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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 131 | 131 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 356 | B | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the nurse staff posting contained the correct date. This practice had the potential to effect more than a limited number of residents and or family members wishing to view the posting. Facility census: 180. Findings include: a) Staff posting Upon entrance to the facility for the initial tour, at 11:14 a.m. on 08/28/18, observation found the staff nursing posting was dated 08/27/17. Employee #104, the [MEDICAL CONDITION] program manager, confirmed the date on the posting was incorrect. Employee #111, a Licensed Practice Nurse (LPN) said she put the incorrect date in error because she had been working all night. The staff posting was corrected immediately. At 1:26 p.m. on 09/06/17, the administrator was advised of the above findings. The administrator provided no comment. | 2020-09-01 |
| 828 | 828 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2017-03-22 | 282 | B | 0 | 1 | ZQ9211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to implement the care plan as directed for two (2) residents reviewed. For Resident #113, staff failed to follow physician's orders [REDACTED]. The facility failed to ensure Resident #91 received a therapeutic diet as directed. Failure to follow the care plan placed residents at risk not to receive the care they were assessed to require. Resident identifiers: #113 and #91. Facility census: 85. Findings include: a) Resident #113 Review of the resident's care plan, on 03/21/17 at 2:32 p.m., revealed a care plan, last revised on 03/14/17, that identified the resident was an insulin dependent diabetic. A listed intervention was for nursing staff to administer insulin as ordered. Physician orders, reviewed on 03/21/17 at 1:35 p.m., revealed an order for [REDACTED]. --Blood sugar of 0 - 150 = 0 units of insulin --Blood sugar of 151 - 200 = 2 units of insulin --Blood sugar of 201 - 250 = 4 units of insulin --Blood sugar of 251 - 300 = 6 units of insulin --Blood sugar of 301 - 350 = 8 units of insulin The (MONTH) (YEAR) Medication Administration Record (MAR), reviewed on 03/22/17 at 9:15 a.m., revealed staff administered an inaccurate dose of insulin on the following dates: -On 02/13/17 at 6:00 a.m., blood sugar was 201 and 2 units of insulin were given instead of the 4 units ordered; --On 02/04/17 at 4:30 p.m., blood sugar was 172 and it appeared staff documented administering 4 units of insulin (the handwriting made it difficult to decipher) instead of the 2 units ordered; and --On 02/14/17 at 4:30 p.m., blood sugar was 374 and staff administered 6 units instead of the 10 units ordered. In an interview, on 03/22/17 at 9:26 a.m., Assistant Director of Nursing (ADON) #79 reviewed the MAR and verified errors occurred in administering physician order [REDACTED]. b) Resident #91 The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/31/17 … | 2020-09-01 |
| 884 | 884 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2017-07-24 | 514 | B | 1 | 0 | 2NJ511 | > Based on resident interview, and record review, the facility failed to ensure resident records were complete and accurate for two (2) of eleven (11) residents. The facility failed to ensure residents' refusals of baths were documented. This failed practice had the potential to affect an isolated number of resident. Resident identifiers: #63 and #11. Facility census: 113. Findings include: a) Resident #63 During an interview with Nurse Aide (NA) #26, the NA stated Resident #63 was scheduled to receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. NA #26 stated that most residents received showers twice a week, but residents' personal preferences were also taken into consideration. Review of the shower schedule confirmed that Resident #63 was scheduled to receive showers twice a week on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. On 07/20/2017 at 12:05 p.m., Registered Nurse #60 stated Resident #63 frequently refused showers. On 07/20/2017 at 12:00 p.m., RN #89 stated Resident #63 refused showers at times because she was would be watching a favorite television program, and did want to be interrupted. RN #150 stated on 07/20/2017 at 2:00 p.m. Resident #63 frequently refuses showers. Review of the bathing section of the Activities of Daily Living (ADL) Records for Resident #63 revealed the following documentation: --05/05/17 - R (refusal of bathing) --05/11/17 - R (refusal of bathing) --05/15/17 - S (shower) --05/31/17 - S (shower) --06/01/17 - S (shower) --06/15/17 - S (shower) --07/05/17 - B (bed bath) --06/06/17 - R (refusal of bathing) --07/13/17 - S (shower) -07/17/17 - R (refusal of bathing) The remainder of the dates on the ADL Records for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR), had no documentation of bathing. The Director of Nursing (DON) stated during an interview on 07/20/17 at 11:45 p.m. R means refusal, B means bed bath, and S means shower. Review of medical records revealed a General Nursing Progress note written 01/04/17, that … | 2020-09-01 |
| 1579 | 1579 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2016-12-15 | 356 | B | 0 | 1 | 32NE11 | Based on observation, record review, and staff interview, the facility failed to post accurate nurse staffing data that reflected the number of registered nurses (RN) and licensed practical nurses (LPN) who were responsible for providing direct care to residents. This had the potential to affect more than a limited number of residents and visitors who would access the staffing information. Facility census: 63. Findings include: a) Nurse Staffing Information During the initial tour of the facility on 12/05/16 at 12:30 p.m., the staffing and census form displayed near the front door of the building listed direct care licensed nurses currently on duty as two (2) RNs and two (2) LPNs. During an interview with Licensed Practical Nurse #11 on 12/05/16 at 12:52 p.m., she said the staffing sheet currently on display was incorrect because there were call ins that morning. As a result, three (3) RNs and one (1) LPN were actually on duty. On 12/05/16 at 1:00 p.m., during interview, Scheduler #68 stated the staffing sheet was updated as changes occurred. She agreed the current staffing sheet was not accurate. She said there had been call ins and she had not put the correct information on the sheet. | 2020-09-01 |
| 2189 | 2189 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2017-03-31 | 159 | B | 0 | 1 | YOOX11 | Based on staff interview and record review, the facility failed to offer a petty cash fund for residents to have ready access to monies when needed such as on weekends. This has the potential to affect the forty-six (46) residents who currently have the facility handle their funds. Facility census: 58. Findings include: a) Interview with Accounts Payable Employee #50, on 03/28/17 at 3:00 p.m., revealed the facility does not have a petty cash procedure to ensure residents have access to their funds when wanted or needed. Review of the admission policy information at the same time showed new residents are informed about how the facility will handle money for them, but does not explain how the process is for them to get money at different times such as when the business office is not open. There was also nothing posted to direct residents how to obtain money when the business office is closed. | 2020-09-01 |
| 2190 | 2190 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2017-03-31 | 161 | B | 0 | 1 | YOOX11 | Based on review of the surety bond, bank statements from the resident trust fund account and staff interview, the facility failed to ensure a surety bond was in place to cover the highest daily balance of the resident trust fund account. This failed practice has the potential to affect at least forty-six (46) residents who allow the facility to handle funds for them. Facility census: 58 Findings include: a) Interview with the Accounts Payable Employee #50, on 03/28/17 at 3:00 p m., revealed the surety bond was in the amount of $30,000. Bank statements from the resident trust fund account for the most recent quarter showed the highest daily balance from the account on (MONTH) 13, (YEAR) was for $30,343.05 which was above the surety bond amount. This was discussed with the Administrator, on 03/28/17 at 3:45 p.m. She was not aware the bond had not been sufficient and would check with financial services division of the facility to see if it had been increased. She returned shortly afterward and stated there had been no increase in the surety bond amount above $30,000 and verified the bond was not enough to cover that highest daily balance. | 2020-09-01 |
| 2218 | 2218 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2017-08-10 | 167 | B | 1 | 0 | PUVN11 | > Based on random observation and staff interview, the facility failed to post and/or have readily accessible, the results of the most recent survey. This had the potential to affect any resident or visitor who desired to examine the most recent survey results. Facility census: 57. Findings include: a) Observation on 08/09/17 at 2:00 p.m. found the facility's survey results were kept inside a binder, and stored inside a wall-mounted container which was located on a wall in the main corridor leading to the residents' rooms. Upon inspection, it was found that the facility's most recent quality indicator survey, which concluded on 03/31/17, was not included in the survey book. On 08/09/17 at 2:15 p.m., an interview was completed with the administrator. She checked, then agreed that the most recent annual quality indicator survey result was not in the facility's survey book. The administrator said a resident once took the survey book and put it in a trash can. She said she found it by watching video surveillance tapes of the hallways to see who took it and its final location. She said she thought that the most recent annual quality indicator survey result had been filed inside the survey book. She then obtained a copy of that survey, with survey end date of 03/31/17, and placed it inside the facility's survey book. | 2020-09-01 |
| 2557 | 2557 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2018-08-16 | 578 | B | 0 | 1 | WFEZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform and provide written information concerning the right to formulate an advanced directive. This affected three out of five sampled residents reviewed for advanced directives. Resident identifiers: #56, #17, #15. Facility census: 98. Findings included: a) Resident #56 Review of the clinical record, on 08/14/18 at 10:15 AM, for Resident #56 revealed an admission history form with an original admission date of [DATE] and a re-admission date of [DATE]. The quarterly minimum data set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13 which represented minimal memory impairment. A Physician Determination for Capacity form dated 02/03/17 documented that Resident #56 lacked the capacity to make health care decisions due to [MEDICAL CONDITION] and that a surrogate had been named to make health care decisions. There was no evidence of information in the clinical record to document that the surrogate decision maker and/or the resident was provided with information about the right to formulate an advanced directive. b) Resident #17 Review of the clinical record, for Resident #17 on 08/14/18 at 10:25 AM, revealed an admission history form with an original admission date of [DATE] and a re-admission date of [DATE]. The significant change of condition minimum data set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which represented no memory impairment. A Physician Determination for Capacity form, dated 10/31/14, documented that Resident #17 had the capacity to make health care decisions. There was no evidence of information in the clinical record to document that the resident was provided with information about the right to formulate an advanced directive. c) Resident #15 Review of the clinical record, for Resident #15 on 08/13/18 at 3:30 PM, revealed an admission history form with an original admis… | 2020-09-01 |
| 2578 | 2578 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2019-08-22 | 812 | B | 0 | 1 | CMRU11 | Based on observation and staff interview, the facility failed to ensure food preparation equipment was clean and sanitary. The inside of microwave in the A hallway nourishment pantry had food debris. This had the potential to affect more than a limited number of residents. Facility census: 101. Findings included: a) Facility task - kitchen On 08/19/19 at 11:30 AM, a tour of the unit nutritional pantries was performed, accompanied by the Dietary Manager. The microwave in the A Hallway nutritional pantry was noted to have debris on the inside. The inside of the door was noted to have a white substance on it. The inside walls and inside top appeared to have dried food debris. The Dietary Manager stated he would have the microwave sanitized. On 08/19/19 at 12:21 PM, the Administrator was informed of the above-mentioned situation. No further information was provided through the completion of the survey. | 2020-09-01 |
| 2886 | 2886 | LINCOLN NURSING AND REHABILITATION CENTER | 515171 | 200 MONDAY DRIVE | HAMLIN | WV | 25523 | 2019-01-17 | 732 | B | 0 | 1 | VF3611 | Based on facility records and staff interview, the facility failed to ensure staff postings were complete and had the census number for each shift. This was evident for the postings that were in place for (MONTH) (YEAR) and (MONTH) (YEAR). This had the potential to affect all residents and public who wished to have access to this information. Facility census: 59. Findings included: a). Staff posting Documents of nurse staffing that was posted previously was received from the administrator on 01/16/19 at 3:14 p.m. This review revealed the forms did not cotain complete information regarding the census for each shift. This would indicate if the census of the facilty had changed and needed adjusted. The days with the incomplete information was 11/05/18, 11/17/18, 11/18/18, 11/21/18, 11/22/18, 11/23/18, 11/24/18, 11/25/18, 11/26/18, 11/29/18, and 11/30/18. For (MONTH) the missing information was on: 12/03/18, 12/04/18, 12/05/18 , 12/10/18, 12/11/18, 12/12/18, 12/16/18, 12,1/187, 12/18/18, and 12/19/18. Spoke with the administrator on 1/16/19 at 3:45 p.m. regarding the blanks on the staff forms. There were some days for the months of (MONTH) and (MONTH) of (YEAR) that did not show the census for some shifts. He verified the forms did contain blanks in the census section. | 2020-09-01 |
| 3282 | 3282 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2017-02-09 | 356 | B | 0 | 1 | UXFJ11 | Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date; the current resident census; the total number and actual hours worked by registered nurses, licensed nurses, and nurse aides per shift. This had the potential to affect more than an isolated number of residents and/or visitors residing or visiting the facility. Facility census: 58. Findings include: a) Observation of the staff posting on the 2nd floor, during the initial tour of the facility, at 10:34 a.m. on 02/06/17, found the facility staff posting was dated 02/02/17. An interview with the director of nursing, at 10:35 a.m. on 02/06/17, confirmed the facility had not displayed the staff posting information for 02/03/17 through 02/06/17. . | 2020-09-01 |
| 3473 | 3473 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2017-09-21 | 252 | B | 0 | 1 | ITHZ11 | Based on observation and staff interview, the facility failed to that six (6) of 32 rooms observed during Stage 1 of the Quality Indicator Survey was home like. Each of the sic (6) bathrooms had the following on the floor just inside the bathroom door, SV2. It appeared this was spray painted. Also the carpet in hallway of the 300 hall was stained and discolored which was not home like. Room Identifiers: 110, 111, 112, 301, 303, 304. Facility Census: 83. Findings Include: a) Room 110 Observations of Room 110 at 8:54 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. The maintenance supervisor indicated that the contractors when they built the building spray painted the letters SV2 on the concrete to let the men laying the floor know what type of flooring to put down. She indicated in some of the rooms these spray painted letter have bleed through and are now visible on the bathroom floors. b) Room 111 Observations of Room 111 at 8:47 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. c) Room 112 Observations of Room 112 at 11:06 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. d) [RM #]1 Observations of [RM #]1 at 9:59 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. e) [RM #]3 Observations of [RM #]3 at 10:11 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. f) [RM #]4 Observations of [RM #]4 at 10:07 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. A tour with the Nursing Home Administrator (NHA) beginning at 1:52 p.m. on 09/19/17 confirmed… | 2020-09-01 |
| 3944 | 3944 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2017-01-19 | 514 | B | 0 | 1 | E2UQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure complete and accurately documented clinical records. The facility transcribed a medication dosage incorrectly onto the physician's orders [REDACTED]. Nursing staff documented they administered this incorrectly transcribed physician's orders [REDACTED]. Resident identifier: #84. Facility census: 52. Findings include: a) Resident #84 Review of the medical record on 01/18/17 found physician's orders [REDACTED]. The medication ordered was [MEDICATION NAME] 30 milligrams (mg) per 0.3 milliliter (ml). [MEDICATION NAME] is a blood thinner used to aid in the prevention of [MEDICAL CONDITION] (blood clots), and [MEDICAL CONDITION] embolism. The physician's orders [REDACTED]. subcutaneously once daily for [MEDICAL CONDITION], until the resident was consistently ambulating. This dose amounted to one-thirtieth of three (3) tenths of a milliliter, which is so minuscule it could not be measured accurately in a syringe. Review of the MAR found that nursing staff initialed that they gave that dosage as written on seven (7) consecutive days at 8:00 a.m. on 11/26/16, 11/27/16, 11/28/16, 11/29/16, 11/30/16, 12/01/16, and 12/02/16, without seeking clarification of the order. Further review of the medical record found the order was changed on the afternoon of 12/02/16 to inject 0.3 ml. one time daily of a 30 mg/0.3 ml solution. An interview was conducted with licensed practical nurse #114 on 01/18/17 at 9:25 a.m. He said [MEDICATION NAME] comes from the pharmacy in a prepackaged syringe. He said one (1) mg. of [MEDICATION NAME] could not possibly be correct, and that the order should have been clarified right from the start. He said that on 12/03/16 he gave the full 0.3 mg. dose of [MEDICATION NAME] as the new order specified. He said he did not recall how this order became corrected. An interview was completed with the director of nursing (DON) on 01/18/17 at 9:35 a.m. She said the… | 2020-04-01 |
| 3992 | 3992 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2016-05-12 | 371 | B | 0 | 1 | GBXO11 | Based on observation and staff interview it was determined facility dietary staff did not ensure the equipment used to prepare food was kept clean and in a sanitary manner. This practice has the potential to affect residents who are served food from this central location. Census: 86. Findings include: a) During the kitchen tour after entrance at 11:15 a.m. on 05/02/16, observation revealed the drip pan under the range top had an accumulation of food debris and was in need of cleaning. This was discussed with the dietary management staff who was present at the time of the observation. | 2020-04-01 |
| 4028 | 4028 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 203 | B | 0 | 1 | 353M11 | Based on review of the facility's notification of transfer/discharge form and staff interview, the facility failed to ensure the notice provided complete and correct information regarding the current professional person who reviews transfer/discharge appeals at the Inspector General's office Board of Review. and contained no telephone number. This had the potential to affect more than a limited number of residents. Facility census: 91. Findings include: a) On 10/13/16 at 4:30 p.m., review of the notification of transfer/discharge form provided by the facility found it included the name of the former professional person who reviewed transfer/discharge appeals at the Inspector General's Board of Review office and it's address. The name of the professional person who reviews transfer/discharge appeals in the Inspector General's Board of Review Office was incorrect. The current professional person assumed that position approximately one and one-half year's ago, and the facility's uniform notice was not revised to reflect this. The uniform transfer/discharge form did not contain the telephone number for the office of the Inspector General's Board of Review. During interview with the DON and the administrator on 10/13/16 at 4:30 p.m., they said they were unaware of those inaccuracies. | 2020-02-01 |
| 4036 | 4036 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2016-10-17 | 516 | B | 0 | 1 | 353M11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure the privacy of residents' personal information. A random observation found personal information including names, birth dates, admitted s, and [DIAGNOSES REDACTED]. The former residents affected were Residents #123, #124, and #125. Facility census: 91. Findings include: a) During the initial tour of the facility on 10/04/16 at approximately 10:00 a.m., observation of a large bulletin board on the wall across from the North hall nurses' station found it contained Patient Overview Reports for three (3) former residents. The residents' names, dates of birth, and medical record numbers were darkened with a black marker, but still legible. No attempt was made to block their diagnoses, payers, admitted s, or discharge destinations. 1. Resident #123 - Her name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained her admitted and discharge location. The payer source was Managed Care RU[NAME] [DIAGNOSES REDACTED]. The report showed her range of motion scores upon admission and discharge, and her bathing/showering scores upon admission and discharge. 2. Resident #124 - Her name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained her admitted and discharge location. The payer source was Medicare Part [NAME] [DIAGNOSES REDACTED]. It noted her range of motion scores for gait and transfers upon admission and discharge, and her bathing/showering scores. 3. Resident #125 - His name, birth date, and medical record number were darkened with a black marker, but still legible. The report contained his admitted and discharge location. The payer source was the Veteran's Administration. [DIAGNOSES REDACTED]. His range of motion scores for gait and transfers were shown for admission and discharge. His bathing/showering and dressing scores were shown for admission and discharge… | 2020-02-01 |
| 4225 | 4225 | LEWISBURG CENTER | 515144 | 979 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2016-08-11 | 371 | B | 0 | 1 | 1GMW11 | Based on observations and staff interview it was revealed the dietary staff had not ensured foods were stored in accordance with acceptable sanitation practices. Refrigeration storage areas had containers of items which were not labeled or dated as required. This practice has the potential to affect more than a limited number of residents as all residents who consume foods by oral means are served from this central location. Facility census: 84. Findings include a) The kitchen tour was completed shortly after entrance, on 08/08/16 at 11:15 a.m. The tour was completed with the assistant dietary manager. The following items were noted in the walk-in refrigerator during the observations: --Two (2) large containers of sweet BBQ (barbeque) sauce were not labeled or dated of when they were opened. --A sheet pan containing saucers which had desserts on them were not labeled nor dated indicating when they were prepared or to be used. --Four (4) plastic containers were not labeled and dated identifying what the content inside was or when it was opened. These were identified with assistant dietary manager and the dietary manager at the time of the observations and the items were immediately removed from the unit. | 2020-02-01 |
| 4243 | 4243 | GRANT REHABILITATION AND CARE CENTER | 515151 | 127 EARLY AVENUE | PETERSBURG | WV | 26847 | 2015-07-30 | 356 | B | 0 | 1 | DRSJ11 | Based on posted document observation and staff interview, the facility failed to post accurate nurse staffing data on a daily basis. This practice had the potential to affect more than a limited number of residents. Facility census: 100. Findings include: a) Upon entry to the facility at 10:45 a.m. on 07/27/15, an observation of the daily staffing sheet, posted on the wall inside the entrance door dated 07/27/15, revealed two (2) registered nurses (RN) were responsible for resident direct care. Review of staff performing direct care upon entering the facility revealed only one (1) RN responsible for direct care. At 11:15 a.m. on 07/27/15, the facility administrator reported the staffing sheet was incorrectly completed. One (1) of the two (2) RNs called off work. The staff member completing the daily staffing posting was not aware of the call off. | 2020-02-01 |
| 4265 | 4265 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2016-10-07 | 467 | B | 0 | 1 | 310011 | Based on observation and staff interview, the ventilation system for the facility's one common shower room, used by all facility residents, was not operational. This had the potential to affect all residents provided bathing care in the common shower area. Facility census 69. Findings include: During an observation of the shower area on 10/04/16 at 4:00 p.m. with the shower aide/nurse aide (NA) #74, the room was noted very humid and air movement could not be detected. A follow-up observation was conducted with the Maintenance Director #19 on 10/04/16 at 4:30 p.m. Maintenance Director #19 then went to the building roof to check on the status of the system and reported back that the air exchange system in the shower room was not working. He stated that during his inspection last month it had been working correctly and he had been unaware that the ventilation was not currently working. He explained that he would order a replacement motor later in the day on 10/04/16 with the expectation that it would be delivered on 10/06/16 and would be installed on 10/06/16. There was a window observed in the shower room that could be opened for ventilation; however, it was not observed open on 10/04/16 or 10/05/16. | 2020-02-01 |
| 4371 | 4371 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2016-11-11 | 514 | B | 1 | 0 | UGKB11 | > Based on medical record review and staff interviews, the facility failed to accurately maintain medical record for meal intake percentage and/or bedtime snack acceptance for five (5) of eight (8) residents. Resident Identifiers: #1, #2, #4, #7 and #8. Facility census 93. Findings include: a) Resident #2 A review of Resident #2's activity daily living (ADL) flow record on 11/09/16 at 5:50 p.m., found in (MONTH) (YEAR), (2) breakfast, (3) lunch, and one (1) dinner meal had no percentage of Resident #2's meal intake. One (1) bedtime snack in (MONTH) (YEAR) had no evidence the resident accepted her bed time snack. In (MONTH) (YEAR), there was one (1) dinner meal had no percentage of the resident's meal intake, and no evidence for one (1) bedtime snack the resident accepted her bed time snack. The assistant director of nursing (ADON ) #98 were interviewed on 11/09/16 at 5:58 p.m., and she confirmed the meal percentage and/or bedtime snack acceptances were not completed on the ADL flow record. b) Resident #1 A review of Resident #1's ADL flow record on 11/09/16 at 6:10 p.m., revealed in (MONTH) (YEAR), three (3) times for breakfast, two (2) times for lunch, and six (6) times for dinner the ADL flow record had no evidence of the percentage Resident #1 had consumed during her meals. Ten (10) times in (MONTH) (YEAR), there was no evidence the resident accepted her bed time snack. In (MONTH) (YEAR), there is no evidence of Resident #1's meal intake for five (5) dinner meals. There were Nine (9) bedtime snack in (MONTH) (YEAR) had no evidence the resident had accepted her snack. In (MONTH) (YEAR), there is no evidence for one (1) breakfast and one (1) lunch meal intake percentages. In an interview and review of Resident #1's ADL flow record on 11/09/16 at 6:18 p.m., with the ADON #91. She reviewed the meal percentage and the acceptance for the bedtime snacks for August, (MONTH) and (MONTH) (YEAR). The ADON confirmed the staff had left the area blank. Employee #91 said after every meal, we put the meal ticket in the in the… | 2019-11-01 |
| 4437 | 4437 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2016-02-03 | 514 | B | 0 | 1 | 47S511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a complete, accurately documented clinical record for one (1) of five (5) sampled residents reviewed for unnecessary medications. A resident receiving opiate pain medication several times daily had no documented bowel movements throughout an eight (8) day period. During this period, the clinical record lacked numerous nurse aide flow records, which should have reflected the resident's bowel movements, or lack thereof. Resident identifier: #8. Facility census: 83. Findings include: a) Resident #78 Review of the medical record on 01/28/16 at 9:00 a.m., found this resident received an opioid pain medication, [MEDICATION NAME] 5 milligrams (mg), three (3) times daily. (Opioid medications have the potential to cause constipation, sometimes to the point of fecal impaction.) The resident's [DIAGNOSES REDACTED]. Review of both the electronic aide flow records and the paper records for the month of (MONTH) (YEAR), revealed the records were silent for evidence of bowel movements (BMs) in the eight (8) day period between 01/11/16 and 01/19/16. During an interview with the director of nursing (DON) on 01/28/16 at 4:30 p.m., she said she was unable to find evidence of any bowel movements for this resident between 01/11/16 and 01/19/16. She said she believed the lapse in recorded BMs from the 11th to the 19th of (MONTH) (YEAR), were documentation errors of not recording them. A review of the computerized nurse aide flow records at 3:00 p.m. on 02/02/16, found the following dates and shifts had no nurse aide flow records for Resident #78: -- Day shift - on 01/12/16, 01/14/16, 01/15/16, and 01/17/16. -- Evening shift - 01/17/16 and 01/18/16. -- Night shift - 01/14/16, 01/17/16, and 01/18/16. No further information was provided prior to exit. | 2019-11-01 |
| 4608 | 4608 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2016-02-29 | 514 | B | 0 | 1 | 7MOP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, policy review, and staff interview, the facility failed to maintain accurate clinical records for four (4) of nineteen (19) residents whose medical records were reviewed during Stage 2 of the Quality Indicator Survey (QIS). The facility failed to document conversations with Resident #102 and #97 relating to care planning, failed to document conversation with Resident #97 relating to a room change, failed to document an oral pain assessment and the reason for refusal of medications for Resident #37, and failed to document intake on an activity of daily living (ADLs) flow sheet for Resident #36. Resident identifiers: #102, #97, #37, and #36. Facility census: 64. Findings include: a) Resident #102 During Stage 1 of the Quality Indicator Survey (QIS) on 02/23/16 at 11:04 a.m., Resident #102 responded to the question, Do staff include you in decisions about your medicine, therapy, or other treatments, by stating, I cant think when they did. b) Resident #97 During Stage 1 of the QIS Resident #97 responded the the question; Do staff include you in decisions about your medicine, therapy, or other treatments, by stating, no they don't. c) On 02/23/16 review of medical records for Residents #102 and #97, found numerous social service notes in which information concerning the residents' care was reported to their respective medical power of attorney with no mention of discussing the same information with the resident. On 02/24/16 at 3:23 p.m., the facility's licensed social worker explained that she speaks to both the residents almost daily, but they do not attend the care plan meetings. She stated the medical power of attorney for each of these residents had requested the resident not attend the care plan meetings due to their inability to accept they cannot go home at this time. The social worker went on to state that in general, residents without medical capacity were not invited to the care plan meetings. … | 2019-09-01 |
| 4782 | 4782 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2016-01-14 | 372 | B | 0 | 1 | D0ID11 | Based on observations of the dumpsters, it was determined the hinged dumpster was not consistently closed, thereby allowing trash to blow out of the container and collect in the area behind the facility along the railroad tracks and the river wall. This had the potential to affect all residents. Facility census: 159. Findings include: a) Observations of the dumpster on 01/11/16 at 8:15 a.m. and 2:00 p.m., on 11/12/16 at 11:30 a.m., on 11/13/16 at 3:30 p.m., and on 01/14/16 at 2:00 p.m., found the hinged lid on the dumpster left open on each of the four (4) days of the survey. Adjacent to the hinge-lidded dumpster was a trash compactor. The door to the compactor was consistently observed to be closed. Observations on 01/11/16 at 8:15 a.m., noted the contents of the dumpster were bagged; however, there was trash blowing around the area. The trash included numerous cigarette butts, napkins, drink lids, bread wrappers, a green bell pepper, empty soda cans and bottles, a large blue plastic bag, straws, pepper packet wrappers, candy wrappers, a portion of a broken fluorescent light bulb, and Pride butter packets. During observation and interview with Dietary Manager #70 on 01/11/16 at 8:15 a.m., he stated kitchen staff utilized the compacter, and housekeeping utilized the dumpster. The back area of the facility butted up against a railroad track and the river wall. The facility grounds ended at the top of the raised area between the curb and the railroad tracks. The majority of the trash was on the railroad tracks and near the wall, not the facility's property. During an interview with Maintenance Director #16, on 01/13/16 at 3:00 p.m., he stated that since the railroad track was not their property, they did not pick up trash on that property. He believed that the majority of the trash observed fell out of the trash truck during their daily pick up at the facility. He stated that the trash service was responsible for getting out of their truck and picking up what they spilled. | 2019-07-01 |
| 4999 | 4999 | STONE PEAR PAVILION | 515130 | 125 FOX LANE | CHESTER | WV | 26034 | 2015-10-01 | 241 | B | 0 | 1 | GCQW11 | Based on observation, record review, resident interview, and staff interview, the facility failed to provide care to residents in a manner that enhanced each resident's dignity. The facility failed to administer morning medications in a dignified and respectful manner that recognized each resident's individuality. Random observations were made of residents lined-up in wheelchairs at the medication cart waiting for morning medications. This had the potential to affect more than a limited number of residents. Facility census: 55. Findings include: a) Medication Pass Random observations, on 09/28/15 at 7:48 a.m., revealed seven (7) residents on the East hallway seated in wheelchairs waiting in line for medications from the nurse. A nurse was standing at the medication cart located in the East hallway outside the nursing station. Interview with a resident waiting in line revealed, We wait in line for medications then go to the dining room for breakfast. Observations on 09/29/15 at 8:32 a.m., revealed three (3) residents seated in wheelchairs in a line in front of the medication cart on the West hallway. Residents were waiting in line to have Licensed Practical Nurse (LPN) #14 administer their medications. Interview with Registered Nurse (RN) #4, on 09/30/15 at 10:50 a.m., verified the residents were lined up in the hallway at the medication cart. She stated during the six (6) years of her employment, medications had always been administered in the hallway. She stated residents have the right to receive medications in the hallway. When told residents expressed they had to wait in line for their medications before breakfast, RN #4 stated residents could bypass the medication cart and go directly to breakfast, if they choose. She stated if residents wanted their medications administered in their rooms, they were accommodated. Interview with NA #23, on 09/30/15 at 11:07 a.m., revealed she wheeled residents down to the medication cart. If there was a long line, she would ask the nurse the wait time. She said she lined the… | 2019-04-01 |
| 5073 | 5073 | MORGANTOWN HEALTH AND REHABILITATION CENTER | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2015-09-14 | 278 | B | 0 | 1 | HR8011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to complete an assessment to accurately reflect the resident's status. Resident #77 had experienced a significant weight loss. This weight loss was incorrectly assessed on three (3) of three (3) Minimum Data Set (MDS) assessments. Resident identifier: #77. Facility census: 88. Findings include: a) Resident #77 A medical record review for Resident #77, on 09/14/15 at 12:00 p.m., revealed Resident #77 was admitted on [DATE] with diagnoses, including [MEDICAL CONDITION] end of right tibia, dislocation of unspecified ankle joint, gastro-[MEDICAL CONDITION] reflux disease without esophagitis, and periapical (encompassing or surrounding the tip of the root of a tooth) abscess without sinus. Her admission weight on 05/29/15 was 238.8 pounds using a mechanical lift. Her weight on 06/10/15 was 221.6 pounds, and this weight was used on the 14-day Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 06/12/15. However, the assessment question at item (K0300) Loss of 5% or more in the last month or loss of 10% or more in last 6 months was answered 0. No or unknown. The general progress note completed by the Dietary Manager #12, on 06/12/15, the same day she completed the MDS stated, Resident has had a 7% wt. (weight) loss since admission. The registered dietician confirmed this in her 06/19/15 note which stated Review for wt (weight) loss: Resident has experienced a 7.2% wt decline The next MDS completed was a 30-day assessment dated with ARD of 06/26/15. The most current weight used for this assessment is still the 221.6 weight from 06/10/15. Again, the question K0300 Loss of 5% or more in the last month or loss of 10% or more in last 6 months was answered 0. No or unknown. A 60 day MDS assessment was completed with an ARD of 07/24/15 and the most recent weight of 213, obtained 07/15/15, was used. Again, the question at item (K0300) Loss of 5% or more in the last month… | 2019-03-01 |
| 5188 | 5188 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2016-03-03 | 329 | B | 1 | 0 | MTOL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for unnecessary medications during a complaint survey did not receive an atypical antipsychotic without adequate indications for the use of the drug. Resident identifier: #5. Facility census: 125. Findings include: a) Resident #5 Review of Resident's #5's medical records on 03/03/16 beginning at 9:00 a.m., revealed a physician's orders [REDACTED]. A nursing note, dated 07/19/15, revealed the facility called the residents son ., to see if he wanted [MEDICATION NAME] (same as [MEDICATION NAME]) started. He stated that he would read up on it at home and sign it if he wanted to start the medications when he is in to visit again. I told him I would place the psychotic medication informed consent in her chart for him to sign if he decided to have his mother take it. The medical record review found there were no behaviors, or evidence the resident was at risk of harming herself or others, for at least 24 hours prior to the medication being initiated. The record was silent for evidence she was exhibiting behaviors on (MONTH) 19, (YEAR), (MONTH) 20, (YEAR), or (MONTH) 21, (YEAR). The Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. An additional physician order [REDACTED]. [MEDICATION NAME] was administered to Resident #5 on three (3) occasions after the resident's son verbally indicated he wanted the antipsychotic medication held until further notice. On 03/03/16 at 2:20 p.m., the director of nursing stated the mediation was given, held, and discontinued according to physician orders. | 2019-03-01 |
| 5219 | 5219 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2015-09-16 | 156 | B | 0 | 1 | 5JCO11 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 81 Findings include: a) Observation of the facility, on 09/14/15 at 11:45 a.m., revealed there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview with the Nursing Home Administrator, on 09/16/15 at 10:20 a.m., verified the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2019-02-01 |
| 5229 | 5229 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2015-07-23 | 156 | B | 0 | 1 | 76WG11 | Based on observation, staff interview, and resident interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits, or how to contact the State Ombudsman. The facility did not prominently display the written information regarding these benefits or the Ombudsman contact information. This had the potential to affect more than an isolated number of residents. Facility census: 160 Findings include: a) On 07/22/15 at 1:35 p.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform residents or responsible parties about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview with the Nursing Home Administrator on 07/22/15 at 3:07 p.m., revealed she was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. b) Ombudsman Information On 07/20/15 at 1:00 p.m., during an interview with the resident council president, the president did not know if the facility had the Ombudsman contact information posted. At 1:20 p.m. on 07/20/15, Director of Nursing #205 and Assistant Administrator #235 toured the facility and confirmed the facility did not have the Ombudsman contact information posted. | 2019-02-01 |
| 5230 | 5230 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2015-07-23 | 167 | B | 0 | 1 | 76WG11 | Based on observation and staff interview, the facility failed to ensure a notice of the results of the most recent survey and any plans of correction were in a place readily accessible to residents. The survey results book was located on the wall at a height not accessible to residents in wheelchairs. This practice had the potential to affect more than an isolated number of residents. Facility census: 160. Findings include: a) An observation on 07/22/15 at 1:35 p.m., revealed the survey results book was located in a plastic holder that hung against a wall in the front lobby. The book was too high for residents in a wheelchair to reach. On 07/22/15 at 3:07 p.m., the Nursing Home Administrator agreed the survey book was not located at a height accessible to a resident in a wheelchair. She stated the survey book would be moved to a location accessible to residents in wheelchairs. | 2019-02-01 |
| 5257 | 5257 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2015-09-30 | 278 | B | 0 | 1 | C8H511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each individual completing Minimum Data Set (MDS) assessments completed the assessments to accurately reflect the resident's condition. Resident #83's assessment did not identify weight loss. Resident #9's MDS did not indicate the resident received Hospice services. Resident #34's assessment did not include the resident's active [DIAGNOSES REDACTED].#62's assessment did not identify the use of antianxiety medication. Assessment coding errors were found for four (4) of sixteen (16) sample residents. Resident identifiers: #83, #9, #34, and #62. Facility Census: 58. Findings include: a) Resident #83 This resident's 14-day MDS assessment, with an assessment reference date (ARD) of 06/26/15, listed the resident's weight as 165 pounds (#). The next MDS, with an ARD of 07/21/15, indicated the resident's weight was 139#, but was not identified as a weight decline of 5% or more in the last month in item K0300. On 09/30/15 at 10:30 a.m., the MDS coordinator verified the 07/21/15 assessment should have been coded showing the weight loss. b) Resident #9 Review of the resident's quarterly MDS with an ARD of 07/30/15, found the assessment failed to show the resident was receiving hospice services during the look back period for the assessment. A significant change MDS with an ARD of 05/16/15, had identified the resident received Hospice services. Hospice services had begun at that time and were identified on the MDS. It was not carried over onto the 07/30/15 assessment. Discussion with the MDS coordinator on 09/29/15 at 10:25 a.m. revealed the assessment was coded in error and should have indicated the resident continued to receive hospice services. c) Resident #34 A review of the medical record for Resident #34, on 09/29/15 1:35 p.m., revealed the quarterly MDS assessment with an assessment reference date (ARD) of 08/20/15, did not accurately reflect a [DIAGNOSES REDACTED]. … | 2019-02-01 |
| 5259 | 5259 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2015-09-30 | 371 | B | 0 | 1 | C8H511 | Based on staff interview and observation, the facility did not ensure food was stored in a sanitary manner. Food items in the dry food storage area and the walk-in refrigerator were found to not be labeled with the name of the item or the date it was opened. This practice had the potential to affect more than a limited number of residents as all residents were fed from this central location. Facility census: 58. Findings include: a) During the initial tour of the dietary department at 11:15 a.m. on 09/27/15, the following items were observed: 1. In the dry food storage area a package of elbow macaroni was on the shelf not labeled or dated of when it was opened. 2. The walk-in refrigerator had a plastic bag that contained lettuce which was not dated of when it was opened. 3. The walk-in freezer storage area had a plastic bag which had broccoli and cauliflower in it and the package did not contain a date of when the product was opened. This practice did not allow the dietary staff to determine how long the product has been opened and if it was still safe for consumption. b) These items were brought to the attention of the cook at the time and then was discussed with the administrator and consultant dietitian on 09/29/15 prior to lunch. | 2019-02-01 |
| 5343 | 5343 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 156 | B | 0 | 1 | 11X211 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 64 Findings include: a) On 01/20/15 at 11:45 a.m., during an observation of the facility, observation revealed there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. During an interview on 01/27/15 at 9:30 a.m. the Nursing Home Administer was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2019-01-01 |
| 5344 | 5344 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2015-01-28 | 167 | B | 0 | 1 | 11X211 | Based on observation and staff interview, the facility failed to post the annual survey results in a prominent and readily available area where residents and families may access without asking for assistance. This practice had the potential to affect more than an isolated number of residents. Facility census: 64 Finding include: a) Observation on 01/20/15 at 3:30 p.m. revealed the results of the past annual survey were located on the wall at the nursing station. They were located high on the wall, behind a tall medication cart. b) An observation and interview with Employee #78, on 01/28/15 at 3:30 p.m., indicated a resident in a wheelchair would not be able to reach the annual survey results without difficulty. Facility personal moved the survey results to a more accessible location for residents. | 2019-01-01 |
| 5369 | 5369 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-06-25 | 167 | B | 0 | 1 | 1EZS11 | Based on observation and staff interview, the facility failed to ensure a notice of the results of the most recent survey and any plans of correction were in a place readily accessible to residents. The survey results book was located on a wall at a height that was not accessible to residents in wheelchairs. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) An observation on 06/24/15 at 9:00 a.m., revealed the survey results book was located on the wall in front of the nurse's station. The book was placed in a plastic holder that was too high for residents in wheelchairs to reach. On 06/25/15 at 1:33 p.m., a second observation of the survey results book revealed it was still located at a height that was not accessible to residents in wheelchairs. At 1:45 p.m. on 06/25/15, Director of Nursing #68 agreed the survey book was located at a height that was not accessible to residents in wheelchairs. She said she could move the survey book to a lower level which would make it easier to view if someone was in a wheelchair. | 2019-01-01 |
| 5442 | 5442 | SUMMERS NURSING AND REHABILITATION CENTER | 515170 | 198 JOHN COOK NURSING HOME ROAD | HINTON | WV | 25951 | 2015-07-09 | 278 | B | 0 | 1 | R3IE11 | **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 ensure three (3) quarterly assessments and one (1) discharge return anticipated assessment, accurately reflected the residents' status for three (3) of sixteen (16) residents whose minimum data set (MDS) assessments were reviewed during Stage 2 of the survey. Resident #26 was inaccurately assessed as taking a hypnotic medication when she was not. Resident #34 was inaccurately assessed as taking a diuretic medication when she was not. Resident #68 had two (2) quarterly assessments which were not coded to reflect the [DIAGNOSES REDACTED]. Resident identifiers: #26, #34, and #68. Facility census: 109. Findings Include: a) Resident #26 A review of Resident #26's medical record at 9:30 a.m. on 07/08/15, revealed a discharge return anticipated minimum date set (MDS) assessment, with an assessment reference date (ARD) of 02/14/15. Item N0410 D. Hypnotic was coded with a six (6). This indicated Resident #26 received a Hypnotic medication six (6) of the seven (7) days during the look back period. Review of Resident #26's Medication Administration Records (MARs) for the month of (MONTH) (YEAR), found Resident #26 did not receive any hypnotic medications during the seven (7) day look back period. The instructions in the RAI Manual for coding Item N0410 are: Indicate the number of days the resident received the following medications during the last 7 (seven) days or since admission/entry or reentry if less than 7 (seven) days. Enter 0 (zero) if medication was not received by the resident during the last 7 (seven) days. An interview with Registered Nurse Assessment Coordinator (RNAC) #43 at 2:30 p.m. on 07/08/15, confirmed Resident #26 did not receive a hypnotic medication during the seven (7) day look back period. She stated, I must have counted the [MEDICATION NAME] because she… | 2019-01-01 |
| 5477 | 5477 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2015-09-24 | 156 | B | 0 | 1 | HNWB11 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 65. Findings include: a) On 09/21/15 at 11:45 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview on 09/24/15 at 10:20 a.m., the Nursing Home Administrator, agreed the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2019-01-01 |
| 5478 | 5478 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2015-09-24 | 253 | B | 0 | 1 | HNWB11 | Based on observations and staff interview, the facility failed to provide maintenance and housekeeping services necessary to maintain a comfortable and sanitary interior. Observations during Stage 1 and Stage 2 of the Quality Indicator Survey (QIS) found fourteen (14) rooms on the 100 hallway, and two (2) rooms on the 200 hallway, had window dressings detached from the rods, causing the drapes to hang unevenly. This was found in Rooms 100, 101, 102, 103, 104, 105, 107, 108, 109, 110, 111, 112, 113, 114, 213, and 215. Facility census: 65 Findings include a) Window dressings on 100 hallway Observations on 09/22/15 at 8:51 a.m., revealed rooms 100, 101, 102, 103, 104, 105, 107, 108, 109, 110, 111, 112, 113 and 114, had drapes detached from the rods causing the drapes to hang unevenly. b) Window dressings on 200 hallway Observation on 09/22/15 at 9:40 a.m., discovered rooms 213 and 215 had curtains separated from the rods causing the curtains to hang unevenly. c) Tour with the Nursing Home Administrator A tour with the Nursing Home Administrator (NHA), beginning at 10:00 a.m. on 09/24/15, confirmed these cosmetic imperfections. He verified the drapes in the residents' rooms on the 100 and 200 hallways needed to be repaired. | 2019-01-01 |
| 5482 | 5482 | SPRINGFIELD CENTER | 515188 | 10797 SENECA TRAIL SOUTH | LINDSIDE | WV | 24951 | 2015-07-30 | 272 | B | 0 | 1 | ZCVH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it was determined the facility had not conducted an accurate assessment of each resident's condition in the area of medical prognosis and uncessary medications for four (4) of 13 minimum data set (MDS) assessments reviewed. Resident identifiers: #73, #20, #68, and #6. Facility census: 56. Findings include: a) Resident #73 This resident was admitted on [DATE] and had orders for comfort measures only. He was offered Hospice services but declined. According to the medical record, reviewed on the afternoon of [DATE], the resident expired at the facility on [DATE]. The admission MDS with an assessment review date (ARD) of [DATE] did not indicate the resident had a condition or terminal illness which would result in a life expectancy of less than six (6) months. Orders showed the resident had comfort care, which began [DATE], and [MEDICATION NAME] for pain ordered on [DATE]. The most recent care plan contained a problem listed as palliative care due to terminal illness. Nursing notes, dated [DATE], revealed the resident was offered hospice services but declined. On [DATE] and [DATE] there were orders to not provide intravenous (IV) medications, tube feedings, or do lab sticks. b) Resident #20 Review of Resident #20's medical record, on [DATE] at 3:10 p.m., found a history and physical (H&P) dated [DATE]. The H&P revealed the resident was offered Hospice services. The resident denied these services. Nursing notes dated [DATE] reflected the resident as being in the dying process, and taking [MEDICATION NAME] for increasing pain. The resident did expire later on [DATE]. Resident #20 was admitted on [DATE] with a Do Not Resuscitate (DNR) order as well as orders for [MEDICATION NAME] and [MEDICATION NAME]. A physician's orders [REDACTED]. The admission MDS with an assessment reference date of [DATE] did not have yes marked under the prognosis in Section J. This section reflected whether or not he resident had a… | 2019-01-01 |
| 5507 | 5507 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2015-10-07 | 156 | B | 0 | 1 | WP4G11 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 22 Findings include: a) On 10/05/15 at 11:45 a.m., an observation of the facility revealed there was no written information posted in the facility to inform a resident how to apply for and use Medicare benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview, on 10/06/15 at 9:45 a.m., the Director of Social Services agreed the information was not posted prominently to inform residents on how to apply for and use Medicare benefits. | 2019-01-01 |
| 5932 | 5932 | MADISON PARK HEALTHCARE | 515021 | 700 MADISON AVENUE | HUNTINGTON | WV | 25704 | 2015-01-16 | 356 | B | 0 | 1 | 947511 | Based on observation and staff interview the facility failed to post nurse staffing data that reflected the current date and the facility's census. The facility staff posting on 01/13/15, the first day of the Quality Indicator Survey was for the week of 12/07/14 through 12/13/14. Additionally, when the facility provided the accurate posting for the week of 01/11/15 through 01/17/15 the census for 01/11/15 and 01/12/15 was not contained on the form. This had the potential to affect more than an isolated of residents currently residing in the facility. Facility census: 38 Findings include: The staff posting was observed, at 2:30 p.m. on 01/13/15, during the initial tour of the second floor. The posting was for the week of 12/07/14 through 12/13/14. It did not contain the census for any of the seven (7) days during that week. An interview with the director of nursing (DON), at 3:58 p.m. on 01/13/15, confirmed the staff posting is always there and accurate. She stated she would have to try to find out where it was and why it was not posted. She confirmed the staff posting, which was posted, was for the week of 12/07/14 through 12/13/14. At 4:15 p.m., on 01/13/15, the human resources director presented the staff posting for the week of 01/11/15 to 01/17/15. The dates of 01/11/15, 01/12/15 and for the 7-3 shift of 01/13/15 was completed on the form, but the census was not filled out for those dates. When asked why it was not posted in a prominent place at the time of the initial tour she stated, I came and got it to make sure it was updated and forgot to put it back up. When asked if the census was included on the staff posting she stated, It's not on these, should it be? | 2018-05-01 |
| 6047 | 6047 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2014-03-27 | 356 | B | 0 | 1 | R3PM11 | The facility failed to ensure the posted nurse staffing data was completed and available for viewing by the residents and/or visitors. The total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were not posted for day shift in Building 1. This had the potential to affect more than a limited number of residents and/or visitors. Facility census: 135. Findings include: a) The completion of the initial tour of building one (1) of the facility took place on 03/17/14 at 12:15 p.m. Observations at and near the nurses' station revealed the facility had not posted the staffing numbers for day shift on 03/17/14. An interview with Employee #119 (nursing supervisor) and Employee #25 (assistant director of nursing) revealed the facility had not posted the required staff posting for 03/17/14 day shift. They said the employee who normally completed the posting was not working on 03/17/14. The nurses went on to say that no other employee had completed this posting on 03/17/14. | 2018-05-01 |
| 6122 | 6122 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2014-05-19 | 356 | B | 0 | 1 | L8JN11 | Based on observation and staff interview, the facility failed to ensure the residents and/or public were informed on a daily basis of the nurse staffing data as required by 42 CFR 483.30(e). The facility failed to include the actual hours worked by the direct care staff on the posting. This had the potential to affect more than a limited number of residents. Facility census: 111. Findings include: a) On 05/15/14 at 1:30 p.m., the nurse staffing data posted daily was reviewed. The actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care each shift was not included in the postings. The form in use did not require inclusion of the hours worked for registered nurses, licensed practical nurses, and nurse aides. This was pointed out to the Administrator at 3:00 p.m. on 05/15/14. He stated he would have this corrected. | 2018-05-01 |
| 6174 | 6174 | MILETREE CENTER | 515182 | 825 SUMMIT STREET | SPENCER | WV | 25276 | 2014-09-23 | 167 | B | 0 | 1 | 577211 | Based on observation, resident interview, and staff interview, the facility failed to make survey results of Federal and State surveys readily accessible to residents. The facility posted the survey too high for a person sitting in a wheelchair to reach This had the potential to affect more than a limited number of residents. Facility census: 62. Findings include: a) Upon initial entry into the facility, on 09/14/14 at 4:15 p.m., the survey results were observed attached to the wall at a height too high to be accessible to a person sitting in a wheelchair. On 09/17/14 at 2:25 p.m., a resident who was sitting in a wheelchair was asked to attempt to reach the survey results. The resident was unable to obtain the survey results. At 3:45 p.m., on this same date, the Administrator was made aware the survey results were not accessible to all residents. The next day the survey results were placed on the wall within reach of all residents. | 2018-05-01 |
| 6182 | 6182 | MILETREE CENTER | 515182 | 825 SUMMIT STREET | SPENCER | WV | 25276 | 2014-09-23 | 356 | B | 0 | 1 | 577211 | Based on observation and staff interview, the facility failed to ensure the nursing staffing data was posted in a timely manner for each shift. This had the potential to affect more than an isolated number of residents. Facility census: 62. Findings Include: a) Upon entry of the facility, on 09/14/14 at 4:15 p.m., observation revealed the daily nursing staffing posting was not completed for the current shift, which began at 2:00 p.m. Licensed practical nurse, Employee #73, confirmed the staffing information for the evening shift was not posted. At 5:20 p.m., the nurse staff posting, in accordance with the number of staff working at the time, was observed completed and posted. | 2018-05-01 |
| 6185 | 6185 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2014-09-18 | 156 | B | 0 | 1 | O60P11 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 55 Findings include: a) On 09/17/14 at 10:10 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview was conducted on 09/17/14 at 1:20 p.m., with the Nursing Home Administrator. She was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2018-05-01 |
| 6305 | 6305 | SISTERSVILLE CENTER | 515131 | 201 WOOD STREET OPERATIONS, LLC | SISTERSVILLE | WV | 26175 | 2014-02-28 | 356 | B | 0 | 1 | WS1J11 | Based on observation, staff interview, and review of staff postings, it was determined the facility failed to post the required nurse staffing data in a prominent place in the facility that was readily accessible to residents and visitors. This had the potential to affect more than a limited number. Facility census: 54. Findings include: a) An attempt to locate the required nurse staffing data posting during the initial tour of the facility on 02/24/14 at 12:30 p.m., revealed it was not posted. During an interview with the director of nursing (DON), Employee #12, on 02/24/14 at 12:37 p.m., she verified there was no posting of the current staffing data in the facility. On 02/26/14 at 4:30 p.m., the staffing sheet was found on a clip board at the nurses' desk with the day shift posting only. Registered Nurse (RN), Employee #4, verified the staff posting was not completed for evening shift and stated she would inform the DON. The staffing was posted for the evening shift at 4:50 p.m. | 2018-04-01 |
| 6326 | 6326 | FAYETTE NURSING AND REHABILITATION CENTER | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2014-07-23 | 356 | B | 0 | 1 | 5EN111 | Based on Review of the POS [REDACTED]. This practice had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Review of the facility's posted nursing staffing information, on 07/11/14 , indicated three (3) registered nurses were working the day shift. Review of the staff schedule indicated only one (1) registered nurse was scheduled for direct care on 07/11/14. This information was reviewed with Employee # 76, the director of nursing (DON), on 07/23/14 at 11:00 a.m. She stated, The nurse who filled this out must have counted me and the other nurse. The other nurse was identified as the minimum data set assessment nurse. The DON confirmed she and the MDS nurse were not performing direct care that day, and should not have been counted on the posting. | 2018-04-01 |
| 6614 | 6614 | HAMPSHIRE MEMORIAL HOSPITAL | 515080 | 363 SUNRISE BLVD | ROMNEY | WV | 26757 | 2014-04-04 | 170 | B | 0 | 1 | EI1111 | Based on resident interview and staff interview, the facility failed to ensure residents received mail on Saturdays when mail delivery was scheduled and available through the postal service. This had the potential to affect all thirty (30) residents residing at the facility. Facility census: 30. Findings include: a) An interview was conducted on 04/03/14 at 8:30 a.m. with the resident council president, Resident #13. During this interview, the resident stated she did not think residents received mail on Saturdays. b) The activity director, Employee #42, was interviewed at 8:48 a.m. on 04/03/14. Employee #42 confirmed residents do not receive mail on Saturdays. She stated, Mail does not run on Saturdays. c) On 04/03/14 at 1:15 p.m., the administrator was interviewed. She stated the facility does not receive mail on Saturdays. d) At 1:52 p.m. on 04/03/14, the administrator contacted the postmaster of the local post office, who stated mail could be delivered to the facility on Saturdays, but was not because the facility had requested the mail not be delivered on Saturdays. The administrator stated she asked the postmaster to deliver the mail on Saturdays. | 2017-12-01 |
| 6640 | 6640 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2014-08-20 | 334 | B | 0 | 1 | R6QV11 | . Based on staff interview, the facility failed to develop policies and procedures which addressed when influenza and pneumococcal vaccines would be offered, what education would be provided to the resident or the resident's responsible party, the resident's right to refuse vaccinations, and what documentation needed to be completed. This practice had the potential to affect more than an isolated number of residents. Facility Census: 34. Findings Include: a) When the facility's policy and procedure for the administration of influenza and pneumococcal vaccines was requested, it was learned the facility did not have a written policy regarding the vaccines. The director of nursing (Employee #27) provided an information sheet, on 08/18/14 at 2:00 p.m., titled Vaccine Information Statement. She stated this information sheet was provided to everyone and was what the Center for Disease Control and Prevention recommended. She verified there was no written policy which addressed when influenza and pneumococcal vaccines would be offered, what education would be provided to the resident or the resident's responsible party, the resident's right to refuse vaccinations, and what documentation needed to be completed. b) Review of five (5) residents found that all five (5) had the appropriate vaccinations offered and administered; however, none of the five (5) was provided all parts of the information required by this regulation. | 2017-12-01 |
| 6732 | 6732 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2013-11-13 | 156 | B | 0 | 1 | IQK011 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 107. Findings include: a) On 11/12/13 at 2:15 p.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of these benefits. An interview was conducted, on 11/12/13 at 2:45 p.m., with the Nursing Home Administrator. He was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2017-11-01 |
| 6777 | 6777 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2014-02-18 | 497 | B | 0 | 1 | 1K7S11 | Based on personnel record review and staff interview, the facility failed to complete annual performance reviews for one (1) of four (4) nursing assistants (NAs) whose records were reviewed. This had the potential to affect more than an isolated number of residents. Employee identifier: #53. Facility census: 94. Findings include: a) Employee records were reviewed on 02/12/14 at 10:00 a.m. The personnel file for Employee #53, a nursing assistant, lacked an evaluation of her work performance. During an interview with the administrator, Employee #100, on 02/12/14 at 2:00 p.m., he confirmed the personnel record for Employee #53 lacked an annual evaluation of her work performance. He reported the facility had recently discovered annual employee evaluations had not been completed by the previous director of nursing. He said the facility managers were in the process of completing reviews on all employees. | 2017-11-01 |
| 6798 | 6798 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2014-08-08 | 356 | B | 0 | 1 | 6TWN11 | Based on observation and staff interview, the facility failed to post, in a prominent place and in a clear and readable format, the information regarding the total number of staff and the actual hours worked by licensed and unlicensed staff directly responsible for resident care each shift. This had the potential to affect all residents and/or visitors. Facility census: 11. Findings include: a) Observations on 08/04/2014 at 11:30 a.m. did not find the posting of staff members for this date. At 11:45 a.m., Employee #20, a licensed practical nurse (LPN), was asked where the staff posting might be located. The LPN pulled the posting off of a cabinet to which it had been taped. The cabinet was behind the desk of the nursing station where it could not easily be seen by residents or families. Additionally, the posting did include the total number of hours worked by each category of staff. b) Interview with Employee #1, Registered Nurse (RN) Manager, at 12:05 p.m. on 08/04/14, revealed the posting should be on the wall across from the nursing station in plain view. c) Further observations did not find the posting on 08/04/2014 at 3:00 p.m. or on 08/05/2014 at 08:30 a.m., 10:30 a.m., or 3:30 p.m. d) Observation on 08/06/2014 at 8:30 a.m., found the posting in place with the correct information regarding the number of licensed staff members, hours worked, and the facility census. At 8:40 a.m. on 08/06/14, Employee #1 confirmed the required information had not been posted on 08/04/14 or 08/05/14. | 2017-11-01 |
| 6819 | 6819 | LEWISBURG CENTER | 515144 | 979 ROCKY HILL ROAD | RONCEVERTE | WV | 24970 | 2014-02-20 | 356 | B | 0 | 1 | SDOD11 | Based on document review and staff interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors. This practice had a potential to affect more than a limited residents. Facility census: 85. Findings include: a) Posting of nursing staffing data Upon entry to the facility, at 4:45 p.m. on 02/09/14, observation found the Daily Staffing Sheet posted on the wall in the main hall found was dated 02/07/14. The initial tour found no postings of the current nursing staffing data. In a discussion with the Administrator, at 7:00 p.m. on 02/09/14, she acknowledged the information was not for the current date. | 2017-11-01 |
| 6835 | 6835 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2013-10-31 | 287 | B | 0 | 1 | PWUW11 | Based on a review of residents minimum data sets (MDS) and staff interview, the facility failed to enter and submit any subsets of items upon a resident's entry, transfer, reentry, or discharge into the computer as required by the Centers for Medicare and Medicaid Services (CMS). A review of the MDS information for three (3) of thirty (30) admission sample residents revealed no admission-entry tracking, reentry tracking, discharge assessment-return anticipated, and/or discharge assessment-return not anticipated, had been completed and entered into the computer as required by CMS. Resident identifiers: Resident #23, #59, and #81. Facility census: 97. Findings include: a) Resident #23 On 10/22/13 at 9:45 a.m., a review of the MDS submissions revealed an Omnibus Budget Reconciliation Act (OBRA) fourteen (14) day admission assessment was completed on 05/20/13, with no prior entry tracking record completed and entered into the computer. On 07/23/13, a significant change readmit tracking record was completed. No discharge and re-entry tracking records were submitted prior to the significant change assessment. On 09/30/13, a death in facility tracking record was completed with no prior discharge-return not anticipated record being submitted. b) Resident #59 A review of Resident #59's MDS was conducted on 10/22/13 at 9:55 a.m An Admission/Medicare - 5 day assessment was completed on 06/18/13. No entry record was submitted prior to the Medicare assessment. On 09/06/13 a death in facility report was submitted and the required discharge - return not anticipated report was not submitted. c) Resident #81 On 10/22/13 at 10:15 a.m., a review of Resident #81's MDS was conducted. A death in facility tracking report was submitted on 10/04/13. The required discharge - return not anticipated report was not submitted. d) An interview was conducted on 10/22/13 at 10:30 a.m., with the MDS coordinator and the DON. They were informed of the findings and were asked if there was any evidence the reports had been completed. The MDS coordina… | 2017-11-01 |
| 6887 | 6887 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2013-05-22 | 514 | B | 0 | 1 | M57P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical record was accurate and complete for two (2) of twenty-two (22) sampled residents reviewed. Resident #3's medical record contained an altered physician's orders [REDACTED]. Resident #88's medication adminsitration records were unclear and inaccurate. Resident identifiers: #3 and #88. Facility census: 62. Findings include: a) Resident #3 A review of the resident's medical record, on 05/15/13, at 3:20 p.m., revealed physician's orders [REDACTED]. This medication was originally ordered to be given as needed (PRN) at bedtime. Further review of the medical record identified on the April 2013 physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR for February 2013, and March 2013, was altered with a line drawn through the at bedtime. An interview with Employee #27, a licensed practical nurse (LPN), at 3:22 p.m. on 05/15/13, revealed Resident #3 was receiving [MEDICATION NAME] ointment in both eyes as needed. She did not state the ointment was to only be given at bed time as needed as indicated on the original physician's orders [REDACTED].>Further interview with Employee #27, LPN, confirmed she did not know why the at bedtime was crossed out on the original physician's orders [REDACTED].#27 was unable to provide verification the physician had consented to this change. Interview with Employee #47, the assistant director of nursing (ADON) and Employee #21, the director of nursing (DON), on 05/15/13 at 3:32 p.m., further confirmed they did not why the at bedtime had been removed from the physician's orders [REDACTED].#21, the director of nursing, on the morning of 05/15/13, revealed she was unable to provide any evidence of a physician order [REDACTED]. She confirmed the resident received the medication whenever needed, not just at bedtime. b) Resident #88 Medication administration records were reviewed with the DON.… | 2017-11-01 |
| 6917 | 6917 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2014-10-08 | 153 | B | 1 | 0 | KVTV11 | Based on review of the facility's policies and procedures, the facility failed to ensure the policies established for accessing medical records was in compliance with this regulation. The current facility policy had the potential to result in residents and/or the legal representative being denied access to medical records within 24 hours (excluding weekends and holidays) as required. This practice had the potential to affect any resident/responsible party who exercised the right to access clinical records. Facility Census: 81. Findings include: a) Review of the facility's policy titled Request for Medical Records, last reviewed 2013, revealed in section 6, . the documents should be produced within five (5) days of receipt of the notification that the request for a medical record is valid. | 2017-10-01 |
| 6919 | 6919 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2014-10-08 | 356 | B | 1 | 0 | KVTV11 | Based on Review of the POS [REDACTED]. The posting was the number of personnel scheduled, and not the number who were actually available and working. This had the potential to affect all residents, families, and /or visitors wishing to review the number of staff providing care to the residents in the facility. Facility Census: 81 . Findings include: a) Confidential staff and family interviews, conducted 10/07/14 to 10/09/14, identified the daily posting of facility staff was frequently incorrect and did not accurately reflect the actual number of direct care staff in the facility providing direct resident care. It was expressed the posting reflected the staff scheduled, and not the actual staff working. b) On 10/08/14 at 3:00 p.m. the facility posting of staff for a period of thirty (30) days was reviewed. The staffing was requested for 08/01/14 to 08/15/14 and also for the period of 09/16/14 to 09/30/14. The schedules, assignment sheets, and time sheets were also reviewed for random days for these time frames. Review of this information identified nineteen (19) of thirty (30) days of posted information reflected incorrect numbers of direct care staff who were working in the facility at that time. Between 08/01/14 and 08/15/14, incorrect staffing information was posted on August 1, 2, 3, 4, 5, 7, 9, 11, 14, and 15. Between 09/16/14 and 09/30/14 incorrect staffing information was posted on September 21, 22, 23, 24, 26, 27, 29, and 30. c) The administrator (Employee #59) was interviewed, on 09/09/14 at 11:00 a.m., concerning the posting of staff. Employee #59 confirmed the numbers of staff were incorrectly posted and the information did not reflect the actual number of direct care staff in the facility providing care at the specified times. | 2017-10-01 |
| 6921 | 6921 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2014-10-08 | 493 | B | 1 | 0 | KVTV11 | Based on review of the facility's policies and procedures and staff interview, the facility failed to ensure the policies established for obtaining copies of medical records was in compliance with State regulations. The current facility policy had the potential to result in the medical record not being produced timely and for excessive charges when obtaining copies of the record. This practice had the potential to affect any resident/responsible party who exercised the right to obtain copies of the medical record. Facility Census: 81. Findings include: a) Review of the facility's policy titled Request for Medical Records, last reviewed 2013, revealed in section 6, . the documents should be produced within five (5) days of receipt of the notification that the request for a medical record is valid. Section 7 provided instructions for the steps of this process. It specified in 7.b In WV, the cost of production of the medical record is as follows: $10.00 search fee plus reasonable expenses, provided that the total charge does not exceed $0.75 per page for copying of records already reduced to written form. The Legislative Rules West Virginia Division of Health Title 64, Series 13 Nursing Home Licensure Rule specifies: -- Regulation 4.4.c: A resident may purchase, at a cost not to exceed twenty-five cents ($0.25) per page, photocopies of the records or any portions of them, upon oral or written request to the nursing home. -- Regulation 4.4.c.1: The nursing home will provide the photocopies materials to the resident within two (2) working days of the request. The administrator (Employee #59) was interviewed on 10/08/14 at 3:00 p.m. Employee #59 verified the policy and procedure of this facility was not in compliance with the state regulations specified in the Nursing Home Licensure Rule. | 2017-10-01 |
| 6960 | 6960 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 496 | B | 0 | 1 | WVZU11 | Based on record review and staff interview, the facility failed to obtain registry verification for one (1) of fourteen (14) employees indicating she was a registered long term care nursing assistant before allowing her to serve as a nurse aide. Employee identifier: #116. Census: 59. Findings include: a) Employee #116 Personnel records for fourteen (14) employees were requested and reviewed on 06/19/13 and 06/24/13. The file of a nursing assistant, Employee #116, contained no evidence she was a registered long term care nursing assistant. During an interview, on 06/20/13 at 11:00 a.m., nursing home administrative consultant, Employee #176, confirmed the required checks were not available. She provided a verification of active registration for NA #116 that had been obtained by the facility on 06/20/13 at 7:48 a.m. About an hour later, a certificate stating that NA #116 had successfully passed the West Virginia Nursing Assistant Written and Skills Performance Examination on 04/14/12 was provided. Employee #176 acknowledged that this documentation had not been maintained as part of the official personnel file. | 2017-09-01 |
| 6971 | 6971 | CORTLAND ACRES NURSING HOME | 515063 | 39 CORTLAND ACRES LANE | THOMAS | WV | 26292 | 2014-09-05 | 241 | B | 1 | 0 | SG0I11 | Based on observation and staff interview, the facility failed to promote care for a resident in a manner that maintained the resident's dignity and respect. While one (1) resident was being pushed forward, another resident was pulled backwards to the dining room. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #58 and #15. Facility census: 88. Findings included: a) Resident #58 On 09/04/14 at 5:20 p.m., observed a nursing assistant (NA#104) pushing Resident #15 and pulling Resident #58 backwards down the hall. The nursing home administrator ((NHA) was notified at 5:40 p.m. of this event and said she would investigate. On 09/05/14 at approximately 10:00 a.m., a review of the hallway security tapes with the NHA, revealed NA #104 did pull Resident #58 down the hallway backwards. The NHA stated the NA involved, as well the other facility NAs, would be inserviced regarding treating residents with dignity and respect. | 2017-09-01 |
| 7026 | 7026 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 514 | B | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of clinical records for one (1) of twenty (20) residents reviewed in Stage 2 of the survey. A physician's response to a pharmacy recommendation was not transcribed to the medical record. Resident identifier: #99. Facility census: 73 Findings include: a) Resident #99 On 08/21/13 at 9:00 a.m., a medical record review was conducted for Resident #99. Review of the Pharmacy consultation report, dated 04/04/13, revealed a recommendation to clarify order to read [MEDICATION NAME] for depression. The attending Physician documented and signed the record on 04/10/13 writing, ok to be for depression. A review of the Medication Administration Records (MAR), dated June, July and August 2013, revealed the MAR indicated [REDACTED]. Employee #13, the Administrator (NHA), provided the requested copies of the attending physician's orders [REDACTED].#99's [DIAGNOSES REDACTED]. Also, the MARs for April and May 2013 had the [DIAGNOSES REDACTED]. At 11:20 a.m. on 08/21/13, an interview was conducted with the NHA. She confirmed an order for [REDACTED]. On 08/21/13 at 11:40 a.m., an interview was conducted with Employee #23, the Director of Nursing (DON). She stated the procedure the facility was supposed to follow regarding pharmacy recommendations was to give the recommendation to the doctor on his visit to the facility. After his signature was obtained, it was to be signed by the DON or the nurse on duty. A physician's orders [REDACTED]. The pharmacy recommendation sheet was then to be placed in the medical record for the pharmacist to review on the next monthly visit. Employee #23 stated, There is not a written policy or procedure regarding this, it was like this when I came here and it has continued. | 2017-09-01 |
| 7027 | 7027 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-08-14 | 156 | B | 0 | 1 | 66WU11 | Based on record review, policy review, and staff interview the facility failed to ensure the information communicated to the residents when there was a change in their skilled status was complete. The liability notices did not identify the services being discontinued and/or the reason for the action for three (3) of six (6) sampled residents who had medicare covered services discontinued. Resident identifiers: #87, #78, and #112. Facility census 68. Findings include: a) Residents # 87, 78, and 112 A review of the Notice of Medicare Provider Non-Coverage document which was provided to the residents and/or their responsible parties revealed the following verbiage: The Effective Date Coverage of Your Current: SKILLED NURSING Services Will End (date). The document did not, in a language the resident can understand, identify all skilled services that were being received by the residents which were being discontinued. The document also did not explain why the service was being discontinued. A review of the medical records of Residents #87, #56, and #86 revealed that they were also receiving Skilled Therapy services. The residents were being asked to make an appeal decision without this information. During an interview with Employee #97 (Physical Therapy Aid) at 8:30 a.m. on 08/07/13, she confirmed Residents #87, #56, and #86 were receiving Physical Therapy services which were discontinued on the date stated in the Medicare Non-Coverage notice. After reviewing the liability notices with the Administrator at 8:45 a.m. on 08/13/13, he acknowledged the notices did not contain what services were being discontinued or why they were being discontinued. During an interview with the Social Worker (Employee #68) at 1:45 p.m. on 08/13/13, she stated she knew the resident or his responsible party should be informed of all services and the reason for discontinuing them. She stated she was not the person who filled out the notices, although she did sign them indicating she issued the notice to Resident #112. | 2017-09-01 |
| 7048 | 7048 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2013-09-13 | 160 | B | 0 | 1 | GJXP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's accounting records and staff interview, the facility failed to convey the personal funds for two (2) deceased residents,and provide a final accounting of the funds to the individual or probate jurisdiction administering the individual's estate within 30 days as provided by State law. This was found for two (2) of 21 account holders. Resident identifiers: #18 and #68. Findings include: a) Resident #18 A review of the accounting records dated [DATE] on [DATE], revealed Resident #18, who expired on [DATE], continued to show a balance in a personal account of $1123.96. This was acknowledged by Employee #58 (Business office manager) in an interview at 4:25 p.m. on [DATE]. She stated they had notified the family and were waiting for them to contact the facility with instructions. There was no evidence of this in the record. b) Resident #68 A review of the accounting records dated [DATE] on [DATE], revealed Resident #68, who expired on [DATE], continued to show a balance in a personal account of $245.82. During an interview with Employee #58 at 4:25 p.m. on [DATE], she acknowledged the funds had been there until yesterday, [DATE], when she contacted the family and was directed to issue a check made out to the executer of the estate and forward it to the funeral home. | 2017-09-01 |
| 7049 | 7049 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2013-09-13 | 167 | B | 0 | 1 | GJXP11 | Based on observation and staff interview, the facility failed to ensure survey results and the approved plans of correction were available to residents without having to ask a staff person. An observation revealed residents in a wheelchair were not able to review the survey results without asking staff for assistance. This had the potential to affect more than a minimal number of residents. Facility census: 61. Findings include: a) On 09/12/13 at 3:15 p.m., an observation of the survey results book revealed it was located at a height of approximately five (5) feet. Any resident who could not stand or was confined to a wheelchair could not reach the book without having to ask staff to retrieve the survey results book. On this same day, the administrator was informed of this finding and agreed the survey results book was located at a height which made the survey results inaccessible to residents who could not stand or were confined to wheelchair without asking the staff for assistance. The survey results book was relocated to above the handrail in the administrative hallway prior to exiting the facility on 09/13/13 making it accessible to any resident without asking for staff assistance. | 2017-09-01 |
| 7066 | 7066 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2014-07-14 | 170 | B | 0 | 1 | U25211 | Based on staff interviews and resident interviews, the facility failed to ensure personal mail was delivered to the residents within 24 hours of delivery to the facility by the postal service. This had the potential to affect more than an isolated number of residents. Facility census: 64. Findings include: a) During an interview with the resident council president (Resident #13) on 07/09/14 at 9:00 a.m., the president said the facility did not deliver residents' mail on Saturdays. On 07/09/14 at 9:40 a.m., Employee #25 (business office) said the facility delivered the mail from Saturday on Monday morning. On 07/09/14 at 9:30 a.m., the activity director (Employee #59) said she worked three (3) Saturday's a month and would be glad to distribute the mail on those days. | 2017-09-01 |
| 7083 | 7083 | MONTGOMERY GENERAL HOSPITAL | 515081 | 401 6TH AVENUE | MONTGOMERY | WV | 25136 | 2013-11-21 | 156 | B | 0 | 1 | DACE11 | Based on observation and staff interview, the facility failed to ensure it had prominently displayed written information about how to apply for and use Medicare and Medicaid benefits. This practice had the potential to affect any residents and/or residents' responsible parties who might need access to this information. Facility census: 36. Findings include: a) During the initial tour of the facility on 11/18/13, at approximately 11:45 a.m., observations found the posting of how to apply for and use Medicare and Medicaid benefits was not present. On 11/21/13 at 11:30 a.m. the director of nursing and the social worker, Employee #35, confirmed the information was not posted in the facility. Employee #35 stated the building had recently been painted and she thought the painters must have removed the information. | 2017-08-01 |
| 7165 | 7165 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2014-07-29 | 203 | B | 1 | 0 | EYNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were provided the required information at discharge. There was no evidence seven (7) of eight (8) residents and/or the responsible party were notified of the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident was transferred, the right of appeal, or how to notify the ombudsman and the appropriate protection and advocacy agency, with the addresses and telephone numbers as required. The facility had no process to ensure this information was completed and provided at the time of discharge. Resident identifiers: #113, #10, #115, #79, #76, #114, and #95. Facility Census: 112. Findings include: a) Residents #113, #10, #115, #79, #76, #114, and #95 Review of the medical records for these residents, who had been transferred from the facility, found no evidence the information provided at discharge included the reason for transfer or discharge, effective date of transfer or discharge, location, right to appeal, or how to notify the ombudsman and the appropriate protection and advocacy agencies with the addresses and telephone numbers for these agencies as required. The following residents were transferred from the facility without evidence they were provided this required information: 1. Resident #113 - transferred to the hospital on [DATE] 2. Resident #10 - transferred to the hospital on [DATE] 3. Resident #115 - transferred to the hospital on [DATE] 4. Resident #79 - transferred to the hospital on [DATE] 5. Resident #76 - transferred to the hospital on [DATE] 6. Resident #114 - transferred to the hospital on [DATE] 7. Resident #95 - transferred to the hospital on [DATE] An interview was conducted with the director of nursing (DON), Employee #97, on 07/29/2014 at 2:40 p.m. She stated the facility did not keep copies of the transfer information provided residents. The DON stated nurses were instructed to pr… | 2017-07-01 |
| 7166 | 7166 | CEDAR RIDGE CENTER | 515087 | 302 CEDAR RIDGE ROAD | SISSONVILLE | WV | 25320 | 2014-07-29 | 205 | B | 1 | 0 | EYNI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure written information, regarding the facility's bed-hold policy was provided to the residents or a legal representative, at the time of transfer of the residents from the facility. This was found for seven (7) of eight (8) sample residents who had been transferred from the facility. Resident identifiers: #113, #10, #115, #79, #76, #114, and #95. Facility Census: 112. Findings include: a) Residents #113, #10, #115, #79, #76, #114, and #95 Review of the medical records for these residents, who had been transferred from the facility, revealed no evidence information regarding the facility's bed-hold policy was provided at the time of transfer to another facility. The following residents were transferred from the facility without evidence they were provided bed-hold information: 1. Resident #113 - transferred to the hospital on [DATE] 2. Resident #10 - transferred to the hospital on [DATE] 3. Resident #115 - transferred to the hospital on [DATE] 4. Resident #79 - transferred to the hospital on [DATE] 5. Resident #76 - transferred to the hospital on [DATE] 6. Resident #114 - transferred to the hospital on [DATE] 7. Resident #95 - transferred to the hospital on [DATE] An interview was conducted with the director of nursing (DON), Employee #97, on 07/29/2014 at 2:40 p.m. She stated the bed-hold policy and re-admission rights information were on the same form as the transfer/discharge information provided residents upon discharge. The DON stated nurses were instructed to provide this information when a resident was transferred or discharged . She said sometimes the fact the information was sent was recorded in the narrative notes, but sometimes the nurses did not record it. The DON said she was unable to provide evidence the information was provided these residents, or that it was actually put in the transfer packet, since the facility did not keep a copy. She stated in the past,… | 2017-07-01 |
| 7275 | 7275 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2014-05-15 | 156 | B | 0 | 1 | SERN11 | Based on observation and staff interview, the facility failed to ensure it had prominently displayed written information about how to apply for and use Medicaid benefits. This practice had the potential to affect any residents and/or residents' responsible parties who might need access to this information. Facility census: 15. Findings include: a) During the initial tour of the facility on 05/12/14 at 10:50 a.m., observations found the posting of how to apply for and use Medicaid benefits was not present. On 11/14/14 at 11:15 a.m., Employee #1, the registered nurse clinical coordinator supervisor (RN, CCS) and Employee #20, the social worker, confirmed the facility had not posted the information in the facility. | 2017-06-01 |
| 7312 | 7312 | PINE VIEW NURSING AND REHABILITATION CENTER | 515184 | 400 MCKINLEY STREET | HARRISVILLE | WV | 26362 | 2013-08-22 | 161 | B | 0 | 1 | E42711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, communication with the state agency office, and review of the surety bond information, it was determined the facility does not have a currently approved surety bond to cover resident funds being held by the facility. This practice has the potential to affect each of the twenty-eight (28) residents who have funds managed by the facility. Facility census: 54. Findings include: a) Interview with Employee #71, the office manager, on [DATE] at 10:00 a.m., revealed the facility had a continuation certification letter from the insurance company who issued the surety bond for the facility. Review of the letter indicated the bond, for a specified amount, was in effect from [DATE] until [DATE]. This continuation notice did not contain a seal or letter from as required from the necessary state agencies to indicate it was approved and effective. Contact with the state survey agency office revealed the most current information on file showed the facility's bond expired in 2012. No other surety bond or evidence of a continuation had been submitted and approved by the state agency or the attorney general's office. Further discussion with Employee #71 indicated the facility had not submitted the most recent continuation certificate letter to the necessary agencies for proper approval. | 2017-06-01 |
| 7358 | 7358 | TYGART CENTER AT FAIRMONT CAMPUS | 515053 | 1539 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2013-07-22 | 156 | B | 0 | 1 | MT7G11 | Based on observation and staff interview, the facility failed to post contact information of pertinent State client advocacy groups in a manner which was accessible to wheelchair bound residents. This had the potential to affect more than a limited number of residents. Facility census: 104. Findings include: a) During a random observation on 07/22/13, a copy of residents' rights with a listing of telephone numbers was observed posted in the lobby of the facility. The bottom of the form was about eye level, if standing. Upon inquiry, on 07/22/13 at 8:15 a.m., Employee #131 (social services), confirmed the information was not posted in another area accessible to residents. She also acknowledged the posted information, containing residents rights and contact information for pertinent State client advocacy groups, would be difficult to read from a seated position, such as a wheelchair, and was therefore not accessible to all residents. | 2017-05-01 |
| 7395 | 7395 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2013-08-15 | 492 | B | 0 | 1 | PDFH11 | Based on staff interview, record review, and review of the county's food handler policy, the facility failed to ensure compliance with the county health department's requirements and regulations regarding food handler's cards for dietary employees. The facility had two (2) newly employed dietary staff employees who had not obtained a temporary food handler's card prior to being allowed to work in the kitchen area. Employee identifiers: #93 and #94. Facility census: 62. Findings included: a) Employees #93 and #94 On 08/12/13 at 1:30 p.m., Employee #73 the Dietary Manager (DM) provided requested copies of the food handler's permits for dietary staff. At 1:35 p.m. on 08/12/13, Employee #73 was asked about two (2) of the permits as none had been provided for Employees #93 and #94. Employee #73 stated they were just hired last week, and were scheduled to take the food handlers' class on 08/26/13. Upon further inquiry, he stated he would provide their temporary food handler's card. Employee #73 also stated the two (2) employees had been working within the kitchen to assist in preparing and serving food since they were employed. 1) At 9:45 a.m. on 08/13/13, a copy of Employee #93's Temporary Food Handler's Permit was received from Employee #33, the administrator. Review of the permit found it was dated as being obtained from the County Health Department on 08/13/13, and would expire on 08/26/13. On 08/13/13 at 11:30 a.m., an interview was conducted with Employee #93. She stated she had been employed at the facility since last week and was scheduled to take the food handler's class at the end of the month. This was verified, on 08/14/13 at 2:00 p.m., by a review of the dietary staffing schedule for August 2013. Employee #93 was employed and worked at the facility in the dietary department since 08/05/13. Her temporary food handler's permit was not obtained until 08/13/13. 2) A copy of a temporary food handler's permit for Employee #94 was received on 08/14/13 at 12:20 p.m. A review of this document revealed it was dated … | 2017-05-01 |
| 7414 | 7414 | CAREHAVEN OF PLEASANTS | 515191 | 506 RIVERVIEW ROAD | BELMONT | WV | 26134 | 2013-08-29 | 225 | B | 0 | 1 | 2QIM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's complaint files, and staff interview, the facility failed to ensure all allegations of abuse/neglect were immediately reported to the appropriate State agencies. Allegations of neglect were made in a letter provided to the facility which expressed concerns regarding the lack of services provided to residents. This letter alleged neglect had occurred for three (3) residents. The alleged neglect issues (lack of care for a medical condition for Resident #5, ineffective pain control for Resident #30, and lack of treatment for [REDACTED].#84) were investigated by the facility, but the facility failed to report these allegations to the required State agencies. This was true for three (3) of twenty-five (25 ) residents who were reviewed in Stage 2 of the survey. Resident identifiers: #5, #30, and #84. Facility Census: 60. Findings include: a) Resident #5 It was identified during a review of the facility's abuse and neglect files, a letter, dated 08/21/13, had been written to the facility alleging this resident had suffered from lack of care from a medical condition ([MEDICAL CONDITION]) that was not being treated. It was identified in the medical record and in the facility's investigation, this resident had received multiple treatments since his admission and prior to his admission for his condition. The physician had visited and examined this resident two (2) times each month. The reasons for the decision to not provide treatments were explained in the medical record and this resident was alert and oriented and chose what treatments he would and would not have done. There was no evidence this allegation of neglect, exemplified by a lack of treatment, was reported to the required State agencies. b) Resident #30 It was identified in a letter received by the facility, dated 08/21/13, Resident #30 was dying and experiencing a lot of pain. It was alleged that her pain control was not effective and she o… | 2017-05-01 |
| 7415 | 7415 | CAREHAVEN OF PLEASANTS | 515191 | 506 RIVERVIEW ROAD | BELMONT | WV | 26134 | 2013-08-29 | 226 | B | 0 | 1 | 2QIM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's complaint files, staff interview, and policy review, the facility failed to ensure its policy regarding reporting of abuse and neglect was implemented. The facility received a letter in which allegations of neglect were made. An allegation was made that Resident #5 did not receive care for a medical condition. Resident #30 was alleged to not have received effective pain control. The letter also alleged a urinalysis was delayed for Resident #84 resulting in a delay of treatment. The facility failed to report these allegations immediately to the required State agencies as specified in their abuse prohibition policy (revised 9/00). This policy was not implemented for three (3) of twenty-five (25) Stage 2 sampled residents. Resident identifiers: #5, #30, and #84. Facility Census: 60. Findings include: a) Resident #5 It was identified during a complaint investigation a letter had been written to the facility, dated 08/21/13, alleging this resident had suffered from a lack of care from a medical condition ([MEDICAL CONDITION]) that was not being treated. There was no evidence this allegation of neglect due to a lack of treatment was reported to the required State agencies. b) Resident #30 It was identified in a letter written to the facility, dated 08/21/13, that Resident #30 was dying and experiencing a lot of pain. It was alleged that her pain control was not effective and she often yelled out in agony. There was no evidence this allegation of neglect regarding the resident's ineffective pain control was reported to the required State agencies. c) Resident # 84 It was brought to the attention of the facility in a letter dated 08/21/13, that Resident #84's physician had been contacted and orders obtained for a urinalysis. The letter stated the resident had been exhibiting a change in orientation and increased behaviors. The letter alleged the facility did not get this urinalysis during day shift w… | 2017-05-01 |
| 7455 | 7455 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 158 | B | 0 | 1 | TA7B11 | Based on resident interview and staff interview, the facility failed to ensure personal funds are available at all times. The facility does not provide access to resident funds in the evenings or on the weekends. This practice has the potential to affect more than a limited number of residents. Facility census: 113. Findings include: a) On 06/03/13 at 1:47 p.m., Resident #24 stated during a Stage 1 interview she did not have access to her personal funds on the weekends. On 06/11/13 at 4:00 p.m., during an interview with the Administrator, Employee #162, a Consultant, Employee #159, and the Director of Nursing Services, Employee #11, it was revealed resident funds are not available at all times. The Administrator verified resident funds are not available in the evenings or on the weekends unless there is a manager on duty in the facility. | 2017-04-01 |
| 7473 | 7473 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 492 | B | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interview the facility failed to comply with WV State Regulations pertaining to the following personnel requirements at Title 64 Legislative Rules, West Virginia Division of Health,Series 13, Nursing Home Licensure Rule: -11.6 Personnel Records. A nursing home shall maintain a confidential personnel record for each employee containing the following information: -11.6.c Results indicating a satisfactory health status for the employees' current job assignment as required in Subsection 8.19 of this rule. -11.6.i A job description signed by the employee. - 8.20.c.3 Employee restrictions. A nursing home shall prohibit employees with a communicable disease or infected [MEDICAL CONDITION] from direct contact with residents or their food, if direct contact will transmit the disease. Findings include. a) Employee #2 On 06/06/13 at 1:30 p.m., a review of Employee #2's personnel file was conducted. This employee was hired on 05/20/13. There was no evidence this employee had a pre-employment physical. b) Employee #52 On 06/06/13 at 1:30 p.m., a review of Employee #52's personnel file was conducted. This employee was hired on 05/20/13. There was no evidence this employee had a pre-employment physical. In an interview, with the human resources director, on 06/06/13 at 2:00 p.m., she could find no evidence of a pre-employment physical in the personnel files of Employee #2 or Employee #52. She stated the facility had recently changed the procedure for employees to have a pre-employment physical and agreed Employee #2 and Employee #52 did not have a pre-employment physical. c) Employee # 148 Review of personnel records for Employee # 148, on 06/11/13 at 2:00 p.m., revealed no evidence of a job description for this employee's position: appointment scheduler/transporter for residents. This was confirmed by Employee #124, human resource director, HR on 06/11/13 at 3:15 p.m. d) The facility failed to ensur… | 2017-04-01 |
| 7637 | 7637 | MONTGOMERY GENERAL ELDERLY CARE | 515152 | 501 ADAMS STREET | MONTGOMERY | WV | 25136 | 2013-04-25 | 170 | B | 0 | 1 | BHXG11 | Based on an interview with the president of the resident council (Resident #3) 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 on this day of the week. This had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) During an interview, on 04/23/13 at 3:30 p.m., the resident council president (Resident #3), stated residents do not receive mail on Saturdays. The activity director, Employee #25, was interviewed at 4:04 p.m. on 04/23/13. She stated the mail comes to the storage department at the hospital and We don't deliver the mail on Saturdays. The administrator, Employee #5, was interviewed on 04/23/13 at 4:22 p.m. She stated the facility shares a post office box at the post office with the hospital next door, who also owns the nursing facility. The mail is picked up and sorted by hospital personnel on Monday through Friday and no one from the hospital picks up the mail on Saturdays. | 2017-03-01 |
| 7686 | 7686 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2013-03-22 | 170 | B | 0 | 1 | B0M411 | Based on interviews and policy review, the facility failed to deliver mail to residents on Saturdays. This had the potential to affect all residents who received mail at the facility. Findings include: On 3/18/13 at 2:10 P.M. the Resident Council President #11 was interviewed. During the interview the Resident Council President stated she was not sure if mail was delivered to residents on Saturdays or not. She stated in the past the residents did get mail on Saturdays. At 2:20 P.M. the Activity Director (AD) #44 was interviewed. The AD stated she only works two Saturdays a month and she does not deliver mail on Saturdays when she works. At 2:30 P.M. the Director of Nursing (DON) #73 was interviewed. She stated there was no staff on the weekend to go get the mail from the post office on Saturdays to deliver to the residents and verified residents did not receive mail on Saturday. At 3:05 P.M. the Assistant Administrator #79 was interviewed. The Assistant Administrator verified the facility used to pick up the mail on Saturday and deliver it to the residents, but not anymore. She stated the mail is picked up from the post office daily Monday through Friday and there was no mail delivery to residents on Saturday. If residents did receive mail delivery on Saturdays it was not delivered to them by facility staff until Monday. The policy and procedure for mail delivery was reviewed. The policy indicated each resident has the right to send and receive mail promptly and delivered to the resident within 24 hours. | 2017-02-01 |
| 7712 | 7712 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2013-01-11 | 159 | B | 0 | 1 | Q01G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to provide a statement of account balances for 1 of 1 residents (Resident #89) with concerns related to personal fund account statements out of 20 residents interviewed. Findings include: Resident #89 was admitted on [DATE]. During an interview on 1/08/2013, Resident #89 reported that he was not given a statement of his facility managed trust fund account. On 1/10/2013 at 5:10 PM, an interview was completed with Bookkeeper #85. Bookkeeper #85 said that trust fund statements go out quarterly. Resident #89 has an account. I don't have have a statement for him for June or October. He did have one for the quarter ending in March (2012). If he didn't sign it and give it back, it won't be in the file. If they don't return the signed sheet, there isn't any way to show they got the statement, but everyone gets one. We provide the envelope with the statement in the daily mail. The residents bring them back up to me. | 2017-02-01 |
| 7715 | 7715 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2013-01-11 | 167 | B | 0 | 1 | Q01G11 | Based on observations and staff interviews, the facility failed to make previous survey results available for review. Findings include: During a tour of the facility on 1/11/2013 at 9:15 AM with Maintenance Supervisor #65, survey results could not be located. Maintenance Supervisor #65 asked the facility Administrator where the results were posted. The Administrator went to a place on the wall where she said the survey results were supposed to be inside an open storage bracket mounted on the wall in the main hallway. She also noted that the notebook had a chain attached securing it to the wall. The Administrator said, I don't know where they are. I saw them there yesterday. You see the holes where they were attached. I will find them. No bracket or chain was observed. There were 4 holes noted in the wall. On 1/13/2013 at 9:20 AM, the survey results notebook was located inside the mail room inside the administrative offices. | 2017-02-01 |
| 7716 | 7716 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2013-01-11 | 172 | B | 0 | 1 | Q01G11 | Based on record review and staff and resident interviews, the facility failed to make residents aware of the ombudsman. Findings include: A review of Resident Council minutes from July through December 2012 revealed no mention of the ombudsman. An interview was completed with Resident #18 on 1/09/2013 at 7:15 PM. Resident #18 stated that she regularly attended Resident Council meetings. Resident #18 said that she did not know the Ombudsman and said she didn't know the term. She also said that she did not recognize the name of the ombudsman. On 1/10/2013 at 9:10 AM, an interview was completed with Activity Director #55 (AD#55) AD #55 said, The Ombudsman shows up once in a while. She probably hasn't been to one (Resident Council meeting) in six months. She calls and asks when they are, but she says she can't always make it. I've told them (Resident Council) what the Ombudsman is and they can ask her to come to the meetings if they want. They know they can get her number if they need it. If someone has a problem that isn't resolved, I tell them we can call the Ombudsman. Every once in a while, I mention it during the meetings. I guess I didn't write it in the minutes. An interview was completed with Social Worker #49 (SW#49) on 1/10/2013 at 9:27 AM. SW #49 said, I have been to most of the Resident Council meeting since June. The Ombudsman hasn't been to any of the meeting that I've gone. Her information is posted on the wall. When she is here she meets with some residents. My opinion is that the residents that she visits would probably be the only ones that know who she is. I haven't even met her yet. On 1/10/2013 9:45 AM, an interview was completed with Resident #35. Resident #35 stated that he frequently attended Resident Council meetings. Resident #35 said that he was not familiar with the term ombudsman or the ombudsman's name. I go to every meeting. I go door to door and invite everyone to the meetings. | 2017-02-01 |
| 7736 | 7736 | CAMERON NURSING AND REHABILITATION CENTER | 515125 | ROUTE 4, BOX 20 | CAMERON | WV | 26033 | 2013-05-01 | 156 | B | 0 | 1 | H1U811 | Based on review of liability notices and staff interview, the facility failed to provide specific written information to three (3) of three (3) residents whose Medicare covered skilled services were discontinued. The liability notices provided these residents did not indicate the reason the services would no longer be covered. Resident identifiers: #9, #53, and #51. Facility census: 44. Findings include: a) Residents #9, #53, and #51 A review of the Notice of Medicare Provider Non-Coverage document which was provided to residents and/or their responsible parties included the following statement: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END (followed by the date). The document did not identify which service was being discontinued and did not explain why the service was being discontinued. The resident was being asked to make an appeal decision without this information. During an interview with the administrator, at 9:45 a.m. on 04/24/13, he acknowledged the form did not indicate which skilled service was being discontinued or the reason for the discontinuation. | 2017-02-01 |
| 7741 | 7741 | CAMERON NURSING AND REHABILITATION CENTER | 515125 | ROUTE 4, BOX 20 | CAMERON | WV | 26033 | 2013-05-01 | 356 | B | 0 | 1 | H1U811 | Based on record review and staff interview the facility failed to post accurate nurse staffing information on a daily basis. The numbers of licensed and unlicensed staff posted did not represent the actual number of staff available for direct resident care for each shift. This practice had the potential to affect more than a limited number of residents. Facility census: 44. Findings include: a) On 04/24/13, a review of staffing information postings dated 04/01/13 through 04/07/13 was conducted. The postings were compared with the facility's staffing worksheet. There was a discrepancy in the number of direct care staff listed. Four (4) of seven (7) actual staffing postings revealed one (1) less direct care staff member on duty, than the information posted for that day. During an interview with the administrator, on 04/24/13 at 2:15 p.m., it was revealed Employee #79 begins the the shift after the day shift staffing is posted. He stated the staffing posted is not updated upon arrival of Employee #79. The administrator presented an individual employee time card for Employee #79 which paralleled the noted inconsistency. The facility did not update the number of available licensed and unlicensed staff when the number of staff members changed. | 2017-02-01 |
| 7742 | 7742 | CAMERON NURSING AND REHABILITATION CENTER | 515125 | ROUTE 4, BOX 20 | CAMERON | WV | 26033 | 2013-05-01 | 364 | B | 0 | 1 | H1U811 | Based on observation and resident interview, the facility failed to ensure hot foods were served at preferable temperatures as discerned by the resident and customary practice. Two (2) residents expressed concerns with the temperature of hot foods. The facility did not implement practices to ensure foods were hot enough when received by the residents. This affected two (2) residents, but had the potential to affect more than an isolated number of residents. Resident identifiers: #6 and #29. Facility census: 44. Findings include: a) Residents #29 and #6 During a Stage 1 interview, on 04/22/13 at 1:31 p.m., Resident #29 stated hot foods were not hot enough upon receipt. Resident #6, during a Stage 1 interview on 04/22/13 at 1:56 p.m., said The hot food is just barely warm. b) The meal tray line was observed, on 04/24/13 during the lunch meal. The meal service was observed from the beginning of the meal, until the last trays were served. The first trays were prepared, placed on carts, and sent to the units. The dining room, which was adjacent to the kitchen, was served last. At 12:12 p.m., prior to serving the last trays, Employee #74, a dietary assistant, was requested to obtain the temperatures of the pureed chicken and the chicken patties. The temperature of the chicken patties was 110 degrees Fahrenheit (F) and the temperature of the pureed chicken was 124 degrees F. At these temperatures, the chicken patties (which were 110 degrees) could not be received by the residents at the customary temperature of 120 degrees for hot foods. In addition, the pureed chicken (which was 124 degrees) was very likely to have fallen below 120 degrees F by the time of receipt by the residents. | 2017-02-01 |
| 7761 | 7761 | CLAY HEALTH CARE CENTER | 515142 | 1053 CLINIC DRIVE | IVYDALE | WV | 25113 | 2013-04-16 | 514 | B | 0 | 1 | KUG911 | Based on medical record review and staff interview, the facility failed to maintain an accurate, complete and systemically organized medical record for nine (9) of thirty-four (34) medical records reviewed during Stage 2 of the survey. The medical record of each resident contained forms which were not fully completed with dates and/or signatures. Records were requested for Resident #12, and the facility was unable to locate the records. In addition, information regarding the consultant pharmacist's monthly medication regimen review was not in each resident's medical record. Resident Identifiers: #12, #34, #50, #63, #57, #2, #30, #27, and #64. Facility census: 57. Findings Include: a) Resident #12 At 3:30 p.m. on 04/03/13, the resident's restorative documentation for the months of January 2013 through March 2013 was requested from the director of nursing (DON). At 11:30 a.m. on 04/04/13, the DON reported they could not locate the requested restorative records. She reported they would continue to look for them. At the time of exit, at 4:30 p.m. on 04/16/13, the facility was unable to provide the requested records for Resident #12. b) Resident #34 A medical record review was conducted at 12:54 p.m. on 04/15/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of February 2013 and March 2013. These forms contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on either form. c) Resident #50 A medical record review was completed at 10:00 a.m. on 04/11/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of January 2013, February 2013, March 2013 and April 2013. These form contained a box which was labeled nurses signature (in accordance with state law). This box was not signed or dated on the forms. d) Resident #63 A medical record review was completed at 11:30 a.m. on 04/11/13. This revealed the resident had nursing rehab/restorative: plan of care forms for the months of Ja… | 2017-02-01 |
| 7828 | 7828 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2012-08-23 | 253 | B | 0 | 1 | 1T2X11 | Based on observation and staff interview, it was found the facility had not ensured the environment in resident rooms was kept in a manner that was sanitary and orderly. Doors to resident bathrooms and furniture, such as nightstands, had scuff marks and scratches that made them unsightly and not easily cleanable. This was evident for four (4) of twenty-eight (28) resident rooms in the facility. Room identifiers: A8, A9, B1 and B12. Facility census: 56. Findings include: a) Rooms A8, A9, B1 and B12 During the initial tour of the facility, and throughout the survey process, it was observed that doors to the bathrooms in these resident rooms, and some of the night stands, had scratches and scuffed marks on the finishes of the items. This made the items unsightly, and not easily cleanable. This was discussed with the maintenance director, Employee #61, on the afternoon of 08/16/12. He was aware of these issues being a concern. | 2017-01-01 |
| 7948 | 7948 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2012-08-20 | 170 | B | 0 | 1 | HTLJ11 | Based on resident and staff interviews, the facility failed to ensure privacy for each resident who receives mail in the facility. The facility failed to ensure that mail was unopened upon delivery to the residents. Findings include: An interview was conducted on 8/14/2012 at 3:00 PM with a member of the resident council (Resident # 60). The resident stated that the residents do not always receive their mail unopened. She stated that she has even received her mail unopened. The resident stated that the type of mail opened usually has to do with health benefits or benefit cards. The resident shared that she prefers to open her own mail and has not signed any document permitting the facility to open her mail. The resident council member stated that the activity director (#79) gives the mail to another resident, who is also a resident council member and that resident delivers the mail. An interview was conducted with the activity director on 8/14/2012 at 5:25 PM. The activity director stated that the activity staff sorts the mail, and we only open the mail for those who cannot. The activity director stated that the mail is open when she receives it from the business office staff. The activity director stated further, The only mail that is opened is their health care cards for Medicaid. Usually something from Medicare or Medicaid. The activity director stated that no one ever questioned the mail being opened. She voiced that she could not remember how many resident's mail would be already open when she received it from the business office. An interview was conducted with the business office manager (#17) on 8/17/2012 at 8:45 AM. She voiced that the facility does open all residents' mail that contains Medicaid information. The business office manager shared that the mail is opened and they take out what they need, make copies and then deliver the mail to the residents. When asked why the business office staff opened resident mail without allowing the resident to first open their own mail, the business office manager r… | 2016-12-01 |
| 8037 | 8037 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2012-08-22 | 156 | B | 0 | 1 | 8KXK11 | Based on record review and staff interview, the facility failed to identify the services being discontinued and/or the reason for the action on the liability notices. This affected three (3) of three (3) sampled residents who had Medicare covered services discontinued. Resident identifiers: #228, #21, and #215. Facility census: 127. Findings include: Residents #228, #21, and #215 A review of the Notice of Medicare Provider Non-Coverage document, which was provided to the residents and/or their responsible parties, found the following verbiage: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END: (followed by the date) The document did not, in a language the resident could understand, identify the service that was being discontinued, nor did it explain why the service was being discontinued. The resident was being asked to decide whether to make an appeal of the decision without this information. During an interview with the Social Worker on the skilled unit, at 11:00 a.m. on 08/22/12, it was revealed that Residents #228 and #21 had met their goals and were either discharged to home or another health care facility. During an interview with the Administrator and the Director of Nurses, at 11:30 a.m. on 08/22/12, the Administrator acknowledged that the name of the service and reason for discontinuing it were not being added to the form, although it was a CMS approved form. | 2016-10-01 |
| 8120 | 8120 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-10-24 | 225 | B | 1 | 0 | 0LWM11 | Based on a review of the abuse/neglect reportable allegations, the abuse/neglect reporting policy, staff interview, and review of complaint files, the facility failed to ensure seven (7) of ten (10) complaints were identified as allegations of abuse and/or neglect and reported to the appropriate outside agencies in accordance with state law. The facility investigated the complaints, but did not recognize them as allegations of abuse/neglect which required reporting to outside agencies. Resident identifiers: #59, #21, #84, #66, #37 #6, and #83. Facility census: 77. Findings include: a) Resident # 59 On 06/10/13, a complaint/concern/grievance/request form for Resident #59 stated, Daughter (name) complained that resident does not receive toileting assistance quickly enough. Stated that mom will proceed to the toilet on her own. Also complained that mother is not being offered continental breakfast. Concerned about inadequate staffing. b) Resident #21 A complaint/concern/grievance/request form for Resident #21, dated 08/06/13, stated 1.) Daughter complained that bed/mattress was noticeably dirty with dried food and also smelled of urine. 2.) Daughter also voiced concern about nursing unit being out of basic supplies like wipes, gloves, and disposable briefs. c) Resident #84 On 09/05/13, Resident #84 complained that her p.m. (night) medicines were given at 11:30 p.m., after her son had to call the facility. d) Resident #66 Resident #66 complained of not receiving baths as scheduled; being told by staff too busy. e) Resident #37 The resident's sister complained that Resident #37 is not warm enough in bed, and has told her she gets cold. The resident's sister believes this is because staff will leave Resident #37 in a thin gown instead of putting pants on her every day in bed as requested. She also believes staff does on provide Resident #37 with the use of a bedpan. The facility received the complaint on 10/02/13. f) Resident #6 Resident #6 complained that aides were not changing her at night every two (2) hours and nu… | 2016-10-01 |
| 8173 | 8173 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-09-20 | 356 | B | 1 | 0 | F3O611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation of the posting of direct care staffing and staff interview, the facility failed to ensure the required information was posted daily at the beginning of each shift. The staffing information sheet on [MEDICATION NAME] Lane was not completed for of 09/16/ 13. This information is to be posted so families and residents will be aware of how many direct care staff members are in the facility at any given time providing care. This had the potential to affect more than an isolated number of residents/families who may want to review this information on each shift. [MEDICATION NAME] Lane Census: 35. Facility Census: 79. Findings Include: a) [MEDICATION NAME] Lane During the initial tour of the facility on 09/16/13 at 7:00 p.m., the staffing available in the facility at that time was checked on each of the facility's three (3) units. The posted form for staffing was observed to be complete for the Lifesteps unit and the Lighthouse unit, but on the [MEDICATION NAME] Lane unit, the form had not been completed. The form posted on [MEDICATION NAME] Lane was blank. At the time of the observation, on 09/16/13, at approximately 7:15 p.m., the form should have been completed for 7-3 shift and 3-11 shift. The Administrator (Employee #116) was made aware of the posting being incomplete on [MEDICATION NAME] Lane on 09/16/13 at 8:30 p.m. She verified the form should be completed at the beginning of each shift. | 2016-09-01 |
| 8186 | 8186 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2012-05-18 | 156 | B | 0 | 1 | 6XWO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate liability notices to one (resident #277) out of four sampled residents reviewed for liability notices and beneficiary appeal rights. Findings Include: Resident #277 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident was notified by the facility that skilled nursing services would end on May 12, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident on May 10, 2012. Resident remained in the facility and was not discharged following the end of covered services. However, the resident was not issued the Skilled Nursing Facility Advance Beneficiary Notice (CMS Form ). An interview with employee #76 was conducted on May 16, 2012. Employee #76 stated that she issued the CMS Form and not the CMS Form . A subsequent interview was conducted with employee #76 on May 17, 2012. Employee #76 stated that she misunderstood the training she received regarding the requirements for issuing liability notices. | 2016-07-01 |
| 8292 | 8292 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2013-02-01 | 356 | B | 0 | 1 | BSMW11 | Based on observation of facility postings and staff interview, it was determined the nurse staffing numbers for the day shift were inaccurate at 3:30 p.m. on 01/28/13. This had the potential to affect all residents and the public, who are to have access to this information. Facility census: 17. Findings include: a) Observation of the staff posting on 01/28/13 at 3:30 p.m., found the facility had two (2) nursing assistants on duty for day shift and the two (2) employees were working a total of sixteen (16) hours. An interview with the director of nursing, Employee #133, at 11:20 a.m. on 01/30/13, confirmed a third nursing assistant had been assigned to the unit at 11:00 a.m. on 01/28/13, and would be working from 11:00 a.m. until 7:00 p.m. She agreed the nurse staffing posting should have been updated to include the third nursing assistant, and the the total number of hours should have been changed from 16 hours to 20 hours. | 2016-07-01 |
| 8354 | 8354 | LOGAN CENTER | 515175 | P.O. BOX 540 | LOGAN | WV | 25601 | 2012-11-07 | 167 | B | 0 | 1 | CDQ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, the facility failed to ensure that survey results were accessible to all residents without having to ask. Findings include: Observations were conducted on November 5, 6, and 7, 2012, of a binder labeled Survey Results, located on a wall near the front entrance of the facility. The survey results were contained within a plastic holder, attached to the wall, approximately 5 and a half feet high. It did not appear that residents in wheelchairs would be able to reach the survey results without having to ask for assistance. Resident #20 was admitted on [DATE], with [DIAGNOSES REDACTED]. An interview was conducted with resident #20 on November 7, 2012. During the interview, the resident stated he was not aware of where the survey results were located and that he would have to ask staff. Resident #55 was admitted on [DATE], with [DIAGNOSES REDACTED]. An interview was conducted with resident #55 on November 7, 2012. During the interview, the resident stated that the survey results were too high for her to reach while in her wheelchair and that she would have to stand to access the survey results which she stated she was not able to do. An interview with the Recreational Director, staff #73, was conducted on November 7, 2012. Staff #73 stated that residents could ask the receptionist for assistance to access the survey results and agreed that residents in wheelchairs would not be able to reach the binder independently because they were located too high upon the wall. | 2016-07-01 |
| 8500 | 8500 | MAIN STREET CARE | 5.1e+155 | PO BOX 7, 1500 TERRACE STREET, SUITE 300 | HINTON | WV | 25951 | 2012-12-05 | 253 | B | 0 | 1 | MNTR11 | Based on observation and staff interview, it was determined the facility had not ensured a sanitary, orderly, and comfortable interior. The doors of the resident rooms, ancillary rooms, the physician exam room, and the storage room had scratches and scuff marks observed. These conditions rendered the doors unable to be easily cleaned and sanitized. This was evident for twelve (12) of thirty-seven (37) resident rooms and two (2) ancillary rooms. Room identifiers: #345, #346, #348, #349, #351, #352, #354, #356, #343, #341, #340, and #338. Facility census: 1. Findings include: a) Rooms #345, #346, #348, #349, #351, #352, #354, #356, #343, #341, #340, and #338 While doing rounds, with the administrator, Employee #15, for environmental observations, on 12/03/12 at 3:15 p.m.,it was noted the hallway doors to twelve (12) resident rooms had scratches and scuff marks that made them unsightly and not easily cleanable. b) Observation of the physician exam room and the storage room door found these doors were scratched and scuffed. c) When the condition of the doors was discussed with the administrator, on 12/03/12 at 3:15 p.m., he verified the doors were in need of repair. He said it was part of a remodeling plan for the doors to be redone with stainless steel panels. | 2016-06-01 |
| 8550 | 8550 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2012-03-15 | 167 | B | 0 | 1 | 17TQ11 | Based on the resident council president interview, observation, and staff interview, it was found the facility failed to post their survey results in a place readily accessible to residents, and failed to post a notice of their availability. The survey results were in a bookcase in the lobby, blending in with several books. This practice had the potential to affect any resident or family member wishing to examine the survey results without asking a staff member where they were located. Facility census: 66. Findings include: a) An interview conducted with the resident council president, on 03/13/12 at 9:30 a.m., revealed the resident council president did not know the location of the state survey results. The survey results were not found during an observation of the front lobby, on 03/13/12, at approximately 2:00 p.m., after the interview with the council president. During an interview with the interim Nursing Home Administrator (NHA), Employee #97, on 03/14/12 at 12:00 p.m., the location of the survey results was requested. The NHA located the survey results in the front lobby in a bookcase that contained many books and survey results book blended in with other books. There was also no notice posted of their availability. The NHA agreed the survey results were not posted in an area that was readily available to residents and families without asking staff for their location. | 2016-05-01 |
| 8574 | 8574 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 356 | B | 0 | 1 | ZPPW11 | Based on observation and staff interview, it was determined the facility failed to post the required nurse staffing data in a prominent place in the facility that was readily accessible to residents and visitors. This information was posted on an inside wall at the entrance to the nurse's station, and not on a wall which would be easily viewed by visitors and residents. This practice had the potential to affect all residents and visitors who were interested in viewing the daily staffing in the facility. Facility census: 54. Findings include: a) An attempt to locate the required nurse staffing data posting, on 05/15/12, revealed it was not posted with the other required postings or in a prominent location convenient for viewing by visitors and residents. During an interview with a random staff member, on 05/15/12 at 11:15 a.m., it was revealed the nurse staffing was located at the nurse's station. Observations found the posting was located just inside the nurse's station on a side wall. The posting was not readily accessible or visible to visitors and residents who was interested in the daily nurse staffing information. On 05/17/12 at 11:45 a.m., an interview was conduced with the administrator (NHA), Employee # 42. The NHA was informed the posting was not located in an area that was easily viewed by visitors and residents. The NHA stated the nurse staff posting was located at the nurse's station so nursing staff could easily update the posting at each shift. This regulation requires the nurse staff posting be in a prominent place which is readily accessible to visitors and residents, not posted in an area for staff convenience. | 2016-05-01 |
| 8583 | 8583 | WILLOW TREE MANOR | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2013-05-02 | 514 | B | 1 | 0 | SKGC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, nursing staff failed to document a time on the Physician/Prescriber order sheets when a verbal or telephone order was written. One (1) of eight (8) records reviewed was found to have orders without the time the order had been obtained noted. Resident identifier: #98. Census: 97. Findings include: a) Resident #98 On 05/02/13 at 12:30 p.m., record review for Resident #98 found five (5) of the Physician/Prescriber order sheets were not timed when the verbal or telephone order had been written. On 05/02/13 at 12:55 p.m., Employee #2, the director of nursign, was interviewed. She said she had conducted mandatory inservices with the staff regarding telephone and verbal orders on 04/12/13 and 04/26/13. She provided copies of the inservice records, but the timing of orders was not listed on the agenda or inservice sheets. The DON stated orders were timed when they were put in the computer, but sometimes the nurses did not time the physician orders [REDACTED]. Upon further questioning of timing the orders when written, Employee #2, the DON again stated they are timed when the nurse enters them in the computer. | 2016-05-01 |
| 8662 | 8662 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 160 | B | 0 | 1 | 46GB11 | Based on review of residents' personal funds and staff interview, the facility failed to convey residents' funds, and to provide a final accounting of those funds, to the individual or probate jurisdiction administering the residents' estates. Instead, the facility paid the residents' funds to the funeral home and did not provide a final accounting of the residents' funds to a legally authorized individual or probate jurisdiction administering the estate. This practice affected three (3) of three (3) sampled residents. Resident identifiers: #2, #9, and #100. Facility census: 76. Findings include: a) Residents #2, #9, and #100 Review of the facility's personal funds accounting records found these three (3) residents' final accounts were paid directly to a funeral home. During an interview, on the afternoon of 01/11/12, a business office manager, Employee #63, confirmed when a resident passed away the facility did provide a final accounting of the residents' funds, and did not send the funds to the individual or probate jurisdiction administering the resident's estate. Employee #63 stated, All funds go directly to the funeral home. | 2016-04-01 |
| 8672 | 8672 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2012-01-11 | 356 | B | 0 | 1 | 46GB11 | Based on observations, review of the nurse staff posting and staff interview, the facility failed to ensure they were in compliance with the requirements set forth by the Center for Medicare and Medicaid Services (CMS) in relation to nurse staffing information. The facility was completing the staff posting in advance, rather than at the beginning of each shift as required. This practice had the potential to affect more than an isolated number of both residents and other interested individuals such as family members or visitors. Facility census: 76. Findings include: a) On 01/03/12, at approximately 4:30 p.m., an observation of the daily staffing sheet revealed the facility had the number of licensed practical nurses and registered nurses for night shift already filled in and counted. On 01/09/12, at approximately 11:00 a.m., a second observation of the daily staffing sheet revealed it had the wrong date listed and had the number of licensed and registered nurses had been filled in for day, evening, and night shifts. On 01/09/12, at approximately 12:00 p.m., the director of nursing (Employee #55) said Employee #89 (licensed practical nurse) took care of the daily staffing post and would answer any questions related to the issue. On 01/09/12, at approximately 1:00 p.m., Employee #89 confirmed she was responsible for the daily staffing posting. She stated she assigned another staff member to fill in the number and hours scheduled for licensed and registered nurses each day. Employee #89 indicated she would discontinue having staff fill out the sheet for the entire day, and instead, fill in the numbers at the beginning of each shift. b) The posting of staff was observed on 01/10/12. Noted on the bottom of this posting was Required staffing is 2.25 hours. This statement was misleading to the public because this is not the required staffing level, but the minimal staffing level required by the State licensure rule. The required staffing is the amount of staff necessary to meet the needs of the residents as described in… | 2016-04-01 |
| 8687 | 8687 | PARKERSBURG CENTER | 515102 | 1716 GIHON ROAD | PARKERSBURG | WV | 26101 | 2012-04-26 | 253 | B | 0 | 1 | S35H11 | Based on observation and staff interview, it was determined maintenance and housekeeping services had not ensured doors to resident bathrooms were free from scratches and gouges, walls were not marred and scuffed, and doorframes did not have chipped paint. This affected nine (9) resident rooms in the facility. Room numbers: 99, 110, 111, 112, 113, 221, 224, 226 and 227. Census: 64. Findings include: a) Resident room #s 99, 110, 111, 112, 113, 221, 224, 226 and 227 Observations of the facility, during Stage I of the quality indicator survey process, revealed doors and walls that were scratched, marred, and/or scuffed. Door frames to bathrooms and to the hallways had paint chipped off of the door frames. This was discussed with the maintenance director, Employee #63, as part of the environmental component of the survey process. It was also made known to the administrator, Employee #55, on the afternoon of 04/25/12. | 2016-04-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );