cms_WV
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11,539 rows sorted by scope_severity descending
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 731 | 731 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2018-08-30 | 880 | L | 0 | 1 | T9WW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, resident interview, review of facility policies, review of the facility's infection control monthly line listings, review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed prevent the spread of infection to the extent possible by implementing contact precautions for residents whose urinary tract infections [MEDICAL CONDITION] included multi-drug resistant organisms. Record review and review of the line listings found five (5) residents identified as having Extended Spectrum Beta lactamase in two (2) months - (MONTH) and (MONTH) (YEAR). (Beta lactamases are enzymes produced by many species of bacteria which destroy one or more antibiotics. It is one of the ways in which bacteria develop resistance.) Observations and staff interviews confirmed contact precautions, in addition to standard precautions, were not employed. Due to the potential for the exposure to other residents, staff, and visitors, an immediate jeopardy to the health and well-being of others was determined. The Administrator and the Director of Nursing were notified of the determination of the immediate jeopardy on 08/29/18 at 2:48 PM and a brief statement of the deficient practice provided. The facility provided an acceptable plan of correction (P[NAME]) at 5:18 PM at which time the immediate jeopardy was removed as implementation of the P[NAME] had occurred. Resident identifiers: #31, #12, #80, #104, #99. After removal of the immediate jeopardy, deficient practices remained at a scope and severity of [NAME] for failure to cohort residents in keeping with infection control. Resident #33, a debilitated resident with a suprapubic catheter was residing in the same room as Resident #31, who had a multi-drug resistant urinary tract infection. Additionally, items such as straws, cups, and plastic utensils were stored under the sink in the medication room where contamination was a potential. This had the pote… | 2020-09-01 |
| 832 | 832 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2018-05-17 | 607 | L | 1 | 1 | H2ZY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on personnel file review, staff interview, and review of the facility's policy for screening of employees, the facility failed to verify fourteen (14) of fifteen (15) direct care staff hired by a staffing agency and used by the facility were thoroughly screened for a history of abuse, neglect, exploitation, and/or any applicable criminal activity that would identify the individual as unfit to work in a long-term care facility. The facility failed to ensure fourteen (14) of the fifteen (15) individuals were screened through the West Virginia Clearance for Access and Employment Screening (WV CARES) system, a program initiated by the Centers for Medicare and Medicaid Services (CMS) National Background Check Initiative. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of three (3) Licensed Practical Nurses (LPNs) and eleven (11) nurse aides (NAs). This practice had the potential to affect all residents residing in the facility. Notice of the Immediate Jeopardy (IJ) was given to the Center Executive Director (CED) on 05/17/18 at 5:15 PM. An acceptable plan of correction (P[NAME]) was received from the CED on 05/17/18 at 7:00 PM. After verification of the implementation of the plan of correction, the immediate jeopardy was abated at 7:00 PM. Employee identifiers: #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, and #72. Facility census: 111. Findings included: a) On 05/17/18 at 12:50 PM, a review of employee background checks with Human Resources Manager (HRM) #20 revealed the facility had employed 15 agency employees. Three (3) of the agency employees were LPNs and eleven (11) were nurse aides (NAs). HRM #20 said she would locate the background checks for the agency employees. According to the facility's records, the employees provided by an agency began working in the facility on the following dates: - LPN #58 - 01/… | 2020-09-01 |
| 835 | 835 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2018-05-17 | 689 | L | 0 | 1 | H2ZY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, resident interview, medical record review, staff interview, and observation of Resident #35, the facility failed to ensure one (1) of three (3) cigarette smokers was capable of safely smoking independently. The resident was observed smoking outside on the sidewalk alone on 05/15/18 at 9:05 a.m. He could not be readily observed by staff inside the building. It was also noted the resident was smoking in an area where a sign was posted prohibiting smoking. The wind was blowing and ashes would blow back on the resident and his clothing. When the ashes would land on his clothing, he appeared unaware of the ashes and made no attempt to brush them off. He was not wearing a smoking apron and there were noticeable holes in the sweatpants he wore. Further investigation found this severely cognitively impaired resident kept his cigarettes and his lighter on his person at all times. These findings were determined to pose a potential for serious harm to the safety and well-being of Resident #35 and to other residents residing in the facility. The Chief Executive Officer (CEO) was informed these findings constituted an immediate jeopardy to the safety and well-being of Resident #35 and to the facility's other residents on 05/15/18 at 9:24 a.m. Written notification of the findings leading to the determination of immediate jeopardy and request for a plan of correction were provided to the CEO. The facility provided an acceptable plan of correction and after verifying implementation of its plan, the immediate jeopardy was abated at 4:30 p.m. on 05/15/18. After removal of the immediate jeopardy, no deficient practice remained for this requirement. Resident identifiers: #35 and the other facility residents. Facility census: 111. Findings included: a) Resident #35 Observations on 05/15/18 at 9:05 a.m., found the resident seated in a wheelchair outside on the front sidewalk smoking a cigarette. No staff were monitoring the resident. Closer… | 2020-09-01 |
| 1594 | 1594 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 607 | L | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, staff interview, and review of the facility's policy for screening of employees, the facility failed to verify two (2) of four (4) direct care staff hired by a staffing agency and used by the facility were thoroughly screened for a history of abuse, neglect, exploitation, and/or any applicable criminal activity that would identify the individual as unfit to work in a long-term care facility. The facility failed to ensure two (2) of three (3) individuals were screened through the West Virginia Clearance for Access and Employment Screening (WV CARES) system, a program initiated by the Centers for Medicare and Medicaid Services (CMS) National Background Check Initiative. Employee identifiers: #64 and #7. After consultation with the State Agency, a determination of immediate jeopardy was made based on the facility's failure to thoroughly screen the backgrounds of two (2) of three (3) Licensed Practical Nurses (LPNs). In addition, two (2) of three (3) LPNs did not have proof of West Virginia Licensure and were currently working at the facility. This practice had the potential to affect all residents residing in the facility. Notice of the immediate jeopardy (IJ) was given to the Administrator on [DATE] at 6:19 PM. An acceptable plan of correction (P[NAME]) was received from the Administrator on [DATE] at 6:35 PM. After verification of the implementation of the plan of correction (P[NAME]), the immediate jeopardy (IJ) was abated on [DATE] at 6:35 PM. After removal of the immediate jeopardy, a deficient practice remained at a scope and severity of [NAME] for this requirement for failure to ensure Nurse Aide #83 maintained a current registration. Facility census: 61 The findings included: a) LPN #64 A review of personnel files, on [DATE] at 3:00 PM, revealed the facility had employed agency staff, LPN #64 on [DATE]. When the employee files were brought to the surveyor for review, the file for Employee LPN #64 was not i… | 2020-09-01 |
| 2031 | 2031 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2018-02-06 | 689 | L | 1 | 1 | 3TSK11 | > Based on observations, medical record review, staff interview, resident interview, and policy review, the facility failed to provide an environment free from accident hazards over which the facility had control. The facility allowed two (2) residents to keep cigarettes and lighters in their room. Resident #9 and #98 both kept their smoking materials in their room. The facility also had a courtyard in which residents could freely access during winter weather and other weather conditions without any type of monitoring by the facility. The doors going into the courtyard did not alarm to alert staff that residents had entered the courtyard area. Residents were observed entering the court yard freely with no alert to the facility. These deficient practices had the potential to affect all residents and had the potential to cause serious harm or death. After consultation with the State office a determination of immediate jeopardy was made based on the facility's failure to ensure each resident received adequate supervision to prevent accidents when out in the courtyard and/or allowing residents to maintain unsecured possession of lighters. The facility administrator was notified of the immediate jeopardies on 01/30/18 at 9:25 p.m. Acceptable plans of correction and their implementation was verified and the immediate jeopardies were abated on 01/31/18 at 12:24 a.m. Resident identifiers: #9 and #98. Facility census: 114. Findings include: a) Resident #9 An interview with Resident #9 on 01/30/18 at 4:20 p.m. revealed the resident was a smoker. She said she kept her cigarettes and lighter in her nightstand. The nightstand was not equipped with a lock to ensure others could not access the lighter. b) Resident #98 An observation of Resident #98 at 7:00 p.m. on 01/30/18 revealed this resident was sitting out in the courtyard with Resident #9. Both were smoking cigarettes. Resident #98 also said she kept her cigarettes and lighter with her and could go out and smoke whenever she wanted. c) On 01/30/18 at 7:29 p.m., an intervi… | 2020-09-01 |
| 6401 | 6401 | GREENBRIER HEALTH CARE CENTER | 515185 | 1115 MAPLEWOOD AVENUE | LEWISBURG | WV | 24901 | 2014-06-27 | 441 | L | 0 | 1 | 35BV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to implement an infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infections within the facility. The facility failed to ensure infection control procedures were in accordance with the Centers for Disease and Control and Prevention (CDC) guidelines. Isolation rooms were not effectively cleaned and sanitized and staff did not effectively use personal protective equipment (PPE). Wound care for Resident #88 was not performed by methods which eliminated the potential for cross contamination. The chairs used for Residents #69, #42, #92, #46, and #50 had areas which could not be effectively sanitized. These deficits were determined an Immediate Jeopardy (IJ) to the health and well-being of all facility residents. The IJ was first called at 4:50 p.m. on 06/16/14. The facility had continued non-compliance with infection control practices until 06/25/14 at 5:48 p.m. At that time the facility was informed the IJ was abated. The scope and severity was reduced from a scope and severity of an L to an F. The practices affected Residents #88, #69, #42, #92, #46, and #50, but had the potential to affect all residents. Facility census: 77. Findings include: a) On 06/16/14 at 12:45 p.m. observations were conducted on the long hall on second floor. A housekeeping staff member (Employee #87) entered room [ROOM NUMBER], an isolation room. At 12:50 p.m. on 06/16/14, the housekeeper exited room [ROOM NUMBER] wearing booties over her shoes. The booties were a part of the isolation personal protective equipment (PPE) required for room [ROOM NUMBER]. As she left the room, Employee #87 swept the debris (dust and debris, such as a napkin and paper products) with a dust mop, from the floor of room [ROOM NUMBER] down the middle of the hallway. She passed by six (6) resident rooms while pushing the dust mop and debris. The housekeeper went into a closet… | 2018-04-01 |
| 9543 | 9543 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 463 | L | 0 | 1 | PL2X11 | Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this skilled nursing unit (SNU) at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means provided to residents to allow them to summon staff in the event of a resident need or an emergency. Family interview, staff interview, and direct observation, on 02/09/11, verified the audible signal component of the nurse call system was still disabled and no alternate means of comm… | 2015-10-01 |
| 9544 | 9544 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 490 | L | 0 | 1 | PL2X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility's governing body failed to ensure the skilled nursing unit (SNU) was administered in an effective and efficient manner to maintain the highest practicable well-being of each resident. The facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this SNU at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means provided to residents to allow them to … | 2015-10-01 |
| 9545 | 9545 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2011-02-15 | 520 | L | 0 | 1 | PL2X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, staff interview, and a review of the facility's disaster plan and other records, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware and failed to implement measures to remedy these quality deficiencies. The facility failed to provide a fully functional nurse call system (with both audible and visual signaling components of the system working as designed) and failed to provide an alternate means of communication to allow residents to summon nursing staff from their rooms, toilets, and bathing facilities when the facility disabled the audible signal component of the nurse call system due to a malfunction. This placed all of twenty-seven (27) residents on this skilled nursing unit (SNU) at in immediate jeopardy due to an inability to summon staff in the event of an emergency. Staff interview revealed the nurse call system went down during a power outage at 6:00 a.m. on 01/28/11. During this power outage, the unit director distributed tap bells to all residents on the SNU as an alternate means of summoning staff when the nurse call system. When the power was restored, these tap bells were collected from the residents after the power was restored at 6:30 a.m. on 01/28/11. After the power was restored on 01/28/11, the emergency nurse call system for two (2) bathrooms located on the SNU malfunctioned, causing the audible signal to the nurse call system for the SNU to sound continuously. The audible signal to the nurse call system was disabled due to its continuous ringing; however, tap bells were not redistributed to all residents as an alternate of summoning staff while the audible signal was disabled. The entire SNU was without a fully functioning nurse call system with an audible signal that would sound at the nurse's station (to alert staff of a resident's need for assistance) since 01/28/11, with no alternate means pro… | 2015-10-01 |
| 10152 | 10152 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-05-05 | 490 | L | 0 | 1 | MKQ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the governing body failed to ensure the facility was administered in such a manner as to provide a safe, sanitary and comfortable environment (to help prevent the development and transmission of disease and infection) and to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism, who did not perform effective handwashing after having episodes of diarrhea, and who independently traveled throughout the facility, entering common areas and touching surfaces used by all residents. The facility's administration failed to develop and maintain an infection control program to effectively prevent the transmission of a highly contagious intestinal infection, [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]), by Resident #143. There were no specific policies for the cleaning of rooms, surfaces, and/or equipment used by this resident infected, and there was no evidence of inservicing to ensure the staff was aware of this resident's infection and the proper techniques to be employed to prevent transmission of the infectious organism throughout the entire building. There was no evidence to reflect the administration provided oversight to the infection control program to ensure infection control policies and procedures were reflective of current standards of practice (in accordance with recommended CDC guidelines) and that staff implemented those policies and procedures as written. These practices placed all residents in the facility in imm… | 2015-06-01 |
| 10153 | 10153 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-05-05 | 224 | L | 0 | 1 | MKQ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism. Resident #143 had an active infection with a highly contagious organism - [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) - a spore-forming organism from which environmental contamination frequently occurs. Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bouts of diarrhea resulting in bowel incontinence.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Resident #143 was also very active, attended out-of-room activities, and ate in the dining room. He received therapy in the common use therapy room, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propell… | 2015-06-01 |
| 10155 | 10155 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-05-05 | 520 | L | 0 | 1 | MKQ811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility's quality and assessment assurance (QAA) committee failed to identify and implement measures to correct quality deficiencies - of which it should have known - to address a system failure with respect to the facility's infection control program. The facility failed to develop and maintain an infection control program to effectively prevent the transmission of a highly contagious intestinal infection, [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) by Resident #143. There were no specific policies for the cleaning of rooms, surfaces, and/or equipment used by Resident #143, and there was no evidence of inservicing to ensure the staff was aware of this resident's infection and the proper techniques to be employed to prevent transmission of the infectious organism throughout the entire building. There was no evidence to reflect the facility ensured its infection control policies and procedures were reflective of current standards of practice (in accordance with recommended CDC guidelines) and that staff implemented those policies and procedures as written. These practices placed all residents in the facility in immediate jeopardy for acquiring a [DIAGNOSES REDACTED] infection. (See citation at F224 for specific information related to the immediate jeopardy.) According to the director of nursing (DON), the facility's QAA committee reviewed the infection control nurse's reports of active infections monthly. Resident #143's [DIAGNOSES REDACTED] infection was not on the March 2010 or April 2010 infection control logs. Although the facility was aware Resident #143 had returned from the hospital with [DIAGNOSES REDACTED] and was being actively tre… | 2015-06-01 |
| 460 | 460 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2018-11-15 | 726 | K | 0 | 1 | T4YY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, training documentation and review of the State Board of Examiners for Licensed Practical Nurses, the facility failed to ensure Licensed Practical Nurses (LPN) were trained and competent to perform Intravenous (IV) therapy including administration of medications via a peripheral inserted central catheter (PICC) within their scope of practice and state regulations. The facility was unable to provide verification of sufficient IV training and competency for nine (#6, #20, #27, #33, #35, #39, #49, #59 and #64) of nine LPNs who were performing IV therapy. This practice resulted in Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18 when Resident #48 was readmitted to the facility with a peripheral inserted central catheter (PICC) and receiving IV therapy. The Immediate Jeopardy continued when Resident #32 was re-admitted to the facility on [DATE] with a PICC line in her right arm for intravenous antibiotic therapy. LPN's #27, #33, #49 and #59 performed IV therapy for Resident #48 and LPNs #6, #20, #39, #49 and #64 performed IV therapy for Resident #32 without sufficient training and competency. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of Resident #48 and Resident #32 to identify any adverse effects related to IV therapy. The facility revised the staffing schedule to ensure an Registered Nurse would be performing IV therapy for the two residents and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until LPNs were trained and competent with IV therapy. See F684 (Quality of Care) regarding Resident #48 and #32. See F883 (Facility… | 2020-09-01 |
| 517 | 517 | MERCER NURSING AND REHABILITATION CENTER | 515052 | 1275 SOUTHVIEW DRIVE | BLUEFIELD | WV | 24701 | 2020-02-04 | 881 | K | 0 | 1 | CN2N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].) In addition, this placed the resident at risk for developing antibiotic-resistance. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. Due to the facility's failure to implement an antibiotic stewardship protocol the State Agency (SA) determined there was an immediate jeopardy (IJ) present for more than a limited number of residents residing in the facility. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. The following details the timeline of the IJ situation. --The IJ started on 01/04/20. --The facility Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) at 12:22 PM on 01/30/20. --The facility submitted their first abatement Plan of Correction (POC) at 1:55 PM on 01/30/20. --The SA requested changes to the abatement POC. --At 2:08 PM and a second abatement POC was submitted by the facility on 01/30/20. --This POC was accepted by the SA at 2:10 PM on 01/30/20. --The IJ was abated at 11:40 AM on 02/03/20 when the SA observed Resident #57's urine culture and sens… | 2020-09-01 |
| 664 | 664 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2018-04-26 | 880 | K | 0 | 1 | FJW311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation and infection control policy review, the facility failed to maintain an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The facility failed to effectively implement isolation practices for Resident #149. Resident #149, who was diagnosed with [REDACTED].#108) who did not [MEDICAL CONDITION] or [MEDICAL CONDITION] [DIAGNOSES REDACTED].#149 would pick scabs from her open [MEDICAL CONDITION] and flick them about. Resident #108 was unable to understand the need for, and to independently practice hygienic measures such as handwashing. Resident #108 ambulated about the room, touching various environmental objects, and about on the nursing unit at will. This had the potential for Resident #108 to become a vector for Resident #149's infectious disease processes, carrying infective material where other residents, staff, and visitors might have contact. These findings were determined to pose an immediate jeopardy to the health and well-being of others. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) on 04/25/18 at 12:48 PM and preparation of a written statement regarding the identified deficient practice, the Administrator and Director of Nursing (DoN) were notified of this immediate jeopardy on 04/25/18 at 1:28 PM. The facility provided an acceptable Plan of Correction at 3:45 pm on 04/25/18. After determining the facility had implemented its plan of correction, the immediate jeopardy was abated on 04/25/18 at 3:53 pm After removal of the immediate jeopardy, a deficient practice, with the potential to affect more than a limited number of residents, remained at a scope and severity of E. A nurse administered medications to Resident #44 after dropping them on the medication cart, picking them up with her bare hands, and placing them in a medication cup with o… | 2020-09-01 |
| 1028 | 1028 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-03-29 | 600 | K | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident council meeting, resident interviews, policy review, review of incident reports and staff interview the facility failed to ensure that each resident in the facility had the right to be free from sexual, physical, psychological and verbal abuse. The facility failed to prevent Resident # 44 from wandering about the facility, entering other residents' rooms, evoking resident to resident altercations and causing fear amongst the other residents. These findings were determined to pose an immediate jeopardy and the health and well-being and represents a pattern to affect more than a limited number of residents. The facility administrator was notified of the immediate jeopardy on [DATE] at 10:45 AM. The facility provided an immediate jeopardy abatement plan of correction on [DATE] at 2:20 PM. The abatement plan of correction included: --Resident #44 was placed on one on one supervision on [DATE] at 10:45 AM until an alterntive and equally effective intervention is identified. One [DATE], Resident #44 was sent to the Emergency Department of a local hospital at 1:00 PM for evaluation due to behaviors. --All interviewable residents were interviewed by the staff of the social services department on [DATE] to ensure there were no other residents affected by Resident #44's behavior. The administrator will interview all staff on [DATE] to determine whether they observed any abusive behaviors affecting non-interviewable residents by Resident #44. --On [DATE] Regional Vice President reeducated the Administrator and Social Services Director regarding abuse prohibition and neglect. This abuse prohibition and neglect training and resident rights training was provided to all staff on [DATE], including a posttest. Staff not availble on [DATE] were to be trained and tested prior to their next work shift. The immediacy of this deficient practice was abated on [DATE] at 4:50 PM. The post-abatement scope and severity was … | 2020-09-01 |
| 1387 | 1387 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2018-10-08 | 684 | K | 1 | 0 | 0O7M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, observations, resident interview, and staff interview, the facility failed to ensure six (6) of twelve (12) residents who were ordered sliding scale insulin received the necessary care and services to maintain their highest practicable physical well-being. For Resident #5, the facility failed to notify the attending physician when the resident's blood sugar was greater than 400 on multiple occasions as directed by the physician's order. Also, Resident #5 was given the incorrect amount of sliding scale insulin based on her blood sugar readings. Furthermore, there was no evidence Resident #5's scheduled insulin was administered as ordered on multiple days with no documented reason why the medication was not given. For Resident #102 the facility failed to notify the physician when Resident #102's blood sugar was greater than 400 on one (1) occasion in (MONTH) of (YEAR). Furthermore, the Medication Administration Record (MAR) had multiple blank spaces in (MONTH) (YEAR) and (MONTH) (YEAR) indicating Resident #102 did not receive his insulin on those dates and at those times. Resident #93 received the wrong dose of sliding scale insulin on five (5) separate occasions since her admission on 09/20/18. Additionally, her MAR was blank indicating she did not get her scheduled insulin on three (3) occasions and on one (1) occasion the MAR was blank indicating she did not get Sliding Scale Insulin Coverage. For Resident #61, the facility failed to notify the physician when Resident #61's blood sugars were greater than 400 on multiple occasions. Also, Resident #61 received the incorrect dosage of sliding scale insulin based on the blood sugar readings. For Resident #12, the facility failed to administer her sliding scale insulin in accordance with the physician's orders on four (4) occasions. For Resident #18, the facility failed to administer his sliding scale insulin in accordance with the physician's orders on multiple occasion… | 2020-09-01 |
| 1599 | 1599 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2018-07-12 | 689 | K | 0 | 1 | 5JPY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the reported allegations of elopement to the nursing home program, and review of facility policy, the facility failed to provide an environment free from accident hazards over which the facility had control. Secure care equipment failed to function properly which had the potential to allow a resident, utilizing the secure care equipment, to leave the facility without staff knowledge. Once the door was opened by a visitor, a resident, or anyone not wearing a secure care alarm, any resident with a secure care alarm could exit the building without activating the alarm. Resident #34 was observed attempting to leave the facility when another resident exited the building. No alarm sounded although the resident had secure care devices on her ankle and wheelchair. Testing of the system found it failed to activate an alarm when a resident wearing a secure care device went through the door when opened by a visitor or other person not wearing a device. Further investigation found an incident when a former resident, Resident #58, had exited the facility while the door was held open by another resident. The report regarding that incident noted, Equipment will be tested , . The transmitter was tested and was working properly according to the immediate action taken. However, the investigation did not indicate if the testing was done when the door was opened or closed. After consultation with the State office a determination of immediate jeopardy was made based on the facility's failure to ensure the secure alarm system was working properly to prevent residents with secure care systems from exiting the facility without staff knowledge. The facility was previously aware of the elopement of Resident #58 on 05/24/18. This incident should have alerted the facility the secure care system was not operating properly. The facility NHA was notified of the immediate jeopardy on 07/11/18 at 12:05 PM The facility provided… | 2020-09-01 |
| 1854 | 1854 | GLASGOW HEALTH AND REHABILITATION CENTER | 515118 | 120 MELROSE DRIVE, BOX 350 | GLASGOW | WV | 25086 | 2017-02-14 | 323 | K | 0 | 1 | JVKC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility policy and procedures, and staff interviews, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible and failed to provide supervision for Resident #69. The facility failed to implement preventative measures for a known accident hazard for all the residents residing on the Alzheimer Care Unit (ACU) regarding possible electrical shock from a missing outlet switch cover in the bathroom located between Room #310 and Room #312. These findings resulted in a determination of immediate jeopardy due to the potential for harm to residents. The Administrator and Director of Nursing were notified of the immediate jeopardy at 5:13 p.m. on 02/06/17. An acceptable plan of correction (P[NAME]) was received at 7:34 p.m. After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:45 p.m. No deficient practice remained for this requirement after removal of the immediate jeopardy. This had the potential to affect more than a limited number of residents. Resident identifier: #69. Facility census: 97. Findings include: a) Electrical outlet covers On 02/06/17 at 1:15 p.m., an observation of the bathroom shared by Room #310 and Room #312 on the Alzheimer Care Unit (ACU) found the cover plate for the light switch was missing, exposing electrical wiring. On 02/06/17 at 3:45 p.m., the ACU Director agreed any mobile resident residing on the unit could receive an electrical shock from the missing light switch covers. He also reported Resident #69 was capable of pulling the outlet covers off the wall. b) Resident #69 A review of the medical record on 02/06/17 revealed the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 11/15/16 revealed the resident's [DIAGNOSES REDACTED]. Resident #69 resided on the locked ACU with twenty-six (26) other residents. Resident #69's care plan identified the behavior of pulli… | 2020-09-01 |
| 2837 | 2837 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2019-11-20 | 689 | K | 0 | 1 | Z38K11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview and observation, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #60, a resident who independently smokes, was noted to keep his cigarettes and lighter in his room with him when he is not smoking. Resident #60 indicated he kept his smoking materials including his lighter in his [NAME]et pocket. The facility's policy verified all smoking materials would be locked up at the nurses desk or in the residents room. The facility's policy prohibited lighters being kept anywhere other than locked up at the nurses station. The facility identified the following residents as being confused, wandering, and rummaging residents: Resident #56, #39,#69, #92, #25, #86, #29, #79, #272, #9, #120, #78, #13, #81, #117, #23, #31, #89, #46, #118, and #116. The facility's failure to implement their smoking policy and their non-compliance to ensure the resident environment was free from accident hazards placed these 21 residents in a situation where serious injury and/or death was likely. The facility was notified of the Immediate Jeopardy (IJ) situation at 2:00 p.m. on 11/19/19. They provided a Plan of Correction (P[NAME]) at 4:28 p.m. on 11/19/19 and the P[NAME] was accepted by the state agency at 4:35 p.m. on 11/19/19. The IJ was abated at 8:50 a.m. on 11/20/19. The facility abatement plan of correction included the following. 1. Director of Nursing (DON) removed smoking supplies, including lighters, from Resident #60 possession @ 1245pm on 11/19/19. DON re-educated Resident #60 regarding the smoking policy and procedure to include all smoking materials including lighters are to be secured at 12:45 PM on 11/19/19 and resident #60 voiced understanding. Residents # 56, 39, 69, 92, 25, 29, 79, 272, 9, 120, 78,13,81, 117, 23, 31, 89, 46, 116, and 118 rooms were searched on 11/19/19 by 2:46 pm with no additional findings on… | 2020-09-01 |
| 2924 | 2924 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2019-12-04 | 684 | K | 0 | 1 | KNB211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the physician orders. The facility failed to ensure care was delivered for residents who are at high risk of aspiration. Medications were left at the bedside table for the resident to self-administer. This was done without a physician order [REDACTED]. The failed practice affected two (2) of twenty-one (21) residents. Resident identifiers: #3 and #413. Facility census: 71. Two immediate jeopardies were called for this deficient practice. 1. Immediate Jeopardy #1 A nurse failed to remain in Resident #413's room during the administration of medications. This resident had a history of [REDACTED]. Consultation with the State Agency, on 12/03/19 at 1:15 PM, revealed that a determination of Immediate Jeopardy was identified. The Immediate Jeopardy was called with the facility's Administrator at that time. An acceptable Plan of Correction (P[NAME]) was approved and the immediacy of this deficient practice was abated on 12/03/19 at 3:35 PM. The P[NAME] included the following interventions: -The Nurse Practioner evaluated Resident #413 at 2:45 PM to ensure respiratory status remained baseline there was no evidence of aspiration and no correction required. -The Licensed Practical Nurse (LPN) #11 was re-educated regarding not leaving medications at the bedsides as per policy by the unit manager immediately upon discovery at 10:00 AM. -All residents of the facility had the potential to be affected. Director of Nursing (DON) and Unit Managers conducted rounds of all residents' rooms on 12/03/19 at 1:45 PM and no additional medication was left at the bedsides. - All licensed and certified nursing staff and dietary staff including agency on duty will be re-educated starting on 12/03/19 at 2:00 PM by the Practice Development Specialist w… | 2020-09-01 |
| 2958 | 2958 | LOGAN CENTER | 515175 | 55 LOGAN MINGO MENTAL HEALTH CENTER ROAD | LOGAN | WV | 25601 | 2019-09-26 | 880 | K | 0 | 1 | OD5711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, Center for Disease Control and Prevention (CDC), Facility Policy, and observation,` the facility has failed to ensure and establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to store clean linens in a safe, clean and sanitary manner. Furthermore, the facility failed to appropriately place Residents #59 and #28, diagnosed with [REDACTED]. In addition, the facility failed to have PPE equipment readily available for staff. Resident #59 currently has a active [DIAGNOSES REDACTED]. There were not any signs on the door to alert staff or visitors of the type of precautions to use. Resident #28 was diagnosed with [REDACTED]. He also has multiple open non-healing wounds, Foley catheter, [MEDICAL CONDITION] bag, and a feeding tube. Staff did not use PPEs when providing care. These failed practices had the potential to affect more than a limited number residents at risk for serious harm and/or death resulting in a determination of an Immediate Jeopardy situation. --The facility was notified of the Immediate Jeopardy on 09/25/19 at 3:40 PM. --The facility submitted their plan of correction (P[NAME]) at 6:40 PM. --The State Agency requested changes at 6:48 PM on 09/25/19. --The facility submitted the second P[NAME] at 7:52 PM on 09/25/19. --The State Agency requested changes on 09/25/19 at 7:59 PM. --The facility submitted the third P[NAME] at 8:03 PM on 09/25/19 and their P[NAME] was accepted by the State Agency at 8:10 PM on 09/25/19. --Implementation of the abatement components of the P[NAME] was observed by the state agency at 9:10 AM on 09/26/19 and the immediacy of the situation was abated. An observation for abatement plan implementation on 09/26/19 at 9:00 AM, revealed that the following rooms had a sign on the door … | 2020-09-01 |
| 3079 | 3079 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2019-11-04 | 600 | K | 0 | 1 | MFEO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, incident report review, resident interview, and staff interview, the facility failed to ensure residents were free from verbal, psychological and physical abuse when confronted with resident to resident altercations. This practice caused actual harm to Resident #307 and #5. Resident #307 experienced actual harm, by Resident #8 through verbal and mental abuse, as evidenced by crying shaking, and showing signs of sadness. Resident #5 was experienced actual harm, by Resident #8 through verbal and mental abuse, as evidenced by expressing feealings of fear and being unsafe. The actual harm and immediate jeopardy was further evident by the fact the facility did not report, investigate, nor put protections in place to safeguard residents from Resident #8, who had exhibited numerous incidents of verbal, mental and physical aggression towards residents and staff. The Centers for Medicare and Medicaid Services determined this deficient practice was an immediate jeopardy. State Agency surveyors notified the facility administrator of the immediate jeopardy on 11/04/19 at 12:32 PM. The facility abatement plan was approved through verification of implementation on 11/04/19 at 4:50 PM. The facility's abatement plan included: 1. Resident # 8 no longer resides in the facility. Resident #s 5, 2, 13, 22, and 45 were seen by facility Nurse Practitioner on 10/14/2019 to evaluate residents for emotional and psychological harm. Resident #s 5, 2, 13, 22, and 45 have not experienced any negative outcomes. On 11/1/2019 Resident #5 denied concerns, anxiety, fear related to any additional residents in the facility. Resident # 307 no longer resides in the facility. 2. All residents of the facility have the potential to be affected. On 10/16/19 all incident reports and resident council minutes from 04/01/2019 to current were audited by the Administrator to ensure all potential incidents of abuse, including resident to resident alterca… | 2020-09-01 |
| 3311 | 3311 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 600 | K | 0 | 1 | KGJN11 | Based on observation, record review, resident interview and staff interview, the facility failed to ensure Resident #33 was free from neglect. Resident #33 went 9 and 16 days without a shower. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #33. Facility census: 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. He stated he asked the Social Worker to please report her to the state. The resident said the Social Worker told him it would just be her word against his and would not do any good. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. A review of records revealed there was not a reportable completed by the facility for the allegation of verbal/mental abuse and neglect … | 2020-09-01 |
| 3320 | 3320 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 684 | K | 0 | 1 | KGJN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to administer Resident #12's and Resident #56's sliding scale insulin in accordance with the physician's orders [REDACTED].#12's blood sugar was recorded as 57. Resident #12 did not receive her sliding scale insulin coverage on 76 occasions when her blood sugar was in excess of 200 which required sliding scale coverage. This was during the time frame of 10/08/18 through current. Also on 01/25/19 the residents blood sugar was 57 and there was no evidence the facility implemented the hypoglycemic protocol. Resident #56 did not receive her sliding scale coverage on four (4) occasions when her blood sugar was in excess of 201 which required sliding scale coverage. This was from 02/09/19 through current. It was determined by the state agency (SA) that these failures place Resident #12 and Resident #56 at an immediate risk for serious harm and/or death placing Resident #12 and Resident #56 in an immediate jeopardy situation. At 12:30 p.m. on 04/09/19 the Nursing Home Administrator (NHA) and Director of Nursing (DON) was notified of the immediate jeopardy. The facility submitted a plan of correction (P[NAME]) at 1:29 p.m. on 04/09/19. The SA requested changes and new P[NAME] was submitted at 2:00 p.m The SA again requested changes and the final P[NAME] was submitted at 2:19 p.m. and was accepted by the SA at 2:27 p.m. The SA observed for implementation of the P[NAME] and determined it had been implemented. The IJ was abated at 4:50 p.m. on 04/09/19. This was true for two (2) of two (2) residents who receive sliding scale insulin coverage. After the IJ was abated a deficient practice remained therefore the scope and severity was decreased from a K to E. A deficient practice remained for Resid… | 2020-09-01 |
| 3352 | 3352 | PRINCETON HEALTH CARE CENTER | 515187 | 315 COURTHOUSE RD. | PRINCETON | WV | 24740 | 2018-11-12 | 600 | K | 0 | 1 | 2C7711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the Centers for Medicare and Medicaid Services Appendix PP State Operations Manual and staff interview the facility failed to ensure all residents were free from verbal and physical abuse from other residents. Resident #110, Resident #93, and Resident #105 have been identified as residents who have on several occasions demonstrated verbally and physically abusive behaviors towards other residents residing on the south wing of the facility. These incidents have been ongoing at least since at least 08/2018. The facility has not demonstrated that they provided enough protection to prevent resident to resident abuse and to protect the other residents currently residing on the south wing of the facility. Residents residing on the south unit have voiced fear of resident #110 and Resident #93 one resident has voiced that he is to fearful to sit in the hallway. Resident #24 was fearful of resident #110 and was afraid he was going to sexually assault her the facility failed to address this fear and failed to make this resident feel safe while residing in the facility. The facility has put into place interventions of redirection and medication changes, but the residents behaviors of physical and verbal abuse continue indicating the interventions have not been successful in changing the residents behavior and/or protecting the other residents residing on the South Wing. These failures have placed all residents currently residing on the South Wing of the facility at an immediate risk for serious harm. The facility was notified of the Immediate Jeopardy on 11/07/18 at 2:56 p.m. The facility submitted a plan of correction to the state agency at 4:52 p.m. on 11/07/18. The plan of correction was accepted by the state agency at 5:18 p.m. on 11/07/18. The state agency observed for implementation of the accepted plan of correction and the Immediate Jeopardy was abated at 6:58 p.m. on 11/07/18. Once the immediate je… | 2020-09-01 |
| 3753 | 3753 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2018-09-21 | 689 | K | 1 | 0 | PCJU11 | > Based on observation, staff interviews, testing of equipment, review of incident reports, and review of incidents reported to the State related to elopements, the facility failed to ensure an environment that was free from accident hazards over which the facility had control and failed to provide supervision to each resident to prevent accidents from wandering into unsafe places. This had the potential to affect the sixteen (16) residents (#42, #30, #38, #44, #50, #46, #37, #39, #45, #15, #12, #11, #26, #14, #10, and #6) identified by the facility as at risk of eloping who wore Secure Care tracking devices. The Secure Care system used by the facility was programmed to elicit an audible alarm whenever any of the 16 residents opened or went out an exit door. Simultaneously, the system was to send an alert identifying the resident and the location of the door the resident was opening to pagers worn by facility staff. In (MONTH) (YEAR), Resident #10, who was wearing a tracking device, had eloped. Staff were unaware of the resident's elopement until a nurse on the first floor heard him yelling outside and saw him sitting on the ground. The door alarm was not heard by staff and alerts were not sent to staffs' pagers. Testing of the system at the time of the survey found it was not functioning as intended. Alarms could not be heard by staff and alerts were not sent to staffs' pagers. Outside environmental safety issues included a busy main highway adjacent to the parking lot, outdoor temperatures that might adversely affect an individual, a nearby in-use railroad, and nearby wooded terrain. The facility's failure to identify and repair the non-working pager system upon which staff were dependent on for elopement prevention system, prior to surveyor intervention, created a situation in which immediate corrective action was necessary. The risk of elopement, along with environmental safety issues, was determined to pose a risk of serious injury, harm, impairment, or death to a resident receiving care in the facility. Aft… | 2020-09-01 |
| 3879 | 3879 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 309 | K | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide diabetic management as ordered by the physician to provide consistent treatment to a resident who had a [DIAGNOSES REDACTED]. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). The facility's failure to follow the physician's orders [REDACTED].#43's Diabetes placed her at an immediate risk for serious harm and/ or death, which resulted in the determination of an immediate jeopardy. The facility's Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified of the immediate jeopardy at 2:57 p.m. on 11/16/16. The NHA submitted a Plan of Correction (P[NAME]) to abate the immediacy at 5:15 p.m. on 11/16/16. After the P[NAME] was reviewed and accepted by the State agency at 5:30 p.m. on 11/16/16, the survey team confirmed implementation of the corrective actions and the immediacy was abated at 6:25 p.m. on 11/16/16. Resident Identifier: #43. Facility Census: 52. Findings: a) Resident #43 A review of Resident #43's medical record beginning at 7:30 a.m. on 11/16/16 found the following physician's orders [REDACTED]. -- Order with start date of 05/10/16 - If blood sugar is over 200 Consistently Call MD (Medical Doctor). -- Order with a start date of 09/19/16 - If patient does not eat do not give coverage. -- Order with start date of 11/22/15 - [MEDICATION NAME] per sliding scale: BS (Blood Sugar) 200-249 give 4 units BS 250 - 299 give 8 units BS 300 - 349 give 12 units BS 350 - 399 give 16 units BS is greater than 399 give 20 units Special instructions: Accu Check before meals and at bedtime with sliding scale coverage (If resident does not eat do not give insulin coverage). -- Order dated 10/13/16 to discontinue the 2:00 a.m. accu check with sliding scale coverage (SSC). -- Order with a start date 07/20/16 - [MEDICATION NAME] 20 units once daily once a day a… | 2020-04-01 |
| 4007 | 4007 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 223 | K | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, incident/accident reports review, facility reportable allegation(s) of abuse review, policy and procedure review, and staff interviews, the facility failed to ensure residents were free from sexual abuse. This was true for seven (7) residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s), who received nonconsensual sexual contact by Residents #10, #11, and/or #62 which were reviewed during the Quality Indicator Survey (QIS) and complaint investigation. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficient practice may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance.) A reasonable person, if touched inappropriately by another person … | 2020-03-01 |
| 4008 | 4008 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 224 | K | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids… | 2020-03-01 |
| 4010 | 4010 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 226 | K | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids… | 2020-03-01 |
| 4103 | 4103 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2019-04-02 | 600 | K | 0 | 1 | HCZ011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident council meeting, resident interviews, policy review, review of incident reports and staff interview the facility failed to ensure that each resident in the facility had the right to be free from sexual, physical, psychological and verbal abuse. The facility failed to prevent Resident # 44 from wandering about the facility, entering other residents' rooms, evoking resident to resident altercations and causing fear amongst the other residents. These findings were determined to pose an immediate jeopardy and the health and well-being and represents a pattern to affect more than a limited number of residents. The facility administrator was notified of the immediate jeopardy on [DATE] at 10:45 AM. The facility provided an immediate jeopardy abatement plan of correction on [DATE] at 2:20 PM. The abatement plan of correction included: --Resident #44 was placed on one on one supervision on [DATE] at 10:45 AM until an alterntive and equally effective intervention is identified. One [DATE], Resident #44 was sent to the Emergency Department of a local hospital at 1:00 PM for evaluation due to behaviors. --All interviewable residents were interviewed by the staff of the social services department on [DATE] to ensure there were no other residents affected by Resident #44's behavior. The administrator will interview all staff on [DATE] to determine whether they observed any abusive behaviors affecting non-interviewable residents by Resident #44. --On [DATE] Regional Vice President reeducated the Administrator and Social Services Director regarding abuse prohibition and neglect. This abuse prohibition and neglect training and resident rights training was provided to all staff on [DATE], including a posttest. Staff not availble on [DATE] were to be trained and tested prior to their next work shift. The immediacy of this deficient practice was abated on [DATE] at 4:50 PM. The post-abatement scope and severity was … | 2020-02-01 |
| 4206 | 4206 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2017-04-11 | 309 | K | 0 | 1 | XDKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and physician interviews, the facility failed to ensure Resident #53 received [MEDICATION NAME], an anticoagulant (blood thinner) upon return from a stay at an acute care hospital. After initiating [MEDICATION NAME] therapy, the facility failed to ensure prompt notification of the resident's physician of the results of ordered [MEDICATION NAME]/International Ratio (PT/INR) laboratory (lab) tests. Additionally, on two (2) separate occasions, the physician gave orders to increase Resident #53's [MEDICATION NAME], but the facility failed to administer the increased dose until the next day despite the fact it was available in the emergency medication box. These significant medication errors placed Resident #53 at an immediate risk for serious harm and/or death, resulting in a determination of immediate jeopardy. Additionally, the discharge summary from the hospital included an appointment was scheduled with a cardiologist for 04/04/17. The resident, who had a recent [MEDICAL CONDITION] infarction, did not attend due to the facility's failure to arrange for transportation to and from the appointment. The Nursing Home Administrator (NHA) and the Director of Nursing (NHA) were notified of the immediate jeopardy at 3:05 p.m. on 04/06/16. The facility provided a plan of correction (P[NAME]) to the State agency at 4:13 p.m. on 04/06/17, which the State agency reviewed and accepted at 4:17 p.m. on 04/06/17. The State agency representatives onsite ascertained implementation of the P[NAME] and abated the immediacy at 4:50 p.m. on 04/06/17. This immediate jeopardy began on 03/21/17, when the facility failed to initiate [MEDICATION NAME] therapy. From 03/21/17, forward the facility continued to make errors in following resident's plan of care. After removal of the immediacy, deficient practices remained for Residents #76 and #79. The scope and severity was decreased from a K to D for the deficient practices that were… | 2020-02-01 |
| 4209 | 4209 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2017-04-11 | 333 | K | 0 | 1 | XDKG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and physician interviews, the facility failed to ensure Resident #53 received [MEDICATION NAME], an anticoagulant (blood thinner) upon return from a stay at an acute care hospital. After initiating [MEDICATION NAME] therapy, the facility failed to ensure prompt notification of the resident's physician of the results of ordered [MEDICATION NAME]/International Ratio (PT/INR) laboratory (lab) tests. Additionally, on two (2) separate occasions, the physician gave orders to increase Resident #53's [MEDICATION NAME], but the facility failed to administer the increased dose until the next day despite the fact it was available in the emergency medication box. These significant medication errors placed Resident #53 at an immediate risk for serious harm and/or death, resulting in a determination of immediate jeopardy. The Nursing Home Administrator (NHA) and the Director of Nursing (NHA) were notified of the immediate jeopardy at 3:05 p.m. on 04/06/16. The facility provided a plan of correction (P[NAME]) to the State agency at 4:13 p.m. on 04/06/17, which the State agency reviewed and accepted at 4:17 p.m. on 04/06/17. The State agency representatives onsite ascertained implementation of the P[NAME] and abated the immediacy at 4:50 p.m. on 04/06/17. After removal of the immediate jeopardy, no deficient practice for this requirement remained. Resident identifier: #53. Facility Census: 113 Findings include: a) Resident #53 Resident #53 was readmitted from an acute care facility on 03/21/17 at 9:00 a.m. Review of the resident's medical record found the hospital discharge summary noted [DIAGNOSES REDACTED]. An echocardiogram completed during her hospitalization showed an ejection fraction of 40-45%, apical hypokinesis (abnormally decreased muscle function) and left ventricular apical thrombus (clot). Her target INR (international ratio) was 3.0. The discharge summary included an instruction for the resident to recei… | 2020-02-01 |
| 4294 | 4294 | PRINCETON HEALTH CARE CENTER | 515187 | 315 COURTHOUSE RD. | PRINCETON | WV | 24740 | 2016-06-01 | 323 | K | 0 | 1 | 8JZH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, observations, medical record reviews, staff interviews, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 6:00 p.m. and 6:30 p.m. on 05/23/16 with the maintenance department using their thermometer found the following water temperatures in the resident hands sinks in resident rooms: -- Room 310 the water temperature was 125.7 degrees Fahrenheit (F) -- Room 303 the water temperature was 126.4 degrees F -- Central Bath 300 hall the water temperature was 127.1 degrees F On 05/24/16 at 10:32 a.m., an additional temperature of 123.1 in room 313 by the maintenance department, was not within acceptable parameters. The maintenance director confirmed, during an interview on 05/23/16 between 5:30 p.m. and 6:30 p.m., the water temperatures had been all over the place, and had been erratic for a long period of time. The maintenance director expressed awareness that the water temperatures were erratic, indicated no intervention had been initiated to identify and correct the problem, and provided no evidence to indicate the facility had properly maintained the mixing valves. This discovery was determined an immediate jeopardy situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 3:10 p.m. on 05/24/16, the Associate Nursing Home Administrator (ANHA), and the Director of Nursing (DON) were notified of the immediate jeopardy due to the elevated water temperature, and the facility ' s culpability in knowing the problem existed without implementing a plan to correct the problem. The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency required re… | 2020-02-01 |
| 4656 | 4656 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-12-18 | 309 | K | 0 | 1 | 5DCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, physician interview, and staff interviews, the facility failed to provide the necessary care and services to enable all residents to maintain and/or attain the highest practicable physical well-being. Resident #107 had an order to obtain blood glucose/sugar levels two (2) times a day for a [DIAGNOSES REDACTED]. The facility failed to notify the resident's physician when the resident's blood sugar was 200 and above on 17 of 39 occasions obtained during the resident's 22 day stay at the facility. The resident was transferred to the hospital emergency roiagnom on day 21 of his nursing home stay, where he was diagnosed with [REDACTED]. Upon returning to the nursing home, the facility failed to follow the hospital's instructions for Accu-cheks (blood sugar monitoring) every 6 hours and sliding scale insulin based on the results of the Accu-cheks. Resident #107 expired at the facility on [DATE]. Further investigation of current residents at the facility with a [DIAGNOSES REDACTED].#53. On eighty-seven (87) occasions from [DATE] through [DATE], the resident's blood sugars were 401 or more. The facility administered insulin in accordance with the sliding scale orders, but failed to re-check the blood sugars within 2 hours as directed by the physician's orders [REDACTED]. The immediate jeopardy began on [DATE] at 11:30 a.m., when Resident #53's blood sugar was 493 and the facility failed to re-check the blood sugar after 2 hours. The facility was notified of the immediate jeopardy at 11:53 a.m. on [DATE]. The facility provided a plan of correction at 2:45 p.m. on [DATE], which self-identified three (3) additional residents whose blood sugars were not re-checked within 2 hours when blood sugars were above 401. The immediacy of this deficient practice was abated at 3:15 p.m. on [DATE]; however deficient practices still remained at a scope and severity of E for Residents #130, #57, #60, and #139. Residen… | 2019-08-01 |
| 4658 | 4658 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-12-18 | 323 | K | 0 | 1 | 5DCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, record review, and review of the facility's policy for Medication Administration, the facility failed to ensure the resident environment, over which the facility had control, was as free of accident hazards as possible. Observations found medications in a medication cup sitting unattended on Resident #57's over-bed table. Resident #57 did not have an order to self-administer medications, nor was the resident capable of medication self-administration. Additionally, the facility provided a list of fifteen (15) residents who had the potential to wander in and out of other residents' rooms. Four (4) of the fifteen (15) identified residents had known histories of entering other residents' rooms and/or taking other residents' belongings. At 5:50 p.m. on 12/08/15, the Administrator and Director of Nursing (DON) were informed the observed, unattended medications found on Resident #57's over-bed table, placed the resident's identified by the facility, with the potential to wander into Resident #57's rooms, and potentially ingest the unattended medications, in an immediate jeopardy situation. The facility provided a Plan of Correction (P[NAME]) at 6:54 p.m. on 12/08/15. A revised P[NAME] was accepted at 7:50 p.m. on 12/08/15. The State agency observed for implementation of the P[NAME] and found it properly implemented. At 8:10 p.m. on 12/08/15, the immediate jeopardy was removed. At that time the scope and severity of the citation was reduced from a K to an E. Resident #67 was unable to ambulate safely to the bathroom located within his room, due to other resident's assistive devices and/or furniture, which blocked the path and the doorway to the bathroom. Resident identifiers: #57, #23, #60, #97, #102, and #67. Facility census: 91. Findings include: a) Resident #57 An observation on 12/08/15 at 9:35 a.m., found a medication cup containing six (6) pills sitting on Resident #57's over-bed table.… | 2019-08-01 |
| 4660 | 4660 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-12-18 | 329 | K | 0 | 1 | 5DCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, consultant pharmacist interview, and staff interview, the facility failed to ensure each resident's medication regimen was free of unnecessary medications. The facility failed to ensure residents receiving antihypertensive (high blood pressure) medications were given those medications only when indicated and to avoid the potential for adverse consequences. Additionally, the facility discontinued the parameters for four (4) residents (#1, #3, #12, and #10) who were identified by the physician to not be stable, thereby not ensuring the residents were adequately monitored. This was found for four (4) of fifteen (15) residents identified by the facility as having parameters associated with medication orders, who were administered medications when the medication should have been held. Additionally, Residents #130 and #62 received an antianxiety medication ([MEDICATION NAME]) without evidence nonpharmacologic interventions were implemented before administration of the medication, no monitoring of side effects, and no targeted behaviors which warranted the use of the medications. For Residents #144, #69, and #60, the facility failed to ensure the residents who received antianxiety/antipsychotic medications had appropriate [DIAGNOSES REDACTED]. At 6:28 p.m. on 12/16/15, the administrator (NHA) and director of nursing (DON) were notified of an immediate jeopardy. On 12/16/15 at 7:35 p.m., the State agency confirmed implementation of the plan of correction and the immediacy was removed. At that time, the scope and severity was reduced from a K to an E because of a remaining deficient practice. Resident identifiers: #1, #3, #12, #10, #130, #62, #144, #69, and #60. Facility census: 91. Findings include: a) Resident #1 Medical record review for Resident #1, on 12/15/15 at 10:00 a.m., found a physician's orders [REDACTED]. Hold for systolic blood pressure (SBP) less than 160 mmHg (millimeters of mercury … | 2019-08-01 |
| 4664 | 4664 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2015-12-18 | 431 | K | 0 | 1 | 5DCP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medication administration pass observations, medical record review, review of facility policy, review of facility's investigations, and staff interviews, the facility, in coordination with the licensed pharmacist, failed to provide a narcotic storage system in which the resident's controlled substances were in permanently affixed compartments for storage of controlled drugs in one (1) of two (2) medication rooms, failed to ensure the proper labeling of medications to assure that they were stored safely and were provided to the residents accurately and in accordance with the prescriber's instructions, and failed to establish a system of medication records that enabled periodic accurate reconciliation, accounting for, and disposition of all controlled medications. The facility had no formal mechanisms in place to maintain accurate and timely medication records. The facility, in coordination with the pharmacist, failed to establish a means to ensure security and safeguarding of controlled medications. There was no system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. The facility was not conducting periodic reconciliations of records of receipt, disposition, and inventory for controlled medications to prevent or identify loss or diversion of these medications. There was no evidence the pharmacist evaluated the facility's systems regarding controlled medications to ensure the facility maintained an accurate accounting of all controlled medications and completed periodic reconciliations. The facility failed to ensure/prevent misappropriation of controlled substances for 63 residents who resided in the facility for the time period of [DATE] through [DATE] who received controlled narcotics (pain medication). The facility's failure to follow a systematic approach for receipt and destruction of narcotics placed all residents receiving narcotics at risk for drug diversion and mis… | 2019-08-01 |
| 4708 | 4708 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2016-04-06 | 323 | K | 0 | 1 | TULX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents. Seven (7) residents resided on the 500 hall/Memory Care Unit (MCU), a separate unit isolated from other parts of the building. The T shaped department was staffed every shift by two (2) people, a nurse and a nurse aide (NA), and contained multiple unsecured, out of sight areas for the residents to wander into unobserved. Three (3) (Residents #61, #93, and #75) of the seven (7) residents had care plans for wandering. The front door, an alarmed egress, malfunctioned intermittently, preventing anyone from exiting the building or turning off the alarm if it sounded. Additionally, staff had difficulty hearing the alarm. Observations on 03/29/16 at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. A faint alarm sounded, but no staff approached in response. Therapy Staff #35 was able to get the door to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. Therapy Staff #37 attempted to enter the unit by pushing the red button, but the door would not open. No staff were observed on the unit except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came in through the door at the end of that hall. When Maintenance Director #6 entered the unit by the back door, Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened last week. After reviewing incident reports and medical records, conducting staff interviews, and multiple observations on the 500 hall/memory car… | 2019-08-01 |
| 4709 | 4709 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2016-04-06 | 353 | K | 0 | 1 | TULX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of staffing schedules, the facility failed to provide sufficient nursing staff to provide needed care and supervision to all residents residing on the 500 hall/memory care unit. Deployed staffing was not adequate for monitoring the resident population which included residents with dementia, and residents that wandered and were at risk of eloping. Seven (7) residents with dementia-related [DIAGNOSES REDACTED]. The T shaped department was staffed every shift by two (2) people, a nurse and a nurse aide (NA), and contained multiple unsecured, out of sight areas for the residents to wander into unobserved. In addition to the [DIAGNOSES REDACTED].#61, #93, and #75) of the seven (7) residents had care plans for wandering. The front door, an alarmed egress, malfunctioned intermittently, preventing anyone from exiting the building or turning off the alarm if it sounded. Additionally, staff had difficulty hearing the alarm. Observations on 03/29/16 at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. A faint alarm sounded, but no staff approached in response. Therapy Staff #35 was able to get the door to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. Therapy Staff #37 attempted to enter the unit by pushing the red button, but the door would not open. No staff were observed on the unit except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came in through the door at the end of that hall. When Maintenance Director #6 entered the unit by the back door, Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened las… | 2019-08-01 |
| 4757 | 4757 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2016-02-12 | 323 | K | 0 | 1 | PDOU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, observations, medical record reviews, staff interviews, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 10:10 a.m. and 10:26 a.m. on 02/10/16 with the maintenance department using their thermometer found the following water temperatures in the resident hands sinks in resident rooms: Room 200 the water temperature was 140 degrees Fahrenheit (F) Room 204 the water temperature was 134.6 degrees F Room 300 the water temperature was 142.9 degrees F Room 303 the water temperature was 132.8 degrees F. This discovery was determined an immediate jeopardy (IJ) situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 12:10 p.m. on 02/10/16, the Nursing Home Administrator (NHA), the Chief Executive Officer (CEO), the Director of Nursing (DON) and the Assistant Chief Nursing Officer (ACNO) were notified of the IJ, and that it was due to the elevated water temperature. This immediate jeopardy began at 10:10 a.m. on 02/10/16 when Employee #63, a facility consultant working with the maintenance department, obtained the water temperature of 140 degrees Fahrenheit (F) in room 200. The facility provided a plan of correction at 1:47 p.m. on 02/10/16. The immediate jeopardy was abated at 2:50 p.m. on 02/10/16. No deficient practice remained after removal of the immediate jeopardy. Eleven (11) residents were identified as being at risk for serious harm as a result of the elevated water temperatures they all suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The eleven (11) residents identifi… | 2019-07-01 |
| 5147 | 5147 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2015-06-23 | 223 | K | 0 | 1 | PDA311 | Based on observation, resident interviews, staff interviews, clinical record review, review of facility records, and facility policy and procedure review, the facility failed to ensure the safety of residents after an allegation of resident to resident sexual abuse. Resident #72 alleged Resident #79 touched her inappropriately. She reported it to a licensed practical nurse (LPN) on 06/13/15; however, the nurse did not report the allegation and an investigation was not immediately initiated. In addition, no efforts were made to protect other facility residents from sexual abuse from Resident #79, who was able to move freely throughout the facility. Investigation during the survey revealed the allegation was brought to the facility's attention in a morning meeting on 06/15/15. Although the facility initiated an investigation at that time, the facility did not put measures in place to protect the residents from sexual abuse by Resident #79. As of 06/16/15, during the survey, measures to protect the residents had not been put into place. Another resident, Resident #2, stated she was made aware of the situation by Resident #79 (the perpetrator). She said she was afraid Resident #79 would do something to her also. On 06/16/15 at 6:58 p.m., the Administrator and Director of nursing (DON) were notified of an Immediate Jeopardy (IJ) situation as the result of the facility's failure to protect residents during the investigation of an allegation of abuse. On 06/16/15 at 8:43 p.m., the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated. The P[NAME] included: Immediate Jeopardy has been identified based on failure to report an allegation of sexual abuse in a timely manner; to protect residents from potential harm during the investigative process; and, to implement the facility policy and procedure regarding abuse. On 06/15/15 at approximately 9:15 AM, the Director of Nursing informed Administrator of a progress note written on 6/13/15 by LPN stating that a female resident had reported to her th… | 2019-03-01 |
| 5734 | 5734 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2015-08-21 | 309 | K | 1 | 0 | Z9U411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the necessary care and services to enable all residents to maintain and/or attain the highest practicable physical, mental, and psychosocial well-being. Residents #79, #73, #4, #85, and #110 had orders for [MEDICATION NAME]given after meals, depending on whether the resident ate more or less than 50% of the meal. [MEDICATION NAME] is an analog insulin that acts more quickly than regular human insulin. The manufacturer ' s instructions to patients includes, . Keep in mind, you will need to eat a meal within 5 to 10 minutes after taking [MEDICATION NAME] Record review found Resident #79 ' s [MEDICATION NAME]was discontinued on 06/19/15 without an order from the physician or family nurse practitioner. Additionally, when ordered, the resident did not receive [MEDICATION NAME] as ordered when the resident consumed more than 50% of a meal; received the medication when the resident ate less than 50% of a meal; and meal consumptions were not recorded, yet the insulin was given or held. This placed the resident at risk of developing [DIAGNOSES REDACTED] (low blood sugar) and/or [MEDICAL CONDITION] (high blood sugar), either which placed the resident ' s health and well-being at risk. The failure to administer the insulin in accordance with the physician ' s and/or family nurse practitioner ' s orders, and failure to document meal consumptions, also had the potential to affect the clinician ' s ability to determine whether the medication, at its ordered dosage, was resulting in the desired effect on controlling the resident ' s blood sugars. These findings were determined to pose an immediate jeopardy to the health and well-being of Resident #79. After identification of the immediate jeopardy for Resident #79, review of four (4) additional found Residents #73, #4, #85, and #110 all had orders for insulin administered after meals and to hold it if the resident consumed less than … | 2018-08-01 |
| 5959 | 5959 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2014-08-05 | 323 | K | 0 | 1 | GK2611 | Based on observation, water temperature measurements, staff interviews, review of facility procedures, and resident interview, the facility failed to ensure the resident's environment, over which the facility had control, was as free from accident hazards as possible for 34 of 64 facility residents. On 07/28/14, water temperatures obtained in resident areas on all hallways exceeded 110 degrees Fahrenheit (F). Three (3) resident rooms had water temperatures at sinks which exceeded 120 degrees F. The maintenance department became aware the facility's water temperatures exceeded 120 degrees F at 9:00 a.m. on 07/28/14. Maintenance did not promptly alert staff and enact a plan to ensure resident safety while they were adjusting the water temperatures. Interviews revealed nursing staff and administrative staff were not notified of any concerns regarding excessive hot water temperatures until 4:00 p.m. on 07/28/14. Staff interviews also confirmed that from 9:00 a.m., when the problem was identified, until 4:00 p.m., residents were provided showers as scheduled on the day shift, and showers continued to be provided into the evening shift until 4:00 p.m. At 4:00 p.m. on 07/28/14, a resident, who was receiving a shower, complained to staff the water temperatures were too hot. At that time all staff were advised to discontinue the showering of residents. Residents #20, #39, #36, #85, #52, #18, #31, #5, #13, #81, #50, #95, #15, #97, #49, #70, and #3 were all provided showers on 07/28/14 between 9:00 a.m. and 4:00 p.m. Between the hours of 9:00 a.m. and 4:00 p.m., all hand sinks were accessible to each resident who was able to independently wash his/her hands. Residents #53, #47, #19, #69, #46, #12, #37 , #32, #67, #78, #61, #58, #81, #90, #95, #7, #6, #11, #76, #49, #70, and #3 were all identified by facility staff as residents who were independently able to wash his/her own hands. A determination was made that an immediate jeopardy existed. The immediate jeopardy began at 9:00 a.m. on 07/28/14, when the maintenance departme… | 2018-05-01 |
| 6001 | 6001 | PLEASANT VALLEY NURSING AND REHABILITATION CENTER | 515064 | 640 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2014-09-18 | 323 | K | 0 | 1 | 7HHJ11 | Based on water temperature measurements, observations, staff interview, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. At 3:10 p.m. on 09/15/14, a water temperature measurement of the water at the hand sink in Room 402 was obtained by facility staff using facility equipment. The water was 131.8 degrees Fahrenheit (F). According to CMS Guidance to Surveyors, a 3rd degree burn can occur in 15 seconds when the water temperature is 133 degrees F. This discovery was determined an immediate jeopardy (IJ) situation, with the potential to affect more than an isolated number of residents. At 4:18 p.m. on 09/15/14, the Nursing Home Administrator (NHA) was notified of the IJ, and that it was due to the elevated water temperature. The NHA was informed the IJ began at 3:10 p.m. on 09/15/14, when a water temperature of 131.8 degrees F was obtained in resident Room 402. During an interview with the NHA, after notification of the IJ, she stated the maintenance department was making adjustments and the temperatures should already be below 120 degrees F. The water temperature in Room 402 was obtained, at 4:22 p.m. on 09/15/14, by facility staff using the facility's thermometer. The temperature of the water in the hand sink in Room 402 was even higher. It was 135 degrees F. The NHA was notified the temperature was hotter than before and would be included in the determination of the IJ. The facility's plan of correction (P(NAME)) was accepted by the state agency at 5:30 p.m. on 09/15/14. The facility submitted the following plan to remove the immediacy of the deficient practice: (typed as written) 4:20 p.m. All employees working were inserviced to immediately inform the Administrator, DON (Director of Nursing) and/or the maintenance director if water is hot when washing hands. 4:30 (pm) Staff was instructed to d… | 2018-05-01 |
| 6242 | 6242 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2014-08-14 | 323 | K | 0 | 1 | EXXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the facility failed to provide an environment that was as free as possible from accident hazards over which it had control. Water temperatures in the public restrooms, that could be accessed by more than an isolated number of residents, were too high for safety. The public restrooms, for men and women, registered 160 degrees Fahrenheit (F) on 08/13/14. Those restrooms were unlocked and could be accessed by mobile residents. Also, water temperatures were high in two (2) resident common use restrooms, registering 120 degrees (F) on 08/13/14. Those restrooms were unlocked and could be accessed by mobile residents. These situations created a potential for serious injury to residents. Affected areas included the men's and women's public restrooms that were located in the corridor between the front hall and back hall resident living quarters, and the two (2) common use restrooms located at the entrance to the C hall resident living quarters. The former resulted in a determination of immediate jeopardy (IJ). A facility maintenance employee verbally reported that they check the water temperatures in all the resident areas once per month. However, they do not keep a log, or records, of when the water temperatures were tested , and/or the results of the testing. There was no evidence the facility monitored and/or used the results of the monitoring of hot water temperatures to ensure resident safety. On 08/13/14 at 1:02 p.m., the State office directed to call an immediate jeopardy (IJ) related to the hot water temperatures of the men's and women's restrooms located in the corridor between the front and back halls. Employee #31, the Person in Charge (PIC), was notified immediately. On 08/13/14 at 1:50 p.m., Employee #31 provided a plan of correction. The correction was that the bathrooms had been locked, and were out of working orde… | 2018-04-01 |
| 6370 | 6370 | BRAXTON HEALTH CARE CENTER | 515180 | 859 DAYS DRIVE | SUTTON | WV | 26601 | 2014-06-02 | 323 | K | 0 | 1 | OMIN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on observations, record review, resident interviews, staff interviews, review of the Centers for Medicare and Medicaid State Operations Manual, and documentation provided by the facility, the facility failed to ensure the resident environment remained as free of accident hazards as possible. The facility also failed to ensure residents received needed supervision and assistance devices for safe transfer of residents requiring assistance for that activity. The facility had an ineffective program for assessing/implementing and reassessing residents after they had a functional status change in transfer ability. The facility also failed to implement an effective educational training program related to safe transfers with mechanical lifts and staff assisted transfers. This placed all residents who needed assistance with transfers in an immediate jeopardy situation. It had the potential to affect fifty-four (54) of sixty-one (61) residents residing in the facility who required transfer assistance. Residents #3, #30, and #66 were each observed being transferred by one (1) aide, although their care plans indicated they needed assistance of two (2) persons for transfers. Resident #26 received a suspected deep tissue injury (SDTI) as a result of being pinched by the lift pad during a full body lift transfer. The SDTI eventually became a Stage IV pressure ulcer. The improper use of the mechanical lift resulted in actual harm for Resident #26. Residents #78, #12, #5, and #60 were each identified as receiving skin tears and/or bruises during transfers using a mechanical lift. The immediate jeopardy situation began on 05/14/14 when Resident #3 slid out of the sit to stand mechanical lift while being transferred from her wheelchair to her bed. The resident was transferred by one (1) aide assisting the resident ,when there should have been two (2) aides assisting the resident with the transfer, as was identified in her care plan. The facility was no… | 2018-04-01 |
| 6394 | 6394 | GREENBRIER HEALTH CARE CENTER | 515185 | 1115 MAPLEWOOD AVENUE | LEWISBURG | WV | 24901 | 2014-06-27 | 323 | K | 0 | 1 | 35BV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure the resident environment, over which the facility had control, was as free of accident hazards as possible. Free standing floor fans, with grills which allowed access to the blades were in use. In addition, it was not possible to immediately determine if each fan was UL (Underwriters Laboratories - an independent, not-for-profit product safety testing and certification organization) listed. This was determined an immediate jeopardy to resident safety. A random observation revealed a resident attempting to place her fingers inside of the grill of a free-standing floor fan, which was located in the dining room on the second floor. Observation revealed the grill of the fan was wide enough to insert a finger and touch the revolving fan blades. It was not known whether or not the fan would shut down if someone touched the blades, so a maintenance employee inserted a tongue depressor into the fan grill and touched the blades. The fan did not shut down. Further observations found free-standing floor fans in the dining areas in the basement and the first floor. Observation revealed the gaps in the grill of the fan would allow residents to insert a finger and touch the revolving fan blades. On 06/25/14 at 10:21 a.m., the administrator was notified of the unsafe conditions related to the use of the fans. She was informed it was an immediate jeopardy (IJ) which had the potential to affect more than an isolated number of residents. Additionally, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of accidents was provided adequate supervision. The resident required the assistance of two (2) staff members for transfers. He was transferred by only one (1) staff member and fell sustaining a head injury for which he was sent to the emergency room . Resident identifiers: #72 and #59. Facility census: 77. Findings include: a) Resident #72 On 06/25/14 at… | 2018-04-01 |
| 6428 | 6428 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2015-03-06 | 323 | K | 1 | 0 | S2LQ11 | Based on record review, staff interview, and observation, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible. The tri-fold door on the health care unit, which is used by ambulance crews to enter and exit the facility, was found to not be closing properly. When facing the door, the left side of the tri-fold door would close automatically as it was intended to do; however, the right side of the tri-fold door would stick in the open position and would have to be closed manually by facility staff. The tri-fold door was not maintained in constant view of facility staff, nor did the WanderGuard system alarm if a resident wearing a WanderGuard passed through the opened half of the door way. This created the potential for serious harm and/or death related to the risk of elopement. Residents #48, #34, #45, and #3 were identified by facility staff as being at risk for elopement. Each resident wore a WanderGuard on their person. The purpose of the WanderGuard was to lock exit doors if the resident was within a certain amount of space of the door, and to alarm should the resident attempt to open the door. Additionally, the WanderGuard should alarm and alert staff if a resident left the facility through an open doorway equipped with the WanderGuard system. It was confirmed the tri-fold door was equipped with the WanderGuard system, but when the right side of the door (the right side identified when standing facing the door) would stick and not close properly, the WanderGuard system did not alarm when a resident wearing a WanderGuard passed through the open half of the door. This placed four (4) of four (4) residents (Residents #48, #34, #45, and #3), identified by the facility at risk for elopement in an immediate jeopardy situation. The facility's Executive Director and the Director of Nursing were notified of the immediate jeopardy on 03/03/15 at 7:10 p.m The Immediate Jeopardy began at 5:20 p.m. on 03/03/15, when the door was observed standing open… | 2018-03-01 |
| 6733 | 6733 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2013-11-13 | 223 | K | 0 | 1 | IQK011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review and policy review, the facility failed to ensure residents were free from verbal, mental and/or physical abuse by another resident. Residents were fearful of harm to themselves or others related to Resident #145's behaviors. In addition, the resident's foul language was upsetting to some of the residents. Three (3) sample residents and one (1) resident identified through a random opportunity for identification were affected; however, the situation had the potential to affect more than an isolated number of residents. At the time of of the resident's admission, the facility had knowledge the resident had a severe mental disorder, was disoriented, displayed inappropriate social behavior, had seriously impaired judgment, and was verbally abusive. There was no evidence the facility developed a plan of care or implemented interventions, when the resident was admitted , to protect other residents and ensure a safe living environment. Between 10/18/13 and the date of review on 11/06/13 (nineteen (19) days), the resident exhibited aggressive behaviors affecting others. These included cursing, threatening behaviors, physical aggression with staff, intrusions on the privacy of others, and significant disruption of resident care and the living environment. The facility failed to identify the impact this resident's behaviors had on other residents. The resident's comprehensive minimum data set (MDS) assessment did not accurately reflect and assess the behaviors. The care plan did not contain interventions related to preventing harm to himself or others, or interventions to protect other residents' privacy. Resident #145 created an environment which four (4) residents interviewed believed was unsafe. No actual harm had occurred at the time this was identified; however the potential existed for this resident to cause harm to more than an isolated number of residents. The administrator was notified… | 2017-11-01 |
| 6950 | 6950 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 323 | K | 0 | 1 | WVZU11 | Based on observations, resident comment, and staff interview, the facility failed to provide an environment free from accident hazards. A resident (Resident #67) was observed to touch a metal heating unit in a room designated for dining on the second floor long term care unit and immediately withdraw his hand. When measured, the temperature on the top surface of this unit was 135 degrees Fahrenheit. The temperature in the area where heat was expelled was measured to be 200 degrees Fahrenheit. This area of the unit was also accessible to anyone who might decide to touch it. The unit was midway down the surface of the wall, immediately below the window, at the level accessible without requiring the resident to bend over. This practice had the potential to affect all residents residing on the 2nd floor long term care unit and rendered the mobile, self-ambulatory residents to be in immediate jeopardy of being burned on the unit. The administrator was advised of the immediate jeopardy at 11:18 a.m. on 06/18/2013. The administrator immediately turned the unit off and had the maintenance department disable the unit. The unit and other like units were subsequently removed from the walls. The immediate jeopardy was removed at 2:25 p.m. on 06/18/2013 and no deficient practice remained relative to the heating units. Census on this unit was 17. However, environmental safety issues were also identified that had a potential for more than minimal harm, but not actual harm or immediate jeopardy. A can of disinfectant deodorizer was left where it was accessible to residents, hand rails had areas that could cause injury to residents, and water temperatures were found to be in ranges above those safe for bathing and which could result in burns with exposure of three (3) to five (5) minutes. Facility census: 59. Findings include: a) While conducting a random tour of the 2nd floor long term care unit of the facility on 06/18/13 at 11:05 a.m., Resident #67 was wheeling about the unit and requested the surveyor look at the plants in th… | 2017-09-01 |
| 7001 | 7001 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 323 | K | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I Based on observation, resident interview, staff interview, review of the facility's policy for Bed Safety Assessment Guidelines, and review of the 03/10/06, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued by the United States Department of Health and Human Services, Food and Drug Administration Center for Devices and Radiological Health, it was determined the facility failed to ensure the resident environment, over which the facility had control, remained as free of accident hazards as possible. With the slight touch of a hand, half side rails on the beds of two (2) resident's, Resident #37 and Resident #63, were able to be tilted inward and outward, forward and backwards. When moved outward, the gap between the mattress and the side rails measured four (4) inches on Resident #37's bed and three (3) inches on Resident #63's bed, resulting in a potential for entrapment. Side rails on an additional nineteen (19) residents' beds were observed and found loose, allowing a slight touch of the hand to rock the rails forward and backwards and inward and outward. Interviews with facility staff, residents, and review of the bed safety assessments for two (2) residents (Residents #52 and #44) confirmed the facility was aware of the ill-fitting side rails. On 12/02/13 at 7:30 p.m. the loose side rails were discussed with the administrator and no further information was presented to verify the facility had assessed the situation or implemented a plan of action for correction. The administrator stated the facility would have work orders to verify the action taken when occurrences of loose rails were reported; however, this information was never presented. At 8:00 p.m. on 12/02/13, the administrator was informed of the ill-fitting side rails and the unsafe conditions present resulting in immediate jeopardy. An acceptable plan of correction was provided on 12/02/13 at 10:20 p.m. Observations of the corrective action… | 2017-09-01 |
| 7071 | 7071 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2014-07-14 | 323 | K | 0 | 1 | U25211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and a review of the Centers for Medicare and Medicaid (CMS) State Operations Manual, the facility failed to ensure the resident environment was as free as possible of accident hazards, over which it had control. Hot water temperatures were too high in resident rooms and common areas, creating a potential for serious injury to residents. The facility was not routinely checking water temperatures, and staff stated they had no means to do so. Affected areas included rooms #113, #114, and #206, and shower rooms on the 100 and 200 hallways. This resulted in a determination of immediate jeopardy (IJ). The facility was also observed with unlocked soiled utility closets which contained chemicals and other potentially hazardous items. The medication room was observed propped open and unattended, creating yet another accident hazard due to the various potentially hazardous supplies in that room. These practices had the potential to affect more than an isolated number of residents. At the time of the discovery, the facility's census was 64 residents. On [DATE] at 3:00 p.m., the hot water temperature in Room #113 was checked and registered 127 degrees Fahrenheit (F). At 3:05 p.m. the hot water temperature in Room #114 was 124 degrees (F). In the 100 hall shower room sink the hot water temperature registered 124.6 degrees (F) at 3:10 p.m., and the 200 hall shower room sink had a temperature of 120.4 degrees (F). At 3:55 p.m. the temperature of the hot water in the sink of Room #206 registered 125 degrees (F). When informed the water temperatures felt hot, Maintenance Employee #9 said he could not find anything to test the water, and asked to borrow one of the surveyor's thermometers. It was learned he did not have a thermometer to test the water temperatures, and had not tested water temperatures for about 3 weeks. On [DATE] at 4:00 p.m., the Administrator was notified of an immediate jeopardy (IJ) due to hot water… | 2017-09-01 |
| 9355 | 9355 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 323 | K | 0 | 1 | 4F0I11 | Based on observation of an emergency egress door, review of the facility's evacuation plan, review of National Fire Protection Association (NFPA) guidelines, and staff interview, the facility failed to assure the emergency egress door located in the A-wing dining room was maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. A test of this emergency egress door found it to be equipped with a magnetic locking system with a timed emergency egress function of 30 seconds. The test, conducted on 09/29/11 at 2:30 p.m., found the alarm sounded when pressure was applied to the door, with the magnetic lock disengaging after approximately 30 seconds. The release of the magnetic locking system did not allow opening of the emergency egress door, as it had been sealed shut from accumulated rust and corrosion of the threshold plate located at the bottom of the door. This egress door displayed emergency exit signage and was designated as an exit on the facility's evacuation plan posted on the wall outside the A-wing dining room. Additionally, interview revealed staff identified this as a door to be used in the event of an evacuation. The program manager of the life safety program of the Office of Health Facility Licensure and Certification (OHFLAC) was contacted at 2:50 p.m. on 09/29/11. He was apprised of the findings related to the emergency egress door located in the A-wing dining room. The life safety program manager determined that if the door was designated as an emergency egress, and this door could not be opened, this constituted a finding of immediate jeopardy. The director of support services (Employee #95) and the director of nursing (DON - Employee #55) were informed by the team leader at 3:05 p.m. on 09/29/11, that the failure to assure the emergency egress doors were operational placed any residents and staff who may be in the dining area and/or nursing station in immediate jeopardy of harm or death, should a fire or other disaster require evacuation. The im… | 2015-11-01 |
| 9362 | 9362 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2011-10-04 | 520 | K | 0 | 1 | 4F0I11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the facility's evacuation plan, review of National Fire Protection Association (NFPA) guidelines, and policy review, the facility's quality assessment and assurance committee failed to develop and implement appropriate plans of action to correct deficiencies of which its members should have been aware in the areas of maintenance and housekeeping services. The QAA committee failed to implement a plan to ensure all doors identified as emergency egresses were able to be opened without impediment, especially in view of staff's awareness that a door identified as an emergency egress in the A-wing dining room had, once or twice before in past years, been sealed shut door due to corrosion at the threshold. This same door, which was labeled an emergency exit, was identified as an emergency exit on the facility's emergency evacuation plan, and was identified by staff as an exit to be used if it were necessary to evacuate this part of the facility, was unable to be easily opened when tested on [DATE], resulting in a finding of immediate jeopardy. The QAA committee also failed to identify quality deficiencies, and implement plans of action to correct these quality deficiencies, related to housekeeping services that were inadequate to prevent the spread of an infectious organism and maintenance services that failed to maintain a clean, comfortable, and sanitary interior for the residents. Facility census: 51. Findings include: a) During an interview with a family member who wished to remain anonymous, an allegation was made that staff members were smoking outside the A-wing dining room doors, causing smoke to enter the dining room. Following receipt of this complaint, an attempt was made, on 09/29/11 at 2:20 p.m., to exit the A-wing egress doors to inspect for evidence of smoking outside this door. The egress door failed to open after multiple attempts by this surveyor. - Assistance was sought from two (2)… | 2015-11-01 |
| 9716 | 9716 | LOGAN CENTER | 515175 | P.O. BOX 540 | LOGAN | WV | 25601 | 2010-08-12 | 323 | K | 0 | 1 | RDGV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, staff interview, staff-assisted checks of facility water temperatures, interview with the life safety code (LSC) surveyor, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), and record review, the facility failed to provide a resident environment as free of accident hazards as possible, by failing to assure water temperatures at hand sinks in resident rooms remained in a safe temperature range to prevent injuries. Water temperatures were measured, using the facility's thermometer in the presence of the maintenance supervisor (Employee #69), to be as high as 128 degrees Fahrenheit (F) at the hand sinks in various residents rooms. According to Table 1 in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur after exposure of only one (1) minute to a water temperature of 127 degrees F, and after exposure of only fifteen (15) seconds to a water temperature of 133 degrees F. The excessively hot water temperatures found in the sinks in various residents' room placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential for scalding / burn injuries, especially for independently mobile residents with cognitive impairment and/or decreased sensitivity to pain and/or extreme temperatures. In the administrator's absence, the director of nursing (DON) was informed of the immediate jeopardy determination at 1:00 p.m. on 08/04/10. The DON was informed, at 2:55 p.m. 08/04/10, that the circumstances leading to the immediate jeopardy were found to have been removed, when the facility was able to able to sustain a maximum hot water temperature of less than 110 degrees F, as verified by surveyor observation and testing. After removal of the immediate jeopardy, no deficient practice remained with respect to excessively h… | 2015-10-01 |
| 9984 | 9984 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2012-06-15 | 223 | K | 1 | 0 | WQ7R11 | Based on record review, staff interview, review of incident reports, resident interview, observation, and confidential staff interview, the facility failed to protect six (6) of ninety-six (96) residents from physical abuse by a resident known to have a history of aggressive behavior. The failure to prevent assaults and to effectively prevent further assaults resulted in a determination of an immediate jeopardy. Record review revealed Resident #45 struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising or skin tears. The most recent battery occurred on 05/28/12, during an unprovoked attack on Resident #60. This incident caused a skin tear above her eye, a bruise to her temple, and broke her eye glasses. Resident #45 was on a 15 minute watch to check his whereabouts, at the time of this attack. Facility staff did not make a decision to send the resident for inpatient evaluation and medication management, due to his aggressive behaviors, until 05/29/12, although the physical abuse happened frequently since 12/16/11. As of 06/01/12, he was still residing in the facility, and the only intervention related to his aggressive behavior was 15 minute watches to check his whereabouts. Confidential staff interviews with twelve (12) employees, who were familiar with Resident #45, revealed they believed he was a threat to others and could seriously harm someone. The employees described the resident had quick mood changes, making the planned 15 minute watches improbable of preventing physical assaults and battery on elderly female residents whom he targeted. A Resident identifiers: #45, #60, #81, #40, #82, #30, and #64. Facility census: 96. Findings include: a) Resident #60 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/16/11, revealed Resident #60 cried, and reported that Resident #45 hit her across the face and eye glasses. The type of injury was redness and a laceration/skin tear. The discussion/plan, on 12/21/12, noted Resi… | 2015-08-01 |
| 9985 | 9985 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2012-06-15 | 225 | K | 1 | 0 | WQ7R11 | Based on record review, staff interview, review of incident reports, resident interview, observation, and confidential staff interviews, the facility failed to protect six (6) of ninety-six (96) residents from physical abuse by a resident known to have a history of aggressive behavior. The facility failed to fully investigate and/or evaluate each incident of abuse by the same resident, and subsequently develop and implement interventions that would prevent further incidents of physical abuse from occurring. Record review revealed Resident #45 had struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising or skin tears. The most recent battery occurred on 05/28/12, during an unprovoked attack on Resident #60. This incident caused a skin tear above her eye, a bruise to her temple, and broke her eye glasses. Resident #45 was on a 15 minute watch to check his whereabouts, at the time of this attack. Facility staff did not make a decision to send the resident for inpatient evaluation and medication adjustment, due to his aggressive behaviors, until 05/29/12, although the physical abuse happened frequently since 12/16/11. As of 06/01/12, he was still residing in the facility, allowed to roam freely about the unit, solarium, and nearby long hallway with only 15 minute watches to check his whereabouts. Record reviewed revealed the facility failed to consider any of the ten (10) attacks to be physically or psychologically abusive from the perspective of the victims, as evidenced by none of the ten (10) attacks being reported to State agencies such as the State survey agency, the Ombudsman, or Adult Protective Services (APS). Confidential staff interviews with twelve (12) employees, who were familiar with Resident #45, revealed they believed he was a threat to others and could seriously harm someone. The employees described the resident had quick mood changes, making the planned 15 minute watches improbable of preventing physical assaults and battery on elderly… | 2015-08-01 |
| 10196 | 10196 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2010-01-28 | 323 | K | 0 | 1 | MFK411 | Based on observation and performance testing, record review, and staff interview, the facility failed to provide an environment as free as possible of accident hazards, by failing to ensure the delayed-egress magnetic locks on three (3) designated doors of emergency egress automatically released upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm, when tested with the application of force at 9:30 a.m. on 01/26/10, and again with the onset of the fire alarm system at 10:30 a.m. on 01/26/10. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room 101 (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when a contracted service company identified these concerns during an inspection of the facility's fire alarm system, yet no affirmative action had been taken to ensure this identified problem had been corrected at that time. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed a… | 2015-06-01 |
| 10197 | 10197 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2010-01-28 | 520 | K | 0 | 1 | MFK411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and performance testing, record review, and staff interview, the facility failed to develop and implement plans of action to correct quality deficiencies of which it was aware, to ensure the resident environment was as free as possible of accident hazards. A fire inspection report, provided to the facility by a contracted service company and dated 11/04/09, identified "access control doors" equipped with delayed-egress locks did not automatically release as designed upon activation of the fire alarm system. Interview with the plant operations director, on the morning of 01/26/10, found he was unable to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected in reaction to the 11/04/09 fire inspection report. Performance testing, on the morning of 01/26/10, found the delayed-egress magnetic locks of three (3) designated doors of emergency egress failed to automatically release as intended upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room [ROOM NUMBER] (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when the contracted service company identified these concerns during an inspection of the facil… | 2015-06-01 |
| 10198 | 10198 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2010-01-28 | 490 | K | 0 | 1 | MFK411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and performance testing, record review, and staff interview, the facility was not administered in an manner that enabled it to use its resources effectively and efficiently to maintain a resident environment as free as possible of accident hazards. A fire inspection report, provided to the facility by a contracted service company and dated 11/04/09, identified "access control doors" equipped with delayed-egress locks did not automatically release as designed upon activation of the fire alarm system. Interview with the plant operations director, on the morning of 01/26/10, found he was unable to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected in reaction to the 11/04/09 fire inspection report. Performance testing, on the morning of 01/26/10, found the delayed-egress magnetic locks of three (3) designated doors of emergency egress failed to automatically release as intended upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room [ROOM NUMBER] (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when the contracted service company identified these concerns during an inspection of the facility's fi… | 2015-06-01 |
| 10225 | 10225 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2010-06-04 | 323 | K | 0 | 1 | 5XSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on observation, staff interview, staff-assisted checks of facility water temperatures, interview with the life safety code (LSC) surveyor, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), and record review, the facility failed to provide a resident environment as free of accident hazards as is possible. The facility failed to assure water temperatures at hand sinks and showers accessible to residents remained in a safe temperature range to prevent injuries. Water temperatures in the resident environment were measured, using the facility's thermometer in the presence of facility staff, to be as high as 136 degrees Fahrenheit (F). According to Table 1 in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur after an exposure of only fifteen (15) seconds to a water temperature of 133 degrees F and after an exposure of only five (5) seconds to a water temperature of 140 degrees F. The excessive hot water temperatures found in the resident environment placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential for scalding / burn injuries, especially those residents with cognitive impairment and/or decreased sensitivity to pain and/or extreme temperatures. The administrator was informed of the immediate jeopardy determination at 11:00 a.m. on 05/27/10. An interview with the life safety surveyor at 11:35 a.m. on 05/27/10 found that the facility could provide no evidence that hot water temperatures were monitored to prevent accidental scalding or burns to facility residents. The administrator was informed, at 1:18 p.m. on 05/27/10, the circumstances leading to the immediate jeopardy were found to have been removed, when the facility was able to sustain a maximum hot water temperature of less than 110 degrees F as veri… | 2015-06-01 |
| 10230 | 10230 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2010-06-04 | 490 | K | 0 | 1 | 5XSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, resident and staff interviews, and review of guidelines published by the Centers for Disease Control and Prevention (CDC), the governing body failed to ensure the facility was administered in an efficient and effective manner as evidence by the presence of system failures in the areas of accident hazards, infection control, and activity programming, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy due to excessive hot water temperatures in resident-accessible areas which had the potential to result in third [MEDICAL CONDITION] exposure of fifteen (15) seconds or less; placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice; resulted in actual harm to one (1) resident who suffered confusion related to her relocation and psychological harm and mental distress due to the facility's failure to develop and implement an effective infection control program and a failure to provide for her need for social interaction during her period of involuntary seclusion; and presented the potential for more than minimal harm to all residents related to the facility's failure to ensure a qualified activity director was involved in the development and implementation of an ongoing program of activities based on the assessed needs and interests of individual residents. These actions resulted in findings of immediate jeopardy, actual harm, and substandard quality of care. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changes to facility systems. Facility census: 48. Findings include: a) Excessive hot water temperatures Based … | 2015-06-01 |
| 10231 | 10231 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2010-06-04 | 520 | K | 0 | 1 | 5XSR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, resident and staff interviews, and review of guidelines published by the Centers for Disease Control and Prevention (CDC), the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it should have been aware reflective of system failures in the areas of accident hazards, infection control, and activity programming, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy due to excessive hot water temperatures in resident-accessible areas which had the potential to result in third [MEDICAL CONDITION] exposure of fifteen (15) seconds or less; placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice; resulted in actual harm to one (1) resident who suffered confusion related to her relocation and psychological harm and mental distress due to the facility's failure to develop and implement an effective infection control program and to provide for her need for social interaction during her period of involuntary seclusion; and presented the potential for more than minimal harm to all residents related to the facility's failure to ensure a qualified activity director was involved in the development and implementation of an ongoing program of activities based on the assessed needs and interests of individual residents. These actions resulted in findings of immediate jeopardy, actual harm, and substandard quality of care. Facility census: 48. Findings include: a) Excessive hot water temperatures Based on observation, staff interview, staff-assisted checks of facility water temperatures, interview with the life safety code (LSC) surveyor, review of the Guidance to Surveyors found in the State Operations M… | 2015-06-01 |
| 10327 | 10327 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-01-13 | 323 | K | 0 | 1 | I28Y11 | . Part I -- Based on comments from a random resident, observation, staff interview, review of facility policy "1.84 Smoking", and medical record review, the facility failed to provide a resident environment as free of accident hazards as is possible, as evidenced by allowing Resident #53 to smoke in the "smoker's lounge" while using oxygen. Three (3) other residents were also present in the smoker's lounge at this time. This practice placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential of combustion of the oxygen. The immediate jeopardy situation was removed when Resident #53 was removed from the smoker's lounge after the surveyor and the facility's administrator verified, at 4:45 p.m., that the resident's oxygen tank was turned on and oxygen was actively flowing through his nasal cannula. The administrator was informed of the immediate jeopardy determination at 4:55 p.m. on 01/04/11, after the survey team conferred by telephone with the program manager of the State survey and certification agency. On 01/04/11 at 5:10 p.m., the administrator stated he was going to remove Resident #53's smoking privileges due to the resident not safely smoking independently. At 5:20 p.m., the administrator was observed by another surveyor removing Resident #53's smoking materials. At 5:28 p.m., the administrator reported Resident #53's care plan was updated to address this issue, and staff was educated regarding this matter. The administrator submitted an action plan to address dependent smokers who also use oxygen. The plan outlined suspension of smoking privileges by Resident #53, evaluation of the remaining independent smokers (with no further smokers having been identified as also using portable oxygen tanks), and that, on 01/05/11, the facility's quality assurance (QA) committee would "hold a special meeting to introduce new policy relating to Independent Smokers who have physician orders that include use of oxygen." Once Resident #53 and his oxygen tank were removed fro… | 2015-05-01 |
| 10333 | 10333 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2011-01-13 | 520 | K | 0 | 1 | I28Y11 | . Based on comments from a random resident, observation, staff interview, review of facility policy "1.84 Smoking", and medical record review, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies of which it was - or should have been - aware which were reflective of system failures in the area of accident hazards, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. On 04/02/10 and 07/23/10, Resident #53 had been assessed as being unsafe to smoke independently due, in part, to his use of oxygen. On 10/23/10, the assessor (Employee #38, a registered nurse) determined he was permitted to smoke independently even though he continued to use oxygen, which was contrary to the directions on the Smoking Evaluation tool, noting that "resident turns off oxygen to smoke". This Smoking Evaluation also was marked by the assessor to indicate that Resident #53's care plan had been updated to address this; however, review of the care plan in effect for Resident #53 at the time of the immediate jeopardy found no mention of smoking. On the afternoon of 01/04/11, Resident #53 was found to be smoking in the facility's "smoker's lounge" with his oxygen tank turned on and oxygen actively flowing through his nasal cannula. This practice placed Resident #53 and three (3) other residents who were present in the smoker's lounge in immediate jeopardy of harm or death due to the potential of combustion of the oxygen. The immediate jeopardy situation was removed when Resident #53 was removed from the smoker's lounge after the surveyor and the facility's administrator verified, at 4:45 p.m., that the resident's oxygen tank was turned on and oxygen was actively flowing through his nasal cannula. In subsequent interviews, the administrator reported having been aware that Resident #53 had been observed outside smoking with his oxygen on and that he (the administrator) would periodically monitor the resident to be sure his oxygen was turned off. T… | 2015-05-01 |
| 10917 | 10917 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2011-07-13 | 323 | K | 1 | 0 | YYWA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on the review of incident / accident reports, medical record review, family interview, staff interview, policy review, review of staff inservice training records, personnel record review, observations, and review of the facility's emergency preparedness plan, the facility failed to provide adequate supervision while smoking to one (1) of two (2) residents who required the use of supplemental oxygen. On 07/03/11, Resident #10 was permitted to smoke while receiving oxygen from a portable oxygen tank via a nasal cannula; a lit cigarette ignited the oxygen resulting in severe facial burns to Resident #10 which required treatment at an out-of-state burn unit. Resident #10 had been assessed by the facility as requiring staff supervision while she smoked, and the individual assigned to provide this supervision on the morning of 07/03/11 was a receptionist. The receptionist was not on the list of staff whose departments were routinely assigned the responsibility for supervising resident smoke breaks, and there was no evidence the receptionist had received training on the dangers / hazards of smoking in the presence of oxygen. This practice placed Resident #10 in immediate jeopardy and presented the potential for more than minimal harm to the other four (4) residents and any staff members in the designated resident smoking area at the time of the occurrence. After the incident involving Resident #10 occurred on 07/03/11, the facility provided training to staff on how to extinguish residents who are on fire using a blanket, sheet, or other large covering (and NOT a fire extinguisher). Observation of the resident smoking area found the only device available to smother a fire was a fire extinguisher, which the policy specifically instructed staff to not use to smother fire on a resident. No large covering was readily available for use by staff if it were again necessary to smother fire on a resident. Although a fire blanket was availabl… | 2014-11-01 |
| 10921 | 10921 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2011-07-13 | 490 | K | 1 | 0 | YYWA11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, staff interviews, and review of the facility's emergency / disaster preparedness records, the governing body failed to ensure the facility was administered in an efficient and effective manner as evidenced by the presence of system failures in the areas of quality of care, infection control, and emergency / disaster training, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy related to the failure to ensure all staff was knowledgeable concerning the dangers / hazards associated with resident smoking, placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice, and presented the potential for more than minimal harm to all residents related to the facility's failure to appropriately train employees in emergency preparedness. These actions resulted in findings of immediate jeopardy and substandard quality of care. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changed to facility systems. Facility census: 97. Findings include: a) Findings of immediate jeopardy Review of facility documents found that, on 07/03/11, Resident #10 suffered severe [MEDICAL CONDITION] treatment in an out-of-state burn unit. Resident #10 was supervised while smoking by a staff member who had not been trained in the hazards / dangers of smoking while utilizing oxygen. The staff member lit Resident #10's cigarette while the resident was receiving supplemental oxygen via a nasal cannula. The oxygen was ignited by the lit cigarette, which caused grievous injury to Resident #10. Observation of the area designated for resident smoking, on 07… | 2014-11-01 |
| 11273 | 11273 | LINCOLN NURSING AND REHABILITATION CENTER, LLC | 515171 | 200 MONDAY DRIVE | HAMLIN | WV | 25523 | 2010-09-22 | 309 | K | 1 | 0 | LVTE11 | . Based on observation, staff interview, review of the facility's list of items to be kept on the crash cart, and review of facility documents, the facility failed to ensure an assembled, readily available suction machine was present in the event of a choking emergency. A facility licensed practical nurse (LPN - Employee #56) brought the crash cart from the nursing station to the room of a resident found to be nonresponsive (Resident #28). Employee #56 was observed to be unable to locate a nasal cannula on the crash cart for administration of oxygen to the resident. It was further noted that the crash cart did not contain a suction machine in the event this resident required suctioning to clear his airway. Following the transportation of Resident #28 to the hospital, Employee #56 was asked to locate a suction machine for use in a choking emergency. Employee #56 searched the drawers of the crash cart, the clean utility room, and the nursing storage room without locating a suction machine. With the assistance of the records information systems clerk (Employee #47) and a member of environmental services (Employee #46), an unassembled suction machine was located in a drawer in the dining room. Seven and one-half (7.5) minutes elapsed before staff could locate a suction machine in the building. The facility identified fourteen (14) residents with swallowing problems and/or who were fed by gastrostomy tube with a facility census of fifty-eight (58) residents. Residents #24, #21, #23, #44, #33, #20, #9, #32, #10, #26, #17, #22, #43, and #56 were placed at risk of serious injury or death from choking should they aspirate food or fluids without a suction machine assembled, readily available, and all staff having knowledge of its location. The administrator was notified that the inability of staff to locate a suction machine in a timely manner placed the fourteen (14) residents with swallowing difficulties in immediate jeopardy of injury or death in the event of a choking emergency. The immediate jeopardy was abated at 4:0… | 2014-07-01 |
| 11278 | 11278 | LINCOLN NURSING AND REHABILITATION CENTER, LLC | 515171 | 200 MONDAY DRIVE | HAMLIN | WV | 25523 | 2010-09-22 | 490 | K | 1 | 0 | LVTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, staff interviews, and review of 64CSR13 (the Nursing Home Licensure Rule), the governing body failed to ensure the facility was administered in an efficient and effective manner as evidenced by the presence of system failures in the areas of quality of care, infection control, and dietary services, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy related to the failure to ensure all staff was knowledgeable of the location of an assembled suction machine ready-for-use in the event of a medical emergency; placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice; and presented the potential for more than minimal harm to all residents related to the facility's failure to procure the services of a qualified dietary manager during the extended absence of the dietary department supervisor. These actions resulted in findings of immediate jeopardy and substandard quality of care. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changed to facility systems. Facility census: 58. Findings include: a) Findings of immediate jeopardy During random observation of the resident environment on 09/15/10 at 2:20 p.m., a call for help was heard from Resident #28's room. Employee #56 was observed to retrieve the crash cart located by the nursing station and race to the resident's room. It was noted that no suction machine was present on the crash cart. Observation in Resident #28's room found Resident #28 slumped forward in his wheelchair and unresponsive to attempts by nursing staff to arouse him. Staff lifted the resident onto… | 2014-07-01 |
| 11495 | 11495 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 224 | K | 50Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to provide a reliable source of heat to maintain safe indoor temperatures and ensure residents were safe from developing hypothermia. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's contingency plan entitled "Heating back up plan" found the plan consisted of purchasing twenty (20) portable space heaters; this number was not sufficient to supply heat to sixty-five (65) unheated rooms occupied by eighty-one (81) residents currently in the facility. The contingency plan was inadequate to ensure the residents' environment remained at safe and comfortable temperature levels. This failure resulted… | 2014-02-01 | ||
| 11496 | 11496 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-10-07 | 493 | K | 50Z111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of ambient air temperatures measured by a life-safety code (LSC) surveyor from the Office of Health Facility Licensure and Certification (OHFLAC), information from the National Weather Service, review of resident body temperatures, review of the facility's 10/01/10 contingency plan entitled "Heating back up plan", review of National Institutes of Health (NIH) news release dated 01/16/09 entitled "Hypothermia: A Cold Weather Risk for Older People", review of facility documents, review of information on hypothermia from the Centers for Disease Control and Prevention (CDC), review of an article entitled "Hypothermia" (06/09/09) by the Mayo Foundation for Medical Education and Research (MFMER), medical record review, review of Appendix PP of the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, and staff interview, the facility's governing body failed to obtain the necessary supplies and services to repair and/or replace this boiler system prior to the cold weather experienced in the area on 10/05/10. The facility's heating boiler system, utilized to heat the common areas and resident rooms, failed to pass inspection on and was "red-tagged" (prohibiting the use of the boiler system until defects in the system were corrected) during inspections on 08/06/10 and 08/09/10. The governing body, possessing the authority to approve and allocate funds for the maintenance of the heating system for this facility, was aware of significant problems with the heating boiler system as early as August 2009. The governing body was also aware the facility's heating boiler system failed to pass inspections in August 2010 and did not act to correct the identified problems prior to a complaint survey beginning on 10/04/10. The failure of the governing body to authorize funding for the necessary repair and/or replacement of the malfunctioning heating boiler system, or to provide for an acceptable alternate heat source, in a timel… | 2014-02-01 | ||
| 332 | 332 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 684 | J | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, resident interview, pharmacy interview and observation, the facility failed to ensure all treatment and care provided to nine (9) or 25 sampled facility residents and one (1) randomly sampled resident was in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to perform finger stick blood glucose monitoring and give sliding scale insulin if needed as directed by the physician for Resident #4. The facility failed to administer medications in accordance with physician's orders [REDACTED]. The facility failed to follow-up on known side effects of hallucinations of a medication for Resident #7. The facility failed to obtain an order for [REDACTED].#1 and Resident #8. The facility failed to follow a bowel protocol for Resident #42. The facility failed to provide turning and positioning for Resident #5 who was dependent for turning and repositioning and had developed a pressure ulcer. The facility failed to ensure they assessed and monitored Resident #2 when the resident experienced a change of condition. On 10/10/18, at 2:35 PM, after consultation with the State Agency a determination of Immediate Jeopardy was identified at the facility. The facility failed to ensure that emergency medication ([MEDICATION NAME] Gel) was provided to a Resident #3 in accordance with physician's orders [REDACTED]. A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review… | 2020-09-01 |
| 336 | 336 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 760 | J | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, pharmacy interview, and observation, the facility failed to ensure that one (1) of 25 sampled residents was free of any significant medication errors. The facility failed to administer emergency [MEDICAL CONDITION] medication to a resident during a [MEDICAL CONDITION]. On 10/10/18, at 2:35 PM, after consultation with the State Agency, a determination of Immediate Jeopardy was identified at Riverside Health and Rehab Center. The facility failed to ensure that emergency medication was provided to Resident #3 in accordance with physician's orders [REDACTED]. A review of the medical record for Resident #3 revealed the resident had a [DIAGNOSES REDACTED]. The resident had a current physician's orders [REDACTED]. The order was originally written 03/30/2017 and remained a current order for Resident #3. A review of the medical record for Resident #3, noted on 09/29/2018, a [MEDICAL CONDITION] occurred at 3:15 AM which ended at approximately 3:34 AM. There was no evidence [MEDICATION NAME] Gel was administered to the resident in accordance with physician's orders [REDACTED]. A review of the medication administration record (MAR) and the controlled medication sign out book, on 10/10/2018, at 8:50 AM, noted the [MEDICATION NAME] Gel had not been signed as given on the MAR for 09/29/18, when the prolonged [MEDICAL CONDITION] for 19 minutes occurred nor had it been signed for in the controlled medication notebook. Interviews with two nursing staff, LPN #105 and LPN #55, at this time, verified the medication was not documented on the MAR and was not signed out. In addition, Resident #3 did not have a sign out sheet for staff to document doses taken out of the locked box when required to treat the resident. Observation of the locked medication box on the cart did not contain any dose of the [MEDICATION NAME] Gel ( [MEDICATION NAME] ) available to administer for Resident #3. Observations of the Automated Dispensing … | 2020-09-01 |
| 342 | 342 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2018-10-16 | 838 | J | 1 | 0 | BYSJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, resident interviews, observations, family interviews and medical record reviews the facility failed to ensure their facility assessment reflected the care required by their patient population. The facility was required to consider the types of diseases, physical and cognitive condition and other pertinent facts that were present within their patient population to ensure they had competent staff in the facility to meet the needs of the patient population. Issues were found in the following areas: Notification of changes, quality of care, freedom from neglect and nursing services. Deficient practices found reflected the nursing staff were not competent in the skills necessary to ensure the residents needs were met. Issues were idienfieid with residents with [MEDICAL CONDITION] disorders, acute change in health status, hallucinations and pressure ulcers. These deficient practices had the potential to affect more than an isoalted number of residents. Resident identifiers: #3, #20, #2, #5, and #7. Facility census: 83. Findings included: a) Resident #5 Notification of changes An interview, with Resident #5's Medical Power of Attorney (MPOA), on 10/14/18 at 6:00 PM, revealed Resident #5 had a (computed tompography (CT) scan. The MPOA said the facility did not inform him of the results from the CT scan. A progress note dated 07/30/18 stated, X-ray of right lower extremity reports [MEDICAL CONDITION] changes but could not rule out fracture of tibia. Discussed with FNP 'family nurse practicioner' and MPOA 'medical power of attorney.' New orders given for CT w/o (without) contrast of right lower extremity on 8/3/18 at (name of local hospital). MPOA (medical power of attorney) aware. A progress note dated 08/3/18 stated, Resident OOF 'out of facility' for CT scan via (name of ambulance company) per stretcher with 2 attendants. Further review of progress notes did not reveal any evidence indicating the MPOA was informed of the… | 2020-09-01 |
| 446 | 446 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2018-01-11 | 693 | J | 0 | 1 | JURJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide treatment and services to prevent potential complications, such as aspiration pneumonia, for a resident receiving enteral nutrition. Even though the head of the bed was elevated 30 degrees, Resident #66 was observed to be slid down in the bed with their head flat during an enteral feeding for approximately thirty (30) minutes. Upon interviewing the staff, a Licensed Practical Nurse (LPN) and a Nurse Aide (NA) were both aware the resident frequently slid down in bed allowing for their head not to be elevated during enteral feedings. Neither staff member reported this behavior. Further investigation revealed there were no interventions in place to help prevent the resident from sliding down in bed allowing their head to be flat during enteral feedings. These findings were determined to pose an immediate jeopardy to the health and well-being of Resident #66. The facility Administrator and Director of Nursing were notified of the immediate jeopardy on 01/10/18 at 10:20 AM. The facility provided a plan of correction on 01/10/18 at 11:40 AM. The immediacy of this deficient practice was abated on 01/10/18 at 11:55 AM. This identified failed practice had the potential to affect four (4) of four (4) residents who received enteral nutrition in the facility. Resident identifier: #66. Facility census: 79. Findings include: a) Resident #66 An observation, on 01/10/18 at 7:15 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident was slid down in the bed with their head flat. An observation, on 01/10/18 at 7:45 AM, revealed Resident #66's head of bed was elevated approximately 30 degrees. The resident was in the same slid down position in bed with their head flat. Upon closer observation, it was discovered the resident was receiving an enteral feeding via a pump. An immediate interview, on 01/10/18 at 7:45 AM, with Licensed Practica… | 2020-09-01 |
| 458 | 458 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2018-11-15 | 684 | J | 0 | 1 | T4YY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure two (Resident #48 and #32) of two sampled residents were provided appropriate care and services related to standards of practice and competency for Intravenous (IV) therapy resulting in Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18, when Resident #48 was readmitted with a peripheral inserted central catheter (PICC) for IV therapy. Licensed Practical Nurses (LPNs) #27, #33, #49 and #59 performed IV therapy without sufficient training and verification of such. The Immediate Jeopardy continued when Resident #32 was re-admitted to the facility on [DATE] with a PICC line in her right arm for intravenous antibiotic therapy. LPNs #6, #20, #35, #39 and #64 performed IV therapy for Resident #32 without sufficient training and verification of competency. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of Resident #48 and Resident #32 to identify any adverse effects related to IV therapy. The facility revised the staffing schedule to ensure a Registered Nurse would be performing IV therapy for the two residents (Resident #48 and #32) and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until LPNs are trained and competent with IV therapy. See F883 (Facility Assessment), F867 (Quality Assurance and Performance Improvement program) and F726 (Staff Competency) for additional information. Findings include: 1. A comprehensive chart review for Resident #48 was conducted on 11/13/18 at 2:00 PM and noted the following information. The Admission Record identified Resident #48 w… | 2020-09-01 |
| 465 | 465 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2018-11-15 | 838 | J | 0 | 1 | T4YY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and Facility Assessment review, the facility identified providing services to residents receiving Intravenous (IV) therapy via a peripheral IV and peripherally inserted central catheter (PICC); however, failed to ensure staff were competent to provide the care needed for this resident population resulting in Immediate Jeopardy. This affected two (Resident #48 and #32) of two sampled residents receiving Intravenous (IV) therapy via a PICC. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18 when Resident #48 was admitted to the facility with a PICC and receiving IV antibiotics. The Immediate Jeopardy continued 11/05/18 when the facility readmitted Resident #32. The Facility assessment dated [DATE] identified providing care and services to residents receiving IV therapy via peripheral IVs and PICC. LPN's #27, #33, #49 and #59 performed IV therapy for Resident #48 and LPNs #6, #20, #39, #49 and #64 performed IV therapy for Resident #32 without adequate training and skill competency in accordance with the Facility Assessment. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility revised the staffing schedule to ensure a Registered Nurse (RN) would be performing IV therapy for the two residents any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until LPNs are trained and competent with IV therapy as identified in the Facility Assessment. See F684 (Quality of Care), F867 (QAPI) and F726 (Staff Competency) for additional information. The facility census was 87. Findings include: The Facility Assessment tool dated 11/10/17 was reviewed on 11/15/18 at 10:10 AM. The facility assessment included a the section titled, Spe… | 2020-09-01 |
| 466 | 466 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2018-11-15 | 867 | J | 0 | 1 | T4YY11 | Based on staff interview and policy review, the facility QAA committee failed to identify Licensed Practical Nurses (LPNs) were performing Intravenous (IV) therapy without sufficient training and implement an appropriate plan of action. This resulted in an Immediate Jeopardy. The facility census was 87. On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18, when Resident #48 was readmitted with a peripheral inserted central catheter (PICC). In (MONTH) (YEAR), the facility conducted a medication management audit through the Quality Assurance and Performance Improvement (QAPI) committee. However, the audit did not include medication management for residents receiving IV therapy or PICCs in order to determine training needs and competency skills. Immediate Jeopardy was abated on 11/13/18 at 8:10 PM. The facility completed an assessment of residents currently receiving IV therapy via PICC and revised staffing schedules. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a severity level two (no actual harm, with potential for more than minimal harm that is not Immediate Jeopardy) until the training and competency of LPNs are addressed in the QAA committee in accordance with the Quality Assurance and Performance Improvement (QAPI) plan. See F684 (Quality of Care), F726 (Staff Competency), and F838 (Facility Assessment) for additional information. Findings include: Facility documentation review was conducted on 11/15/18 at 12:00 PM and included the following. The Quality Assurance & Performance Improvement Program and Committee policy and procedure dated (MONTH) (YEAR) revealed, The facility maintains an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance (QAPI) Program. The QAPI Program is managed by the QAPI Committee, which is responsible to the facility's Governing Body. The Quality Plan dated 11/01/17 under Addressing Care and Services stated, the QAPI program will strive f… | 2020-09-01 |
| 647 | 647 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2018-04-26 | 600 | J | 0 | 1 | FJW311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review the facility failed to ensure each resident was free from verbal abuse and neglect. The facility failed to provide timely incontinence care to Resident #119. The resident also tearfully reported being verbally abused by a nurse aide because he had called the nurses' station for help after no one responded to his call bell for thirty (30) minutes. The lack of incontinence care and the verbal abuse caused the resident to experience pain, skin breakdown, and psychological harm. Until the surveyor identified the resident's problems and intervened, staff were not aware of the seriousness of his condition. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. This affected one (1) of seven (7) residents reviewed for activities of daily living. Resident identifier: #119. Facility census: 156. Findings included: a) Resident #119 During the initial screening for the Long Term Care Survey Process, an interview on 04/23/18 at 11:37 AM, Resident #119 stated he had a pressure ulcer on his buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, that he tried to use a urinal, but sometimes did not get all of the urine in the urinal. Medical record review found his [DIAGNOSES REDACTED].>- muscle weakness - heart failure - Retention of urine - Type 2 Diabetes underlying condition with hyperosmolarity - Chronic [MEDICAL… | 2020-09-01 |
| 909 | 909 | MOUND VIEW | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2019-07-10 | 600 | J | 0 | 1 | 9FZF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to provide care and services in a manner that was free from sexual abuse. The findings were determined to pose an immediate jeopardy to the health and well-being of the residents. The facility Administrator was notified of the Immediate Jeopardy on 07/10/19 at 11:50 AM. The facility provided a Abatement Plan of Correction on 07/10/19 at 2:26 PM. The Abatement Plan of Correction was accepted by the state survey agency on 07/10/19 at 2:30 PM. The facility's Abatement Plan of Correction was: --Resident #89's care plan was reviewed and updated on (MONTH) 10, 2019 by facility social worker for sexually inappropriate behaviors. --Resident #89 was placed on 1:1 staff supervision on (MONTH) 10, 2019. --Resident #89's medical power of attorney was notified of 1:1 supervision and alleged incident on (MONTH) 10, 2019. --A psychiatry consultation will be scheduled for resident #89 by the Social Worker/designee by (MONTH) 10, 2019. Resident #89 was seen by the physician on (MONTH) 10, 2019 in relation to history of sexually inappropriate behaviors with recommendations to continue current medications and begin 1:1 supervision. --An initial audit of all nursing documentation since (MONTH) 6, 2019 for allegations of abuse will be completed by the Administrator/designee by (MONTH) 10, 2019. Any allegations will be immediately reported and investigated within 5 days. --All residents will be interviewed to determine if there are any allegations of abuse by the Administrator/designee by (MONTH) 10, 2019. Any allegations will be immediately reported and investigated within 5 days. --All facility staff will be educated on the definition of abuse and facility reporting procedures by the Staff Development Coordinator/designee by (MONTH) 12, 2019. Education began on (MONTH) 10, 2019. --Facility social worker will be educated on facility policy and procedure for investigation of abuse alleg… | 2020-09-01 |
| 1126 | 1126 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2019-11-07 | 684 | J | 0 | 1 | YW7A11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to ensure Resident #35 had a physician's order when given a narcotic. Resident #35 received [MEDICATION NAME] (a [MEDICATION NAME] oral concentrate) without a physician's order. After receiving the medication, the resident became unresponsive and lethargic and was sent to the hospital. This failed practice resulted in actual harm to Resident #35 which resulted in an immediate jeopardy situation. The facility did not have a physician order to administer [MEDICATION NAME]. As a result the resident's oxygen saturation levels feel to the 82-84% range, and she became lethargic. Resident #35 was noted as unresponsive to both verbal and tactile stimulus. The facility failed to recognize their medication administration error, and the need for this resident to be transferred to the emergency department of the hospital. The resident's daughter requested an ambulance be called and her mother be transferred to the hospital. As a result, the ambulance personnel assessed the resident and administered [MEDICATION NAME] due to the symptoms of opioid overdose. After the Centers for Medicare and Medicaid Services, Regional Office review of the deficient practice, it was determined to support the deficient practice at an immediate jeopardy level. Facility administrator notified of the immediate jeopardy on 11/06/19 at 11:01 AM. Facility abatement plan of correction accepted on 11/06/19 at 2:52 PM. Immediate Jeopardy Abatement Plan of Correction: 1. All residents have the potential to be affected by this deficient practice. The DON and Unit Manager will review all the Medication Administration Records and physician's orders of all Residents receiving a narcotic to ensure all narcotics have a current physician order. The DON or Designee will review the previous 6 months of Controlled Substance sign out sheet to determine if there are any discrepancies between what was administered and wh… | 2020-09-01 |
| 1461 | 1461 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2019-03-12 | 684 | J | 1 | 1 | QF3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure [MEDICATION NAME] (PT) and International Normalized Ratio (INR) testing was obtained per the physician order for [REDACTED]. This finding was determined to constitute immediate jeopardy to Resident #79. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) and preparation of a written statement, the Administrator was notified of the Immediate Jeopardy on 03/06/19 at 4:15 PM. The facility provided an acceptable Plan of Correction on 03/06/19 at 6:46 PM. The Plan of Correction was accepted, and implementation was verified. The immediate jeopardy was abated at 6:49 PM on 03/06/19. Resident identifier: #79. Facility census: 134. Based on medical record review, staff interview, and policy review, after removal of the immediate jeopardy, deficient practice remained at a scope and severity of [NAME] for six (6) of 42 residents reviewed during the long-term care survey process. The facility failed to ensure laboratory testing and weights were performed according to the physician's orders for Resident #123. The facility failed to ensure measurement of Resident #223's peripherally inserted central catheter (PICC) as ordered by the physician. The facility failed to obtain blood pressure and heart rate monitoring prior to medication administration as ordered by the physician and also to administer enteral tube feedings and flushes as ordered by the physician for Resident #275. The facility failed to follow the order to notify the physician when Resident #18's blood glucose levels were above 400. The facility failed to ensure neurological assessments were performed appropriately after unwitnessed falls for Resident #114. The facility failed… | 2020-09-01 |
| 1563 | 1563 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2016-12-15 | 223 | J | 0 | 1 | 32NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, State and Federal guidelines, and policy review, the facility failed to implement policies and procedures to protect one (1) of thirty-five (35) Stage 2 residents from potential abuse. The hospital transfer information recorded the resident alleged rape by a male perpetrator; the physician identified a history of possible sexual abuse by the father; the resident had a history of [REDACTED]. On 12/05/16 the physician assessed the resident as incapacitated, and the father was recorded as the responsible party. The Clinical Admission Director (CAD) had noted on 12/01/16 she had been informed the resident became agitated after speaking with the father on the telephone. The father was noted as the only emergency contact, and the facility notified him of the resident's location on 12/05/16. On 12/07/16 at 6:15 p.m., the administrator was notified of an immediate jeopardy related to the facility's failure to identify and act upon Resident #128's allegation of a history of sexual abuse, an allegation of rape from an unknown male perpetrator, and fear of her father and to protect the resident from potential abuse, sexual and/or psychosocial, or another other resident who might have been at risk. The facility provided a plan of correction to the State agency which was reviewed and accepted at 10:55 p.m. The plan of correction was reviewed for implementation and the immediacy abated at 11:00 p.m. on 12/07/16. No deficient practice remained for this requirement after the immediate jeopardy was removed. Resident identifier: #128. Facility census: 63. Findings include: a) Resident #128 During a Stage 1 interview on 12/06/16 at 10:55 a.m., Resident #128 voiced she was scared of her father and that he was mean. The medical record, reviewed on 12/06/16, indicated the father was Resident #128's emergency contact and authorized Health Insurance Portability and Accountability Act (HIPAA) contac… | 2020-09-01 |
| 1578 | 1578 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2016-12-15 | 322 | J | 0 | 1 | 32NE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide treatment and services to prevent potential complications, such as aspiration pneumonia, for a resident receiving enteral nutrition. Resident #111 had both a physician's orders [REDACTED]. A nurse aide (NA) was observed placing Resident #111 in a supine position (flat on back) in order to provide care while an enteral feeding was in progress. Further investigation found that the facility's clinical competency validation of nurse aide skills regarding aspiration precautions did not include residents receiving enteral nutrition. These findings were determined to pose immediate jeopardy to the health and well-being of Resident #111. The immediate jeopardy began on 12/05/16 at 3:45 p.m. when the NA placed the resident, who had enteral nutrition infusing, in the supine position without ensuring the feeding was stopped. The facility administrator and the Center Nurse Executive (CNE) were notified of the immediate jeopardy on 12/05/16 at 9:45 p.m. The facility provided a plan of correction on 12/05/16 at 11:02 p.m. The immediacy of this deficient practice was abated on 12/05/16 at 11:25 p.m. after surveyors verified all residents with tube feedings were assessed and the physician notified. The team also verified that the off going (afternoon) and the oncoming shifts were receiving education as they came to work. After the immediate jeopardy was removed, no deficient practice remained for this requirement. This identified failed practice had the potential to affect three (e) of three (3) residents who received enteral nutrition. Resident identifier: #111. Facility census: 63. Findings include: a) Resident #111 Upon entering Resident #111's room on 12/05/16 at 3:45 p.m. to observe NA #65 provide care to the resident found the resident lying on her back with the head of the bed elevated approximately 30 to 45 degrees. NA #65 lowered the head of the resident's bed s… | 2020-09-01 |
| 1666 | 1666 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2017-10-10 | 223 | J | 1 | 1 | UKRP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, clinical record review, review of facility records and review of facility policy and procedures, the facility failed to ensure the safety of residents from physical and verbal abuse. Resident #1 reported on [DATE] that Registered Nurse (RN) #10 had verbally and physically abused her roommate Resident #22 on [DATE]. Resident #1 reported incident to Social Worker (SW) #39 on [DATE]. The facility initiated an investigation regarding verbal abuse but did not investigate the allegation of physical abuse. On [DATE] RN #10 verbally abused Resident #51. The incident was witnessed by an anonymous family member, Nurse Aide (NA) #23. NA #23 attempted to report the incident on [DATE] to the Director of Nursing (DON) #35. The facility failed to protect the resident or conduct any investigation. Resident #51 expired on [DATE]. On [DATE] Resident #86 reported NA #26 had verbally abused him on [DATE]. Resident #26 reported the incident to NA #23. NA #23 reported allegation to RN #80. The facility failed to protect the resident or conduct any investigation of the allegation. On [DATE] at 4:45 PM, the Administrator was notified of Immediate jeopardy (IJ) related to based on the center's failure to identify and report allegations of physical and verbal abuse in a timely manner; to protect residents from potential harm during the investigative process; and to implement the facility policy and procedures regarding abuse. On [DATE] at 8:40 PM, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated. The P[NAME] included: At the time that the allegation of verbal abuse was brought to the attention of the Administrator and DON, Resident #22 was assessed by Assistant Director of Nursing (ADON) on [DATE] (date of the allegation) and no signs or symptoms were identified. The involved nurse was suspended at the time of the allegation [DATE] per phone by the Administrator, center initiated an … | 2020-09-01 |
| 1674 | 1674 | MADISON, THE | 515104 | 161 BAKERS RIDGE ROAD | MORGANTOWN | WV | 26508 | 2017-10-10 | 328 | J | 1 | 1 | UKRP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, observation, resident interview, staff interview, and record review, the facility failed to ensure provision of respiratory services. The facility failed to ensure staff were knowledgable about how to provide care for Resident #83's [MEDICAL CONDITION] (an artificial opening through the neck into the trachea, usually for the relief of difficulty in breathing). Investigation during the survey indicated as of 09/25/17 nurses had not been provided training regarding [MEDICAL CONDITION] care and suctioning. Observation included RN #86 failed to suction Resident #83 when he required suctioning. RN #86 was unable to identify location of emergency equipment in the resident's room. On 09/25/17 at 6:00 PM, the facility administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Regional clinical education specialist (CES) were notified of an Immediate Jeopardy (IJ) situation as the result of the facility's failure to train staff to provide care for a resident with a [MEDICAL CONDITION] and to ensure the resident was suctioned correctly when required. On 09/25/17 at 8:10 PM, and revised on 09/26/17 at 11:40 am, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated. After the plan of correction for the immediate jeopardy was implemented, a deficient practice at a scope and severity of a [NAME] remained for inability of the facility to complete re-education for 1 of 18 licensed nurses, lack of completion of observation audits and QA review. Additionally, the facility failed to ensure Resident #26 recieved humidification of his oxygen, and failed to ensure Resident #39 received tube feedings as ordered. Resident identifiers: #83, #26, and #39. Facility census: 48. Findings include: a) Resident #83 Clinical record review revealed Resident #83 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His 08/27/17 physician orders [REDACTED].#6 Shiley (extra [MEDICAL… | 2020-09-01 |
| 2030 | 2030 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2018-02-06 | 684 | J | 0 | 1 | 3TSK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, pharmacist interview, laboratory policy review, and review of the facility's nursing drug handbook, the facility failed to monitor Resident #66 for an adverse drug interaction of which the pharmacy had made the facility aware of the potential to develop. The pharmacy had informed the facility of the need to monitor the [MEDICATION NAME] time/partial [MEDICAL CONDITION] time (PT/INR) levels for a resident receiving a macrolide antibiotic while receiving [MEDICATION NAME] (blood thinner). Taking these two (2) medications at the same time can increase the risk of the individual's blood becoming too thin. While taking the combination of these two drugs, Resident #66's PT/INR value reached a critical value requiring implementation of interventions that included sending the resident to the emergency room . The facility's failure to heed the pharmacist's warning was determined to constitute an immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to the health and well-being of residents. On 02/02/18 at 6:45 PM, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. After removal of the immediate jeopardy, deficient practices remained at a level of E. The facility failed to ensure laboratory values were obtained in a timely manner for Resident #461, failed to obtain a PT/INR test was completed as ordered by the physician for Resident #110, failed to provide care and services upon admission to the facility for Resident #39, failed to follow-up on results of a PT/INR laboratory value for Resident #16, and failed to complete neurologica… | 2020-09-01 |
| 2036 | 2036 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2018-02-06 | 760 | J | 0 | 1 | 3TSK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, pharmacist interview, laboratory policy review, and review of the facility's nursing drug handbook, the facility failed to monitor Resident #66 for an adverse drug interaction of which the pharmacy had made the facility aware of the potential to develop. The pharmacy had informed the facility of the need to monitor the [MEDICATION NAME] time/partial [MEDICAL CONDITION] time (PT/INR) levels for a resident receiving a macrolide antibiotic while receiving [MEDICATION NAME] (blood thinner). Taking these two (2) medications at the same time can increase the risk of the individual's blood becoming too thin. While taking the combination of these two drugs, Resident #66's PT/INR value reached a critical value requiring implementation of interventions that included sending the resident to the emergency room . The facility's failure to heed the pharmacist's warning was determined to constitute an immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to the health and well-being of residents. On 02/02/18 at 6:45 PM, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. After removal of the immediate jeopardy, deficient practices remained at a level of E. The facility failed to ensure Resident #39 received ordered medications when readmitted from the hospital. Doses of an antibiotic and a blood thinner were omitted. Two (2) of twenty-three (23) residents reviewed during the facility's annual survey were affected. Resident identifiers: #66 and #39. Facility census: 114. Findings include: a) Resident #66 Observations on 01/29/18 at 4:13 PM… | 2020-09-01 |
| 2628 | 2628 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2018-12-07 | 684 | J | 1 | 1 | F19R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review and staff interview, the facility failed to obtain prompt emergency medical services, resulting in Immediate Jeopardy, for one (Resident #143) of 21 sampled residents whose clinical records were reviewed for quality of care. One additional resident (Resident #41) was placed at no actual harm but potential for more than minimal harm that is not Immediate Jeopardy when the facility failed to provide care and treatment for [REDACTED]. On [DATE] at 1:36 PM, the Administrator and Regional Director of Clinical Operations #135 were notified Immediate Jeopardy began on [DATE] at 3:40 AM, when Resident #143 became short of breath, requested the inner cannula of her [MEDICAL CONDITION] be re-inserted and be suctioned. Attempts to re-insert the inner cannula were unsuccessful, Resident #143's shortness of breath worsened, and her oxygen saturation went down to 52% (normal range is 95%-100%). Blood oxygen saturation levels below 80% can compromise organ function. The Licensed Practical Nurse (LPN) #73 in charge did not call 911 for 29 minutes. Subsequently, Resident #143 went into respiratory arrest and required cardiopulmonary resuscitation as emergency medical services arrived nine minutes after 911 was called. The Immediate Jeopardy was removed on [DATE] at 4:43 PM, when the facility reduced the potential for imminent danger as no other residents had a [MEDICAL CONDITION]. Additionally, the facility conducted an audit for all residents for a change in condition and notification of the physician. The facility provided in-service for nurse regarding notification of change in condition, notification of physician and sending residents out 911. Although the Immediate Jeopardy was removed, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) until all staff attended inservice training and completed competencies on [MEDICAL CON… | 2020-09-01 |
| 2676 | 2676 | CRESTVIEW MANOR NURSING AND REHABILITATION | 515160 | 199 COURT STREET | JANE LEW | WV | 26378 | 2019-11-14 | 600 | J | 0 | 1 | 71MM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, resident interview and staff interview, the facility failed to ensure a resident was free from neglect when they failed to appropriately respond to the resident's psychiatric emergency. Resident #23 had a [DIAGNOSES REDACTED]. On [DATE] at 6:07 PM, a staff member documented Resident #23 had been heard saying she wanted to die and did not care anymore. On [DATE] at 6:41 PM the same staff member documented that Resident #23 had expressed a desire to die a second time. Multiple staff members documented numerous times in the days following Resident #23's comments on [DATE] that Resident #23 was lethargic, less conversational than normal, resistive to care, verbally and physically aggressive, and had a flat affect. Review of facility records also found that following her comments on [DATE] Resident #23 refused food numerous times. However, no one in the nursing facility acted on the comments made by Resident #23 on [DATE] until surveyor intervention on [DATE]. This deficient practice was found during a random opportunity for discovery and affected one (1) resident with the potential to affect more than an isolated number of residents. Resident identifier: #23. Facility census: 60. The facility's failure to appropriately and timely respond to Resident #23's psychiatric emergency placed Resident #23 at risk for likely serious psychological harm and/or death, resulting in the determination of an Immediate Jeopardy (IJ) situation. This occurrence was the result of a system failure to prevent neglect. The facility's Administrator and Director of Nursing (DoN) were notified of the IJ on [DATE] at 6:25 PM. The facility submitted their Plan of Correction (PoC) via electronic mail (email) on [DATE] at 6:53 PM. The State Agency requested changes to the facility's PoC on [DATE] at 7:12 PM. The requested changes were made to the PoC by the facility and resubmitted via email on [DATE] at 8:23 PM. The PoC was … | 2020-09-01 |
| 2819 | 2819 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2018-11-09 | 684 | J | 0 | 1 | KBQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff and resident interviews, and facility policy review, the facility failed to ensure two (Resident #58 and #76) of four sampled residents were provided appropriate care and services related to standards of practice and competency for Intravenous (IV) therapy resulting in an Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). Resident #58 and #76 was ordered to have IV therapy. An audit provided by the Administrator and the Director of Nursing (DON) on 11/09/18 at 8:30 AM revealed LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having IV training and verification of such. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure a Registered Nurse (RN) or an IV trained and verified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs are trained and competent with IV therapy. See F726 (Staff Competency) for additional information. Findings included: 1. A comprehensive chart review for Resident #58 was conducted on 11/06/18 at 11:07 AM and noted the following information. The Admission Record identified Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per review of the hospital records, Resident #58 was admitted to the hospital on [DATE] after a CT (computerized tomography) scan identified the resident … | 2020-09-01 |
| 2821 | 2821 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2018-11-09 | 726 | J | 0 | 1 | KBQP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of the State Board of Examiners for Licensed Practical Nurses, and review of the facility policy, the facility failed to ensure Licensed Practical Nurses (LPN) who performed the skill set of Intravenous (IV) therapy were competent and trained to perform IV therapy within their scope of practice and state regulations. The facility was unable to provide verification of competency and IV training for five (#3, #27, #133, #156 and #177) of 13 LPNs who were performing IV therapy. This practice resulted in Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). According to nurse standards of practice and state regulations, only Registered Nurses and trained LPNs with verification were to perform IV therapy. According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy without having IV training and verification as required by the facility. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility by completing a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs were trained and competent with IV therapy including PICCs (peripheral inserted central catheters which is a thin, soft, long catheter (tube) that is inserted into a vein in the upper arm, leg or neck and positioned in a large ve… | 2020-09-01 |
| 2825 | 2825 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2018-11-09 | 838 | J | 0 | 1 | KBQP11 | Based on interview and review of the Facility Assessment Tool, the facility failed to ensure Licensed Practical Nurses (LPNs) were competent performing Intravenous (IV) therapy for the resident population. This affected five (#3, #27, #133, #156 and #177) of 13 LPNs performing IV therapy without IV training and verification of such. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). Resident #58 and #76 was ordered to have IV therapy. According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having IV training and demonstrating competency. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM, The facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy) until LPNs were trained and competent in IV therapy. See F726 (Staff Competency), F867 (QAPI) and F684 (Quality of Care) for additional information. The facility census was 128. Findings included: The Facility Assessment Tool dated 11/27/17 was reviewed on 11/08/18 at 8:30 AM. The facility assessment identified in Section, Acuity, that the facility offered IV medications to two residents at the time the assessment was completed. In the Section, Resident support/care needs, the facility documented IV (peripheral or central lines) therapy would be a service the facility provided. In the Section Staff training/education and competencies, … | 2020-09-01 |
| 2826 | 2826 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2018-11-09 | 867 | J | 0 | 1 | KBQP11 | Based on staff interview and facility policy review, the facility failed to ensure an effective quality assurance (QA) program was implemented after determining Licensed Practical Nursing (LPN) staff were performing Intravenous (IV) therapy without having IV training and verification which resulted in an Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having an IV certification. This information was not addressed in QAPI (Quality Assurance and Performance Improvement). committee. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM when the facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy until systemic issues related to IV training and verification of LPNs. See F883 (Facility Assessment), F726 (Staff Competency) and F684 (Quality of Care) for additional information. The facility census was 128. Findings include: An interview was conducted on 11/08/18 at 11:20 AM, the staff development Registered Nurse (RN) #15 who was responsible for staff development. She stated she completed an audit on 10/03/18 regarding which LPN staff had IV training and verification. She stated she identified a number of LPN staff who were not IV trained and notified the Director of Nursing (DON) and the Administrator of th… | 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 |
| 3744 | 3744 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2019-05-22 | 678 | J | 1 | 0 | SJQD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to follow a resident's and/or responsible party's directive to provide cardiopulmonary resuscitation (CPR) to a resident when he ceased breathing and his heart stopped beating. This was evident for one (1) of three (3) deceased residents reviewed for advanced directives. A nurse aide found Resident #9 was not breathing as he lay in his bed. The exact time the resident ceased breathing and his heart ceased to beat was unknown as the event was not witnessed when it occurred. The nurse aid summoned a licensed nurse, #200 (LPN #200). LPN #200 erroneously assessed he was a DNR (Do Not Resuscitate) status. Another LPN #201 telephoned both the physician and the registered nurse on call and notified them of the resident's death. After those notifications were completed, LPN #201 then looked for the contact information of the medical power of attorney to also notify him/her of the death. At that time, LPN #201 and a registered nurse (RN #202) saw in the medical record that the resident was a full code status. LPN #201 took the crash cart to the resident's bed to begin CPR while a RN #202 called the physician back to relay that the resident was supposed to be a full code. The physician then gave telephone orders to stop CPR, and gave new orders for Do Not Resuscitate. As a note, CPR was about to begin, but had not yet begun. This situation was deemed to be an immediate jeopardy situation. On [DATE], the facility conducted its own internal investigation after first notifying the Office of Health Facility Licensure and Certification (OHFLAC), adult protective services, and the ombudsman. Based on the facility's internal investigation that substantiated neglect. In response to the facility's internal investigation, they implemented the following corrective action plan: --All facility staff (100%) participated in inservice education on advance directives for staff who may have contac… | 2020-09-01 |
| 3848 | 3848 | HOLBROOK HEALTHCARE CENTER | 515076 | 183 HOLBROOK ROAD | BUCKHANNON | WV | 26201 | 2016-11-10 | 323 | J | 0 | 1 | 6GKK11 | Based on observation, record review, and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible and failed to provide supervision to Resident #69 with toileting. Resident #69 fell in the bathroom while attempting to toilet herself. These findings resulted in a determination of immediate jeopardy due to the potential for harm to residents. The Administrator and Director of Nursing were notified of the immediate jeopardy 5:00 p.m. on 11/02/16. An acceptable plan of correction (P[NAME]) was received at 7:05 p.m. After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:45 p.m. The facility also failed to prevent accident hazards by storing care and cleaning equipment in a hallway resident bathroom and failed render a pipe end protruding from the floor safe. This was true for one (1) of two (2) resident hallway bathrooms. After removal of the immediate jeopardy, a deficient practice remained at a scope and severity of [NAME] for this requirement due to the failure to prevent accident hazards by storing care and cleaning equipment in a hallway resident bathroom and failure to render a metal piece protruding from the floor safe. This had the potential to affect a limited number of residents. Resident Identifier: #69. Facility census: 92. Findings include: a) Resident #69 A review of Resident #69's medical record on 11/02/16 revealed the Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 07/20/16, the resident assessed as requiring the extensive assistance of one (1) staff for transfers, toileting, locomotion off the unit, and supervision of one (1) staff for locomotion on the unit. A review of the Fall Risk (Acuity) evaluations completed by Restorative Nursing for Resident #69 on 01/08/16, 04/08/16, 07/07/16, 07/22/16, and 08/22/16 found the scores higher than ten (10), which indicated this resident was at a high risk for falls. The care plan for Resident #69, revised on 08… | 2020-07-01 |
| 4715 | 4715 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2016-04-06 | 490 | J | 0 | 1 | TULX11 | Based upon observation, record review, staff interview, and policy review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to make an appropriate corrective response to concerns identified by the consultant pharmacist, failed to operationalize its policies and procedures for the prevention, reporting, and investigation of abuse/neglect, and was cited for immediate jeopardy for insufficient monitoring and supervision to ensure residents' safety. These deficient practices had the potential to affect all residents. Facility census: 92. Findings include: a) The facility was cited for failure to recognize and implement corrective measures for pharmacy reviews that identified blank signature/initial areas for reconciliation of the shift to shift controlled substances counts for five (5) of five (5) hallways/units. b) The facility failed to implement and operationalize its policies to prevent neglect. Written reports of incidents or accidents in which a resident was involved were not consistently completed, and injuries of unknown origin were not reported or investigated. c) An immediate jeopardy was identified related to the failure of the facility to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. The citations related to elopements and injuries of unknown origin on the 500 wing. d) The review found Administration should have been aware of the concerns reported by the consultant pharmacist and working to ensure those concerns were addressed. Administration should also have been aware of the concerns regarding abuse/neglect including injuries of unknown origin, and the concerns regarding incidents/accidents including elopements, falls, and injuries of unknown origin. Systemic failures such as the failure to consistently comple… | 2019-08-01 |
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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 );