cms_WV: 3288
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3288 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 520 | F | 0 | 1 | UXFJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, review of water temperatures, staff interviews, and resident interviews, the quality assessment and assurance (QA & A) committee failed to identify and address quality deficiencies of which they were aware, or should have been aware. Deficient practices related to quality of life and quality of care were identified during the Quality Indicator Survey (QIS). The issues identified were results of systemic breakdowns in the manner in which the facility staff administered care and services to their residents. The issues had been ongoing for multiple months giving the QA & A committee ample time to identify and correct the deficient practices prior to its QIS survey which began on 02/06/17 and ended on 02/09/17. Quality of Life: The facility failed to maintain an environment which was clean, sanitary, and in good repair. Walls were marred and scratched, door frames and doors were rusted, floor tile was cracked, resident equipment was dirty and/or rusted, shower room floors were dirty, blinds were bent and broken, and facility floors in resident rooms and common areas were dirty. Quality of Care: The facility was notified on 02/08/17 at 6:22 p.m. of an immediate jeopardy (IJ) situation due to elevated water temperatures. It was noted the facility had been monitoring the water temperature and on 02/07/17 had the hot water shut off to room [ROOM NUMBER] and 105 for a period of time. However, on 02/08/17 at 2:21 p.m. the hot water temperature in room [ROOM NUMBER] was 144 degrees and was not turned off, not had the hot water been turned off to the front public restrooms which had also had elevated temperatures. Furthermore, the hot water tank and the mixing valve in question serviced the entire first floor of the facility and no other actions had been taken by the facility to ensure resident safety until the problem is resolved. These deficient practices had to potential to affect all residents residing in the facility. Facility Census:58 Findings include: a) The facility failed to ensure the resident environment over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 2:30 p.m. and 3:00 p.m. on 02/06/17 with the maintenance department using the facility's laser thermometer found a water temperature of 130 degrees Fahrenheit (F) at a resident's hand sink. Throughout the survey, measurements of water temperatures found significant fluctuations of water temperatures at different times of the day, and in different rooms at the same time of the day. Additionally, the water temperature would peak, and then drop drastically after the water ran for several minutes. The facility identified fifteen (15) residents who had cognitive impairments that were able to use the hand sinks independently for handwashing and other activities; placing them at risk for serious harm because of the elevated water temperatures. Resident identifiers: #55, #44, #50, #42, #98, #2, 35, #15, #29, #22, #66, #11, #78, #95 and #81. Additionally, review of the facility's water temperature logs found water temperatures were often in excess of 120 degrees F for months without evidence of adjustments or evidence of the effectiveness of the adjustments. This was determined to constitute an immediate jeopardy (IJ) to the health and well-being to more than a limited number of the facility's residents. At 6:22 p.m. on 02/08/17, the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Maintenance Supervisor were notified of the IJ due to the elevated water temperatures. The facility provided an acceptable plan of correction (P[NAME]) at 9:00 p.m. on 02/08/17. After verifying the hot water supply to all resident areas was off, the survey team determined the immediacy of the deficient practice was abated at 9:00 p.m. on 02/08/17. 1. Measurement of Water Temperatures Water temperature measurements taken between 2:30 p.m. and 3:00 p.m. on 02/06/17 with a member of the maintenance department using the facility's laser thermometer found the water temperatures in the resident hands sinks in three (3) resident rooms were: -- room [ROOM NUMBER] the water temperature was 130 degrees Fahrenheit (F) -- room [ROOM NUMBER] the water temperature was 103 degrees F -- room [ROOM NUMBER] the water temperature was 109 degrees F After consulting with the Office of Health Facility Licensure and Certification's (OHFLAC) Life Safety Program Manager on 02/06/17 at 4:00 p.m. concerning the use of a laser thermometer, the facility's maintenance department was asked to use a thermometer that could be immersed in the water in order to obtain a more accurate water temperature. Between 4:15 p.m. and 4:40 p.m. on 02/06/17, water temperature measurements taken with the maintenance department using a submersible thermometer found the following water temperatures in the residents' hand sinks: -- room [ROOM NUMBER] the water temperature was 127.9 degrees Fahrenheit (F) -- room [ROOM NUMBER] the water temperature was 115.9 degrees F -- room [ROOM NUMBER] the water temperature was 112.9 degrees On 02/07/17, the facility provided a list of water temperatures randomly obtained by maintenance of hand sinks on first floor. The water temperatures ranged from 83.1 to 100.6 degrees F. On 02/08/17 at approximately 2:25 p.m., when washing her hands in the public restroom (room [ROOM NUMBER]), Surveyor noted steam rising from the water. The surveyor could not comfortably hold her hands under the water because it was too hot. Upon request at that time, maintenance obtained water temperatures at residents' hand sinks. On 02/08/17 the water temperatures taken between 2:30 p.m. and 3:00 p.m., found the following: -- room [ROOM NUMBER] the water temperature was 144 degrees F. (According to CMS Guidance to Surveyors, a 3rd degree burn can occur in 15 seconds when the water temperature is 133 degrees F.) -- room [ROOM NUMBER] the water temperature was 120.6 degrees F -- Shower room (Bathing 136) the water temperature was 111 degrees F -- Public bathroom (room [ROOM NUMBER]) the water temperature was 105.1 degrees F -- Public bathroom (room [ROOM NUMBER]) the water temperature was 107.3 degrees F Throughout the survey, significant fluctuations of water temperatures were noted at different times of the day and in different rooms at the same time of the day. The water temperature also decreased if allowed to run for several minutes. The temperature of the water would peak for a few minutes, and then drop drastically. At 4:21 p.m. on 02/08/17, the maintenance director obtained the following temperature: -- Public bathroom (room [ROOM NUMBER]) the water temperature was 119.2 degrees F. At 5:32 p.m. on 02/08/17, maintenance obtained the following temperature: -- Public bathroom (room [ROOM NUMBER]) the water temperature was 125.9 degrees F. On 02/07/17, the facility consulted a contractor who found the mixing valve needed replaced, but would not arrive until the morning of 02/09/17. The facility monitored the water temperatures and on 02/07/17, had the hot water shut off to rooms [ROOM NUMBERS] for a period. However, on 02/08/17 at 2:21 p.m. the hot water remained on in room [ROOM NUMBER] and was found to be 144 degrees F. Additionally, the hot water remained on in the front public restrooms which had also had elevated temperatures. Furthermore, the hot water tank and the mixing valve in question serviced the entire first floor of the facility and no other actions were taken by the facility to ensure resident safety until the problem was resolved. 2. CMS Guidance to Surveyors According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur at: --120 degrees F with an exposure time of five (5) minutes, --124 degrees F with an exposure time of three (3) minutes --127 degrees F with an exposure time of one (1) minute --133 degrees F with exposure time of 15 seconds, and --140 degrees F with an exposure time of 5 seconds, noting [MEDICAL CONDITION] occur even at water temperatures below these levels depending on the exposed individual's condition and length of exposure. 3. Review of Six (6) Months of Water Temperatures At 6:00 p.m. on 02/08/17, review of the facility's Daily Check Form for the previous six (6) months, revealed the following notable high water temperatures: -- 06/17/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/20/16 - room [ROOM NUMBER] - water temperature - 123 F -- 06/22/16 - room [ROOM NUMBER] - water temperature - 123 F -- 06/23/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/27/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/28/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/01/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/05/16 - room [ROOM NUMBER] - water temperature - 126 F -- 07/06/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/07/16 - room [ROOM NUMBER] - water temperature - 121.2 F -- 07/08/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 07/12/16 - room [ROOM NUMBER] - water temperature - 122 F -- 07/18/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/19/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 132.8 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 129.9 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 07/22/16 - room [ROOM NUMBER] - water temperature - 126.2 F -- 07/25/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/27/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 08/01/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 08/01/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 08/02/16 - room [ROOM NUMBER] - water temperature - 120.1 F -- 08/04/16 - room [ROOM NUMBER] - water temperature - 121.1 F -- 08/05/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 08/18/16 - room [ROOM NUMBER] - water temperature - 139.1 F -- 08/19/16 - room [ROOM NUMBER] - water temperature - 123.3 F -- 08/22/16 - room [ROOM NUMBER] - water temperature - 128.2 F -- 08/23/16 - room [ROOM NUMBER] - water temperature - 126.4 F -- 08/24/16 - room [ROOM NUMBER] - water temperature - 121.1 F -- 08/26/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 08/30/16 - room [ROOM NUMBER] - water temperature - 121.4 F -- 08/31/16 - room [ROOM NUMBER] - water temperature - 123.1 F -- 08/30/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 09/01/16 - room [ROOM NUMBER] - water temperature - 123.6 F -- 09/02/16 - room [ROOM NUMBER] - water temperature - 121.7 F -- 09/06/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 09/07/16- room [ROOM NUMBER]-water temperature - 123.6 F -- 09/07/16 - Shower Room A - water temperature - 120.3 F -- 09/08/16 - room [ROOM NUMBER] - water temperature - 121.4 F -- 09/09/16 - room [ROOM NUMBER] - water temperature - 134.4 F -- 09/09/16 - room [ROOM NUMBER] - water temperature - 123.5 F -- 09/12/16 - room [ROOM NUMBER] - water temperature - 138.6 F -- 09/12/16 - room [ROOM NUMBER] - water temperature - 122.3 F -- 09/13/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 09/13/16 - room [ROOM NUMBER] - water temperature - 122.6 F -- 09/14/16 - room [ROOM NUMBER] - water temperature - 120.1 F -- 09/15/16 - room [ROOM NUMBER] - water temperature - 120.2 F -- 09/15/16 - room [ROOM NUMBER] - water temperature - 121.5 F -- 09/19/16 - room [ROOM NUMBER] - water temperature - 122.5 F -- 09/19/16 - room [ROOM NUMBER] - water temperature - 123 F -- 09/20/16 - room [ROOM NUMBER] - water temperature - 130.8 F -- 09/20/16 - room [ROOM NUMBER] - water temperature - 123.2 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 138.5 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 133.4 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 125.2 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 124.7 F -- 09/23/16 - room [ROOM NUMBER] - water temperature - 133.7 F -- 09/26/16 - room [ROOM NUMBER] - water temperature - 137.4 F -- 09/26/16 - room [ROOM NUMBER] - water temperature - 129.4 F -- 09/27/16 - room [ROOM NUMBER] - water temperature - 130.9 F -- 09/28/16 - room [ROOM NUMBER] - water temperature - 136.3 F -- 09/29/16 - room [ROOM NUMBER] - water temperature - 123.6 F -- 09/30/16 - room [ROOM NUMBER] - water temperature - 131.3 F -- 10/04/16 - room [ROOM NUMBER] - water temperature - 125.4 F -- 10/06/16 - room [ROOM NUMBER] - water temperature - 122.4 F -- 10/07/16 - room [ROOM NUMBER] - water temperature - 136.5 F -- 10/10/16 - room [ROOM NUMBER] - water temperature - 131.9 F -- 10/11/16 - room [ROOM NUMBER] - water temperature - 137.8 F -- 10/11/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 10/13/16 - room [ROOM NUMBER] - water temperature - 126.9 F -- 10/14/16 - room [ROOM NUMBER] - water temperature - 134.0 F -- 10/14/16 - room [ROOM NUMBER] - water temperature - 127.5 F -- 10/17/16 - room [ROOM NUMBER] - water temperature - 135.8 F -- 10/18/16 - room [ROOM NUMBER] - water temperature - 129.2 F -- 10/18/16 - room [ROOM NUMBER] - water temperature - 120.5 F -- 10/21/16 - room [ROOM NUMBER] - water temperature - 121.9 F -- 10/24/16 - room [ROOM NUMBER] - water temperature - 130.8 F -- 10/24/16 - room [ROOM NUMBER] - water temperature - 121.8 F -- 10/25/16 - room [ROOM NUMBER] - water temperature - 127.4 F -- 10/26/16 - room [ROOM NUMBER] - water temperature - 128.5 F -- 10/27/16 - room [ROOM NUMBER] - water temperature - 123.7 F -- 11/01/16 - room [ROOM NUMBER] - water temperature - 122.9 F (After (MONTH) (YEAR), water temperatures were measured using the laser thermometer. Because the laser thermometer can be affected by a number of variables, the temperatures were questionable.) The facility had hot water temperatures in excess of 120 degrees F weekly since 06/17/16. On 02/09/17 at 11:15 a.m., when asked about the elevated temperatures recorded on the log, the administrator said, The maintenance department supervisor reviews those water temperatures daily and adjusts the temperature as needed. The facility provided no evidence to support the water temperatures were adjusted or that water temperatures were retaken after adjustments to ensure the adjustments were effective. The facility provided no other information to indicate other measures were implemented in an effort to ensure safe water temperatures despite the continuing problem. The facility identified fifteen (15) residents who had cognitive impairments that were able to use the hand sinks independently for handwashing and other activities; placing them at risk for serious harm because of the elevated water temperatures. The identified residents were #55, #44, #50, #42, #98, #2, 35, #15, #29, #22, #66, #11, #78, #95, and #81. These findings were determined to constitute an immediate jeopardy (IJ) to the health and well-being of more than a limited number of the facility's residents. At 6:22 p.m. on 02/08/17, the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Maintenance Supervisor were notified of the IJ due to the elevated water temperatures. The facility provided an acceptable plan of correction (P[NAME]) at 9:00 p.m. on 02/08/17. After verifying the hot water supply to all resident areas was off, the survey team determined the immediacy of the deficient practice was abated at 9:00 p.m. on 02/08/17. b) Environment 1. Dining room a. Observation of the main dining room (used for food service and activities) with the Housekeeper/Laundry/Maintenance supervisor, Employee #73, began at 8:10 a.m. on 02/09/17. The following items were found: -- Debris behind the door leading into the dining room. -- The floor around the baseboards was dirty. -- The baseboards were splashed with debris. -- The wall, above the heater had cracked plaster. -- The door frames leading into the dining room were rusted and scraped. -- Trash, straws, napkins and paper products were littered behind the trash can. -- The floors were dirty in the alcove beside the ice machine. -- The floor had the remains of strips of tape which appeared to once be an outline of a shuffle board. --The tape had collected hair, lint and other debris. Employee #73 said the tape could be scraped from the floor, it just needed cleaned. -- The ice cart was splashed with dirt and debris. 2. Main Dinning Room On 02/06/17 at 11:40 a.m., observations of lunch in the main dining room noted the dining room floor soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/06/217 at 4:42 p.m., residents were seated for dinner at tables in the main dining room. The dining room floor was soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/07/17 at 7:51 a.m., observations of residents served breakfast in the main dining room noted the dining room floor soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/07/17 at 9:27 a.m., Staff #84 was mopping the main dining room floor. Staff #84 stated the floor should be mopped three times a day, and it had a lot of coffee and juice stains, and wheelchair marks. On 02/07/17 at 9:31 a.m., Staff #94 stated the main dining room floor es supposed to be cleaned after every meal. 3. Resident rooms Observations during the tour of the facility with the administrator began at 3:20 p.m. on 02/08/17. The following observations were made: -- room [ROOM NUMBER] - The light beside bed A had a cotton cord used to turn on the light over the bed was soiled. The floor tile was cracked in the corner beside bed-[NAME] -- room [ROOM NUMBER] - The plaster was missing at the corner of the closet. The corner behind the entrance door was littered with cob webs and dirt and debris. A wash pan and brief were found on the closet floor. The tile was stained around the commode. The plaster was cracked beside the toilet. Debris was found in the heater. -- room [ROOM NUMBER] - The floor tile of the room was cracked. The crack extended out the doorway and into the main hallway. The door facing, leading into the bathroom was rusted. The tile was chipped with holes beside bed-[NAME] -- room [ROOM NUMBER] - The wall was patched, but not painted under the bed-B window. Debris and dirt were found along the cove molding in the bathroom. -- room [ROOM NUMBER] - The wall beside the closet was marred and scratched. The over-the-bed table was rusted. The veneer on the table top was chipped and cracked. The wooden drawers beside the sink were scratched, marred, and water marked. The door facing, leading into the room was rusted. Upon entrance to the room the bed sheets were soiled with a runny brown/yellow substance on the top sheet of the bed. The administrator changed the sheets on the bed when found. -- room [ROOM NUMBER] - The over-bed table for bed A had rusted legs and splashes of dried debris on the legs. Debris was present along the baseboard in the bathroom. The tile under the sink was cracked. The wall beside the sink was marred and scratched. During the tour, the resident in the bed-B, said the crank at the foot of the bed was missing, making it impossible to raise the head of her bed. The administrator said she would get someone to fix the bed. (Observation found the bed cranking handle was missing from the bed.) There was also a round jagged hole in the resident's footboard at least the size of a fifty-cent piece. The door frame leading into the bathroom was rusted. -- room [ROOM NUMBER] - The walls were scratched with drywall exposed. The dresser drawers beside the sink were scratched and marred with chunks of wood missing. The sink top was discolored and had places of the finish missing. The tile beside the sink was broken. The cove molding and the area on the floor around the cove molding was dirty and splashed with dried debris. The cove molding in the bathroom was dirty around the floor of the bathroom. Debris was able to be cleaned from the cove molding with a piece of wet toilet paper. -- room [ROOM NUMBER] - Debris was found in the wall unit heating and air conditioner. The floor was dirty. The bathroom walls were scraped and marred with missing plaster. -- room [ROOM NUMBER] - A large head of a screw was sticking up out of the floor beside the sink with a broken piece of metal remaining under the screw. The administrator said this was a broken doorstop. The finish on the drywall in the bathroom (above the cove molding behind the toilet) was missing. At 8:10 a.m., on 02/09/17, the remaining tour of the facility resident rooms was conducted with Housekeeping/Laundry/ Maintenance Supervisor #73. -- room [ROOM NUMBER] - The sink was stained and the water from the facet was dripping. The dresser beside the sink was water marked, with the varnish missing, scraped, and marred. The finish on the countertop housing the sink was stained and the finish missing. -- room [ROOM NUMBER] - The door facings were rusted. The plaster beside the closet was marred and scraped. The over-the-bed table was dirty with debris splashed on the legs of the table. -- room [ROOM NUMBER] - The over-the-bed table at A-bed was rusted and dirty. -- room [ROOM NUMBER] - Observation found a dirty build up along the baseboards of the bathroom walls. The floor was dirty. The bed-A over-the-bed table, had legs which were rusted and dirty. -- room [ROOM NUMBER] - The over-the-bed table was rusted. The walls, beside the closet were scratched and marred with missing plaster. -- room [ROOM NUMBER] - The facing of the entrance door was rusted. A strong urine odor was present in the room. The arms of the resident's wheelchair were cracked with rough edges. -- room [ROOM NUMBER] - Observation found pieces of the tile under the sink were missing. The drawers beside the sink were marred, scratched and water marked. The wall beside the sink was marred and scratched. -- room [ROOM NUMBER] - The wall behind bed-A was scraped and scratched. There were holes in the tile beside the sink. Dirt and debris were found in the corner behind the door leading into the hallway. 4. Long hall shower room During the initial tour of the facility, observation of the long hall bathroom at 10:45 a.m. on 02/06/17, found a brown stain that appeared to be feces, on the seat of a shower chair in the bathroom. The director of nursing (DON) was present during this observation. She said she would have staff clean the shower chair. 5. A-Shower room The tour of the facility with Housekeeping/Laundry/Maintenance Supervisor #73 which began at 8:10 a.m., on 02/09/17 found the following issues in the shower room: -- Just inside the door of the shower were several large spots of a dried brown substance. Employee #73 identified the substance as feces. -- Two (2) pairs of gloves, turned inside out and rolled up, were in the sink. -- Several gloves littered the floor of the shower room. -- A dried brown substance was present on a shower chair. -- A comb and a bottle of bath wash were laying on the sink with no name to identify the owner. -- During Stage 1 of the Quality Indicator Survey a confidential interview with a resident found she did not want to take showers in the shower rooms on this floor because of the filth. She said the shower room should be called the, poop room, because everyone just pooped in there. She said it would be on the walls and in the floor of the shower room. She said she only showers in the upstairs shower room, Where it is cleaner. Employee #73 verified no showers had been given in this shower room since the issues with the hot water identified on the evening of 02/08/17. She said, All showers are being given on the upper floor of the facility not affected by the mixing valve. 6. Day room beside the nurses' station Four (4) of the five (5) blinds covering the windows had slats that were broken and bent. The exit door was rusted and cracked leaving exposed jagged edges of metal. There was dirt and debris buildup along the baseboards of the room. 7. room [ROOM NUMBER] At 11:15 a.m. on 02/09/17, observation of the grab bar beside the toilet was made with Employee #73. With a slight touch of the hand, the grab bar was found to move away from the wall. c) Interview Interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on 02/09/17 at 2:03 p.m., found the water temperatures were never taken to the QA&A committee meetings and the facility had addressed the environmental issues and had even hired a outside housekeeping consultant. | 2020-09-01 |