cms_WV
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8700 | 8700 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2011-11-03 | 170 | B | 0 | 1 | S3DJ11 | Based on resident council representative interview and staff interview, the facility failed to ensure residents received prompt delivery of mail. The facility elected not to have mail delivered on Saturdays. Therefore, residents had to wait until Monday to receive mail when the postal service would normally deliver mail to persons living in the community on Saturdays. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) During an interview on 11/02/11 at approximately 9:00 a.m., Resident #29 (who represents the resident council as president) reported that residents at this facility did not receive mail on Saturdays. When interviewed on 11/02/11 at approximately 9:30 a.m., Employee #60 (administrative assistant) acknowledged the facility had the mail delivery stopped on Saturday due to the mail box being broken into and mail being stolen. On 11/03/11 at approximately 1:00 p.m., the director of nursing (DON) reported an activity assistant would start getting the mail out of the box after the facility resumed Saturday delivery. According to the guidance to surveyors for determining a nursing facility's compliance with this requirement: 'Promptly' means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service. | 2016-04-01 |
| 8734 | 8734 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY STREET | HARRISVILLE | WV | 26362 | 2012-04-12 | 371 | B | 0 | 1 | QOYO11 | Based on observation and staff interview, it was found the facility was using coffee cups which had some of the finish worn off. Additionally, a residue was found inside of cups which could be scratched off with a fingernail. This had the potential to affect more than a limited number of residents who might be served coffee in these cups. Census: 54. Findings include: a) On the morning of 4/10/12, coffee cups were found to have the finish worn off of the insides of the cups. A residue was also noted in the bottom of the cups that could be scratched with ones fingernail. Further observations in the kitchen found other cups that were ready to be used to serve residents in the same condition. This was discussed with the consultant dietitian, Employee #85, in the afternoon on 04/11/12. She stated she usually discarded the cups when they were found to be in that condition and had them replaced by the food equipment company. | 2016-04-01 |
| 8829 | 8829 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2011-08-31 | 160 | B | 0 | 1 | 5Y7411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document reviews, staff interviews, and review of the facility's policy, the facility failed to convey personal funds within thirty (30) days after death for seven (7) deceased residents. Resident identifiers: #19, #22, #70, #66, #91, #96, and #97. Facility census: 100. Findings include: a) Residents #19, #22, #70, #66, #91, #96, and #97 Review of facility documentation. on [DATE] at 2:00 p.m., revealed that the facility failed to convey residents' personal funds within thirty (30) days of death. The documentation contained the following information: - Resident #19 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - one hundred-five (105) days after death. - Resident #22 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - seventy-nine (79) days after death. - Resident #66 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - fifty-two (52) days after death. - Resident #70 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - one hundred fifty-seven (157) days after death. - Resident #91 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - sixty-nine (69) days after death. - Resident #96 - date of death recorded as [DATE] and conveyance of funds by check not sent as of [DATE] - thirty-nine (39) days after death. - Resident #97 - date of death recorded as [DATE] and conveyance of funds by check not sent as of [DATE] - fifty (50) days after death. - During an interview on [DATE] at 2:15 p.m., the bookkeeper (Employee #83) stated she was new to the position since [DATE] and did not realize the facility was not in compliance with conveyance of resident personal funds within thirty (30) days of death, until a few days ago. During an interview on [DATE] at 9:00 a.m., Employee #120 (the interim director of nursing) and Employee #119 (the interim administrator) indicated they were aware of the facility's n… | 2016-03-01 |
| 8853 | 8853 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2012-03-15 | 159 | B | 0 | 1 | 8YB611 | Based on interviews with six (6) residents in Stage I of the Quality Indicator Survey (QIS) and staff interview, the facility failed to ensure residents had access to personal funds after normal business hours. This was true for six (6) of thirty-two (32) Stage II sample residents. Resident identifiers: #22, #16, #29, #21, #4, and #26. Facility census: 59. Findings include: a) Residents #22, #16, #29, #21, #4, and #26 During stage I of the survey, these residents were interviewed and were asked, Can you get money when you need it, including on the weekends. Each of the residents stated money was not available when the business office was closed. Review of the resident funds accounts found all six (6) residents had a personal account at the facility. Employee #34, a licensed practical nurse, was interviewed, at approximately 10:00 a.m., on 03/14/12. Employee #34 stated money was not available after the business office was closed. Employee #36, a register nurse, was interviewed, at approximately 10:15 a.m., on 03/14/12. This employee stated if residents needed money after the business office closed, she would call the office staff and they could come into the facility and unlock the safe to get money. | 2016-03-01 |
| 8871 | 8871 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-02-01 | 514 | B | 0 | 1 | RZ6L11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, five (5) of forty-nine (49) Stage II clinical records were not accurate and / or maintained in a systematically organized manner. Medical information from specific resident medical records were found in the wrong residents' medical records for four (4) residents. Additionally, information was inaccurate in one (1) resident's medical record. Resident identifiers: #32, #94, #61, #118, and #43. Findings include: a) Resident #118 While reviewing the closed medical record of Resident #118, it was found that other residents' medical record information was misfiled in this individual's record. Occupational therapy (OT), speech therapy (ST) and physical therapy (PT) progress notes and plans of care were mixed in with Resident #118's documentation. b) Resident #61 OT progress notes, dated 01/02/12, and plan of care notes, effective 12/19/11 to 02/12/12, were filed in another resident's medical record. c) Resident #94 The resident's PT plan of care notes (effective from 12/22/11 to 02/15/12), PT therapist progress report dated 01/17/12, OT progress report dated 01/04/12, and OT plan of care dated effective 12/22/11 to 02/15/12 was located in another resident's medical record. d) Resident #32 ST progress notes of 12/28/11, ST plan of care effective from 12/28/11 to 01/24/12, OT progress report dated 01/10/12, OT plan of care effective from 12/28/11 to 02/07/12, PT plan of care effective 12/28/11 to 02/21/12, PT progress note dated 01/09/12 and progress note dated 01/16/12 were misfiled in Resident #118's closed medical record. This was discussed with Employee #92, a corporate nurse, and the misfiled documentation was provided Employee #92 at 3:40 p.m. on 01/25/12. e) Resident #43 Review of the medical record for this resident revealed there were physician orders [REDACTED]. According to this order, staff was also to check the placement of the steri-strip on the resident's left forearm and leave it unti… | 2016-03-01 |
| 8897 | 8897 | WAYNE NURSING AND REHABILITATION CENTER, LLC | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2012-03-29 | 167 | B | 0 | 1 | EEP611 | Based on observation and staff interview, the facility failed to ensure the results of the most recent surveys were available for examination. The facility's survey results book did not contain the results of the last annual survey and subsequent complaint investigations which were completed after the last annual survey. This issue had the potential to affect more than an isolated number of residents. Facility census: 60. Findings include: a) On 03/28/12, observation of the facility's survey results book revealed the results of a revisit to a complaint investigation completed in August 2011. According to the Centers for Medicare and Medicaid Services (CMS), results of the most recent survey means the statement of deficiencies (HCFA-2567) and the statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys and any deficiencies from any subsequent complaint investigation(s). On 03/19/12 at 9:00 a.m., the executive director (Employee #72) said she had taken out the last resurvey results and other complaints and agreed the only thing in the book was the result of the 08/16/11 complaint revisit. | 2016-03-01 |
| 8902 | 8902 | RAVENSWOOD VILLAGE | 515177 | 200 RITCHIE AVENUE | RAVENSWOOD | WV | 26164 | 2011-12-14 | 253 | B | 0 | 1 | WGCM11 | Based on observations and staff interview, it was found housekeeping services had not ensured bedroom and bathroom doors, as well as dining room furniture, were in good repair and therefore easy to clean and keep sanitary. This was evident for eight (8) resident rooms (202, 204, 205, 206, 207, 208, 209, 210) and several chairs in the main dining room. Census: 60. Findings include: a) During the Stage I observation portion of the survey process, the main doors and / or bathroom doors in rooms 202, 204, 205, 206, 207, 208, 209, and 210 were found to have deep scratches and / or damaged areas which prevented them from being easily cleaned and sanitized. b) Environmental rounds were conducted with Employee #1 (administrator) and Employee #13 (maintenance supervisor), on the morning of 12/14/11. It was found that the wooden legs on many of the chairs in the dining room were scarred and scratched. This made them unsightly and not easily cleanable. These issues were discussed with Employee #1 at the time. | 2016-03-01 |
| 8968 | 8968 | BRIDGEPORT HEALTH CARE CENTER | 5.1e+153 | 1081 MAPLEWOOD DRIVE | BRIDGEPORT | WV | 26330 | 2014-05-22 | 167 | B | 0 | 1 | VDMM11 | Based on observation and staff interview, the facility failed to ensure all survey results were available for examination, and posted in a place readily accessible to residents. The survey book was in a container on a wall in the dining room that was not accessible to residents in wheelchairs who were unable to stand. In addition, the book did not contain the results of the three (3) most recent complaint investigations. This had the potential to affect more than a limited number of residents. Facility census: 42. Findings include: a) On 04/23/14 at 1:00 p.m., the survey book was reviewed. The annual recertification survey, dated 09/27/12, was the most recent survey filed in the survey book. The reports for the three (3) complaint investigation surveys (abbreviated surveys) conducted since 09/27/12, were not filed in the survey book for residents and/or visitors review. All three (3) of the complaint investigations had deficient practices cited. On 04/23/14 at 1:40 p.m., the administrator acknowledged the complaint investigations completed since the annual recertification survey were not filed in the survey book. She located copies of the three (3) complaint investigation surveys, dated 11/30/12, 10/17/13, and 01/16/14, and filed them in the survey book. b) Observations, on 04/24/14 at 1:00 p.m., found the survey results were located in the dining room. The book containing the results was in a file holder attached to the wall. The file holder was mounted above the height of a resident's head, if he/she were sitting in a wheelchair. At 1:27 p.m. on 04/24/14, the social worker (Employee #35), agreed the survey results were posted at a height too high for all residents to access. On 04/29/14 at 3:35 p.m., an interview was conducted with the director of nursing (DON). She said all surveys, which included annual surveys and complaint investigation surveys, were supposed to be made available and easily accessible for review by residents, visitors, or staff. She acknowledged the survey book, which was kept on the dining… | 2016-03-01 |
| 8969 | 8969 | BRIDGEPORT HEALTH CARE CENTER | 5.1e+153 | 1081 MAPLEWOOD DRIVE | BRIDGEPORT | WV | 26330 | 2014-05-22 | 203 | B | 0 | 1 | VDMM11 | Based on medical record review, review of the facility's uniform notification of transfer/discharge form, and staff interview, the facility failed to provide all necessary information for residents transferred or discharged from the facility. The transfer/discharge information provided to residents who were transferred to another facility did not contain all necessary components for the transfer/discharge. The form did not contain a written reason for the resident's transfer/discharge, or a statement informing the resident or responsible party of his/her right to appeal the action to the state. This affected one (1) resident, but had the potential to affect all residents discharged or transferred from the facility. Resident identifier: #51. Facility census: 42 Findings include: a) Resident #51 A closed record reviewed for transfer/discharge requirements, on 04/30/14 at 3:00 p.m., revealed the transfer/discharge form used by the facility did not contain the reason for the resident's transfer to another facility or inform the resident or medical power of attorney (MPOA) of the resident's right to appeal the discharge from the facility. On 04/30/14 at 3:15 p.m., an interview was conducted with the licensed social worker (Employee #35). She acknowledged she was in charge of completing transfer and discharge notices, and did so for Resident #51's discharge to another facility. The social worker provided a copy of Resident #51's transfer/discharge report, dated 04/10/14. She said she was unaware of the need to give appeals notice information to a resident and/or MPOA at the time of discharge. She said she was also unaware the reason for the discharge or transfer from the facility was supposed to be included with the discharge/transfer notice. | 2016-03-01 |
| 8986 | 8986 | BRIDGEPORT HEALTH CARE CENTER | 5.1e+153 | 1081 MAPLEWOOD DRIVE | BRIDGEPORT | WV | 26330 | 2014-05-22 | 514 | B | 0 | 1 | VDMM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical records for one (1) of twenty-three (23) residents reviewed in Stage 2 of the survey. The medical record for a resident, who had a gastrostomy tube ([DEVICE]) and a physician's orders [REDACTED]. Resident identifier: #52. Facility census: 42. Findings include: a) Resident #52 On 04/30/14 8:05 a.m., a review of the medical record for Resident #52 revealed the form titled CNA (certified nursing assistant) - ADL (activities of daily living) tracking form. The director of nursing (DON) stated the form was only used for contract nursing assistant (NA) documentation. This form was dated 04/2014. It contained a section titled Eating Fluids Offered - Indicate Number Offered and ml's. The form showed Resident #52 received oral fluids on 04/03/14, 04/04/14, 04/06/14, 04/07/14, 04/09/14, 04/11/14, 04/13/14, 04/16/14, and 04/17/14. According to the medical record, Resident #52 was NPO and received nourishment via a [DEVICE]. This resident was evaluated by a speech therapist (ST) on 03/17/14. The ST gave the resident only small amounts of ice chips and pureed food. In an interview, with the DON on 04/29/14 at 2:30 p.m., the DON reviewed the documentation. She stated the documentation related to oral fluids was not accurate because the resident was NPO. The DON stated this documentation was habitual documentation. An interview was conducted at this time, with the NA (Employee #56) who documented she gave fluids to Resident #52. When the DON asked what type of diet and fluids Resident #52 received, the NA stated the resident was NPO and did not receive fluids or foods. Employee #56 offered no explanation as to why she documented she had given Resident #52 fluids when she had not. | 2016-03-01 |
| 9024 | 9024 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-01-31 | 356 | B | 0 | 1 | EZVZ11 | Based on observation and staff interview, the facility failed to post staffing data as required by the regulations. During the initial tour of the facility, the information was not posted for public view. Facility census: 70. Findings include: a) During the initial tour of the facility, on 01/23/12, it was discovered the facility had not posted the required staffing information. Further review of the past staff postings found incomplete staffing information. The staff posting failed to identify the total number of hours worked, the category numbers of staff working, and some shifts were missing all of the required information. This finding was presented and verified by the director of nursing (Employee #17) at 11:00 a.m. on 01/30/12. | 2016-02-01 |
| 9025 | 9025 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-01-31 | 360 | B | 0 | 1 | EZVZ11 | Based on a review of the facility's disaster menu and staff interview, the facility failed to ensure they had prepared a menu that provided each resident with a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of each resident. Twelve (12) of seventy (70) residents received a pureed diet. The facility's emergency menu had food items that did not meet the needs of resident's who received a pureed diet. Resident identifiers: #80, #70, #48, #18, #10, #24, #30, #32, #22, #26, #49, and #26. Facility census: 70. Findings include: a) On 01/26/12, at approximately 10:00 a.m., the dietary manager (Employee #92) assisted in the review of the facility's emergency menu. The menu called for the following items at dinner: - Day one: Vegetable juice, peanut butter, jelly, corn, tortilla chips, cookies, milk, salt, pepper, and sugar -Day two: Tomato juice, canned pork/ham, baked beans, potato chips, vanilla wafers, hard candy, milk, salt, pepper, and sugar -Day three: Vegetable juice, tuna, mayonnaise, carrots, tortilla chips, graham crackers, jelly beans, milk, salt, pepper, and sugar The menu indicated the facility had the following pureed items: Chicken, pork or ham, fish, jar baby cereal, carrots, green beans, peas, peaches, pears, and apricots. The dietary manger indicated her consultant dietitian had reviewed the menu and approved of the selections. The menu indicated hard candy and jelly beans would be omitted based on individual tolerance for those on ground and pureed diets. On 01/26/12, at approximately 12:00 p.m., the dietary manager said the staff would provide mashed potatoes in place of potato chips or tortilla chips for those on pureed diets. She said the facility could offer Jell-O in place of the hard candy / jelly beans. On 01/30/12, at approximately 10:00 a.m., the dietary manager indicated she had spoken with the registered dietitian and had come up with some adjustments to the emergency menu. She provided a copy of the new menu. The bottom of the menu stated … | 2016-02-01 |
| 9117 | 9117 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2011-09-22 | 170 | B | 0 | 1 | REFP11 | Based on an interview with the president of the resident council (Resident #1) and staff interview, the facility failed to afford residents with the right to promptly receive mail. The facility did not distribute resident mail on Saturdays, although mail was available for delivery to the facility on this day of the week. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 50. Findings include: a) An interview with the president of the resident council (Resident #1), on the afternoon of 09/14/11, elicited that the residents did not receive mail on Saturdays. An interview with the facility's bookkeeper (Employee #22), on the morning of 09/15/11, confirmed the facility does not distribute mail to residents on Saturdays. Employee #22 stated they have the post office hold the mail until Monday, in case the mail contains any money. According to Employee #22, the facility has both delivery at the facility and a post office box, and they do not check the post office box for mail on Saturdays. Mail is delivered to the front office, sorted, and given to the activity director to distribute to the residents. An interview with the activities director (Employee #38), at 9:25 a.m. on 09/15/11, revealed she does not go to the post office on Saturdays and mail is not delivered to the facility due to no one being in the front office to receive it. She agreed she did not check the post office box on Saturdays. | 2016-02-01 |
| 9187 | 9187 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-09-21 | 156 | B | 0 | 1 | 2WLP11 | Based on review of beneficiary liability notices and staff interview, the facility failed to complete the liability notices in accordance with CMS instructions. The facility was not documenting the reasons why Medicare-covered services were being discontinued and/or specific information regarding the delivery of the notices themselves. This was evident for three (3) of three (3) discharged residents whose beneficiary liability notices were reviewed. Resident identifiers: #147, #48, and #104. Facility census: 94. Findings include: a) Resident #147 Review of Resident #147's Notice of Medicare Provider Non-Coverage form found it did not contain any information regarding the reason the Medicare-covered services were being discontinued. The notice recorded the date the service was ending (05/08/11), and there was a note stating: Wife was notified by phone on 5-8-11. -- b) Resident #48 Review of Resident #48's Notice of Medicare Provider Non-Coverage form indicated the Medicare-covered services would end on 07/17/11. The notice also stated staff notified son (POA) (power of attorney) by phone on 7-17-11. -- c) Resident #104 Review of Resident #104's Notice of Medicare Provider Non-Coverage form found the Medicare-covered services were to be discontinued on 05/10/11. The only other notation was: Wife notified by phone 5-10-11. -- d) According to instructions from the Centers for Medicare & Medicaid Services (CMS), when completing the Generic Notice CMS- form, the facility is to insert the kind of services being terminated, such as skilled nursing, home health, hospice or comprehensive outpatient rehab. This information was not recorded on any of the forms reviewed. The instructions further stated that, if the provider is unable to personally deliver a notice of non-coverage to a person legally acting on behalf of a beneficiary, then the provider should telephone the representative to advise him or her when the beneficiary's services are no longer covered as follows: - The beneficiary's appeal rights must be explained to… | 2016-01-01 |
| 9216 | 9216 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2011-06-08 | 356 | B | 0 | 1 | MZQB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, the facility failed to post the required nurse staffing information in an area readily accessible to the residents. The posting was observed in the front lobby on the office door, in an area not readily accessible to most of the residents. This practice has the potential to affect more than an isolated number of residents who may desire to view this information. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Findings include: a) Upon entrance to the facility on [DATE] at 12:00 p.m., the nurse staffing posting was observed in the front lobby on the office door. During a tour of the facility, other areas of the facility were observed, and the front lobby was the only area where the nurse staffing posting was displayed. Access to the front lobby through double doors from the nursing unit was restricted for any resident wearing a Wanderguard bracelet. Observations were continued throughout the survey event from 05/24/11 to 06/08/11, and the front lobby was the only area in which the nurse staffing posting was displayed. According to the requirement, this posting must be in a prominent place readily accessible to residents and visitors. The front lobby area was readily accessible to visitors, but this area was not readily accessible to all residents. | 2016-01-01 |
| 9322 | 9322 | CRESTVIEW MANOR NURSING & REHABILITATION | 515160 | 199 COURT STREET | JANE LEW | WV | 26378 | 2011-09-20 | 160 | B | 0 | 1 | GVDH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of financial records and staff interview, the facility failed to convey the resident's funds and/or a final accounting of those funds within 30 days after the death of the resident for two (2) of eighteen (18) sampled residents with personal funds as required by State law. Resident identifiers: #3 and #150. Facility census: 62. Findings include: a) Residents #3 and #150 A review of the facility's financial records showing the balances in the resident trust accounts at the end of [DATE] revealed accounts for two (2) residents who had expired over thirty (30) days prior. During an interview with Employee #26 at 11:50 a.m. on [DATE], she stated Resident #3 had expired on [DATE], and a check for the balance of his account ($606.17) had been issued to the facility for payment of outstanding room charges on [DATE]. There was no evidence to reflect the resident's power of attorney (POA) had been issued a final accounting of the resident's personal funds. In a follow-up interview with Employee #26 with Employee #1 (the facility's office manager) at 3:00 p.m. on [DATE], they stated Resident #150 had expired on [DATE], and a check for the balance of his personal fund account ($414.61) had been issued to the facility for payment of outstanding room charges on [DATE]. There was no evidence this resident's POA had been issued a final accounting of the resident's personal funds. | 2015-12-01 |
| 9400 | 9400 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2010-04-08 | 156 | B | 0 | 1 | 85AT11 | Based on record review and staff interview, the facility failed to assure one (1) of one (1) applicable resident / responsible party was informed of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. This practice had the potential to affect any resident who was discontinued from Medicare-covered skilled services. Resident identifier: #60. Facility census: 97. Findings include: a) Resident #60 On 04/07/10 at 3:30 p.m., a review was conducted, with the facility's business office manager, of residents whose Medicare-covered skilled services had been discontinued by the facility. Three (3) of four (4) residents reviewed had met their rehabilitation potential and were discharged home. One (1) resident (Resident #60) was discontinued from Medicare-covered services but remained in the facility. He had not exhausted his allowable one hundred (100) Medicare days, but facility staff believed he had met his rehabilitation potential. Because of this, he should have been offered the opportunity to request a demand bill. Review of the notice provided to the resident revealed the form did not contain an option for the resident / responsible party to request a demand bill. There was a space to indicate no regarding submission of a demand bill, but no space to indicate yes requesting the facility to submit a demand bill. In an interview conducted with the social worker (Employee #103) at 4:00 p.m. on 04/07/10, Employee #103 stated she had no idea how this situation had happened but confirmed the form did not contain the required information to allow a resident / responsible party to request the facility submit a demand bill in the resident's behalf. | 2015-11-01 |
| 9416 | 9416 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2012-11-07 | 514 | B | 1 | 0 | I0U011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document percentages or acceptance of supplement intake. This was evident for three (3) of ten (10) sampled residents. Resident identifiers: #35, #66, and #11. Facility census: 102. Findings include: a) Resident #35 Review of the physician's orders [REDACTED].#35 was to receive a house supplement three (3) times daily. Review of the snack, nourishment, supplements and pantry stock policy (3.14) on 11/07/12 found the nourishment list was printed from the tray tracker and used as a guide for delivery of supplements to residents and to record acceptance. Nourishment list records were reviewed for a sample of fourteen (14) days. The dates reviewed were 10/24/12 through 11/06/12. This afforded forty-two (42) opportunities for the resident to receive a supplement. An interview with Employee #102, the director of nurses, Employee # 92, the director of food services, and Employee #37, the assistant food director, revealed no evidence was available to indicate the resident had been offered the supplement on six (6) of fourteen (14) days. A nourishment list was not available for the dates of 11/03/12, 11/02/12, 10/30/12, 10/28/12, 10/27/12, and 10/25/12. The nourishment forms for this resident were blank for five (5) of forty-two (42) opportunities reviewed. These dates included 11/04/12, 11/01/12 and 10/29/12. Acceptance only, with no percentage of consumption noted, occurred on two (2) occasions. Additionally, consumption was unable to be identified on one (1) occasion due to the report indicated both acceptance and refusal of the same date and time of distribution. b) Resident #11 Review of the medical record indicated this resident had an order to receive a house supplement twice daily. This afforded twenty-eight (28) opportunities for consumption during the fourteen (14) days reviewed. The dates reviewed were 10/24/12 through 11/06/12. Review of the snack, nourishment, supplements … | 2015-11-01 |
| 9468 | 9468 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2011-02-02 | 161 | B | 0 | 1 | U0V411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's continuation certificate and staff interview, the facility failed to provide evidence that the facility's surety bond had been reviewed (for sufficiency of form and amount) and approved by the Attorney General's Office for the funds of eleven (11) residents that were being managed by the facility. Review of the continuation certificate found it had not been submitted for review and approval by the Attorney General's Office; therefore, this facility was managing residents' personal funds without an approved surety bond. Facility census: 63. Findings include: a) Review of the facility's surety bond continuation certificate revealed a lack of evidence that it had been reviewed, for sufficiency of form and amount, by the West Virginia Attorney General's Office. Review of the facility's surety bond, held by the Office of Health Facility Licensure and Certification (OHFLAC), found the last surety bond that had been approved through the Attorney General's Office (#B 895) had expired on [DATE]. During a telephone interview on [DATE] at 2:00 p.m., the facility's office manager (Employee #31) confirmed the facility had not submitted the continuation certificate to OHFLAC for review and approval by the Attorney General's Office. Facility records revealed the facility managed funds for eleven (11) residents, and their current high balance for the month of January, 2011 was $1,300.00. Review of the continuation certificate noted the amount of the bond was for $20,000.00. | 2015-11-01 |
| 9602 | 9602 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 356 | B | 1 | 0 | D8F011 | Based on observation and staff interview, the facility failed ensure the nurse staff posting was completed at the beginning of the shift and contained the total number and the actual hours worked for licensed and unlicensed nursing staff for the day shift of 10/01/12. This had the potential to affect more than an isolated number of residents and visitors. Facility census: 89. Findings include: a) During the initial tour of the facility, on 10/01/12 at 12:35 p.m., observation of the nurse staff posting found the number of licensed and unlicensed nursing staff for the day shift of 10/01/12 had not been completed. The nurse staffing posting was observed with the director of nursing (DON) on 10/01/12 at 12:35 p.m. The DON confirmed the information had not been completed. | 2015-10-01 |
| 9635 | 9635 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-05-20 | 492 | B | 0 | 1 | SWBO11 | Based on a review of personnel files and staff interview, the facility failed to assure four (4) of five (5) sampled nursing assistants were provided with the West Virginia State Rule 69CSR6-8.1 regarding the WV Nurse Aide Registry as required by State law. Employee identifiers: #37, #172, #173, and #99. Facility census: 111. Findings include: a) Employees #37, #172, #173, and #99 A review of the personnel files for Employees #37, #172, #173, and #99, on 05/20/10 at 11:20 a.m., revealed they were hired as nursing assistants, but there was no evidence to reflect they were provided with a copy of the West Virginia State Rule 69CSR6-8.1 regarding the WV Nurse Aide Registry, as required by State law. When interviewed on 05/20/10 at 11:50 a.m., the human resources director (Employee #141) confirmed there was no evidence that the required information was provided to these four (4) nursing assistants. According to 69CSR6-8. Facility Notice and Record Keeping: 8.1. Facilities shall provide a copy of this rule to each Nurse Aide on their staff and to each Nurse Aide at the time of hiring and keep signed proof that each Nurse Aide has received a copy of the rule. | 2015-10-01 |
| 9659 | 9659 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2010-08-24 | 167 | B | 0 | 1 | GDQ711 | Based on resident interview, observation, and staff interview, the facility failed to make readily accessible to all residents wishing to review the results of the most recent survey of the facility conducted by State surveyor and any plan of correction in effect. The survey results were kept out of reach of residents who were wheelchair-dependent, with no posting to direct residents to their current location in the facility. Facility census: 110. Findings include: a) Interview with Resident #9, on 08/16/10 at 1:50 p.m., found she did not know where the survey results were kept. Observations, made on 08/24/10 at 1:00 p.m., failed to find the survey results that were supposed to be located at the front nurse's station. Interview at this time with the social services secretary (Employee #93) found the results were usually kept on the top of a file cabinet located just to the left of the nurse's station, but they were not there. At 2:00 p.m., the person-in-charge (Employee #132) said the survey results were usually kept on an end table beside of a chair by the nursing station, but some of the residents who were on the hallway just off of the nursing station picked them up, so they were moved to the top of the filing cabinet. Residents who were in wheelchairs and could not stand would not be able to access the survey results without asking for assistance. | 2015-10-01 |
| 9668 | 9668 | GRANT COUNTY NURSING HOME | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2010-08-24 | 514 | B | 0 | 1 | GDQ711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the completeness and accuracy of the medical record, by failing to transcribe a hospital discharge order for an indwelling urinary catheter to the facility admission orders [REDACTED]. Resident identifier: #101. Facility census: 110. Findings include: a) Resident #101 A review of the medical record revealed Resident #101 was an [AGE] year old female who was initially admitted to the facility on [DATE], and was readmitted on [DATE], after a hospitalization and surgery to repair a [MEDICAL CONDITION]. The resident was readmitted to the nursing home with an indwelling Foley urinary catheter in place, as documented in the nursing notes by a nurse (Employee #52) at 9:30 p.m. on 06/04/10, even though there was no physician's order for the catheter. Her incontinence assessment, dated 06/04/10, also documented the resident was readmitted with a urinary catheter in place. During an interview with the person-in-charge (Employee #132) at 11:00 a.m. on 08/24/10, she produced the discharge instructions from the hospital which included an order for [REDACTED].> | 2015-10-01 |
| 9693 | 9693 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2010-01-07 | 203 | B | 0 | 1 | 9PJH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form and staff interview, the facility failed to correctly communicate to all residents and responsible parties the contact information of the appropriate state agencies for residents with developmental disabilities or those who are mentally ill. This error in the uniform notice has the potential to lead a resident/responsible party to contact the wrong agency to provide assistance, and may interfere in the resident's ability to exercise his or her right to contact. The uniform discharge notice provided incorrect information regarding the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility with developmental disabilities or mental illness. Facility census: 72. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: This was followed by the names and contact information for West Virginia Advocates Local Mental Health and Medicaid Fraud. This uniform notification form contained the following errors: - The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc, not West Virginia Advocates Local Mental Health. - Medicaid Fraud does not provide protection and advocacy services to persons with mental [MEDICAL CONDITION] and/or mental illness. | 2015-10-01 |
| 9724 | 9724 | BRAXTON HEALTH CARE CENTER | 515180 | 859 DAYS DRIVE | SUTTON | WV | 26601 | 2010-10-06 | 156 | B | 0 | 1 | U9W011 | Based on observations and staff interviews, the facility failed to ensure the name of the State long-term care ombudsman was posted, and failed to ensure residents had ready access to information regarding Medicare and Medicaid. This had the potential to affect more than a limited number of residents. Facility census: 60. Findings include: a) State long-term care ombudsman On 10/05/10 at approximately 10:00 a.m., the posting of required information was reviewed as a part of the CMS- Environment observations, triggered by findings in Stage 1. The name of the State long term care ombudsman did not appear on any of the postings, just the address and telephone number. The posting requirement is: A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, . -- b) Medicare & Medicaid information On 10/05/10 at approximately 10:00 a.m., the Medicare information (a publication entitled Medicare at a Glance - from CMS) and Medicaid information (Your Guide to Medicaid - from WVDHHR) were observed posted in the entrance hall in a locked glass-covered display case. These contents of these multi-page documents would not be readily accessible to residents wishing to review them. This was discussed with the administrator and social worker during the mid-afternoon on 10/06/10. The administrator stated the social worker had copies and would provide / discuss them with residents / responsible parties and that the nurses had keys to the enclosed display case should a copy be needed. However, it was pointed out that the requirement was for the information to be posted. | 2015-10-01 |
| 9750 | 9750 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2010-09-15 | 253 | B | 0 | 1 | 5OCP11 | Based on observations and staff interviews, the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for the residents. Doors and walls were found to have scuffs and scrapes that made them unsightly and not easily cleanable. This was found for seven (7) rooms on the 800 and 900 hallways. (Three (3) on 800 hall and four (4) on 900 hall.) Room numbers: #804, #805, #806, #901, #902, #903, #904, #905, and #907. (Some rooms shared toilet rooms, making seven (7) rooms involved.) Facility census: 90. Findings include: a) Rooms #804, #805, #806, #901, #902, #903, #904, #905, and #907 Observations of above identified resident rooms, during Stage I of the survey on 09/08/10, found bathroom doors and/or corridor doors that were scraped, scratched, had gouges or other unsightly marks and bangs on them. This did not give the facility an orderly appearance in the environment or make them easily cleanable. This was discussed with the administrator (Employee #108) on 09/15/10 at 12:56 p.m., at which time she mentioned there were plans for renovations, and the renovations would include doors and furnishings. | 2015-10-01 |
| 9870 | 9870 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-11-07 | 465 | B | 1 | 0 | XBKB12 | . Based on observation and staff interview, the facility failed to provide a safe and sanitary environment for the residents, staff, and the public in the long term care area located on the second floor of the main hospital building, by failing to keep the perimeters of the floors in the diet kitchen, the hallways, and the elevators clean and free of debris. This had the potential to affect all who came to this area. Facility census: 66. Findings include: a) During a follow-up tour of NCF II (Nursing Care Facility II is the unit located on the second floor of the main hospital building), at 12:45 p.m. on 11/05/07, the floor of the diet kitchen was observed to be dirty overall and grime around baseboards and pipes (near the ice machine). There were papers and debris, including a wash basin on the floor under the cabinets. The floors along the edges, near the baseboards, both in rooms and hallways were unclean. The thresholds of each room were also in need of cleaning. In the soiled utility room, the metal cabinet under the sink was rusted (completely through in spots). While there were no sterile supplies or supplies for direct resident care, there were new red (infectious waste) bags and other supplies stored there. The elevator tracks were dirty and filled with debris. Employee #67 (RN) was present in the diet kitchen at 1:00 p.m. on 11/06/12, and agreed the floor needed cleaned. The DON was informed shortly after and visited the area on her own. During an interview with the head of housekeeping (Employee #64), at 2:08 p.m. the same day, Employee #64 first stated they had a new employee working on this floor, but had no answer when it was pointed out to her the areas described had grime that was not of recent origin. She stated she would schedule these floors to be stripped and cleaned. . | 2015-08-01 |
| 9871 | 9871 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2012-11-07 | 253 | B | 1 | 0 | XBKB12 | . Based on observation and staff interview, the facility failed to provide adequate housekeeping to ensure a clean and orderly environment by failing to keep the outer perimeters of the floors, both in the residents' rooms and in the hallways of the nursing unit located on the second floor of the main hospital, clean. This had the potential to affect all residents (24) residing in this location. Facility census: 66. Findings include: a) During the initial tour of NCF II (Nursing Care Facility II is the unit located on the second floor of the main hospital building), at 12:15 p.m. on 11/05/07, the floors along the edges, near the baseboards, both in rooms and hallways were noted to be in need of cleaning. The thresholds of each room were also unclean in appearance. A revisit to NCF II, at 12:45 p.m. on 11/06/12, revealed the floors were still grimy at the edges in both rooms and hallways. These observations were reported to the DON at 1:00 p.m. on 11/06/12, and discussed with the head of housekeeping (Employee #64) at 2:08 p.m. the same day. Employee #64 first stated they had a new employee working on this floor, but had no answer when it was pointed out to her that the areas described had grime that were not of recent origin. She stated she would schedule these floors to be stripped and cleaned. . | 2015-08-01 |
| 9873 | 9873 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-12-01 | 244 | B | 0 | 1 | ENOI11 | . Based upon review of facility documentation, resident interview, and staff interview, the facility did not notify and/or discuss a proposed change in dining services with residents prior to implementing the change, and did not adequately address grievances that were expressed following the implementation of the change. This had the potential to affect more than an isolated number of residents. Facility census: 85. Findings include: a) Prior to entry for the survey, the regional ombudsman had advised the survey team that there had been concerns expressed over the facility stopping the practice of providing soda for residents. Resident #14, the vice president of resident council, and the resident who led the last three (3) council meetings of 9/30/11, 10/21/11, and 11/18/11, was interviewed on 11/28/11 at 10:45 a.m. She was asked about any resident council concerns regarding the facility providing soda to residents in recent months. She replied that the facility had stopped providing soda, and now they only got soda during some activities, or had to buy it from the machine. She said several residents were upset by this. She was asked for permission to review the minutes of recent resident council meetings, which she granted. b) Resident council meeting minutes for 8/26/11, 9/30/11, 10/2/11, and 11/18/11 were reviewed on 11/29/11 at 9:00 a.m. The minutes for the 11/30/11 meeting had concerns noted for the dietary department, including (typed as written): "Suppose to have lemonade to replace soda" and "Don't like having the soda taken away." The facility grievance file was reviewed on 11/29/11 at 9:30 a.m. A complaint was found from 10/4/11, which stated: (typed as written): "Resident requested soda, staff informed resident that facility no longer provides soda. POA (power of attorney) stated back to employee, 'Don't you think it is awful to pay $7,200.00 per month and can't get a soda.'" The resolution as documented was that "activity dept. is to provide soda during room visits." No other documentation was found t… | 2015-08-01 |
| 9905 | 9905 | WHITE SULPHUR SPRINGS CENTER | 515100 | ROUTE 92, PO BOX 249 | WHITE SULPHUR SPRING | WV | 24986 | 2012-07-26 | 514 | B | 1 | 0 | U0Q511 | . Based on observation, review of documentation of shower/bath administration forms, interviews with residents, and interviews with staff, it was determined staff had not completed ADL (activity of daily living) flow sheets to show that baths/showers were consistently given. There were many blanks and incomplete documentation on these forms for residents on two (2) of four (4) hallways. Hallways involved: 200 and 300. Census: 62. Findings include: a) A review of bath and shower records on the morning of 07/26/12 revealed there were many records that contained numerous blanks and inconsistent documentation on whether baths/showers were given or not. Discussion with the director of nursing, Employee #72, at the time indicated, verified better documentation should be implemented that would verify the baths were given as needed. A short while later, Employee #72 returned and explained that after further review, the problem with documentation of baths for residents was on the 200 and 300 hallways. By observations of residents, staff interviews, and resident interviews, it was determined that baths were being given and it was a documentation issue as opposed to the baths not being provided. Residents expressed they received their baths on time. Staff interviews revealed that they were able to get the showers done for the residents on their assignment as required. No odors or grooming issues were noted when doing observations of residents. . | 2015-08-01 |
| 9929 | 9929 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-06-01 | 356 | B | 1 | 0 | J5IV11 | . Based on observation and staff interview, the facility failed to ensure the required staff posting contained an accurate resident census. This had the potential to affect more than an isolated number of residents and visitors. Facility census: 78. Findings include: a) During the initial tour of the facility, on 05/29/12 at 3:50 p.m., it was noted the required nursing staff posting contained an inaccurate resident census. The facility census was 78, while the posting stated the facility had 49 residents. The discrepancy was brought to the attention of the administrator. He agreed the resident census was not correct on the posting. . | 2015-08-01 |
| 10064 | 10064 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2012-01-19 | 514 | B | 0 | 1 | ZNLH11 | . Based on medical record review and staff interview, the facility failed to ensure clinical records were accurate and kept in a systematically organized fashion for two (2) of forty-nine (49) Stage II sampled residents. A resident's therapy records were found in another resident's medical record. Resident identifiers: #137 and #34. Facility census: 118. Findings include: a) Residents #137 and #34 Review of the medical records found therapy notes for Resident #34 had been placed in Resident #137's record. This finding was reported to Employee #12 (medical records) at 2:24 p.m. on 01/18/12. . | 2015-07-01 |
| 10157 | 10157 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2009-10-08 | 279 | B | 0 | 1 | SM0211 | Based on record review and staff interview, the facility failed to develop care plans for two (2) female residents to address refusal of staff assistance with grooming. Resident identifiers: #41 and #55. Facility census: 66. Findings include: a) Residents #41 and #55 On 10/08/09 at approximately 9:30 a.m., two (2) female residents (#41 and #55) were observed to have long facial hair. When the administrator was questioned about the residents, he indicated these two (2) residents would not allow staff to trim their facial hair. Record review revealed these two residents' current care plans did not reflect their refusal of this care. The administrator agreed this needed to have been included in their care plans. . | 2015-06-01 |
| 10303 | 10303 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2010-05-13 | 431 | B | 0 | 1 | MM9U11 | . Based on observation and staff interview, the facility failed to assure the safe storage of drugs and biologicals, by retaining a vial of immunization past the manufacturer's expiration date and storing it in a refrigeration rather than in the freezer as recommended. This practice had the potential to affect any resident with orders for this medication. Facility census: 34. Findings include: a) On 05/11/10 at 9:20 a.m., observation of the facility's medication storage room, including the medication storage refrigerator used to store all medications requiring refrigeration for facility residents, found a boxed ampul with a label reading "Varicella Virus Vaccine". The labeled box also stated the medication should be stored at an average temperature of 5 degrees Fahrenheit (F), and the noted expiration date of the medication was 19 March 2010. The refrigerator temperature at that time was 46 degrees F. Two (2) licensed practical nurses (LPNs - Employees #21 and #22) were present at the time ,and although neither of the nurses had any idea why the medication was there or who it was for, they both confirmed the medication was beyond the expiration date and was not stored as recommended on the label. . | 2015-05-01 |
| 10338 | 10338 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2012-01-13 | 167 | B | 1 | 0 | VNEB11 | . Based on observation and staff interview, the facility failed to ensure the results of all surveys were readily accessible for resident or visitor viewing. Review of the survey book, located in the lobby of the facility, found the absence of the two (2) most recent complaint investigation surveys. Findings include: a) On 01/12/12, review of the survey book, located in the lobby at the entrance of the facility, revealed the most recent survey result posted was a complaint investigation survey completed in February 2011. During an interview with the director of nursing (DON), on 01/12/12 at 8:45 a.m., she stated she thought there was a complaint survey in December 2011. She was uncertain whether there were any others between February and December 2011. The DON stated the administrator would have copies of any surveys in his office. Interview with the administrator, on 01/12/12 at 9:00 a.m., revealed he had two (2) complaint surveys with deficiencies in his office that were not posted in the survey book in the lobby. One (1) missing complaint survey with citations was conducted in April 2011, and the other missing complaint survey with citations was conducted in October 2011. . | 2015-05-01 |
| 10353 | 10353 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-10-08 | 285 | B | 0 | 1 | 5TIO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the mental health status of a new resident had been evaluated under the Pre-Admission Screening and Resident Review (PASRR) program prior to the resident being admitted into the facility for three (3) of fifteen (15) sampled residents. Resident identifiers: #60, #36, and #49. Facility census: 58. Findings include: a) Resident #60 Review of Resident #60's medical record, on 10/07/09, revealed he was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 06/19/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. b) Resident #36 Review of Resident #36's medical record, on 10/06/09, revealed she was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 07/27/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. c) Resident #49 A review of the clinical record revealed Resident #49 was admitted to the facility on [DATE]. However, the Level II determination was not made, as indicated by the dated signature in Section V of the PASRR, until 07/15/09. During an interview with the administrator and the social worker at 10:15 on 10/08/09, they acknowledged the dates noted above were correct. . | 2015-05-01 |
| 10409 | 10409 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2009-08-27 | 156 | B | 0 | 1 | Y5MX11 | Based on observation and staff interview, the facility failed to prominently display written information on how to apply for and use Medicare and Medicaid benefits. The facility also failed to include information on how residents / families could receive refunds for previous payments covered by Medicare and Medicaid benefits. This practice has the potential to affect more than an isolated number of residents at the facility. Facility census: 76. Findings include: a) On 08/27/09 at approximately 11:00 a.m., a tour of the facility revealed no posting describing how residents and their families could make application for and use Medicaid or Medicare benefits. The facility had information posted regarding how to file complaints and also advocacy information such as the name / address of the ombudsman; however, Medicare / Medicaid information was not on display. At approximately 11:30 a.m., the administrator agreed this information was not posted. He then made arrangements to have it posted for public display in the facility's main hallway. . | 2015-04-01 |
| 10421 | 10421 | POCAHONTAS CENTER | 515183 | 5 EVERETT TIBBS ROAD | MARLINTON | WV | 24954 | 2009-09-23 | 364 | B | 0 | 1 | JZ9F11 | Based on observation and staff interview, the facility failed to ensure residents who were ordered a pureed / mechanical soft diet were served attractive and colorful meals. Fifteen (15) residents received pureed or mechanically altered diets. Resident identifiers: #3 #4, #5, #7, #10, #11, #15, #18, #30, #35, #48, #51, #54, #61, and #64. Facility census: 65. Findings include: a) Residents #3 #4, #5, #7, #10, #11, #15, #18, #30, #35, #48, #51, #54, #61, and #64 On 09/22/09 at approximately 6:00 p.m., residents were observed eating their evening meal in both the dining room and their individual rooms. A nurse aide assisting Resident #15 indicated she could not identify the main entree on the resident's plate. Other residents also could not definitively identify the main entree. Staff members in the dining room indicated they thought the entree was fish but were not sure. The menu revealed the mechanical soft and puree diets received lemon baked fish, two (2) slices of white bread, mashed potatoes, and a mayonnaise packet. All of these food items were bland in color. The dietary manager said she realized the food lacked color but did not know what to do, because those were the items listed on the menu. . | 2015-04-01 |
| 10452 | 10452 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2009-08-13 | 156 | B | 0 | 1 | 924C11 | Based on observation and staff interview, the facility failed to post contact information for all pertinent State client advocacy groups in a location accessible to all residents. This practice has the potential to affect more than an isolated number of residents who could benefit from this information. Facility census: 153. Findings include: a) Observation, on the morning of 08/13/09, found the names, addresses, and telephone numbers for State advocacy groups were posted on a bulletin board located between two (2) sets of double doors as one enters the facility. Many residents do not go near this location and would not easily access the information on these postings. When brought to the attention of the administrator on the early afternoon of 08/13/09, he verified the information would be more easily accessible at another location and stated he would move them to a new area which was frequented more often by residents. . | 2015-03-01 |
| 10602 | 10602 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 514 | B | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 1: oxygen tubing treatment sheets not complete Based on observation, medical record review, and staff interview, the facility failed to each resident's clinical record was accurate and complete. Staff failed to document weekly oxygen tubing changes ordered by the physician. Resident identifiers: #2188 and #3439 on the 400 Hall, and Residents #3163 and #1889 on the 100 Hall. Facility census : 95. Findings include: a) Residents #2188, #3439, #3163, and #1889 During random observations during tour on 05/19/09 and during resident interviews on the day of entry, four (4) residents were observed to have no dates on their oxygen tubings to indicate when they had most recently been changed. Also, there was no documentation on the residents' treatment records to reflect the tubing had been changed weekly as the physician had ordered. 1. Residents #2188 and #3439 On the 400 Hall on 05/19/09 at 9:30 a.m., Residents #2188 and #3439 were noted to have oxygen concentrators in use with no dates to show when the tubing had been changed. The filters on both concentrators were dirty. On 05/20/09 at 9:55 a.m., interview with the charge nurse (Employee #26) revealed the facility did not have a separate respiratory therapy department. Rather, a nurse came to the facility twice weekly, and she changed all the oxygen tubing in the facility on Fridays. Employee #26 also reported they had aides change the tubing if the nurse is not there. The charge nurse and surveyor checked the residents' treatment records and found Resident #2188's tubing change was not recorded for 05/08/09, and Resident #3439's tubing change was not recorded for 05/08/09 or 05/15/09. Both residents had orders for oxygen tubing to be changed weekly. The director of nursing (DON), who was present at this time, stated oxygen tubing was changed weekly in the facility and, when told of the above findings, said they would take care of it right away. 2. Residents #3163 and #1889 On the 100 Hal… | 2015-01-01 |
| 10622 | 10622 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2010-12-09 | 159 | B | 0 | 1 | GCMN11 | . Based on resident and staff interview, the facility failed to assure residents had access to their funds on weekends and/or at other times the business office was closed. This practice had the potential to affect all residents for whom the facility managed funds. At the time of the survey, the facility maintained a trust fund for sixty-nine (69) residents. Facility census: 83. Findings include: a) During Stage I confidential resident interviews on 11/29/10 and 11/30/10, four (4) residents described that their personal funds were not available on weekends and/or at other times the business office was not open. On 12/08/10 at 2:00 p.m., an interview was conducted with the business office staff member who assists in resident funds. At that time, this staff member described that, prior to 11/30/10, residents had not been able to get funds except during business office hours. This person stated that, on that date, resident funds became available to residents at times the business office was closed, by means of a small amount of money provided to nursing personnel for this purpose. . | 2015-01-01 |
| 10716 | 10716 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 285 | B | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of a new resident were evaluated prior to admission through the State-mandated pre-admission screening tool, the form PAS-2000. This was evident for two (2) of twenty-four (24) residents on the sample. Resident identifiers: #33 and #140. Facility census: 138. Findings include: a) Resident #33 Clinical record review disclosed the resident was admitted on [DATE], but the determination as to whether a Level II evaluation was required was not made until 03/17/09, as indicated by the dated signature in Section V of the form PAS-2000. b) Resident #140 Clinical record review disclosed the resident was admitted on [DATE], but the determination as to whether a Level II evaluation was required was not made until 07/08/09, as indicated by the dated signature in Section V of the form PAS-2000. c) In an interview at 2:40 p.m. on 08/19/09, the facility's three (3) social workers acknowledged the Level II determinations occurred after admission for both residents. . | 2014-12-01 |
| 10726 | 10726 | SUMMERSVILLE REGIONAL MEDICAL CENTER D/P | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2010-10-20 | 156 | B | 0 | 1 | H9I611 | . Based on a review of the facility's Medicare demand bill records and staff interview, the facility failed to provide the appropriate beneficiary liability and appeal notices for three (3) of three (3) residents who had recently had their Medicare-covered services terminated. There was no evidence that the facility notified the beneficiary of his/her potential liability for payment and standard appeal rights. This practice affected Resident #40 and had the potential to effect more than an isolated number of residents who received Medicare-covered services. Facility census: 49. Findings include: a) Resident #40 Record review of residents who had received Medicare-covered services in the last three (3) months revealed one (1) demand bill had been requested. This was for Resident #40. The letter used to notify the resident / responsible party that services would no longer be covered by Medicare was a letter designed by the facility which did not contained all required elements found in Form CMS- or one (1) of the five (5) uniform denial letters found in the CMS Skilled Nursing Manual. The letter sent by the facility did not notify the legal representative of the beneficiary's potential liability for payment of the non-covered services. An interview with the staff member responsible for patient accounts (Employee #130) confirmed the facility was not utilizing the CMS forms to notify residents / responsible parties of Medicare non-coverage and of their right to request demand bills, which contained all of the required information for notification to the beneficiary. . | 2014-12-01 |
| 10765 | 10765 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-11-18 | 514 | B | 0 | 1 | 667113 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to utilize the correct reporting forms for submitting initial and five (5) day follow-up reports for allegations of resident abuse / neglect to the State survey agency's Nursing Home Program; failed to incorporate all necessary data onto one easy-to-read form for infection control tracking; and failed to ensure a transcription error did not occur for one (1) of forty-three (43) observed medication administrations. Facility census: 73. Findings include: a) Review of the facility's abuse policy, on 11/17/09, revealed, on page 3 Item #5 "Investigation and Reporting", the facility's plan to send immediate fax reportings of allegations and five (5) day follow-up reports to the State survey agency's Nurse Aide Abuse Registry. Review of all the self-reported allegations and their respective investigations for September, October, and November 2009 revealed several were submitted using the Nurse Aide Abuse Registry's reporting forms for instances where a nursing assistant was not involved in the alleged event and the Nursing Home Program's reporting forms (which is a separate program within the same State survey agency) should have been used, as follows: 09/13/09 involving Resident #34; 09/20/09 involving Resident #69; 09/24/09 involving Resident #34; 09/25/09 involving Resident #2; 09/29/09 involving Resident #67; and 10/04/09 involving Resident #25. Five (5) of the above events were related to unknown perpetrators, and one (1) event (dated 09/13/09) was related to a licensed practical nurse. In all of the cases, no allegations of abuse or neglect were substantiated. During interview with the director of nursing on 11/18/09 at 9:00 a.m., the above findings were discussed, and she received a copy of the two-page Table 1 - Abuse / Neglect Reporting Requirements for WV Nursing Homes and Nursing Facilities revised August 2009. She stated the social worker completes and faxes the five (5) day… | 2014-12-01 |
| 10868 | 10868 | GLEN WOOD PARK, INC. | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2009-12-11 | 253 | B | 0 | 1 | IPRG11 | Based on observations, the facility failed to provide maintenance services to maintain an orderly interior. Walls in residents' rooms were damaged and/or had been repaired but not painted. Multiple rooms were affected. Facility census: 61. Findings include: a) During the initial tour of the facility and throughout the survey, observation found the walls in various residents' rooms were damaged. The damage appeared to have been caused by the raising and lowering of the residents' beds. Examples of the observed damages were (the list is representative, but not all inclusive): 1. Room 33 The wall behind the first bed, which faced the door to the hall, had gouges that were at least twelve (12) to eighteen (18) inches long, at least two (2) inches wide and at least one-half (1/2) inch deep. The backing of the drywall could be felt in some areas. 2. Room 30 The wall beside one (1) bed had been patched but not been painted. The patched area had new scarred areas. The other bed had gouges in the all next to the window and behind the head of the bed. . | 2014-11-01 |
| 10903 | 10903 | GOLDEN LIVINGCENTER - GLASGOW | 515118 | PO BOX 350 | GLASGOW | WV | 25086 | 2009-09-11 | 201 | B | 0 | 1 | OF0Z11 | Based on staff interview and review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with four (4) different agencies. This error in the uniform notice may lead a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. This had the potential to affect all residents in the facility who are transferred or discharged . Facility census: 92. Findings include: a) Review of the uniform discharge notice of transfer / discharge form provided by the facility revealed the following: "If you disagree with this transfer/discharge or wish to appeal this transfer/discharge...:" This was followed by the names and contact information of the State Long-Term Care Ombudsman, Medicaid Fraud, and the WV Advocates. Below the above list of names and addresses was "For Medicaid Residents: Please include the provided self addressed stamped envelope which includes the address of the.... Inspector General". This uniform notification form contained the following error: The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the three (3) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may lead a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Interview with the director of nursing, on 09/10/09, revealed the facility changed this form a year or more ago and they were under the impression this form in its current format was appropriate. . | 2014-11-01 |
| 10942 | 10942 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 159 | B | 0 | 1 | HO2T11 | Based on record review and staff interview, the facility failed to obtain written authorization from the legal representatives, of five (5) of six (6) sampled residents with lack capacity, prior to holding and managing personal funds for these residents. Resident identifiers: #15, #23, #26, #39, and #41. Facility census: 61. Findings include: a) Resident #15 Medical record review revealed Resident #15 lacked capacity, and a representative from West Virginia Department of Health and Human Resources (DHHR) had been appointed as health care surrogate (HCS) to make medical decisions, because both the resident's daughter and her sister declined this responsibility. Resident #15 had $1,860.39 in a personal funds account being held and managed by the facility based on the signature of her daughter, although there was no evidence the daughter had the legally authority to either grant this permission or determine how the money would be disbursed. During an interview with the social worker at 4:00 p.m. on 06/16/09, she stated the resident's daughter had told her she was the resident's power of attorney (POA), but the daughter had never produced the documentation to verify this claim. b) Resident #23 Medical record review revealed Resident #23 lacked capacity to make medical decision, and a HCS was appointed to make these decisions for him. Resident #23 had $1700.63 in a personal funds account being held and managed by the facility based on the signature of the HCS, although there was no evidence the HCS had the legally authority to either grant this permission or determine how the money would be disbursed. (State law does not authorize a HCS to also make financial decisions on behalf of an incapacitated person.) During an interview with Employee #62, who was responsible for managing the personal funds accounts, she stated she was aware of this and that part of this money was to be paid to the funeral home for a burial plan. c) Residents #26 and #39 Residents #26 and #39, both of whom had been determined to lack capacity, h… | 2014-11-01 |
| 10983 | 10983 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2011-06-02 | 242 | B | 1 | 0 | TI3G11 | . Based on confidential resident interviews, review of the facility's planned cycle menus, observation, and staff interview, the facility failed to afford residents the right to choose a meal plan containing a variety of food items. The planned cycle menus for Weeks #1 and #3 were repetitious of entrees comprised of meat / tomato products and fish with breading and tartar sauce, respectively. Facility census: 109. Findings include: a) In confidential interviews, residents complained of the food items on the menu being "all the same", with little variety at times. Observation of the facility's current 4-week cycle menu found, in Week #1, three (3) consecutive days when the entrees included meat and tomato products in combination. On Tuesday 05/31/11 at the noon meal, the entree was Coney Chili on Bun; this was tasted by two (2) surveyors. On Wednesday 06/01/11 at the evening meal, the entree was Sloppy Joe on Bun; this was also sampled by the surveyors and was found to be very similar in taste, appearance, and texture to the Coney Chili offered the previous day at lunch. A review of the cycle menu and the recipes for both Coney Chili and Sloppy Joes, with the dietary manager (Employee #10) on the evening of 06/01/11, found the contents, flavor, and appearance of both items were similar. Further review of the menu with the dietary manager found a third meat / tomato product entree was to be served at the noon meal on Wednesday 06/02/11 - BBQ Pork on Bun. All three (3) of these items were found on the planned cycle menu for Week #1. Further review of the same cycle menu found, for Week #3, the following three (3) entrees that would be similar in content, taste, and appearance: - Sunday evening meal - Fish Sandwich with Tartar Sauce - Tuesday evening meal - Breaded Fish with Tartar Sauce - Wednesday noon meal - Crumb Topped Fish with Tartar Sauce The dietary manager acknowledged the menu did appear to include entrees that were similar to each other, and she agreed the taste and appearance of these entrees would be si… | 2014-10-01 |
| 11016 | 11016 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 514 | B | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate clinical records for two (2) of twenty one (21) sampled residents. Resident identifiers: #53 and #92. Facility census: 121. Findings include: a) Resident #53 Record review, on 02/04/09, revealed a doctor's progress note indicating the resident lacked the capacity to make healthcare decisions. This progress note contained no date and time. A social worker (Employee #79) provided a copy of the doctor's progress note at 2:50 p.m. on 02/04/09. The social worker was interviewed at this time, reviewed the record, and verified the note contained no date and time. b) Resident #92 A review of the medical record revealed a social services progress note, dated 10/22/08, which contained the following: "Resident is a full-code status per POST." Review of the Physician order [REDACTED]. These additional limitations would be contrary to a "Full Code". During an interview with the two (2) social workers (Employees #79 and #119) at 11:45 a.m. on 02/04/09, they reviewed the record and agreed that "Full Code" was an error in their notes. . | 2014-09-01 |
| 11057 | 11057 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 285 | B | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the mental health needs of applicants for admission were screened, in accordance with the Pre-Admission Screening and Resident Review (PASRR) program, prior to admission to the facility for three (3) of twenty-eight (28) sampled residents. Resident identifiers: #19, #74, and #113. Facility census: 128. Findings include: a) Resident #19 A review of the clinical record revealed Resident #19 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 04/10/09, as indicated by the dated signature in Section V. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he acknowledged this determination was made after the resident's admission to the facility. b) Resident #74 A review of the clinical record revealed Resident #74 was admitted to the facility on [DATE]. However, the PASRR determination with respect to a Level II evaluation was not made until after admission on 01/12/09, as indicated by the dated signature in Section V. During an interview with the social worker at 11:00 a.m. on 06/24/09, he acknowledged the determination was made after the resident's admission to the facility. c) Resident #113 The medical record of Resident #113, when reviewed on 06/23/09, disclosed the resident was admitted to the facility on [DATE]. Further review disclosed, at Item 42 on page 6 of the PASRR form, that a determination with respect to a Level II evaluation was not made until 03/25/09, after the resident's admission to the facility. . | 2014-09-01 |
| 11138 | 11138 | BRAXTON HEALTH CARE CENTER | 515180 | 859 DAYS DRIVE | SUTTON | WV | 26601 | 2009-08-06 | 252 | B | 0 | 1 | R1DI11 | Based on observations, the facility failed to ensure window curtains were in good repair. Holes were observed in the curtains in five (5) rooms on the 200 hall. This had the potential to affect the residents living in those rooms. Facility census: 58. Findings include: a) During the initial tour of the facility on 08/04/09, holes were observed in the window curtains in rooms #200, #202, #206, #210, and #212. . | 2014-08-01 |
| 11149 | 11149 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 159 | B | 0 | 1 | OCKG11 | Based on a review of the resident trust account information and staff interview, the facility failed to ensure quarterly account balances / statements were being sent only to persons with the legal authority to access this information. The facility sent quarterly account balances / statements to unauthorized third parties for four (4) residents. Resident identifiers: #11, #36, #30, and #33. Facility census: 50. Findings include: a) Residents #11, #36, #30, and #33 Record review for Residents #11, #30, #33, and #36 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal fund records, with the business office manager on 08/12/09 at 10:00 a.m., found quarterly financial statements were being sent to unauthorized representatives for all four (4) residents, two (2) of whom were alert and oriented and were entitled to this information themselves. . | 2014-08-01 |
| 11301 | 11301 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2010-06-10 | 281 | B | 1 | 0 | 4NN912 | . Based on observation, medical record review, and staff interview, the facility failed to assure physician's orders to change the humidifier bottles on the oxygen concentrators were followed for four (4) of twenty (20) residents receiving oxygen therapy. Resident identifiers: #83, #33, #14, and #23. Facility census: 87. Findings include: a) Residents #83, #33, #14, and #23 Observations, conducted on the afternoon of 06/09/10, found the above residents were receiving oxygen therapy. Inspection of the humidifier bottles noted a date of "05/27/10" was written on the front of the bottles. Review of the resident's medical records found physicians' orders to change the humidifier bottles each week. Review of the treatment administration records (TARs) found the humidifier bottles for the above residents were scheduled to be changed on 06/03/10. An interview with a licensed practical nurse (LPN - Employee #4) verified the humidifier bottle on Resident #23's bottle was dated 05/27/10. No resident appeared to be in distress from this failure to follow physicians' orders. . | 2014-07-01 |
| 11302 | 11302 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2010-06-10 | 514 | B | 1 | 0 | 4NN912 | . Based on observation, medical record review, and staff interview, the facility failed to assure the clinical record for each resident was accurately documented in accordance with accepted professional standards. This deficient practice affected four (4) of twenty (20) residents receiving oxygen therapy. Resident identifiers: #83, #33, #14, and #23. Facility census: 87. Findings include: a) Residents #83, #33, #14, and #23 Observations, conducted on the afternoon of 06/09/10, found the above residents were receiving oxygen therapy. Inspection of the humidifier bottles noted a date of "05/27/10" was written on the front of the bottles. Review of the resident's medical records found physicians' orders to change the humidifier bottles each week. Review of the treatment administration records (TARs) found the humidifier bottles for the above residents were scheduled to be changed on 06/03/10 and contained nursing documentation that the bottles had been changed on that date. The director of nursing (DON), when informed of the above observations at 9: 45 a.m. on 06/10/10 at 9:45 a.m., agreed the records were not accurately documented. | 2014-07-01 |
| 11323 | 11323 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 364 | B | 0 | 1 | IH3P11 | Based on observation and staff interview, the facility failed to provide food that was attractive in appearance for the evening meal on 02/09/09. The food items served during evening meal provided only white, brown, and yellow as colors on the resident trays. This had the potential to affect all residents who chose the main entree for dinner on 02/09/09. Facility census: 106. Findings include: a) Observation of the dinner meal, on 02/09/09 at 5:00 p.m., found the meal consisted of chicken nuggets, cauliflower, and hashbrown casserole, which were brown and white in color. Pineapple was the dessert and was yellow in color. The appearance of the items on the residents' plates offered no variety in color and texture. An interview with the dietary manager ,and a review of the menus on the late morning of 02/12/09, found that fruit ambrosia was supposed to have been on the menu for that day. . | 2014-06-01 |
| 11365 | 11365 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2009-07-02 | 240 | B | MWZ111 | Based on resident interview, observation, and staff interview, the facility failed to ensure residents received fresh ice and water every shift. This was evident for four (4) of four (4) sampled residents, three (3) of whom were located on the same hall. Resident identifiers: #57, #108, #6, and #31. Facility census: 102. Findings include: a) Resident #31 During an interview on 06/30/09, Resident #31 voiced a complaint of not having ice for his pitcher. He said he could not stand to drink the water that was not cold and elaborated that he will awaken from sleep and crave a cold drink, but many times there was no ice in his pitcher. He said he had not voiced complaints about this to anyone. He felt the facility should know to provide ice water to people who cannot easily get their own. He said there have been many times he had to get cold water from the bathroom in order to have a cold drink, and this may happen by day or by night. At 8:55 a.m. on 07/01/09, observation of his water pitcher found it contained only water, no ice. His pitcher was checked for ice again at 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., and no ice was present on any of these observations. Observations of every water pitcher on the same hall found none of the residents on that hall had ice in their pitchers. During an interview on 07/01/09 at 4:30 p.m., a nurse (Employee #139) stated ice was supplied to residents every shift. When informed that sampled residents had received no ice in their pitchers on day shift today, and currently none of the residents on the hall in question had ice, she stated she would take care of it immediately. b) Resident #6 Record review revealed Resident #6 was dependent on staff for all activities of daily living (ADLs) except eating. On 07/01/09, observations of her water pitcher, at 8:55 a.m., 10:00 a.m., 12:00 p.m., 3:00 p.m., and 4:15 p.m., found no fresh ice water at any time this day. This was reported to the nurse (Employee #139) at 4:30 p.m. on 07/01/09. c) Resident #108 Record review revealed Resid… | 2014-04-01 | ||
| 11479 | 11479 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 278 | B | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for four (4) of twenty (20) sampled residents. Resident identifiers: #65, #3, #4, and #81. Facility census: 113. Findings include: a) Resident #65 Record review (on 01/06/09) revealed the resident had a Stage II pressure ulcer to the coccyx which was recorded as being healed on 12/02/08. This information was noted on the December 2008 treatment administration record and a nurse's note dated 12/02/08. A skin assessment, dated 12/20/08, recorded no pressure ulcer(s) present at that time. Review of the resident's MDS, with an assessment reference date (ARD) of 12/24/08, found the assessor recorded in Section M1 the resident had one (1) Stage II ulcer. The MDS nurse (Employee #23) was interviewed on 01/07/09 about the information coded in Section M1 of the MDS. After reviewing the issue, she verified the MDS was coded incorrectly. On 01/08/09 at 11:05 a.m., the MDS nurse provided a copy of a corrected MDS, with an ARD of 12/24/08. In Section M1, the assessor documented no pressure ulcer(s). b) Resident #31 Review (on 01/07/09) of the admission MDS, completed on 12/24/08, revealed the assessor indicated, in Section I2, the resident had an antibiotic-resistant infection. Interview with the director of nursing (DON - Employee #2), at about 6:00 p.m. on 01/07/09, and review of the laboratory reports confirmed that, when the resident was admitted on [DATE], the resident had a [DIAGNOSES REDACTED]. c) Resident #40 Review (on 01/06/09) of the quarterly MDS, completed on 11/12/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/0… | 2014-02-01 | ||
| 11498 | 11498 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2010-12-02 | 431 | B | 50Z112 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on random observation, staff interview, and review of drug manufacturer's information, the facility failed to assure all medications were maintained in safe and secure storage. This deficient practice affected two (2) of four (4) sampled residents. Resident identifiers: #7 and #60. Facility census: 86. Findings include: a) Resident #7 Random observations of the resident environment, on 11/29/10 at 2:10 p.m., found a 4 ounce tube of Vitamin A&D ointment lying on the windowsill of the resident's room. Interview with Resident #7 found him to be alert and oriented, and he answered questions appropriately. When asked what the tube of medication was used for, he stated, "They rub it on me," while making rubbing motions around his groin area. It was noted that no residents were wandering in the hallway. Following this observation, the director of nursing (DON) was informed that the ointment had been left unsecured in the resident's room. She agreed the ointment should be secured. Review of the manufacturer's insert found no indications the ointment could cause poisoning should it be accidently ingested by a confused resident. b) Resident #60 Random observations of the facility, on 11/29/10 at 2:15 p.m., found tubes of Collagenase (utilized for treatment of [REDACTED]. It was noted that no residents were wandering in the hallway. The DON was notified of the presence of the tubes of ointment in the resident's room. She removed the ointment and agreed the medication should be secured. Review of the manufacturer's information found the following, "No systemic or local reaction attributed to overdose has been observed in clinical investigations and clinical use...". | 2014-02-01 | ||
| 250 | 250 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2019-02-27 | 576 | C | 0 | 1 | DBDN11 | Based on resident interview and staff interview, the facility failed to ensure residents had the right to receive mail on Saturdays when delivery was available through the postal service. This had the potential to affect all residents residing at the facility. Facility census: 65. Findings included: a) Resident council meeting At 2:15 PM on 02/26/19, residents attending the council meeting were asked the question, is mail delivered unopened and on Saturdays? The residents agreed their mail was unopened, but they didn't know if mail was delivered on Saturdays. The activity director (AD) #10 attended the meeting. The AD said the facility did not get mail on Saturdays. She did not know if the mail could be delivered. On 02/27/19 at 3:46 PM, the administrator said the mail hadn't been delivered on Saturdays. The administrator contacted the postal carrier who can deliver mail on Saturdays and mail delivery has been arranged. | 2020-09-01 |
| 297 | 297 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2017-03-08 | 167 | C | 0 | 1 | UN5811 | Based on observations and staff interview, the facility failed to have a notice posted as to the location of the most-recent survey results during a random observation. This has the potential to affect all residents and visitors. Facility census 81. Findings include: a) Observation On 03/05/17 during an initial tour of the facility, the recent State survey results were observed in the main dining room in a box on the wall. A notice as to the location of the survey results was not observed during the survey week (03/05/17- 03/08/17). b) Interview During an interview with the Administrator, on 03/08/17 at 10:30 a.m., the Administratorwas asked where the notice was located to inform a visitor where the survey results would be located. The Administrator said we do not have a notice. She was not aware a posting was required to inform visitors of where to find the facility's survey results. | 2020-09-01 |
| 306 | 306 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2017-03-08 | 356 | C | 0 | 1 | UN5811 | Based on observation, and staff interview, the facilty failed to post the nurse staff posting information on 03/05/17. This was found during a random observation. This failed practice had the potential to affect all residents. Facility census: 81. Findings include: Observation on 03/05/17 at 10:20 a.m., found the nurse staff posting information up front near the main lobby. The date on the nurse staff posting form was 03/04/17. In an interview and review of the nurse staff posting form near the main lobby on 03/05/17 at 10:33 a.m., with registered nurse (RN) #29, she confirmed the posting on the wall was for 03/04/17. The NSRN stated that 03/05/17's nurse staff posting form should have been posted at 7:00 a.m. this morning. | 2020-09-01 |
| 352 | 352 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2018-04-26 | 756 | C | 0 | 1 | J1N911 | Based on policy review and staff interview, the facility failed to develop and maintain policies and procedures for the monthly drug regimen review that included but were not limited to, time frames for the different steps in the monthly medication regimen review process. This practice had the potential to affect all residents. Facility census: 134. Findings included: The facility policy titled Monthly Regimen Review stated under section seven (7): Timelines and responsibilities for Medication Regimen Review (MRR): --The consultant pharmacist shall schedule at least one monthly visit to the facility, and shall allow sufficient time to complete all required activities. --The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review. --If the pharmacist should identify an irregularity that requires urgent action to protect a resident, the DON (Director of Nursing) or designee is informed verbally. --For residents experiencing a change in condition and the nurse deems a MRR is necessary outside the routine visit, the facility will notify the pharmacy provider. --Facility shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. The policy did not include time frames identified for physician notification following routine or urgent requests and no time frames for physician responses to pharmacy reviews. The Director of Nursing (DON) reviewed the current policy during an interview on 04/25/18, and confirmed the policy lacked specific time frames for the MRR review process, including times for physician notification and physician responses to monthly reviews and urgent requests. | 2020-09-01 |
| 489 | 489 | ST. JOSEPH'S HOSPITAL | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2018-05-09 | 577 | C | 0 | 1 | VZPJ11 | Based on resident interviews during the Resident Council meeting and staff interviews, the facility failed to post in a place readily accessible to residents, family members and legal representatives, the most recent state inspection survey results of the facility. This had the potential to affect all individuals wanting to review the results of survey and any plan of correction for this facility. Facility census: 16. Findings included: a) Posting survey results During the Resident Council meeting on 05/09/18 at 10:00 AM, the resident council members did not know the state inspection was to be made available for them to review, nor did they know where it was located in the facility. Explained the results of the most recent survey and any plan of correction was to be posted and readily accessible for them and their family members to review. In an interview with Employee #31, social services director on 05/09/18 at 10:25 AM, verified the state inspection survey results were not posted and readily accessible to residents, family members or visitors. | 2020-09-01 |
| 1116 | 1116 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2018-10-24 | 880 | C | 0 | 1 | V96711 | Based on policy review and staff interview, the facility's Infection Prevention and Control Program (IPCP) failed to establish an infection prevention and control policy and/or 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 IPCP policy is unsigned and lacks an effective date and/or any review dates. This practice has the potential to affect all residents residing in the facility. Facility census: 33. Findings includes: Review of the facility policy titled Infection Prevention and Control Plan obtained from the Infection Control Nurse #5 on 10/24/18, revealed the policy lacks an effective date and/or a review date. In addition, there are no signatures indicating the approval by the Medical Director, the Chief Executive Officer or any other administrative staff. During an interview on 10/24/18, the Director of Nursing reported she was unaware of when the IPCP policy was received from the state. The DON acknowledged the policy lacks an effective date, an annual review date and approval signatures. | 2020-09-01 |
| 1712 | 1712 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2018-06-07 | 576 | C | 0 | 1 | 2KKW11 | Based on resident interview, staff interview and record review, the facility failed to ensure residents' mail was delivered on Saturdays. This had the potential to affect all residents in the facility. Facility census: 67. Findings included: a) Mail delivery on Saturday During a group meeting with seven (7) members of the facility resident council on 6/5/17 at 11:00 AM, The group said they did not receive mail on Saturdays. When asked if they had been given a reason for this, they said they had not, they just figured there was no one there on Saturdays to deliver it. The Activities Director, #40, who facilitates monthly Resident Council Meetings, was interviewed on 6/7/18 at 11:47 AM. She was asked about residents getting their mail on Saturdays. She said they did not. She said right after she had started working at the facility as Activities Director, about two (2) years ago, the former Administrator told her she had called the Post Office and canceled Saturday deliveries to the facility. Review of the Activities Calendars on 6/5/18 at 12:00 PM, it was found there was a notice on the calendars stating Mail delivered Monday thru Friday. During an interview on 6/5/18 at 3:00 PM, the Director of Nursing (DON), #77, confirmed the Saturday mail delivery had been canceled by the former Administrator about two years ago. Facility Administrator, #60 said on 6/5/18 at 4:00 PM he had contacted the Post Office and Saturday mail delivery would resume on 6/9/18. | 2020-09-01 |
| 1713 | 1713 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2018-06-07 | 583 | C | 0 | 1 | 2KKW11 | Based upon the resident group meeting, staff interview and review of facility documents, the facility failed to ensure the residents' right to promptly receive mail, except when there is no regularly scheduled postal delivery and pick-up service. Promptly as defined within the regulation, means: delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service. This had the potential to affect all the resident of the facility. Facility census: 67. Findings included: a) During a group meeting with seven (7) members of the facility resident council on 6/5/17 at 11:00 AM, The group said they did not receive mail on Saturdays. When asked if they had been given a reason for this, they said they had not, they just figured there was no one there on Saturdays to deliver it. b) The Activities Director, #40, who facilitates monthly Resident Council Meetings, was interviewed on 6/7/18 at 11:47 AM. She was asked about residents getting their mail on Saturdays. She said they did not. She said right after she had started working at the facility as Activities Director, about two (2) years ago, the former Administrator told her she had called the Post Office and canceled Saturday deliveries to the facility. c) Review of the Activities Calendars on 6/5/18 at 12:00 PM, it was found there was a notice on the calendars stating Mail delivered Monday thru Friday. d) During an interview on 6/5/18 at 3:00 PM, the Director of Nursing (DON), #77, confirmed the Saturday mail delivery had been canceled by the former Administrator about two years ago. e) Facility Administrator, #60 said on 6/5/18 at 4:00 PM he had contacted the Post Office and Saturday mail delivery would resume on 6/9/18. | 2020-09-01 |
| 1782 | 1782 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2019-03-20 | 732 | C | 0 | 1 | MRLP11 | Based on review of staffing documentation and by staff interview, the facility failed to ensure the complete staffing numbers for each shift is posted daily. There were days noted where the staff available for only one shift was recorded on the form and the other two shifts were blank. This was for three days out of months of (MONTH) and March. This practice has the potential to affect more than a limited number of residents and family who are to have access to this informaiton. Findings included: a) 03/19/19 at 1:20 p.m. discussion with the director of nursing (DON) verified the staff postings had not been completely filled out for the evening and night shifts This was found during a review of the staff posting sheets on file for (MONTH) and so far for the month of March. The documentation was incomplete for (MONTH) 14 and 17. Also for (MONTH) 9, 2019. This informaiton is to be posted for all the public to have access to the information. | 2020-09-01 |
| 1855 | 1855 | GLASGOW HEALTH AND REHABILITATION CENTER | 515118 | 120 MELROSE DRIVE, BOX 350 | GLASGOW | WV | 25086 | 2017-02-14 | 356 | C | 0 | 1 | JVKC11 | Based on review of posted staffing sheets, review of previous staffing sheets, and staff interview, found the form used by the facility did not contain all of the required information. The name of the facility was not included on the document. This had the potential to affect residents and families who wished to review the staffing information. Facility Census: 97. Findings include: a) Review of the POS [REDACTED]. Federal regulation requires the posted information include the name for the facility. On 02/13/17 at 11:15 a.m., Employee #79, the staff member in charge of preparing the posted staffing information confirmed the form being used did not have the name of the facility. | 2020-09-01 |
| 2126 | 2126 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2016-08-30 | 203 | C | 0 | 1 | 6MCU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer/discharge form and staff interview, the facility failed to provide residents and responsible parties with the correct contact information of the single State agency responsible for reviewing making decisions for all transfer/discharge appeals. Additionally, the uniform discharge notice provided incorrect information regarding the agency designated in West Virginia (WV) to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. These findings had the potential to affect more than a limited number of residents. Facility census: 53. Findings include: a) Review of the facility's uniform notification of transfer/discharge form provided by the facility on 08/25/16, revealed it included, You have the right to appeal this action to: , This was followed by the names and contact information of the regional Ombudsman, State Ombudsman, Office of Heath Facility Licensure and Certification, and the Board of Review. Immediately following the list of names and contact information of appeals was Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: . This was followed by the contact information for West Virginia Advocates and for Medicaid Fraud. This uniform notification form contained the following errors: 1. The Office of the Inspector General's Board of Review is the only agency in WV which hears and makes determinations about appeals of transfer/discharge. None of the five (5) other agencies identified in the notice are responsible for this activity. This misinformation has the potential to delay a decision for an appeal should the resident/resident's representative submit the appeal to the wrong agency. 2. The single agency designated in WV to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc. Medicaid Fraud does not prov… | 2020-09-01 |
| 2201 | 2201 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2017-03-31 | 356 | C | 0 | 1 | YOOX11 | Based on record review and staff interview the facility failed to ensure the accuracy of the staff posting. Over a three-month period, the daily staff posting sheets were not filled out for every shift for 14 days. This practice had the potential to affect all residents as well as visitors. Facility census: 58. Findings include: a) On 03/29/17 at 12:00 p.m. Admissions Director #51 provided copies of the daily nursing staff form for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). A review of the forms revealed the following for (MONTH) (YEAR): --12/05/16 - the daily nurse staffing form did not include the number of hours and number of Registered nurses (RN), Licensed Practical Nurses (LPN), and nurse aides (NA) who worked on 3:00 p.m. -11:00 p.m. The form also did not list the number of RNs and hours worked for 11:00 p.m. - 7:00 a.m. shift. --12/06/16 - the number and hours worked for RNs, LPNs and NAs was not listed. --12/12/16 - the number of RNs, LPNs, and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. --12/13/16 - the number of RNs, LPNs and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. --12/19/16 - the number of RNs, LPNs and NAs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. The number of RNs and hours worked was not listed for 11:00 p.m. - 7:00 a.m. shift. --12/27/16 - the number of RNs, LPNs, and NAs and hours worked was not listed for 3:00 p.m. - 11:00 p.m. shift and the number of RNs and hours worked was not listed for 11:00 p.m. - 7:00 a.m. shift. --12/30/16 - the number of RNs, LPNs, and NAs and hours worked for 7:00 a.m. - 3:00 p.m. shift was not listed. The number of RNs and hours worked for 3:00 p.m. - 11:00 p.m. shift was not listed. A review of the forms revealed the following for (MONTH) (YEAR): --01/01/17 - The number of RNs and hours worked for 7:00 a.m. - 3:00 p.m. shift was not listed. The number and hours worked for RNs was noted listed at 3:00 p.m. - 11:00 p.m. shift was not listed. The number and hours worked for RNs for… | 2020-09-01 |
| 2266 | 2266 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2019-03-27 | 880 | C | 0 | 1 | TD9H11 | Based on observation and staff interview, the facility failed to 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. This was true for the laundry room having air flow pulling the air from the soiled side into the clean side and air drying and storing clean items in the soiled laundry room. This failed practice had the potential to have a minimal affect on the residents of the facility. Facility census 105. Findings included: During a tour and interview on 03/27/19 at 8:03 AM, Laundry Employee # 116 was asked to get the Maintenance Supervisor to come to the laundry room. She was asked about the mop heads being dried in the soiled laundry room and the personal items hanging on a clothing rack being stored in the soiled side of the laundry room uncovered. She said, that it was things that did not have names on them and when someone was missing something they would look there to see if the lost items were there. She was asked if the clothing were rewashed before returning them to the residents, and she said no. During a tour and interview on 03/27/19 at 8:07 AM, Maintenance #98 was shown that the air flow from the soiled side was being pulled into the clean side with a tissue paper, Also the suction on the door was very strong pulling the soiled air into the clean side. He alerted Maintenance Supervisor #1 and Maintenance Supervisor Assistant #75 about the problem. They stated the problem was the exhaust fan in the dryer room was pulling the air from the soiled to the clean. They stated that they would fix that immediately. During an interview on 03/27/19 at 8:17 AM, Housekeeping Supervisor #72 about the storing clean items of clothing and drying mop heads in the soiled laundry room. She voiced understanding and had the items removed. During a brief interview on 03/27/19 at 9:00AM, Maintenance Supervisor #1 stated that they have a plan in place … | 2020-09-01 |
| 2308 | 2308 | MEADOWVIEW MANOR | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2019-08-07 | 732 | C | 0 | 1 | LHAE11 | Based on observation and staff interview the facility failed to ensure the staff posting was readily available for residents and visitors to view at any given time. This has the potential to affect all residents/family members who might wish to review the posting. Facility census: 60. Findings included: a) Observation of staff posting On 08/05/19 at 11:59 AM, Nursing Scheduler, employee #19 verified the staff posting was not available. [NAME] #19 looked at the wall across from the nurses station and said, It is normally up there, I don't know where it is. On 08/05/19 at 12:03 PM, the above observation was discussed with the administrator. At 10:57 AM on 08/06/19, the administrator suggested the surveyor talk with the nurse who had just removed the staff posting to make corrections due to staff not reporting for work. On 08/19/19 at 10:59 AM, Employee #59, a Registered Nurse (RN), said she took the posting down at 7:30 AM on 08/19/19 when she entered the facility because some staff had called in. She said she was busy assisting with breakfast and never put the posting back up. RN #59 confirmed she should have made the corrections when she entered the building and should have returned the staff posting promptly after completion. The administrator was present for the interview. After the interview concluded, the administrator said she had been given the wrong information. She thought the posting had just been taken down minutes before the observation. | 2020-09-01 |
| 2349 | 2349 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2019-02-20 | 732 | C | 1 | 0 | TETE11 | > Based on observation and staff interview, the facility failed to ensure the staff posting was complete and correct. This had the potential to affect all residents. Facility census: 86. Findings included: a) At 10:25 AM on 02/18/19, observation of the Daily Nurse Staffing form found information posted regarding the facility's census had not been completed. The census was blank. Registered Nurse (RN), Infection Prevention Nurse, RN #114 observed the posting and said she would get a corrected copy. At 8:35 AM on 02/20/19, the Director of Nursing said the facility prints forms for the following week every Friday. It is the nurses job to update the information each day and make sure the information is correct on every shift, every day. On 02/20/19 at 1:21 PM, Employee #52, the scheduler/payroll clerk, provided a corrected copy of what should have been posted on 02/18/19 at 10:25 AM. The corrected copy, supplied by [NAME] #52, noted the census was 65. The hours previously posted as worked for registered nurses was increased from 15 hours to 25 hours. The number of hours previously posted as worked by certified nursing assistants increased from 75 hours to 82.5 hours. | 2020-09-01 |
| 2616 | 2616 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2017-08-17 | 371 | C | 0 | 1 | OM4311 | Based on observation and staff interview, the facility failed to ensure the cook's production area was sanitary for food preparation. This had the potential to affect all residents consuming food prepared in the kitchen. The facility census was 101. Findings include: a) During initial observations in the kitchen on 08/14/17 at 8:30 a.m., the far wall of the kitchen, where the convection oven, grill, and steamer were located, was observed to have a heavy build-up of grease and grime on the floor underneath the equipment. The front of the oven/grill had greasy spills on the surface. Additionally, the entire perimeter of the kitchen had a visible area of grime near the wall. During an interview with Food Service Manager #72 and the Corporate Consultant on 08/17/17 at 2:30 p.m., the Food Service Manager stated that when she took the job at the facility on 07/03/17, there was no regular cleaning schedule in place for the dietary employees. She was in the process of developing cleaning schedules and was researching access to a power washer to deep clean the floors. Additionally, she was coordinating with facility housekeeping staff related to their ability to assist with deep cleaning of the kitchen floor on a periodic basis. These plans had not yet been finalized or implemented. | 2020-09-01 |
| 2663 | 2663 | CRESTVIEW MANOR NURSING AND REHABILITATION | 515160 | 199 COURT STREET | JANE LEW | WV | 26378 | 2018-03-09 | 607 | C | 0 | 1 | QUGB11 | Based on record review, policy review and staff interview, the facility failed to develop an abuse policy that included all required components. The policy did not address training related to dementia management and resident abuse prevention. The practice had the potential to affect all residents in the facility. Facility census: #70. Findings included: a) Policy and Procedure Review Review of the facility's Abuse and Neglect Policy and Procedure revealed staff in-service training would be conducted. The staff in-service training included the following topics: - Review facilities policy and procedures including State and Federal Rules and Regulations - Recognizing signs and symptoms of abuse - Conflict resolution and dealing with incidents - Burnout - Stress - Frustration - Appropriate behavior in a long term care setting - Resident rights and responsibilities - Reporting procedures Dementia management and resident abuse prevention was not included as a staff in-service training topic in the facility's Abuse and Neglect Policy and Procedure. Review of the in-service training of five (5) randomly selected direct patient staff revealed these staff members had completed trainings in dementia management. During an interview on 03/07/18 at 8:08 AM, the facility administrator was informed the facility's Abuse and Neglect Policy and Procedure did not include the required component of staff training related to dementia management and resident abuse prevention. The administrator stated staff received training related to dementia management and resident abuse prevention, even though the policy did not specify the training would be included for abuse prevention. The administrator stated the facility's Abuse and Neglect Policy and Procedure would be revised to include staff training related to dementia management and resident abuse prevention. | 2020-09-01 |
| 2703 | 2703 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2018-11-28 | 801 | C | 0 | 1 | DZOV11 | Based on staff interviews, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility failed to employ a Dietary Services Supervisor hired after 11/28/17 that was a Certified Dietary Manager (CDM). This affected one of one kitchen in the facility. The resident census at the time of the survey was 93. Findings include: The Dietary Services Supervisor (DSS) was interviewed on 11/27/18 at 9:04 AM. He said he was currently enrolled in the CDM class. He started the class in the summer; approximately (MONTH) or July. He was enrolled once before but said he never took the test. He said they do not have a full-time dietician. They have a dietician in their corporate office and they have a consultant dietician that comes every two weeks. The DSS was interviewed on 11/28/18 at 12:57 PM. He said he did not have a degree in food service management. He only had experience as a food service manager. He said he started with the company as a DSS in 07/2017 and started at this facility in 01/2018. He again confirmed that he was enrolled in his CDM classes. He was hoping to finish and test for his CDM in the summer of 2019. He thought he had one year to complete the CDM once he was hired. He did not know that he needed to be a CDM prior to starting the position. The Nursing Home Administrator (NHA) was interviewed on 11/28/18 at 2:10 PM. She thought that the DSS had a year after hire to complete the CDM course and take the test. She did not realize that the DSS had to be a CDM by 11/28/17. | 2020-09-01 |
| 2865 | 2865 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2017-12-14 | 814 | C | 0 | 1 | EBN311 | Based on observation and staff interview the facility failed to ensure that garbage was disposed of properly in a manner that would prevent the attraction of vermin. Observation revealed a dumpster overflowing with bags of garbage as well as bags of garbage on the ground beside the dumpster. This practice had the potential to affect all residents. Facility Census: 123 Findings include: On 12/14/17 at 12:45 p.m., the Dietary Manager and this surveyor observed various debris laying on the ground beside three (3) trash dumpsters. Observed on the ground outside the trash dumpsters was a smashed used plastic milk jug without the lid, various small pieces papers, an empty cigarette, and pieces of food wrappers. The Dietary Manager confirmed no trash is to be laying on the ground but inside the trash dumpsters. | 2020-09-01 |
| 2938 | 2938 | LOGAN CENTER | 515175 | 55 LOGAN MINGO MENTAL HEALTH CENTER ROAD | LOGAN | WV | 25601 | 2019-07-02 | 732 | C | 1 | 0 | 42VZ11 | > Based on record review and staff interview, the facility failed to post complete and accurate staffing information as required by regulation. This practice had the potential to minimally affect more than a limited number of residents. Facility census: 66. Findings included: a) Staff posting During review of the daily staff posting for 05/29/19 showed there were no registered nurses working on this day. A interview with the scheduler on 07/01/19 at 2:10 p.m. revealed there were three nurses working on 05/29/19. The posting was inaccurate for the number of registered nursing working on 05/29/19. A staff posting form dated 06/13/19 indicated three registered nurses were on duty. Interview with the scheduler on 07/01/19 at 1:57 pm revealed compared to the actual schedule there were two nurses present. The staff posting was inaccurate as to the number of registered nursing working on 07/01/19. | 2020-09-01 |
| 2962 | 2962 | LOGAN CENTER | 515175 | 55 LOGAN MINGO MENTAL HEALTH CENTER ROAD | LOGAN | WV | 25601 | 2017-09-28 | 226 | C | 0 | 1 | BKPR11 | Based on policy review, and staff interview, the facility failed to develop an abuse policy that included all required training. The policy did not address training related to dementia management and resident abuse prevention. This failure has the potential to affect all residents residing in the facility. Facility Census: 61. Findings include: a) Policy Development Review of the facility's policy titled, Abuse Prohibition at 1:48 p.m. on 09/26/17 found the following related to training of employees (typed at written): .3. Training will be provided to all employees, through orientation and a minimum of annually, and will include: 3.1 the Genesis HealthCare Abuse Prohibition Policy; 3.2 appropriate interventions to deal with aggressive and/or catastrophic reactions of patients; 3.3 how staff should report their knowledge related to allegations without fear of reprisal; 3.4 how to recognize signs of burnout, frustration, and stress that may lead to abuse; 3.5 what constitutes abuse, neglect, misappropriation of patient property, and 3.6 prohibition of staff from using any type of equipment (e.g. cameras, smartphones, and other electronic devices) to take, keep, or distribute photographs and recordings of patients that demeaning or humiliating. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revision 168, with a revision date of 03/08/17 found the following, F226 ** (Rev. 168, Issued: 03-08-17, Effective: 03-08-17, Implementation: 03-08-17) 483.12(b) The facility must develop and implement written policies and procedures that . (3) Include training as required at paragraph 483.95 . 483.95(c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in 483.12, facilities must also provide training to their staff that at a minimum educates staff on- 483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at 483.12. 483.95(c)(2) Procedures for… | 2020-09-01 |
| 3027 | 3027 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2017-07-14 | 356 | C | 0 | 1 | CPO811 | Based on facility record review and staff interview, the facility failed to maintain completed copies of all daily staff postings for a minimum of 18 months. This had the potential to affect all residents residing in the facility. Facility census: 52. Findings include: a) Review of daily postings on 07/11/17 at 2:30 p.m. for the period of 04/13/17 through 07/10/17 revealed there were no postings for: -- 04/14/17, -- 05/01/17, -- 05/11/17, -- 05/13/17, -- 05/15/17, -- 05/16/17, -- 05/21/17, -- 05/26/17, -- 05/29/17, and -- 06/04/17. The Administrator acknowledged the missing staff posting forms during an interview on 07/11/17 at 4:32 p.m. The Administrator stated, That is why that person no longer works here. | 2020-09-01 |
| 3331 | 3331 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2019-04-11 | 838 | C | 0 | 1 | KGJN11 | Based on review of the Facility Assessment and staff interview, the facility failed to ensure the assessment contained all the necessary components to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require. Information regarding staffing levels and competencies, facility resources necessary to provide for resident needs, health information technology resources, evaluation of the physical environment, and community based risk assessment were not included in the Facility Assessment. This had the potential to affect all residents residing at the facility. Facility census: 57. Findings included: a) Facility Assessment review On 04/10/19 at 12:46 PM, the administrator and the company president, Employee #88 were interviewed regarding the Facility Assessment. Information regarding the following components required for the assessment were not included in the copy provided by the facility: The staff competencies that are necessary to provide the level and types of care needed for the resident population. An evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs. A competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across these staff assignments. An evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment should also include an evaluation of what policies and procedures may be required in the provision of care and that these meet cur… | 2020-09-01 |
| 3411 | 3411 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 868 | C | 0 | 1 | 0LCE11 | Based on facility record review and staff interview, the facility failed to ensure the Quality Assurance and Process Improvement (QAPI) Committee is composed of the required committee members. The Medical Director or his designee failed to attended the QAPI Committee meetings at least quarterly. This has the potential to affect all residents. Facility census 108. Findings include: a) The facility Administrator presented the QAPI sign in sheets for the months of September, October, November, (MONTH) (YEAR) and (MONTH) 2019, on 01/31/19. The sign in sheets were dated 09/27/19 (should have been 09/27/18), 10/25/18, 11/30/18, 12/27/18, and 01/25/19. Further review of the sign in sheets revealed the Medical Director only attended the QAPI meeting once in five months, on 10/25/18. No other physician signatures were identified. On 01/31/19 at 2:43 PM and interview with the facility Administrator confirmed she was the person responsible for the Quality Assurance and Process Improvement (QAPI) Committee. The Administrator reported the QAPI meeting is held monthly and attended by all departments. The Administrator reviewed the sign in sheets and confirmed the Medical Director had only signed the QAPI attendance record on 10/25/18. Once in five months, not quarterly. | 2020-09-01 |
| 3567 | 3567 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2019-08-28 | 577 | C | 0 | 1 | EC8V11 | Based on observation and staff interview, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Review of posted survey results found no results from a recent complaint investigation that was conducted in (MONTH) 2019. This practice has the potential to affect all residents and visitors to the facility. Facility census: 23. Findings included: Observations at 1:00 PM on 08/27/19, found the survey results from the most recent complaint investigation completed on 01/17/19 was not in the three ring binder labeled Survey Result Posting. An interview with the Administrator at 1:23 PM on 08/27/19, confirmed the results from the complaint survey completed on 01/17/19 were not posted as required. | 2020-09-01 |
| 3602 | 3602 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2019-03-15 | 732 | C | 1 | 0 | YGIL11 | > Based on observation, staff interviews the facility failed to post the nurse staffing data on a daily basis at the beginning each shift. This had the potential to affect a minimum number of resident and visitors. Facility census 73. Findings included: a) Nurse Staff Posting Observation with Licensed Practical Nurse (LPN) #13 on 03/11/19 at 9:05 AM, revealed no staff posting for 03/11/19. The nurse staff posting that was in the clear plastic contain had the date of 03/08/19. The Nurse said probably someone is filling out the posting form. The Nurse was asked what time you come to work she said 7 AM. LPN #13 said no one has filled out the form as of yet. Observed the Director of Nursing (DON #18 on 03/11/19 at 9:15 AM, filling out the staff posting form at her desk in her office. The DON acknowledge the nurse staff posting had not been posted since 03/08/19. | 2020-09-01 |
| 3741 | 3741 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2019-02-08 | 947 | C | 0 | 1 | YS5611 | Based on staff interview and record review the facility failed to show evidence of dementia training for 7 of 7 nurse aides reviewed training (HSW #38, #4, #1, #22, #25, #2, #71). This had the potential to affect all residents. Facility Census 49. The findings are: Review of facility personnel and education records revealed: --Health Service Worker #38 was hired on 09/01/2009. Her record did not contain evidence of dementia training. --Health Service Worker #4 was hired on 01/28/2014. Her record did not contain evidence of dementia training. --Health Service Worker #2 was hired on 10/01/2010. Her record did not contain evidence of dementia training. --Health Service Worker #1 was hired on 09/05/2017. Her record did not contain evidence of dementia training. --Health Service Worker #71 was hired on 11/16/16. Her record did not contain evidence of dementia training. --Agency HSW #22 was hired on 11/13/2017. Her record did not contain evidence of dementia training. --Agency HSW #25 was hired on 03/12/2018. Her record did not contain evidence of dementia training. During an interview, on 02/07/19 at 10:47 am, Staff development educator (SDC) stated she had been in the position for 15 months. SDC stated she was unable to provide any evidence that the facility or agency HSW had any dementia training in the 15 months since she had been in the position. | 2020-09-01 |
| 3756 | 3756 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2016-10-05 | 356 | C | 0 | 1 | 17JD11 | Based on observation and staff interview the facility failed to comply with the CMS guidelines for the daily Nursing Staff postings by failing to include all information required, by not including the actual hours worked by the direct care staff; and/or including staff outside of nursing in their direct care total. This had the potential to effect all residents. Facility census 54. Findings include: a) During the general tour of the facility at 11:20 a.m. on 10/03/16, the daily nursing staff postings were observed in various locations throughout the facility. The posting indicated the total number of RN's, LPN's, and CNA's present on each shift; but failed to include the actual hours worked. The posting incorrectly included Physical Therapy staff in the day shift total of nursing care staff. During interviews with the Director of Nurses (at 10:00 a.m. on 10/05/16) and the Administrator (at 10:15 a.m. on 10/05/16), they were informed of the requirements for the daily staff postings. The director of nurses said she remembered the hours being listed at other facilities and would research for an appropriate form. The Administrator also said they would correct the posting. | 2020-09-01 |
| 3823 | 3823 | GRANT MEMORIAL HOSPITAL | 515045 | 117 HOSPITAL DRIVE | PETERSBURG | WV | 26847 | 2016-05-11 | 167 | C | 0 | 1 | 2V8S11 | Based on observation and staff interview, the facility failed to post the results of the most recent survey in a place readily accessible to residents. This practice had the potential to affect all residents residing in the facility. Facility census: 13. Findings include: a) On 05/09/16 at 2:00 p.m., an observation of the survey findings posted in a blue folder on the bulletin board in the hallway revealed the latest survey results had a date of 02/20/14. According to State records, the facility had an annual survey ending (MONTH) 24, (YEAR). During an interview with Nurse Manager #23 on 05/10/16 at 8:30 a.m., she agreed the most recent survey results were not posted. She stated, We were surveyed in (YEAR) and I never noticed the most recent survey results were not posted for examination by residents. On 05/10/16 at 8:55 a.m., Nurse Manager #23 reported, The survey results for (YEAR) are up now on the bulletin board on the unit. | 2020-07-01 |
| 3874 | 3874 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2017-01-19 | 520 | C | 0 | 1 | DBHB11 | Based on record review and staff interview, the facility failed to ensure the medical director or his designee attended quarterly Quality Assurance and Assessment (QA&A) meetings. This practice was discovered during review of the mandatory facility task of QA&[NAME] Facility census: 62. Findings include: a) The QA&A quarterly attendance sign-in sheets were reviewed with the administrator at 9:16 a.m. on 01/19/17. Review of the attendance sign-in sheets from 01/01/16 to 01/19/17 found the medical director only signed two (2) attendance sheets - 04/28/16 and 10/27/16. The administrator was unable to verify the medical director or his designee attended quarterly QA&A meetings as required by the regulations. | 2020-04-01 |
| 4039 | 4039 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 272 | C | 0 | 1 | WA6611 | Based on Minimum Data Set (MDS) review, review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI Manual), and staff interview, the facility failed to provide the dates of information used to complete the Care Area Assessments (CAA) for five (5) of five (5) residents reviewed during Stage 2. This affected all residents residing in the facility. Resident identifiers: #39, #26, #62, #11, and #10. Facility census: 61. Findings include: a) Resident #39 On 02/28/17 at 2:16 p.m., a review of the resident's annual MDS with an assessment reference date (ARD) of 06/16/16 revealed the CAA summary contained no dates of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record and see H&P (history and physical), but did not identify the dates of the referenced documents, interviews, or observations. b) Resident #26 A significant change MDS with an ARD of 11/25/16, contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. c) Resident #62 A significant change MDS with an ARD of 11/25/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained interview/record, record, interview and activity record, but did not identify the dates of the referenced documents, interviews, or observations. d) Resident #11 The resident's admission MDS with an ARD of 09/08/16 contained no dates of the location of the CAA documentation. Areas that triggered and marked to be care planned contained, interview/record, record, interview, interview/observation/record, Activity participation record, Medication Administration Record [REDACTED]. e) Resident #10 The annual MDS with an ARD of 03/24/16, contained no dates of the location of the CAA documentation. Areas that wer… | 2020-02-01 |
| 4046 | 4046 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 356 | C | 0 | 1 | WA6611 | Based upon observation, staff interview, and review of staffing and payroll documentation, the facility failed to post complete and accurate staffing information. This had the potential to affect all residents and visitors. Facility census: 61. Findings include: a) On 02/13/17 at 11:10 a.m., during the initial tour of the facility, staffing sheets posted for review by residents and visitors were observed on the second floor unit, Nursing Care Facility Two (NCF2). The posting showed the facility name, the date, the shift, the census, and the total hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Nurse Aides (NA), but did not show the total number of RNs, LPNs, and NAs working the shift. b) The 02/13/17 posting for the day shift showed there were two (2) nurses and one (1) nurse aide working on the unit. When asked if there was only one (1) NA working the day shift, RN #141 said the posting was not correct, that someone had come down from the third floor to cover and there were two (2). She pulled the posting sheet off the bulletin board and began to correct it. c) Complaints about inadequate staffing on both the second floor unit (NCF2) and the basement unit (NCF1) led to a detailed review of the staff posting, the schedules, and the payroll data for the period from 01/29/17 through 02/21/17. Numerous, almost daily discrepancies were noted between the posting sheets designed to keep residents and visitors informed about how many staff were working each unit and the actual hours reflected in the payroll information provided. d) When questioned about the discrepancies on 02/20/17 at 2:20 p.m., the facility's Administrator, #114, said, Almost none of the staff postings are accurate. | 2020-02-01 |
| 4081 | 4081 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-07-19 | 226 | C | 0 | 1 | KKFY11 | Based on policy review and staff interview, the facility failed to ensure its abuse policy addressed the reporting of allegations of neglect. This practice had the potential to affect all residents. Facility census: 105. Findings include: a) On 07/14/16 at 4:30 p.m., review of the facility's abuse prohibition policy, revised on 10/15/15, the policy stated under Process 5., Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will: 6.1 Enter allegation into the Risk Management System (RMS) 6.2 Report as follows: . This section did not mention neglect. During an interview on 07/14/16, at 4:45 p.m., when questioned about the policy not addressing neglect under the section titled Process 5, Social Worker (SW) #157 said she would review the policy. On 07/18/16 at 2:11 p.m., SW #157 said the facility felt the statement under Process 1, The administrator or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property would address the reporting of neglect. SW #157 was told that even though the statement under Process 1. did address operationalizing policies, it did not address reporting neglect. In #5, the policy addressed reporting, but did not specify the facility would report allegations of neglect. At 3:00 p.m. on 07/18/16, SW #157 said a corporate employee would add the word neglect to the facility's abuse prohibition policy under #6 regarding allegations to be reported. | 2020-02-01 |
| 4097 | 4097 | MOUND VIEW | 515067 | 2200 FLORAL STREET | MOUNDSVILLE | WV | 26041 | 2016-01-08 | 334 | C | 0 | 1 | UKTS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review the facility failed to educate each resident and/or their legal representative on the benefits and potential side effects of the influenza vaccine prior to administering the vaccine during the current (YEAR)-2016 flu season. This was found for five (5) of five (5) Stage 1 sampled residents reviewed during the annual Quality IndicatorSsurvey (QIS). Resident identifiers: #78, #71, #67, #76 and #6. Facility census: 95. Findings include: a) Review of medical records for Residents #78, #71, #67, #76, and #6, on 01/07/16 at 9:00 a.m., revealed all five (5) medical records lacked documentation indicating the resident and/or the resident's legal representative received education regarding the benefits and potential side effects of the influenza vaccine prior to administration during the current flu season. Residents #78, #67, #76, and #6 received the [MEDICATION NAME] flu vaccine on 10/23/15, and Resident #71 received the [MEDICATION NAME] flu vaccine on 10/28/15. Interview with the Medical Records Supervisor #21, on 01/07/16 at 9:30 a.m., confirmed the medical records did not contain consents and/or education regarding the benefits and potential side effects of the influenza vaccine during an interview. Interview with Registered Nurse (RN) #22, on 01/07/16 at 9:35 a.m., revealed she was unaware of the requirement to educate the resident and/or legal representative of the benefits and potential side effects of the current influenza vaccine prior to administering the annual flu shot. RN #22 acknowledged the facility did not hand out and/or educate the resident and/or legal representative prior to administering the annual influenza vaccine for the (YEAR)-2016 flu season. The facility vaccinations policy #4A, states under #4 of the section titled, Policy Interpretation and Implementation: Prior to the vaccinations, the resident or legal representative will be provided information and education re… | 2020-02-01 |
| 4151 | 4151 | JOHN MANCHIN SR HEALTH CARE CENTER | 515075 | 401 GUFFEY STREET | FAIRMONT | WV | 26554 | 2016-11-04 | 520 | C | 0 | 1 | JLJC11 | Based on record review and staff interview, the facility's quality assessment and assurance (QA & A) program failed to meet quarterly as required. This practice has the potential to effect all residents currently residing in the facility. Facility census: 29 Findings include: a) Meets at Least Quarterly Review of the facility's QA & A committee sign-in sheets for the previous year found the committee met on 02/10/16, 04/20/16 and 07/27/16, which did not represent a meeting every quarter. After this review, the Director of Nursing (DON) stated she was on vacation when one of the meetings was to be held in (MONTH) for the 3rd quarter of (YEAR), and that meeting was not held. | 2020-02-01 |
| 4187 | 4187 | REYNOLDS MEMORIAL HOSPITAL | 515112 | 800 WHEELING AVENUE | GLEN DALE | WV | 26038 | 2016-08-04 | 356 | C | 0 | 1 | YB6F11 | Based on observation and staff interview the facility failed to include all required nurse staffing data on the daily nurse staffing posting; or to maintain a copy of the information for the required 18 months. This had the potential to effect all residents. Facility census 13. Findings include: a) At 8:30 a.m. on 08/02/16, an observation made of the nurse staffing data posted at the nurses' station revealed the information was written on a chalk board, but the information was dated 07/31/16 and was for day shift only. The required information was present on the board, but the board was erased at the end of each shift, when it was kept correctly. Registed Nurse (RN) #11 was asked if there was a written record of the nurse staffing data; and replied there was a written record kept at the desk. A review of the form provided by RN #11 at 9:00 a.m. on 08/02/16, was reviewed. The form entitled Census Sheet For SNU (skilled nursing unit) was a record of each shift's attendance recorded on one line of a log. The data consisted of: Date, Census (residents), shift, RN (by #), LPN (#), CNA (#), and total staff. Thirteen (13) days could be recorded on each page and did not include the hours worked. This was reviewed with RN #52 (Director of Nurses) at 9:30 a.m. on 08/02/16, who said she would correct this immediately. At 3:30 p.m. on 08/02/16, RN #52 and RN #11 presented a corrected form written on paper and mounted on the chalk board for residents and/or visitors to read. | 2020-02-01 |
| 4197 | 4197 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2017-04-11 | 170 | C | 0 | 1 | XDKG11 | Based on staff interview and resident interview, the facility failed to ensure residents received mail delivery on Saturdays. This practice had the potential to affect all residents at the facility. Resident identifier: #121. Facility census: 113. Findings include: a) Resident #121 At 3:00 p.m. on 04/03/17, when asked about mail delivery on Saturdays, Resident #121 (the resident council president) said she did not believe residents received mail on Saturdays. She said the activities staff delivered the mail to the residents. Activity Director (AD) #98, when interviewed at 6:40 a.m. on 04/06/17, said there was no mail delivery on Saturdays. At 04/06/17 at 7:15 a.m., the administrator confirmed there was mail delivery from the post office in the neighborhood on Saturdays. At 8:11 a.m. on 04/11/17, the administrator said he arranged for the mail carrier to deliver the mail to the facility on Saturdays. I guess he (the mail man) didn't come before because he knew there was nobody in the office on Saturdays. | 2020-02-01 |
| 4210 | 4210 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2017-04-11 | 356 | C | 0 | 1 | XDKG11 | Based on observation and staff interview, the facility failed to ensure the nurse staff posting reflected staffing numbers for nigh shift. This practice had the potential to affect all residents and/or family members/visitors wishing to see how many staff were working. Facility Census: 113. Findings include: a) Upon entrance to the facility at 6:00 a.m. on 04/06/17, observation found the nurse staff posting form dated 04/05/17 contained spaces for staffing numbers for all three (3) shifts. 1. Day shift 6:30 a.m. to 2:30 p.m., 7:00 a.m. to 3:00 p.m., 9:00 a.m. to 5:00 p.m., and 10:30 a.m. to 6:30 p.m. 2. Evening Shift 2:30 p.m. to 10:30 p.m., 3:00 p.m. to 11:00 p.m., 3:00 p.m. to 3:00 a.m., 7:00 p.m. to 7:00 .a.m. 3. Night Shift: 10:30 p.m. to 6:30 a.m., 11:00 p.m. to 7:00 a.m., and 3:00 a.m. to 3:00 p.m. The day shift and evening shift staffing numbers were completed, but the night shift numbers were not filled in. An interview with Nurse Aide Supervisor (NAS) #41 confirmed the nurse staff posting was not completed for night shift. She stated, I take care of updating it before I leave in the evenings and I forgot to update it yesterday evening. | 2020-02-01 |
| 4263 | 4263 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2016-10-07 | 368 | C | 0 | 1 | 310011 | Based on observation, staff interview and review of the facility posted meal service time, the facility had routinely scheduled the evening meal and the next breakfast meal 14.5 hours apart. This had the potential to affect all residents served meals in the facility. Facility census: 69. Findings include: Observation on 10/03/16 revealed the meal times posted in the facility were: Breakfast --Hall #100 at 7:30 a.m. --Hall #200 / Private Dining Room at 7:40 a.m. --Main Dining Room at 7:45 a.m. --Hall #300 at 7:50 a.m. --Hall #400 at 8:00 a.m. Lunch Service --Hall #100 at noon --Hall #200 / Private Dining Room at 12:10 p.m. --Hall #300 at 12:15 p.m. --Hall #400 at 12:20 p.m. --Main Dining Room at 12:30 p.m. Dinner Service --Hall #100 at 5:00 p.m. --Hall #200 / Private Dining at 5:10 p.m. --Hall #300 at 5:15 p.m. --Hall #400 at 5:20 p.m. --Main Dining Room at 5:30 p.m. The posted meal schedule exceeds the 14 hour limit between the evening dinner meal and breakfast the following morning. During interview on 10/05/16 at 10 a.m., Food Service Manager #10 stated he had become the department manager in (MONTH) (YEAR) and that the current meal times were established before his arrival and had not been adjusted since his arrival. Food Service Manager #10 confirmed during the interview that the dietary department stocked nourishments to a room located near the nursing station. However, there was no plan to approach each resident and offer a nourishing snack each evening. The available floor stock nourishments were only available upon resident request. | 2020-02-01 |
| 4284 | 4284 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2016-03-22 | 356 | C | 0 | 1 | WJYE11 | Based on observation and staff interview, the facility failed to post nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents. Facility census: 61. Findings include: a) During the initial tour of the facility at 12:45 p.m. on 03/14/16, an observation of the daily staff posting of the direct care staff was made. The posting form was located in the upper left corner of a bulletin board in the resident common lounge area. The information occupied an 8 inch x 11 inch sheet of sheet of paper in a typed form filled in with small typed font information. The form could not be easily read by residents and/or visitors and could not be read by anyone in a wheelchair. This was acknowledged by the Assistant Director of Nursing (ADON) at 12:50 p.m. on 03/14/16. On 3/15/16 at 8:30 a.m. Scheduler #28 reported she had corrected the staff posting. The posting is now located on the outer left side of the nurses station desk approximately 3 feet from the floor at the w/c residents' eye level, in dark ink, easily readable. In addition the original posting remains high up on the bulletin board in case the other posting disappears. | 2020-02-01 |
| 4351 | 4351 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2016-01-20 | 356 | C | 0 | 1 | 96LU11 | Based on observation and staff interview, the facility failed to post nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents. Facility census: 115. Findings include: a) During the initial tour at 8:00 a.m. on 01/18/16, an observation of the daily staff posting of the direct care staff found the posting forms on the north and south halls were located behind the nurses' stations. The postings were approximately five (5) feet off of the floor and occupied an eight (8) by eleven (11) inch sheet of paper. The typed form was filled in with faint handwritten figures. The daily posting form could not be easily read by the residents or visitors and could not be read by anyone in a wheelchair. This was acknowledged by the Director of Nursing (DON) on 01/19/16 at 2:00 p.m. A follow up observation on 01/19/16 at 2:30 p.m., found both staff postings relocated on the outside of the nurses' stations, approximately four (4) feet from the floor and written in darker ink. | 2019-11-01 |
| 4406 | 4406 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2016-08-04 | 167 | C | 0 | 1 | BBQT11 | Based on Resident Council President interview, staff interview, and record review, the facility failed to ensure the results of its most recent survey were posted in a place which made them readily accessible for review by residents and/or family members. The facility had a Survey Book located in its lobby; however, the results located in the book were not from the most recent survey. This practice had the potential to affect all residents residing in the facility. Facility Census: 58 Findings Include: a) An interview with the Resident Council President at 1:50 p.m. on 08/01/16 revealed she was not aware of where the current state survey results were posted. She stated that she had never really looked for them but she did not know where to look even if she wanted to. At 2:04 p.m. on 08/01/16, the state survey results were located in a three ring binder in the main lobby labeled, Survey Results for Ohio Valley Health Care. Review of the results located in the three ring binder found it contained the results from the facility's Quality Indicator Survey (QIS) completed on 07/11/14. The results of the facility's last QIS completed on 09/24/15, were not readily accessible for review. An interview with the Director of Nursing at 2:19 p.m. on 08/01/16 confirmed the results in the lobby were from the (MONTH) 2014 survey and not the most recent survey completed on 09/24/15. She stated that she would have to get those results and put them in the survey results binder kept in the main lobby for the residents and families to review. | 2019-11-01 |
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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 );