cms_WV: 4438

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
4438 LAKIN HOSPITAL 5.1e+125 1 BATEMAN CIRCLE WEST COLUMBIA WV 25287 2016-03-10 276 E 0 1 EQIS11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0 (RAI Manual), and staff interview, the facility failed to complete quarterly minimum data sets (MDS) as specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS). Quarterly assessments were not completed within fourteen (14) days of the assessment reference date (ARD) for four (4) of twenty-one (21) residents whose MDSs were reviewed during Stage 2 of the Quality Indicator Survey (QIS). This was true for Residents #95, #96, #72, and #92. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #95, #96, #72, and #92. Facility census: 96. Findings include: a) Resident #95 On 03/07/16 at 11:25 a.m., reconciliation of the current residents residing in the facility found Resident #95 was not on the list of residents who had resided or continued to reside in the facility. This resident had resided in the facility since admission date of [DATE]. Review of Resident #95's MDSs found an MDS with an ARD of 02/16/16, was incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. On 03/08/16 at 1:00 p.m., review of the MDS with the ARD of 02/16/16, found item Z0400, signed and dated on 02/26/16 by MDS Coordinator #78 to indicate sections A, B, C, G, H, I, J, L, M, N, and S were completed on 02/26/16. In addition, Item Z0500 - Signature of RN Assessment Coordinator Verifying Assessment Completion, was signed MDS Coordinator #78 on 02/26/16 to certify the assessment was complete. Review of the MDS assessment report for the MDS with the ARD of 02/16/16, found MDS Coordinator #78 had not completed sections A, B, C, G, H, I, J, L, M, N, S, and Z until 03/08/16 at 11:39 a.m. The MDS Coordinator had certified the assessment as complete and ready for submission on 03/08/16 at 12:24 p.m. According to the RAI Manual, Chapter 2, page 16, the assessment must be complete by fourteen (14) calendar days of the ARD date. Interview on 03/08/16 at 2:30 p.m., with MDS Coordinator #78 revealed she thought she had 28 days to complete, certify, and submit the MDS. On 03/08/16 at 3:15 p.m., during a review of the MDS with the ARD of 02/16/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/01/16. She also verified the MDS was completed on 03/08/16, not 02/26/16 as indicated in Section Z by MDS Coordinator #78. b) Resident #96 On 03/07/16 at 11:45 a.m., reconciliation of the current residents residing in the facility also found Resident #96 was not on the list of current residents. This resident had resided in the facility since admission on 02/02/01. Review of Resident #96's MDSs found an MDS with an ARD of 02/19/16. Sections A, B, C, G, H, I, J, L, M, N, S, and Z of this assessment were incomplete. On 03/08/16 at 3:30 p.m., the MDS with an ARD of 02/19/16 was reviewed with the director of nursing (DON). She agreed the MDS should have been completed by 03/04/16. She also verified the MDS remained incomplete at the time of the interview. c) Resident #72 Review of Resident #72's medical records on 03/08/16 at 12:30 p.m., found an MDS with an ARD of 02/19/16. This MDS was found to be incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. On 03/08/16 at 3:30 p.m., after review of the MDS with an ARD of 02/19/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/04/16. She also verified the MDS remained incomplete at the time of the interview. d) Resident #92 Record review at 10:00 a.m. on 03/09/16, found a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 02/19/16. Sections J - Health conditions, L - oral/dental status, M - skin conditions, and N - medications had not been completed. The MDS should have been completed on 03/04/16. 2019-11-01