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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3625 | 3625 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 655 | D | 0 | 1 | 0WYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a baseline care plan for Resident #1 to provide effective and person-centered care of the resident to meet professional standards of quality care. This was true for 1 of 3 residents reviewed for the care area of accidents. Resident identifier: #1. Facility census: 22. Findings included: a) Resident #1 A review of Resident #1's medical record at 9:00 a.m. on 08/07/19 found a nursing note dated 05/10/19 which indicated the resident had a fall on this date. The note indicated the resident was walking with staff and reached for her wheelchair, lost balance and started to fall, and the staff member helped the resident to the floor. Further review of the record found the resident was admitted to the facility on [DATE] at which time her risk for falls was assessed and it was determined Resident #1 was at a high risk for falls. A review of the baseline care plan which was completed on 05/08/19 indicated for the section ambulation the following word was listed, transfers. The base line care plan was created by the Director of Nursing (DON). An interview with Nurse Aide #32, at 11:05 a.m. on 08/07/19, confirmed the facility told the NA's how to care for residents using the care plan. When asked how I would now how to care for someone she directed me to the care plan book which was maintained at the nursing station. She stated, Everything you need to know is right here in the care plan. An interview with the Director of Nursing (DON) at 11:10 a.m. on 08/07/19 confirmed the facility uses the care plans to communicate the care needs of the residents to the NA's. She stated at the time of Resident #1's fall the baseline care plan would have been in the book. We reviewed the baseline care plan together and when asked what the word transfers means after the heading of ambulation she stated, That means she does not ambulate she only transfers. The DON was then asked why staff was attem… | 2020-09-01 |
| 3626 | 3626 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 656 | D | 0 | 1 | 0WYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive, person-centered care plan for each resident, including the measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. This was true for 1 of 13 sampled residents. Resident identifier: #1. Facility census: 22. Findings included: a) Resident #1 A review of Resident #1's medical record at 9:00 a.m. on 08/07/19 found a nursing note dated 05/10/19 which indicated the resident had a fall on this date. The note indicated the resident was walking with staff and reached for her wheelchair, lost balance, started to fall, and staff member helped the resident to the floor. Further review of the record found the resident was admitted to the facility on [DATE] at which time her risk for falls was assessed and it was determined Resident #1 was at a high risk for falls. Further review of the record found that Resident #1 had an assessment titled Ambulation Assessment completed on 05/15/19. This assessment was completed by Licensed Practical Nurse (LPN) #64 and indicated the resident needed the extensive assistance of two (2) staff members and the use of a gait belt to safely ambulate. A review of the resident current care plan found no focus statement, goal or intervention that indicated Resident #1 was an extensive assist of two (2) staff members and that the use of a gait belt was required. An interview with Nurse Aide #32 at 11:05 a.m. on 08/07/19 confirmed the facility told the NA's how to care for residents using the care plan. When asked how I would now how to care for someone she directed me to the care plan book which was maintained at the nursing station. She stated, Everything you need to know is right here in the care plan. An interview with the Director of Nursing (DON) at 11:10 a.m. on 08/07/19 confirmed the facility uses the care plans to communicate the care needs… | 2020-09-01 |
| 3627 | 3627 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 657 | D | 0 | 1 | 0WYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise Resident #12's nutrition care plan when her diet changed. This deficient practice affected 1 of 13 sampled residents. Resident identifier: #12. Facility census: 22. Findings included: a) Resident #12 During record review on 08/05/19 at 2:52 PM, the physician's orders [REDACTED]. A review of Resident #12's nutrition care plan on 08/06/19 at 9:05 AM found the following intervention, initiated on 06/12/19, 1800 mechanical soft diet with pureed meats, NAS, with no nuts, seeds, or hulls; may have beans at her request. On 08/07/19 at 9:21 AM, the facility's Certified Dietary Manager (CDM) was asked to clarify Resident #12's diet. She stated that Resident #12's diet was just updated last week. She stated that the 1800 part of the diet in the care plan was incorrect and that Resident #12 was to receive an NCS diet in addition to NAS, mechanical soft with pureed meats, no nuts seeds, or hulls, and beans as tolerated. The facility's CDM agreed that the nutrition care plan was not revised to reflect the diet change. The above information was discussed with the facility's Director of Nursing (DoN) on 08/07/19 at 10:14 AM. She stated, Okay. She added that she had updated Resident #12's care plan that day (08/07/19) to reflect the change that went into effect the previous week. | 2020-09-01 |
| 3628 | 3628 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 684 | D | 0 | 1 | 0WYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and nursing professional journal review, the facility failed to provide needed care and services in accordance with professional standards of practice regarding neuro checks for a resident who had an unwitnessed fall and head injury. This was true for 1 of 2 residents reviewed for the care area of accidents. This practice had the potential to affect more than a limited number of residents. Resident identifier: R#7. Facility census: 22. Findings included: a) Resident (R#7) During the initial tour of the facility R#7 was noted to have a fading bruise on her left upper cheek beside the bottom of her eye glass rim. Resident #7's fall risk assessments determined her to be at risk for falls due to weakness, impaired balance, use of medications, and dementia. The risk assessment revealed a score of fourteen (14). Her MDS (minimum data set) ARD (assessment reference date) 07/ 03 /19 indicated R#7 required extensive assistance for bed mobility, transfers, and walking. Her balance was assessed as not steady, and she was only able to stabilize with assistance. On [DATE] at 03:39 PM review of facility accident reports revealed R#7 had an unwitnessed fall in the resident's room on [DATE] at 2:05 AM. R#7 reported she fell off her bed. A post fall report was completed and revealed R#7 experienced black and purple bruising around her left eye and a small bruise to the left elbow. Review of Licensed Practical Nurse (LPN#66)'s nursing progress notes revealed the resident was found on the floor lying face down beside her bed. Resident's vital signs and pain was assessed. There was no mention of any neurological assessments (neuro checks) being performed. The physician and POA (power of attorney) was notified. The nurse (LPN#66) wrote, Dr notified, stated to keep an eye on her and use ice pack on left eye if needed. Will continue to monitor. The next nurse's note (LPN#64) entry was on [DATE] at 1:15 PM, this entry describe… | 2020-09-01 |
| 3629 | 3629 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 689 | J | 0 | 1 | 0WYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview, water temperature measurements, review of the State Operations Manual (SOM) Appendix PP, and policy review the facility failed to provide an environment free from accident hazards. This was true for 2 of 3 residents reviewed for accident hazards. The facility failed to supervise smoking for Resident (R#13), an oxygen dependent resident. The facility also failed to safely secure R#13's lighter and cigarettes to ensure other residents did not have access to them. The facility failed to ensure R#1 was assessed upon admission for the assistance that she needed when ambulating. Resident #1 suffered a fall 2 days after admission and the resident's ambulation was not assessed until 5 days after admission. The facility failed to ensure safe water temperatures that were less than 120 degrees. These practices have the potential to affect more than a limited number of residents. On 08/07/19 at 3:39 PM, after consultation with the State Agency a determination of Immediate Jeopardy was identified at the facility. The facility allowed an oxygen dependent resident to go outside and smoke unsupervised. No safe smoking assessment was completed. The facility is supposed to be a smoke free facility, however this resident lived at the facility prior to changing to smoke free and they only allow her to smoke, no other residents. This resident is on 4L (liters) of oxygen continuously, she keeps her cigarettes and lighter in her room, where she says she hides them very well. When the resident goes out by herself, she uses her wheelchair like a walker and pushes the wheelchair with the oxygen tank attached outside herself. An interview with nurse aide (NA#32) revealed the nurse aides have held the door open for R#13 to let her go outside alone to smoke by herself. Futhermore, NA#32 confirmed she uses her wheelchair to carry her oxygen tank outsiden when she smokes. There is the potential for a… | 2020-09-01 |
| 3630 | 3630 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 758 | E | 0 | 1 | 0WYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure drug regimens of Residents #12 and #2 were free from unnecessary medications. The facility's Physician rejected a gradual dose reduction (GDR) attempt for two (2) [MEDICAL CONDITION] medications prescribed to Resident #12 without providing sufficient documentation to show the GDR of the medications was clinically contraindicated. Additionally, Resident #2 received an antipsychotic medication without an appropriate indication for use. These deficient practices affected 1 of 5 residents reviewed for the care area of unnecessary medications. Resident identifiers: #12. Facility census: 22. Findings included: a) Resident #12 During a chart review on 08/06/19 at 8:41 AM, two (2) Consultation Reports regarding Resident #12 from the facility's Pharmacist were found. On 07/24/19, the Pharmacist recommended that a gradual dose reduction (GDR) be completed for both Resident #12's [MEDICATION NAME] (a [MEDICAL CONDITION] drug used to treat depression) and [MEDICATION NAME] (a [MEDICAL CONDITION] drug used to treat anxiety) prescriptions. The Physician rejected both recommendations on 07/25/19. The explanation the Physician documented for rejecting the GDR of [MEDICATION NAME] was chronic anxiety & depression. The explanation the Physician documented for rejecting the GDR of [MEDICATION NAME] was chronic anxiety. The Physician gave no indication that a GDR of the medications would be clinically contraindicated. Further review of the medical record during the survey found that Resident #12 had been receiving [MEDICATION NAME] since 03/15/18 and [MEDICATION NAME] since 03/13/15. A review of the care plan during the survey found that Resident #12 had failed a GDR of [MEDICATION NAME] in the past. The facility's Director of Nursing (DoN) was asked to provide any information regarding past GDR attempts for [MEDICATION NAME] and [MEDICATION NAME]. The requested information was rev… | 2020-09-01 |
| 3631 | 3631 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 761 | E | 0 | 1 | 0WYC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the Center for Medicare & Medicaid Services (CMS) State Operations manual (SOM) Appendix PP (Guidance to Surveyors for Long Term Care Facilities requirements of Federal regulations and interpretive guidance), recommendations from the Centers of Disease Control (CDC), and the United States Pharmacopeia (USP) General Chapter 797, the facility failed to ensure durgs were stored and labeled in accordance with currently accepted professional principles. The facility failed to label resident's prescribed solution and various over the counter medications, as well as resident's multi-dose insulin vials with the date the medications was opened. The facility failed to ensure safety in the use of multi-dose vials of insulin by failing to track and monitor the date vials were accessed to assure its usage within the recommended time frame for safe use. This practice had the potential to affect more than an isolated number of residents. Resident identifier: R#2, R#4, R#9, #R12, R#16, R#19, R#20, and R#73. Facility census: 22. Findings included: a) Medication storage (refrigerator and cart) On 08/06/19 at 10:17 AM review of the medication refrigerator revealed a bottle of Acidophilus that was not dated when it was opened. Licensed practical nurse (LPN#66), upon seeing the bottle, stated it should have been dated when it was opened and did not know why it was not. Also observed was a bottle of prescribed [MEDICATION NAME] suspension 1 gm (gram)/10 ml (milliliter), for Resident R#16, that did not have the date the bottle was opened. On 08/06/19 at 11:18 AM review of the resident's insulin vials with licensed practical nurse (LPN#36) revealed the multi-use insulin vials were not dated when the nurse opened them. There were no dates hand-written on any of the insulin vials or boxes to indicate the date the nurse initially opened the vial to access it. Without the 'open' date, the staff would not know when to disp… | 2020-09-01 |
| 3632 | 3632 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 804 | E | 0 | 1 | 0WYC11 | Based on resident interview, staff interview and examination of a test tray, the facility failed to ensure each resident was served food prepared by methods that conserve nutritive value, flavor, appearance palatable, and attractive. This practice has the potential to effect more than an isolated number of residents. Facility census: 22. a) Food Complaints During the resident council meeting on 08/06/19 at 2:00 p.m. multiple residents voiced concerns about the food. They indicated the food was burnt a lot of the time, the meat was so dry that you could not eat, the vegetables were always overcooked and just mush, and they serve stuff that they don't like and they will not change the menus. They indicated they had voiced this concern on multiple occasions and nothing is never done about it. On 08/07/19 at 12:20 p.m. a test tray was requested. On the test tray was beef brisket with a pineapple topping, California blend vegetables, and a baked potato. Upon examination of the test tray the beef brisket looked to be a little dry (the pineapple topping helped to provide moisture to the meat but not all residents received it), the California blend was overcooked. This was evidenced by the broccoli being an pale green color and both the broccoli and carrots could easily be smashed with plastic fork. The Certified Dietary Manager agreed the vegetables were overcooked. She stated that it was because they had been on the steam table for so long that they got overcooked. She also confirmed that she goes to the resident council meetings when able and has the ability to change the menu if the residents do not like what is being served. | 2020-09-01 |
| 3633 | 3633 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2019-08-07 | 842 | D | 0 | 1 | 0WYC12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete and accurate medical records related to the resident's Ambulation assessments. This was a random opportunity for discovery concerning 3 of 3 residents reviewed for care plan revision. This practiced had the potential to affect more than a limited number. Resident identifiers: R#1, R#7, and R#12. Facility census: 23. Findings included: Review of the Ambulation Assessment form revealed the instructions were to complete this form upon admission, quarterly, or if a significant change occurs. The Ambulation Assessment's form #2 Assistance needed with Ambulation, reveals the following options: independent, supervision, limited assist, extensive assist, total dependent, NA not applicable, and whether 1 assist or 2 assist was needed. Interview with the Director of Nursing (DoN), on 10/01/19 at 2:00 PM, revealed the Ambulation Assessment is used to determine the care needed and is described in the care plan and is to be completed in its entirety. a) Resident (R#1) On 10/01/19 at 11:12 AM, review of R#1's Ambulation assessment dated [DATE], revealed R#1 requires extensive assistance of 1 and at times extensive assistance of 2 with ambulation. Interview with the Director of Nursing (DoN), on 10/01/19 at 2:00 PM, revealed the Ambulation Assessment is used to determine the care needed to be described in the care plan. The DoN said the assessment should have been marked as extensive assistance of 1. The DoN confirmed if the resident needed extensive assistance of 2 at times then the care plan would be revised to reflect that. b) Resident (R#7) Review of R#7's Ambulation Assessment form, dated 08/01/19, under #2 Assistance needed with Ambulation revealed it was left blank except for assist of 1 was needed. The assessment did not indicate if the resident was independent or needed supervision, limited assist, extensive assist, or was totally dependent. c) Resident (R#12) Revi… | 2020-09-01 |
| 3634 | 3634 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2018-10-25 | 583 | F | 0 | 1 | 6SVK11 | Based on observation and staff interview the facility failed to ensure the residents records were stored in a manner to ensure privacy of the residents records were maintained. This practice had the potential to effect all residents currently residing in the facility. Facility Census: 24 Findings included: a) Resident Records An initial tour of the facility on 10/22/18 at 11:30 a.m. the residents medical records were observed to be in the rack and parked in the hall way with the names facing outward and were easily accessible to any visitor or any other resident who would be passing by. The records were not secured in any manner to protect the privacy of the resident records. An interview with the Long Term Care Director of Nursing at 1:29 p.m. on 10/22/18 confirmed the resident records should not be sitting in the hall. She stated they are usually kept in the nurses station, but sometimes the nurse aides will pull them into the hallway so they can get residents into the shower room. She agreed they should not be in the hall way and if they are they should be turned around with the names facing the wall. | 2020-09-01 |
| 3635 | 3635 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2018-10-25 | 641 | E | 0 | 1 | 6SVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the resident assessment instrument (RAI) manual, and staff interview the facility failed to ensure Resident #4, #8 and #21's minimum data sets (MDS) was accurately coded to reflect their medication regimen. For Resident #1 the MDS was not completed to accurately reflect their nutritional status. Finally, for Resident #18 the residents MDS was not completed to accurately reflect their medical diagnosis. This was true for five (5) of 12 residents reviewed during the Long Term Care Survey Process. Resident Identifiers: #4, #1, #8, #21 and #18. Findings included: a) Resident #4 A review of Resident #4's medical record at 9:00 a.m. on 10/24/18 found an MDS with an Assessment Reference Date (ARD) of 09/28/18 found section No1410. Medications Received E. was coded with a seven (7) indicating Resident #4 received an anticoagulant seven (7) of the seven (7) days in the look back period. A review of the Medication Administration Record [REDACTED]. An interview with the Long Term Care Director of Nursing on 10/24/18 at 9:54 a.m. confirmed Resident #4 had not received any anticoagulant medications. She indicated she had counted the medication [MEDICATION NAME] when completing this MDS and now knows she should not have counted that medication. She agreed the MDS was incorrect. b) Resident #21 Review of medical records for Resident #21 revealed a discrepancy in Section N of the minimum data set (MDS) assessment dated [DATE]. Medication Administration Record [REDACTED]. Resident #21 was administered an antiplatelet medication ([MEDICATION NAME], 75mg daily) within the reported timeframe. On 10/23/18 at 1:08 PM during an interview, Director of Nursing (DoN) #65 stated, I realized I could not count the [MEDICATION NAME] as an anticoagulant on the MDS The DoN stated that she mistakenly reported the [MEDICATION NAME] (antiplatelet medication) as an anticoagulant on section N of the MDS for the resident, and just realized her mi… | 2020-09-01 |
| 3636 | 3636 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2018-10-25 | 657 | D | 0 | 1 | 6SVK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure a care plan was revised following the discontinuation of a nutritional supplement as well as the discontinuation of Speech Therapy. This was true for one (1) of 12 residents reviewed. This has the potential to affect less than a minimal number of residents. Resident identifier: #1. Facility census 24. Findings included: a) Resident #1 1. Nutritional supplement A review of Resident #1's care plan with the date of 09/26/18 stated Resident #1's intake is only 27%, taking less than 50% of his supplement. Resident #1 and his power of attorney (POA) requests no further weights to be done; as it is too painful for him. Resident #1 requires a mechanically altered diet with nectar thickened liquids. Under Resident #1's intervention is Juven one (1) packet twice a day (BID). A review on 10/23/18 at 8:50 AM, of Resident #1's (MONTH) (YEAR)'s physician order [REDACTED]. In an interview on 10/23/18 at 9:00 AM, with licensed practical nurse (LPN) #89, she was asked whether Resident #1 was on Juven one (1) packet twice a day (BID). The LPN stated that Resident #1 did not want to drink the Juven so the drink was discontinued. In an interview with the Director of Nursing (DoN) on 10/23/18 at 4:00 PM, she was asked whether the resident is still receiving Juven one (1) packet BID. The DoN reviewed the physician orders [REDACTED]. The DoN reviewed the care plan for Resident #1 and stated that she did not revise the care plan to reflect the Juven was discontinued. 2. Speech therapy A review of Resident #1's care plan on 10/23/18 at 11:15 AM, revealed a care plan date of 09/26/18. The care plan' showed Resident #1 is receiving speech therapy due to dysphagia; recently refused modified [MEDICATION NAME] swallow as recommended. The approach start date is 09/26/18. The resident is to receive speech therapy four (4) days a week for four (4) weeks. In an interview with Speech Therapist (ST) #97 … | 2020-09-01 |
| 3637 | 3637 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2018-10-25 | 812 | E | 0 | 1 | 6SVK11 | Based on observation and staff interview the facility failed to store and prepare foods in a safe and sanitary manner. During the kitchen tour it was discovered, thickening, corn and vegetable medley and a box of dry cereal were not dated after opening. This had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 24 Findings include a) Kitchen tour During the kitchen tour on 10/22//18 at 11:35 AM, it was discovered in the reach-in refrigerator a 48 ounce (oz) container of clear Easy Thickening not dated after opening, in the walk-in freezer packages of corn and vegetable medley had been opened and not dated. Also in the Nutrition Pantry a 12 oz box of dry cereal was opened and not dated. These unsafe practices did not follow the standards for storing and preparing foods in a safe and sanitary manner. In an interview and observation of the kitchen on 10/22/18 at 11:35 AM, with the Dietary Manager, verified the thickener, the packages of corn and vegetable medley and cereal had not been dated after opening and these practices did not follow the guidelines for storing and preparing foods in a safe and sanitary manner. | 2020-09-01 |
| 3638 | 3638 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2018-10-25 | 865 | F | 0 | 1 | 6SVK11 | Based on observation, policy review, and staff interview the facility failed to ensure the Quality Assessment and Assurance made good faith attempts to correct quality deficiencies which it did have or should have had knowledge of. The facility failed to implement the antibiotic stewardship program as required by the federal regulations and also failed to ensure the laundry facilities at the facility was set up in a manner to prevent the spread of diseases and infections also as required by the federal regulations. This practice had the potential to effect all residents currently residing in the facility. Facility Census: 24. Findings included: a) Antibiotic Stewardship Based on staff interview and policy review, the facility's Infection Prevention Control Program failed to develop an antibiotic stewardship program that promoted the appropriate use of antibiotics. Assessment tools were not utilized prior to the prescribing and administration of antibiotics. During an interview on 10/23/18 at 10:48 AM, Infection Control Nurse (ICN) #16 reported the facility does not utilize an infection assessment tool such as the Loeb's minimum criteria or the McGeer's, prior to initiating antibiotics. ICN #16 provided the facility's policy on antibiotic stewardship program, with a policy effective date of 10/24/17. The policy lacked any information related to the utilization of an infection assessment tool (such as the McGeer's or the Loeb minimum criteria for initiation of antibiotics) prior to prescribing antibiotics in the long-term care facility. ICN #16 stated the program is still in the infancy stage and they did not have a standardized form for screening. ICN #16 attended a seminar approximately three (3) months ago, and she stated they planned to use the suggested McGeer criteria as a screening tool; however they had not been able to put it into place yet. No education to staff had been done regarding the antibiotic stewardship program. On 10/23/18 at 1:08 PM Director of Nursing (DoN) #65 stated that she did not think sh… | 2020-09-01 |
| 3639 | 3639 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2018-10-25 | 880 | F | 0 | 1 | 6SVK11 | Based on observation, staff interview and policy review, the facility failed to maintain a clean and sanitary laundry room to prevent cross contamination of linens to help prevent the development and transmission of communicable diseases and infections. The laundry room lacked separation between the clean and soiled area to prevent cross contamination of linen and resident clothing. Staff was unable to determine theexistence of a negative air flow from the clean area to the dirty section. Speed Queen washer and laundry cart within the laundry room was found to be unsanitary. This practice has the potential to affect all residents. Facility census: 24. Findings included: a) Observation of the laundry room on 10/22/18 at 3:44 PM, in the presence of Environmental Service Attendant (ESA) #93 and ESA #95 revealed the laundry room to have no separation between the soiled and clean linen areas and no identified negative airflow from the clean to soiled areas. ESA #93 stated he did not know anything about the duct work within the laundry department. Doors leading into the laundry room, out into the hallway, and into the clean linen room from within the laundry room were sustained open with wooden door wedges. b) On 10/23/18 at 09:34 AM Environmental Service Coordinator (ESC) #22 provided policy and procedure for laundry/housekeeping services. Policy and procedures for transporting soiled linens stated after soiled linens are picked up from resident care areas, the soiled lines are to be taken to the soiled linen receiving area to be sorted and washed. The facility did not have a designated soiled linen area in the laundry room that was separate from the clean area for these soiled linens to be washed. c) ESC #22 was in agreement during an interview on 10/23/18 at 1:23 PM that the laundry room area did not have any separation between soiled and clean linen areas to prevent cross contamination while processing the linens. ESC #22 also confirmed the metal wheeled cart found in the laundry area in front of washers was used t… | 2020-09-01 |
| 3640 | 3640 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2018-10-25 | 881 | F | 0 | 1 | 6SVK11 | Based on staff interview and policy review, the facility's Infection Prevention Control Program failed to develop an antibiotic stewardship program that promoted the appropriate use of antibiotics. Assessment tools were not utilized prior to the prescribing and administration of antibiotics. This practice had the potential to affect all residents residing in the facility. Facility census 24. Findings included: a) During an interview on 10/23/18 at 10:48 AM, Infection Control Nurse (ICN) #16 reported the facility does not utilize an infection assessment tool such as the Loeb's minimum criteria or the McGeer's, prior to initiating antibiotics. ICN #16 provided the facility's policy on antibiotic stewardship program, with a policy effective date of 10/24/17. The policy lacked any information related to the utilization of an infection assessment tool (such as the McGeer's or the Loeb minimum criteria for initiation of antibiotics) prior to prescribing antibiotics in the long-term care facility. ICN #16 stated the program is still in the infancy stage and they did not have a standardized form for screening. ICN #16 attended a seminar approximately three (3) months ago, and she stated they planned to use the suggested McGeer criteria as a screening tool; however they had not been able to put it into place yet. No education to staff had been done regarding the antibiotic stewardship program. b) On 10/23/18 at 1:08 PM Director of Nursing (DoN) #65 stated that she did not think she has did any specific training for antibiotic stewardship, it had been mentioned in staff meetings that it would be rolling out once they got everything in place. DoN #65 stated that ICN #16 did attend seminar approximately three (3) months ago regarding the antibiotic stewardship program, and brought back information that they planned to implement and use in the future. c) During an interview at 10:20 AM on 10/24/18, Director of Quality Assurance #57 stated the facility was not using a standard tool for assessment of criteria for utilization of… | 2020-09-01 |
| 3641 | 3641 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 164 | E | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the privacy of medical records was maintained during medication administration observation for five (5) of seven (7) opportunities observed. This failed practice had the potential to affect more than a limited number of residents who received medications administered by facility staff. Resident identifiers: #15, #7, #19, and #1. Facility census: 22. Findings include: a) Resident #15 At 8:59 a.m. on 10/31/17 licensed practical nurse (LPN) #2 was observed administering medication to Resident #15. After LPN #2 entered the room for Resident #15 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. At 2:13 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #15. After LPN #2 entered the room for Resident #15 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. b) Resident #7 At 2:05 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #7. After LPN #2 entered the room for Resident #7 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. c) Resident #19 At 2:09 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #19. After LPN #2 entered the room for Resident #19 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. d) Resident #1 At 2:19 p.m. on 10/31/17 LPN #9 was observed administering medication to Resident #1. Resident #1 was in the hallway, past the water fountain near the nursing station. LPN #2 left her medication cart outside of the room for Resident #15, she went to the end of the hall and entered the room of Resident #1. She then walked back up the hall, passing her medication cart, and walked towards the nursing station to give Resident #1 his medication. She left the MAR indicated [REDACTED]. A medical record review was … | 2020-09-01 |
| 3642 | 3642 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 246 | D | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interviews and staff interviews, the facility failed to ensure reasonable accommodation of needs with call bell accessibility. Two (2) residents who were not independent were observed with call bells placed in a fashion making it difficult, unsafe, if not impossible for them to use. This failed practice affected two (2) of twenty (20) residents reviewed. Resident identifiers: #1 and #12. Facility census: 22. Findings include: a) Resident #1 A record review revealed Resident #1 was admitted [DATE]. His [DIAGNOSES REDACTED]. According to his most recent minimum data set (MDS) quarterly assessment with an assessment reference date (ARD) of 09/13/17, he was totally dependent on staff and required assistance of one (1) to two (2) staff with all of his activities of daily living (ADL's). His brief interview of mental status (BIMS) score on his 09/13/17 quarterly MDS was 10. This means he had moderate cognitive impairment. A resident observation and interview was conducted with Resident #1 on 10/30/17 at 1:50 p.m. He had a special call bell clipped to his pillow that he was meant to press with his head in order to call for staff. When asked if he was able to use his call bell, Resident #1 said I have a hard time getting to it. He then demonstrated that he could not reach the bell, as it was clipped too far for him to reach with his head. Licensed practical nurse (LPN) #1 was summoned to the room. She re-adjusted the call bell and Resident #1 demonstrated he could use it. She had no comment about the bell being out of reach. b) Resident #12 A record review for Resident #12 revealed she was admitted on [DATE]. She had a [DIAGNOSES REDACTED]. She was ninety-eight (98) years old. Her most recent quarterly MDS with an ARD of 09/06/17 identified her as having a BIMS score of fifteen (15), meaning she was cognitively intact. Her MDS also stated she required assistance of staff for dressing and personal hygiene … | 2020-09-01 |
| 3643 | 3643 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 253 | D | 0 | 1 | 0.0 | Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services for one (1) of eleven (11) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The issues identified included a resident's room with oxygen on the floor and stained ceiling tiles with multiple holes. Room identifier: #300-B. Facility census: 22. Findings include: a) Observations The following observations were made on 10/30/17: --[RM #]0-B-Multiple holes and stains on the ceiling tiles. Oxygen tubing on the floor. The following observation was made on 10/31/17: --[RM #]0-B-Oxygen tubing on the floor. b) Interviews An interview with Licensed Practical Nurse (LPN) #2 on 10/31/17 at 10:00 a.m. revealed the oxygen tubing should not be touching the floor. The LPN stated she would let maintenance know about the ceiling tiles. An interview with the Director of Nursing (DON) on 11/01/17 at 9:00 a.m. revealed the DON did not know that oxygen tubing could not be on the floor. She stated she thought just as long as the part that touched the face was off the floor then everything else was okay to touch the floor. The DON stated she would inform the maintenance department of the ceiling tiles. | 2020-09-01 |
| 3644 | 3644 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 279 | D | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan based on a resident's assessed vision impairment. This practice was found for one (1) of ten (10) Stage 2 Sample Residents whose Care Plans were reviewed during the Quality Indicator Survey (QIS). Resident identifier: #20. Facility census: 22. Findings include: a) Resident #20 An observation of Resident #20 on 10/30/17 at 11:00 a.m. revealed the resident was not wearing glasses. A review of Resident #20's Quarterly Minimum Data Set (MDS), dated [DATE], was conducted on 10/31/17 at 10:45 a.m. Section B (B1000)-Vision-revealed the resident was assessed as having impaired vision with the ability to see large print, but not regular print in newspapers/books. A review of Resident #20's initial Nursing Admission Assessment, dated 08/25/15, was conducted on 10/31/17 at 11:00 a.m. The resident was assessed as being visually impaired. A review of Resident #20's annual Social Service Assessment, dated 07/11/17, was conducted on 10/31/17 at 11:15 a.m. The resident was assessed as being visually impaired. A review of Resident #20's annual Nursing Assessment, dated 07/11/17, was conducted on 10/31/17 at 11:25 a.m. The resident was assessed as being visually impaired. A review of Resident #20's Activity Progress Notes, dated 10/18/17, was conducted on 10/31/17 at 11:45 a.m. The progress note stated Participation is limited due to hearing and vision problems. A review of Resident #20's current Care Plan, dated 07/25/17, was conducted on 10/31/17 at 12:00 p.m. The care plan did not include any problem, goals, or interventions for the resident's assessed vision impairment. An interview with Licensed Practical Nurse (LPN) #2, on 10/31/17 at 12:30 p.m., revealed Resident #20 has never had glasses since he has been in the facility. The LPN stated she was not aware the resident had any vision impairment. An interview with the Director of Nursing (DON), on … | 2020-09-01 |
| 3645 | 3645 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 313 | D | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assist in providing vision treatment and devices for a resident. A resident with vision impairment was not assisted in seeing a physician or obtaining any type of vision correcting devices. This practice was found for one (1) of three (3) residents reviewed for vision services in Stage II of the Quality Indicator Survey (QIS). Resident identifier: #20. Facility census: 22. Findings include: a) Resident #20 An observation of Resident #20 on 10/30/17 at 11:00 a.m. revealed the resident was not wearing glasses. A review of Resident #20's Quarterly Minimum Data Set (MDS), dated [DATE], was conducted on 10/31/17 at 10:45 a.m. Section B (B1000)-Vision-revealed the resident was assessed as having impaired vision with the ability to see large print, but not regular print in newspapers/books. A review of Resident #20's initial Nursing Admission Assessment, dated 08/25/15, was conducted on 10/31/17 at 11:00 a.m. The resident was assessed as being visually impaired. A review of Resident #20's annual Social Service Assessment, dated 07/11/17, was conducted on 10/31/17 at 11:15 a.m. The resident was assessed as being visually impaired. A review of Resident #20's annual Nursing Assessment, dated 07/11/17, was conducted on 10/31/17 at 11:25 a.m. The resident was assessed as being visually impaired. A review of Resident #20's Activity Progress Notes, dated 10/18/17, was conducted on 10/31/17 at 11:45 a.m. The progress note stated Participation is limited due to hearing and vision problems. A review of Resident #20's current Care Plan, dated 07/25/17, was conducted on 10/31/17 at 12:00 p.m. The care plan did not include any problem, goals, or interventions for the resident's assessed vision impairment. Further review of the medical record on 10/31/17 at 12:45 p.m. revealed no indication the resident had any type of vision corrective devices or had been assisted in seeing a physician fo… | 2020-09-01 |
| 3646 | 3646 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 323 | E | 0 | 1 | 0.0 | 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 in the dining and shower rooms. This practice had the potential to affect more than a limited number of residents. Facility census: 22. Findings include: a) Dining Room A tour of the unit, on 10/30/17 at 9:30 a.m., revealed the dining room door was not shut. The room contained the following items on a cart: --One (1) container of Avagard Instant Hand Antiseptic with Moisturizer with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center. --One (1) container of Spartan Steriphone II Disinfectant Deodorant Spray with the warning Precautionary Statement-Hazard to humans and animals-Warning-Causes substantial but temporary eye injury-Harmful if absorbed through the skin. An interview with the Director of Nursing (DON) on 10/30/17 at 9:35 a.m. revealed the items should have never been left in the dining room and that they should be locked up in a secured cabinet or room. b) Shower Room A tour of the unit, on 10/31/17 at 10:25 a.m., revealed the shower room door was not shut. The room contained the following items in an unlocked cabinet: --Two (2) containers of Clorox Bleach Germicidal Cleaner with the warning Caution-Causes moderate eye irritation-Avoid contact with eyes or clothing. --Three (3) containers of Spartan Steriphone II Disinfectant Deodorant Spray with the warning Precautionary Statement-Hazard to humans and animals-Warning-Causes substantial but temporary eye injury-Harmful if absorbed through the skin. --One (1) container of Spartan-Non Acid Disinfectant Bathroom Cleaner with the warning Hazard to humans and animals-Caution-causes moderate eye irritation-Harmful if absorbed through the skin. --One (1) container of Stride Citrus Neutral Cleaner with the warning Warning-Causes serious eye irritation-Avoid contact with eyes skin and clothing. An… | 2020-09-01 |
| 3647 | 3647 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 441 | D | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure staff practices were consistent with infection control principles. A nurse administered medication after potential contamination. Resident oxygen tubing was found on the floor. This failed practice affected an isolated number of residents observed during the survey. Resident identifiers: #15 and #19. Facility census: 22. Findings include: a) Resident #15 An observation of medication administration for Resident #15 was held on 10/31/17 at 8:59 a.m. Licensed practical nurse (LPN) #2 dropped a tablet on to the top of the medication cart when she popped it out of the package. She donned a glove, picked up the tablet with her gloved hand, and placed the tablet into the cup with the rest of the medications she had already poured. LPN #2 then removed the glove and took the cup of medications in to Resident #15. This concern was discussed with LPN and the DON together on 10/31/17 at 3:37 p.m. They both verbalized understanding. b) Oxygen tubing The following observation was made on 10/30/17: --room [ROOM NUMBER]-B-Resident #19-Oxygen tubing on the floor. The following observation was made on 10/31/17: --room [ROOM NUMBER]-B-Resident #19-Oxygen tubing on the floor. An interview with Licensed Practical Nurse (LPN) #2 on 10/31/17 at 10:00 a.m. revealed the oxygen tubing should not be touching the floor. An interview with the Director of Nursing (DON) on 11/01/17 at 9:00 a.m. revealed the DON did not know that oxygen tubing could not be on the floor. She stated she thought just as long as the part that touched the face was off the floor then everything else was okay to touch the floor. | 2020-09-01 |
| 4546 | 4546 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2016-12-07 | 253 | E | 0 | 1 | CR3E11 | Based on observation and staff interview, the facility failed to provide adequate housekeeping and maintenance services to maintain a clean and/or sanitary area by ensuring ceiling fans were cleaned on a daily basis in the nursing station area (which is also a main thoroughfare to the resident community shower room and bathroom) and in dining room B/recreation room. This practice was found for two (2) of three (3) areas utilized by residents and has the potential to affect more than an isolated number of residents. Facility census: 23. Findings include: a) On 12/06/16 at 1:40 p.m., observed the ceiling fan being turned off to allow the Life Safety surveyor access to the ceiling above the central nursing station. When the ceiling fan was turned off observed a large build-up of dust and dirt on the top and sides of the fan blades. The maintenance staff immediately paged the housekeeping staff to the area to clean the ceiling fan. Upon arrival Housekeepers #51 and #52 proceeded to clean and dust the blades on the ceiling fan and then proceeded to sweep the floor due to the dust and dirt falling from the ceiling fan blades during cleaning. During an interview immediately following the previous observation Housekeeper #52 stated, No we have not cleaned this fan for a long time because someone is always sitting at the desk or residents are being transported to or from the shower room/restroom. We haven't cleaned the fan in that room either (pointing toward dining room B/recreation room) because either residents are having their meals there, sitting in there or having an activity. b) At 4:05 p.m. on 12/06/16 accompanied by the DON, the ceiling fan in dining room B/recreation room was turned off by maintenance worker #53. The ceiling fan blades had a large amount of visible dust and dirt on the top and sides of the blades. The DON agreed the ceiling fan blades needed to be cleaned and immediately notified housekeeping to clean the ceiling fan blades. The DON stated, The ceiling fan can be cleaned at any time and the resi… | 2019-10-01 |
| 4547 | 4547 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2016-12-07 | 279 | D | 0 | 1 | CR3E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan for a resident on the anti-platelet medication [MEDICATION NAME] with measurable goals, interventions and timetables related to the medication side effects and precautions. This practice was found for one (1) of nine (9) Stage 2 sample residents whose care plan was reviewed during the Quality Indicator Survey (QIS). Resident identifier: #5. Facility census: 23. Findings include: a) Resident #5 On 12/06/16 at 2:43 p.m. a medical record review for Resident #5 revealed his [DIAGNOSES REDACTED]. The care plan dated 09/14/16 was silent for precautions and side effects related to the medication [MEDICATION NAME]. After reviewing the care plan, on 12/06/16 at 3:27 p.m., the DON agreed and verified the care plan for Resident #5 did not contain any goals or interventions related to the precautions or side effects for the medication [MEDICATION NAME]. | 2019-10-01 |
| 4548 | 4548 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2016-12-07 | 425 | D | 0 | 1 | CR3E11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed, in collaboration with the consultant pharmacist, to ensure safe and effective use of medications when it failed to notify the physician of possible drug interactions of medications administered at the same time. This was evident for one (1) of three (3) residents randomly observed during medication administration by a licensed nurse. Resident identifier: #10. Facility census: 23. Findings include: a) Resident #10 Observation during medication administration, on 12/06/16 at 8:28 a.m., found licensed practical nurse (LPN) #8 administered Levothyroxine 25 micrograms (mcg) to Resident #10. Levothyroxine is a medication used in the treatment of [REDACTED].#8 also gave Resident #10 a 600 milligram (mg) calcium tablet, and a 325 mg ferrous sulfate (iron) tablet. Observation of the ingredients listed on the stock bottle of calcium found that the tablet is comprised of 600 mg of calcium carbonate. Resident #10 was eating her breakfast at this time, and swallowed her oral medications with milk. Review of current physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] An interview was conducted with the facility's consultant pharmacist #54, on 12/06/16 at 11:42 a.m. It was discussed Resident #10 took her Levothyroxine with milk at her breakfast meal, as well as calcium carbonate and ferrous sulfate. He said he was not aware of any problems with taking thyroid medication simultaneously with calcium carbonate and ferrous sulfate, or with a full meal. On 12/06/16 at 12:00 p.m., an interview was conducted with the director of nursing (DON). She said she was not aware of any contraindication with giving Levothyroxine, calcium carbonate, and ferrous sulfate at the same time. She said she would check with the physician. On 12/07/16 at 9:00 a.m., a review of the facility's Nursing (YEAR) Drug Handbook 35th Edition for manufacturer guidelines for the medication Levoth… | 2019-10-01 |
| 4549 | 4549 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2016-12-07 | 520 | C | 0 | 1 | CR3E11 | Based on review of quality assessment and assurance (QA&A) meeting attendance records and staff interview, the facility failed to ensure the attendance and/or participation of the facility's medical director in QA&A meetings. This had the potential to affect all of the residents in the facility. Facility census: 23. Findings include: a) During interview with the director of nursing (DON) on 12/07/16 at 10:00 a.m., she was asked to provide attendance records/sign-in sheets of all facility staff who attended quality assessment and assurance (QA&A) meetings for the most recent six (6) months. She said the QA&A meets once a month, but the medical director does not attend the QA&A meetings. Rather, nursing administration's director of QA&A /Risk e-mails the minutes of the QA&A meetings to the medical director. She said the facility's QA&A minutes are then placed on the agenda of the monthly medical staff meetings, and the medical director reviews the QA&A meeting minutes at those meetings. Upon request to provide evidence the facility's medical director does review the facility's QA&A meeting minutes as signified by his signature, or initials, or some form of communication, the DON said she would try to locate that information. ON 12/07/16 at 12:00 p.m. the DON said she found the facility's QA&A minutes are not placed on the monthly physician's staff meeting agenda for review by the medical director. Rather, the director of QA&A /risk emails the monthly QA&A meeting minutes to the medical director for his review. She said she would ask the director of QA&A /risk for a copies of the most recent six (6) months' of emails she sent to the current medical director, and to the former medical director of the facility, which contained QA&A meeting minutes. She said she would also provide some evidence of the medical directors' review of the monthly QA&A meeting minutes. On 12/07/16 at 1:00 p.m. the DON said she was unable to find evidence of the medical directors' review of any of the most recent six (6) months' QA&A meeting … | 2019-10-01 |
| 5507 | 5507 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2015-10-07 | 156 | B | 0 | 1 | WP4G11 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 22 Findings include: a) On 10/05/15 at 11:45 a.m., an observation of the facility revealed there was no written information posted in the facility to inform a resident how to apply for and use Medicare benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview, on 10/06/15 at 9:45 a.m., the Director of Social Services agreed the information was not posted prominently to inform residents on how to apply for and use Medicare benefits. | 2019-01-01 |
| 5508 | 5508 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2015-10-07 | 250 | D | 0 | 1 | WP4G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide medically-related social services to meet the needs of one (1) of twelve (12) Stage 2 residents. A follow-up visit with an eye doctor was not arranged for a resident who had cataracts and glaucoma. Resident identifier: #4. Facility census: 58. Findings include: a) Resident #4 Review of the resident's medical record, on 10/07/15 at 1:19 p.m., revealed a physician's orders [REDACTED]. The consult section of the medical record indicated Resident #4 received a consult with an optometrist on 04/22/15. The report noted Resident #4 was followed for cataracts and glaucoma. The report indicated the resident would have a follow-up appointment in four (4) months, in (MONTH) (YEAR). A notation indicated the office would contact the facility with a date and time of the appointment. The medical record, with dates from 04/01/15 through 10/07/15, was reviewed. This included nurses' notes, physician's progress notes, physician's orders [REDACTED]. There was no evidence the resident was scheduled for a follow-up appointment. An interview with Licensed Practical Nurse (LPN) #27, on 10/07/15 at 3:11 p.m., confirmed an appointment was not scheduled for the follow-up visit. The nurse reviewed the medical record and related she was unaware Resident #4 needed the appointment. LPN #27 acknowledged the facility had a responsibility to ensure the resident received the care and services needed, and should have initiated the follow-up. An interview with the director of nursing (DON), on 10/07/15 at 3:56 p.m., also confirmed the facility did not arrange a follow-up appointment with the optometrist. The DON also related Resident #4's brother approached Social Worker (SW) #25 last week, because the resident was complaining of problems with her eyes. He requested an eye appointment, which had not been made as of the chart review with LPN #27 at 3:11 p.m. on 10/07/15. | 2019-01-01 |
| 5509 | 5509 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2015-10-07 | 279 | D | 0 | 1 | WP4G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan, with measurable objectives, to assist one (1) of twelve (12) Stage 2 residents to attain or maintain the highest practicable well-being. The resident's care plan did not address [MEDICAL CONDITION] or anything related to the resident's eyes. Resident identifier: #4. Facility census: 22. Findings include: a) Resident #4 Review of the resident's medical record, on 10/07/15 at 1:19 p.m., revealed a physician's orders [REDACTED]. The care plan, reviewed a 1:25 p.m. on 10/07/15, did not address [MEDICAL CONDITION] or any conditions associated with Resident #4's eyes. The consult section of the medical record indicated Resident #4 received a consult with the optometrist (eye doctor) on 04/22/15. The report noted Resident #4 was followed for [MEDICAL CONDITION] and [MEDICAL CONDITION]. An interview with the Director of Nursing (DON) on 10/07/15 at 3:56 p.m., revealed Resident #4's brother had approached Social Worker (SW) #25 last week, because the resident was complaining of problems with her eyes. The care plan was reviewed with the DON on 10/07/17 at 4:00 p.m. The DON confirmed [MEDICAL CONDITION] was not addressed in the resident's care plan. | 2019-01-01 |
| 5510 | 5510 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2015-10-07 | 280 | D | 0 | 1 | WP4G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plan for one (1) of twelve (12) sample residents. The resident's care plan was not revised to include interventions for monitoring and/or management of anticoagulant therapy. Resident identifier: #6. Facility census: 22. Findings include: a) Resident #6 A review of the resident's medical record, on 10/07/15 at 4:11 p.m., revealed the care plan for Resident #6 was not revised to include the required laboratory (lab) work for [MEDICATION NAME] time (PT) and international normalized ratio (INR) for monitoring and/or management of anticoagulant therapy. The physician's orders [REDACTED]. Lab work, a PT/INR, was to be completed monthly for the [DIAGNOSES REDACTED]. An interview with the Director of Nursing (DON), on 10/07/15 at 4:45 p.m., verified the care plan did not include the lab work, PT/INR, as an intervention for the management of anticoagulant therapy for this resident. | 2019-01-01 |
| 5511 | 5511 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2015-10-07 | 334 | E | 0 | 1 | WP4G11 | Based on medical record review, staff interview, and policy review, the facility failed, for five (5) of five (5) resident's reviewed, to inform the residents and/or families about the benefits and potential risks of the influenza (flu) and/or pneumococcal (pneumonia) vaccines. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #11, #23, #5, #6, and #25. Facility census: 22. Findings include: a) Residents #11, #23, #5, #6, #25 On 10/05/15, beginning at 3:10 p.m., review of these residents' medical records revealed annual consent forms for pneumonia and flu vaccines. The form read: I ___, give/do not give permission for____ to receive the pneumonia vaccine as ordered by the physician. (I have been informed and understand some of the side effects include, fever, rash, and soreness at the site, with administration of the pneumonia vaccine.) Below the pneumonia vaccine entry, the form contained the flu vaccine consent. It read: I ____ give/do not give permission for _____ to receive the flu vaccine annually in the fall. (I have been informed and understand that some of the side effects include fever, malaise and soreness at the site.) The Resident/Responsible Party then signed below, as did a witness, and the form was dated. Thereafter, the form was re-evaluated annually. An interview with Licensed Practical Nurse #48, on 10/05/15 at 3:45 p.m., revealed one form was utilized for both the pneumonia vaccine and the flu vaccine. She related the facility was obtaining consents for the (YEAR)-2016 flu season, but no vaccines had yet been administered. An interview with the director of nursing (DON), on 10/06/15 at 9:56 a.m., revealed no risk/benefit information was provided to the resident and/or family. She stated the form they provided was related to side effects. Review of the influenza infection control policy, on 10/07/15 at 3:30 a.m., revealed it did not direct the facility to provide risks/benefit education when offering the flu and pneumonia vaccines. A follow-… | 2019-01-01 |
| 5512 | 5512 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2015-10-07 | 431 | E | 0 | 1 | WP4G11 | Based on observation, staff interview, and policy review, the facility failed to provide safe and secure storage of controlled substances. An emergency kit was stored in a labeled file cabinet at the nurses' station. The medications were not monitored and Schedule II medications were not secured in a permanently affixed compartment. This practice had the potential to affect more than a limited number of residents. Facility census: 22. Findings include: a) An interview with Licensed Practical Nurse (LPN) #27, on 10/06/15 at 2:34 p.m., revealed a controlled substance emergency kit (E-kit) was stored in a filing cabinet at the nurses' station. The nurses' station was not enclosed, and could be accessed by anyone. Observation revealed a drawer labeled NARC ER box (narcotic emergency box). The nurse unlocked the cabinet revealing a box labeled with a dispensing number of R 3.12 ; NDC (National Drug Code): 1; route, gray, and noted to order after 10/05/15. The E-box was secured with two (2) numbered zip ties (number and ) and contained a list of medications which was visible without opening the box. The contents were not visible for reconciliation purposes. The list indicated the contents included the following: Acetaminophen/codeine (Tylenol #3), five (5) tablets Alprazolam (Xanax) 0.25 milligrams (mg), five (5) tablets Klonopin 0.5 mg, three (3) tablets Lomotil 2.5 mg, three (3) tablets Fentanyl patch 25 micrograms (mcg) two (2) patches Fentanyl patch 50 mcg, two (2) patches Norco 5/325 mg, six (6) tablets Norco 7.5/325 mg, six (6) tablets Norco 10/325 mg, six (6) tablets Ativan 0.5 mg, five (5) tablets morphine sulfate extended release (ER) (MScontin) 15 mg, five (5) tablets Roxanol 20 mg/ml (milligrams/milliliter) solution, two (2) bottles with 30 ml each Oxycontin 10 mg, three (3) tablets Roxicodone 5 mg, five (5) tablets Percocet 5/325 mg, six (6) tablets Phenobarbital 32.4 mg, three (3) tablets Ultram 50 mg, three (3) tablets Ambien 5 mg, three (3) tablets Upon inquiry, LPN #27 related the controlled substance E… | 2019-01-01 |
| 6665 | 6665 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 253 | E | 0 | 1 | JR2311 | Based on observation and staff interview, it was determined the facility failed to ensure effective housekeeping and maintenance services. The physical environment was not in good repair and/or clean. Eleven (11) of eleven (11) rooms observed had issues with housekeeping and/or maintenance. Identified were floors with discolored and/or had broken tile, holes in walls, a rusted grab bar, exposed drywall, marred doors, furniture which was marred and/or with the finish worn off, knobs missing from dresser drawers, light bulbs not working, and the heating/cooling units had an accumulation of dust. Rooms #300, #302, #304, #306, #307, #308, #309, #310, #311, #312, and #314 were affected. In addition, the wooden handrails in the hallway were in disrepair. These identified problems had the potential to affect more than a limited number of residents. Facility Census: 23. Findings include: a) Observation of the facility during Stage 1 and Stage 2 of the Quality Indicator Survey revealed the following rooms had environmental concerns: 1. Room #300 The bathroom had broken tile around the commode. There were small round holes (1/2 - 3/4 inch) in the wall which had not been patched or painted. A grab bar was rusted. The sink had exposed/unsealed areas between the drywall and the sink. The outside of the entrance door to the bathroom had areas which were marred to the bare wood. 2. Room #302 The bathroom had discolored tile around the commode. There were small round holes (1/2 - 3/4 inch) in the wall which had not been patched or painted. There was bare drywall, with no paint, around a hand soap dispenser. A dresser in the resident room had finish worn down to bare pressed wood. 3. Room #304 The bathroom had discolored grout around the commode and some of the tile was cracked. One (1) of two (2) light bulbs over the sink was not working. The heating/cooling unit in the resident room had an accumulation of dust in the vents. A dresser in the resident room had four (4) pull knobs missing and one (1) screw protruding out of the dr… | 2017-12-01 |
| 6666 | 6666 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 256 | E | 0 | 1 | JR2311 | Based on observation and staff interview, the facility failed to have adequate and comfortable lighting levels in five (5) of eleven (11) bathrooms observed. Each of the five (5) bathrooms had a light fixture over the bathroom sink requiring two (2) working light bulbs. The light fixture in five (5) bathrooms had only one (1) working light bulb. Room identifiers: #304, #309, #311, #312, and #314. Facility census: 23. Findings Include: a) Rooms #304, #309, #311, #312, and #314 On 07/30/14 at 1:40 p.m., a tour through resident rooms was completed with the housekeeping supervisor, Employee #28. The bathroom sink light fixtures in rooms #304, #309, #311, #312, and #314 all required two (2) light bulbs. Each of the light fixtures in these rooms had only one (1) light bulb in working condition. When the light was turned on there was a significant difference in the level of lighting as compared to the lighting level in the resident bathrooms with both light bulbs in working order. Employee #28, agreed the bathroom lighting fixtures should have both light bulbs in working order to provide adequate lighting for the residents. | 2017-12-01 |
| 6667 | 6667 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 279 | D | 0 | 1 | JR2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to develop a care plan based on the comprehensive assessment, for three (3) of fourteen (14) Stage 2 sampled residents. Resident #5, who preferred afternoon showers, did not have a care plan to communicate his preference. Resident #15 had physician's orders [REDACTED]. Resident #20, who received medications known to contribute to constipation, and who had known episodes of constipation, had no care plan developed for constipation. Resident identifiers: #5, #15, and #20. Facility census: 23. Findings include: a) Resident #5 During an interview with Resident #5, on 07/28/2014 1:02 p.m., he said staff get him up any time they want to, even at or before 6:00 a.m. Upon inquiry as to what staff do when they get him up that early, he said sometimes he was showered. He said he would prefer to sleep a little later, and have his showers later in the day. The medical record was reviewed on 07/29/14 at 12:30 p.m. The nursing admission assessment, dated 12/04/13, stated as written, Prefers showers in afternoon. Review of the Nursing Assistant Daily Flow Sheet found the resident received four (4) showers during the night shift in June, and six (6) showers during the night shift in July. At 1:00 p.m. on 07/30/14, interviews were conducted with Nursing Assistants (NAs) #12 and #13. They said Resident #5 had never asked them to let him sleep later in the mornings. The NAs said he was showered every Monday, Wednesday, and Friday morning. They said they began showers for some residents at 6:00 a.m. Sometimes he was awakened to see if he was ready for his shower. Upon inquiry, they said if a resident refused a shower or asked for it at a different time, they honored that request; however, they were not aware of Resident #5's preference for afternoon showers. On 07/30/14 at 1:15 p.m., Licensed Practical Nurse (LPN) #10 was unable to find documentation about the resident's… | 2017-12-01 |
| 6668 | 6668 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 323 | E | 0 | 1 | JR2311 | Based on observation and staff interview, the facility failed to ensure the environment remained as free of accident hazards as possible. The wooden hand rails on the resident unit were found with areas of broken down finish, making them rough to the touch. The areas had the potential to cause harm to fragile skin tissue of all mobile residents who came in contact with the hand rails. This was a potential for harm for more than an isolated number of residents. Facility census: 23. Findings Include: a) On 07/30/14 at 3:25 p.m., the wooden hand rails on the long term care unit were observed in poor repair. The finish on the hand rails was worn down to bare wood, and hard rough areas. When one rubbed one's hand across a rail, there were areas which felt rough and had the potential to injure a resident. On this same date and time, the director of nursing observed the areas of disrepair, and confirmed an accident hazard existed. | 2017-12-01 |
| 6669 | 6669 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 329 | E | 0 | 1 | JR2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review, and review of the State Operations Manual Appendix PP guidelines, the facility failed to ensure five (5) of five (5) residents reviewed for unnecessary medications were free from unnecessary medications. Residents #15, #23, #13, and #17 had no evidence of monitoring for gradual dose reductions (GDR) for psychopharmacological medications (any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders) used for depression, anxiety and/or sleep induction. Resident #20 lacked evidence of monitoring when she received duplicate medications for constipation. Resident identifiers: #15, #23, #13, #7, and #20. Facility census: 23. Findings include: a) Resident #15 [DIAGNOSES REDACTED]. On 07/29/14 at 2:00 p.m. the medical record was reviewed. On 04/04/12, Physician #2 prescribed the antidepressant [MEDICATION NAME] fifteen (15) milligrams (mg) daily for depression. He also prescribed a hypnotic medication,[MEDICATION NAME] (5) mg. at bedtime daily as needed or desired (prn). She remained on those medications and dosages through 07/30/14. Current medications also included [MEDICATION NAME]/Tylenol 5/325 mg. four (4) times daily for chronic pain at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m., and anti-anxiety medication [MEDICATION NAME] 0.5 mg. daily at 4:00 p.m. for anxiety. Review of the pharmacist's monthly medication regimen reviews found no irregularities recorded for the [MEDICATION NAME] or for [MEDICATION NAME] 05/08/13 through 07/16/14. On 07/29/14 at 4:45 p.m., the director of nursing (DON) said she would look through the thinned records to try to locate evidence of pharmacy recommendations to the physician and/or for gradual dose reductions (GDR) of these two (2) [MEDICAL CONDITION] medications ([MEDICATION NAME] and Ambien). She said she would also look for the accompanying physician rationales for either continuing the medications at the curre… | 2017-12-01 |
| 6670 | 6670 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 372 | F | 0 | 1 | JR2311 | Based on observation and staff interview, the facility failed to dispose of garbage properly. Two (2) lids of the facility's large green dumpster were left open. There were filled bags of garbage inside the dumpster. This had the potential to attract animals or pests, which in turn had the potential to affect all the residents in the facility. Facility census: 23. Findings include: a) Observation of the dumpster, on 07/31/14 at 8:41 a.m., found two (2) lids were left open on the dumpster. Five (5) black plastic bags of garbage were visible inside the dumpster. One (1) of the bags was partially opened or torn, and some kitchen food wrappers were lying outside that garbage bag. The certified dietary manager, Employee #27, said dietary staff took their trash bags outside and placed them in a small plastic dumpster by the exit door closest to the kitchen. She said someone in housekeeping or maintenance then transferred their garbage bags to the large green dumpster. At 8:45 a.m. on 07/31/14, environmental attendant, Employee #33, said the lids on the dumpster were always to be kept closed. At that time, Employee #33 closed the dumpster lids. | 2017-12-01 |
| 6671 | 6671 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 428 | E | 0 | 1 | JR2311 | Based on medical record review, staff interview, policy review, and the State Operations Manual Appendix PP, the pharmacist failed to identify and report medication irregularities for four (4) of five (5) residents reviewed for unnecessary medications. There were no recommendations for a gradual dose reduction (GDR) for the psychopharmacological medications (any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders) used by each resident for depression, anxiety and/or sleep induction. Resident identifiers: #15, #23, #13, and #7. Facility census: 23. Findings include: a) Resident #7 Review of the medical records, on 07/31/14 at 9:00 a.m., found the resident was prescribed Lexapro 20 mg by mouth at 9:00 a.m. daily, related to depression. The beginning date for this medication was 12/21/11. Review of the pharmacist consulting report found no recommendations to reduce the prescribed Zoloft. On 07/30/14 at 2:30 p.m., the DON stated there had not been a pharmacist review with the recommendation to reduce antidepressants because the pharmacist was under the impression GDRs did not need to be attempted on antidepressants. b) Resident #13 Review of the resident's medical record, on 07/30/14 at 11:10 a.m., found the resident was prescribed Zoloft 25 mg by mouth at 9:00 a.m., related to depression. This medication was first prescribed on 06/25/09. Review of the pharmacist consulting report found no recommendations to reduce the prescribed Zoloft. At 12:40 p.m. on 07/30/14, the DON stated there was never an increase or decrease in the prescribed 25 mg Zoloft, since the start date of 06/25/09. On 07/30/14 at 2:30 p.m., the DON stated there had not been a pharmacist's review with a recommendation to reduce antidepressants because the pharmacist was under the impression GDRs did not need to be attempted on antidepressants. Review of the MAR indicated [REDACTED]. The pharmacist, Employee #25, stated, on 07/30/14 at 3:40 p.m., he had not been recommending gradual dose reductions for antidepres… | 2017-12-01 |
| 6672 | 6672 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 441 | E | 0 | 1 | JR2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an infection control program designed to provide a sanitary environment which helped prevent the development and transmission of disease and infection. The physical environment in eleven (11) of eleven (11) rooms was not maintained in a clean, sanitary manner and/or in a manner to enable effective cleaning and sanitation. Identified were floors with broken tile, holes in walls, a rusted grab bar, exposed drywall, furniture with the worn off finish, and heating/cooling units had an accumulation of dust. Rooms #300, #302, #304, #306, #307, #308, #309, #310, #311, #312, and #314 were affected. The wooden handrails in the hallway were also in disrepair. In addition, the facility failed to ensure nursing staff implemented effective infection control practices during administration of medications, affecting Residents #7 and #23. The identified infection control deficits had the potential to affect more than a limited number of residents. Facility census: 23. Findings include: a) Observation of the facility during Stage 1 and Stage 2 of the Quality Indicator Survey, revealed the following rooms had infection control concerns. The condition of the areas, and/or furnishings rendered them incapable of being effectively sanitized. Some rooms also had heating/cooling units with accumulations of dusty debris. 1. room [ROOM NUMBER]. The bathroom had broken tile around the commode. There were unpainted/unfinished small holes in the wall. A grab bar with rust on the area a resident would touch, a sink with exposed/unsealed area between the drywall and the sink, and the entrance door to the bathroom having areas marred to the bare wood on the outside of the door. 2. room [ROOM NUMBER]. The bathroom had small holes in the wall and unfinished bare drywall around a hand soap dispenser. A dresser in the resident room had the finish worn down to bare pressed wood. 3. room [ROOM NUMBER]. The … | 2017-12-01 |
| 6673 | 6673 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2014-07-31 | 520 | E | 0 | 1 | JR2311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, and staff interviews, it was determined the facility's quality assessment and assurance (QA&A) committee failed to identify and/or correct quality deficiencies in the facility's daily operations in which it did have or should have had knowledge. The QA&A committee failed to identify and develop and implement a plan regarding the facility's failure to recommend and/or attempt gradual dose reductions (GDRs) for residents receiving psychopharmacological medications (such as antidepressants and hypnotic medications). This was found for four (4) of five (5) Stage 2 sample residents who were reviewed for unnecessary medications. Residents #13, #7, #15, and #23. The QA&A committee failed to identify and develop and implement a plan related to the multiple environmental issues which were present in eleven (11) of eleven (11) rooms in which observations were made. These issues included holes in the walls; burned out light bulbs in bathrooms; caulking missing around sinks; air conditioning/heating vents in resident rooms with dust and debris; dressers in multiple resident rooms were scratched, had bare pressed wood exposed and missing and/or broken handles; and the wooden hand rails in the hallways had bare wood exposed. The QA&A committee failed to identify and develop and implement a plan to correct infection control deficits related to an inability to clean and sanitize surfaces due to their disrepair. This was found in rooms #300, #302, #304, #306, #307, #308, #309, #310, #311, #312, and #314. In addition, the condition of the wooden hand rails in the hallway posed an infection control problem due to their inability to be effectively sanitized. These facility practices had the potential to affect more than a limited number of residents. Facility census: 23. Findings include: a) Gradual Dose Reduction The pharmacist failed to identify and report medication irregularities for four (4) of five (5) residen… | 2017-12-01 |
| 7875 | 7875 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2013-03-28 | 241 | D | 0 | 1 | W5BK11 | Based on staff interview and observations, the facility failed to promote care for all residents in a manner and in an environment which maintained and enhanced each resident's dignity. Resident #3's dignity during dining was not maintained because Employee #12 was standing over him while feeding him. The facility did not respect Resident #20's private space as evidenced by facility activity supplies being stored in the resident's personal shower space. These issues were present for two (2) of twenty-four 24 sampled residents. Resident Identifiers: #3 and #20. Facility Census: 24. Findings Include: a) Resident #3 Dining observations conducted in Dining Room A, at 12:14 p.m. on 03/26/13, Employee #12 was observed feeding Resident #3. Resident #3 was seated in a reclining chair and Employee #12 was standing up while feeding the resident. b) Resident #20 During room observations, at 2:30 p.m. on 03/25/13, Resident #20's shower was observed. In the shower were numerous activity items such as a portable basketball goal, inflatable bowling pins, a basketball, a canvas bag containing bingo cards, and a black plastic bag containing other items. An interview with Employee #1 was conducted at 2:50 p.m. on 03/25/13. Employee #1 confirmed the items in the shower were facility activity supplies. She confirmed the supplies should not be stored in the shower. She did report the resident did not use the shower, but she agreed the items should not be stored in the resident's shower. | 2017-01-01 |
| 7876 | 7876 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2013-03-28 | 246 | D | 0 | 1 | W5BK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews, and measurement of water temperatures, it was determined the facility had failed to provide one (1) of twenty-four (24) residents on the sample with reasonable accommodation of needs. Resident #18's desired, and was capable of, showering in his personal shower, but was unable to do so because of water temperatures that were too cold. Resident identifier: #18. Facility census: 24. Findings include: a) Resident #18 Resident #18 reported, at 2:00 p.m. on 03/25/13, he could not use his shower because it did not work. He stated he did not know why they could not get hot water to his room because the facility was only one floor. He stated, I have been on the 48th floor in a hotel in New York and had hot water, but I cannot get hot water in my room here and there is only one floor. At 10:26 a.m. on 03/28/13, the water temperature in Resident #18's shower was obtained by Employee #24, the maintenance supervisor. The water temperature in the resident's shower was 80 degrees Fahrenheit (F). This was confirmed by Employee #24, who stated the anti-scald guard on this shower may need changed. The water temperature in the common shower room and in the shower in room [ROOM NUMBER] were also obtained at this time. The water temperature in the common shower was 92.5 degrees F and the temperature in the shower in room [ROOM NUMBER]'s shower was 93 degrees F. Another resident interview was conducted with Resident #18 at 11:44 a.m. on 03/28/13. He stated he would like to use the shower in his room, but he could not because the water was too cold. He reported he has to go to the common shower room to shower because he cannot use the shower in his room. He reported if the water was warmer he would use the shower in his room and would not have to go to the common shower room. An interview was conducted with Employee #1, the director of nursing, at 11:55 a.m. on 03/28/13. She confirmed Resident #18 does shower in the co… | 2017-01-01 |
| 7877 | 7877 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2013-03-28 | 323 | E | 0 | 1 | W5BK11 | Based on observation and staff interview, the facility failed to provide an environment free of accident hazards by storing chemical supplies in a manner that permitted access by residents. In Dining Room A, an open container of Comet cleanser was found stored in an under sink cabinet where residents had access. This had the potential to affect more than a limited number of residents. Facility census: 24. Findings include: a) During the initial tour of the facility, at 11:50 a.m. on 3/25/13, an open bottle of Comet cleanser was found in an under sink cabinet in Dining Room A. This cabinet was readily accessible to residents in the area. At 3:30 p.m., an interview with Employee #10 was conducted. She went directly to the sink and removed the cleanser. | 2017-01-01 |
| 7878 | 7878 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2013-03-28 | 371 | E | 0 | 1 | W5BK11 | Based on observation and staff interview, food was stored in the dining room refrigerator in a manner that did not meet sanitation requirements. Foods were not labeled and dated to ensure staff knew whether it was still safe for consumption. This had the potential to affect all residents. Facility census: 24. Findings include: a) During the initial tour, at 11:50 a.m. on 03/25/13, a large white refrigerator was observed in Dining Room A. There were numerous items in this refrigerator that did not have dates or labels signifying when they would no longer be safe for consumption. The contents of the refrigerator included: -- one unlabeled jar of an unidentified substance -- a jelly jar with no date -- three (3) ketchup jars and two (2) mustard jars which had no dates -- one (1) jar which had a label on the lid stating hot dog 10/10. An interview was conducted at 12:00 p.m. with Employee #15 who stated the kitchen staff were responsible for keeping up with the resident refrigerator except for the supplements in the door. She verified the aforementioned items had no labels and confirmed the label stating hot dog 10/10. The contents of the refrigerator were again observed at 10:00 a.m. on 3/26/13 and the deficient practice had been corrected. | 2017-01-01 |
| 3575 | 3575 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 550 | D | 0 | 1 | 61Y611 | Based on observation and staff interview, the facility failed to ensure a resident is treated with dignity and their environment enhances their dignity. Resident #38 was wearing a hospital gown during day 1 and day 2 of the survey and had bed linens in poor repair. This practice was found for one (1) of 22 residents reviewed during the survey. Resident identifiers: #38. Facility census: 77. Findings included: a) Resident #38 An observation on 1/28/19, at 1:50 PM, revealed R#38 in bed wearing a hospital gown and being served lunch. On 1/29/19 at 7:40 AM, an observation revealed R#38 in bed wearing a hospital gown and still wearing a gown at 2:14 PM. On 1/29/19 at 2:14 PM, Licensed Practical Nurse (LPN) #31, verified the resident was wearing a hospital gown because he had fought staff that morning during morning his care. The resident receives pain medication at 9 AM and staff should tried again after the pain medication was given in case pain was a factor for refusal. An observation from the doorway on 1/29/19, at 7:40 AM, revealed R#38 in bed. The bedspread used by the resident contained two (2) large holes visible from the doorway. Nurse Aide (NA) #15 verified the torn bedspread was a facility spread and needed to be thrown away. During an interview on 1/29/19, at 2:14 PM, the Director of Nursing (DON) stated, the spread was thrown away, it was getting ratty. | 2020-09-01 |
| 3576 | 3576 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 656 | E | 0 | 1 | 61Y611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure non-pharmacological interventions were developed for residents receiving psychoactive medications. In addition, Resident #74 did not have a care plan for oxygen therapy. This was true for three (3) of five (5) residents reviewed for unnecessary medications and one (1) resident reviewed for oxygen therapy. Resident identifiers: #45, #30, #55, #74. Facility census: 77. Findings included: a) Resident #45 On 01/29/19 at 8:51 PM a review of the medical record revealed Resident #45 was admitted on [DATE]. [DIAGNOSES REDACTED]. Behaviors include yelling out, swatting at staff, pulling away from staff and crying spells. A review of the care plan found no non-pharmacological interventions when this resident had behaviors. b) Resident #30 Resident #30 was admitted on [DATE]. [DIAGNOSES REDACTED]. A review of the care plan found no non pharmacological interventions such as offering a drink, something to eat, toileting, pain assessment in the care plan. On 01/29/19 at 2:42 PM, an interview with the Minimum Data Set (MDS)/Care Plan (CP) Coordinator #26 revealed, after reviewing the care plan, no non-pharmacological interventions were included in the care plan. c) Resident #55 On 01/29/19 at 11:38 PM a review of the medical record found R#55 was admitted [DATE]. [DIAGNOSES REDACTED]. A review of the Annual MDS with an Assessment Reference Date (ARD) of 03/12/18 and quarterly MDS's on 09/11/18 and 12/11/18, found behaviors(E 0200) were marked as occurring daily. A review of the care plan found no non-pharmacological interventions when this resident had behaviors. On 01/30/19 at 10:01 AM, the Social Worker revealed she was aware there were issues with the care plans and had recently hired a new Care Plan Coordinator. The Social Worker was in agreement that non-pharmacological interventions should be included in the care plan. d) R #74 A medical record review for R #74 on 01/29/… | 2020-09-01 |
| 3577 | 3577 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 657 | D | 0 | 1 | 61Y611 | Based on medical record review and staff interview, the facility failed to revise a care plan for the use of a physical restraint. This was true for one (1) of 22 care plans reviewed during the survey process. The care plan for R45 had been developed for the use of an enclosed framed walker, but there was no intervention for frequently releasing the use of the meri walker. Resident identifier: R#45. Facility census: 77. Findings included: a) R#45 A review of the medical record for R#45 on 01/30/19 revealed the care plan with a Problem-May use meri walker when out of bed as a less restrictive restraint when attempting to walk unassisted related to unsteady gait. Goal-Restraint will be used when resident is out of bed and wants to ambulate related to unsteady gait. Approaches was not revised to include monitoring when the meri walker was being used and the frequency of releasing the restraint. During an interview on 01/30/19 at 10:45 AM, the Director of Nursing (DON) verified the care plan for R#45 had not been revised to include the approaches for monitoring the use of the meri walker and frequency of releasing the restraint. | 2020-09-01 |
| 3578 | 3578 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 684 | D | 0 | 1 | 61Y611 | Based on medical record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. The physician's order for R45 did not include the medical symptom being treated requiring the use of an enclosed framed walker (meri walker) and the frequency for releasing when using the (meri walker). This was true for one (1) of twenty-two (22) resident physician's orders reviewed during the survey process. Resident identifier: R#45. Facility census: 77. Findings included: a) R#45 Review of the medical record for R#45 on 01/30/19 revealed a physician's order did not include the medical symptom being treated requiring the use of the meri walker and the frequency of releasing the meri walker when being used for R#45. During an interview on 01/30/19 at 8:48 AM, the Director of Nursing (DON) verified the physician's order did not include the medical symptom being treated and the frequency of releasing the meri walker when being used by R45. | 2020-09-01 |
| 3579 | 3579 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 689 | E | 0 | 1 | 61Y611 | Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. A kitchenette door located on a resident hallway, was not locked allowing for several chemical substances to be readily available to residents. This practice had the potential to affect more than a limited number of residents. Facility census: 77. Findings included: a) A-Hall Kitchenette An random observation of the A-Hall, on 01/30/19 at 10:36 AM, revealed the Kitchenette's door propped open. There were no staff members within sight of the room during this observation. Inside the room, there was an unlocked cabinet that contained the following items: One (1) container of Swan Nail Polish Remover with the warning Keep out of reach of children. One (1) container of Disinfectant Spray with the warning Hazardous to humans. One (1) container of Top Job Glass Cleaner with the warning Keep out of reach of children-May cause eye irritation. An interview with Licensed Practical Nurse (LPN) #3, on 01/30/19 at 10:40 AM, revealed she had no idea how or why the items were in the room. The LPN stated the items should be locked up. The LPN stated the Kitchenette door is usually not propped open. | 2020-09-01 |
| 3580 | 3580 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 695 | D | 0 | 1 | 61Y611 | Based on observation, staff interview, and policy review, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen tubing was not labeled with a date as to when it was last changed. This practice affected two (2) of five (5) residents reviewed for respiratory care during the Long Term Care Survey Process (LTCSP). Resident identifiers: #11 and #50. Facility census: 77. Findings included: a) Resident #11 An observation on 01/30/19 at 8:15 AM, revealed the Resident #11 was receiving oxygen via nasal cannula. There was no date on the oxygen tubing or bag that it was stored in. An interview with Licensed Practical Nurse (LPN) #3, on 01/30/19 at 8:20 AM, revealed the oxygen tubing should be changed and dated every seven (7) days. She stated, the night shift nurse is responsible for changing and dating the tubing. LPN #3 verified the tubing was not dated and stated she would immediately change and date the tubing. b) Resident #50 On 01/30/19 at 8:25 AM an observation revealed Resident #50 was receiving oxygen via nasal cannula. There was no date on the oxygen tubing or bag that it was stored in. An interview with LPN #3, on 01/30/19 at 8:30 AM, revealed the tubing was not dated and stated she would immediately change and date the tubing. The facility policy titled Changing Oxygen Tubing, with a revision date of 01/05/18, was reviewed on 01/30/19 at 9:30 AM. The policy stated the Nurse on 11-7 will change oxygen tubing once a week. This will be done on Tuesday and the tubing will be dated by the nurse when changed. | 2020-09-01 |
| 3581 | 3581 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 812 | E | 0 | 1 | 61Y611 | Based on observation, staff interview and policy review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. The A-Hall Kitchenette contained opened and undated resident food items. The facility kitchen had a dirty ice machine and drip pan as well as no trash can near the hand washing sink. A refrigerator in the kitchen also failed to have a working light. These practices had the potential to affect more than a limited number of residents. Facility census: 77. Findings include: a) A-Hall Kitchenette An observation of the A-Hall Kitchenette, on 01/30/19 at 10:31 AM, revealed cabinets which contained containers of undated and opened donuts and maple syrup. There was also an opened container of fruit with no name or date sitting on the sink. An interview with Licensed Practical Nurse (LPN) #3, on 01/30/19 at 10:35 AM, revealed the open donuts and syrup should have been thrown away. LPN #3 stated, the container of fruit was brought to her today by dietary for medication administration, but should have been labeled and dated. The facility policy titled Kitchenette, with a date of 01/05/17, was reviewed on 01/30/19 at 10:45 AM. The policy stated all food items must be labeled and dated with the resident's name. | 2020-09-01 |
| 3582 | 3582 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 868 | E | 0 | 1 | 61Y611 | Based on Quality Assurance and Assessment (QAA) quarterly attendance sheets and staff interview, the facility failed to ensure the (QAA) committee consisted of a Medical Director being in attendance for quarterly meetings. This was true for two (2) of the four (4) attendance sheets reviewed. This practice had the potential to affect more than a limited number of residents. Facility census: 77. Findings include: a) QAA quarterly attendance sheets On 01/30/19 at 11:55 AM, E#35, Licensed Social Worker (LSW) provided the QAA quarterly attendance sheets. The Medical Director was discovered to be in attendance on 02/22/18 and 12/28/18. On 01/30/19 at 12:20 PM, E#35 verified the Medical Director had only attended two (2) of four (4) QAA quarterly meetings. | 2020-09-01 |
| 3583 | 3583 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 880 | E | 0 | 1 | 61Y611 | Based on observation, staff interview, and policy review, the facility failed to provide a safe and sanitary environment that prevents the development and transmission of communicable diseases and infections. The soiled laundry room door was open, a nourishment room was accessible to all residents and oxygen tubing being used by residents was on the floor. These practices could potentially affect more than a limited number of residents. Resident identifiers: #11 and #50. Facility census: 77. Findings include: a) Resident #11 An observation on 01/30/19 at 8:15 AM, revealed Resident #11 receiving oxygen via nasal cannula. The tubing being used for the oxygen administration was on the floor. An interview with Licensed Practical Nurse (LPN) #3, on 01/30/19 at 8:20 AM, revealed the oxygen tubing should not be on the floor. LPN #3 immediately removed the tubing from the floor. b) Resident #50 An observation on 01/30/19 at 8:25 AM, revealed Resident #50 receiving oxygen via nasal cannula. The tubing being used for the oxygen administration was on the floor. An interview with LPN #3, on 01/30/19 at 8:30 AM, revealed the tubing should be kept off the floor and she removed the tubing off the floor. c) B Hallway Nutrition Pantry During random observations on 01/29/19, discovered the Nutrition Pantry on B Hallway located behind the nurses desk, had the door propped open allowing unauthorized staff to enter. At 2:15 PM a resident entered the Nutrition Pantry and removed milk from the refrigerator to put milk in her coffee, when finished with milk returned it to the refrigerator. At 2:22 PM a different resident entered the Nutrition Pantry and removed a diet soda from the pantry refrigerator. This practice allowed for unsanitary conditions. On 01/29/19 at 2:30 PM, the Director of Nursing (DON) verified residents enter the Nutrition Pantry. She agreed the Nutrition Pantry should only be accessible to authorized staff. d) Laundry An observation on 1/29/19, at 12:20 PM revealed the door was open to the soiled utility room. Five b… | 2020-09-01 |
| 3584 | 3584 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 883 | D | 0 | 1 | 61Y611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the vaccine administration packet and review of Centers for Disease Control (CDC) guidelines, the facility failed to provide pneumonia vaccines in accordance with CDC guidelines. This practice was found for two (2) of five (5) residents. reviewed during the survey. Resident identifiers: #21 and #38. Facility census: 77. Findings included: a) Resident #38 Medical record review for R#38 noted a pneumonia vaccine had been administered to the resident on 03/21/18. An interview with LPN #9, on 1/29/19, at 12:10 PM, revealed R#38 received the PPSV23 ([MEDICATION NAME]) when the resident should have received the PCV13 (Prevnar13). b) Resident #21 Medical record review for R#21 found a pneumonia vaccine had been administered to the resident on 03/22/18. An interview with LPN #104, on 1/29/19, at 12:10 PM, revealed that R#21 received the PPSV23 ([MEDICATION NAME]) when the resident should have received the PCV13 (Prevnar 13). A review of the facility's immunization packet and interview with LPN#9, on 1/29/19, at 12:10 PM, verified the facility would provide the pneumonia vaccine in accordance with CDC and physician recommendation. Review of the current CDC guidelines found that CDC recommends routine administration of pneumococcal conjugate vaccine (Prenvar 13) first , followed one year later with a dose of [MEDICATION NAME] 23. If the patient already received one (1) or more doses of of [MEDICATION NAME] 23, the Prevnar 13 should be given at least one (1) year after they received the most recent dose of [MEDICATION NAME] 23. In accordance with CDC recommendations for adults aged 65 and older, both Prevnar 13 and [MEDICATION NAME] 23 are recommended to protect against pneumococcal pneumonia and invasive pneumococcal disease. | 2020-09-01 |
| 3585 | 3585 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-01-30 | 921 | E | 0 | 1 | 61Y611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents. Resident rooms were found to have scratched walls, bent and broken blinds, cracked caulking, missing paint, and a leaking faucet. This was true for eight (8) of fifty (50) rooms inspected during the Long Term Care Survey Process (LTCSP). Room identifiers: A-Hall (room [ROOM NUMBER], #109, and #125) & B-Hall (room [ROOM NUMBER], #105, #109, #111, and #114). Facility census: 77. Findings include: a) A-Hall The following findings were observed on the A-Hall during the LTCSP survey on 01/28/19, 01/29/19, and 01/30/19: --room [ROOM NUMBER]-The window blind was bent and broken. --room [ROOM NUMBER]-The wall behind the beds had deep scratches in several places. --room [ROOM NUMBER]-The window blind was bent and broken. b) B-Hall The following findings were observed on the B-Hall during the LTCSP survey on 01/28/19, 01/29/19, and 01/30/19: --room [ROOM NUMBER]-The caulking around the sink was cracked. The bathroom wall was scraped. The bathroom floor was stained around the commode. The right side of wall upon entering the room was scraped in several places. --room [ROOM NUMBER]-The bathroom rail was scraped and loose. --room [ROOM NUMBER]-There was loose paint and caulking around the right side of the sink. --room [ROOM NUMBER]-The sink faucet was noted to be dripping and was unable to be turned off. The caulking around the toilet was cracked. --room [ROOM NUMBER]-The caulking was cracked around the sink. The vinyl floor was cut near the commode in the bathroom. An interview with the facility's Maintenance Supervisor (MS), on 01/30/19 at 9:30 AM, revealed rounds for resident rooms are done monthly. The MS stated some rooms are inspected more frequently based on need. The MS stated he would have the issues found during the LTCSP fixed by the end of the day. | 2020-09-01 |
| 3586 | 3586 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 550 | D | 0 | 1 | VTHQ11 | Based on observation and staff interview, the facility failed to ensure dignity during dining for one (1) of eighteen (18) residents reviewed during the long term care survey process. Resident identifier: #38. Facility census: 76. Findings included: a) Resident #38 Observation of the noon meal served on 02/23/20 at 12:17 PM, found Resident #38's roommate received a tray at approximately 12:19 PM. On 02/23/20 at 12:31 PM, Resident #38 received his tray. Licensed Practical Nurse, (LPN) #67, confirmed Resident #38 did not get tray at same time of roommate. LPN #67 said, Resident #38 has to be fed, we pass the trays to the ones who can feed themselves, then we come back and pass the trays to the residents who need help. | 2020-09-01 |
| 3587 | 3587 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 580 | D | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the resident's representative when a new form of treatment commenced. This was true for one (1) of 19 residents reviewed during the long term care survey. Resident identifier: #58. Facility census: 76. Findings included: a) Resident #58 Review of Resident #58's medical records revealed a nursing note written on 01/05/20 which stated, Noted small red area to right buttocks. The note also stated a dressing with [MEDICATION NAME] was started every day for three (3) days. There was no documentation the resident representative was notified. A nursing note written on 01/07/20 stated an open area was noted on the right buttock, measuring 1x1x0.1 cm, with reddish yellow center. An order was received for hydrogel and dressing daily. According to the nursing note, Resident #58's power of attorney was notified at this time. During an interview on 02/25/20 at 10:25 AM, Licensed Practical Nurse (LPN) #13 and the Director of Nursing (DON) were informed Resident #58's representative was not notified when a new form of treatment, a dressing to the resident's buttock, was started on 01/05/20. LPN #13 and the DON had no further information regarding the matter. | 2020-09-01 |
| 3588 | 3588 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 641 | D | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete each Minimum Data Set (MDS) to reflect the resident's status. This was true for three (3) of nineteen resident's reviewed. Resident identifiers: #76, #18 and #52. Facility Census: 76. Findings included: a) Resident #76 Review of Resident #76's medical records indicated a hospice consult was initiated on 01/30/20. On 01/31/20, Resident #76 was started on hospice with the admitting terminal [DIAGNOSES REDACTED].#76's prognosis for life expectancy was six (6) months or less if the terminal illness runs its normal course. Review of the significant change MDS with an assessment reference date (ARD) of 02/07/20, found Section J 1400 (Prognosis) was answered to indicate the resident had no terminal prognosis and under Section I (active diagnosis) Heart failure was not checked as a current diagnosis. An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/24/20 at 2:45 pm, confirmed the MDS with the ARD of 02/07/20 was inaccurate in the areas of prognosis and active diagnosis. b) Resident #18 Review of Resident #18's medical records found the resident uses bilateral one-half (1/2) side rails for turning and positioning. Resident #18 is unable to transfer herself, she requires the assistants of two (2) and the use of a Hoyer lift. Review of the admission MDS with an ARD of 12/01/19 found under section P the bilateral one-half siderails were coded as restraints. Interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/24/20 at 2:45 pm, found the MDS with the ARD of 12/01/19 was inaccurate in the area of restraints. c) Resident #52 A review of the medical record for Resident #52 on 02/24/20, revealed the last two (2) quarterly Minimum Data Set (MDS) assessments with ARDs of 10/11/19 and 01/11/20 were not coded accurately for the [DIAGNOSES REDACTED]. Further review of the [DIAGNOSES REDACTED].#5… | 2020-09-01 |
| 3589 | 3589 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 656 | D | 0 | 1 | VTHQ11 | Based on medical record review and staff interview, the facility failed to appropriately develop the comprehensive care plan in the area of Activities of Daily Living (ADLs) for one (1) of one (1) residents reviewed for the care area of Activities of Daily Living. Resident identifier: #53. Facility census: 76. Findings included: a) Resident #53 Resident #53's comprehensive care plan contained a focus related to self-care deficit. An intervention for this focus was May use Hoyer lift for transfers with staff assist x2. Another intervention for this focus was See ADL (activities of daily living) Kardex for assist required. Resident #53's comprehensive care plan also contained a focus related to being high risk for falls. An intervention for this focus was Requires staff assist x 2 using Hoyer lift for transfers bed to chair. Resident #53's ADL Kardex included for transfer help, Staff x 2 using Hoyer. During an interview on 02/25/20 at 10:25 AM, Licensed Practical Nurse (LPN) #13 and the Director of Nursing (DON) confirmed Resident #53 was always transferred with a Hoyer lift. LPN #13 and the DON were informed Resident #53's care plan contained an intervention for a Hoyer lift as needed. LPN #13 and the DON were informed this is not acceptable because a resident who has required a Hoyer lift cannot safely be transferred without the lift. No further information was provided through the completion of the survey. | 2020-09-01 |
| 3590 | 3590 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 684 | E | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that each residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true for two (2) of nineteen (19) residents reviewed. Resident identifiers: #176 and #26. Facility Census: 76. Findings include: a) Resident #176 Review of medical records for Resident #176, found the resident was re-admitted to the facility on [DATE] with an order for [REDACTED]. Meals are at 7 am, 12noon and 5 pm. Accuchecks are obtained four (4) times daily before meals and at night (6:30 am, 11:30 am, 4:30 pm and 9:00 pm). Review of the Medication Administration Record (MAR) for 01/17/20 through 01/24/20 found the [MEDICATION NAME] regular [MED] was given thirty (30) minutes prior to meals at 6:30 am, 11:30 am and 4:30 pm instead of with meals as directed by the physician order. Interview with the Director of Nursing (DON) on 02/24/20 at 3pm, found the [MED] was not administered as directed by the physician. No further information provided. b) Resident #26 A review of the medical record for Resident #26 on 02/25/20, revealed the accucheck for blood sugars had not been completed on 0[DATE]. The Medication Administration Record (MAR) did not record Resident #26 as receiving any testing for her blood sugars on 0[DATE]. Further review revealed a physician's orders [REDACTED]. An interview with Licensed Practical Nurse (LPN) #87 on 02/25/20 at 8:48 AM, verified there was no evidence documented on the MAR or in the Nursing Progress notes that a blood sugar was completed on 0[DATE] as ordered by the physician. | 2020-09-01 |
| 3591 | 3591 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 695 | E | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure residents who need respiratory care, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals. Cautionary and safety signs, indicating the use of oxygen, were not present for Resident's #23, #3, and #48. For Resident #23 there was no evidence the [MEDICAL CONDITION] (Bi-level Positive Airway Pressure), machine was consistently used or offered daily per physician orders. In addition, Resident #48's oxygen was not set at the prescribed flow rate. This was true for three (3) of three (3) residents reviewed for respiratory care. Resident identifiers: #23, #3, and #48. Facility census: 76. Findings included: a) Resident #23 Review of the current physician's orders [REDACTED]. [MEDICAL CONDITION] is a non-invasive ventilation machine that is capable of generating two adjustable pressure levels - Inspiratory Positive Airway Pressure (IPAP) - high amount of pressure, applied when the patient inhales and a low Expiratory Positive Airway Pressure (EPAP) during exhalation. Review of the treatment administration record (TAR) and Medication Administration Record [REDACTED]. The TAR's included orders for weekly cleaning of the [MEDICAL CONDITION] machine and daily cleaning the [MEDICAL CONDITION] mask but no orders for daily use of the [MEDICAL CONDITION] machine. On 02/24/20 at 8:33 AM, the Director of Nursing (DON) reviewed the January and February TAR and MAR, and confirmed there was no order for daily use of the [MEDICAL CONDITION] machine. The DON reviewed the December 2019 TAR and found daily documentation the [MEDICAL CONDITION] was in use. The DON said the order to use the [MEDICAL CONDITION] machine daily did not get transcribed to the January 2020 and February 2020 TAR. The DON said the nurses' notes say the [MEDICAL CONDITION] machine was used daily. Review of the nursing not… | 2020-09-01 |
| 3592 | 3592 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 727 | F | 0 | 1 | VTHQ11 | Based on record review and staff interview, the facility failed to ensure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This was true for two (2) days reviewed for the week of 0[DATE] through 02/29/20. Facility Census: 76. Findings included: Review of the schedule, assignment sheets, staff postings and time cards for the period of 0[DATE] through 02/29/20, found on 0[DATE] and 02/23/20, the facility failed to have a registered nurse (RN) for eight (8) consecutive hours for each day. Interview with the Director of Nursing on 02/25/20 at 2:15 pm, confirmed the RN did clock out and was not in the building for eight (8) consecutive hours on 0[DATE] and 02/23/20. | 2020-09-01 |
| 3593 | 3593 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 755 | E | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an adequate system was in place for the tracking and control of controlled substances, which were received, stored at, and administered by the facility. The facility failed to identify the risk of diversion for high abuse medications. This failure had the potential to affect any resident who had controlled substances sent to, stored at, or administered by the facility. Facility Census: 76. Findings included: a) Controlled Medication Count/ Reconciliation During observation of medication administration on 02/25/20 at 8:15 am, Resident #13 was administered [MEDICATION NAME] 0.5 milligrams (mg) from the locked box on the medication cart. Resident #50 was administered [MEDICATION NAME] 5 mg from a locked box in the medication room by Employee #87, a Licensed Practical Nurse (LPN). Employee #87 failed to sign either medication out on the Individual Resident's Controlled Substance Record. Interview of Employee #87, on 02/25/20 at 9:00 am, found the facility has the Individual Resident's Controlled Substance Record in a separate notebook at the nurses' station. A periodical count was performed on these sheets, but no indication the controlled medications were accurately counted on each shift. There is no system to know how many resident's received controlled medications. An interview with the Director of Nursing (DON) on 02/26/20, found the facility was unsure of the exact count of residents receiving controlled medications and no evidence could be located to indicate the nurses did a narcotic count at the beginning and ending of their shifts to determine if a discrepancy/diversion occurred. Immediate action was taken to count the cards of each resident receiving narcotic (controlled) medication and a system to count before and after each shift was put into place. | 2020-09-01 |
| 3594 | 3594 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 756 | D | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and staff interview, the physician failed, after a pharmacy recommendation, to document the rational for continuing an antidepressant medication. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #38. Facility census: 76. Findings included: a) Resident #38 Medical record review found the resident is receiving [MEDICATION NAME], 10 milligram tablets, by mouth, daily for a [DIAGNOSES REDACTED]. On 08/26/19, the pharmacist reviewed the residents medication and recommended: Resident is currently on [MEDICATION NAME], 10 mg QD (daily) - Depression. This medication is due for review according to C[CONDITION] (Centers for Medicare / Medicaid Services) The physician signed the pharmacy review but did not provide the date of the signature. In addition, the physician failed to document the reason for continuation of the medication. On 02/24/20 at 11:44 AM, the Director of Nursing (DON) confirmed the physician did not provide a date the pharmacy recommendation was reviewed. In addition, the physician failed to provide a rational for the continued use of the antidepressant. Review of the behavior monitoring sheets, with the DON, for the months of August 2019 through February 2020 found no documentation of any behaviors indicating the resident was depressed. | 2020-09-01 |
| 3595 | 3595 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 757 | D | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications for one (1) of five (5) residents reviewed for medication pass. Resident identifier: #326. Facility census: 76. Findings included: a) Resident #326 Resident #327's Medication Administration Record (MAR) was reviewed after his medication pass was observed. Resident #327 was noted to have the following medication orders written on 02/12/20: - [MEDICATION NAME] 10 mg orally twice a day for hypertension, hold for systolic blood pressure less than 100 - [MEDICATION NAME] 50 mg every day, hold for systolic blood pressure less than 110 or pulse less than [AGE] He also had an order for [REDACTED]. Review of Resident #327 s Medication Administration Record (MAR) demonstrated he had received [MEDICATION NAME] every day at 9:00 AM and 9:00 PM. He had also received [MEDICATION NAME] every day at 9:00 AM. The resident's blood pressure and pulse measurements were not documented on the MAR. Additionally, the resident's blood pressure and pulse readings were not documented on the vital signs sheet. On 02/24/20 at 10:30 AM, the Director of Nursing (DON) stated blood pressure and pulse measurements for Resident #327 were recorded in the progress notes. Review of Resident #327's progress notes revealed blood pressure and pulse measurements had been recorded twice daily in the progress notes. On 0[DATE] at 8:00 AM, Resident #327's blood pressure was recorded as 98/[AGE]. Review of Resident #327's MAR documented he had received both [MEDICATION NAME] and [MEDICATION NAME] at 9:00 AM on 0[DATE]. On 02/24/20 at 10:45 AM, the Director of Nursing acknowledged Resident #327's blood pressure on the morning of 0[DATE] was below the parameters for which he should have received [MEDICATION NAME] and [MEDICATION NAME] administration. | 2020-09-01 |
| 3596 | 3596 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 812 | E | 0 | 1 | VTHQ11 | Based on observation, refrigerator temperature log review and staff interview the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items in both the refrigerator and freezer areas, store items in a tightly sealed container and properly log refrigerator temperatures. The failed practice had the potential to affect more than a limited number of residents. Facility census: 76. Findings included: A policy review titled, Food Safety Requirements with no revised date noted, on 02/24/20 at 1:00 PM, revealed, Food will be stored, prepared and served in accordance with professional standards for food service safety. Refrigerator storage- Labeling, dating and monitoring food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded. Keeping food covered or in tight containers. a) Initial Tour An observation during initial tour, on 02/23/20 at 10:35 AM, revealed an incomplete refrigerator temperature log located near door of the walk-in refrigerator. An interview with Assistant Kitchen Supervisor (AKS) #11, on 02/23/20 at 10:40 AM, confirmed on 0[DATE] and 02/23/20 refrigerator temperatures were not completed. AKS #11 stated that she would have expected that the dates of 0[DATE] and 02/23/20 to be completed by now. An observation in the refrigerator, on 02/23/20 at 10:45 AM revealed the following sanitation concerns: - One (1) pack of approximately 50 hotdog's were opened and not labeled or dated - Four (4) individual Dairy Pure low fat milk cartons laying on the floor of the refrigerator - A plastic bag that contained three (3) blocks of white American Cheese was not properly sealed and had no label or date. - A plastic bag that contained two (2) blocks of yellow American Cheese did not have a legible date. An immediate interview with AKS #11, on 02/23/20 at 10:45 AM, confirmed the hotdogs should have been labeled and dated, the white American Cheese should have been sealed tig… | 2020-09-01 |
| 3597 | 3597 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 842 | E | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure and maintain medical records on each resident that were complete and accurate. This had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #55, #13, #50 and # 376. Facility Census: 76. Findings include: a) Medication Observation and Record Review Medication observation completed on 02/25/20 with Employee # 87, an Licensed Practical Nurse (LPN), found medication was administered to Residents #55, #13 and #50. Review of Medication Administration Records (MAR) and Physician order [REDACTED]. 1) Resident #55's MAR indicated [REDACTED]. [MEDICATION NAME] dose was marked through and new dosage was inserted with no explanation. Further review found the [MEDICATION NAME] dosage had been changed on 10/28/19. Review of the physician orders [REDACTED]. Some of the writing was illegible. 2) Resident #13's MAR indicated [REDACTED]. Review of the physician orders [REDACTED]. Some of the writing was illegible. 3) Resident #50's MAR indicated [REDACTED]. Review of the physician orders [REDACTED]. Some of the writing was illegible During an Interview with the Director of Nursing (DON) on 02/26/20 at 9:00 am, she agreed the physician orders [REDACTED].#55, #13 and #50's did not match with times and dosages and was unable to determine who or when the changes had been made. She also agreed some were illegible. B) Resident #376 Review of Resident #376's medical records revealed an order written [REDACTED]. The administration parameters, or the blood pressure reading that would require the medication, were not specified. Resident #376's Medication Administration Record [REDACTED]. The medication had not been administered since the medication was ordered. On 02/24/20 at 10:17 AM, the Director of Nursing (DON) was informed Resident #376's as needed [MEDICATION NAME] order did not specify the parameters for admini… | 2020-09-01 |
| 3598 | 3598 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 880 | D | 0 | 1 | VTHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Hand hygiene was not performed between medication administration. Additionally, a resident's medication capsule was touched with bare hands. This was a random opportunity for discovery during the facility of task of medication administration. Also, one (1) of three (3) residents reviewed for the care area of oxygen did not have the [MEDICAL CONDITION] mask and tubing properly stored in a sanitary manner. Resident identifiers: #62, and #23. Facility census: 76. Findings included: a) Medication administration On 02/24/20 at 8:17 AM, medication administration by Licensed Practical Nurse (LPN) #67 was observed. LPN #67 prepared medications for Resident #326 from the medication cart. He then entered the resident's room and administered the medications to the resident. LPN #67 then returned to the medication cart and began preparing the medications for Resident #62. He did not perform hand hygiene between administering medications to Resident #326 and preparing medications for Resident #62. Preparing Resident #62's medications included puncturing the resident's vitamin D capsule so the medication could be squeezed into her mouth. LPN #67 touched the capsule with his bare hands to puncture the tablet. LPN #67 also did not perform hand hygiene before entering Resident #62's room and administering medications to her. On 02/24/20 at 8:45 AM, LPN #67 was informed he did not perform hand hygiene between administering medications to Resident #326 and preparing and administering medications to Resident #62. LPN #67 stated there was hand sanitizer located in the hallway he could use for hand hygiene during medication pass. On 02/24/20 at 8:56 AM, the Director of Nursing was notified of the situation, and sh… | 2020-09-01 |
| 3599 | 3599 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2020-02-26 | 883 | D | 0 | 1 | VTHQ11 | Based on medical record review and staff interview, the facility failed to document screening to assess for potential medical contraindications for influenza vaccination administration for one (1) of five (5) residents reviewed for the care area of vaccinations. Resident identifier: #41. Facility census: 76. Findings included: a) Resident #41 Review of Resident #41's medical records revealed on 09/27/19 the resident's representative consented for the resident to receive influenza (flu) vaccination by signing a Vaccine Consent and Administration Record form. The form included screening questions to assess for potential medical contraindications for receiving the vaccination. None of these questions had been answered. During an interview on 02/25/20 at 3:27 PM, Licensed Practical Nurse (LPN) #20 was informed Resident #41's vaccination consent signed by the resident's representative on 09/27/19 was incomplete because the screening questions to assess for potential medical contraindications for receiving the vaccination were not completed. LPN #20 had no additional information regarding the matter. No additional information was provided through the completion of the survey. | 2020-09-01 |
| 3600 | 3600 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-03-15 | 639 | D | 1 | 0 | YGIL11 | > Based on review of the Minimum Data Set (MDS) and staff interview, the admission MDS completed on 02/07/19 was not available in the active medical record for readily and easy accessibility for staff or for review by the survey team. This was true for one (1) of five (5) residents MDSs that were reviewed. Resident identifier: #65. Facility census: 73. Findings included: a) Resident #65 A review of the medical record on 03/14/19 at 11:30 AM found no MDS with an Assessment Reference Date (ARD) of 02/07/19 for Resident #65. The facility stored all MDSs at the nurses station. No admission assessment MDS was found for Resident #65. A request was made to print the MDS. An interview with Licensed Practical Nurse (LPN #46) and the MDS Coordinator on 04/14/19 at 1:00 PM were in agreement the printed copy of the admission MDS had not been placed in the residents medical record and was only available in electronic form which was not accessible to the nursing staff. | 2020-09-01 |
| 3601 | 3601 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-03-15 | 684 | G | 1 | 0 | YGIL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interviews, hospital emergency room records, and the facility's hydration policy, the facility failed to provide treatment and care in accordance with professional standards of practice. Resident #72 had a change in condition related to her fluid intake for five (5) days and bladder incontinent for four (4) days. The facility staff did not notify the physician. On 02/19/19 Resident #72 had a temperature of 102.7 Axillary (AX). Resident #72 was then sent to the emergency room to be treated. This deficiency practice caused harm. Resident Identifier #72. Facility census 73. Findings included: a) Resident #72 A review of the nutritional assessment completed on 01/14/19, finds the Certified Dietary Manager (CDM) estimated Resident #72's fluid needs to be 1378 milliliters (ML) on 01/14/19. A review of the Registered Licensed Dietician (RLD)#88 dietary progress note on 01/04/19, revealed that Resident #72's average documented fluid intake is 1,173 ML times three (3) days. The NA document Resident #72's fluid intake on the Nurse Aide Monthly Record (NAMR). Below is what the NA documented Resident #72's fluid intake in ML from 02/01/19- 02/14/19. 02/01/19 =560 ML but if you add what was given on this day it equals =1560 02/02/19 =1520 ML 02/03/19 =1620 ML 02/04/19 =1520 ML 02/05/19 =1500 ML 02/06/19 =1520 ML 02/07/19 =1620 ML 02/08/19 =1920 ML 02/09/19 =off, but what fluid intake for the whole day = 820 02/10/19 =1640 ML 02/11/19 =1620 ML 02/12/19 =1600 ML 02/13/19 =1600 ML 02/14/19 =1760 ML Below is Resident #72's fluid intake in ML below the NA documented from 02/15/19 - 02/19/19. 02/15/19 = 1080 ML 02/16/19 = 1220 ML 02/17/19 = 740 ML 02/18/19 = 760 ML 02/19/19 = 570 ML A review of the NAMR finds Resident #72 was continent (the individual has control of their bladder) from 02/01/19- 02/15/19. On 02/16/19 the resident had a change in her condition related to her ability to control her bladder. Below is what th… | 2020-09-01 |
| 3602 | 3602 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-03-15 | 732 | C | 1 | 0 | YGIL11 | > Based on observation, staff interviews the facility failed to post the nurse staffing data on a daily basis at the beginning each shift. This had the potential to affect a minimum number of resident and visitors. Facility census 73. Findings included: a) Nurse Staff Posting Observation with Licensed Practical Nurse (LPN) #13 on 03/11/19 at 9:05 AM, revealed no staff posting for 03/11/19. The nurse staff posting that was in the clear plastic contain had the date of 03/08/19. The Nurse said probably someone is filling out the posting form. The Nurse was asked what time you come to work she said 7 AM. LPN #13 said no one has filled out the form as of yet. Observed the Director of Nursing (DON #18 on 03/11/19 at 9:15 AM, filling out the staff posting form at her desk in her office. The DON acknowledge the nurse staff posting had not been posted since 03/08/19. | 2020-09-01 |
| 3603 | 3603 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-03-15 | 842 | D | 1 | 0 | YGIL11 | > Based on record review and staff interview, the facility failed to complete an accurate medical record. The Nurse Aide Monthly Report (NAMR) was not legible to read. This had the potential to affect a limited number of residents. Resident Identifier #72. Facility census 72. Finding included: a) Resident #72 A review of Resident #72's NAMR record for (MONTH) 2019, shows writing that is not legible. -- Bladder incontinent episodes 02/09/19 on the 3:00 PM - 11:00 PM shift crossing out multiple times. -- Bladder incontinent episodes on 02/16/19 on 7:00 AM - 3:00 PM shift has a zero (0), and then a x mark and beside it is a three (3). -- Bladder incontinent on 02/19/19 on the 7:00 AM - 3:00 PM shift is a two (2) with a one (1) over top of the two (2). -- Bladder incontinent episodes on 02/16/19 on 3:00 PM - 11:00 PM shift is a zero with a three (3) over top of the 0. -- Bladder continent episodes on 02/06/19 the 7:00 AM - 3:00 PM shift is crossed out and then a two (2). -- Bladder continent episodes on 02/09/19 on the 3:00 PM - 11:00 PM shift is crossed out multiple times, and then a three (3) is written. -- Bowel incontinent episodes on 02/09/19 on the 3:00 PM - 11:00 PM shift is not legible. Unable to tell what was written. -- Bowel incontinent episodes on 02/10/19 on the 11:00 PM - 7:00 AM shift has a zero (0) and then a one (1) over top of the 0. -- Percentage of meal consumed on 02/12/19 for the Supper meal is not legible. Unable to tell what was written. -- On 02/ 16/19 from 7:00 AM - 3:00 PM, bowel movement (BM) record on the 02/16/19 has scribbles for none. -- On 02/21/19 from 3:00 AM - 11:00 PM bowel record is not legible. Resident #72 was not in the nursing home on this date. In an interview on 03/14/19 at 10:00 AM with Licensed Practical Nurse (LPN ) # 46, was shown the NAMR form for (MONTH) 2019 and she acknowledge the Nurse Aide (NA) have been crossing out, scribbling on the NAMR. LPN #46 stated that, the NA need to educated on the proper way to mark out their errors. | 2020-09-01 |
| 3604 | 3604 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 600 | G | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure residents are free from physical and verbal abuse of any type by other residents. The facility's failure to provide effective interventions, including physical environmental interventions, and adequate monitoring of residents with known verbal, physical, and sexual behaviors, resulted in actual harm to Resident's #61 and #73, who voiced being afraid and scared of other residents. Resident #84 repeatedly displayed verbal and physical aggression toward other residents. The interdisciplinary teams' failure to address the ineffectiveness of the current care plan interventions put the other residents at risk for abuse. These findings caused mental anguish to Residents #61 and #73 and had the potential to affect other residents residing in the facility. Resident identifiers: #61, #73, and #84. Facility census: 87. Findings include: a) Resident #61 1. On 12/06/17 at 11:50 a.m., a conversation at the Nurses' station between Resident #61 and the Activities Director #30 was overheard. Resident #61 reported to the Activities Director, That man (first name of resident later identified as Resident #6) comes in my room all the time and steals things from me. He is a tall thin man who scares me takes my glasses and shoes. I chased him out. The Activities Director #30 responded, Well good. During an interview with Resident #61 on 12/06/17 at 11:56 a.m., she stated, (Resident #6) comes into my room all the time, just walks in even when I am sleeping which is scary. He will take things like my glasses and my shoes. He scares me because he just comes in and he has hit people before I am afraid he will hit me too. Upon inquiry if staff had been notified, Resident #61 stated, I tell them all the time but they tell me nothing can be done to keep him out of my room. They have come in and taken him out of my room before, but that's all they do. Her r… | 2020-09-01 |
| 3605 | 3605 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 607 | G | 0 | 1 | HHMR11 | Based on medical record review, resident interview, staff interview, and policy review, the facility failed to implement its policies to ensure residents are free from physical and verbal abuse of any type by other residents. Resident's #61 and #73, voiced occurrences causing them to be afraid of certain residents. Resident #84 repeatedly displayed verbal and physical aggression towards other residents. The facility failed to implement its policies and ensure staff compliance with those policies. Resident identifiers: #61, #73, #6, #20, and #84. Facility census: 87. Findings include: a) Resident #61 On 12/06/17 at 11:50 a.m., Resident #61 was overheard telling Activities Director #30, That man (first name of resident later identified as Resident #6) comes in my room all the time and steals things from me. He is a tall thin man who scares me takes my glasses and shoes. I chased him out. The Activities Director #30 responded, Well good. During an interview with Resident #61 on 12/06/17 at 11:56 a.m., she stated, (Resident #6) comes into my room all the time, just walks in even when I am sleeping which is scary. He will take things like my glasses and my shoes. He scares me because he just comes in and he has hit people before I am afraid he will hit me too. Upon inquiry if staff had been notified, Resident #61 stated, I tell them all the time but they tell me nothing can be done to keep him out of my room. They have come in and taken him out of my room before but that's all they do. Her roommate Resident #56 confirmed Resident #6 comes into their room sometimes. A medical record review on 12/06/17 at 12:09 p.m., revealed Resident # 61's Brief Interview for Mental Status (BIMS) for her 10/03/17 Minimum Data Set assessment was 15, indicating she is cognitively intact. At 12:25 p.m. on 12/06/17, upon inquiry regarding the overheard conversation during an interview the Activities Director #30 reported, She (Resident #61) always says a man is coming in her room. It is because of her history of seeing a tall thin man com… | 2020-09-01 |
| 3606 | 3606 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 609 | E | 0 | 1 | HHMR11 | Based on medical record review, resident interview, staff interview, and policy review, the facility failed to report allegations of abuse to the appropriate State agencies. Resident's #61 and #73, voiced occurrences causing them to be afraid of certain other residents. Resident #84 repeatedly displayed verbal and physical aggression towards other residents. Not reports were found for Resident #61, #73, or any residents affected by the behaviors of Residents #84, #6, or #20. This had the potential to affect more than a limited number of residents. Resident identifiers: #61, #73, #6, #20, and #84. Facility census: 87. Findings include: a) Resident #61 On 12/06/17 at 11:50 a.m., Resident #61 was overheard telling Activities Director #30, That man (first name of resident later identified as Resident #6) comes in my room all the time and steals things from me. He is a tall thin man who scares me, takes my glasses and shoes. I chased him out. The Activities Director #30 responded, Well good. During an interview with Resident #61 on 12/06/17 at 11:56 a.m., she stated, (Resident #6) comes into my room all the time, just walks in even when I am sleeping which is scary. He will take things like my glasses and my shoes. He scares me because he just comes in and he has hit people before. I am afraid he will hit me too. Upon inquiry if staff had been notified, Resident #61 stated, I tell them all the time but they tell me nothing can be done to keep him out of my room. They have come in and taken him out of my room before but that's all they do. Her roommate Resident #56 confirmed Resident #6 comes into their room sometimes. A medical record review on 12/06/17 at 12:09 p.m. revealed Resident # 61's Brief Interview for Mental Status (BIMS) for her 10/03/17 Minimum Data Set assessment was 15, indicating she is cognitively intact. At 12:25 p.m. on 12/06/17, upon inquiry regarding the overheard conversation during an interview, the Activities Director #30 reported, She (Resident #61) always says a man is coming in her room. It i… | 2020-09-01 |
| 3607 | 3607 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 656 | D | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to develop and implement comprehensive person-centered care plans with measurable objectives for Residents #84 and #73. Resident #84's care plan did not identify meaningful activities related to his interests and preferences, lacked individualized goals for his expressions of distress, and failed to identify specific approaches for staff to utilize in response to his behaviors. Resident #73's care plan inaccurately reflected the monitoring of an arterial-venous fistula. This was found for three (3) of eighteen (18) residents reviewed. Resident identifiers: #84 and #73. Facility census: 87. Findings include: a) Resident #84 Review of the resident's medical record, on 12/05/17 at 9:00 a.m., revealed Resident #84 was admitted to the facility with no history of behaviors. The Minimum Data Set (MDS) comprehensive assessment with an assessment reference date (ARD) of 01/23/17, noted the resident had a Brief Interview Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. He was noted to wander daily and the MDS identified his wandering put him at a significant risk of getting into a potentially dangerous place. His [DIAGNOSES REDACTED]. He was not prescribed any medications and did not receive any psychological therapies by licensed mental health professionals. The quarterly MDS, with an ARD of 10/23/17, noted Resident #84's BIMS score declined to 4, indicating severe cognitive impairment. Resident #84 was evaluated at the mental health clinic on 02/09/17. The target symptoms were noted to be behavioral symptoms of dementia with a goal to, Improve agitation without hospitalization s. The physician's note stated, Per chart review has been placed at (Name) and had a fall yesterday. Staff was confused regarding appointments and he was fit in for a visit today. Has had 2 falls per staff .Unsure of his appetite or sleeping at night, but he does na… | 2020-09-01 |
| 3608 | 3608 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 684 | D | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, contract review, and staff interview, the facility failed to ensure a resident received Hospice care and treatment in accordance with professional standards of practice. Resident #237's record lacked documentation of Hospice nursing visits after 11/13/17. The facility did not have a contract outlining services and treatment to be provided by Hospice Services which included an agreement between the resident and/or resident representative. In addition, the Hospice care plan did not reflect Resident #237's change in residence from her home to admission to the facility. This practice was found for one (1) of one (1) resident reviewed for hospice during the Long-Term Care Survey Process (LTCSP). Resident identifier: #237. Facility census: 87. Findings include: a) Resident #237 A medical record review on 12/06/17 at 8:04 a.m. revealed Resident #237 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was admitted to Hospice Services on 10/31/17 at her residence prior to her admission. According to documentation in the medical record, Resident #237 was seen by Hospice services on 11/08/17 and 11/13/17. No further evidence of hospice visits was found as of 12/06/17. The Hospice care plan dated 10/31/17 (showing her home address as the place of Hospice services) noted Skilled Nursing visits two (2) times a week for fourteen (14) weeks and ten (10) prn (as needed) visits. The medical record lacked a care plan developed upon her admission to the facility which should have included services, treatment, nursing visits, and interventions while in the facility. In addition, the record lacked a Hospice agreement between the Hospice company and the Resident and/or Resident representative. Review of the Hospice Services contract on 12/06/17 at 9:05 a.m. revealed the following (typed as written): under the title Agreement .3. C. Care Plans: Specific to the Hospice patient and upon admission to Home, Hospice will … | 2020-09-01 |
| 3609 | 3609 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 740 | D | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide the necessary behavioral health care and services and/or treatment to attain or maintain the highest practicable mental and psychosocial well-being for Resident #84. The interdisciplinary team approach to care failed to provide individualized behavioral health services to assist the resident in understanding, preventing, relieving, and/or accommodating any distress he might demonstrate with the loss of his abilities. Psychiatric recommendations were not followed and additional psychiatric appointments were not made when behaviors escalated. No plans were in place to address his increase in behaviors during the evening and nights. Diversional activities included food and drinks, toileting and one on one care and were not based on the resident's preferences and/or history. This practice had the potential to cause harm to the resident and potential to cause harm and affect to all residents and staff. Resident identifier: #84. Facility census: 87. Findings include: a) Resident #84 Review of the resident's medical record, on 12/05/17 at 9:00 a.m., revealed Resident #84 was admitted to the facility with no history of behaviors. The Minimum Data Set (MDS) comprehensive assessment with an assessment reference date (ARD) of 01/23/17, noted the resident had a Brief Interview Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. He was noted to wander daily and the MDS identified his wandering put him at a significant risk of getting into a potentially dangerous place. His [DIAGNOSES REDACTED]. He was not prescribed any medications and did not receive any psychological therapies by licensed mental health professionals. The quarterly MDS, with an ARD 10/23/17, again noted Resident #84 did not receive any psychological therapies by licensed mental health professionals. In addition, his BIMS score had declined to 4, indicating severe cogni… | 2020-09-01 |
| 3610 | 3610 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 742 | D | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and staff interview, the facility failed to ensure a resident who displays psychosocial adjustment difficulty receives the appropriate person-centered treatment and services to correct the assessed problem. Resident #84's behaviors towards self and others were not addressed. Individualized care plans were not developed to address the resident's' assessed emotional and psychosocial needs. Goals that were established were not stated in measurable terms to enable determination of the effectiveness of interventions, and interventions did not provide guidance to the direct care giver. This was found for one (1) of two (2) residents reviewed for behaviors and had the potential to affect more than a limited number of residents. Resident identifier: #84. Facility census: 87. Findings include: a) Resident #84 Review of the medical record on 12/05/17 at 9:00 a.m., revealed Resident #84 was admitted to the facility in (MONTH) (YEAR). The Minimum Data Set (MDS) comprehensive assessment with an assessment reference date (ARD) of 01/23/17, noted the resident had a Brief Interview Mental Status (BIMS) of 10, indicating moderately impaired mental function. He was assessed to wander daily and that his wandering put him at a significant risk of getting into a potentially dangerous place. His [DIAGNOSES REDACTED]. He was not prescribed any medications and did not receive any psychological therapies by licensed mental health professionals. The quarterly MDS with an ARD 10/23/17 again noted Resident #84 did not receive any psychological therapies by licensed mental health professionals. In addition, his BIMS score declined to 4 indicating severe cognitive impairment. Resident #84 was evaluated at the mental health clinic on 02/09/17. The target symptoms were noted to be behavioral symptoms of dementia with a goal to improve agitation without hospitalization s. The physician's note stated, Per chart review has been place… | 2020-09-01 |
| 3611 | 3611 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 744 | D | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement individualized interventions to address a resident's behavioral care needs. An individualized care plan was not developed to address the emotional and physical needs of Resident #84. Psychiatric recommendations were not followed and additional psychiatric appointments were not obtained when behaviors changed. This practice had the potential to cause harm to the resident and to more than a limited number of residents and staff. Resident identifier: #84. Facility census: 87. Findings include: a) Resident #84 The resident's Minimum Data Set (MDS) comprehensive assessment with an assessment reference date (ARD) of 01/23/17, noted the resident wandered daily and that his wandering put him at a significant risk of getting into a potentially dangerous place. His [DIAGNOSES REDACTED]. He was not prescribed any medications and did not receive any psychological therapies by licensed mental health professionals. Resident #84 was evaluated at the mental health clinic on 02/09/17. The target symptoms were noted to be behavioral symptoms of dementia with a goal to improve agitation without hospitalization s. The physician note states: Per chart review has been placed at (Name) and had a fall yesterday. Staff was confused regarding appointments and he was fit in for a visit today. Has had 2 falls per staff .Unsure of his appetite or sleeping at night, but he does nap some during the days. He often is trying to leave or looking for his vehicle. Having more difficulty in afternoon/evening .Notes reviewed and significant for periods of confusion. He receives [MEDICATION NAME] from time to time for agitation. Recommendation included starting a trial of [MEDICATION NAME] (antidepressant) 25 milligrams (mg) every evening for behavioral symptoms of dementia and avoid [MEDICATION NAME] as able since it is likely to increase his fall risk. Follow up in 4 months or sooner if problems arise. … | 2020-09-01 |
| 3612 | 3612 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 755 | E | 0 | 1 | HHMR11 | Based on review of narcotic reconciliation sheets, policy and procedure review, and staff interview, the facility failed to maintain drug records that periodically reconciled all controlled drugs. The controlled drugs were not reconciled every shift on the Hall A medication cart. This was true for one (1) of two (2) medication carts. Resident census: 87. Findings include: a) On 12/07/17 at 1:00 p.m., a review of the narcotic reconciliation sheets on the medication cart on Hall A revealed on 11/26/17 at 7:00 a.m., there was no signature of the oncoming nurse. On 11/27/17 at 7:00 p.m. there was no signature of the off going nurse. The facility's policy and procedure Checking narcotics, reviewed on 12/07/17 at 1:32 p.m., included, All narcotics must be checked before the change of each shift . In an interview with Registered Nurse (RN) #77 on 12/07/17 at 1:46 p.m., she agreed the narcotic drugs had not been reconciled on the 26th and 27th of (MONTH) (YEAR). | 2020-09-01 |
| 3613 | 3613 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 756 | E | 0 | 1 | HHMR11 | Based upon record review and staff interview, the facility failed to develop a policy and procedure for Medication Regimen Review (MRR) that gave all specific time frames and expectations for communication of urgent concerns and for timeliness of physician's responses. This had the potential to affect all residents. Facility census: 87. Findings include: a) The facility's policies for Medication Regimen Review were reviewed on 12/7/17 at 8:30 a.m. They were dated 11/2011. There was no specificity regarding urgent recommendations or specific time frames for all the different steps in the process including physician responses. There was a statement regarding urgent communication under section B saying in the event of a problem requiring immediate attention, the physician would be contacted by the consultant pharmacist or the facility. There was also a statement under section H that said When pharmacist is reviewing resident chart and notice that a medication need to be change immediately he will inform the nurse . These two sections did not reflect consistent procedure. During an interview with Director of Nursing #8 on 12/7/17 at 9:40 a.m., she expressed understanding the policy related to MRR was dated 2011, and did not contain the aforementioned detail. A telephone conversation was conducted with Pharmacy Representative #102, for the company contracted by the facility on 12/7/17 at 9:50 a.m. He said the company was finalizing the new policy to reflect the new regulations which was anticipated to be released in (MONTH) (YEAR). | 2020-09-01 |
| 3614 | 3614 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 761 | D | 0 | 1 | HHMR11 | Based on observation and staff interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments. During a medication administration observation, medications were not kept under the direct observation of the person administering the medications or locked in the medication storage area/cart. This practice had the potential to affect more than an isolated number of residents. Facility census: 87. Findings include: a) Medication administration observation On 12/05/17 at 9:15 a.m., upon approaching Registered Nurse (RN) #42 to observe medication administration, there was a medication cup containing two (2) tablets on top of medication cart. The medication cup containing the tablets remained unsecured and out of the nurse's line of sight, on top of the medication cart which was left on the opposite side of the hallway during the medication administration for two (2) different residents. After completing the second medication administration for a resident and returning to the medication cart at 9:40 a.m., RN #42 proceeded to place the medication cup containing the two (2) tablets in the top drawer of the medication cart and locked the cart. Immediately following this observation, during an interview with RN #42, she agreed the medication cup had remained atop the medication cart unsecured and out of the nurse's sight. RN #42 stated, They (the medications) should have been locked in the medication cart in case a resident would pick them up. Since I could not always see the cart that certainly could have happened. I was nervous and wasn't thinking. | 2020-09-01 |
| 3615 | 3615 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 814 | F | 0 | 1 | HHMR11 | Based on observation and interview, the facility failed dispose of garbage and refuse properly. Refuse was overflowing and lids were un secured. This had the potential to affect all residents. Census: 87. Findings included: a) At 12/05/17 on 02:15 PM, observations of the dietary areas accompanied by Employee #48, found the dumpsters lids were open with garbage bags protruding above the dumpster opening. Another dumpster was full of cardboard boxes. The lids of the dumpsters were not closed. Employee #48 acknowledged the dumpster lids were not closed due to garbage bags being higher than the dumpster sides. Employee #48 did not believe the kitchen was responsible for the dumpster filled with cardboard, however after speaking with the maintenance supervisor and the assistant administrator following this observation, it was found that the kitchen was responsible for both dumpsters. | 2020-09-01 |
| 3616 | 3616 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 835 | F | 0 | 1 | HHMR11 | Based upon record review, policy review, and staff interview, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility did not have a Medication Regimen Review policy in place that gave specific instruction regarding urgent recommendations or specific time frames for all the different steps in the process including physician responses. The facility was not providing all aspects of an influenza immunization program as required. These deficient practices had the potential to affect all residents. Facility census: 87 Findings include: a) Deficient practice was cited during the survey for failure to develop an adequate policy and procedure for Medication Regimen Review as required by Federal Regulation. The facility did not have a Medication Regimen Review policy in place that gave specific instruction regarding urgent recommendations or specific time frames for all the different steps in the process including physician responses. b) Deficient practice was cited during the survey for failure to provide all aspects of an influenza immunization program as required. The facility failed to educate each resident and/or their legal representative on the pertinent information regarding immunizations such as the benefits and potential side effects of the influenza vaccine prior to administering the vaccine during the current (YEAR)-2017 flu season. This was found for five (5) of five (5) residents reviewed during the annual Long Term Care Survey Process. Review of the medical records for Residents #20, #14, #84, #18, and #10, on 12/05/17 at 1:30 p.m., revealed all five (5) medical records lacked documentation indicating the residents and/or their legal representatives received current education regarding the benefits and potential side effects of the influenza vaccine prior to administration during the current flu season. Residents #20, #14, #18, and … | 2020-09-01 |
| 3617 | 3617 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 838 | F | 0 | 1 | HHMR11 | Based upon record review, policy review, and staff interview, the facility failed to develop a Facility Assessment that gave consideration the of physical environment interventions to protect residents from identified wanderers with potential to enter other residents' rooms. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require. This deficient practice had the potential to affect all residents. Facility census: 87. Findings include: a) Deficient practice was cited during the survey for failure to consider any physical environment interventions to protect residents from identified wanderers with potential to enter other residents' rooms, such as stop signs or wander alarms. During an interview on 12/6/17 at 3:00 p.m., Social Worker #7 was unable to identify any environmental interventions in place or under consideration to prevent or discourage wanderers from entering other residents' rooms. b) During an interview on 12/06/17 at 3:00 p.m., Social Worker #7 was unable to describe any systematic assessment process to determine adequate deployment of staff to effectively monitor and redirect identified wanderers. c) The Facility Assessment developed by the facility was reviewed on 12/06/17 at 4:00 p.m. The document identified seventy-seven (77) residents had behavioral health needs. There was no identification of the risk presented by identified wandering residents with behaviors. When asked how many residents exhibited wandering behaviors, the Activity Director, #30, said We have eighty-six (86) residents in the facility so we have eighty-six (86) wanderers. The staffing section of the facility Assessment simply identified the current budgeted staffing levels without any recognition or consideration of the needs of the current population including identified wanderers with behavioral health issues and resulting instances of abuse discovered during the current survey. | 2020-09-01 |
| 3618 | 3618 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 842 | E | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, and review of the Hospice contract, the facility failed to ensure the record for Resident #237 contained needed documentation regarding hospice services. For Resident #73, the facility did not ensure [MEDICAL TREATMENT] communication sheets were completed. For Resident #74, the medical record identified the wrong ankle was fractured. There were no signatures by the resident or responsible party for the consent forms for the influenza or pneumococcal vaccines for Resident #437. The medical record for Resident #84 did not contain the results of psychiatric consults. These issues affected five (5) of eighteen (18) residents whose medical records were reviewed. Facility census: 87. Findings include: a) Resident #237 1. Hospice A medical record review on 12/06/17 at 8:04 a.m. revealed Resident #237 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was admitted to Hospice Services on 10/31/17 at her residence prior to her admission. According to documentation in the medical record Resident #237 was seen by Hospice services on 11/08/17 and 11/13/17. There was no further evidence of hospice visits as of 12/06/17. The Hospice care plan dated 10/31/17, (showing her home address as the place of Hospice services) displayed Skilled Nursing visits two (2) times a week for fourteen (14) weeks and ten (10) prn (as needed). The medical record lacked a care plan developed upon her admission to the facility which should have included services, treatment, nursing visits and interventions while in the facility. Review of the Hospice Services contract on 12/06/17 at 9:05 a.m. revealed the following (typed as written): under the title Agreement .3. C. Care Plans: Specific to the Hospice patient and upon admission to Home, Hospice will provide the Home with: i. a copy of any existing care plans, including without limitation, the most recent plan of care . Hospice will prepare a comprehensive care plan fo… | 2020-09-01 |
| 3619 | 3619 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 849 | D | 0 | 1 | HHMR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, contract review, and staff interview, the facility failed to ensure the record for Resident #237 contained evidence of Hospice nursing visits, a care plan identifying hospice services to be provided. In addition, the Hospice care plan did not reflect change in residency from her home to admission to the facility. This practice was found for one (1) of one (1) resident reviewed for hospice during the Long-Term Care Survey Process (LTCSP). Resident identifier: #237. Facility census: 87. Findings include: a) Resident #237 A medical record review on 12/06/17 at 8:04 a.m. revealed Resident #237 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was admitted to Hospice Services on 10/31/17 at her residence prior to her admission. According to documentation in the medical record, Resident #237 was seen by Hospice services on 11/08/17 and 11/13/17. There was no further evidence of any nursing visits as of 12/06/17. The Hospice care plan, dated 10/31/17 (showing her home address as the place of Hospice services) displayed Skilled Nursing visits two (2) times a week for fourteen (14) weeks and ten (10) prn (as needed). The medical record lacked a care plan upon her admission to the facility which should have included services, treatment, nursing visits and interventions while in the facility. Review of the Hospice Services contract on 12/06/17 at 9:05 a.m. revealed the following (typed as written): under the title Agreement .3. C. Care Plans: Specific to the Hospice patient and upon admission to Home, Hospice will provide the Home with: i. a copy of any existing care plans, including without limitation, the most recent plan of care . Hospice will prepare a comprehensive care plan for that patient at time of admission or within twenty-four (24) hours of admission . ii. Communicating with the Home and other health care providers participating in the provision of care for the terminal illness and related … | 2020-09-01 |
| 3620 | 3620 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 867 | F | 0 | 1 | HHMR11 | Based on record review, staff interview, and policy review, the facility's quality assurance committee failed to identify and correct quality deficiency issues of which they had knowledge or should have had knowledge. The facility failed to ensure the resident records are complete, failed to develop comprehensive person centered care plans, failed to provide care/services for the resident's highest well-being, and failed to ensure medical records were accurate, accessible, and complete. This deficient practice had the potential to affect all residents. Facility census: 87 Findings include: a) Completion of the Quality Assessment and Assurance review found the facility had a committee that met at least quarterly. All the Department heads and the Medical Director &/or the Assistant Medical Director attended the meetings. b) The facility was cited for failure to have an effective Quality Assessment and Assurance (QAA) Program. c) The facility was cited for failure to develop, implement and revise comprehensive person centered care plans . d) The facility failed to provide care and services for highest well-being for all residents . e) The facility failed to ensure the resident records were complete, accurate and accessible . g) The review found the QAA Committee should have been aware of the failure to develop, implement and revise comprehensive person centered care plans. The Committee should have been aware the facility failed to provide care and services for the highest well-being for all residents. The Committee should have been aware the facility failed to ensure the resident records were complete, accurate and accessible. | 2020-09-01 |
| 3621 | 3621 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 880 | E | 0 | 1 | HHMR11 | Based on observation, medical record review, staff interview, and policy/procedure review, the facility failed to maintain an effective Infection Prevention and Control Program (IPCP) designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infections. Staff failed to establish a barrier for a multi-dose medication bottle when placed on a table in the resident's room for administration. These findings had the potential to affect more than a limited number of residents residing in the facility. Resident identifier: #237. Facility census: 87. Findings include: a) Resident #237 During a medication administration observation on 12/05/17 at 9:15 a.m., Registered Nurse (RN) #42 obtained a multi-dose bottle of Ilevro eye drops from the medication cart, entered the room of Resident #237, and placed the medication on the over-bed table without benefit of a barrier. RN #42 positioned the resident, administered the medication, performed hand hygiene and exited the room. The bottle of Ilevro eye drops was returned to the cart without sanitizing the bottle, creating a potential to transmit organisms to and from Resident #237. During an interview immediately following this observation, RN #42 agreed and verified the eye drops were placed directly on the over-bed table without benefit of a barrier. RN #42 stated, Yes, it is definitely an infection control issue - should have had a barrier down or at least cleaned it before putting it back in the med cart. | 2020-09-01 |
| 3622 | 3622 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 881 | E | 0 | 1 | HHMR12 | Deficiency Text Not Available | 2020-09-01 |
| 3623 | 3623 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 883 | E | 0 | 1 | HHMR11 | Based on medical record review, policy review, and staff interview, the facility failed to educate each resident and/or their legal representative on the pertinent information regarding immunizations such as the benefits and potential side effects of the influenza vaccine prior to administering the vaccine during the current (YEAR)-2017 flu season. This was found for five (5) of five (5) residents reviewed during the annual Long Term Care Survey Process. Resident identifiers: #20, #14, #84, #18, and #10. Facility census: 87. Findings include: a) Review of the medical records for Residents #20, #14, #84, #18, and #10, on 12/05/17 at 1:30 p.m., revealed all five (5) medical records lacked documentation indicating the residents and/or their legal representatives received current education regarding the benefits and potential side effects of the influenza vaccine prior to administration during the current flu season. Residents #20, #14, #18, and #10 received the influenza vaccine on 10/09/17 and Resident #84 received the flu shot on 10/16/17. The facility's undated Pneumonia & Flu Guideline Policy stated, The resident and or the responsible party will be educated about the advantages and disadvantages of receiving the vaccines. The Informed Consent for Influenza Vaccine lacked any dates and was not updated to match current resources such as the Vaccine Information Statement (VIS) dated 08/07/15, provided by the United States Centers for Disease Control and Prevention (CDC). An interview with the Infection Control Nurse / Licensed Practical Nurse (LPN) #25 on 12/05/17 at 2:30 p.m., confirmed the education regarding the benefits and potential side effects of the influenza vaccine provided to the residents and/or their legal representatives for the (YEAR)-2017 flu season was outdated and did not match CDC's current VIS (Vaccine Information Statements. | 2020-09-01 |
| 3624 | 3624 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 943 | E | 0 | 1 | HHMR11 | Based on observation, record review, resident interviews, review of facility abuse training records, and staff interview, the facility failed to ensure staff recognized and/or identified allegations of abuse by a resident and implemented their training for abuse. Allegations/Incidents of abuse were not reported, and consequently, were not investigated within the required time frame. In addition, the facility failed to assess and monitor the physical environment to prevent resident to resident abuse. This practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifier: #61. Facility census: 87. Findings include: a) Resident #61 On 12/06/17 at 11:50 a.m. overheard a conversation at the Nurses' station between Resident #61 and Activities Director #30. Resident #61 reported to the Activities Director #30, That man (first name of resident later identified as Resident #6) comes in my room all the time and steals things from me. He is a tall thin man who scares me . takes my glasses and shoes. I chased him out. The Activities Director #30 responded, Well good. During an interview with Resident #61 on 12/06/17 at 11:56 a.m., she stated, (Resident #6) comes into my room all the time, just walks in even when I am sleeping which is scary. He will take things like my glasses and my shoes. He scares me because he just comes in and he has hit people before I am afraid he will hit me too. Upon inquiry if staff had been notified, Resident #61 stated, I tell them all the time but they tell me nothing can be done to keep him out of my room. They have come in and taken him out of my room before but that's all they do. Her roommate Resident #56 confirmed Resident #6 came into their room frequently. During a confidential interview, Employee #M and Employee #Z reported We have thirty (30) dependent residents on B-wing requiring sometimes the assistance of two (2). We have two (2) male residents (named Resident #6 and Resident #84) who wander the most into other resident's room… | 2020-09-01 |
| 3986 | 3986 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2016-05-12 | 253 | E | 0 | 1 | GBXO11 | Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services for five (5) of twenty-five (25) resident rooms observed during Stage I of the Quality Indicator Survey (QIS). The rooms had walls with damage and peeling paint. The bathrooms had scrapes on the floor, caulking missing around the commode base and walls with unpainted areas. This affected more than an isolated number of resident rooms. Room identifiers: A 108, A 114, A 119, A 126 and B 122. Facility census: 86. Findings include: a) Room A 108 Observation of this room on 05/03/16 at 3:26 p.m., noted the wall above the cove base near the bathroom door had an area of the wallboard missing. b) Room A 114 Observation of this room on 05/02/16 at 2:42 p.m., found the wallboard under the sink had water damage and peeling paint. c) Room A 119 Observation of this room on 05/02/16 at 3:17 p.m., discovered paint was bubbled up at the head of bed A and the bathroom floor had deep scrapes in the flooring. d) Room A 126 Observation of this room on 05/02/16 at 3:59 p.m., found unpainted areas on the bathroom walls and the caulking around the commode needed to be replaced. e) Room B 122 Observation of this room on 05/02/16 at 3:26 p.m., noted the privacy curtain had four (4) missing hooks. f) Interview with Maintenance Supervisor On 05/12/15 at 9:15 a.m., the Maintenance Supervisor verified Rooms A 108, A 114, A 119, B 122 and A 126 needed the walls repaired and painted, he also verified the privacy curtain needed to be fixed and the bathroom flooring and caulking around the commode needed to be replaced. | 2020-04-01 |
| 3987 | 3987 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2016-05-12 | 272 | D | 0 | 1 | GBXO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately assess three (3) of twenty-five (25) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The comprehensive Minimum Data Set (MDS) for Resident #44 did not accurately reflect the [DIAGNOSES REDACTED]. The MDS for Resident #97 did not reflect the [DIAGNOSES REDACTED].#103 did not reflect a [DIAGNOSES REDACTED].#44, #97 and # 103. Facility census: 86. Findings include: a) Resident #44 A review of the medical record for Resident #44 on 05/10/16 at 11:12 a.m., revealed Resident #44 had active [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. A review of the comprehensive MDS with an Assessment Reference Date (ARD) of 08/05/15 did not reflect the active [DIAGNOSES REDACTED]. An interview on 05/10/16 at 1:28 p.m., with the MDS Coordinator, verified the MDS with the ARD of 08/05/15 Section I: Active [DIAGNOSES REDACTED].#44 had [DIAGNOSES REDACTED]. b) Resident #97 A review of the medical record for Resident #97 on 05/10/16 at 2:52 p.m., revealed this resident had a [DIAGNOSES REDACTED]. A review of the comprehensive MDS with an ARD of 03/12/16 did not reflect an active [DIAGNOSES REDACTED].#97. An interview on 05/10/16 at 3:40 p.m., with the MDS Coordinator, verified the MDS with an ARD of 03/12/16 did not have an active [DIAGNOSES REDACTED].#97. c) Resident #103 The medical record, reviewed on 05/09/16 at 3:14 p.m., revealed physician's recapitulation orders for [MEDICATION NAME] ten (10) milligrams (mg) orally for chronic pain and [MEDICATION NAME] 5 mg daily for chronic pain. Additionally, Resident #103 received [MEDICATION NAME] 5 mg at bedtime and [MEDICATION NAME] 15 mg daily. The hospital history and physical, dated 03/15/16, reviewed at 3:44 p.m. on 05/09/16 indicated Resident #103 had taken [MEDICATION NAME] for about [AGE] years for chronic abdominal pain/[MEDICAL CONDITION]. The hospital transfer summary, reviewed on 05/09/16 … | 2020-04-01 |
| 3988 | 3988 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2016-05-12 | 279 | D | 0 | 1 | GBXO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for Resident #103. The care plan did not address the advance directive implementation for one (1) of one (1) residents reviewed for hospice care during Stage 2. Residents identifier: #103. Facility census: 86. Findings include: a) Resident #103 A review on of the medical record on 05/04/16 at 9:22 a.m., revealed the Physician order [REDACTED]. An interview on 05/04/16 at 10:10 a.m., with the Licensed Social Worker (LSW) and the Director of Nursing (DON) verified the current care plan for Resident #103 did not address the resident's choices regarding her advance directives and end-of -life care. | 2020-04-01 |
| 3989 | 3989 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2016-05-12 | 280 | E | 0 | 1 | GBXO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to reassess the effectiveness of interventions and revise the plan of care, to meet the needs to the extent possible for one (1) of 25 Stage 2 sample residents. Resident #100 had related he did not want finger stick blood sugars four (4) times a day. Facility census: 86. Resident identifier: Resident #100. Findings include: a) Resident #100 On 05/09/16 at 9:32 a.m., review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 03/12/16 indicated Resident #100 rejected care almost daily. During a stage one interview with Resident #100 on 05/05/16 at 9:48 a.m., the resident was alert to person, place, time and situation. The resident related he participated in his care plan, but the facility did not always implement his request. The care plan, reviewed on 05/09/16 at 9:33 a.m., revealed staff would actively involve the resident in care, would allow the resident options, would allow the resident to have control over situations if possible, and would assess the resident's resistance to care. The medical record, reviewed concurrently with the care plan, included [DIAGNOSES REDACTED]. The physician's determination of capacity, dated 12/01/15, indicated Resident #100 had the capacity to make medical decisions. physician's orders [REDACTED]. The fingerstick blood sugars were scheduled at 6:30 am., 11:30 a.m., 4:30 p.m. and 9:00 p.m. Laboratory orders included Hemoglobin A1C (HgbA1C) annually, due in December, and a fasting blood sugar (FSB) every three (3) months due December, March, (MONTH) and September. Further review of the medical record revealed no evidence of the Hemoglobin A1c level. Nurses' progress notes, reviewed on 05/09/2016 10:21 a.m., revealed Resident #100 refused the Accucheck fingersticks on 05/06/16, 05/04/16 at 9:00 p.m., 05/02/16 at 9:00 p.m., 05/02/16 at 6:30 a.m., 04/22/16, and 04/23/16. Furthermore, the pr… | 2020-04-01 |
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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 );