cms_WV
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41 rows where "inspection_date" is on date 2014-01-24
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 6078 | 6078 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 154 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to fully inform residents who had been determined to possess the capacity to act as their own decision-maker, in a language that he or she could understand, of identified concerns regarding his or her total health status, including their cognitive status and psychosocial status as initiated in their individualized care plans. Residents were not informed of care plans established for behaviors. This was found for four (4) of four (4) residents who had voiced multiple documented complaints during 2013. Resident identifiers: #19, #62, #25, and #57. Facility census: 100. Findings include: a) Review of complaints, concerns, and abuse/neglect reporting began on 01/08/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of the extended survey protocol. 1) Resident #19 Review of the complaint/concern files identified this resident had thirty (30) documented concerns in 2013 to date. According to the documentation regarding these issues, the facility had attempted to resolve all of the resident's issues. The facility had not dismissed any of the resident ' s concerns as being unfounded or untrue. The high number of concerns filed by this resident prompted review of her medical record. This review the resident's physician had determined she possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal for this problem was (typed as written), Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care a… | 2018-05-01 |
| 6079 | 6079 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 155 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure four (4) of thirty-four (34) sample residents were afforded the right to formulate an advance directive. The facility failed to clarify and periodically review existing advance directives. Advance directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. Resident identifiers: #114, #130, #99, and #5. Facility census: 100. Findings include: a) Resident #114 A medical record review was conducted on [DATE]. Resident #114 had a FULL CODE sticker on his condition alert tab in the chart. A green page in the chart stated Full Code. The monthly physician's orders [REDACTED]. (A full code would mean the facility would attempt to resuscitate the resident.) The resident's West Virginia Physician order [REDACTED]. The POST form was signed by the medical power of attorney on [DATE], and was signed by the physician on [DATE]. The information on the POST form was not transferred to the remainder of the medical record. b) Resident #130 Resident #130 was admitted to Hospice services on [DATE]. A copy of a physician's prescription on the medical record stated Please make patient DNR (do not resuscitate) dated [DATE]. This information was not updated in the medical record. His condition alert tab stated FULL CODE. A green page in the medical record stated Full Code. A sticker was placed on this page stating, Do Not Thin From Chart. A physician's orders [REDACTED]. No POST form was in the medical record. c) Resident #99 The condition alert tab in the medically record of Resident #99 did not address the code status of Resident #99. A Medical Power of Attorney, notarized [DATE], stated Do Not Resuscitate. The physician's orders [REDACTED]. No POST form was present. This medical record provided conflicting information in regards … | 2018-05-01 |
| 6080 | 6080 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 166 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of snack-related forms provided by the dietitian, review of resident council minutes, resident interviews, and staff interviews, the facility failed to actively seek a resolution to grievances and/or to keep the resident informed of the progress being made. Residents had voiced reoccurring concerns regarding the availability and/or the variety of snacks available when the kitchen was closed; and/or the extended length of time required for care needs to be met for fifteen (15) of thirty (30) residents interviewed. Resident identifiers: #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, #141, #210 and #78. Facility census: 100. Findings include: a) Grievance: Snacks are not available and/or there was no variety of snacks when the kitchen was closed: 1) Resident #62 During an interview with Resident #62 at 3:30 p.m. on 01/07/14, during Stage 1 of the survey, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she received was from a nursing assistant, who said the kitchen would not stock snacks on the unit. 2) Resident #78 An interview with Resident #78 at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to … | 2018-05-01 |
| 6081 | 6081 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 225 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of complaint files, review of incident reports, review of personnel files, and staff interview, the facility failed to ensure all allegations of mistreatment, neglect, injury of unknown origin, or abuse were reported immediately to the appropriate State agencies in accordance with this regulation and with Code of State Rules, Title 64 Series 13 - Nursing Home Licensure Rule for West Virginia. The facility also failed have evidence all allegations were thoroughly investigated. This was found for seven (7) of forty-three (43) documented grievances/concerns reviewed. Additionally, the facility had not ensured it did not employee individuals who had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. Thirteen (13) of twenty (20) personal files reviewed did not have this information. These issues had the potential to affect all residents. Employee identifiers: #49, #15, #122, #119, #177, #178, #179, #180, #181, #182, #183, #184, and #187. Resident identifiers: #50, #148, #111, #47, #27, #71, and #25. Facility census: 100. Findings include: a) Resident #50 A review of a Concern Form revealed the son of Resident #50 made the following allegations during the course of a care plan meeting attended by both the resident and his son on 01/09/14: 1. Resident #50's trash can and/or phone were frequently not within the reach of the resident. 2. The resident was receiving poor nail care. 3. Resident #50 stated he gets poor response time to his call light. A written report was completed for each of these allegations on 01/09/14. The concerns were assigned to Employee #116 (RN and Director of Care Delivery) on 01/10/14, to be resolved by 01/15/14. Notices were distributed to All nursing staff in service on 01/10/14, instructing corrective action to be taken regarding the allegations and the following Resolution of Concern was written on the forms and signed by Nurse #116 - At this time, resident et (and) family ar… | 2018-05-01 |
| 6082 | 6082 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 226 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, personnel file review, and policy review, the facility failed to develop facility specific policies and procedures regarding identification, investigation and reporting of allegations of resident mistreatment, neglect, abuse and misappropriation of resident property. The facility had no facility specific written policies and procedures which included procedures for investigating different types of incidents, identifying the staff member responsible for the initial reporting, reporting of results to the proper authorities, and identifying what constituted an allegation of abuse, neglect, or mistreatment of [REDACTED]. This was found for thirteen (13) of twenty-one (21) employees reviewed (Employees #119, #49, #15, #122, #177, #178, #179, #180, #181, #182, #183, #184, and #187). The residents affected included Residents #50, #148, #111, #47, #27, #71, and #25; however, the practice had the potential to affect all residents. Facility census: 100. Findings include: a) During the survey, seven (7), of forty-three (43) Concern Reports reviewed, which should have been reported to the appropriate State agencies as allegations of neglect or mistreatment of [REDACTED]. In addition, the facility failed to thoroughly investigate the allegations. Affected residents were Residents #50, #148, #111, #47, #27, #71, and #25. Below are the allegations which were not addressed as required: 1) Resident #50 During a care plan meeting on 01/09/14, attended by the resident and a family member, the following allegations of neglect were made: -- The resident's trash can and/or phone were frequently not within reach of the resident. -- The resident was receiving poor nail care. -- The resident stated he gets poor response time to his call light. 2) Resident #148 Resident #148 voiced a complaint of neglect to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose we… | 2018-05-01 |
| 6083 | 6083 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 242 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of snack-related forms provided by the dietitian, review of resident council minutes, resident interviews, and staff interviews, the facility failed to ensure eight (8) of thirty (30) residents interviewed were afforded the right to make choices about aspects of their lives in the facility, which were significant to the residents. Residents voiced reoccurring unresolved concerns regarding the availability and/or the variety of snacks available when the kitchen was closed. Affected residents included Residents #62, #64, #15, #133, #115, #58, #210, and #78; however, the practice had the potential to affect more than an isolated number of other residents. Facility census: 100. Findings include: a) Resident #62 In Stage 1 of the survey, during an interview with Resident #62, at 3:30 p.m. on 01/07/14, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open, you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she had received was from the aide who said the kitchen would not stock snacks on the unit. b) Resident #78 An interview with Resident #78, at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to nursing staff and the kitchen staff, but she was told there was nothing they… | 2018-05-01 |
| 6084 | 6084 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 244 | E | 0 | 1 | ZW4411 | Based on resident interviews, staff interviews, and review of resident council meeting minutes, the facility failed to act upon the grievances and recommendations of the resident council in a timely manner. In addition, the facility failed to communicate its decisions to the group. An example was the facility's failure to respond to repeated complaints of slow response by staff to call lights. This had the potential to affect all resident council members, as well as all residents who used call lights to summon assistance. Facility census: 100. Findings include: a) Residents #62, #133, #19, #141, and #78 In interviews, these residents stated they attended Resident Council Meetings. According to the residents, during the meetings, they frequently expressed complaints about the slow answering of call lights. A review of the council meeting minutes from the previous six (6) months revealed concerns addressed about slow response to needs in five (5) of the six (6) months reviewed. In September 2013 and October 2013, the minutes indicated the call light problem was . a little bit better. However, in November 2013, there were again complaints registered. None of the residents interviewed could state what the facility had done to try to solve this problem. b) Resident #62 In an interview with Resident #62, the Resident Council President, at 3:30 p.m. on 01/07/14, she stated the residents at council complained almost every meeting about the staff taking too long to respond to their needs. She added she did not feel the facility was understaffed. The resident said from her room, which was adjacent to the nurses' station, she could hear the aides talking. She said she heard them say such things as, . not me this time and I'm not going in there again. She said she had said this during a council meeting, but did not know if it had been passed on. She said she thought Employee #109 (Activities Director) filled out a separate form and gave it to the social worker and Employee #109 reviewed the complaints at the next meeting. Sh… | 2018-05-01 |
| 6085 | 6085 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 247 | E | 0 | 1 | ZW4411 | Based upon resident interview, staff interview, policy review, and record review, the facility had no evidence that notice was given before the resident's room or roommate in the facility was changed. This was found for one (1) of 35 residents reviewed in the Quality Indicator Survey sample, and for three (3) randomly reviewed residents who had room changes in December 2013 or January 2014. Resident identifiers: #58, #109, #148, and #141. Facility census: 100. Findings include: a) Review of facility's policy and procedure for room change notification was on 01/13/14 at 3:00 p.m. The Social Services manual stated Notify patients and responsible parties, as directed, about changes such as room or roommate changes. and Notify the patient or responsible responsible party of the change, the reason for the change, and respond to questions. b) The Social worker (agency), Employee #44, was interviewed on 01/14/14 at 12:19 p.m. She said that social workers do notifications of room/roommate changes when they are aware of them, but the notifications were also done by admissions and by nursing. She was asked where the notification would be documented. She said that social workers document the notification as a progress note in the electronic medical record. She felt that admissions and nursing probably did so as well, but could not say for sure. The Administrator, Employee #120, was interviewed on 01/14/14 at 12:40 p.m. She said she thought there was a form designed for documentation of room/roommate change notification. She was asked to provide a list of room/roommate changes for the past two (2) months. c) The list was provided on 01/14/13 at 1:40 p.m. The Administrator said that although notice of room/roommate changes may have been provided, admissions staff and/or nursing were not always documenting that notice was given. d) Resident #58 said during an interview on 01/07/14 at 10:23 a.m., that she was never notified of a room change in October 2013. Review of the records found no evidence that any notice was ever given.… | 2018-05-01 |
| 6086 | 6086 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 272 | D | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of the comprehensive assessments for two (2) of thirty-four (34) Stage 2 sample residents. The minimum data set (MDS) assessments completed during Resident #74's stay in the facility did not identify the resident had a pacemaker. Resident #52's urinary continence status was coded incorrectly on the MDS. Resident identifiers: #74 and #52. Facility Census: 100. Findings include: a) Resident #74 Review of this resident's medical record, on 01/14/14 included a review of the admission history and physical, completed by the Medical Director, Employee #102 on 07/18/13. The physician noted under Past Surgical History, the resident had a pacemaker. The cumulative [DIAGNOSES REDACTED]. At no time did the nursing progress notes describe the resident as having a pacemaker throughout his stay at the facility. Both Physical therapy and Occupational therapy notes, dated 10/03/13 and 10/14/13 (a total of four forms), listed pacemaker under the precautions area on the form. The Medical Directory had signed these forms. A review of the Minimum Data Sets (MDS) for Resident #74, along with the Resident Assessment Coordinator, Employee #99, found none of the resident's assessment identified the resident's pacemaker. The MDS Section for Active Diagnoses, I8000, did not have an ICD-9 Code entered to indicate the resident had a pacemaker. Review of the resident's care plan found it did not the resident's pacemaker. In a discussion with the Administrator, Employee #120, on 01/14/14 at 2:00 p.m., she agreed it was problematic. b) Resident #52 A review of the medical record revealed this [AGE] year-old male was admitted to the facility on [DATE]. The resident's admitting [DIAGNOSES REDACTED]. The resident's comprehensive assessment (MDS) on admission indicated he was occasionally incontinent (less than 7 episodes) of urine. The 30 day MDS, with an assessment reference date (ARD) of 0… | 2018-05-01 |
| 6087 | 6087 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 278 | D | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the assessments for (2) of thirty-four (34) Stage 2 sample residents did not accurately reflect the residents' status. Resident #74's MDS did not identify the resident had a pacemaker. The MDS for Resident #52 did not accurately reflect the resident's continence status. Resident identifiers: #74 and #52. Facility Census: 100 Findings include: a) Resident 74 Medical record review, on 01/14/14, noted the Medical Director had documented the resident had a pacemaker on the resident's admission history and physical which was completed on 07/18/13. The [DIAGNOSES REDACTED]. Nursing progress notes did not describe the resident had a pacemaker throughout his stay at the facility. Both Physical therapy and Occupational therapy notes, dated 10/03/13 and 10/14/13, (a total of four (4) forms) listed pacemaker under the precautions area on the form. Review of the resident's MDS with the Resident Assessment Coordinator, Employee #99, found none of the MDS assessments completed during the resident's stay identified the resident had a pacemaker. In an interview with the Administrator, Employee 120, on 01/14/14 at 2:00 p.m., she agreed it was problematic. b) Resident #52 A review of the medical record revealed this [AGE] year-old male was admitted to the facility on [DATE]. The resident's admission MDS indicated he was occasionally incontinent (less than 7 episodes) of urine. The 30 day MDS, with an assessment reference date of 09/02/13, indicated the resident was always continent of urine. A skilled nursing note written at 01:38 on 10/2/2013, stated: Resident alert and oriented . Communicates all needs effectively.Requires minimal assist from staff for adl's (activities of daily living). Transfers independently. Ambulates with walker with steady gait noted. Continent of bladder and bowel with occasional episodes of incontinence. No s/s of acute distress. Will continue to monitor. Call bell in reach. The quarterly M… | 2018-05-01 |
| 6088 | 6088 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 279 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan with individualized, measurable goals and interventions related to identified needs for eight (8) of thirty-four (34) sample residents and six (6) residents identified through random opportunities for identification during Stage 1 and Stage 2 of the Quality Indicator Survey (QIS) survey. Pacemakers were not addressed for Residents #5, #47, #68, #71, #84, #88, #104, #105, #115, and #134. Behaviors were not addressed for Residents #19, #62, #25, and #57. Resident identifiers: #5, #47, #68, #71, #84, #88, #104, #105, #115, #134, #19, #62, #25, and #57. Facility Census: 100. Findings include: a) Residents #5, #47, #68, #71, #84, #88, #104, #105, #115, and #134 On 01/13/14 at 2:00 p.m., a list was received from Employee #77, the Director of Nursing as requested, of the current residents who had cardiac pacemakers. These residents were on the list. The medical records of these residents were reviewed between 01/04/14 and 01/13/14. It was found all of these resident's care plans had cardiac pacemakers listed as a focus area. The interventions included (typed as written): pacemaker checks as ordered, dated and initiated by the nurse providing care. Further review of each care plan found the care plans did not identify the type of pacemaker, or whether the checks were to be performed within the facility or at a consulting Cardiologist's office. In addition, the care plans did not have individualized goals pertaining to the intervention of pacemaker check . for each resident. An interview was conducted with Employee #99, the Registered Nurse Assessment Coordinator (RNAC) on 01/24/14 at 8:00 a.m. After reviewing the care plans of these ten (10) residents, she commented the nurse who initiated interventions on a resident's care plan was responsible for also providing goals related to the intervention. Employee #99 also confirmed and agreed each of the resi… | 2018-05-01 |
| 6089 | 6089 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 282 | D | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, procedure/policy review, and physician interview, the facility failed to provide or arrange services by qualified persons in accordance with the resident's written plan of care. The facility failed to identify Resident #5 had not had a cardiac pacemaker check in over a year. The facility also did not ensure evaluation of the effectiveness of Resident #130's pain medication as directed in his care plan. This was found for two (2) of thirty-four (34) Stage 2 sample residents. Resident identifiers: #5 and #130. Facility census: 100. Findings include: a) Resident #5 On 01/13/14 at 8:45 a.m., medical record review found the resident was admitted to the facility on [DATE]. Her admitting [DIAGNOSES REDACTED]. A review of the care plan noted an intervention of pacemaker check as ordered. Review of the consultation report documentation revealed the resident had pacemaker checks dated 06/6/11, 03/12/12, and 12/11/12. In an interview, on 01/14/14 at 8:30 a.m., with Employee #116, who introduced himself as the Unit Manager (UM) for(NAME)Court, he confirmed Resident #5 had her most recent cardiac pacemaker check in December 2012. He stated the pacemaker check process was to place the physician appointment in the appointment book as recommended by the cardiologist. The consulting cardiologist reviewed his progress notes for Resident #5 and confirmed he had seen her in his office for a cardiac pacemaker check on 12/11/12. Resident #5 was given a return appointment card to be seen again in nine (9) months or sooner if there were any problems. He said her usual schedule was for her to be seen every nine (9) months. He stated she did not return for her scheduled appointment in September 2013. He further commented he was not aware the resident was on Hospice services, . but, either way a patient with a cardiac pacemaker still needs pacemaker checks. The facility had not ensured Resident #5 received checks of her pacemake… | 2018-05-01 |
| 6090 | 6090 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 371 | F | 0 | 1 | ZW4411 | Based observation and staff interview, the facility failed to ensure sanitary conditions were maintained in the kitchen. A ceiling vent over a sink was soiled with dust and debris. In addition, beverages stored in the refrigerators on the nursing units were not labeled to identify when they had been opened. This had the potential to affect all residents. Facility census: 100. Findings include: a) During the initial tour of the kitchen, at 2:30 p.m. on 01/06/14, observation of the ceiling vent over the pot-washing sink noted it was laden with dust webs and debris on the cross rails. Observations on a revisit at 11:45 a.m. on 01/09/14, noted it remained in the same condition. Employee #15 (Food Service Supervisor) was advised of this finding at 9:00 a.m. on 01/09/14. She said she would notify maintenance to clean it immediately. b) At 8:30 a.m. on 01/14/14, a tour of the nourishment kitchen on the 100/200 hall unit revealed an opened bulk container of orange juice and one of sweet tea in the refrigerator. Neither of these containers were labeled to identify when they had been opened. During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor), at 12:50 p.m. on 01/14/14, they were informed of the unlabeled drinks. | 2018-05-01 |
| 6091 | 6091 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 431 | E | 0 | 1 | ZW4411 | Based on observation and staff interview, the facility failed to provide safe and secure storage of a medication cart. Observations noted an unlocked and unattended medication cart in the 300 hallway. This had the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) During observation of the 300 hall, at 11:40 a.m. on 01/07/14, the medication cart was unlocked and unattended at the nurses' station. There were no staff members in view of the cart. There were residents in the hall at that time. After a few minutes, Employee #36, Licensed Practical Nurse (LPN) approached the cart. She verified the cart was unlocked. She stated it was the medication cart she was responsible for that day on the 300 hall. In a discussion with the Administrator, on 01/16/14 at 10:00 a.m., she agreed the cart should not have been unlocked and unattended. | 2018-05-01 |
| 6092 | 6092 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 441 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the spread of disease and infection. Two (2) employees were observed during meal service to have direct contact with a resident and the environment, then serve another resident without performing hand hygiene. The(NAME)Court nourishment kitchen floor was not maintained in a sanitary manner. These issues had the potential to affect all residents. Employee Identifiers: #7 and #66. Resident identifiers: #47 and #58. Findings include: a) Residents #47 and #58 On 01/07/14, observations were made of the lunch service on the 300-400 halls. At 11:50 a.m., Employee #7, Nurse Aide, served Resident #47's lunch tray. She applied a clothing protector to this resident, set up his tray, touched the over-bed table, and left the room. After exiting the room, she removed another tray from the food cart in the hall and served it without performing hand hygiene. At 12:15 p.m., Employee #66, housekeeper, served a tray to Resident #58. She applied a clothing protector to this resident, touched both the over-the-bed table and the bed linens. She then left the room, ran her fingers through her hair with both hands, and removed a tray from the food cart and served it to a resident in room [ROOM NUMBER] without performing hand sanitation. In interviews at that time, both employees stated the policy was to use hand sanitizer between trays and wash their hands every third tray. In an interview, on 01/16/14 at 9:00 a.m., Employee #61, housekeeper, stated housekeeping passes trays often, but not every day. This was confirmed with Employee #6, Environmental Services Supervisor 01/16/14 at 9:30 a.m. She said housekeepers received verbal training on how to set up trays. On 01/16/14 at 10:00 a.m., during an interview with the Administrator, she provided in-service information in which both Employees #7 and #66 had completed courses on hand w… | 2018-05-01 |
| 6093 | 6093 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 463 | D | 0 | 1 | ZW4411 | Based on observation, resident interview, and staff interview, the facility failed to maintain a functioning call system for one (1) of thirty-five (35) Stage 2 sample residents and one (1) randomly observed resident during during Stage 1 of the Quality Indicator Survey (QIS) process. The call lights in the room of Residents #52 and #132 were not functioning. The call lights were adaptive call systems (rubber air bulb style), When the bulb call light was squeezed, it became flat and the call light did not come on to alert staff of the residents' need for assistance. Resident identifier: #132 and #52. Facility census: 100. Findings Include: a) Resident #132 On 01/07/14 at 2:30 p.m., during a room observation for Resident #132, it was discovered that her adaptive (rubber air bulb) call light was not operational and functioning when tested . The bulb became flat when squeezed and did not activate the call light to alert staff the resident needed assistance. The resident commented she was unaware it was not functioning. She said her husband, who was also her roommate, usually turned it on for her since she had vision problems and was legally blind. b) Resident #52 At 2:32 p.m. on 01/07/14, Resident #52's adaptive (rubber air bulb) call light was tested since he was in the same room as Resident #132. Resident #52's call light was not operational and functioning when tested . When the bulb was squeezed to call for assistance, it became flat and the call light did not come on to alert staff. Resident #52 commented the call light was working last night, but was unaware it was not working today. c) Employee #86, a Licensed Practical Nurse (LPN), verified these findings on 01/07/14 at 2:35 p.m. She agreed neither call light was functioning for either resident to call for assistance. d) Employee #116, a Direct Care Delivery/Registered Nurse (DCD/RN) replaced the call system with another adaptive rubber air bulb call light on 01/07/14 at 2:40 p.m. He commented the call system was working last night and the call lights were c… | 2018-05-01 |
| 6094 | 6094 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 465 | E | 0 | 1 | ZW4411 | Based on observation and staff interview, the facility failed to maintain a safe, sanitary, and comfortable environment. During Stage 1 and Stage 2 of the Quality Indicator Survey (QIS), the hallways and five (5) of forty (40) rooms observed were in need of repairs. Torn pieces of wall coverings hung from the walls in the hallways. There were cracked and uneven tiles on the floor of the hallway leading to the main dining room. Tiles and caulking around toilets were stained and discolored. Plaster walls had cracks, stains, unpainted areas, gouges, and holes. Loose vinyl baseboard and scratched and scuffed doors were also noted. This practice had the potential to affect more than an isolated number of residents. Room numbers: #116, #117, #302, #309, and #400. Facility census: 100. Findings include: a) On 01/13/14, between 2:15 p.m. and 2:45 p.m., a tour of the facility was conducted, accompanied by Employee #87, the Director of Maintenance. The tour revealed the following issues: -- There were torn and hanging pieces of wallpaper-type covering observed on the hallway walls between rooms #403 and #404, #412 and #413, and #410 and #411. -- The entrance to the residents' main dining room had discolored, cracked, and uneven floor tile. -- Room #116 - There was stained and discolored caulking around the base of the toilet. -- Rooms #117 and #302 - The bathroom floors had stained and discolored tile surrounding the base of the toilet. -- Room #309 - The wall behind bed B had scraped areas and gouges in the wall with the unpainted plasterboard visible. There were also holes in the wall measuring 3 x 1, 1 x 1 and 1 x 1. Between the closet door and the bathroom door, the ceiling had cracked plaster, the wall had cracked and stained plaster, and the vinyl baseboard was loose from the wall. The interior portion of the bathroom door was scratched and contained torn jagged wooden type areas half (1/2) way up from the bottom of the door. -- Room #400 - The exterior door to the resident's room was scratched and scuffed. At the co… | 2018-05-01 |
| 6095 | 6095 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 490 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, review of facility policies, resident interviews, and staff interviews, 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. Multiple systems related failures were found with abuse/neglect prohibition, accuracy of information in medical records, maintenance of the physical environment, operationalization and implementation of facility specific policies and procedures, and the establishment of a functional, effective, quality assurance program. These systemic problems had the potential to result in harm to all residents in the facility. Facility census: 100 Findings include: a) Record review, staff interview, and policy review identified the facility failed to clarify and periodically review existing advance directives. Advanced directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. This was true for four (4) of thirty-four (34) sample residents. Residents #114, #130, #99, and #5 ' s medical records had conflicting information about whether the individual to be a full code (resuscitated) or was not to be resuscitated. Licensed Practical Nurses, Employees #151, #69, #110, and #52 were asked what they looked at in the medical record to determine the code status. Based on the responses, it would be possible for nurses to look at the Condition Alert tab and find the resident was to be coded, while the physician's order [REDACTED]. The conflicting information found in the medical record and among staff members in regards to code status was discussed with the Administrator, Employee #120 and the Director of Care Delivery, Employee #124, Registered Nurse (RN) on [DATE] at 1:00 p.m. They acknowledged there was … | 2018-05-01 |
| 6096 | 6096 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 492 | F | 0 | 1 | ZW4411 | Based upon record review and staff interview conducted for each specific citation, the facility failed to operate and provide services in compliance with all applicable State and local laws, regulations, and codes. There were multiple deficient practices cited for failure to comply with West Virginia Nursing Home Licensure Rule 64CSR13. This had the potential to affect all residents. Facility census: 100. Findings include: a) The facility failed to develop and maintain written policies and procedures, and failed to ensure the policies and procedures were effectively operationalized by the facility as required by 64-13-10.3.d. The facility had not implemented policies and procedures regarding the investigation and reporting of allegations of abuse and neglect. b) The facility failed to maintain personnel files containing all required information as required by 64-13-11.6.a-i. Personnel files did not contain reference verifications, signed job descriptions, verification of current licenses, evidence of criminal background checks, evidence the abuse registry had been checked, and/or evaluations of work performance. c) The facility failed to have a written disaster and emergency preparedness plan that had been approved by the director as required by 64-13-9.11.b. | 2018-05-01 |
| 6097 | 6097 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 493 | F | 0 | 1 | ZW4411 | Based upon record review, review of facility policy and procedure, and staff interviews the governing body, and designated administrator, failed to ensure policies regarding the management and operation of the facility were established and implemented. The facility failed to effectively maintain and operationalize policies and procedures. This had the potential to affect all residents. Facility census: 100. Findings include: a) The facility's failure to fully operationalize and maintain effective policies and procedures resulted in deficient practices being cited related to employee screening for abuse prevention. Review of thirteen (13) employees ' personnel files found the files did not contain all State required information, such as signed job descriptions, verification of current license/registration, evidence the nurse aide abuse registry and been checked to make sure the individual was not listed, etc. Three (3) of the thirteen (Employees #40, #119, and #49 did not have evidence of a statewide criminal background check. b) The facility failed to ensure allegations of abuse/neglect were identified, investigated, and reported to the appropriate administrative personnel and State agencies. The facility did not identify the staff member responsible for initiating the reporting process. Seven (7) of forty-three allegations of abuse/neglect were not thoroughly investigated and/or reported. (Resident identifiers: #50, #148, #111, #47, #27, #71, and #25.) c) Following the discovery of the lack of facility specific policies and procedures for abuse/neglect prohibition, a discussion was held with administrator, Employee # 120 on 01/20/14 at 9:00 a.m. She said the corporate owner of the facility had policies and procedures, which were available on the Internet, and these policies and procedures were revised and updated by corporate personnel as needed. There was no evidence that the facility itself had adopted them or that the medical director, administrator, director of nursing, or other department heads had read, re… | 2018-05-01 |
| 6098 | 6098 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 496 | E | 0 | 1 | ZW4411 | Based upon personnel file review and staff interview, the facility failed to ensure it had received registry verification that an individual met competency evaluation requirements before allowing an individual to serve as a nurse aide. This was found for two (2) of twenty (20) personnel records reviewed. This had the potential to affect more than a limited number of residents. Employee Identifiers: #37 and #93. Facility census: 100. Findings include: a) Ten (10) personnel files were reviewed on 01/13/14 at 10:00 a.m. The review found the facility failed to obtain registry verification for Employee #37 to ensure the individual met competency evaluation requirements before allowing the employee to serve as a nurse aide. b) During an interview with human resources director, Employee #40, on 01/13/13 at 11:00 a.m., she confirmed that the facility failed to obtain the required registry verification. c) An additional sample of ten (10) nursing assistants' personnel files was chosen at random to supplement the sample for an extended survey. These records were reviewed for registry verification on 01/20/14 at 1:00 p.m. The review found the facility failed to obtain registry verification that Employee #93 met the competency evaluation requirements before allowing the individual to serve as a nurse aide. | 2018-05-01 |
| 6099 | 6099 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 503 | C | 0 | 1 | ZW4411 | Based on contract review and staff interview, the facility failed to maintain an agreement to obtain laboratory services from a laboratory that meets the applicable requirements. This practice has to potential to affect all residents. Facility census: 100. Findings include: a) On 01/23/14, during a review of contracts the facility had with outside agencies, a contract between a laboratory company and the facility was found. A former administrator had signed the contract, but it was not dated. The laboratory company portion had no signature. In an interview with the Administrator, on 01/23/14 at 10:00 a.m., she verified the facility still used that laboratory for services. She stated she did not have a signed and dated contract between the facility and the laboratory company. | 2018-05-01 |
| 6100 | 6100 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 508 | D | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview, and physician interview, the facility failed to ensure the provision of diagnostic services to meet the needs of two (2) of eleven (11) residents with cardiac pacemakers. Resident #5 had a cardiac pacemaker for which the facility did not arrange cardiac pacemaker checks by the consulting cardiologist. Resident #74 was admitted with a pacemaker for which the facility did not determine if there was a need for a pacemaker check during his stay at the facility. Resident identifiers: #5 and #74. Facility Census: 100. Findings include: a) Resident #5 On 01/14/14 at 8:15 a.m., a medical record review was conducted for Resident #5. She was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the care plan found interventions of pacemaker check as ordered. Review of the consultation report documentation revealed the resident had pacemaker checks dated 06/06/11, 03/12/12, and 12/11/12. At 8:20 a.m. on 01/14/14, an interview was attempted with Resident #5. She was not able to be interviewed due to her cognitive status. An interview was conducted with Employee #116, who introduced himself as the Unit Manager (UM) for(NAME)Court on 01/14/14 at 8:30 a.m. During the interview, Employee #116 confirmed Resident #5 had her most recent cardiac pacemaker check in December 2012. He stated the pacemaker check process was to place the physician appointment in the appointment book as recommended by the Cardiologist. At 10:10 a.m. on 01/14/14, Employee#116 provided the requested cardiac pacemaker policy. He commented there was only a telephonic pacemaker policy. During the interview he stated according to the manufacturer's recommendation there was no specific time frame, it was determined by the physician. Employee #116 said usually the residents were seen by their cardiologist every three (3) to six (6) months, or for some it was nine (9) months to a year. He stated the pacemaker check f… | 2018-05-01 |
| 6101 | 6101 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 510 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility obtained diagnostic tests without a physician's order for nine (9) of nine of thirty-four (34) sample residents whose medical records were reviewed during the Quality Indicator Survey. Nine (9) of nine (9) cardiac pacemaker checks were arranged and performed for residents without a physician's order to do so. Resident identifiers: #47, #68, #71, #84, #88, #104, #105, #115, and #134. Facility Census: 100. Findings include: a) Residents #47, #68, #71, #84, #88, #104, #105, #115, and #134 The care plans for these residents had cardiac pacemakers listed as a focus area. The interventions for each of the residents included (typed as written): Pacemaker checks as ordered. Each was dated and initiated by the nurse providing care. Further review of the medical records confirmed each resident had a cardiac pacemaker. None of the residents had a physician's order for pacemaker checks; however, each resident had a cardiac pacemaker check during 2012 or 2013. On 01/13/14 at 12:25 p.m., an interview was conducted with Employee #124, the Direct Care Delivery (DCD) Registered Nurse (RN) for Nutter Fort and Employee #77, the Director of Nursing (DON). Employee #124 stated, There are no written orders for pacemaker checks. She explained cardiac pacemaker checks were put in the appointment book when they were scheduled, and this was the facility's only means of tracking pacemaker checks for the residents. After a review of the care plans for the nine (9) residents, the RN, Employee #124, said If you want to argue verbiage, it is not correct. This statement was made regarding the care plan interventions which stated, pacemaker checks as ordered. The DON stated she would contact the corporate office regarding the residents not having a physician's order for cardiac pacemaker checks. She agreed it was a standard of practice to have a physician's order for diagnostic tests to be performed. At 1:50 p.m. on … | 2018-05-01 |
| 6102 | 6102 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 514 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to maintain clinical records that were complete, accurately documented, readily accessible, and systematically organized for six (6) of thirty-four (34) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Code status was conflicting in the medical records for Residents #114, #130, #99, and #5. The medical record contained nursing progress notes in both paper and electronic formats for Residents #130 and #115. The nurse's notes in the medical record of Resident #74 did not note the resident had a pacemaker. There were blanks (no initials) in the medication administration records of Resident #114. Resident identifiers: #114, #130, #99, #5, #74, and #115. Facility census: 100. Findings include: a) Resident #114 Medical record review, on 01/16/14, revealed this resident had a FULL CODE sticker on the condition alert tab in his medical record. A green page in the medical record identified the resident was a Full Code status, as did the physician's orders [REDACTED]. The West Virginia Physician order [REDACTED]. It was marked Do Not Attempt Resuscitation. The POST form was signed by the medical power of attorney on 11/02/13 and by the physician on 12/12/13. b) Resident #130 Resident #130 was admitted to Hospice services on 11/08/13. The medical record contained a copy of a physician's prescription, dated 11/13/13, which stated, Please make patient DNR. A physician's orders [REDACTED]. The condition alert tab identified the resident was a FULL CODE. A green page in the medical record also stated Full Code. A sticker on this page stated Do Not Thin From Chart. In addition, nursing progress notes were found on the electronic medical records for all residents reviewed during the survey. On 01/16/14 handwritten paper nursing notes were found on the medical record. They were written by Employee #134, an Agency Registered Nurse (RN) on 09/06/13, Employee #… | 2018-05-01 |
| 6103 | 6103 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 520 | F | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, staff interviews, record review, facility policy and procedure review, and review of other facility documents, the quality assessment and assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge. The QAA Committed failed to implement plans of action to correct identified problems, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The QAA committee identified area as permanent items on their monthly agenda. Items included on the monthly agenda, which were identified as deficient practices during the survey included abuse/neglect reporting and investigation, complaints, and environmental issues. These quality deficiencies were not effectively addressed, as allegations of neglect and complaints related to resident life in the facility continued to not be identified, investigated, and/or reported as appropriate. In addition, there was no follow-up to prevent recurrence. Environment was also an identified deficit during the survey. There was no evidence the QAA committee effectively addressed this area of concern which had previously been identified by the facility. In addition, the facility failed to recognize the need to obtain physician orders [REDACTED]. These practices had the potential to affect all residents residing in the facility. Findings include: I) The facility failed to develop facility specific policies and procedures regarding identification, investigation and reporting of allegations of resident mistreatment, neglect, abuse and misappropriation of resident property. The facility had no facility specific written policies and procedures which included procedures for investigating different types of incidents, identifying the staff member responsible for the initial reporting, reporting of results to the proper auth… | 2018-05-01 |
| 6254 | 6254 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 272 | D | 0 | 1 | 4OKO11 | Based on medical record review and staff interview, the facility failed to accurately assess one (1) of twenty-three (23) Stage 2 residents. A comprehensive assessment was coded inaccurately for pressure ulcers. Resident identifier: Resident #66. Facility census: 88. Findings include: a) Resident #66 This resident's medical record was reviewed on 01/22/14 at 12:16 p.m., and revealed the resident's history of pressure ulcers since admission. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/18/13, was coded 1 under Item M0210, which indicates the presence of one or more unhealed pressure ulcers at Stage 1 or higher. Item M0900, was coded 1, which indicated pressure ulcers were present on the prior assessment. The annual MDS assessment, with an ARD of 12/18/13, was coded 0, under Item M0900, which indicated pressure ulcers were not present on the prior assessment. An interview conducted with Employee #102 (Registered Nurse Assessment Coordinator), on 01/22/14 at 4:20 p.m., confirmed the MDS assessment was coded incorrectly. | 2018-04-01 |
| 6255 | 6255 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 278 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the health professional who completed Item M0900, healed pressure ulcers, of the comprehensive assessment for one (1) of twenty-three (23) Stage 2 sample residents certified the accuracy of this portion; however, Item M0900 did not accurately reflect the resident's pressure ulcer status. Resident identifier: #66. Facility Census: 88. Findings include: a) Resident #66 Review of the medical record on 01/22/14 at 12:16 p.m., revealed Resident #66 had a history of [REDACTED]. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/18/13, was coded as 1 for Item M0210, which indicated the presence of one or more unhealed pressure ulcers at Stage 1 or higher. The annual MDS assessment, with an ARD of 12/18/13, was coded 0, for Item M0900, which indicated pressure ulcers were not present on the prior assessment. An interview conducted with Employee #102 (Registered Nurse Assessment Coordinator), on 01/22/14 at 4:20 p.m. confirmed the MDS assessment had been coded inaccurately. | 2018-04-01 |
| 6256 | 6256 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 279 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans which described the care and services necessary to meet the medical, mental, and/or psychosocial needs for four (4) of twenty-three (23) residents in Stage 2 of the Quality Indicator Survey. The care plans lacked nonpharmacologic interventions for conditions being treated with [MEDICAL CONDITION] medications, in an effort to reduce or eliminate the use of the medications. Resident identifiers: #91, #104, #151, and #87. Facility census: 88. Findings include: a) Resident #91 Medical record review revealed Resident #91 was prescribed [MEDICATION NAME] for a [MEDICAL CONDITION],[MEDICATION NAME], and [MEDICATION NAME] for anxiety. Review of the medical records revealed the care plan did not identify specific nonpharmacologic interventions to address the resident's [MEDICAL CONDITIONS], and anxiety. On 01/23/14 at 10:43 a.m., registered nurse, Employee #102, acknowledged there were no nonpharmacologic interventions in the care plan for this resident. b) Resident #104 Medical record review revealed Resident #104 was currently [MEDICATION NAME], [MEDICATION NAME] and [MEDICATION NAME] for anxiety, and [MEDICATION NAME], and [MEDICATION NAME] for a [MEDICAL CONDITION]. Review of the medical records revealed the care plan did not include nonpharmacologic interventions for the resident's [MEDICAL CONDITION], anxiety, or [MEDICAL CONDITION] in an effort to reduce or eliminate the use of the pharmaceuticals. On 01/23/14 at 10:43 a.m., register nurse, Employee #102, acknowledged there were no nonpharmacologic interventions in the resident's care plan to address the conditions for which the resident was receiving medications. c) Resident #151 Medical record review revealed Resident #151 was prescribed [MEDICATION NAME] related to a [MEDICAL CONDITION] to [MEDICAL CONDITION]. Review of the medical records revealed the resident's care plan did not identify specific nonpharm… | 2018-04-01 |
| 6257 | 6257 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 280 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to update a care plan to reflect the resident's current medical condition. This was found for one (1) of twenty-three (23) Stage 2 sample residents. Resident #99's current care plan contained goals and interventions for insulin dependent diabetes, a [DIAGNOSES REDACTED]. Resident identifier: #99. Facility census: 88. Findings include: a) Resident #99 Review of the resident's medical record, on 01/22/14 at 8:30 a.m., revealed Resident #99's current medical [DIAGNOSES REDACTED]. The resident's current care plan, dated 12/16/13, and updated on 12/31/13, listed insulin dependent diabetes as a current diagnosis. Goals and interventions had been established and remained a part of the care plan. Further review of the Medication Administration Record [REDACTED]. An interview was conducted with Employee #102 (registered nurse assessment coordinator) on 01/22/14 at 11:18 a.m. She reviewed the resident's current Medication Administration Record [REDACTED]. She acknowledged the resident was no longer receiving insulin and agreed the care plan needed to be revised to indicate this issue was resolved. | 2018-04-01 |
| 6258 | 6258 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 282 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observation the facility failed to provide care as indicated on the care plan for six (6) of twenty-three (23) Stage 2 quality indicator survey, sample residents. Residents #91, #104, #151, #147, and #87's care plans included monitoring for side effects of [MEDICAL CONDITION] medications. This monitoring did not occur. Resident #71's care plan included using a positioning wedge and Prevalon boots which were either not used or used inappropriately. Resident identifiers: #91, #104, #151, #147, #71, and #87. Facility census: 88. Findings include: a) Resident #91 On 01/23/14, review of the care plan, with an initiated date of 01/10/14, revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. The resident was prescribed an anti-depressant. An intervention was, Monitor for side effects and report to physician. Review of medical records revealed no evidence monitoring for side effects of [MEDICAL CONDITION] medications was being done. b) Resident #104 Resident #104's care plan, with an initiated date of 07/12/13, was reviewed on 01/23/14. The care plan revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications for for anxiety and depression. Both medications had interventions to: Monitor for side effects and report to physician. Review of medical records revealed no evidence that monitoring for side effects of [MEDICAL CONDITION] medications was being done. c) Resident #151 Review of the 01/23/14 care plan for Resident #151 revealed a problem related to a potential for drug related complications associated with the use of [MEDICAL CONDITION] medications. The resident's current Medication Administration Record [REDACTED]. Care plan interventions for both of these medications included Monitor for side effects and report to physician. Review … | 2018-04-01 |
| 6259 | 6259 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 309 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and policy review, the facility failed to provide the care and services to attain, or maintain the highest practicable physical,mental,and psychosocial well-being for one (1) of three (3) residents reviewed for skin integrity. A resident with impaired skin integrity was not assessed and monitored. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. He related it had bled pretty bad, and staff put a bandage on it. The resident said the rim he used to propel himself had a sharp area on it causing the scratch. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff would monitor the resident for skin tears, and bruising for increased bleeding related to [MEDICATION NAME] therapy. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no orders for treatments to the resident's skin. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. The determination of capacity, completed on 01/08/14, indicated the resident had capacity. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident. He informed her he had cut his finger on the silver part of the wheelchair because It may have been related to the rust lifted. He added, I bled pretty bad. He showed her rust areas along the rim and the taped area. He indicated staff used tape to cover the area where he cut his finger. Employee #6 told the resident she would have someone look at the… | 2018-04-01 |
| 6260 | 6260 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 323 | D | 0 | 1 | 4OKO11 | Based on medical record review, staff interview, resident interview, and observation, the facility failed to ensure the residents environment was as free from accident hazards as was possible for one (1) of three (3) residents reviewed with impaired skin integrity. A resident alleged an injury from a defective wheelchair. The chair had rusted causing sharp areas on the wheel utilized for self-propelling. Resident identifier: Resident #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on a sharp area on the wheelchair rim he used to propel himself. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because It may have been related to the rust lifted. He added, I bled pretty bad. He showed her rust areas along the rim. He also showed her a taped area, which he said staff used to cover the area where he cut his finger. She told the resident she would have someone look at it, and placed the chair back at the lower side of his bed. He informed the nurse he was concerned someone else may get a bigger cut than he did. An interview with the occupational therapist (OT), on 01/22/14 at 1:17 p.m., indicated she was not aware of a problem with the wheelchair. The OT said therapy provided the chair to the resident. She observed the tape and said it was not there when the chair was given to the resident. She looked at the chair and acknowledged rust along the silver area of the chair. Incident and accident reports were reviewed on 01/22/14 at 1:46 p.m. They revealed no evidence a report had been completed to identify or evaluate hazards or risks associated with the wheelchair. An interview with the therapy program director, a physical therapist (… | 2018-04-01 |
| 6261 | 6261 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 328 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, resident comment, and staff interviews, the facility failed to ensure a resident with a gastrostomy tube received proper treatment and care. A nurse administered a resident's medication through his gastrostomy tube using ice water. Resident identifier: #92. Facility census: 88. Findings include: a) Resident #92 During an observation of medication administration, on 01/22/14 at 3:31 p.m., Employee #73, a licensed practical nurse (LPN) poured the medication [MEDICATION NAME] sulfate 325 milligrams (mg), crushed it, and placed it in a cup. She poured water from the pitcher into the cup to mix the medication. She poured an additional cup of water from the same pitcher. The LPN carried both cups into the room and set them on the bedside stand. She administered the medication via the resident's enteral tube, utilizing the water she had poured from the pitcher. When she first flushed the tube with the water, the resident startled, and his eyes widened. Upon inquiry, the resident said he was okay. An interview with Employee #73 (LPN), on 01/22/14 at 4:45 p.m. confirmed she used ice water to administer the medication and flush the feeding tube. She said she should have used tap water. (Putting the ice water through the tube did not allow warming of the water as would happen if the resident had swallowed the water and it had warmed while passing through the esophagus before reaching the stomach.) Review of the facility's medication administration competency check list for enteral tubes, on 01/22/14 at 4:00 p.m., revealed medications were to be administered with warm water. Review of the pharmacy enteral tube medication administration, on 01/23/14 at 4:30 p.m., also indicated warm water was to be utilized. During an interview with the director of nursing (DON) on 01/22/14 at 4:50 p.m., she confirmed the standard of practice was not followed; and the nurse incorrectly administered the medication to Reside… | 2018-04-01 |
| 6262 | 6262 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 329 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to ensure three (3) of five (5) Stage 2 quality insurance survey sample residents reviewed for unnecessary medications, were free of unnecessary medications. The facility failed to identify nonpharmacological interventions for residents prescribed [MEDICAL CONDITION] medications, failed to monitor for adverse effects of medications and failed to identify the wrong reason for medication administration on a physician order. Resident identifiers: #104, #149, #87, and #22. Facility census: 88. Findings Include: a) Resident #104 Review of medical records, on 01/23/14, revealed Resident #104 received [MEDICATION NAME] and [MEDICATION NAME] for depression,[MEDICATION NAME], and [MEDICATION NAME] for anxiety. Continued review, of Resident #104's medical records, failed to find evidence the facility attempted to implement non-pharmacologic interventions or explore any underlying causes of distressed behavior before administering a psychopharmacologic medication. Employee #102 provided the Behavior Monthly Flow Sheets for the last three (3) months. These flow sheets were completed by the licensed nursing staff each shift. These documents listed the medications and the reason the medication was prescribed. The Behavior Monthly Flow Sheet did not list non-pharmacological interventions specific to Resident #104 and revealed no evidence of monitoring the resident for side effects of the medications. This was confirmed by Employee #102 on 01/23/14 at 2:00 p.m. b) Resident #149 Review of the medical record, on 01/23/14 at 8:23 a.m., revealed Resident #149 was admitted to the facility on [DATE] for rehabilitation services. His admission orders [REDACTED]. The medication orders included an order for [REDACTED]. The Medication Administration Record [REDACTED]. Resident #149 received the [MEDICATION NAME] daily between 01/17/14 and 01/23/14. [MEDICATION NAME] is given for [MEDICAL COND… | 2018-04-01 |
| 6263 | 6263 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 332 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure the medication error rate was below five percent. Observation of medication administration pass identifed two (2) errors in the thirty (30) opportunities observed. This resulted in an error rate of 6%. A resident's blood pressure and pulse were not obtained for a resident as required by the physician's orders [REDACTED]. Resident identifiers: #106 and #144. Facility census: 88. Findings include: a) Resident #106 Observation of medication administration was completed with Employee #11, a licensed practical nurse (LPN), on 01/22/14 at 4:40 p.m. Resident #106 was not in his room. The LPN went down the hallway to find the resident. The nurse returned to the cart and the resident propelled himself up the hallway to the medication cart. The LPN poured the medications and administered them to the resident. Vital signs (VS) were not taken at that time. Review of the physician's orders [REDACTED]. Review of vital signs through 01/23/14 noted the last blood pressure taken was dated 01/21/14. Review of the Medication Administration Record [REDACTED]. Additionally, the progress notes were reviewed and revealed no evidence vital signs were obtained prior to administering the medication. An interview with the director of nursing (DON),on 01/23/14 at 1:00 p.m., confirmed no evidence was available to indicate vital signs were obtained prior to administering the medication. Review of the administration procedures for all medications, on 01/23/14 at 4:30 p.m., revealed prior to removing the medication package/container from the cart/drawer, the nurse was to check the Medication Administration Record [REDACTED]. b) Resident #144 Observation of medication administration with Employee #85, a licensed practical nurse (LPN), on 01/23/14 at 8:41 a.m., revealed [MEDICATION NAME] 100 mg (one capsule) was administered orally to Resident #144. Review of the med… | 2018-04-01 |
| 6264 | 6264 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 428 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and staff interview, the pharmacist failed to identify a medication irregularity during her monthly medication review and report it the attending physician and the director of nursing. This was found for one (1) of five (5) Stage 2 sampled residents. Resident #149's admission orders [REDACTED]. Resident identifier: #149. Facility census: 88. Findings include a) Resident #149 Review of the medical record, on 01/23/14 at 8:23 a.m., revealed Resident #149 was admitted to the facility on [DATE] for rehabilitation services. His admission orders [REDACTED]. The medication orders included an order for [REDACTED]. The order stated (typed as written): Prilosec capsule delayed release 20 mg (milligrams) (Omeprazole) Give 1 capsule by mouth one time a day related to depressive disorder not elsewhere classified (311). (Prilosec is given for gastrointestinal disorders.) The medication administration record (MAR) also stated (typed as written): Prilosec capsule delayed release 20 mg (Omeprazole) Give 1 capsule by mouth one time a day related to depressive disorder not elsewhere clasiffied (311). Resident #149 received the Prilosec daily between 01/17/14 and 01/23/14. The clinical pharmacist medication regimen review summary indicated the pharmacist (Employee #104) reviewed the resident's medications on 01/17/14 and documented she had no recommendations. The facility policy titled, Medication Monitoring Medication Regimen Review, section 9.1, included in section E The consultant pharmacist's evaluation includes, but is not limited to reviewing and/or evaluating the following: 1) A written diagnosis, indication, or documented objective findings support each medication order. Part 3 of section E states: Indications for use and therapeutic goals are consistent with current medical literature and clinical guidelines. During an interview on 01/23/14 at 1:20 p.m., Employee #23 (director of nursing) reviewed Resident #149's MA… | 2018-04-01 |
| 6265 | 6265 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 431 | E | 0 | 1 | 4OKO11 | Based on observation, staff interview, review of manufacturer's instructions, and policy review, the facility failed to ensure medications were stored appropriately or according to pharmacy recommendations. A resident's medication was stored with stock medications, a multi dose vial was not labeled with the date opened, tuberculin serum was not refrigerated, and intravenous fluids with and without medications added were expired. This had the potential to affect more than a limited number of residents. Facility census: 88. Findings include: a) Medication Storage 1) North hall During an observation of the north hall medication room, with Employee #68, a licensed practical nurse (LPN), on 01/21/14 at 2:00 p.m., heparin lock flush belonging to a resident, was stored with stock medications. The nurse said, It shouldn't be here. Review of the south hall medication room with Employee #5 (LPN), on 01/21/14 at 2:15 p.m., found expired intravenous (IV) solutions. The IV solutions were: -- Lactated Ringers 1000 milliliters (ml), expired June 2013 -- Lactated Ringers 1000 ml, expired July 2013 -- 0.45 Normal Saline (NS) 1000 ml, expired June 2013 -- 0.9% (percent) Sodium Chloride (NaCl) attached to piperacillin/tazopactum (an antibacterial agent) 50 ml x 5 doses, expired December 2013 -- 0.9% NaCl 50 ml with meropenem (an antibiotic) expired October 2013 0.9% NaCl 50 ml with cefepime (an antibiotic) x 2 doses expired December 2013 0.9% NaCl 50 ml with Rocephin (an antibiotic) expired December 2013 0.9% NaCl 50 ml with Rocephin expired July 2013 0.9% NaCl 50 ml with Rocephin expired August 2013 Additionally, the pharmacy label was removed from one bag of 0.9% NaCl 50 ml with meropenum. Employee #5, (LPN) said the pharmacy representative reviewed the medications in September. She said the pharmacy came in Labor Day. The LPN also related the medications and intravenous fluids were to be checked monthly. 2) South hall Review of the south hall medication cart 2, with Employee #11 (LPN) on 01/22/14 at 3:00 p.m., found an open mult… | 2018-04-01 |
| 6266 | 6266 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 441 | E | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, and review of infection control organism reports, the facility failed to maintain an infection control program to provide a safe, sanitary environment, and to help prevent the development and transmission of disease and infection. The infection control program did not conduct surveillance and investigate identified organisms in the facility in order to attempt to identify possible transmission of organisms from one resident to another. This practice had the potential to affect more than a limited number of residents residing in the facility. In addition, staff failed to adhere to posted contact precautions by not wearing personal protective equipment (PPE) during an observed dressing change. This was true for one (1) resident of the one (1) dressing change observed. Resident identifier: #99. Facility census: 88. Findings include: a) Infection Control Program On 01/23/14 at 9:00 a.m. a review of the infection control program and reports was conducted. During this review of the available reports, for August, September and October 2013, revealed a Query Summary Report from the local area hospital conducting the facility's culture and sensitivity laboratory reports. August reports revealed the following organisms: -- [MEDICATION NAME] faecium (2) -- Proteus mirabilis September reports revealed the following organisms: -- [DIAGNOSES REDACTED] Pneumoniae -- Morganella morganii -- Proteus mirabilis -- Escherichia coli October reports revealed the following organisms: -- [MEDICATION NAME] faecium -- Escherichia coli (3 residents) -- Pseudomonas aeruginosa -- Providencia stuartii An additional report, titled Golden Living Center Infection Control Committee Meeting Minutes for August, September and October 2013, was reviewed at this same time. This report did not identify any of the above organisms present in the facility during these months. On 01/23/14 at 9:55 a.m., an interview with the infection… | 2018-04-01 |
| 6267 | 6267 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 514 | D | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the clinical health status/change of condition guideline, and staff interview, the facility failed to ensure the accuracy of the medical record for one (1) of three (3) residents reviewed for impaired skin integrity. The medical record did not reflect the status of an accident with injury. Resident identifier: #147. Facility census: 88. Findings include: a) Resident #147 During a Stage 1 interview on 01/20/14 at 4:09 p.m., a white bandage was observed on Resident #147's 5th finger of his right hand. He said he had scratched it on the wheelchair rim. The resident said the rim he used to propel himself had a sharp area on it. The interim care plan, dated 01/08/14, was reviewed on 01/22/14 at 12:59 p.m. It indicated staff was to monitor the resident for skin tears and bruising for increased bleeding. No actual skin impairment was noted. Review of the comprehensive care plan, dated 01/13/14 noted to inspect skin with care. No indication of skin impairment was evident. Further review of the medical record, on 01/22/14 at 1:01 p.m. revealed no order for treatment. Progress notes, reviewed from the date of admission, indicated the resident's skin was intact. Employee #6, a registered nurse (RN) supervisor, was interviewed on 01/22/14 at 1:15 p.m. She said she was not aware of an injury or concern with the wheelchair. She spoke with the resident and he informed her he had cut his finger on the silver part of the wheelchair because it may have been related to the rust lifted. He added, I bled pretty bad. An interview with director of nursing (DON and executive director (ED), on 01/22/14 at 2:06 p.m.,revealed they were unaware of an injury or problem with the wheelchair. The DON said the policy was to complete a DQI (incident report) and the facility would follow up with the problem. The DON reviewed the progress notes and DQI reports and said no information was available. She also reviewed the medical record a… | 2018-04-01 |
| 6268 | 6268 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2014-01-24 | 520 | F | 0 | 1 | 4OKO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview the Quality Assessment and Assurance (QAA) committee failed to identify and/or act upon quality deficiencies within the facility operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The facility failed to address deficiencies identified during pharmacy audits which included improper storage and labeling of medications, and expired medications. The facility failed to identify, monitor and track infections and there were no audits in place to evaluate isolation precaution practices. This had the potential to affect all residents. Facility census: 88. Findings include: a) The medication safety system assessments were reviewed for the months of November 2013, December 2013, and January 2014 on 01/23/14 at 3:50 p.m. Deficiencies identified by the pharmacist included: medication stored without a label, a multidose vial not dated, and expired medications. An interview was conducted with Employee #37 (executive director), Employee #149 (assistant director of nursing), and Employee # 23 (director of nursing) on 01/24/14 at 10:45 a.m. They reported there was no plan of correction in place to correct the ongoing issues related to the improper storage and labeling of medications or the presence of expired medications. On 01/24/14 at 11:00 a.m., Employee #37 (executive director and QAA Contact Person) reported the QAA committee had stopped performing audits six (6) months ago after completing a mock survey. The QAA committee reviewed resident care areas including activities of daily living, pressure ulcers, infections, incontinence, catheter care, pain, psychiatric medication use, behaviors, falls, elopement, [MEDICATION NAME] and grievances monthly. The committee was aware of the pharmacy audi… | 2018-04-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );