitted to the Veterans Administration Medical Center (VAMC), on 12/11/17, due to suddenly having problems with both his arms. RN#49 said the VAMC recommended the cervical collar. When asked where the physician's orders [REDACTED]. RN#49 requested the Coordinator Health Information Management, Staff#73, to try and locate the order. The Coordinator Health Information Management Staff#73, on 01/07/18 at 12:17 PM, agreed there should have been an order for [REDACTED]. Review of Resident#92's care plan with RN#49 revealed there were no resident specific interventions to ad… | 2020-09-01 |
| 4 | 4 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 677 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, facility staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to ensure Resident #92 received the care and services regarding an aspect of his life in the facility which was significant to the resident regarding bathing and shaving, and did not receive proper grooming when going to appointments outside the facility. This was true for one (1) of eleven (11) sample residents. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Baths and shaving On 02/06/18 at 9:05 AM, review of grievance and concerns revealed a grievance dated 09/12/17 revealing one of the issues was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face. Resolution to the concerns were completed by 09/ 27/17 with staff being educated, Kardex being updated with the resident's preferences. The KARDEX provides specific instructions for the nursing assistants concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed it was important for resident to choose between a tub bath, shower, bed bath, or sponge bath, and under skin care it was noted as written ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. Resident #92 a legally blind paraplegic, totally dependent for all care, was to receive a shave and bed bath daily. The resident was incontinent of bowel and had a Foley catheter. Review of the ADL (activities of daily living) Record, on 02/07/18 at 4:00 PM, revealed during the month of (MONTH) (YEAR), Resident#92 had a minimum of twenty-five (25) opportunities to receive a bed bath and he only received fifteen (15) according to the ADL Record. There are thirty-one (31) days in … | 2020-09-01 |
| 5 | 5 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 684 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide a resident with the necessary care and services to maintain the highest practicable level of well-being for one (1) of three (3) sample resident reviewed for neglect during a complaint investigation. The facility failed to obtain a physician's orders [REDACTED].#92, after being diagnosed with [REDACTED]. Resident identifier: #92. Facility census: 107. Findings include: a) Resident #92 On 02/05/18 at 12:48 PM, review of records revealed Resident #92, a legally blind paraplegic (paralysis of legs and lower body) with [MEDICAL CONDITION] bladder, totally dependent for all care, was admitted to the Veterans Administration Medical Center (VAMC) on 12/11/17 due to complaints of numbness of his arms, inability to raise his arms, and nausea. Resident returned to the facility on [DATE] with a new [DIAGNOSES REDACTED]. C1 indicates the first cervical vertebrae. Cervical vertebrae are bones that are a part of the neck. C1 is located at the base of the head. Compression or a pinching of the C5 nerve can produce numbness, paresthesia (pins and needles), and paralysis of the arms. Records show Resident #92's forearms, wrists, and hands were affected and symptomatic from the C5 compression. Review of medical records from VAMC physician progress notes [REDACTED]. C5 shows chronic cord compression possibly from an old trauma. Review of VAMC physician progress notes [REDACTED]. Resident#92 returned to the facility and with a soft cervical collar. Interview with the Minimum Data Set Registered Nurse (RN#49), on 02/07/18 at 11:55 AM, revealed the resident was found to have cord compression of his cervical spine and a fracture. RN#49 said this was found after the resident was admitted to the Veterans Administration Medical Center (VAMC), on 12/11/17, due to suddenly having problems with both his arms. RN#49 said the VAMC recommended the soft cervical collar. When asked where the physicia… | 2020-09-01 |
| 8 | 8 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 253 | E | 1 | 1 | ELSQ11 | > Based on observation and staff interview, the facility failed to provide housekeeping and/or maintenance services necessary to maintain a comfortable and sanitary interior. This was evident for fifteen (15) of thirty-four (34) rooms observed during Stage I of the Quality Indicator Survey. Cosmetic imperfections or items in need of repair and/or cleaning in resident rooms included discolorations of the toilet bowl jets, debris noted on the floor for prolonged period of time, window sills and/or window blinds dirty/dusty in need of cleaning, a sliding curtain type bathroom door with a black-colored substance on the bottom portion, caulk missing around a toilet base, veneer missing from a bathroom door with the wood or particle board beneath it visible, cove base pulled away from the wall in a bathroom, the inside of a wall heating unit had a dirty vent with loose debris, and a piece of wallpaper not adhered to a wall. Affected rooms included room #101, #102, #103, #104, #105, #106, #111, #118, #126, #128, #129, #134, #141, #142, and #163. Facility census: 116. Findings include: a) Stage I findings During Stage I of the Quality Indicator Survey on 05/15/17 and on 05/16/17, thirty-four (34) resident rooms were observed. Of that number, fifteen (15) rooms were found with concerns related to maintenance and/or housekeeping issues. The identified rooms were toured with Housekeeping Manager (HM) #83 on 05/17/17 between 3:00 p.m. and 3:30 p.m., and with Maintenance Supervisor (MS) #88 between 3:30 p.m. and 3:45 p.m. Identified concerns were: - Room 101 The water jets in the toilet looked dirty. During a tour on 05/17/17, HM #83 said they had been using a type of acid-base cleanser to try to remove the discoloration as other products have not worked as well. A small piece of tissue lay on the floor at the head of the bed next to the window. Beneath that bed was what looked like a broken piece of hard, white colored vinyl. These objects were first observed on the floor on 05/16/17 at 11:14 a.m. On 05/17/17 at approximatel… | 2020-09-01 |
| 13 | 13 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 309 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure eight (8) of thirty-two (32) Stage 2 residents received care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being. The facility did not assess and monitor a resident's pain, did not ensure implementation of physician's orders [REDACTED].#163). Staff failed to properly position residents during meals and/or in bed (#76 and #101), did not ensure monitoring of residents receiving [MEDICAL TREATMENT] (#159 and #45), did not obtain neuro checks after a fall (#59), and did not follow physician's orders [REDACTED].#59). For Resident #100, the facility failed to monitor the resident's [MEDICATION NAME] as ordered and failed to provide physician ordered foods to Resident #124. Additionally, the facility failed to follow orders for restorative ambulation for and assessment of a pulse rate prior to administration of a medication. Additionally, the facility failed to follow physician's orders [REDACTED].#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141). Facility census: 116. Findings include: a) Resident #163 1. Medical record review revealed a physician's orders [REDACTED]. Another order noted to cleanse an unstageable wound to the right second toe with wound cleanser and apply sure prep daily. Observation of wound care on 05/18/17 at 10:21 a.m., with Licensed Practical Nurse (LPN) #72, revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. When asked whether the unit charge nurses completed treatments, the LPN said she completed the treatments for the entire facility. The medical record and treatment administration records, reviewed for (MONTH) and (MONTH) (YEAR), revealed no evidence the treatment for [REDACTED]. No … | 2020-09-01 |
| 18 | 18 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 353 | E | 1 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, visitor interview, staff interview, medical record review, observation, and policy review, the facility failed to ensure sufficient staff to implement resident care plans and respond to residents' needs for thirty-four (34) of thirty-four (34) residents reviewed for restorative services (#101, #104, #105, #107, #112, #116, #121, #124, #125, #150, #153, #16, #160, #187, #192, #195, #2, #20, #21, #26, #31, #37, #4, #45, #47, #49, #5, #59, #61, #64, #7, #76, #82, and #141) and twelve (12) residents (#93, #125, #34, #43, #103, #126, #41, #121, #22, 104, 189, and #93) observed during the dining experience. Facility census: 116. Findings include: a) Resident #76 Medical record review found a minimum data set (MDS) with an assessment reference date (ARD) of 05/09/17 that identified Resident #76 required the extensive assistance of one (1) person for bed mobility. The MDS indicated the resident had impairment on both sides of his upper and lower extremities. The resident received hospice services for end of life care related to end stage [MEDICAL CONDITIONS]. Nurse Aide (NA) #135, interviewed on 05/23/17, verbalized Resident #76 had gotten weak and now staff did more for him than he did for himself. She said he was not eating at all. Licensed Practical Nurse (LPN) #62 concurred the resident had a recent decline. A Stage 1 observation on 05/15/17 at 2:14 p.m. found Resident #76 leaning to the right side without support to maintain an upright position. On 05/23/17 at 9:12 a.m., the resident was in bed lying on his back with the head of the bed elevated to about 45 degrees. The resident had slid down in bed. At 2:44 p.m., an observation revealed Resident #76 slid down in bed and was eating lunch. An unidentified NA was feeding the roommate and his brother and sister-in-law were standing at the bedside. Licensed Practical Nurse (LPN) #62 observed the resident and confirmed he was not positioned correctly and needed pulled u… | 2020-09-01 |
| 51 | 51 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 689 | D | 1 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide adequate supervision in accordance with the resident's plan of care to prevent accidents. Specifically, two (2) residents reviewed for Accidents, the facility failed to follow aspiration precautions when each was allowed to use a straw despite physician's orders [REDACTED]. Resident identifiers: #93 and #8. Facility census: 142. Findings included: a) Resident #93 Review of the care plan, dated 3/5/18, revealed Resident #93 had nutritional risks based, in part, on a recent [DIAGNOSES REDACTED]. Review of the current Kardex (care directives provided for and used by Certified Nurse Aides - CNA) revealed Diet: ST (speech therapy) Orders: no straw protocol w/ liquids. The physician's orders [REDACTED]. Observation on 5/2/18 at 8:43 AM revealed CNA #110 place a breakfast tray in front of Resident #93. The CNA set up the resident's meal, including opening the resident's milk carton, placed it in front of him, and left. A straw was observed on the tray. Resident #93 picked up the straw, removed the paper wrap and placed it in the milk carton. He then began to drink using the straw. CNA #105 and #110 both passed by in the next few minutes, but did not intervene. There was no nurse on the unit during this observation. The meal card on the resident's tray did not identify the resident was not to have straws. In an interview on 5/2/18 at 8:52 AM CNA #110 stated she was not aware the resident was not supposed to have a straw. She said she did not think it was identified on the Kardex. At 9:01 AM CNA #105 stated she did not know Resident #93 was not supposed to have a straw. In an interview on 5/2/18 at 10:41 AM Nurses #3 and #82 explained there were three nurses splitting Unit 5 today. They explained there were extended periods of time they would each be on their other respective units, and so no nurse would be present on Unit 5. Both stated they were not aware Resident #9… | 2020-09-01 |
| 53 | 53 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 725 | E | 1 | 1 | X20F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure an adequate number of nurses and certified nursing assistants (CNAs) were present on a regular basis to provide care and supervision to residents. This resulted in extended call light response times, delays in meal delivery and assistance with eating, failure to follow care plans with regards to swallowing precautions, and extended periods of time where no staff were available on a unit. This failed practice had the potential to affect more than a limited number of residents. Facility census: 142. Findings included: a) Resident Council Review of Resident Council meeting minutes revealed residents voiced concern about staffing at the 3/6/18 meeting. Specifically, Extended call light response time was voiced. A resident discussed having had to wait 1.5 hours for her call light to be answered. (She needed a bed pan). The identified action was that the facility will reinforce to all staff that all employees are responsible for answering all call light. Additionally, residents voiced a concern regarding the Shortage of qualified nursing staff. The facility noted they would be offering another CNA class within the following months and that volunteers are continuously being sought. In addition, Coverage for extensive call-offs was voiced. Administration identified benefits being offered in an attempt to hire new staff. In a Resident Council meeting held as part of the survey process on 5/1/18 at 11:00 AM, residents voiced ongoing concerns about staffing. One resident stated her roommate recently waited an hour to be put to bed. She stated the staff working are very good, there just are not enough staff to meet needs timely. Resident #21 stated on night shift, she frequently waited 45 minutes to be placed on the bed pan and then another 45 minutes to be taken off the bedpan. Several other residents at the meeting reported waiting to be gotten out of bed in the morning, … | 2020-09-01 |
| 54 | 54 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2018-05-03 | 805 | E | 1 | 1 | X20F11 | > Based on observation, interview and record review, the facility failed to ensure food was prepared in a form to meet individual needs of the residents. Specifically, the facility failed to ensure proper pureed texture and failed to follow recipes for pureed food items for 12 residents that received a pureed texture out of 146 residents. This failed practice had the potential to affect more than a limited number of residents. Facility census: 142. Findings included: a) Facility policy The Progressive dysphagia diet: Puree policy, revised 01/2018, was provided by the Assistant Director of Nursing (ADON) #88 on 5/3/18 at 9:00 AM. The policy documented in pertinent part, .The diet uses slurried, blenderized, or pureed food that has a moist, pudding-like consistency without pulp or small food particles . Blenderized foods do not require chewing. They should have a pudding-like consistency without lumps (i.e., sour cream or mayonnaise thickness/moistness). All foods are appropriate if the consistency is pureed smooth without fibrous particles . b) Observations On 5/1/18 at 11:34 AM, Cook #119 was observed to remove two pans from the oven to take their temperatures. Cook #119 stated one was the mechanical texture pork and one was the pureed pork. The pureed pork was observed to have a similar texture as the mechanical pork. It appeared chunky. At 11:36 AM, the pureed cabbage was pulled out of the oven. The cabbage was observed to have visible chunks of cabbage in it. Staff began to plate meals for the lunch service at 11:54 AM, including pureed meals. The pork and cabbage were observed to be very chunky and the cabbage was watery. At 12:02 PM, the pureed pork and cabbage were taste tested . Neither of the puree food items had a smooth texture. Particles of meat and cabbage could be visualized and felt. On 5/2/18, the preparation of the pureed foods was observed from 10:08 AM to 10:30 AM. At 10:08 AM, Cook #119 was observed to place a third of the mixed vegetables in a 2.5 quart food processor. She processed the mixed … | 2020-09-01 |
| 61 | 61 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 602 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the resident's medications were not diverted to an unlicensed person for administration. A nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of facility for an appointment. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. a) Resident #239 Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Resident #239's (MONTH) 2019 Medication Administration Record [REDACTED]. A new order with a start date of 02/13/19 is to give [MEDICATION NAME] 15 mg every four (4) hours as needed for pain. The first dose of this order was given on 02/13/19 at 7:54 PM. On 02/14/19 the MAR indicated [REDACTED]. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/19. 3. A note written by SS #111 in which Resident #239 stated she did not feel like it was not right for the van driver to give her [MEDICATION NAME]. 4. A note written by RN #136, with a date of… | 2020-09-01 |
| 62 | 62 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 609 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to identify and report an allegation of abuse/neglect related to a threat to discharge Resident #239, if she refused to go to an appointment and an allegation the nursing staff gave [MEDICATION NAME] to the van driver to dispense to Resident #239, while out of the facility. This is true for one (1) of two (2) complaint concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: Review of a complaint/concern with a date of 02/14/19 revealed Resident #239 reported to Social Services (SS) #111 on 02/14/19 a threat was made by facility staff that she would be discharged if she did not go to an appointment scheduled for this same day. She also reported the van driver was given [MEDICATION NAME] to dispense to her while on the trip. Further review found no evidence a Reportable was completed and sent to the Office of Health Facility Licensure and Certification (OHFLAC) concerning the allegations. On 07/31/19 at 4:00 PM the director of nursing expressed the incident was not reported to OHFLAC. On 08/05/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. | 2020-09-01 |
| 70 | 70 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 679 | E | 1 | 1 | WJ7O11 | > Based on resident interviews, staff interviews, van specifications and family interview, the facility failed to implement an on-going resident centered activities program that meets resident preferences. This has the potential to effect more than a limited number. Resident identifiers: #82, #48, #21. Facility census: 140. Findings included: a) Resident #82 An interview with Resident #82, on 07/29/19 at 11:40 PM, revealed, the activities can be very juvenile at times. Resident #82 stated one activity was to finger paint. As an adult I will finger paint with my grandchildren maybe but for an adult activity? Resident #82 revealed finger painting made her feel belittled and degraded. b) Resident #48 A family interview with Resident #48's husband, on 07/29/19 at 12:42 PM, revealed Resident #48 enjoyed being around other residents even though no one can understand what is said by her. Resident #48's husband stated, A couple of weeks ago they had a movie night and when I found out Resident #82 was not invited and sat out in the hall looking in at the movie I raised a fit about that. Resident #48's husband stated, the residents had nothing in the building to stay occupied so I bought the 30 puzzles for residents laying here in the day room for them to have something to do. c) Resident #21 An interview with Resident #21, on 07/29/19 at 2:10 PM, revealed, the activities provided by the facility is not always enjoyable when other residents disrupt the group. Resident #21 stated, they have two vans for transportation and usually only one driver so this does not allow everyone to go to activities when off site. On 07/29/19 at 3:00 PM during Resident Council meeting, residents voiced concerns about activity programs often starting late, and the inability for the facility to transport groups of people out in the community. They explained the vans are not available due to all the medical appointments. Thirteen (13) of sixteen (16) residents in the Resident Council meeting would like to go out in the community for meals, and ev… | 2020-09-01 |
| 71 | 71 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 684 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, Hospice service contract and staff interview, the facility failed to ensure prescribed Hospice services were provided to a resident in accordance with professional standards of practice. This practice was found for one (1) of one (1) Hospice resident reviewed during the survey. In addition the facility failed to ensure staff followed physician orders [REDACTED]. This practice was found for one (1) of thirty-one (31) residents reviewed during the survey. Resident identifiers: #130 and #233. Facility census: 140. Findings include: a) Resident #130 On 07/31/19 at 11:45 AM, review of the medical record revealed Resident #130 was admitted to Hospice services on 07/19/19 for a terminal health condition. Continued review of the medical record found no evidence of documentation of further Hospice care visits following her admission to Hospice services. Review of the Hospice care plan created on admission was silent for the identification of services to be provided. After reviewing the medical record on 07/31/19 at 12:35 PM, the Director of Nursing (DON) was unable to locate documentation of Hospice visits following Resident #130's initial admission to Hospice services. The DON stated, I am sure that they have been here to visit, but there is nothing to prove it. I agree their care plan does not even tell who is going to visit and when. Review of the facility agreement/contract with the contracted Hospice services provided by the DON revealed the following (typed as written): .III Services provided by Hospice: .C. Hospice shall develop the Plan of care to be provided to the Home specifying information pertinent to the resident's treatment. The Plan will be updated bi-weekly by the hospice team . M. Documentation of all visits by Hospice staff shall be placed on the Home chart at the time of the visit . b) Resident #233 Review of medical records for Resident #233, found an order with a start date of 07/26/19 to give Me… | 2020-09-01 |
| 74 | 74 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 741 | D | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility to failed to provide competent staffing for the care and services delivered to maintain resident safety and attain the highest practicable physical mental and psychosocial well-being of each resident. The facility failed to thoroughly investigate an allegation of neglect related to threatening a resident with discharge and an incident in which a nurse gave [MEDICATION NAME] to a van driver to give to a resident while out of the facility. This is true for one (1) of two (2) compliant/concerns reviewed. Resident #239. Facility census. 140. Findings included: a) Resident #239 Review of medical records revealed a physician order [REDACTED]. The first dose of this order was given on 02/13/19 at 7:54 PM. The previous order with a start date of 01/23/19 was [MEDICATION NAME] 15 mg every six (6) hours as needed for pain. Review of a complaint/concern with a date of 02/14/19 revealed a statement by registered nurse (RN) #94, explaining both she and the night nurse signed out, the pain medication, and placed the medication in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. The dosage is not revealed in the note. A grievance investigation form completed by risk manager RN #136 reveals, Resident left for at 7:15 AM for an appointment and medication was given to the van driver by nursing staff. According to Resident #239 she was given the medication, by the van driver, at approximately 8:30 AM. Review of documentation concerning this matter found. 1. Van driver #63 was given the mediation by RN #94 who instructed the van driver to give to the resident at 12:00 PM. 2. A note written by the director of nursing reveals she spoke to van driver #63, who stated RN #94 gave him medication in a bag with instructions to give the medication to Resident #239 at 12:00 PM. This documentation is not signed by van driver #63. It is signed by the DON with a date of 02/15/… | 2020-09-01 |
| 75 | 75 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 755 | E | 1 | 1 | WJ7O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to safely provide pharmaceutical services including administering drugs to meet the needs of resident. The facility failed to utilize only persons authorized by state or local, regulations to administer medication to a resident. A nurse gave medication to a van driver to give to a resident while out of the facility. This is true for one (1) of two (2) complaint/concerns reviewed. Resident identifier: #239. Facility census: 140. Findings included: a) Resident #239 Review of complaint concerns found a note written by social services #111 in which Resident #239 stated she did not feel like it was right for the van driver to give her [MEDICATION NAME] (a highly additive medication). A complaint/concern with date of 02/14/19 includes a statement by register nurse (RN) #94 explaining she and the night nurse signed out, the pain mediation, and placed it in a bag, and instructed the van driver to give the medication at 12:00 PM on this same date. On 02/15/19 a note by the director nursing (DON) reveals, van driver #63 confirmed he was given medication by nursing staff to give to Resident #239 while out of the facility for a medical appointment. On 02/14/19 risk manager RN #136 documented [MEDICATION NAME] was sent with the van driver #63 and the van driver gave it to the resident at approximately 8:30 AM, and this dose of medication was not on the Medication Administration Record [REDACTED] On 0805/19 at 3:58 PM the DON agreed sending medication with the van driver was inappropriate. b) Incomplete Narcotic Counts On 07/31/19 at 4:31 PM, a review of the Controlled Substance Forms on the 200 hall with Licensed Practical Nurse (LPN) #143 revealed nurses failed to initial the sheets at the change of shift after controlled medications were counted. LPN #143, confirmed medication counts are to be completed between two (2) nurses at the change of shift and both nurses are to initial the forms… | 2020-09-01 |
| 87 | 87 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-12-18 | 583 | E | 1 | 0 | 0M5911 | > Based on observation and staff interview, the facility failed to protect the personal privacy of residents including personal and medical information. Documents containing personal and medical information for multiple residents were left unattended on a medication cart and in a staff bathroom. Personal identifiers including residents' names, date of births, social security numbers, phone numbers, addresses, medications, diagnoses, and other health information were accessible. This was a random observation. This practice affected eight (8) residents. Resident identifiers: #11, #12, #13, #14, #15, #16, #17, and #18. Facility census: 144. Findings include: a) Medication Cart A random observation on 12/18/17 at 9:45 a.m., on the 800 Wing, revealed Resident #11's Pre-Admission Screening form was left on a medication cart uncovered and unattended. The Pre-Admission Screening form contained the following personal information: --Resident's name --Resident's address --Resident's phone number --Resident's Social Security Number --Resident's date of birth --Resident's Medicare Number An interview with Licensed Practical Nurse (LPN) #2, on 12/18/17 at 9:50 a.m., revealed the Pre-Admission Screening form should have never been left on top of the medication cart unattended. b) Staff Bathroom A random observation on 12/18/17 at 10:10 a.m., on the 500 Wing, revealed a bin of folders in the staff bathroom. The bin containing information for Resident #12, #13, #14, #15, #16, #17, and #18 was readily accessible for anyone using the restroom. The folders within the bin contained multiple Minimum Data Set assessments, Care Plan Team Meeting Summaries, and admission records. These documents contained: --Resident's names --Resident's Social Security Numbers --Resident's date of births --Resident's diagnoses --Resident's treatment and medical information An interview with LPN #2, on 12/18/17 at 10:15 a.m., revealed the the bin of folders had been in the bathroom for a while. The LPN stated he was not sure why medical information was b… | 2020-09-01 |
| 88 | 88 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2017-12-18 | 689 | E | 1 | 0 | 0M5911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Chemical substances, shaving razors, skin treatments, needles, and a knife, were unsecured and accessible to residents on the 500, 600, and 800 Wings. This practice had the potential to affect more than a limited number of residents. Facility census: 144. Findings include: a) 500 Wing A tour of the 500 Wing, on 12/18/17 at 9:50 a.m., revealed the Shower Room door was open. The room contained the following items: --Five (5) containers of Medspa Shave Cream with the warning Keep out of reach of children. --One (1) container of Medline Shampoo & Body Wash with the warning Caution-Keep out of reach of children-Avoid contact with eyes. --One (1) container of [MEDICATION NAME] Maltodextrin Powder Dressing. b) 600 Wing A tour of the 600 Wing, on 12/18/17 at 10:15 a.m., revealed the Nutrition Room was open for access by anyone. On the top shelf in the unlocked cabinet was a knife with approximately an 8 inch blade. An interview with Licensed Practical Nurse (LPN) #1, on 12/18/17 at 10:20 a.m., revealed she had no idea why the knife was in the cabinet. The LPN stated she would ensure the knife was taken away immediately. c) 800 Wing A tour of the 800 Wing, on 12/18/17 at 10:25 a.m., revealed one (1) container of [MEDICATION NAME] Solution 4%-Antiseptic/Antimicrobial Skin Cleanser was on the counter of the nurses station unattended. The container had the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center right away. Further touring of the 800 Wing, on 12/18/17 at 10:30 a.m., revealed the Examining Room had a key in the door and was accessible to anyone. The room contained the following items: --Seven (7) containers of Medspa Shave Cream with the warning Keep out of reach of children. --Seven (7) containers of Medline Shampoo & Body Wash with the warn… | 2020-09-01 |
| 89 | 89 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 580 | D | 1 | 0 | 6GC411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and policy and procedure review, the facility failed to promptly notify a resident's physician and responsible party when there was an accident involving injury, a significant change in the resident's condition including a need to alter treatment significantly for one (1) of five (5) residents reviewed. The facility failed to immediately notify a resident's representative when there were new orders involving care and treatment upon return from the hospital. Resident identifier:: R1 The findings included: a) Resident #1 (R1) Record review on 3/11/19, noted R1 had sustained a fall on 01/26/19, at 12:10, resulting in a laceration to the face. R1 was taken to the hospital for care and further treatment. R1 was released back to the nursing facility on 01/26/19, with the following change in orders: --[MEDICATION NAME] Suspension Reconstituted 250 milligrams {mg} / 5 milliliters {ml}. Give 10 ml by mouth four times a day for periorbital laceration status [REDACTED]. --Neuro checks per facility policy times 72 hours --Therapy to evaluate wheelchair status [REDACTED].>Further review of the medical record on 3/12/19, revealed no evidence the resident's responsible party had been notified of the orders upon return from the hospital. A review of the policy and procedure, Changes in Resident Condition, revision date, (MONTH) (YEAR), noted under Guideline 2. prompt notification is required when there is a need to alter treatment significantly. An interview with the Director of Nursing (DON), on 03/12/19, at 01:26 PM, revealed there was no documentation of the medical power of attorney (MPOA) for R1 being notified of the new orders for Cepahalexin suspension , the neuro checks or therapy evaluation when R1 had returned from the hospital. The DON further stated I did not see where the MPOA was notified and agreed notification was not done in accordance with facility policy. | 2020-09-01 |
| 90 | 90 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 656 | D | 1 | 0 | 6GC411 | > Based on observation, record review, resident interview, and staff interview, the facility failed to ensure the implementation of individualized care plan interventions related to high fall risks. Call lights were not within reach for residents as directed by their care plans. This practice affected two (2) of five (5) residents reviewed for high fall risks. Resident identifiers: #3 and #4. Facility census. 182. Findings include: a) Resident #3 An observation of the Resident, on 03/12/19 at 10:05 AM, revealed the Resident was in bed. The Resident's call light was under the bed and out of reach of the resident. An interview with Licensed Practical Nurse (LPN) #100, on 03/12/19 at 10:10 AM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/12/19 at 11:15 AM. The Care Plan dated 01/21/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b) Resident #4 An observation of the Resident, on 03/12/19 at 10:30 AM, revealed the Resident was up in his wheelchair in his room watching television. The Resident's call light was under the opposite side of the bed where he was sitting and out of reach of the resident. An interview with the Resident, on 03/12/19 at 10:32 AM, revealed the Resident did not know where his call light was. The Resident stated I do not see it anywhere. An interview with Nurse Aide (NA) #101, on 03/12/19 at 10:35 AM, revealed the Resident does not need his call light near him because he is more mobile than most other residents. A review of the Care Plan was conducted on 03/12/19 at 11:30 AM. The Care Plan dated 02/25/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance a… | 2020-09-01 |
| 91 | 91 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2019-03-13 | 689 | D | 1 | 0 | 6GC411 | > Based on observation, record review, resident interview, and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. Call lights were not within reach for high fall risk residents as directed by their care plans. This practice affected two (2) of five (5) residents reviewed for high fall risks. Resident identifiers: #3 and #4. Facility census. 182. Findings included: a) Resident #3 An observation of the Resident, on 03/12/19 at 10:05 AM, revealed the Resident was in bed. The Resident's call light was under the bed and out of reach of the resident. An interview with Licensed Practical Nurse (LPN) #100, on 03/12/19 at 10:10 AM, revealed the Resident's call light should be within reach at all times. The LPN placed the Resident's call light on the bed within reach of the Resident. A review of the Care Plan was conducted on 03/12/19 at 11:15 AM. The Care Plan dated 01/21/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. b) Resident #4 An observation of the Resident, on 03/12/19 at 10:30 AM, revealed the Resident was up in his wheelchair in his room watching television. The Resident's call light was under the opposite side of the bed where he was sitting and out of reach of the resident. An interview with the Resident, on 03/12/19 at 10:32 AM, revealed the Resident did not know where his call light was. The Resident stated I do not see it anywhere. An interview with Nurse Aide (NA) #101, on 03/12/19 at 10:35 AM, revealed the Resident does not need his call light near him because he is more mobile than most other residents. A review of the Care Plan was conducted on 03/12/19 at 11:30 AM. The Care Plan dated 02/25/19 with a focus of Actual fall and continues to be at risk for falls with the intervention Be sure the resident's call light is within reach and encourage the resident to use it for assistance as n… | 2020-09-01 |
| 92 | 92 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 550 | E | 1 | 0 | R6BQ11 | > Based on observation, staff interview, and policy review, the facility failed to ensure residents were treated with dignity and respect. A staff member was yelling at a resident during care and a catheter bag was not covered . This practice affected two (2) of eleven (11) residents observed. Resident identifiers: #4 and #8. Facility census: 178. Findings included: a) Resident #8 A random observation by two surveyors on the A Hall on the 4th floor, on 04/17/18 at 7:40 AM, revealed Nurse Aide (NA) #22 was getting Resident #8 dressed in the Resident's room. NA #22 was heard yelling loudly and forcibly Jesus, what the hell are you doing to Resident #8. NA #4 was also present in the room. When both NAs exited the room NA #22 stated Oh my God, there is state. An interview with NA #22, on 04/17/18 at 7:42 AM, revealed the NA was helping Resident #8 get dressed. The NA stated the resident must be dizzy because she would not cooperate like usual. The NA stated she laid the Resident back down due to her functioning level at the time of care. An observation of the Resident, on 04/17/18 at 7:45 AM, revealed the Resident was lying in bed. The Resident was unable to answer yes and no questions. An interview with the Administrator, on 04/17/18 at 7:50 AM, revealed that any abusive behavior is not tolerated and the situation would be investigated immediately. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:30 AM, revealed both NA #22 and #8 were suspended and a full investigation had begun. The DDCS stated all residents in the facility were immediately being interviewed and checked for abuse. The DDCS stated the behavior of CNA #22 was absolutely abuse and was highly unacceptable. The DDCS stated any kind of abuse would never be acceptable or tolerated at any of my facilities. A review of the facility policy titled OP 00 Abuse & Neglect Prohibition, with a revision date of (MONTH) (YEAR), was conducted on 04/18/18 at 9:45 AM. The policy stated Each resident has the right to be free from ab… | 2020-09-01 |
| 93 | 93 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 558 | D | 1 | 0 | R6BQ11 | > Based on observation, resident interview, and staff interview, the facility failed to provide services with reasonable accommodation for residents. A resident's over the bed light cord was not long enough to be easily reached and a resident could not access his bathroom due to the door being locked. This practice affected two (2) of eleven (11) residents observed. Resident identifiers: #10 and #11. Facility census: 178. Findings included: a) Resident #10 An observation of the Resident, on 04/16/18 at 11:10 AM, revealed the Resident's over the bed light cord was approximately 6 inches long. An interview with the District Director of Clinical Services (DDCS), on 04/16/18 at 11:15 AM, revealed the Resident could not easily reach the over the bed light cord without having to get up out of bed. b) Resident #11 An observation of the Resident's room, on 04/16/18 at 11:25 AM, revealed the Resident's bathroom door was locked. The bathroom was not occupied at the time of the observation. An interview Resident #11, on 04/16/18 at 11:27 AM, revealed the door to the bathroom is locked almost daily. The Resident stated he has to go to room next door to enter his bathroom. The Resident stated whoever uses the bathroom in that room keeps the door locked preventing him from getting in. An interview with the DDCS, on 04/16/18 at 11:30 AM, revealed she had no idea Resident #11 was being locked out of his bathroom. The DDCS stated she would take care of the issue. | 2020-09-01 |
| 94 | 94 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 583 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to protect the personal privacy of residents including medical and health information. A medication re-order sheet was left unattended on medication cart in the hallway. Personal identifiers including residents' names, medications, and other health information were viewable by any person in the hall. This was a random observation. This practice affected five (5) residents. Resident identifiers: #20, #21, #22, #23, #24, and #25. Facility census: 178. Findings included: a) Medication Re-Order Sheet A random observation of the 3rd Floor B-Hall, on 04/16/18 at 11:45 AM, revealed a medication re-order sheet was left on top of the medication cart. The medication re-order sheet contained the following: -Resident #20-Resident's name, room number, medication, and dosage -Resident #21-Resident's name, room number, medication, and dosage -Resident #22-Resident's name, room number, medication, and dosage -Resident #23-Resident's name, room number, medication, and dosage -Resident #24-Resident's name, room number, medication, and dosage -Resident #25-Resident's name, room number, medication, and dosage An interview with Licensed Practical Nurse (LPN) #10, on 04/16/18 at 11:48 AM, revealed the LPN should not have left the medication re-order sheet unattended on the medication cart. The LPN stated she usually turns the paper over or takes it with her when away from the cart so that no patient information can be seen by others. | 2020-09-01 |
| 95 | 95 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 584 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to ensure a safe, clean, comfortable and homelike environment for 3 of 11 sampled residents. The facility failed to ensure the resident's room was in good repair, clean and /or homelike. Resident identifiers: #8, #3 and #4. Facility census: 178. Findings included: An observation on 04/17/18 at 10:30 AM, revealed a lack of personal items noted in Resident #8's room. An interview with the District Director of Clinical Services, on 04/17/18, at 12:20 PM, verified it was uncertain why Resident #8 did not have personal effects making the room homelike. It was further stated, staff would assess resident's preferences and assist the resident to make the room homelike. An observation of Resident #3's room, on 04/16/18 at 11:05 AM, revealed a plastic glove laying under a chair. An additional observation, on 04/17/18, at 7:30 AM, revealed a plastic glove laying under the same chair and debri on the floor, in the area close to the door. c) Resident #4 An observation of Resident #4, on 04/16/18 at 11:05 AM, revealed paint missing along with paint chips hanging from the ceiling above the bed. An interview with the District Director of Clinical Services (DDCS), on 04/16/18 at 11:10 AM, revealed the ceiling would be taken care of immediately. | 2020-09-01 |
| 96 | 96 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 600 | E | 1 | 0 | R6BQ11 | > Based on observation, staff interview, and policy review, the facility failed to ensure residents were free from verbal abuse and mistreatment. A staff member was yelling at a resident during care. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #8. Facility census: 178. Findings included: a) Resident #8 A random observation by two surveyors on the A Hall on the 4th floor, on 04/17/18 at 7:40 AM, revealed Nurse Aide (NA) #22 was getting Resident #8 dressed in the Resident's room. NA #22 was heard yelling loudly and forcibly Jesus, what the hell are you doing at Resident #8. NA #4 was also present in the room. When both NAs exited the room NA #22 stated Oh my God, there is state. An immediate interview with NA #22, on 04/17/18 at 7:41 AM, revealed the NA was helping Resident #8 get dressed. The NA stated the resident must be dizzy because she would not cooperate like usual. The NA stated she laid the Resident back down due to her functioning level at the time of care. An observation of the Resident, on 04/17/18 at 7:43 AM, revealed the Resident was lying in bed. The Resident was unable to answer yes and no questions. An interview with the Administrator, on 04/17/18 at 7:50 AM, revealed that any abusive behavior is not tolerated and the situation would be investigated immediately. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:30 AM, revealed both NA #22 and #8 were suspended and a full investigation had begun. The DDCS stated all residents in the facility were immediately being interviewed and checked for abuse. The DDCS stated NA #22 works all over the facility. The DDCS stated the behavior of NA #22 was absolutely abuse and was highly unacceptable. The DDCS stated abuse would never be acceptable or tolerated at any of my facilities. A review of the facility policy titled OP 00 Abuse & Neglect Prohibition, with a revision date of (MONTH) (YEAR), was conducted on 04/17/18 at 9:45 AM. The policy stated Each resident ha… | 2020-09-01 |
| 97 | 97 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 684 | E | 1 | 0 | R6BQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to ensure that 5 of 11 sampled residents received care and treatment in accordance to the comprehensive assessment and plan of care. Heels were not floated for Resident #1, Resident #2, and Resident #4. Fall mats were not provided for Resident #7, and Resident #9. Resident identifiers: #1. #2, #4, #7 and #9. Facility census: 178. Findings included: a) Resident #2 A review of the medical record for Resident #2 revealed a physician's orders [REDACTED]. An observation made of Resident #2, while in bed, on 04/16/18, at 11:45 AM, revealed the resident's right sock was off her foot, laying on the floor, and her right heel was positoined directly on the bed. Both heels were not being floated in accordance with physician's orders [REDACTED]. An interview with the District Director of Clinical Services, on 04/17/18, at 12:15 PM, verified understanding of following physician orders [REDACTED]. b) Resident #1 A review of the medical for Resident #1, on 04/16/18, revealed a physician's orders [REDACTED]. An observation made of Resident #1, while in bed, on 04/17/18, at 07:20 AM, revealed the resident's heels were not floated in accordance with physician's orders [REDACTED]. An interview with the District Director of Clinical Services, on 04/17/18, at 12:15 PM, verified understanding of following physician orders [REDACTED]. c) Resident #7 An observation of Resident #7 on 04/17/18 at 7:20 AM, revealed a bruised area on the right side of the resident's face. A review of the medical record for Resident #7, on 04/17/18, revealed Resident #7 had sustained a fall on 04/16/18 at 10:44 AM. The facility implemented the Fall Protocol related to the fall occurrence. Resident was to have a fall mat to right side of bed. An observation made, 04/17/18 at 09:25 AM, revealed no fall mat present beside Resident #7's bed. On 04/17/18, at 09:40 AM, an interview with Staff #4 verified there was n… | 2020-09-01 |
| 98 | 98 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 880 | E | 1 | 0 | R6BQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to carry out proper infection control practices. A resident's sheets and bed had multiple areas stained with blood, a staff member failed to ensure contact isolation procedures were utilized, and several resident's oxygen tubing was on the floor and not dated. This practice affected six (6) of eleven (11) residents observed. Resident identifier: #1, #2, #5, #7, #10, and #11. Facility census: 178. Findings include: a) Resident #10 An observation of Resident #10, on 04/16/18 at 11:00 AM, revealed the Resident was lying in bed. At the time of the observation the Resident's sheets and bed railings had multiple areas that were stained with blood. An interview with Certified Nursing Assistant (CNA) #50, on 04/16/18 at 11:00 AM, revealed the Resident must have scratched an open area and got blood on her bed and sheets. The CNA stated she would ensure the sheets were changed and the bed cleaned immediately. b) Resident #5 An observation of Resident #5, on 04/16/18 at 11:20 AM, revealed the Resident was lying in bed. The Resident was on contact isolation. CNA #1, entered the resident's room, pulled up her covers, and exited the room. The CNA did not wash her hands before or after touching the resident's covers nor use gloves. The CNA did not use any isolation equipment that was provided at the Resident's door. An interview with CNA #1, on 04/16/18 at 11:24 AM, revealed the Resident is on contact isolation. The CNA stated as long as she did not touch the resident then she did not have to wear any gloves or isolation precautions while in the room. An review of the Resident's physician orders, on 04/16/18 at 11:35 AM, revealed an order for [REDACTED]. A review of the facility policy titled Standard and Transmission-Based Precautions-Contact Precautions, with a revision date of 02/2018, was conducted on 04/16/18 at 11:45 AM. The policy stated for someone on Contact Precautions… | 2020-09-01 |
| 99 | 99 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2018-04-17 | 924 | E | 1 | 0 | R6BQ11 | > Based on observation and staff interview, the facility failed to ensure handrails were securely and firmly affixed to the walls. Several handrails throughout the facility were coming undone and were loose. This practice had the potential to affect more than a limited number of residents. Handrail identifiers: WV Building-A Hall, WV Building-B Hall, and WV Building C-Hall. Facility Census: 178. Findings included: a) Handrails A random observation of the WV Building A-Hall, B-Hall, and C-Hall, on 04/17/18 at 8:45 AM, revealed multiple loose handrails. The handrails were coming loose on the ends causing them not to be securely and firmly attached to the walls. An interview with the District Director of Clinical Services (DDCS), on 04/17/18 at 9:40 AM, revealed she was not aware of the handrails coming undone but would ensure they were looked at immediately. The DDCS stated the handrails should be secure. | 2020-09-01 |
| 121 | 121 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 282 | D | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to implement the care plan for two (2) of twenty-nine (29) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #19 did not receive restorative services according to the care plan. Resident #320's care plan was not implemented for bladder incontinence. Resident identifiers: #19 and #320. Facility census: 180. Findings include: a) Resident #19 Review of the resident's current care plan found the following problem: Resident has limited physical mobility related to disease process dementia, [MEDICAL CONDITION], weakness, revised on 08/24/17. The goal associated with the problem: Resident will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury through the next review date, revised on 08/24/17. Interventions included; Nursing Rehabilitation/Restorative: Active range of motion, revised on 08/24/17. On 08/22/17, the physical therapist referred the resident to the facility's restorative program. On 08/24/17, the resident began the following restorative program: The goal for restorative therapy was: Maintain strength and functional mobility level Activities to be performed for restorative: 1. Stretching to Bilateral hamstrings and bilateral gastrocnemius muscles 30-45 second hold. (MONTH) do in seated or supine position. 2. Therapeutic exercises for bilateral lower extremities ankle pumps, heel slides straight leg raises, hip abduction/adduction and hip flexions long arc quads, 2 sets of 10 reps; may do in seated or supine. 3. Wheel chair mobility 50-100 feet Bilateral upper extremities and bilateral lower extremities for propulsion, min Assistance to SBA (stand by assistance); instruct patient on safe turning of wheel chair, safe negotiation of obstacles and correct upper extremity and lower extremity placement. At 2:19 p.m. on 08/30/17, the unit manager, … | 2020-09-01 |
| 122 | 122 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 309 | E | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, resident interview, and policy review the facility failed to ensure that each resident received the necessary care and services to enable them to maintain and or attain their highest practicable physical, mental and psychosocial well-being. For Resident #235 the facility failed to follow a physician order [REDACTED]. The facility failed to ensure Resident #141 received a physician ordered medication to treat a headache. For Resident #284 and #336 the facility failed to assess a pressure ulcer upon admission to the facility. The facility failed to coordinate care between the [MEDICAL TREATMENT] center and the facility for Resident #382. For Resident #19 the facility failed to follow the physician guidance to contact the responsible party in regards to completing further laboratory testing. These failures affected six (6) of twenty-nine (29) sampled Stage 2 residents. Resident Identifiers: #235, #141, #284, #336, #382, and #19. Facility Census: 180. Findings include: a) Resident #235 1. Aspirin A review of Resident #235's medical record at 9:44 a.m. on 09/06/17 found the following physician order [REDACTED]. Increase ASA (Aspirin) dose to 325 mg (milligrams) 1 po (by mouth) qd (every day) for PE (pulmonary embolism). CBC (completed blood count) 1 wk (week). Review of Resident #235's Medication Administration Record [REDACTED]. In fact Resident #235 has received Aspirin 81 mg daily since 01/05/17 with no change in dosage. An interview with the interim Director of Nursing (DON) at 2:41 p.m. on 09/06/17 confirmed Resident #235's aspirin dose was never increased as the physician order [REDACTED]. 2. Pain Management A review of Resident #235's medical record at 9:44 a.m. on 09/06/17 found the following physician note dated 02/21/17 which read under the section titled, Plan: For Chronic pai[DIAGNOSES REDACTED] continue biofreeze . Further review of the record found a physician order [REDACTED]. This order ha… | 2020-09-01 |
| 124 | 124 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 312 | D | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident interview, record review, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of activities of daily living (ADL's) was provided care for oral hygiene. The facility was unaware Resident #90, who had resided at the facility since 02/12/15, had a upper partial. Resident identifier: #90. Facility census: 180. Findings include: a) Resident #90 Observation of the resident's oral cavity at 10:41 a.m. on 08/29/17, found the resident had what appeared to be her own teeth. Some were missing, discolored and were covered with a white, chalky substance that appeared to be plaque. Observation of the resident's oral cavity with the Registered Nurse (RN) unit manager, at 12:57 p.m. on 09/05/17, found RN #116 discovered the resident had an upper partial and, What looks like a cavity on the lower back tooth. The resident said she had a partial. She stated, I am not going to show it to you because you might steal it. Three (3) nursing assistants (NA's) #47, #5 and #58, (all working on the resident's unit) and RN #116 denied knowing the resident had a partial at 1:21 p.m. on 09/05/17. All denied removing the partial for cleaning. RN #116 was asked if she could find any evidence the facility was ever aware the resident had a partial or any documentation the partial had been removed for cleaning. Record review found the resident was admitted to the facility on [DATE]. The most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 06/29/17 notes the resident requires extensive assistance of 1 staff member for personal hygiene, which includes brushing teeth. Review of the last 3 nursing monthly assessments, dated 06/12/17, 07/12/17, and 08/12/17 noted the resident has her own teeth under the section entitled, Dentition. The form also allowed the nurse completing the assessment to note the resident had a Partial(s) Bridge(s). This section was no… | 2020-09-01 |
| 126 | 126 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 323 | D | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure the resident's environment, over which the facility had control, was free from accidents. Resident #350's over the bed table was sitting on a fall mat. Resident #214's grab bars in the bathroom were loose. This was true for one of three residents reviewed for the care area of accidents during Stage 2 of The Quality Indicator survey (QIS) and one random observation. Resident identifiers: #350 and #214. Facility census: 180. Findings include: a) Resident #350 Record review found the resident was admitted to the facility on [DATE]. The resident's current care plan, included a problem for: Being at risk of falls related to CVA (cerebral vascular accident) with aphasia, incontinence, muscle weakness, impaired balance, impaired cognition, history of falls. The goal associated with the problem is: Resident will not sustain serious injury through the review date Interventions included: Low bed with bilateral floor mats per MD (physician) order The resident needs a safe environment with (even floor free from spills and or clutter, etc.) Record review found the resident had seven (7) falls since his admission: --06/09/17 - Resident up in wheelchair in room attempted to stand and fell in floor no injuries noted. --06/13/17 - Resident seen by nurse sliding off edge of bed onto the floor on his knees. --06/20/17 - Resident found lying on his left side on the floor mat beside his bed. --06/22/17 - at 5:30 a.m., Resident noted sitting in floor on mat beside his bed --06/22/17 - at 1:15 a.m., Resident observed sitting in the floor next to his bed --08/21/17 - Resident found lying in front of his wheelchair in the day room. --08/27/17 - Resident found sitting on the left side of his bed on floor mat, obtained a skin tear to the upper part of the back of his right and left arm. Five (5) of the falls occurred when the resident fell from bed. On 06/28/17, the physical ordered a low bed wit… | 2020-09-01 |
| 127 | 127 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 325 | D | 1 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview and staff interview, the facility failed to identify and address a severe weight loss for one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 Quality Indicator Survey. Resident #320 lost 10.8% (percent) of his body weight, from 04/22/17 to 05/05/17, which represented a severe weight loss. Additionally, Resident #320 lost 13.1% of his body weight from 04/22/17 to 06/ , which again represented a severe weight loss. There was no evidence the facility identified these weight losses nor assessed causes and/or provided interventions to prevent additional weight losses. As no interventions had been implemented, the weight loss could not be determined to be unavoidable. This represents actual harm to resident #320. Resident Identifier: #320. Facility Census: 180 Findings Include: a) Resident #320 A record review on 08/30/17 at 8:28 a.m., revealed the following weights for Resident #320: -- 04/22/17: 277.0 pounds -- 05/05/17: 247.0 pounds (-10.8%, -30.0 pounds) -- 06/04/17: 240.8 pounds (-13.1%, -36.2 pounds) The resident's percentage of weight loss from 04/22/17 to 05/05/17 and from 04/22/17 to 06/06/17 were calculated using the following formula % of weight loss = (usual weight - actual weight) / (usual weight) x 100. -- From 04/22/17 to 05/05/17, the resident lost 10.8% of his body weight. -- From 04/22/17 to 06/04/17, the resident lost 13.1% of his body weight. Review of resident #320 physician's orders [REDACTED]. Dietary supervisor clarified this order as Controlled Carbohydrate Diet, No Added Salt Diet, Regular Texture, Regular Consistency. Review of resident #320 medical record found a Minimum data set (MDS) with an assessment reference date of 06/17/17. Section K of this MDS Swallowing/Nutritional Status K0300: Weight Loss of the MDS, indicated Resident #320 had not had a Loss of 5% or more in the last month or loss of 10% or more in last 6 months. Further … | 2020-09-01 |
| 165 | 165 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-06-20 | 223 | E | 1 | 0 | HCKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of reported allegations, resident interview, staff interview, family interview, staffing records, policy review, and personnel record review; the facility failed to protect residents after an allegation of abuse for one (1) of five (5) allegations reviewed. This practice affected one (1) resident but had the potential to affect more than a limited number of residents. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., had verbalized the facility completed annual training in-services, and had one scheduled for Wednesday, 06/21/17, related to abuse and neglect. The nurse said the LPN's role was to tell the director of nursing (DON) and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. LPN #66 said if the alleged perpetrator was an employee, the person would not be allowed to work with the involved resident. NA#79, interviewed via telephone on 06/20/17 at 12:10 p.m. verbalized she usually worked day shift, but had worked over that day. The nurse aide said the resident was toileted on the bedside commode and when done was put in the wheelchair (w/c). The … | 2020-09-01 |
| 166 | 166 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-06-20 | 225 | D | 1 | 0 | HCKF11 | > Based on review of reported allegations, staff interview, family interview, and policy review, the facility failed to report timely and/or investigate an allegation of abuse for one (1) of five (5) allegations reviewed. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., said the LPN's role was to tell the director of nursing (DON), and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. NA#79, interviewed via telephone on 06/20/17 at 12:10 p.m. verbalized she usually worked dayshift, but had worked over that day. The nurse aide said the resident was toileted on the bedside commode and when done was put in the wheelchair (w/c). The NA said the resident asked what time dinner was served and was told about 5:30 p.m. NA#79 stated Resident #1 asked to be put back to bed because it was only 4:00 p.m. The nurse aide alleged NA#22 told the resident they were not playing these f-----g games and don't (do not) care what your daughter says. You are not being babied. NA#79 verbalized she notified LPN #63, who was passing medications. The LPN then ensured the resident was placed back in bed. NA #79 verbalized during the interview, that she went back in… | 2020-09-01 |
| 167 | 167 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2017-06-20 | 226 | E | 1 | 0 | HCKF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of reported allegations, resident interview, staff interview, family interview, staffing records, policy review, and personnel record review; the facility failed to implement policies and procedures after an allegation of abuse for one (1) of five (5) allegations reviewed. The facility failed to protect residents, and failed to report and/or investigate the allegation in a timely manner. This had the potential to affect more than an isolated number of residents. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., had verbalized the facility completed annual training in-services, and had one scheduled for Wednesday, 06/21/17, related to abuse and neglect. The nurse said the LPN's role was to tell the director of nursing (DON) and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. The LPN voiced she was unaware of any reportable allegations, other than six (6) to eight (8) months ago. LPN #66 said if the alleged perpetrator was an employee the person would not be allowed to work with the involved resident. NA#79, interviewed via telephone on 06/20/17 at 1… | 2020-09-01 |
| 168 | 168 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-06-26 | 584 | E | 1 | 0 | UZ4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure a safe, comfortable, orderly, homelike environment. The screens in the windows of ten (10) out of thirty (30) resident rooms were either torn or not adequately secured snugly to the window. This had the potential to allow entrance of insects or flies into resident rooms. Rooms: 27, 29, 24, 21, 20, 18, 15, 13, 10, 9. Facility census: 53. Findings included: a) room [ROOM NUMBER] On 06/25/19 at 9:45 AM an inspection was made of room [ROOM NUMBER]. The first bed was stripped bare. A tag on the foot of the bed noted this bed was deep cleaned by housekeeping staff on 06/22/19. Resident #49 lay in the bed by the window. The large picture window in this room was closed. A screen was observed in the middle section of the picture window. When asked if she ever opened this window, she replied in the affirmative. The interim director of nursing (DON) unlocked the window and slid it toward the right. The screen had a tear in the lower left corner which was opened to about a two (2) inch by two (2) inch hole. This hole could allow entrance of an insect or a fly into the room if the window was to be opened. The interim DON said she did not know this window could be opened or ever was opened. She noted that the screen also did not fit tightly against the window pane and was loose. She said she would have maintenance make the necessary repairs to this window screen. When asked if a visitor or family member of either resident in this room could potentially have opened the window and let a fly into the room, she said she guessed that was possible. The interim DON informed the administrator of the window screen situation. The administrator then gave directives to the maintenance department to check all the windows in resident rooms for tears in screens or for ill-fitting screens. b) A tour of the facility to check the windows and screens of resident room was conducted on 06/25/19 from 12:30… | 2020-09-01 |
| 169 | 169 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2019-06-26 | 656 | D | 1 | 0 | UZ4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to develop person-centered, individualized care plan with measurable goals and appropriate interventions for one (1) of four (4) sampled residents. Resident identifier: #4. Facility census: 53. Findings included: a) Resident #4 The medical record was reviewed on 06/25/19 and continued through 06/26/19. Resident #4 was an elderly resident with [DIAGNOSES REDACTED]. On 04/24/19 a nurse's note conveyed that a venous stasis ulcer was beginning to open on the top of the right foot. Nursing notified the physician. The physician gave orders to cleanse the venous stasis ulcer to the top of the right foot with normal saline, pat dry, apply Silversorb gel to the wound bed, and cover with a dry dressing every day shift and as needed. A nurse's note dated 04/30/19 described the wound to the top of the right foot as full thickness tissue loss, 80% black tissue and 20% slough. The next nurse's note related to the stasis ulcer to the top of the right foot occurred on 05/18/19, when the physician gave new orders for [MEDICATION NAME] (antibiotic) 875 milligram (mg)/125 milligrams (mg) orally twice daily for seven (7) days for wound. A physician's hand-written progress note dated 05/18/19 assessed that the right foot has open area, and skin surrounding it has [DIAGNOSES REDACTED] and some purulent drainage. The diagnostic impression was [MEDICAL CONDITION] of the right foot. The plan was to administer [MEDICATION NAME] 875 mg. twice daily for a week. Review of the weekly wound observation tool dated 06/07/19 found the nurse described the stasis ulcer to the top of the right foot as 100% black, scab-like tissue with a small amount of serosanguinous drainage. The wound measured 75 millimeters long by 22 millimeters wide. A weekly wound observation tool dated 06/21/19 assessed that the stasis ulcer was 100% black, scab-like tissue with a small amount of serosanguinous drainage. Measurement… | 2020-09-01 |
| 212 | 212 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-06-07 | 278 | D | 1 | 0 | 5ZTQ11 | > Based on record review and staff interview, the facility failed to ensure an accurate assessment for one (1) of six (6) residents. Resident #12's 30-day minimum data set (MDS) assessment for section M, Skin conditions revealed the dimensions of unhealed stage 3 or 4 pressure ulcers or eschar was entered incorrectly. Resident identifier: #12. Facility census: 40. Findings include: a) Resident #12 A review of the MDS, assessment reference date 03/22/17, showed the resident had one (1) stage two (2) pressure ulcer. Further review of the MDS, revealed measurements for length and width for a stage three (3) or four (4) pressure ulcer. An interview with Assistant Director of Nursing (ADON) #42 on 06/07/17 at 1:38 pm, advised she had entered the measures incorrectly in this section. She commented she would be corrected this section of the MDS. | 2020-09-01 |
| 213 | 213 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-06-07 | 465 | F | 1 | 0 | 5ZTQ11 | > Based on policy review, observation and staff interview, the facility failed to ensure they maintained a safe environment for all residents. Observations revealed areas where oxygen was being used, had no signs or signage advising no smoking was allowed in the area. Resident # 15 was observed in the dining area, with oxygen in use. This practice had the potential to affect all residents. Resident identifier: #15. Facility census: 40. Findings include: a) Resident #15 An observation of the second floor dining room on 06/05/17 at 12:40 pm, revealed Resident #15 sitting at a table in the dining room, with oxygen in use via oxygen concentrator. Further observation in the dining room did not reveal signage advising smoking was not permitted. Observation on 06/05/17 of the facility's main entrance of the building revealed no signs or signage advising no smoking was allowed in the building. Facility policy Patient care related electrical equipment dated (MONTH) (YEAR), procedure item 7. stated. Place an 'Oxygen in Use' sign on the door frame. This was to ensure safe usage and operation of oxygen concentrators and other fixed or portable patient care related electrical equipment. According to 2012 Life Safety Code, In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. During an interview with the administrator on 06/07/17 at 2:45 pm, it was pointed out there were no signage posted on front door indicating no smoking. The administrator commented she believed that a no smoking sign does not need posted at the entrances because the entire county has not allowed smoking indoors for quite a while now. | 2020-09-01 |
| 214 | 214 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2017-06-07 | 514 | D | 1 | 0 | 5ZTQ11 | > Based on record review and staff interview, the facility failed to ensure accurate and complete medical records for two (2) of six (6) residents. Resident #4 and Resident #12 had medical records that were not complete. Resident identifiers: #4 and #12. Facility census 40. Findings include: a) Resident #4 Resident #4 experienced a fall on 02/19/17, at 1:20 p.m. After the fall, he reported left hip pain. Resident was sent to a local hospital's emergency room for evaluation and treatment on 02/19/17 at 2:09 p.m. A nursing note written at 9:14 p.m., on 02/19/17 stated, Resident returned from (name of outside hospital), no orders, no paperwork. Resident was at hospital about 2 1/2 hours. When Assistant Director of Nursing (ADON) #42 was asked on 06/06/17 at 1:00 p.m. if records from the emergency room evaluation performed on 02/19/17 had been obtained for resident's file, she contacted the outside hospital to obtain the records. The emergency room evaluation performed on 02/19/17 was faxed to the long-term care facility on 06/06/17. The print date and time indicated on the records was 06/06/17 at 3:15 p.m. Interview with ADON #42 on 06/07/17 at 10:35 a.m. revealed that it was not an unusual occurrence for a resident to be returned from evaluation at a local hospital without accompanying paperwork. However, ADON #42 commented the hospitals call the long-term facility with a report on the resident prior to transfer. b) Resident #12 Medical record review on 06/06/17 revealed Resident #12 Appointment of Health Care Surrogate was not in the medical record. On 06/07/17 at 8:15 a.m., the administrator brought a copy of the appointment of health care surrogate form. She stated the facility had to redo this form because they could not locate the original. She said it should have been in the medical record. The form was dated 06/06/17. At 11:00 a.m. on 06/07/17 Social Worker #17, stated she had contacted the family and they could not locate the original appointment of health care surrogate form. | 2020-09-01 |
| 215 | 215 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-02-16 | 656 | E | 1 | 0 | EN1S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview, family interview, and staff interview, the facility failed to develop comprehensive person-centered care plans for four (4) of four (4) sample residents who had an identified problem of anxiety. The care plans for Residents #49, #45, #65, and #79 did not identify specific non-pharmacological interventions for direct care staff to employ that were based on the residents' individual assessed needs. Resident identifiers: #49, #45, #65, and #79. Facility census: 102. Findings include: a) Resident #49 Review of the resident's medical record on 02/12/18 at 1:20 PM, revealed Resident #49, a [AGE] year-old female admitted to the facility in (MONTH) (YEAR), had [DIAGNOSES REDACTED]. According to her Minimum Data Set (MDS) quarterly assessment with an assessment reference date (ARD) of 01/10/18 her Brief Interview for Mental Status (BIMS) score was 15 indicating she was cognitively intact, that she continuously displayed inattention with fluctuating disorganized thinking and demonstrated behaviors 1-3 days. Her Mood score increased to 14 (indicating moderate depression). The MDS with an ARD of 10/11/17, identified a BIMS of 14 (cognitively intact), with continuous inattention and fluctuating disorganized thinking. Her Mood score was 8 indicating mild depression. No behaviors were noted in this assessment. She required assistance with all ADLS and received Antipsychotics, antidepressants, and antianxiety meds daily. The resident's care plan with a revision date of 01/21/18 identified problems of depression and anxiety. The focus for depression stated, Long history of depression related to medical condition and progression of her disease as evidenced by excessive worrying and feeling down. Resident will state, I am getting worse. The goal was, Resident will have a reduction in depressive episodes to weekly throughout next review. Interventions included (typed as written), 1. Administer medication for … | 2020-09-01 |
| 216 | 216 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-02-16 | 740 | D | 1 | 0 | EN1S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview, family interview, and staff interview, the facility failed to provide behavioral health care and services and/or treatment to assist Resident #49 in maintaining her highest practicable mental, and psychosocial well-being. The facility failed to provide individualized behavioral health services to assist the resident in coping with her disease process. The resident's care plan did not offer needed guidance to direct care staff to meet the resident's needs with respect to the resident's anxiety and depression. This was found for one (1) of four (4) residents reviewed for behaviors. Resident identifier: #49. Facility census: 102. Findings include: a) Resident #49 Review of the resident's medical record on 02/12/18 at 1:20 PM, revealed this [AGE] year-old resident, admitted to the facility in (MONTH) (YEAR), had [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/10/18 identified the resident's Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. The assessment also identified she continuously displayed inattention with fluctuating disorganized thinking and she demonstrated behaviors 1-3 days. When compared to the previous assessment, her Mood score had increased to 14 (indicating moderate depression). She required assistance with all activities of daily living (ADLs) and was occasionally incontinent of bladder and always incontinent of bowel. She received antipsychotics, antidepressants, and antianxiety medications (meds) daily. She had bed and chair alarms and had had more than 2 falls since admission. The MDS with an ARD of 10/11/17, identified a BIMS of 14 (cognitively intact), with continuous inattention and fluctuating disorganized thinking. Her Mood score was 8 indicating mild depression. No behaviors were noted in that assessment. She required assistance with all ADLs, re… | 2020-09-01 |
| 217 | 217 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-02-16 | 742 | D | 1 | 0 | EN1S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident and family interview, and staff interview, the facility failed to ensure a resident with [MEDICAL CONDITION]'s Chorea received appropriate treatment and services to assist the resident to attain the highest practicable mental and psychosocial well-being. The facility failed to utilize outside resources to assist Resident #49 in coping with her progressive disease process. The facility failed to develop a care plan to provide guidance to direct care staff regarding the resident's individual needs. No individualized plans were in place to address her mental and physical expressions of distress. Diversional meaningful activities were not based on the resident's preferences, and/or abilities. This was found for one (1) of four (4) residents reviewed for behaviors. Resident identifier #49. Facility census: 102. Findings include: a) Resident #49 Review of the medical record on 02/12/18 at 1:20 PM, revealed Resident #49 is a [AGE] year-old admitted to the facility in (MONTH) (YEAR). [DIAGNOSES REDACTED]. Resident #49 was evaluated by a psychiatrist on 04/03/17. The summary notes for the evaluation noted Resident #49's [MEDICAL CONDITION]'s disease was currently being treated with Tetrabenzene ([MEDICATION NAME]) (a medicine used to treat involuntary movements of [MEDICAL CONDITION]'s disease) to suppress her motor symptoms. It is important to be aware that this treatment might aggravate mood problems such as depression. The treatment plan stated, The patient will benefit from the continued use of [MEDICATION NAME] 50 mg (milligrams) at bedtime. A smaller dose of 25 mg can be added in the daytime to reduce irritability. Because of the concern of [NAME]D ([MEDICAL CONDITION]) symptoms and possible development of depression, the patient might benefit from adding [MEDICATION NAME] 10 mg per day, which can be increased after two weeks to 20 mg per day. The Psychotherapy section stated (typed as written): Althoug… | 2020-09-01 |
| 218 | 218 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-02-16 | 758 | E | 1 | 0 | EN1S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, policy review, and staff interview, the facility failed to ensure residents did not receive [MEDICAL CONDITION] drugs unless the medication was necessary to treat a specific condition. The medical records of four (4) of four (4) sampled residents reviewed for behaviors, lacked documentation of specific nonpharmacological interventions employed by staff and the residents' responses to those interventions so the effectiveness of interventions could be determined. Resident identifiers: #49, #45, #65 and #79. Facility census: 102. Findings include: a) Resident #49 Review of the resident's medical record on 02/12/18 at 1:20 PM, revealed this resident's [DIAGNOSES REDACTED]. The care plan with a revision date of 01/21/18 identified depression and anxiety as problems for the resident. One of the interventions was to, Offer non-pharmacological interventions if resident is upset such as 1:1 interaction, calling her mother, or a snack. The Medication Administration Record [REDACTED] -- [MEDICATION NAME] 20 mg at 6:00 AM for major [MEDICAL CONDITION] -- [MEDICATION NAME] 100 mg at 7:00 PM and 25 mg at 7:00 AM related to [MEDICAL CONDITION]'s disease -- [MEDICATION NAME] 1 mg 7:00 AM and 7:00 PM for anxiety -- [MEDICATION NAME] HCL 10 mg 7:00 AM, 1:00 PM, and 7:00 PM for major [MEDICAL CONDITION] The (MONTH) and (MONTH) MARs include a daily section for charting with the following information (typed as written): -- Resident receives [MEDICATION NAME] for Depression AEB yelling out questions, observe for behavior during shift. 0= not present 1 = present. If coding a 1, were non-pharmacological interventions per the CP attempted? Yes/NA --Resident receives [MEDICATION NAME] for [MEDICAL CONDITION]'s Disease AEB tearful, withdrawn, observe for behavior during shift. 0 = not present 1 = present. If coding a 1, were non-pharmacological interventions per CP attempted Yes/N[NAME] -- Resident receives [MEDICATION NAME] for Anxiet… | 2020-09-01 |
| 237 | 237 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-06-12 | 755 | D | 1 | 0 | LZL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and review of the facility's guidance tool for insulin storage, the facility failed to discard two (2) vials of insulin after having been opened for use for greater than twenty-eight (28) days. Another insulin vial was not inscribed with the date of initial opening, which rendered it so that it could not be determined as to what date to dispose of that vial. This was evident for one (1) of five (5) medication carts, and affected Residents #17 and #57. Facility census: 94. Findings include: a) Resident #17 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #17 which was marked as having been initially opened on 05/05/18. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. This guidance tool for the storage of medications stated that [MEDICATION NAME] may be used for twenty-eight (28) days after having been initially opened, and may be stored in a refrigerator or at room temperature from thirty-six (36) degrees Fahrenheit (F) to eighty-six (86) degrees F. b) Resident 57 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of Humalog insulin for Resident #57 which was marked as having been initially opened on 05/10/18. The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #57 which was delivered to the floor on 05/03/18. There was no date inscribed to indicate when this vial of insulin had been initially opened for use. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. … | 2020-09-01 |
| 238 | 238 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2018-06-12 | 761 | E | 1 | 0 | LZL711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and review of the facility's guidance tool for insulin storage, the facility failed to discard two (2) vials of insulin after having been opened for use for greater than twenty-eight (28) days. Another insulin vial was not inscribed with the date of initial opening, which rendered it so that it could not be determined as to what date to dispose of that vial. This was evident for one (1) of five (5) medication carts, and affected Residents #17 and #57. Facility census: 94. Findings included: a) Resident #17 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #17 which was marked as having been initially opened on 05/05/18. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. This guidance tool for the storage of medications stated that [MEDICATION NAME] may be used for twenty-eight (28) days after having been initially opened, and may be stored in a refrigerator or at room temperature from thirty-six (36) degrees Fahrenheit (F) to eighty-six (86) degrees F. b) Resident 57 Observation of the Mountain Village medication cart was completed on 06/11/18 at 2:05 p.m. while accompanied by licensed nurse Employee #133 (E#133). The medication cart contained an opened and partially used vial of Humalog insulin for Resident #57 which was marked as having been initially opened on 05/10/18. The medication cart contained an opened and partially used vial of [MEDICATION NAME] for Resident #57 which was delivered to the floor on 05/03/18. There was no date inscribed to indicate when this vial of insulin had been initially opened for use. E#133 showed a copy of the insulin storage recommendations that is kept on the medication cart in a three (3) ring binder. … | 2020-09-01 |
| 239 | 239 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-10-08 | 609 | D | 1 | 0 | RZPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon staff interview, observation and record review, the facility failed to ensure that an allegation of neglect was reported to the state survey agency and the state protective services agency. A resident's responsible party made a complaint that after she requested he be put to bed, her family member was left unattended in his wheelchair for two hours in his room, resulting in a fall. This was found for one (1) of seven (7) residents reviewed. Resident identifier: #54. Facility census: 103. Findings included: a) Resident #54 Record review revealed a complaint documented on 09/03/19 from a family member to Social Worker #132. The description of the concern was (typed as written): MPOA (Medical Power of Attorney) concerned that she left resident at 7:30 (PM) with his call light on to lay down and he fell at 9:30 (PM) from his wheelchair. (The incident report for the fall also documented he was found on the floor in front of his wheelchair.) Niece had requested he be transferred to bed or wheelchair to prevent fall. (Social Worker #132 explained on 10/8/19 at 2:35 PM she meant to write recliner but wrote wheelchair in error.) She feels he is not being repositioned or moved out of wheelchair and gets tired. The niece remarked she .would like resident to not be left in wheelchair unattended. Move to recliner or bed. Social Worker #132 stated on 10/8/19 at 2:35 PM she had educated Nursing Staff to not leave resident #54 in his wheelchair unattended previously on 8/20/19, and this had been added to his care plan. A care plan note written by Social Worker #132 on 8/20/19 stated in part (typed as written): Resident's niece attended meeting. Resident lacks capacity and is a full code. His niece is his POA and MPO[NAME] He has a [DIAGNOSES REDACTED]. He takes [MEDICATION NAME] and [MEDICATION NAME]. Niece would like him to be out of his wheelchair and in his bed or recliner more during the day. The investigation of the complaint was done by Ad… | 2020-09-01 |
| 240 | 240 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2019-10-08 | 689 | D | 1 | 0 | RZPJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon staff interview, observation, and record review, the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents. A resident was observed without ordered leg rests and chair alarms. This was found for one (1) of seven (7) residents reviewed. Resident identifier: #54. Facility census: 103. Findings included: a) Resident #54 Record review found a complaint documented on 9/3/19 from his family member to Social Worker #132. The concern was (typed as written): MPOA (Medical Power of Attorney) concerned that she left resident at 7:30 (PM) with his call light on to lay down and he fell at 9:30 (PM) from his wheelchair. (The incident report for the fall also documented he was found on the floor in front of his wheelchair.) Niece had requested he be transferred to bed or wheelchair to prevent fall. (Social Worker #132 explained on 10/8/19 at 2:35 PM she meant to write recliner but wrote wheelchair in error.) She feels he is not being repositioned or moved out of wheelchair and gets tired. The niece remarked she .would like resident to not be left in wheelchair unattended. Move to recliner or bed. Social Worker #132 stated on 10/8/19 at 2:35 PM she had educated Nursing Staff to not leave resident #54 in his wheelchair unattended previously on 8/20/19, and this had been added to his care plan. A care plan note written by Social Worker #132 on 8/20/19 stated in part (typed as written): Resident's niece attended meeting. Resident lacks capacity and is a full code. His niece is his POA and MPO[NAME] He has a [DIAGNOSES REDACTED]. He takes [MEDICATION NAME] and [MEDICATION NAME]. Niece would like him to be out of his wheelchair and in his bed or recliner more during the day. Review of resident #54's current physician's orders [REDACTED]. Resident #54 was observed at least four times each day during the investigation. On 10/8/19 at 10:50 AM, resident #54 was observed in his wheelchair ju… | 2020-09-01 |
| 271 | 271 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-11-06 | 609 | D | 1 | 0 | L1WQ11 | > Based on policy review, record review, and staff interview, the facility failed to report allegations of abuse and neglect within the required timeframe. This deficient practice was found for three (3) of four (4) residents reviewed for the care area of abuse. Resident identifiers: #65, #26, #40. Facility census: 65. Findings included: a) Policy Review A review of the facility's abuse policy titled, Abuse, Neglect and Exploitation, implemented on 11/27/17 and last revised on 02/01/19 abuse and neglect are to be reported to the required agencies within specified time frames. b) Resident #65 Per a review of the facility's abuse and neglect logs during the survey, Resident #65 was noted to have an incidence of abuse and/or neglect in (MONTH) 2019. Resident #65's abuse/neglect investigation with an incident date of 08/29/19 was reviewed on 11/05/19 at 12:16 PM. According to the investigation, the incident occurred between 11:00 AM and 4:00 PM on 08/29/19. Per the fax sheets attached to the investigation, the incident was reported to Adult Protective Services (APS), the Nurse Aide Registry, and the Office of Health Facility Licensure and Certification (OHFLAC) on 08/30/19 at 4:25 PM, more than 24 hours after the incident occurred. The Ombudsman was faxed on 08/30/19 at 4:26 PM, more than 24 hours after the incident occurred. c) Resident #26 Per a review of the facility's abuse and neglect logs during the survey, Resident #26 was noted to have had two (2) incidences of abuse and/or neglect in (MONTH) 2019. Resident #26's abuse/neglect investigation with an incident date of 09/10/19 was reviewed on 11/05/19 at 10:50 AM. According to the investigation, the incident occurred on 09/10/19 at 9:00 AM. Per the fax sheets attached to the investigation, the incident was reported to APS on 09/11/19 at 5:21 PM, more than 24 hours after the incident occurred. OHFLAC was notified on 09/11/19 at 5:22 PM, more than 24 hours after the incident occurred. The Ombudsman was notified on 09/11/19 at 5:27 PM, more than 24 hours after the … | 2020-09-01 |
| 323 | 323 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-08-17 | 580 | E | 1 | 0 | M7U611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The facility failed to immediately inform the representative of a resident who was determined by a physician to lack the capacity to make informed medical decisions of a change in treatment and a change of condition. The responsible party for Resident #89 was not notified of a change in enteral feeding or of a change in condition that required being sent to an acute care hospital. Inconsistencies in the designation of the responsible party on the face sheets of the medical records were identified which had the potential to affect more than a limited number of residents. Resident identifiers: 89. Facility census: 86. Findings included: a) The initial review of medical records found there were some charts in which residents, who had been determined by a physician to lack the capacity to make informed medical decisions, and had another person designated as their responsible party for medical decisions had the designation Responsible Party listed beside the resident's name instead of the legally appointed decision maker's name. b) Facility Social Worker #89 was interviewed on 8/14/18 at 8:00 AM. She was asked about the face sheets listing some residents as responsible party, even though they may not have capacity and have a Medical Power of Attorney, Health care Surrogate, or Guardian in place making their medical decisions. She said the term as used by the corporation owning the facility refers to financial responsibility rather than health care decision making responsibility. She said in the electronic health record (EHR), you have to check the other persons listed to see if they have a specific designation of Health Care Surrogate, Medical Power of Attorney, or Guardian. If they do not, or if they say only Emergency Contact, then the resident is the decision maker. On the paper chart, you could look at the determination of capacity under the advance directives tab. The determinations of capacity are not included in the EHR. She said the curr… | 2020-09-01 |
| 324 | 324 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 557 | E | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident interview, record review and staff interview the facility failed to ensure three (3) of 25 residents were treated with respect and dignity. Resident identifiers: #44, #45 and #7. Facility census: 83. Findings included: a) Resident #44 During a random observation, on 10/16/18, at 9:40 AM, Resident #44 was observed from the hallway, exposed from the waist down. The resident was noted to have an incontinence brief on visible to those passing by the doorway. Further observation noted Resident #44 holding her gown in her hand and exposing the upper and lower body with the brief remaining. On 10/16/18, at 9:50 AM, an interview with Nurse Aide (NA) #11, revealed that Resident #44 was noted to disrobe, and NA #11 tried to pull the curtains when this behavior is occurring. A review of the comprehensive care plan for Resident #44, did not identify interventions to assist staff to care for Resident #4 hen this behavior was seen. On 10/16/18, at 12:10 PM, an interview with the Social Services Director , verified no intervention had been initiated for Resident #44's problem of disrobing and being exposed to those passing by the room. b) Resident #45 During a random observation, on 10/14/18, at 6:25 PM, Resident #45 was observed having the meal tray delivered. Nurse Aide (NA) #35 was observed to set up the tray to assist the resident. NA #35 began assisting Resident #45 but stood up as she fed him. An interview, on 10/15/18, at 4:00 PM, with NA #38, revealed they were trained to get a chair and sit with the resident when assisting with meals. NA #35 said, Staff are not permitted to stand to feed a resident. c) Resident #7 During an interview, on 10/09/18 at 9:58 AM, Resident #7 expressed concerns with having hallucinations. He said he had told staff but they did not listen to the concerns. A review of the minimum data set (MDS) quarterly assessment dated [DATE] and review of medical record progress notes, revealed was no ev… | 2020-09-01 |
| 325 | 325 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 558 | E | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure two (2) of 25 sampled and five (5) randomly observed residents had access to their call lights. Resident identifiers: #43, #14, #15, #42, #13, #4, and #45. Facility census: 83. Findings included: a) Resident #43 On 10/14/18 at 5:55 PM Resident #43 said he had to urinate. He could not find his call light. The call light was clipped to the inside of the resident's privacy curtain. The resident had a pressure pad call system. This system allowed the resident to call for assistancr by lightly pressing on the pad. The resident had limited use of his hands and arms. He could not locate the call light on his own. A review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #43 had functional limitations in range of motion on both sides of his upper extremities. On 10/16/18 at 8:40 AM Resident #43 said he could use his call system. He said he used it when he needed to urinate/have a bowel movement. b) #14 On 10/09/18 at 10:17 AM Resident #14 said he needed help. He could not locate his call light. Another resident in the room pushed his call light to summon help for this resident. When Nurse Aide (NA) #41 and Licensed Practical Nurse (LPN) #72 responded to the call light Resident #14's call light was found underneath the wooden wardrobe beside his bed. c) Resident #15 On 10/09/18 at 10:17 AM Resident #15 said he needed his biscuits and gravy heated up. He was asked to use his call light for assistance. He could not locate the call light. Another resident residing in the room was asked to use his call light to get assistance for Resident #15. When NA #41 and LPN #72 responded Resident #15's call light was down beside his bed out of reach. d) Resident #42 On 10/14/18 at 5:35 PM Resident #42 was observed sitting in his wheelchair at a table in his room. He said he needed to use the bathroom. He further explained that he felt like he needed to have a bo… | 2020-09-01 |
| 326 | 326 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 561 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, and medical record review, the facility failed to honor Resident #11 choices regarding an aspect of her life in the facility which was significant to the resident. The resident was not afforded the opportunity to receive showers according to her preferences and choice. This was true for one (1) of eight (8) residents reviewed. Resident identifier: #11. Facility census: 83. Findings included: a) Resident #11 On 10/09/18 at 12:45 PM, observations revealed Resident #11 appeared clean and groomed. An interview with Resident #11 revealed the resident did not always get her showers as they were scheduled or when she wanted them. The resident said she preferred showers and did not care much for a bed bath. Resident #11 stated she had told nursing staff many times about the fact she did not always get her showers and that she wanted them in the afternoons not mornings. Resident#11 could not recall the names of the different staff she said she had spoken with. Resident #11 said, You got different nurses coming in here from other nursing homes filling in, you just can't always keep up with their names. We got a new administrator now and I am hoping things will change around here. The resident said she was to have her showers on Wednesday and Saturday, in the afternoons or evenings, but never mornings. Resident #11 said she never refused showers because she likes showers. Resident #11 said she had refused only one time a few weeks ago, when a nurse aid came into her room in the morning to try to give her a shower, instead of the afternoon when she was supposed to get them. Review of records, on 10/10/18 at 8:40 AM, revealed the resident was admitted to the facility on [DATE]. An annual minimum data set (MDS) assessment reference date (ARD) of 07/07/18 showed the resident had adequate hearing and clear speech. The resident could understand and make herself understood. Resident #11's Brief Interview for Ment… | 2020-09-01 |
| 327 | 327 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 580 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, family interview and staff interview the facility failed to ensure they notified the responsible parties for two (2) of 25 sampled residents when those residents experienced a change in condition, had a new treatment ordered and experienced a significant error in administration of a medication. Resident #5 had a computerized tompography (CT) scan performed to rule out a fracture. Resident #3 experienced a [MEDICAL CONDITION] and was not given a medication to treat [MEDICAL CONDITION] activity. Resident identifiers: #5 and #3. Facility census: 83. Findings included: a) Resident #5 An interview with Resident #5's Medical Power of Attorney on 10/14/18 at 6:00 PM revealed Resident #5 had a CT scan. The MPOA said the facility did not inform him of the results from the CT scan. A progress note dated 07/30/18 stated, Xray of right lower extremity reports [MEDICAL CONDITION] changes but could not rule out fracture of tibia. Discussed with FNP family nurse practicioner and MPOA medical power of attorney. New orders given for CT w/o contrast of right lower extremity on 8/3/18 at (name of local hospital). MPOA (medical power of attorney) aware. A progress note dated 08/3/18 stated, Resident OOF out of facility for CT scan via (name of ambulance company) per stretcher with two (2) attendants. Further review of progress notes did not reveal a note indicating the MPOA was informed of the results of the CT. On 10/15/18 at 11:38 AM Licensed Practical Nurse #72 and Scheduler #16 looked through the resident's thinned medical record and located the results of the CT. There was no indication the facility had informed the MPOA of the results from the CT completed on 08/03/18. The CT scan report dated 08/03/18 did have hand written notes showing the family nurse practicioner was notified and that there was a new order for an orthopedic consult. However, there was no note to reflect the MPOA was notfieid of the CT results. b) Resid… | 2020-09-01 |
| 328 | 328 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 600 | E | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, resident interview and pharmacy interview, the facility failed to ensure five (5) of 25 residents were provided care and services necessary to avoid neglect. The facility failed to ensure adequate and timely medical care to Resident #3 during a [MEDICAL CONDITION]. The facility failed to ensure staff were aware of and trained on how to use a vagal stimulator for Resident #20. The facility failed to adequate assess and monitor the status of Resident #2 who was experiencing a change in medical condition. The facility failed to provide treatment and services to Resident #7 who was experiencing hallucinations. The facility failed to ensure Resident #5, who had a pressure sore received turning and repositioning. Resident identifiers: Residents #3, #20, #2, #7, and #5. Facility census: 83. Findings included: a.) Resident #3 On 10/10/18, at 2:35 PM, after consultation with the State Agency a determination of Immediate Jeopardy was identified at Riverside Health and Rehab Center. The facility failed to ensure that emergency medication was provided to a Resident #3 in accordance with physician's orders [REDACTED]. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 08:44 PM. A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/… | 2020-09-01 |
| 329 | 329 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 625 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview the facility failed to provide notification of bed hold policy at time of hospital transfer. This was true for one (1) of one (1) resident reviewed. Resident identifier: #2. Facility census: 83 Findings included: a) Resident #2 Resident #2 was admitted for rehabilitation, on 05/19/18 status [REDACTED]. Resident has capacity. Resident has a history of pathologic fractures due to [MEDICAL CONDITION] metastasized to bones. Resident #2 was Sent to hospital on [DATE] for Femur IM Nail placement on 08/05/18 and returned to facility on 08/08/18. Resident #2 was sent to the hospital on [DATE], for left Humerous open reduction. The Humerous is the long bone located in the upper arm of the body which extends from the shoulder joint to the elbow. Resident was pulling herself to left side of bed by pulling on bed side bar. Resident heard her left arm snap accompanied by acute onset pain. Was sent out and returned to facility on 09/07/18. The resident was again sent to the hospital on [DATE] and has not returned to the facility. Review of records, on 10/09/18 at 11:15 AM, revealed no bed hold notices for Resident#2 for the dates the resident was sent to the hospital. Resident #2 was sent to the hospital on [DATE], 09/02/18, and 09/22/18. Review of facility 'Transfer and Discharge Procedure', on 10/15/18 at 4:00 PM, revealed #13 under Procedure for Transfer or Discharge said, Facility designee provides notice in writing of the facility's Bed Hold and readmission policies to the resident and the resident's representative. Review of the facility's 'Bed Hold/Leave of Absence' Policy revealed under the 'Procedure' for 'Bed Hold Notification' #1 states Upon admission or leave of absence, a facility designee will provide the resident, and/or the responsible party written information concerning the option to exercise the 'Bed Hold /Leave of Absence' Policy. 1b states Upon Leave of Absence, a Bed Hold Authorizat… | 2020-09-01 |
| 330 | 330 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 641 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and medical record review, the facility failed to complete an assessment to accurately reflect two (2) resident's status. This was a random opportunity for discovery. Resident #2's assessment did not accurately reflect the resident's range of motion ability nor accurately reflect the resident's status concerning a fracture. Resident #11's assessment was inaccurate concerning activities of daily living (ADL). This practice has the potential to affect more than a limited number of residents. Resident identifier: #2 and #11. Facility census: 83. Findings included: a) Resident #2 Review of medical records, on 10/09/18 at 11:00AM, revealed the resident was admitted to the facility on [DATE] status [REDACTED]. Resident #2 had capacity and a history of pathologic fractures due to [MEDICAL CONDITION] metastasized to bones. Resident #2 was sent to the hospital on [DATE] for a Femur IM (Intramedullary) Nail on 08/05/18. The femur is a bone of the leg situated between the pelvis and knee. Intramedullary nail fixation has become the standard of treatment for [REDACTED]. The resident returned to facility on 08/08/18. Review of records, on 10/09/18 at 11:15 AM, revealed a quarterly minimum data set (MDS) with an assessment reference date (ARD) 8/22/18. The MDS reflected resident had adequate hearing and vision, clear speech, can make self-understood and understands. Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 15 indicating the resident was cognitively intact with no impairment. The resident needed extensive assistance with activities of daily living (ADLs), except supervision with meals and was totally dependent for bathing. The resident needed extensive assistance with balance during surface to surface transfer, moving on and off toilet, and resident was not steady only able to stabilize with staff assist. Functional limitations in range of motion (ROM) revealed there was 'NO' impairment on both si… | 2020-09-01 |
| 331 | 331 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 656 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview the facility staff had not developed care plans for two (2) randomly observed and one (1) sampled resident. Resident #7 expressed concern with hallucinations. No care plan interventions were developed to monitor for adverse reactions of antidepressant use which included hallucinations. Resident #20 did not have a care plan developed for the use of a vagal stimulator. Resident #44 was found to have an identified behavior of disrobing and staff had not developed a care plan for this behavior. This was evident for two (2) random residents and one (1) resident identified in the complaint sample. Resident identifiers: #7 , #20 and #44. Facility census: 83 Findings included: a) Resident #7 Resident #7 expressed he was having hallucinations when he was interviewed during the tour on 10/09/18 at 9:58 AM. He stated staff did not listen to him when he had expressed this concern many times. A review of the medical record on 10/10/18 at 10:00 AM revealed Resident #7 was taking an antidepressant medications. One of the interventions listed was to monitor adverse reactions that could be a side effect. Discussion with Administrator Designee (AD) #51 at 10:35 AM on 10/10/18 revealed AD #51 was not aware of the resident having hallucinations and that he would be scheduled to be seen by the physician on a visit next week. A review of a nursing summary report dated 10/01/18 did not show that hallucinations had been identified as a concern to monitor. Review of the care plan on 10/10//18 and 10/11/18 at 9:30 a AM . did not show that hallucination had been identified as an actual problem which needed to be monitored and treated once it was noted as an adverse reaction. b) Resident #44 During a random observation, on 10/16/18, at 09:40 AM, Resident #44 was observed from the hallway, exposed from the waist down. The resident was noted to have an incontinence brief on visible to those passing by the doorway. Furth… | 2020-09-01 |
| 332 | 332 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 684 | J | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, resident interview, pharmacy interview and observation, the facility failed to ensure all treatment and care provided to nine (9) or 25 sampled facility residents and one (1) randomly sampled resident was in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to perform finger stick blood glucose monitoring and give sliding scale insulin if needed as directed by the physician for Resident #4. The facility failed to administer medications in accordance with physician's orders [REDACTED]. The facility failed to follow-up on known side effects of hallucinations of a medication for Resident #7. The facility failed to obtain an order for [REDACTED].#1 and Resident #8. The facility failed to follow a bowel protocol for Resident #42. The facility failed to provide turning and positioning for Resident #5 who was dependent for turning and repositioning and had developed a pressure ulcer. The facility failed to ensure they assessed and monitored Resident #2 when the resident experienced a change of condition. On 10/10/18, at 2:35 PM, after consultation with the State Agency a determination of Immediate Jeopardy was identified at the facility. The facility failed to ensure that emergency medication ([MEDICATION NAME] Gel) was provided to a Resident #3 in accordance with physician's orders [REDACTED]. A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review… | 2020-09-01 |
| 333 | 333 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 695 | D | 1 | 0 | BYSJ11 | > Based on medical record review and staff interview there were no physician orders for oxygen use for two (2) of two (2) residents who were receiving oxygen treaments. Resident identifiers are: #1 and #8. Census; 83 Findings included: a) Resident #1 During observations of 10/09/18. the resident was observed in the dining room at the table with portable oxygen in place. It was set for 2 liters per minute. Another observation on 10/09/18 at 4 pm. in the hallwasy, she was in her wheelchair with portable oxygen set for 2 liters per minute. A review of the medical record on 10/10 /18 at 2:00 pm did not show the resident had orders for oxygen therapy. A reveiw of the current care plan indicated there was no oxygen therapy being listed as a concern with treatment. Discussion with the administrator desigee#51 on 10/10/18 at 2:30 p.m. revealed she would have to see what had happended to the oxygen order. It may have not gotten carried over from the previous month. b) Resdient #8 The resident was observed in bed in her room during the initial tour of10/09/18 at 9:48 a.m. The resident did have oxygen being administered at that time. Review of the resident's medical record showed there was no order noted for oxygen thereapy. Additionally, the current care plan did show there was a problem listed as oxygen therapy and have interventions noted. Nursing notes of 10/02/18 stated the resident's oxygen saturation level dropped and oxygen had to be administered. A new order for oxygen was found at 4 pm after the surveyor had brought it to their attention. | 2020-09-01 |
| 334 | 334 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 726 | F | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, family interview, staff interview, record review, and observation the facility failed to ensure staff were trained and competent in the area of identifying and obtaining treatment for [REDACTED]. Resident identifiers: Resident #4, 42, #5, #3, #7, #1, #6, #8, #20, and #2. Facility census: 83. Findings included: a) Resident #42 On 06/14/18 at 5:45 PM, during an interview with Resident #42, the resident explained he had some trouble with his bowels since he came to the facility. The medical record review revealed the resident came to the facility on [DATE]. Review of the documentation survey report revealed Resident #42 had no bowel movements recorded on 10/04/18, 10/05/18, 10/07/18. A medium sized bowel movement was recorded between 11:00 PM and 7:00 AM on 10/08/18. A review of the physician's orders revealed the following orders: Milk of Magnesia Suspension 1200 MG (milligram)/15 ML (milliliter) (Magnesium [MEDICATION NAME]) Give 30 ml by mouth as needed for Bowel Management x1 if no bowel movement in 3 days. The resident also had an order for [REDACTED]. During an interview with Assistant Director of Nursing (ADoN) #106, at 2:26 PM on 10/16/18, the ADoN verified the resident was admitted on [DATE] and did not have a bowel movement until sometime during the 11:00 PM - 7:00 AM shift that began on 10/08/18. She was asked if the resident had received Milk of Magnesia or the [MEDICATION NAME] Powder prior to the bowel movement. She said he had not. b) Resident #5 A review of Resident #5's treatment sheet revealed an order to turn and reposition the resident every two (2) hours due to increased risk of skin breakdown. Care plan review revealed Resident #5 had been treated for [REDACTED]. The care plan reflected the resident was incontinent of bowel and bladder and moved around in bed by sliding. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] reflected the resident was totally dependent for bed mob… | 2020-09-01 |
| 335 | 335 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 742 | D | 1 | 0 | BYSJ11 | > Based on medical record, staff and resident interview it was found that the faciilty failed to provide services for a resident with such psychosocial issues as hallucaintions. This was evident for one (1) of 25 residents reviewed in the sample. Resident identifier: #7. Census: 83. Findings included: a) Resident #7 Resident #7 expressed during interview of the initial tour, on 10/09/18 at 9:58 AM, he was having halluciantions. He stated he had told staff before and they would not listen to him. He said the halluciantions seem so real to him. A review of a nursing assessment dated 10 01/18 shows several problem areas for the resident but halluinations was not identifed as needing addressed and treated. Resident #7 did recieve anitdepressants and halluciantions was a side effect listed in the current care plan as needing monitored due to the use of antidepressants. During interview, with Administrator Designee (AD) #51 on 10/10/18 at 10:35 AM, it was determined that the resident had not been monitored for hallucination. AD #51 said the resident would be evaluated by the phyisician on the following Tuesday. | 2020-09-01 |
| 336 | 336 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 760 | J | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, pharmacy interview, and observation, the facility failed to ensure that one (1) of 25 sampled residents was free of any significant medication errors. The facility failed to administer emergency [MEDICAL CONDITION] medication to a resident during a [MEDICAL CONDITION]. On 10/10/18, at 2:35 PM, after consultation with the State Agency, a determination of Immediate Jeopardy was identified at Riverside Health and Rehab Center. The facility failed to ensure that emergency medication was provided to Resident #3 in accordance with physician's orders [REDACTED]. A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, noted the [MEDICATION NAME] Gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two nursing staff, LPN #105 and LPN #55, at this time, verified the medication was not documented on the MAR and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box on the cart did not contain any dose of the [MEDICATION NAME] Gel ( [MEDICATION NAME] ) available to administer for Resident #3. Observations of the Automated Dispensing … | 2020-09-01 |
| 337 | 337 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 761 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview and policy and procedure review, the facility failed to ensure all drugs and biologicals were labeled in accordance with professional principles for two (2) of (2) medication carts. Four (4) medications were not dated when opened and put into use. Findings included: a.) An observation of the East Short Hall cart, on 10/14/18, at 6:30 PM revealed the following: 1.) A vial of [MEDICATION NAME] was observed in the medication cart and not dated and in use. 2.) An interview, on 10/14/18, at 6:30 PM, with LPN #150, verified there was no date on the medication when opened and the insulin was being administered to a resident. b.) An observation of the West Short Hall cart, on 10/16/18, at 09:20 AM, revealed the following: 1.) A vial of [MEDICATION NAME] R insulin was observed in the medication cart, with no date when opened and put into use. 2.) A [MEDICATION NAME] Flex pen was observed in the medication cart, with no date when opened and put into use. 3.) A [MEDICATION NAME] Flex pen was observed in the medication cart, with no date when opened and put into use. 4.) An interview, on 10/16/18, at 09:25 AM , with LPN #34, verified the medications did not have a date when opened and all medications observed above were being administered to residents. c.) A review of the Policy and Procedure 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, no date, notes that medications, once opened, will not be retained longer than the manufacturer's guidelines. An interview, on 10/16/18, at 09:20 AM, with LPN #20 and LPN #34, verified all insulin should have been dated when opened to ensure not administering the medication past the acceptable date established by the manufacturer. | 2020-09-01 |
| 338 | 338 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 773 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to provide or obtain laboratory services when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, including scope of practice laws for two (2) of 25 sampled residents. The facility failed to ensure laboratory tests were completed for Resident #3. Resident identifier:: Resident #3. Findings included: a.)Resident #3 A review of the current physician's orders [REDACTED].) A review of the laboratory section of the medical record revealed no documented results for the [MEDICATION NAME] level ordered for (MONTH) (YEAR). An interview, on 10/15/18, at 02:30 PM with LPN#7, revealed no results were received and placed on the medical record. Upon further investigation, LPN#7 stated the lab had not been drawn according to the laboratory book. Additionally, the repeat Ammonia level ordered 08/20/18 was not done as well. Review of the available labs, revealed Resident #3 had previously had higher levels than normal of [MEDICATION NAME]/[MEDICATION NAME] Acid at level 110 (normal range indicated 50-100 MCG/ML) {microgram/ milliliter} and Ammonia levels at level 40 (normal range indicated as 9.0-33.0 UMOL/L) {micromole per liter}. | 2020-09-01 |
| 339 | 339 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 804 | D | 1 | 0 | BYSJ11 | > Based on observation, staff and resident interview it was found the facility staff had not always served attractive food. This was determined through a random observation . There are 10 residents who receive pureed diets. Resident identifier: #42. Facility census: 83 Findings include: a) Resident #42 During dinner meal observations on 10/14/18, the resident who was eating alone in his room was noted to have puree kielbasa. The item was very thin and running into other items on the plate, such as the red potatoes and cabbage. When Resident #42 saw the puree item he stated, well that is interesting. The observation of the unattractive runny purred food was discussed with the food service supervisor and the corporate regional manager of food service on 10/15/18 at 1:50 PM. They had no comment. | 2020-09-01 |
| 340 | 340 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 805 | E | 1 | 0 | BYSJ11 | > Based on observation, review of the facility puree recipe, resident and staff interviews the dietary staff had not prepared puree foods in a manner that made it the right texture and consistency. This practice had the potential to affect 10 (ten) of 83 residents that were ordered pureed consistency dietary regimens. Resident identifier: #42 Facility census: 83 Findings included: a) During dinner meal observations on 10/15/18 it was found the puree kielbasa was very thin and running in to other items such as red potatoes and cabbage on Resident #42's plate. The surveyor requested to see the recipe for the puree item from the dietary service supervisor and the corporate regional manager of food services on 10/15/18 at 1:50 PM A review of the recipe found no specific instructions on how much thickener to add to the product to reach the correct consistency. The recipe just said to add thickener to item. It did not indicate how much to start with and then how much to keep adding until it would be the desired texture. During an interview on, 10/16 /18 at 5:13 PM, the dietary manager said there were 10 residents who receive pureed diets and had the potential to receive the item that was incorrectly prepared. | 2020-09-01 |
| 341 | 341 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 835 | D | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, observation, family interview, and resident interview the facility failed to ensure effective oversight and management of its operations. This failure resulted in deficient practices in the following areas: Notification of changes, nursing services, quality of care, and freedom from neglect. Resident #20 had a vagal nerve stimulator device used to control [MEDICAL CONDITION]. The facility staff were not trained on how to use this device. Some of the nursing staff assigned to care for the resident did not know the resident had the device. Resident #7 had experienced hallucinations and the staff did not acknowledge the resident's mental health issues in order to provide treatment for [REDACTED].#5 had experienced a stage IV pressure. The resident was dependent for turning and repositioning. Staff were not providing turning and repositioning every two (2) hours as indicated in the care plan. Staff did not timely assess and monitor Resident #2 at for changes in condition. On 10/10/18, at 2:35 PM, after consultation with the state agency a determination of immediate jeopardy was made. The facility failed to ensure that emergency medication was provided to a Resident #3 in accordance with physician's orders [REDACTED]. After the receipt of an acceptable plan of correction and implementation of the plan of correction (P[NAME]), the immediate jeopardy was abated on 10/10/18, at 8:44 PM. The facility implemented in-services for direct care staff regarding [MEDICAL CONDITION] care. Resident #3's physician was notified and orders for Intramuscular (IM) [MEDICATION NAME] was obtained. IM [MEDICATION NAME] was available in the emergency cart. Resident identifiers: #2, #7, #3, #5, and #20. Facility census: 83. Findings included: a) Resident #7 Resident #7 expressed he was having hallucinations when he was interviewed on 10/09/18 at 9:58 AM. He stated staff did not listen to him when he had expressed this c… | 2020-09-01 |
| 342 | 342 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 838 | J | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, resident interviews, observations, family interviews and medical record reviews the facility failed to ensure their facility assessment reflected the care required by their patient population. The facility was required to consider the types of diseases, physical and cognitive condition and other pertinent facts that were present within their patient population to ensure they had competent staff in the facility to meet the needs of the patient population. Issues were found in the following areas: Notification of changes, quality of care, freedom from neglect and nursing services. Deficient practices found reflected the nursing staff were not competent in the skills necessary to ensure the residents needs were met. Issues were idienfieid with residents with [MEDICAL CONDITION] disorders, acute change in health status, hallucinations and pressure ulcers. These deficient practices had the potential to affect more than an isoalted number of residents. Resident identifiers: #3, #20, #2, #5, and #7. Facility census: 83. Findings included: a) Resident #5 Notification of changes An interview, with Resident #5's Medical Power of Attorney (MPOA), on 10/14/18 at 6:00 PM, revealed Resident #5 had a (computed tompography (CT) scan. The MPOA said the facility did not inform him of the results from the CT scan. A progress note dated 07/30/18 stated, X-ray of right lower extremity reports [MEDICAL CONDITION] changes but could not rule out fracture of tibia. Discussed with FNP 'family nurse practicioner' and MPOA 'medical power of attorney.' New orders given for CT w/o (without) contrast of right lower extremity on 8/3/18 at (name of local hospital). MPOA (medical power of attorney) aware. A progress note dated 08/3/18 stated, Resident OOF 'out of facility' for CT scan via (name of ambulance company) per stretcher with 2 attendants. Further review of progress notes did not reveal any evidence indicating the MPOA was informed of the… | 2020-09-01 |
| 343 | 343 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 842 | E | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and staff interviews the facility failed to ensure the accuracy of the medical records for four (4) of twenty-five (25) sample residents. The facility failed to ensure complete documentation concerning [MEDICAL CONDITION] activity, showers, and bed hold notices. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #20,11,2, and #3. Facility census: 83. Findings included: a) Resident #20 Review of Resident#20's care plan, on 10/10/18 at 10:15 AM, revealed an intervention related to [MEDICAL CONDITION] activity under the focus of impaired Neurological status related to [MEDICAL CONDITION] disorder . An intervention included [MEDICAL CONDITION] documentation: location of [MEDICAL CONDITION] activity, type of [MEDICAL CONDITION] activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after [MEDICAL CONDITION] activity. Another intervention related to [MEDICAL CONDITION] activity was found under the focus of risk for falls. The intervention is, Keep vagal stimulator (used during [MEDICAL CONDITION] activity) handy at all times. Use vagal stimulator as ordered if resident has more than one [MEDICAL CONDITION] in a row. Review of records for Resident#20, on 10/10/18 at 2:00 PM, revealed an order for [REDACTED]. The MAR indicated [REDACTED]. No details concerning the [MEDICAL CONDITION] activity was found in the record, no description on how long it lasted or if the vagal stimulator was used. No [MEDICAL CONDITION] documentation was found in the record. b) Resident #11 An interview with Resident #11, on 10/09/18 at 12:45 PM, revealed the resident did not always get her showers as they were scheduled or when she wanted them. The resident said she is to have her showers on Wednesday and Saturday, in the afternoons or evenings, but never mornings. Resident #11 said she never refuses showers beca… | 2020-09-01 |
| 344 | 344 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 880 | D | 1 | 0 | BYSJ11 | > Based on observation and staff interview the facility failed to ensure they maintained an infection control program designed to provide a safe, sanitary environment and help prevent the development and transmission of communicable diseases and infections. A wash basin was found lying on the floor in Resident #5's room. Resident #9's catheter bag was touching the floor. The aforementioned practices had the potential to affect more than an isolated number of residents. Resident identifiers: #5, and #9. Facility census: 83. Findings include: a) Resident #5 On 10/09/18 at 12:20 PM an observation in Resident #5's room revealed a gray plastic wash basin on the floor across from the bed, near the wall. The basin was not stored in a bag and was directly on the floor. On 10/09/18 at 12:25 PM Licensed Practical Nurse (LPN) #7 came in the room and was asked about the wash basin on the floor. He said it was probably there because it was dirty. He threw it away. b) Resident #9 An observation of Resident #9's catheter bag, on 1:35 PM on 10/09/18, revealed the catheter bag was sitting directly on the floor. On 10/09/18 at 1:40 PM, LPN #62 was told about the observation made at 1:35 PM. She said she would take care of it. | 2020-09-01 |
| 357 | 357 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2017-05-03 | 323 | E | 1 | 0 | 2DTW11 | > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Chemical substances were unsecured and accessible to residents. This practice had the potential to affect more than a limited number of residents. Facility census: 135. Findings include: a) A tour of the 3rd floor, on 05/02/17 at 1:20 p.m., revealed the whirlpool room door was propped open. The room contained the following items: --One (1) container of HDQ Neutral-Disinfectant, Mildewstat, Fungicide, and Viricide with the warning Danger-Keep out of reach of children-Corrosive-Causes irreversible eye damage and skin burns-Harmful if swallowed or absorbed through the skin-Contact a Poison Control Center or doctor immediately if exposed. --One (1) container of Derma Daily Moisturizing Lotion with the warning Avoid contact with eyes-Keep out of reach of children. --Ten (10) containers of McKesson Shaving Cream with the warning Keep out of reach of children. An interview with the Director of Nursing (DON), on 05/02/17 at 1:30 p.m., revealed all chemical substances should be secured away from the residents at all times. The DON stated the chemicals in the whirlpool room should have been placed in the locked cabinets while not in use. | 2020-09-01 |
| 395 | 395 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2017-08-11 | 156 | D | 1 | 0 | C6IS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon family interview, staff interview, record review, and facility policy review, the facility failed to ensure that one (1) of eleven (11) (Resident #115) sampled residents family representative was informed of the resident's rights and Medicare charges, and failed to obtain a consent for treatment upon admission. Facility census: 114. Findings include: a) Resident #115 Review of the resident's clinical record revealed he was admitted to the facility on [DATE] and discharge to home on 07/03/17. The resident's admissions [DIAGNOSES REDACTED]. On 06/15/17, the physician determined the resident lacked the capacity to make health care decisions. The admission agreement was signed by the resident's representative and Social Worker (SW) #38 on 07/03/17, but there was no signed consent for treatment in the resident's clinical record. During an interview on 08/08/17 at 4:01 p.m., SW #38 stated one of her responsibilities included obtaining the resident's signature, or the signature of the resident's representative on admission paperwork, which included consent for treatment, resident rights, and Medicare charges. SW #38 stated this information was obtained on admission to the facility within one (1) to two (2) days. SW #38 confirmed she had obtained Resident #115's representative signature on 07/03/17, but was unable to provide why the consent for treatment, resident rights and Medicare charges were not obtained on admission to the facility. During an interview on 08/08/17 at 4:20 p.m., Business Office Manager (BOM) #121 stated the social worker did all the admission paperwork with residents and their families. The BOM #121 stated the corporate expectation was for all admission paperwork to be completed within 72 hours of admission. During a telephone interview on 8/9/17 at 1:21 p.m., Resident #115's representative stated she was in the facility daily from 06/27/17 until the resident's discharge to home on 07/03/17. The representative state… | 2020-09-01 |
| 396 | 396 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2017-08-11 | 204 | D | 1 | 0 | C6IS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, staff interviews, clinical record review, and review of home health records, the facility failed to provide a safe and orderly discharge for Resident #115. The facility failed to arrange for post discharge services as ordered by the physician. This affected one (1) of four (4) sampled residents reviewed for discharged to home with home health services. Facility census: 114. Findings include: a) Resident #115 Clinical record review revealed Resident #115 was admitted to the facility on [DATE] and discharged to home on 07/03/17. On 07/03/17, the physician ordered, Discharge to home with home health, physical therapy, occupational therapy, nurse aide, and nursing. The 07/03/17 nursing discharge summary did not include any evidence of a referral to home health services. The 07/03/17 Physical Therapy (PT) discharge summary recommended, Continued home health services and 24/7 (24 hours a day, 7 days a week) supervision due to poor safety awareness. The Occupational Therapy (OT) discharge summary stated discharge destination, Private home with home health services. The resident's clinical record contained no evidence of an assessment or discharge planning done by Social Work (SW). The clinical record contained no evidence of a referral to home health services. During an interview on 08/08/17 at 1:59 p.m., PT #23 stated Resident #115 required ongoing PT services at discharge. PT #23 stated the SW made the referrals to a home health agency. During an interview on 08/08/17 at 2:17 p.m., OT #14 stated Resident #115 required ongoing OT services at discharge. OT #14 stated the SW made the referrals to a home health agency. During an interview on 08/08/17 at 4:01 p.m., SW #38 stated she had not completed an admission assessment for Resident #115 for determining his discharge needs. SW #38 stated she saw the resident only on his day of discharge. SW #38 stated she was unable to provide any evidence that a referral to home health… | 2020-09-01 |
| 397 | 397 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2017-08-11 | 283 | D | 1 | 0 | C6IS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and clinical record review, the facility failed to provide a physician discharge summary for one (1) of four (4) (Resident #115) sampled residents reviewed for discharged to home with home health services. Facility census 114. Findings include: a) Resident #115 Clinical record review revealed Resident #115 was admitted to the facility on [DATE] and discharged to home on 07/03/17. Resident #115's [DIAGNOSES REDACTED]. A 07/03/17 physician's orders [REDACTED]. The clinical record contained no physician discharge summary. During an interview, on 08/10/17 at 1:20 pm, the Administrator stated Resident #115's clinical record did not contain a physician discharge summary or recapitulation of his stay in the facility. The facility did not contact the home health agency until 2 days after the resident's discharge, but the facility still did not have a discharge summary identifying the resident's individual care and treatment. | 2020-09-01 |
| 398 | 398 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2017-08-11 | 309 | D | 1 | 0 | C6IS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, clinical record reviews, and facility policy review, the facility failed to provide ongoing assessment and evaluation after falls for one (1) of ten (10) (Resident #115) sampled residents to determine the need for revision of interventions to minimize future falls. Facility census: 114. Findings include: a) Resident #115 Clinical record review revealed Resident #115's [DIAGNOSES REDACTED]. The 07/03/17 Minimum Data Set 5-day assessment indicated the resident required extensive assistance of 2 persons with bed mobility, transfers, walking, and toilet use. He had experienced two (2) or more falls since admission with no injury. A 06/15/17 physician determined resident lacked long term capacity to make health care decisions. The 06/27/17 care plan for falls included interventions of, assure lighting is adequate and keep room free of clutter, check on resident frequently, encourage resident to call for assistance, hipsters at all times, low bed, toilet every two hours. A 06/29/17 at 11:46 a.m. nurse's note stated, Resident found on floor in front of nurses station on the floor. Resident denies any pain. No injuries noted. Family and MD (doctor) notified. Neuro checks and vital signs in place. Will continue to monitor resident. Review of neurological assessment flow sheet indicated neuro checks were performed on 06/29/17 at 2:30 p.m., 10:30 p.m., on 06/30/17 at 6:30 a.m., 3:30 p.m., 11:30 p.m. and 07/01/17 7:30 a.m., 3:30 p.m. The facility had no incident report for this fall. The clinical record contained no interdisciplinary team (IDT) evaluation of the resident fall. A 06/30/17 at 10:00 p.m. nursing note stated Resident #115 was witnessed sliding from his wheelchair by the nurses' station. The record contained no IDT evaluation of the resident's fall. During an interview on 08/09/17 at 9:50 a.m., Registered Nurse (RN) #130 stated she completed the 06/29/17 at 11:46 nurse's note. She confirmed she did not complete th… | 2020-09-01 |
| 400 | 400 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2018-11-07 | 880 | D | 1 | 0 | Z7KV11 | > Based on observations and staff interviews, the facility failed to ensure staff utilized proper hand hygiene and wound care procedures for 1 of 3 sampled residents requiring wound care. (Resident #9 ). Facility census 113. The findings are: a.) Resident #9 On 11/05/18 at 10 am, Registered nurse ( RN) #7 was observed providing wound care on Resident #9's left heel. RN #7 entered the room to provide care and placed all dressing supplies on resident's bed clothes without any barrier to protect wound supplies. RN #7 then washed her hands with soap and water for 8 seconds and applied gloves. RN #7 pulled trash can close to resident sitting in her chair and degloved. RN #7 did not wash her hands or use hand sanitizer and regloved and removed old dressing. RN #7 did not have saline to cleanse wound. RN #7 degloved and did not wash or sanitize her hands. RN #7 left the room to obtain saline. RN #7 returned to the room, regloved her hands but did not wash her hands prior to regloving. RN #7 completed wound care, removed her gloves, bagged her trash and left the room. RN #7 washed her hands with soap and water for 5 seconds in the utility room. During an interview, on 11/5/18 at 10:15 am, RN #7 provided no for not washing her hands with soap and water after changing her gloves. RN #7 provided no explanation for the lack of barrier to place wound supplies and properly disposing of trash with gloved hands. During an interview on 11/5/18 at 10:30 am, the Administrator and Director of Nursing (DON) confirmed staff are to use hand sanitizer when changing gloves or soap and water for 20 seconds if hands are visibly soiled. The DON confirmed all wound supplies should be placed on a barrier and not on the resident's bed linens. The DON stated all staff disposing of trash should were gloves. | 2020-09-01 |
| 401 | 401 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 157 | D | 1 | 1 | FUQO11 | > Based on resident interview, staff interview, and record review, the facility failed to notify a resident of a room change for one (1) resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifier: #47. Facility census: 98. Findings include: a) Resident #47 An interview with Resident #47 on 08/03/17 at 10:00 a.m. revealed she had been moved to a new room without any notice. The resident stated she could not remember the exact date but the move recently took place. The resident stated she had left her room to visit another resident and upon returning the staff was moving her belongings to a room across the hall. The resident stated she became very upset because nobody told her she was switching rooms. An interview with Licensed Social Worker (LSW) #15 on 08/03/17 at 10:45 a.m. revealed a resident is supposed to be contacted before a room change occurs in order to provide options and to ease the transition for the resident. The LSW stated she did not contact Resident #47 before the room change on 07/03/17 because she was unaware the resident was switching rooms until the change was completed. An interview with the Administrator on 08/08/17 at 12:00 p.m. revealed she is the one who ordered the room change to occur on 07/03/17. The Administrator stated she let the resident's daughter know about the change and instructed the nursing staff to inform the resident. The Administrator stated she cannot be certain if the nursing staff informed the resident prior to the room change. A review of Resident #47's medical record on 08/08/17 at 12:30 p.m. revealed no indication the resident was informed of the room change prior to it occurring. A review of the resident's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/17, was conducted on 08/08/17 at 12:45 p.m. Section C-Cognitive Patterns of the assessment revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) assessment. A score of 14 indicated the resident h… | 2020-09-01 |
| 402 | 402 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 164 | D | 1 | 1 | FUQO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to offer privacy during a medical treatment and ensure medication packets with pharmacy labels were disposed of in a manner that protected personal, medical, and health information. Personal identifiers including a resident's name, physician, diagnosis, and medication were listed on the pharmacy labels. These were random observations. Resident identifiers: #74, #89, and #108. Facility census: 98. Findings include: a) Medication Packets A random observation of the West Hall on 08/01/17 at 12:20 p.m. revealed three (3) visible empty medication cards/packets in the trash can of the medication cart. The following medication cards contained the resident's full name, physician, diagnosis, and medication orders [REDACTED] -Resident #89-Entacapone 200 mg-1 tablet four times a day for [MEDICAL CONDITION] -Resident #89-[MEDICATION NAME]/[MEDICATION NAME] 25 mg-250 mg-1 Tablet by mouth four times a day for [MEDICAL CONDITION] -Resident #108-[MEDICATION NAME]-[MEDICATION NAME] 5 mg-325 mg An interview with the Director of Nursing (DON) on 08/01/17 at 12:25 p.m. revealed the nursing staff is supposed to take a black marker and cover all resident information before discarding the medication packets. b) Blood Draw A random observation of the West Hall on 08/07/17 at 9:00 a.m. revealed Resident #74 having his blood drawn by Phlebotomist #222 in the hall beside the West Wing Nurses Station. An interview with the Director of Nursing (DON) on 08/07/17 at 9:05 a.m. revealed blood draws should be done in the resident's room or a private location. | 2020-09-01 |
| 403 | 403 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 246 | D | 1 | 1 | FUQO11 | > Based on observation, staff interview, and record review, the facility failed to provide services with reasonable accommodation. Two resident's call lights were out of reach. This practice affected two (2) of forty (40) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifiers: #101 and #138. Facility census: 98. Findings include: a) Resident #101 An observation of Resident #101 during Stage 1 of the QIS on 08/02/17 at 8:45 a.m. revealed the resident's call light was on the floor beside the bed out of reach of the resident. An interview with Certified Nurse Aide (CNA) #46 on 08/02/17 at 8:55 a.m. revealed Resident #101's call light should not be on the floor and should be within reach of the resident at all times. A review of Resident #101's Care Plan was conducted on 08/03/17 at 8:00 a.m. The Care Plan dated 05/16/17 with a focus of High Risk for Falls included the intervention Ensure call light is within reach and encourage the resident to use it for assistance as needed. Provide prompt response to all requests for assistance to be implemented by Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. b) Resident #138 An observation of Resident #138 during Stage 1 of the QIS on 08/02/17 at 8:50 a.m. revealed the resident's call light was attached to the bed while the resident was up in his chair. An interview with Certified Nurse Aide (CNA) #46 on 08/02/17 at 8:55 a.m. revealed Resident #138's call light should be within reach of the resident at all times. A review of Resident #138's Care Plan was conducted on 08/03/17 at 8:15 a.m. The Care Plan dated 07/06/17 with a focus of Risk for Falls included the intervention Ensure call light is within reach and encourage the resident to use it for assistance as needed to be implemented by Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. | 2020-09-01 |
| 404 | 404 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 272 | D | 1 | 1 | FUQO11 | > Based on record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of twenty (20) residents. A community acquired pressure ulcer was not accurately assessed as a pressure ulcer risk on an admission/5 day minimum data set (MDS) assessment. The failed practice affected one (1) resident reviewed. Resident identifier: #116. Facility census: 98. Findings include: a) Resident #116 A review of the medical record for Resident #116 was conducted at 4:00 p.m. 08/01/17. His admission/5 day MDS with an assessment reference date (ARD) of 02/16/17 revealed he had a pressure ulcer upon admission to the facility. Specifically, Section M skin conditions question M0210 of the MDS, Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? was answered yes by the facility. Also, questions MO300 G1 and G2 Number of unstageable pressure ulcers due to suspected deep tissue injury in evolution (SDTI) and Number of these unstageable pressure ulcers that were present upon admission or reentry were both answered 1 by the facility. Section M0100 determination of pressure ulcer risk, however, was contradictory to the other responses given. Question M0100 a, Resident has a stage 1 or greater, a scar over boney prominence, or a non-removable dressing/device was answered no in spite of the presence of the one (1) SDTI identified in the assessment. This matter was discussed with reimbursement assessment coordinator #58 at 10:15 a.m. 08/03/17 and she stated she would have answered the question M0100 a Resident has a stage 1 or greater, a scar over a boney prominence or a non-removable dressing/device as yes, because a SDTI is pressure and worse than a stage 1 (pressure ulcer). She provided evidence the MDS was corrected prior to survey completion. | 2020-09-01 |
| 405 | 405 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 279 | D | 1 | 1 | FUQO11 | > Based on record review and staff interview, the facility failed to develop a comprehensive individualized care plan including measurable goals and interventions for a resident who received hospice services. The failed practice affected one (1) of twenty (20) residents reviewed. Resident identifier: #80. Facility census: 98. Findings include: a) Resident #80 During a record review conducted at 11:00 a.m. 08/08/17 for Resident #80, it was established the resident was ordered and received hospice services since 06/02/17. Examination of the care plan found a focus problem of Resident is a hospice Resident last revised 07/29/17. There were no goals or interventions associated with the identified focus in the care plan. During an interview with reimbursement assessment coordinator #58 at 11:42 a.m. 08/08/17, she was asked if the facility formulated care plans when a resident received hospice to describe collaboration between the facility and hospice. She replied Yes, and how to reach them (hospice), and what days the aides come. This matter was discussed with the director of nursing (DON) at 11:30 a.m. 08/08/17. While she was able to locate areas in the care plan where hospice was mentioned, there was no detailed plan for coordination of care between the facility and hospice as well as a process of information exchange between both entities to assure the needs of Resident #80 were met. | 2020-09-01 |
| 406 | 406 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 280 | D | 1 | 1 | FUQO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to revise a Care Plan for a resident with behaviors. This practice affected one (1) of twenty (20) residents reviewed. Resident identifier: #154. Facility census: 98. Findings include: a) Resident #154 An observation on 08/02/17 at 10:30 a.m. revealed Resident #154 was receiving one on one care by Nurse Aide (NA) #83. The resident was yelling and attempting to get out of bed without assistance. The resident was cursing at the N[NAME] An interview with NA #83 on 08/02/17 at 10:35 a.m. revealed the resident was started on one to one care due to increased behaviors. The NA stated the resident was attempting to get out of his bed and chair unassisted and cursing at the staff more. A review of the Progress Notes on 08/07/17 at 10:45 a.m. revealed the resident was having increased attempts to ambulate unassisted, increasing hostile verbalizations towards the staff, and was receiving one to one care on 07/31/17, 08/01/17, 08/02/17, 08/03/17, 08/04/17, and 08/05/17. A review of the physician's orders [REDACTED]. A review of the Care Plan, dated 07/26/17, was reviewed on 08/07/17 at 11:00 a.m. The Care Plan did not not include the one to one care interventions or the increased behaviors the resident was exhibiting since 07/31/17. An interview with the Director of Nursing (DON) on 08/08/17 at 10:00 a.m. revealed the Care Plan had not been updated for the resident's increased behaviors or the one to one care interventions. | 2020-09-01 |
| 407 | 407 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 282 | D | 1 | 1 | FUQO11 | > Based on observation, record review, and staff interview, the facility failed to implement care plan interventions for residents at risk for falls. Resident #101 and #138 did not have their call lights within reach as directed on their care plans. This practice affected two (2) of forty (40) residents observed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifiers: #101 and #138. Facility census: 98. Findings include: a) Resident #101 An observation of Resident #101 during Stage 1 of the QIS on 08/02/17 at 8:45 a.m. revealed the resident's call light was on the floor beside the bed out of reach of the resident. An interview with Nurse Aide (NA) #46 on 08/02/17 at 8:55 a.m. revealed Resident #101's call light should not be on the floor and should be within reach of the resident at all times. A review of Resident #101's Care Plan was conducted on 08/03/17 at 8:00 a.m. The Care Plan dated 05/16/17 with a focus of High Risk for Falls included the intervention Ensure call light is within reach and encourage the resident to use it for assistance as needed. Provide prompt response to all requests for assistance to be implemented by Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. b) Resident #138 An observation of Resident #138 during Stage 1 of the QIS on 08/02/17 at 8:50 a.m. revealed the resident's call light was attached to the bed while the resident was up in his chair. An interview with Nurse Aide (NA) #46 on 08/02/17 at 8:55 a.m. revealed Resident #138's call light should be within reach of the resident at all times. A review of Resident #138's Care Plan was conducted on 08/03/17 at 8:15 a.m. The Care Plan dated 07/06/17 with a focus of Risk for Falls included the intervention Ensure call light is within reach and encourage the resident to use it for assistance as needed to be implemented by Certified Nursing Assistants, Licensed Practical Nurses, and Registered Nurses. | 2020-09-01 |
| 408 | 408 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 323 | E | 1 | 1 | FUQO11 | > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Resident Room #39 and the Shower Room on the West Hall contained multiple capped and uncapped disposable razors. This practice had the potential to affect more than a limited number of residents. Facility census: 98. Findings include: a) West Hall An initial tour of the facility on 07/31/17 at 11:30 a.m. revealed Room #39 on the West Hall had five (5) capped razors in the bathroom cabinet and two (2) uncapped razors on the sink. A random observation on 07/31/17 at 3:00 p.m. revealed the West Hall Shower Room contained two (2) uncapped razors in a unsecured cabinet. An interview with the Director of Nursing (DON) on 07/31/17 at 11:45 a.m. revealed all razors should be stored and secured in a locked cabinet or room. The DON stated she would do an audit of the entire facility to ensure all razors were secure. | 2020-09-01 |
| 409 | 409 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 364 | E | 1 | 1 | FUQO11 | > Based on observation, interviews, and review of resident council minutes, the facility failed to ensure foods were served at temperatures that promoted palatability. This practice has the potential to affect more than a limited number of residents who receive food from this central location. Census: Findings include: a). Resident council minutes A review of resident council minutes on 08/07/17 revealed the residents had expressed concern with food temperatures during meetings. The minutes indicated concern with food temperature, (MONTH) meeting notes said residents stated mashed potatoes and gravy are cold, (MONTH) meeting minutes indicate residents stated breakfast is cold when served in her room and at lunch sometimes when eating in the dining room, while another resident in the meeting said meals are cold at all meals when served in her room. b) Test tray evaluations Due to residents expressing cold food and family member bringing cold food issues to surveyors attention, a test tray for temperatures was conducted at lunch on 08/07/17 at 11:58 a.m. on west hall. Trays arrived at 11:59 a.m. and the last tray was served at 12:15 p.m. Surveyors requested a hot tray for the resident who was to receive the last one off the cart and temperatures were taken of those food items. Temperatures were found to be 109 F for puree meat, 103 F pureed starch item and 60 degrees for pudding. This was discussed with the dietary manager and corporate staff prior to exit on 08/08/17. | 2020-09-01 |
| 410 | 410 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 371 | F | 1 | 1 | FUQO11 | > Based on observation and staff interview, the facility failed to store and serve foods in a manner that promoted proper sanitary techniques. Food items were stored opened with no date of when they were opened and staff were noted to use the same gloved hands to touch food and non-food items. This practice has the potential to affect all residents who consume food by oral means that is served from this central location. Census: 98. Findings include: During the initial tour of the dietary department on 08/01/17 the following sanitation issues were noted: 1. Staff were observed to handle food and non-food items using the same gloves hands. The cook was noted to reach in the bread bag and retrieve slices of bread then return to handling other non-food surfaces such as handles of serving spoons, plates, etc. 2. In the walk in refrigerator packages of cheese slices, shredded lettuce, a container of chicken base and thick and easy were all found with no date indicating when they were opened. This allows the staff to determine freshness and safety of the food item. 3. A 1/2 gallon of buttermilk dated 07/24/17 was opened and was still opened on 07/31/17 at the time of tour. The dietary staff stated the procedure is for items to be kept for no longer that 72 hours. This was after that time frame. 4. A dirty wiping cloth was found in the dishmachine area not stored in sanitized solution. This cloth was not in use and was very soiled needing to be washed or sanitized. The cook was with the surveyor during these observations and these issues were discussed with the dietary manager on 08/08/17 at 9:20 a.m She agreed these items were in violation of sanitary techniques. | 2020-09-01 |
| 411 | 411 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2017-08-08 | 514 | D | 1 | 1 | FUQO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to maintain an accurate and complete medical record The failed practice affected one (1) of twenty (20) residents. A physician's orders [REDACTED]. Resident identifier: #80. Facility census: 98. Findings include: a) Resident #80 During a record review performed at 11:00 a.m. 08/08/17 for Resident #80, it was established the resident was ordered hospice services on 06/02/17. The monthly physician's orders [REDACTED].#28 was interviewed at 11:18 a.m. 08/08/17. She said that in (MONTH) (YEAR) the pharmacy had taken over the task of monthly changeover (preparing physician's orders [REDACTED]. She said the order must have been dropped off the monthly orders when the pharmacy took over. Review of the hospice tab in the medical record found Resident #80 was still receiving the services as intended. | 2020-09-01 |
| 453 | 453 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2017-06-21 | 323 | E | 1 | 0 | GRYX11 | > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. The South Hall Shower Room, which contained chemical substances and razors was unlocked and accessible to residents. This practice had the potential to affect more than a limited number of residents. Facility census: 82. Findings include: a) South Hall Shower Room An initial tour of the facility, on 06/19/17 at 10:15 a.m., revealed the South Hall Shower Room door was unlocked. The door contained a punch code lock which was not functioning. The following items were located on the sink, back of the toilet, and inside a unsecured cabinet in the shower room: --Three (3) containers of 11 ounce Medspa Shave Cream with the warning Keep out of reach of children. --Two (2) containers of 8 ounce Medline Body Lotion with the warning Keep out of reach of children. -One (1) container of 4 ounce Medspa Aftershave with the warning Keep out of reach of children. -One (1) container of 8 ounce Medline Shampoo & Body Wash with the warning Keep out of reach of children. -Five (5) disposable razors. Two (2) of the five (5) razors were uncapped. An observation with the Director of Nursing (DON), on 06/19/17 at 10:25 a.m., revealed the South Hall Shower Room was unlocked. An interview with the DON, on 06/19/17 at 10:30 a.m., inside the South Hall Shower Room revealed the door should have been secured by the punch lock. The DON stated she would ensure that maintenance looked at the door immediately. The DON stated she would secure the items inside the shower room until the door was locked. | 2020-09-01 |
| 518 | 518 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 583 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to safeguard, ensure, and maintain the privacy and confidentiality of a resident's clinical record. An unauthorized disclosure of Resident#6's clinical record, without Resident#6's consent or knowledge, was given by accident to another resident's family member to take to a consulting physician's appointment. This is true for one (1) of one (1) resident reviewed for privacy and confidentiality. This practice had the potential to affect more than a limited number of residents. Resident identifier: #6. Census: 85. Findings included: a) Resident #6 On 04/16/18 at 1:05 PM, an interview with the Ombudsman information concerning issues that had been brought to the Ombudsman's attention. The Ombudsman stated it was revealed a resident's family member had mistakenly been given another resident's clinical records to take with them to a doctor's appointment. On 04/16/18 at 2:38 PM, an interview with Resident#3's daughter-in-law revealed, upon arriving with Resident #3 at a doctor's appointment in another city, it was discovered she had mistakenly been given Resident #3's roommates medical records to take to the appointment. The daughter-in-law had requested Resident#3 records, but by mistake was given Resident#6's medical records. The daughter-in-law said she returned the records back to the facility, when she returned the resident (Resident #3) back to the facility. Resident#3's daughter-in-law said, she was asked by the facility to not tell Resident #6 (the roommate of Resident #3) what had occurred. The daughter-in-law, also a nurse, said she was very upset about the incident and told the facility she was concerned her mother-in-laws records could also be compromised. On 04/18/18 at 9:30 AM, review of all Resident Council meeting minutes; all Incident/Accident logs; all Grievances/Complaint/Concern logs and reports; and all Reportable incidents with related investigations for the past six (6) months, revealed no incidents or grievances co… | 2020-09-01 |
| 519 | 519 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 585 | E | 1 | 0 | DQUX11 | > Based on staff interview, family interview, and record review, the facility failed to promptly address complaints/grievances to resolution and keep the residents appropriately apprised of progress toward resolution of complaints/grievances. This was evident by the lack of documentation of any follow up regarding resident council grievances and concerns; lack of a grievance filed concerning a staff member hanging up on a resident's family member where disciplinary action was taken against the staff member; and failure to promptly address a complaint of finding several feces soiled items stored in a resident's room. This practice had the potential to affect more than a limited number of residents. Resident identifier: #1, and #9. Census: 85. Findings included: a) Resident #9 On 04/16/18 at 3:10 PM, review of Resident Council meeting minutes for the past six (6) months, revealed a lack of documentation and/or evidence as to whether issues and concerns expressed during Resident Council meetings were addressed and followed up on. An interview with Social Worker (SW#90) revealed she does not write down resolutions or outcomes to issues discussed. SW#90 said, We talk about any concerns and, if say it is about food, I'll get someone from the kitchen to come and talk to the residents. I do not write anything down. SW#90 after looking over Resident Council meeting minutes confirmed the minutes did not reflect follow up or outcomes to issues. On 04/17/18 at 3:59 PM, Social Worker (SW#124), requested the surveyors speak with the resident council president, so that the resident council president could tell the surveyors the council's internal process for dealing with issues and concerns. SW#124 said They do it different here, they bring up issues and deal with it right then and there at the meeting. SW#124 left the room to get the Resident Council President, Resident #9. Resident #9 entered the room alone. SW#124 did not return. The Resident Council President was asked by this surveyor, If there is anything you would like t… | 2020-09-01 |
| 520 | 520 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 609 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required. | 2020-09-01 |
| 521 | 521 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 610 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required. | 2020-09-01 |
| 522 | 522 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 745 | E | 1 | 0 | DQUX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, family interview, and record review, the facility failed to provide medically related social services regarding timely notification of care plan meetings to ensure attendance and participation of residents and/or resident's family members responsible for making decisions concerning resident care. The facility also failed to provide medically related social services to assist residents and/or resident's family members responsible for making decisions in voicing and obtaining resolution to complaints and grievances. This practice had the potential to affect more than a limited number of residents. Resident identifier: #1, #4, #5, and #6. Census: 85. Findings included: Both surveyors on the investigative team conducted an interview, on 04/17/18 at 1:10 PM, with two (2) of the joint Medical Power of Attorneys (MPOAs) for Resident #1. The interview revealed they do get letters notifying them of care plan meetings. The MPOAs issues and concerns where they were not being notified in enough time to make any arrangements at work, so they could attend the care plan meetings. They said they might get a letter on Friday, for a meeting scheduled for the following Monday. They both confirmed it is just too hard to get off work and make any arrangements with such a short notice. The MPOAs revealed an incident where they arrived on the date and time the letter indicated, and as they sat waiting for the meeting, they were informed the meeting had already taken place on a different day. The MPOAs said the facility did go ahead and meet with them that day, because they refused to leave until they did. The MPOAs said they have shared these concerns about timely care plan meeting notices with staff before. Review of grievance and concern records did not reveal any of these issues or concerns had been identified, filed, and/or addressed. On 04/17/18 at 5:10 PM, an interview with Social Worker (SW#62), revealed the following. SW#62 said,… | 2020-09-01 |
| 523 | 523 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 804 | E | 1 | 0 | DQUX11 | > Based on observation, staff interview, family interview and record review, the facility failed to serve foods that are at proper temperature and palatable. This practice has the potential to affect more than a limited number of residents are consume foods served from this central location. Census: 85. Findings included: a) Review of resident council minutes on 04/18/18 revealed the residents had expressed concern with the food being cold. Such things as coffee being cold was listed in the 03/02/18 meeting and then food being cold if you ate in the room. Chicken noodle soup was described as being poured staight out of the can and not heated. b) Confidential family interview on 04/16/18 after lunch revealed the food does not always look appealing or appetizing. Sandwiches will often be a piece of bread with a slice of lunch meat on it. Did not have condiments or anythisg else on the sandwich. c) This was reviewed with the dietary manager on 04/18 /18 in the morning. She verified the residents had expressed concern about cold foods in resident council meetings and they have been attempting to resolve the issue. d) These issues were discussed with the director of nursing and the corporate regional director of operations on 04/18 /18 in the afternoon. e) Random confidential resident interviews During the initial tour on 04/16/18 at 12:45 PM, observations and interviews with several randomly chosen residents having lunch in their rooms revealed complaints of food being served cold. One resident stated, Lunch is warm today, but it is not always. Another resident said, Sometimes it's cold, the meals were sometimes cold on a few days last week. A different resident shared, Most of the time it (meals) is cold. On 04/17/18 at 3:59 PM, an interview with the Resident Council President revealed a recurring problem about food being served cold, that was supposed to be served hot. The Resident Council President said, The food was cold just the other day, and one day last week, everyone in the dining hall was talking about it. | 2020-09-01 |
| 524 | 524 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2018-04-19 | 880 | D | 1 | 0 | DQUX11 | > Based on staff interview, family interview and record review, the facility failed to implement proper infection control monitoring. Soiled clothing was left in Resident #1's drawers and closets creating an infection control concern. This was evident for one (1) of four (4) sampled residents currently in the faciilty. Census: 85. Findings included: a) Resident #1 During the investigation confidential interviews were conducted with family members on 04/16/18 in the afternoon. It was found that Resident #1 was known to remove soiled clothing and place them in the drawer or closet in their room. This issue was known to staff and the care plan interventions required staff to monitor the draweres and closets in the room every shift for soiled clothing and perform visual checks of the area. This was not being implemented and soiled cloting is still being left in these areas and family will come in and notice odors which are coming from the soiled clothing. This procendure could lead to an infection control issue and soiled clothing is not being handled using proper infection control techniques. The issue was discussed with the director of nursing on 04/17/18 in the afternoon. An inservice was conducted on 12/24/17 but this has still not corrected the problem. | 2020-09-01 |
| 559 | 559 | TYGART CENTER AT FAIRMONT CAMPUS | 515053 | 1539 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2019-07-09 | 580 | D | 1 | 0 | TYZC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to notify a resident's responsible party when an existing form of treatment (medication) was discontinued. This was evident for one (1) of seven (7) sampled residents. Resident identifier: #7. Facility census: 101. Findings included: a) Resident #7 The medical record was reviewed on 07/08/19 and 07/09/19. On 02/20/19 the consultant pharmacist completed a consultation report whereby she recommended to discontinue the [MEDICATION NAME] (anti-anxiety medication) 0.5 milligrams every four (4) hours prn (as needed), unless the physician deemed the medication should not be discontinued at that time. The physician accepted the recommendation to discontinue the prn [MEDICATION NAME]. The physician and director of nursing (DON) signed the pharmacy consultation report form on 02/22/19. A nurse progress note dated 05/17/19 conveyed that the resident's responsible party expressed in a telephone conversation earlier that day her concern about the resident no longer having the prn order for [MEDICATION NAME]. After first speaking with the Hospice, the nurse re-entered the order for [MEDICATION NAME] every four (4) hours prn per order of the resident's attending physician. A telephone interview was conducted with the resident's responsible party on 07/09/19 at 3:45 PM. She said she was unaware that the resident's [MEDICATION NAME] was discontinued until about the middle of May, 2019, at which time the resident had a urinary tract infection and was scratching herself. Upon inquiry as to whether she was informed in (MONTH) 2019 of the discontinuation of the [MEDICATION NAME], she replied in the negative. An interview was conducted with the DON and the administrator on 07/09/19 at 4:00 PM. After they reviewed nurse progress notes, physician visit notes, and the 02/25/19 care plan meeting notes, they reported they were unable to find evidence that the responsible party was notified when t… | 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 );