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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 8109 | 8109 | LOGAN CENTER | 515175 | 55 LOGAN MINGO MENTAL HEALTH CENTER ROAD | LOGAN | WV | 25601 | 2013-10-01 | 465 | E | 1 | 0 | UB5911 | c) Room 105 The bathroom in room 105 was observed on 09/30/13 at 11:45 a.m. A small amount of bowel movement was smeared on the seat of the toilet. Two (2) hospital gowns were wadded up on the bathroom floor beside a pair of underpants. A wet washcloth was hanging from the grab bar on the wall by the commode. On 09/30/13 at 12:12 p.m., licensed nurse, Employee #69, was shown the bathroom in room 105. She saw the commode with the bowel movement smear, the dirty gowns and underpants on the floor, and the wet wash cloth hanging from the grab bar. She agreed that dirty linens and clothing should not have been left lying in the bathroom. She said she would notify housekeeping of the bowel movement on the commode seat, and staff would dispose of the dirty linens properly. d) Room 103 On 09/30/13 at 11:46 a.m. the bathroom in room 103 was observed. A pair of latex gloves was left lying on the bathroom floor. At 12:12 p.m. licensed nurse Employee #69 was shown the latex gloves on the bathroom floor. She donned a clean pair of latex gloves. She picked up the pair of gloves that were lying on the bathroom floor. She then removed her newly donned gloves by turning them inside out, thereby containing the gloves that had been lying on the floor of the bathroom. She disposed of the gloves by dropping them in the bathroom trash can. Based on observation and staff interview, the facility failed to provide a safe and sanitary environment. The shower rooms on the 200 and 300 halls had lingering offensive odors, loose gloves, a razor, soiled linens, soiled bandages, used toilet paper and/or opened and unmarked toiletries. There were also pools of standing water, a shower stall with the water running and several pairs of unmarked resident clothing items on the floor. There were two (2) resident's rooms in which the bathrooms contained resident's clothing on the floor, a used washcloth on the grab bar, loose gloves on the floor and a brown substance smeared on the back of the toilet seat. This had the potential to affect more than an… | 2016-10-01 |
| 9083 | 9083 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-02-21 | 225 | D | 1 | 0 | RESW11 | br>Based on review of the facility's reported allegations of resident abuse/neglect, review of facility policy, and staff interview, the facility failed to report the results of all abuse/neglect investigations to state agencies as required by law. The law requires all investigation results be reported to appropriate state agencies within five (5) working days of the incident. The facility did not do this for the one (1) investigation of resident to resident sexual abuse which was alleged in the past six (6) months. Resident Identifiers: # 47 and # 34. Facility census: 107. Findings Include: a) Resident #34 and #47 Review of facility reportable incidents, at 3:55 p.m. on 01/22/13, revealed a reportable incident dated 11/19/12. The incident revealed on 11/18/12, Resident #47 was observed by a visitor to the facility, .to pat/rub Resident #34's thigh over her pants up to the middle or private area of her body. This visitor stated he/she felt this touching was conducted in an inappropriate manner, but could not confirm Resident #47 touched the private area of Resident #34. The facility conducted an investigation which entailed taking statements from staff members who were working at the time of the incident. None of the statements confirmed seeing Resident #47 doing anything inappropriate to Resident #34. Facility staff also completed a body audit of Resident #34 which revealed no signs or symptoms of abuse or neglect. The statements also revealed Resident #47 had never in the past exhibited sexually inappropriate behaviors with Resident #34, or any other resident. This allegation was immediately reported to the appropriate state agencies in accordance with state law. However, the facility could produce no evidence they reported the results of the investigation to the appropriate state agency within five (5) working days of the onset of the investigation as required by state law. Interview with Employee #73, the social worker, was conducted at 9:20 a.m. on 01/23/12. During this interview, Employee #73 stated she was… | 2016-02-01 |
| 9084 | 9084 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-02-21 | 241 | D | 1 | 0 | RESW11 | br>Based on random resident observation, medical record review, and staff interview , the facility failed to promote care for a resident in a manner and environment which enhanced and/or maintained the resident's dignity. One (1) resident was randomly observed wearing clothing which was labeled in an undignified manner. Resident Identifier: #16. Facility Census: 107. Findings include: a) Resident #16 During a random observation, conducted at 12:02 p.m. on 01/22/13, Resident #16 was observed wearing a pair of pants which were labeled with a white label sewn to the outside of the resident's pants with his nickname written on the white label in large black letters. An interview was conducted with Employee #119, the Nursing Home Administrator (NHA) at 2:30 p.m. on 01/22/13, regarding this resident. The NHA reported the resident's healthcare decision maker labeled his clothes in this manner, and most of his clothing contained the white patches sewn to the outside with the resident's nickname written on the patch. This statement was confirmed on 01/24/13 at 11:30 a.m., during an observation of the resident's clothing in his closet. The NHA was also present during this observation. Most of the resident's clothes were observed with a white patch sewn to the outside with his nickname written on the patch in large black letters. On 01/23/12 at 9:20 a.m., an interview was conducted with Employee #73, the master level social worker. She reported she had spoken to the family regarding this issue. This interview revealed the family labeled the clothes in this manner to ensure the resident could identify his clothing. A medical record review was completed at 10:30 a.m. on 01/23/13. This review revealed no documentation regarding the resident's family member labeling his clothes in an undignified manner. There was no evidence to suggest the facility had spoken to the family member regarding the issue. On 01/24/13 at 12:15 p.m., an interview was conducted with Employee # 18, the social worker for Resident #16. Employee # 18 repor… | 2016-02-01 |
| 9301 | 9301 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-01-17 | 441 | D | 1 | 0 | BKIB11 | br>Based on random observation, the facility failed to implement infection control practices to prevent, to the extent possible, the onset and spread of infection for one (1) resident who was on isolation. A bin, with a flat bottom, which contained the isolation supplies for this resident, was stored directly on the floor. Resident identifier: #33. Facility census: 68 Findings include: a) Resident #33 Random observations of the facility, on 01/15/13 at 12:55 p.m., revealed this resident was on isolation. A flat plastic bin, which contained isolation supplies, was stored directly on the floor in the hallway outside the resident's room. The bin had three (3) drawers. One (1) drawer contained isolation gowns, the next drawer contained isolation masks, and the next drawer contained shoe covers. An interview was conducted, on 01/15/13 at 1:05 p.m., with a physical therapy assistant (PTA). Upon inquiry, the PTA stated the resident had a positive nasal swab for the flu, and was on isolation. At 1:15 p.m. on 01/15/13, Employee #42, the director of nursing (DON) was questioned regarding the isolation bin in the hallway. The DON stated the isolation bin was supposed to be on a table off the floor. Upon viewing the bin on the floor, the DON agreed it was not an acceptable practice. She stated she would contact the infection control nurse, stating, She is new. Observation at 1:35 p.m. on 01/15/13 revealed the flat isolation bins outside the resident's room was on a metal cart and was covered with a sheet. | 2016-01-01 |
| 9318 | 9318 | GOLDEN LIVINGCENTER - GLASGOW | 515118 | PO BOX 350 | GLASGOW | WV | 25086 | 2012-12-12 | 253 | E | 1 | 0 | F0Z611 | br>Based on observations and staff interview, the facility failed to ensure housekeeping and/or maintenance provided services to maintain an interior environment in good repair. Throughout the facility, resident and ancillary doors bore numerous black markings. A wall in the Alzheimer's unit remained unpainted following repair and one (1) resident room contained visible rust above the heater/air conditioning unit. This had the potential to affect more than an isolated number of residents residing in the facility. Resident Identifiers: #75 and #78. Facility Census: 96. Findings include: a) During the initial tour, on 12/12/12 at 10:15 a.m., black markings were visualized on the lower half of numerous resident and ancillary doors. Large areas of the white protective panels on the doors were covered with black marks. On the upper half of the doors, there were large areas of chipped/peeling paint. On the east hall, there was a large area surrounding a hand sanitizer that was stained and had splatter marks. Several white patches were unpainted on the outside wall of the nursing station on the Alzheimer's unit. Grievance forms were reviewed on 12/12/12 at 10:45 a.m. Several complaints were reviewed regarding maintenance/cleanliness issues. These complaints were from September to the second week of November 2012. Two (2) grievances, made by employees, were regarding hallway cleanliness on the weekends. The reports stated housekeeping had to be called to mop and sweep hallways multiple times. One (1)grievance form was voiced for various residents concerning dirty bathrooms. Other grievance forms were related to dirty floors and painting of a resident room. The contracted housekeeping services supervisor, Employee #91, and the contracted housekeeping services district manager, Employee #101, were interviewed, at approximately 2:15 p.m. on 12/12/12. Employee #91 indicated the cleaning of the doors was a special project. Inquiry was made into the schedule of door cleaning. He reiterated this was a special project and stated… | 2015-12-01 |
| 9151 | 9151 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2013-02-14 | 280 | D | 1 | 0 | Z0GB11 | br>Based on observation, medical record review, and staff interviews, the facility failed to review and revise the care plan for Resident #20, as her ambulatory status changed in reference to her wandering. This practice affected one (1) of six (6) sample residents. Resident identifier: #20. Facility census: 103 Findings include: a) Resident #20 On 02/13/13 at 10:05 a.m., and on 02/14/13 at 9:45 a.m., Resident #20 was observed lying in bed. During the observation on 02/14/13, Employee #57 (RN) was present. She reported the resident was unable to get out of bed and required the assistance of two (2) health service workers and a Maxi lift when being transferred to a geri-chair. The resident's care plan was reviewed on 02/13/13. The care plan indicated the resident wandered into other residents' rooms and wandered the halls when up at night. This care plan was not revised to reflect the resident's current non-ambulatory status. On 02/14/13 at 10:25 a.m., interviews were conducted with Employees #91, the Director of Nursing (DON), and Employee #121, the Assistant Director of Nursing (ADON). Both confirmed the care plan had not been revised to reflect the current non-ambulatory status in regards to the resident's wandering. | 2016-02-01 |
| 9115 | 9115 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-02-12 | 441 | D | 1 | 0 | 8F5011 | br>Based on observation and staff interview, the facility failed to provide a sanitary environment to help prevent the development and transmission of infection. One (1) of seven (7) sample residents was observed with a Foley catheter bag and its opened drainage port, lying directly on the floor by his bed. Resident identifier: #18. Facility census: 73. Findings include: a) Resident #18 Observation on 02/11/13 at 7:41 a.m., found Resident #18 in his room, lying in the first bed closest to the door. Visible from the hallway was a Foley catheter urinary drainage bag lying directly on the floor by his bed, with the drainage port out of its holder, also lying directly on the floor. Observation of the hallway between 7:41 a.m. and 8:11 a.m. found twelve (12) different employees made a total of sixteen (16) trips past this resident's room, then back down the hall, without stopping to address the Foley drainage bag lying directly on the floor. These employees were comprised of nursing assistants, a ward clerk, and therapy staff. Also, a licensed nurse, Employee #48, passed this room, pushing her medication cart, while facing toward the resident's room, as she made her way to the end of the hall delivering medications to residents. Licensed nurse, Employee #91, was located at the end of the hallway, after pushing her medication cart past this resident's room, while delivering medications to residents on the other side of the hallway. On 02/11/13 at 8:11 a.m., Employee #91 was asked to look at the Foley drainage bag. She said typically the drainage bag was not placed directly onto the floor, and the open spout was not left open and touching the floor, as it was in this case. She said she would correct the situation. At the next observation, the Foley drainage bag was not touching the floor, and it was later found housed in a privacy bag that was also not touching the floor. This was reported to the administer on 02/11/13 at 6:00 p.m. She agreed it was facility policy not to allow the drainage bag to be in direct contact w… | 2016-02-01 |
| 9319 | 9319 | GOLDEN LIVINGCENTER - GLASGOW | 515118 | PO BOX 350 | GLASGOW | WV | 25086 | 2012-12-12 | 371 | D | 1 | 0 | F0Z611 | br>Based on observation and staff interview, the facility failed to properly dispose of expired food from a refrigerator in 1 (one) of 3 (three) sampled nourishment centers. As 2 (two) items of the 3 (three) which were found to be expired were labeled for specific residents, they had the potential to affect 2 (two) residents. While the third item was not labeled or dated, it had the potential to affect all residents who would receive any of this item from the refrigerator. Facility census: 96. Findings include: a) Observation of the West Wing nourishment center was completed at 10:40 a.m. on 12/12/12. There were 3 (three) findings as follows: 1) an open package of bologna, labeled with a resident's name, dated as opened on 12/04/12; 2) an open package of deli sliced turkey, labeled with a resident's name, dated as opened on 12/03/12. Both of these items were past the 7 (seven) day period for safe food storage; 3) a large plastic bottle of iced tea. The bottle was two-thirds empty with a large piece of ice in the bottle as well. This bottle was not labeled or dated. At 3:20 p.m. on 12/12/12, the West Wing nourishment center was again observed accompanied by the Assistant Director of Nursing (ADON), Employee #3. Employee #3 was shown the expired lunch meat items as well as the bottle of iced tea. Employee #3 expressed understanding and agreement the items needed to be thrown away. | 2015-12-01 |
| 9087 | 9087 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-02-21 | 441 | E | 1 | 0 | RESW11 | br>Based on observation and staff interview, the facility failed to maintain an environment free of the opportunity for the spread of infection. Housekeeping carts were stored in the resident bath/shower rooms. This practice was observed in two (2) of two (2) resident bath/shower rooms. This practice had the potential to affect more than an isolated number of residents. Facility Census: 107 Findings include: a) Initial tour of the facility was conducted at 11:30 a.m. on 01/22/13. Two (2) resident bathing/shower rooms were observed. The bathing/shower rooms were located in a main hallway where they could easily be accessed by residents. Two (2) housekeeping carts were stored in each of the two (2) bath/shower rooms. On the carts were used mops, cloths, and bags of trash. One housekeeping cart was pushed entirely into a resident shower stall in the first bath/shower room observed. Licensed Practical Nurse (LPN), Employee #95, observed the bath/shower rooms at 11:45 a.m. on 01/22/20. Employee #95 acknowledged the housekeeping carts should not be stored in the resident bath/shower rooms. She advised she was, going to get them now. The administrator, Employee #119, was advised of findings at 11:55 a.m. on 01/22/13 with expressed understanding. | 2016-02-01 |
| 9086 | 9086 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-02-21 | 323 | E | 1 | 0 | RESW11 | br>Based on observation and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible by not ensuring the residents did not have access to items that had the potential to result in harm to the residents. Two (2) of two (2) resident bath/shower rooms were accessible to residents. Plastic buckets containing used razors and large bottles of body wash/shampoo were accessible to any resident who entered these areas unattended. This practice had the potential to affect more than a limited number of residents. Facility Census: 107. Findings include: a) During the initial tour of the facility, conducted at 11:30 a.m. on 01/22/13, two (2) resident bath/shower rooms were observed. Both rooms were accessible to residents. Inside both shower/bath rooms, were large bottles of body wash/shampoo with press down pump dispensers. Also noted in each room was a five (5) gallon plastic bucket with a plastic snap-on lid. These buckets each had a large hole cut in the top, and each were 1/2 to 3/4 full of used razors. At 11:45 a.m. on 01/22/13, Licensed Practical Nurse (LPN), Employee #95, also observed the shower rooms. She was shown the safety concerns and confirmed the potential for accidents. The Administrator, Employee #119, was made aware of the findings and expressed understanding at 11:55 a.m. on 01/22/13. | 2016-02-01 |
| 9300 | 9300 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2013-01-17 | 225 | D | 1 | 0 | BKIB11 | br>Based on medical record review, facility policy review, and staff interview, the facility failed to investigate and/or report, to the appropriate State agencies, allegations which were potentially abuse or neglect for three (3) of eighteen (18) sample residents. Resident identifiers: #26, #69, and #34. Facility census 68 Findings include: a) Resident #26 Review of Grievance / Complaint Reports, at 10:00 a.m. on 01/16/13, revealed a report of an allegation of potential abuse/neglect received from the daughter of Resident #26 on 12/09/12. The daughter alleged the resident told her the aides had slammed her on the bed with the Hoyer lift. While there was an investigation into the allegation, and an explanation given to the resident's daughter, there was no evidence the allegation was reported to the Regional Ombudsman, Adult Protective Services (APS), or the Office of Health Facility Licensure and Certification (OHFLAC) in accordance with State requirements. In an interview with the director of nurses (DON) and the social worker (Employee #61), at 2:10 p.m. on 01/16/13, this allegation was reviewed. The DON confirmed the allegation was not reported to the above offices. She stated the facility discussed the allegation and decided it did not require reporting, although they did investigate the allegation. b) Resident #69 During a review of Grievance / Complaint Reports, at 10:00 a.m. on 01/16/13, a report of an allegation of potential verbal abuse made by Resident #69 was reviewed. The resident made a statement to the social worker (Employee #61) that on 11/10/12, her nurse had spoken to her inappropriately and was huffy and mad at her. The resident had described the entire incident. There was an investigation into the allegation, but there was no evidence the allegation was reported to the appropriate state agencies. This was confirmed, by the DON, during an interview at 2:10 p.m. on 01/16/13. She and Employee #61, who was present, stated the facility discussed the allegation and decided it did not require report… | 2016-01-01 |
| 9082 | 9082 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-02-21 | 157 | D | 1 | 0 | RESW11 | br>Based on medical record review, and staff interview the facility failed to notify the resident's healthcare decision maker of changes when there was a change of condition. One (1) of four (4) sampled residents had a change of condition in which the facility failed to promptly contact the resident's healthcare surrogate. Resident Identifier: #108. Facility Census: 107. Findings include: a) Resident #108: Medical record review, completed on 01/22/13 at 2:00 p.m., revealed a Health Care Surrogate (HCS) appointment which appointed Resident #108's daughter as his health care decision maker. The HCS appointment was completed on 06/08/10. Also contained in the medical record was a hand written note which read as follows: Call Daughter (the note identified the HCS by first name), with any issues. Some examples were listed in parentheses and included, Med refusals, shower refusals, low blood sugars, and med changes. The note further stated, Anything and Everything and FNP is to phone daughter after seeing the patient. The medical record for Resident #108 contained a change of condition form which was dated 12/26/12. The change of condition was related to the resident's blood sugar level being 32. The change of condition form was completed by Licensed Practical Nurse (LPN), Employee # 64. Employee #64 documented she contacted the physician, but there was no evidence Employee #64 notified the HCS of the change of condition at this time. Review of the medical record review also revealed another change of condition form completed by Employee #64 concerning Resident #108. This change of condition was completed related to the resident having a decrease in oxygen saturation and complaints of not being able to breath. Employee #64 contacted the physician and a new order was obtained for the resident to have oxygen at three (3) liters per minute. There was no evidence Employee #64 contacted the resident's HCS concerning this change of condition. An interview was conducted with Employee #64 on 01/23/13 at 8:00 a.m. During this i… | 2016-02-01 |
| 9152 | 9152 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2013-02-14 | 282 | D | 1 | 0 | Z0GB11 | br>Based on medical record review and staff interview, the facility failed to implement the care plan interventions for a resident who exhibited behaviors. A nurse documented one (1) episode of behaviors, then sent the resident to a local hospital without any evidence of implementation of the care plan interventions. This was true for one (1) of six (6) sample residents. Resident identifier: #24. Facility census: 103. Findings include: a) Resident #24 Review of the resident's current care plan, on 02/13/13, found the problem, Resident exhibits behavioral concerns, i.e. verbal and physical combativeness, as well as suicidal ideation statements. He wears a helmet for his safety and also exhibits agitation about wearing this. Resident has also began making threats to swallow items that will harm him, for example batteries, plastic, and water (the resident had a feeding tube and was not to drink water). The original date of this care plan was 02/27/12. The three (3) goals associated with this problem were: -- Resident will exhibit 0 episodes of physical/verbal aggression through the next review period. -- Resident will exhibit 0 instances of refusing / resisting care through the next review period. -- Resident will have 0 episodes of threatening self harm. The interventions associated with this care plan were: -- Resident will have a monitor to ensure resident's safety. -- Remove any items that resident may harm himself on. Any items containing batteries will be kept in a basket with the monitor for resident's safety. -- Document instances of resistance to care. -- If resident becomes agitated allow resident to discuss his frustrations. Respond to resident in a calm, reassuring manner when he discusses these frustrations. -- Resident will be observed when using sink in room due to threats of self harm. -- Report to physician / psychiatrist as appropriate when resident engages in episodes of self harm, or threatening I should just kill myself. Review of the nurses' notes found a note, dated 10/03/12, Resident crawling… | 2016-02-01 |
| 9157 | 9157 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2013-02-14 | 505 | D | 1 | 0 | Z0GB11 | br>Based on medical record review and staff interview, the facility failed to ensure the physician was notified of all lab results in a timely manner. This was found in one (1) of six (6) sample residents. Resident identifier: #55. Facility census: 103. Findings include: a) Resident #55 Review of medical records, on 02/13/12 at 10:00 a.m., found laboratory tests had been obtained for Resident #55 on 07/12/12 and 07/19/12. The physician was not notified of the results until 08/13/12. An interview, on 02/13/13 at 2:20 p.m., with Employee #113, the director of nursing (DON) and Employee #10, the administrator, confirmed that due to the changing of lab services, they had not received the results of the resident's ammonia levels, obtained on 07/12/12 and 07/19/12, until 08/13/12. | 2016-02-01 |
| 9156 | 9156 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2013-02-14 | 428 | D | 1 | 0 | Z0GB11 | br>Based on medical record review and staff interview, the facility failed to ensure the pharmacist's recommendations, reported during the monthly drug regimen review, were reported to the attending physician. This was true for one (1) of six (6) residents whose medical records were reviewed. Resident identifier: #19. Facility census: 103. Findings include: a) Resident #19 Review of the medical record found a pharmacy drug regimen review dated 08/27/12. The pharmacist's detailed description of irregularities and recommendations included: (name of resident is a new admission) Please consider the following labs to help monitor the adverse affects of his medications: [REDACTED] 1) Lipid profile and LFT (liver functioning test) now and every 6 months 2) Hga1c (hemoglobin-a1c which measures the average blood glucose control for the past 2 to 3 months) now and every 6 months. The report was acknowledged as received by Employee #113, a registered nurse. Employee #113 was interviewed on 02/13/13 at 11:00 a.m. She was unable to provide verification the physician had reviewed and responded to the pharmacists' report. | 2016-02-01 |
| 9158 | 9158 | JACKIE WITHROW HOSPITAL | 5.1e+110 | 105 SOUTH EISENHOWER DRIVE | BECKLEY | WV | 25801 | 2013-02-14 | 514 | E | 1 | 0 | Z0GB11 | br>Based on medical record review and staff interview, the facility failed to ensure residents' medical records contained accurate documentation. The behavior monitoring sheets, used to document resident behaviors and interventions, did not correlate with the information contained in the nurses' notes regarding the resident's behaviors. This practice occurred on numerous occasions for one (1) of six (6) residents whose medical records were reviewed. Resident identifiers: #24. Facility census: 103. Findings include: a) Resident #24 Review of a nurse's note, entered on 10/03/12 at 9:29 a.m., included Resident crawling around in floor of room. Very confused trying to crawl under bed. Playing in trash. Combative with staff. Further review of the behavior monitoring flow record, for 10/03/12, found the same nurse documented the resident had no behaviors on that shift. A nurse's note on 10/07/12 at 11:02 a.m. included, Resident refused breakfast this am (morning), refused bolus feeding, agitated with care, refused assistance from HSW (health service worker). This nurse re-attempted and he did allow me to provide hygiene care, although when I re-attempted to talk about a feeding he stated go to hell, leave me alone. Review of the behavioral monitoring flow sheet for 10/07/12 found the author of the nurse's note documented the resident had no behaviors on that shift. A nursing entry, dated 10/18/12 at 10:07 a.m., noted Resident very agitated, paranoid and aggressive this a.m. Review of the behavior monitoring flow record found the same nurse documented the resident had no behaviors on that shift. The administrator, Employee #10, and the assistant director of nursing, Employee #121 were interviewed on 02/12/13 at 11:30 a.m. The administrator verified the nurse's notes did not correlate with the behavior monitoring flow sheet. | 2016-02-01 |
| 9161 | 9161 | WAR MEMORIAL HOSP, D/P | 5.1e+151 | 1 HEALTHY WAY | BERKELEY SPRINGS | WV | 25411 | 2013-02-13 | 280 | D | 1 | 0 | 1G6H11 | br>Based on medical record record review and staff interview, the facility failed to revise a care plan for one (1) of five (5) sampled residents, to include additional activities and/or services to ensure optimal quality of life. Resident identifier: #1. Facility census: 14. Findings include: a) Resident #1 Review of a social service's progress note, dated 09/14/12, revealed the Medical Power of Attorney (MPOA) had asked about hospice services. The MPOA's goals for hospice services were to ensure more people visited the resident because the MPOA was not able to visit often. A social services progress note, dated 10/12/12, revealed the MPOA had met with the facility care plan team. An agreement was reached to have increased visits from pastoral care and volunteers in lieu of Hospice, related to the MPOA only wanting Hospice for increased visits. The current care plan included interventions to increase 1:1 visits with staff and activities, as the resident enjoyed 1:1 visits and conversation. According to the current care plan, he enjoyed 1:1 making over him, smiles, laughs and loves extra attention. The current care plan made no mention of increased visits from pastors and volunteers, as previously decided in the October 2012 care plan meeting. During an interview with the licensed social service manager, on 02/13/13 at 9:45 a.m., she said that Resident #1 receives pastoral visits from two (2) to four (4) times each month. She said that he does not have an assigned volunteer, but when volunteers visit during the week, they will visit with him 1:1. During an interview with the MDS (Minimum Data Set) coordinator/registered nurse, Employee #18, and the consultant administrator, on 02/13/13 at 4:00 p.m., they agreed there was not a care plan to have extra pastoral visits and volunteer visits. | 2016-02-01 |
| 9138 | 9138 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-02-06 | 497 | F | 1 | 0 | EVNT11 | br>Based on employee file reviews and staff interview, the facility failed to complete a performance review of every nurse aide at least once every 12 months. The performance evaluations are necessary to ensure deficient care practices are identified and appropriate in-service education is provided which addresses the identified areas of weakness. Twenty-one (21) of twenty-one (21) nurse aides currently employed by the facility had no performance evaluation. This practice had the potential to affect the care of all residents. Facility census: 54. Findings include: a) A review of all twenty-one (21) nurse aide employee files was conducted on 02/06/13 at 9:00 a.m. No evidence of any performance evaluations were found in any file for any nurse aide. During an interview with Employee #47, the Administrator, on 02/06/13 at 10:00 a.m., it was confirmed that no performance evaluations would be found in any nurse aides' file. The Administrator revealed the facility had not been completing performance evaluations for nurse aides. | 2016-02-01 |
| 9139 | 9139 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2013-02-06 | 498 | F | 1 | 0 | EVNT11 | br>Based on employee file review and staff interview, the facility was unable to provide evidence eighteen (18) of twenty-one (21) currently employed nurse aides were competent in the skills and techniques necessary to care for residents' needs, as identified through resident assessments, and as described in the plan of care. The competency of nurse aides is essential to ensure each resident receives optimum care and services. This practice had the potential to affect the care of all residents. Facility Census: 54. Findings include: a) A review of all nurse aide files was conducted on 02/06/13 at 9:00 a.m. Competency skills checklists were discovered for Employee #4, Employee #15, and Employee #57. All other nurse aide files did not contain competency skills checklists. During an interview with Employee #47, the Administrator, on 02/06/13 at 10:30 a.m., it was confirmed that no competency skills checklists were completed other than those for Employee #4, Employee #15, and Employee #57. | 2016-02-01 |
| 9171 | 9171 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-01-01 | 309 | D | 1 | 0 | 8XAM11 | br>Based on closed medical record review, review of the facility's policy and procedure for neurological assessment, review of incident reports, and staff interview, the facility failed to monitor and assess neurological vital signs in accordance with facility policy after a resident fell out of bed and hit her head on the floor. This affected one (1) of five (5) sample residents reviewed who fell and hit their heads. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 Review of incident reports revealed a report, dated 09/06/12 at 9:30 p.m., which described this resident had fallen. The report included, Resident sitting up on side of bed prior to fall. Aide heard resident fall to floor. Resident found on floor beside bed. Resident alert and states hit head. One bruise on forehead and another on eye and cheek of left side. Skin tear (deep) on left elbow. Floor free of clutter. Head placed a foot away from night stand and resident between bed and sink. Lying on back. Resident denies pain and sat up to be put back to bed. fell out of right side of bed (side facing door). No mats in place. Bed low. Review of Resident #111's neurological assessment flow sheet, revealed neurological checks were completed as follows: -09/06/12- 9:30 p.m.-completed -09/06/12- 9:45 p.m.- completed -09/06/12-10:00 p.m.- completed -09/06/12-10:15 p.m.- Out of facility to acute care facility for evaluation -09/07/12-completed- Back in facility from acute care facility -09/07/12- completed No further entries were noted on the form. A review of facility's policy and procedures for neurological assessment revealed the following: Policy- Neurological assessment will be performed as indicated or ordered. When a patient sustains an injury to the head and/or has an unwitnessed fall, neurological assessment will be performed: -every 30 minutes x two hours, then -every one hour x four hours, then -every four hours x 24 hours Purpose- To monitor patient for neurological compromise. An interview with Employee #126, the … | 2016-01-01 |
| 3406 | 3406 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 803 | E | 0 | 1 | 0LCE11 | b)Resident #43 During an interview on 01/28/19 at 11:30 AM, Resident #43 said his breakfast was and the portions were very small. He went on to say that he really like bacon, but only gets a half of a slice of bacon. During an interview and observation on 01/29/19 at 8:33 AM, Resident # 43 received his breakfast tray, which consisted of two (2) muffins and small scoop of scrambled eggs, no bacon which was on the menu to be served. Resident # 43 stated his food was not warm. During an interview on 01/29/19 at 2:30 PM, with Consultant Detain and Kitchen Manager # 28 they were asked about the portion sizes of bacon. The print out that was provided read that a regular diet was one (1) slice, and a large portion was two (2) slices. Consultant Detain stated that Resident #43 was to get a large portion. They were asked if they were aware that on 01/29/19 he did not get any bacon or any other meat in place of it. They did not provide any further information. The facility failed to follow the menu and/or provide an alternative to not serving a complete breakfast meal plan. Based on observation, resident interview, and staff interview, the facility failed to ensure that food was served per facility menus and in the correct portion sizes. This deficient practice had the potential to affect more than an isolated number of residents. Resident identifier: #43. Facility census: 108. Findings included: a) The Kitchen On 01/28/19 during dining observations, portion sizes appeared small. On 01/31/19 at 11:45 AM, an observation of the lunchtime tray line began in the kitchen. Cook #24 was observed placing a pair of tongs in a container of barbecue meat on the tray line. Cook #24 then began using the tongs to transfer the barbecue meat from the container to sandwich buns for service. Several observations of this tong use were completed and the serving size of the barbecue meat appeared to vary each time. Due to the use of the tongs, it was impossible to tell if each tray was receiving a full portion of the meat. On 01/31/19 at 11:50… | 2020-09-01 |
| 8597 | 8597 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2013-05-30 | 201 | D | 1 | 0 | BVS711 | The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; The health of individuals in the facility would otherwise be endangered; If transfer is due to a significant change in the resident's condition, but not an emergency requiring an immediate transfer, then prior to any action, the facility must conduct the appropriate assessment to determine if a new care plan would allow the facility to meet the resident's needs. (See ?483.20(b)(4)(iv), F274, for information concerning assessment upon significant change.) Refusal of treatment would not constitute grounds for transfer, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. Documentation of the transfer/discharge may be completed by a physician extender unless prohibited by State law or facility policy. Procedures: During closed record review, determine the reasons for transfer/discharge. o Do records document accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary interventions, accommodation of individual needs and attention to the resident's customary routines? o Did a physician document the record if residents were transferred because the health of individuals in the facility is endangered? o Do the records of residents transferred/discharged due to safety reasons reflect the process by which the facility concluded that in each instance transfer or discharge was necessary? Did the survey team observe residents with similar safety concerns in the facility? If so, determine differences between these residents and those who were transfer… | 2016-05-01 |
| 1794 | 1794 | ST. MARY'S HOSPITAL | 515113 | 2900 FIRST STREET | HUNTINGTON | WV | 25702 | 2018-05-09 | 640 | E | 0 | 1 | QVCY11 | The facility failed to transmit discharge tracking Minimum Data Set (MDS) assessments within 14 days of the residents' discharge. This was true for thirty-three (33) of thirty-three (33) of residents MDS discharge tracking's reviewed. Resident identifiers: #3, #4, #5, #6, #1, #7, #8, #9, #10, #11, #13, #12, #14, #15, #16, #18, #21, #22, #24, #20, #25, #19, #26, #27, #28, #29, #30, #31, #34, #33, #85, #101 and #23. Census: 13. Findings include: a) Discharge MDS tracking: Review of the medical records, on 05/08/18 at 9:15 a.m., found the following resident was discharged from the facility with no discharge MDS tracking completed: Residents' number (#) and discharge date as follows; #3-11/17/17, #4-11/18/17, #5-11/18/17, #6-11/22/17, #1-11/23/17, #7-11/23/17, #8-11/24/17, #9-11/26/17, #10-11/30/17, #11-12/02/17, #13-12/04/17, #12- 12/04/17, #14- 12/09/17, #15- 12/13/17, #16- 12/15/17, #18- 12/19/17, #21-12/21/17, #22-12/22/17, #24- 12/22/17, #20- 12/23/17, #25- 12/24/17, #19- 12/27/17, #26- 12/28/17, #27- 12/29/17, #28- 01/02/18, #29-01/03/18, #30- 01/05/18, #31- 01/06/18, #34-01/09/18, #33- 01/10/18, #85-03/25/18, #101- 04/14/18, and #23- 12/21/17. Review of the regulation found the facility within 7 days must encode the following information for each resident in the facility: a subset of items upon a resident's transfer, reentry, discharge, and death. Additionally, within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. Interview on 05/08/18 at 11:30 a.m., with the Director of Nursing (DON) and the MDS Coordinator, found the facility thought they did not have to do a discharge tracking MDS did not need to be completed. During this interview, all participants reviewed the regulation and found the facility was in error of not completing a MDS tracking and su… | 2020-09-01 |
| 8628 | 8628 | WAR MEMORIAL HOSP, D/P | 5.1e+151 | 1 HEALTHY WAY | BERKELEY SPRINGS | WV | 25411 | 2012-12-07 | 364 | E | 0 | 1 | L97I11 | The facility failed to provide pureed foods attractive in appearance. This was true for four (4) of nine (9) residents. Resident identifiers: Resident #1, #9, #6, #15. Facility census sixteen (16). Findings include: a.) During lunch on 12/3/12, two (2) residents were observed with pureed meals with food white in color and lacking any accent color with the meal. Resident identifiers #6 and #15. b.) When Breakfast was served to Resident #1 on 12/4/12 it was all white and shades of beige. c.) The lunch meal received by Residents #1 and #9 on 12/4/12 was also white and shades of beige. d.) On 12/5/12 Resident #9 was served a lunch that was all white and lacked any accent color. e.) The appearance of the meals was discussed with the DON at 3:00 p.m. on 12/5/12. The Dietary Manager and the Dietician at 8:00 a.m. on 12/7/12. | 2016-05-01 |
| 4302 | 4302 | BRIDGEPORT HEALTH CARE CENTER | 515194 | 1081 MAPLEWOOD DRIVE | BRIDGEPORT | WV | 26330 | 2016-11-11 | 253 | E | 0 | 1 | NH6O11 | The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for six (6) of 24 rooms observed during Stage 1 of the Quality Indicator Survey (QIS). Room identifiers: #3, #9, #16, #21, #27, and #31. Facility census: 42. Findings include: a) Observations during Stage 1 of the QIS noted the following cosmetic imperfections: --Observation of Room #3, at 11:00 a.m. on 11/08/16, found missing paint on the dresser drawers and the door frames leading into the bathroom and the main door leading into the room. The walls about one foot up from the floor was missing paint and the walls were observed to have deep scratches on them. --Observation of Room #9, at 3:17 p.m. on 11/08/16, found the over the bed table was leaning downward and was scratched and marred. --Observation of Room #16, at 2:44 p.m. on 11/08/16, found the wall behind the resident ' s recliner had deep scratches and the paint was missing exposing the dry wall. --Observation of Room #21, at 3:01 p.m. on 11/08/16, found the doors to the bathroom and the main door used to enter the room was scratched and the varnish was missing. The dresser drawers were also scratched and were missing paint. --Observation of Room #27, at 3:10 p.m. on 11/08/16, found were deep scratches on the closet door. --Observation of Room #31, at 3:04 p.m. on 11/08/16, found the door facing leading into the room and the door facing leading into the bathroom were scratched and missing paint. The closet door also had deep scratches. At 1:53 p.m. on 11/09/16, a tour was conducted with Employee #61, the corporate environmental coordinator and the Nursing Home Administrator. They confirmed the observed environmental/cosmetic imperfections were in need of repair. | 2020-02-01 |
| 2754 | 2754 | WYOMING NURSING AND REHABILITATION CENTER | 515164 | 236 WARRIOR WAY | NEW RICHMOND | WV | 24867 | 2018-08-01 | 686 | D | 0 | 1 | VC1411 | The facility failed to provide care and services to promote healing of pressure ulcers. For one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident identifier: #16. Facility census 54. Findings included: a) Resident #16 During an interview on 07/30/18 at 10:35 AM, Resident #16 stated he had a wound vac for a bed sore (pressure ulcer) on buttock. It was noticed he was lying on a pressure ulcer prevention mattress, OneCare Dolphin fluid Immersion Simulation. He was tilted to his left side facing the window. Review of records revealed the following: Pressure Ulcer #1 Left Lower Leg Newly Acquired 01/09/18, Risk factors Impaired mobility or transfer last Braden Score on 12/21/17, 15-18 mild risk. Stage II, length 2.0 centimeters (cm), width 1 cm, depth 0 cm. Resolved 04/25/18. Pressure Ulcer #2 right upper back newly acquired 02/04/18, Stage II, Length 3.8 cm Width 2.2 cm Depth 0.1 cm. Resolved on 02/21/18. Pressure Ulcer #3 right top of foot Newly Acquired 05/01/18, Stage II, Length 1.8 cm, Width 1.4 cm, Depth 0 cm, noted to resolve on 5/23/18. Pressure Ulcer #4 left buttock returned to facility with the Pressure ulcer on 04/28/17, Stage III, 3cm length, 3.5 cm width and 1. cm depth. -05/05/17, Stage III, 5.5 cm length, 3.5 cm width, 1 cm depth. -05/19/17, Unstageable, 5.5 cm length, 3.0 cm width, 1.3 cm depth. -06/06/17, Unstageable, 8 cm length, 4 cm width, 4 cm depth. -06/29/17, Unstageable, 6 cm length, 6 cm width, 4.4 cm depth. -07/06/17, Unstageable, 5 cm length, 7 cm width, 4 cm depth. -07/12/17, Unstageable, 8 cm length, 4.5 cm width, 3 cm depth. -07/19/17, Unstageable, 6.5 cm length, 6 cm width, 3 cm depth. -07/26/17, Unstageable, 7 cm length, 5.5 cm width, 2.8 cm depth. -08/02/17, Unstageable, 8.2 cm length, 5 cm width, 2.6 cm depth. -08/09/17, Stage IV, 8 cm length, 4.4 cm width, 3 cm depth. -08/16/17, Stage IV, 8.5 cm length, 5.5 cm width, 3.8 cm depth. -08/23/17, Stage IV, 8.2 cm length, 4 cm width, 3.8 cm depth. -08/30/17, Stage IV, 6 cm length, 7 cm width, 3.8 cm depth. … | 2020-09-01 |
| 7901 | 7901 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2013-12-31 | 204 | D | 1 | 0 | 6YCS11 | The facility failed to provide a safe and orderly discharge from the facility for one (1) of eleven (11) residents reviewed. A resident was transferred to an acute care hospital. The resident was provided a thirty (3) day involuntary discharge notice during the hospital stay. There was no evidence the facility actively assisted the resident and the family in selecting a new residence. Resident identifier: #115. Facility census: 114. Findings include: a) Resident #115 Review of the medical record on 12/31/13 at 2:00 p.m., revealed Resident #115 was transferred to an acute care hospital for a psychiatric evaluation on 12/03/13. The minimum data set (MDS), with an assessment reference date (ARD) of 12/03/13, indicated the resident was discharged with return anticipated. An interview with the family (Interviewee #2) on 12/31/13 at 2:30 p.m., revealed the facility provided them a thirty (30) day discharge notice dated 12/19/13. She said the facility refused to readmit Resident #115 and wanted to refer her to another psychiatric facility. She said one other option was given at a location over two (2) hours away. The family member said she asked the social worker to try to transfer Resident #115 to a facility in the surrounding area, and was told no one would take the resident. Further review of the medical record, on 12/31/13 at 3:00 p.m., revealed no evidence the family was provided information indicating the resident would not be allowed to return to the facility. Additionally, no evidence was present to indicate the facility had adequately attempted to facilitate the relocation of Resident #115. The social worker, Employee #55 , was interviewed on 12/31/13 at 12:15 p.m. She confirmed no referrals had been made to assist with relocation of the resident. She also confirmed no evidence was present to indicate the situation had been discussed with the family, prior to the hospitalization or during the course of the hospital stay. Employee #55 said she had called the power of attorney and discussed a referral to another … | 2016-12-01 |
| 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 |
| 3403 | 3403 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 761 | D | 0 | 1 | 0LCE11 | The facility failed to ensure medications used in the facility were labeled in accordance with currently accepted professional principles. Three (3) of three (3) of Resident #72's metered-dose inhaler medications were not labeled with the dates the inhalers were opened. Resident identifier: #72. Facility census: 108. Findings include: a) Resident #72 Morning medication pass was observed for Resident #72 on 01/30/19 at 7:20 AM. The medication pass was performed by Licensed Practical Nurse (LPN) #4. Resident #72 had orders for the following metered-dose inhaler medications: [REDACTED]. The Breo inhaler stated the inhaler should be discarded within six (6) weeks of opening. LPN #4 confirmed Resident #72's inhalers were not dated when opened. She stated facility practice was to date medication, including inhalers, with the date the medication was opened. During an interview on 01/30/19 at 11:19 AM, the Director of Nursing (DoN) was informed Resident #72's three (3) metered-dose inhaler medications were not dated to indicate when the inhalers were opened. The DoN had no additional information regarding the matter. | 2020-09-01 |
| 5537 | 5537 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2014-09-16 | 371 | F | 0 | 1 | 0EZS11 | The facility failed to ensure foods were prepared and distributed under sanitary conditions. Fans with lint and debris were in use in the kitchen and a metal paper towel holder was rusted, preventing proper sanitation of the holder. The use of unclean and/or defective equipment in the kitchen area had the potential to result in contamination of the food being prepared and served to residents. This had the potential to affect all residents receiving foods from the kitchen. Facility census: 97. Findings include: a) During the observation of food preparation and service in the kitchen at 4:45 p.m. on 09/15/14, there were two (2) auxiliary floor fans in use. One was near the door to the dietary office and one was across the room from the steam table where the food was located. The fan was directed towards the steam table. Both of the fans were dirty with debris and lint visible on the wire-like blade covers. There was also a metal paper-towel holder mounted adjacent to the handwashing sink in the kitchen. The holder opening for the towels to emerge through was rusted, which would not allow for thorough cleaning of the equipment. These observations were pointed out to the dietary manager who was present in the kitchen at that time. | 2018-10-01 |
| 3358 | 3358 | PRINCETON HEALTH CARE CENTER | 515187 | 315 COURTHOUSE RD. | PRINCETON | WV | 24740 | 2018-11-12 | 692 | D | 0 | 1 | 2C7711 | The facility failed to ensure Resident #60 was offered sufficient fluid intake to maintain proper hydration and health. Resident #60 consistently consumed less fluids than recommended by the dietician, and the facility failed to identify this and put interventions in place to prevent dehydration. This was true for one (1) of three (3) residents reviewed for the care area of hydration during the Long Term Care Survey Process. Resident Identifier: #60. Facility Census:115. Findings Include: a) Resident #60 An interview with Resident #60's caregiver at 11:00 a.m. on 11/05/18 when asked if she felt Resident #60 got plenty to drink she stated, She seems like she is always thirsty when I come to visit. She stated, I just gave her a glass of ice water and juice and she drank them all. She indicated, I don't know if she gets enough to drink or not. Observations of this residents room found there was no water pitcher available for the resident. Resident #60's caregiver indicated she is not able to give herself water anyway. She indicated, The staff will have to help her drink anything she gets. A review of Resident #60's medical record at 2:56 p.m. on 11/06/18 found a Nutritional Assessment completed by the licensed dietician on 09/04/18 which was the date Resident #60 was admitted to the facility. This nutritional assessment indicated Resident #60 needed 1730 milliliters of fluid each day to maintain her hydration status. A review of the fluid intake roster for Resident #60 from 09/04/18 through current found Resident #60 only met her fluid intake goal of 1730 MLs on the following occasions 09/07/18, 10/01/18, 10/02/18, 10/06/18, 10/16/18, 10/20/18, 10/21/18, 10/22/18, 10/24/18, 10/25/18 and 11/02/18. All other dates in the review period Resident #60 did not meet her recommended fluid intake. An interview with the Director of Nursing (DON) at 10:14 a.m. on 11/08/18 found the Certified Dietary Manager (CDM) usually reviews the fluid intake records and will put interventions in place if they are needed. She was not sure ho… | 2020-09-01 |
| 4233 | 4233 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2015-12-10 | 282 | D | 0 | 1 | X38Q11 | The facility did not ensure services were provided in accordance with each resident's plan of care. One (1) of three (3) residents reviewed for activities of daily living (ADLs) of sixteen (16) Stage 2 residents, did not receive encouragement to partcipate in her ADLs. Resident identifier: #74. Facility census: 89. Findings include: a) Resident #74 Review of the resident's care plan, on 12/08/15 at 3:58 p.m., found it identified the resident required assistance with activities of daily living (ADLs). The goal included, Resident will wash upper body daily with limited assistance through next review, dated 10/09/14. Interventions included: Encourage resident participation while providing appropriate ADL care; Identify self and expected tasks prior to beginning care; The care plan also indicated Resident #74 is physically able to assist with some ADL's, and Emphasize what this person can still do and encourage it daily, and Empower resident by involving in all aspects of care. On 12/09/2015 12:15 p.m., an interview with Nurse Aide (NA) #31, revealed Resident #74 never refused her showers, when offered. The NA related she had tried before to get the resident to wash herself, but said the resident, . forgets to wash some, so I shower her head to toe. The NA indicated the resident required total care because sheforgot to clean some parts of her body, and indicated Resident #74 did not participate as much as she was able. The NA said she washed the resident's upper body, though the resident was capable. The assistant director of nursing (ADON), interviewed on 12/10/15 at 4:45 p.m., reviewed the care plan and confirmed the care plan indicated staff should have encouraged the resident to participate in her care, and the care plan was not implemented correctly. | 2020-02-01 |
| 8306 | 8306 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2012-07-24 | 323 | F | 0 | 1 | TTVD11 | Part I Based on observation, staff interview, staff-assisted checks of facility water temperatures, review of the Guidance to Surveyors found in the State Operations Manual (SOM) published by the Centers for Medicare & Medicaid Services, and the West Virginia Nursing Home Licensure Rule, the facility failed to provide a resident environment as free of accident hazard as possible. Water temperatures were measured by the maintenance director, using the facility's thermometer, to be as high as 120 degrees Fahrenheit (F) at the hand sinks in various residents' rooms and a shower room sink. This had the potential to affect more than an isolated number of residents due to the potential for scalding/burn injuries, especially for independently mobile residents with cognitive impairment and/or decreased sensitivity to pain and extreme temperatures. Facility census: 52. Findings include: a) On 07/23/12 at 10:40 a.m., a surveyor informed the maintenance supervisor the hot water in resident sinks felt too hot to touch and requested the hot water temperatures be checked using a facility thermometer. A check of the hand sinks, on 07/23/12 between 10:50 a.m. and 11:10 a.m., located in the following resident rooms, found the excessively hot water temperatures registered as follows: Room #100 - 120 degrees F Room #105 - 120 degrees F Room #202 - 120 degrees F Room #211 - 120 degrees F Room #302 - 120 degrees F Room #313 - 120 degrees F Shower room on 200 Hall - 120 degrees F The maintenance supervisor stated he had been told by his predecessor the water temperatures were to be maintained between 115 and 120 degrees (F). He further stated he visually checked the water temperatures each day but had no written evidence of the temperatures. Information in the Guidance to Surveyors for this requirement, found in Appendix PP of the CMS State Operations Manual, revealed the following: Water Temp - Time Required for a 3rd Degree Burn to Occur 155 degrees F - 1 sec 148 degrees F - 2 sec 133 degrees F - 15 sec 127 degrees F - 1 min 124 deg… | 2016-07-01 |
| 9570 | 9570 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2011-07-14 | 225 | D | 0 | 1 | L3JB11 | Part I -- Based on review of the facility's patient / family concern forms, policy review, and staff interview, the facility failed to assure an allegation abuse / neglect was thoroughly investigated and immediately reported to other officials, including the State survey and certification agency, in accordance with State law. In addition, the facility allowed the alleged perpetrator to continue to work at the facility even though their resolution to the concern stated this employee would not be scheduled to work at the facility. This was true for one (1) of twenty (20) patient / family concern forms reviewed. Facility census: 114. Findings include: a) Review of the facility's patient / family concerns reports revealed a concern reported to a staff member on 06/03/11. On 06/03/11, an employee of the ambulance service reported the following: (Name of ambulance service employee) overheard a nurse, (name of nurse) interacting with the above resident. She states the (name of resident) was trying to tell (name of nurse) something and resident was stuttering. She states that the nurse told the resident to spit it out, I don't have time for you. Stated you need to get away. EMT (emergency medical technician) confronted nurse and told her that she didn't need to be rude. The staff member who recorded the concern also wrote: Spoke with EMT's partner, (name of partner). re. (regarding) incident. She states she cannot recall exactly what was said by the nurse but stated that it was basically - I don't have time to deal with you. She stated that the nurse was rude and disrespectful to the resident. Further review of the concern revealed the facility's steps to resolve the problem were: (Name of nurse) has not worked at (name of facility) since 05/20/11. Scheduling manager instructed not to utilize her services in the future. Review of the facility's abuse prohibition policy revealed: Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents o… | 2015-10-01 |
| 8777 | 8777 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2011-07-27 | 226 | E | 0 | 1 | WXEM11 | Part I -- Based on review of sampled employees' personnel files, staff interview, and policy review, the facility failed to develop policies and procedures to ensure reasonable efforts were taken, prior to hiring new employees, to uncover information about any past criminal prosecutions or findings of abuse / neglect that would indicate unfitness for service in a nursing facility. One (1) of ten (10) sampled employees resided in - and was licensed to practice nursing by another state. The facility's policy did not require the human resources personnel to complete a criminal background investigation of the individual in this other state (in an effort to uncover information about any past criminal prosecutions of this individual that may have occurred in that other state), nor did the policy require a check of the WV or the other state's Nurse Aide Registry and/or applicable professional licensing boards to ensure this individual had no findings of resident abuse / neglect. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #170. Facility census: 134. Findings include: a) Employee #170 A review of sampled employees' personnel files, with human resources personnel (Employee #16) on 07/25/11 at 3:00 p.m., found Employee #170 (a licensed practical nurse - LPN) was hired on 03/16/09. Review of this LPN's employment application revealed she lived in and had been licensed to practice nursing by another state. Further review of the LPN's personnel file found the facility failed to check both the WV Nurse Aide Registry and the Nurse Aide Registry in the individual's state of residence for findings of resident abuse / neglect before allowing the individual to come to work at the facility. On 07/27/11 at 10:35 a.m., the facility's administrator produced a policy titled Procedure for New Hires (not dated), which stated (quoted as typed): When an application is received and the applicant is deemed a potential hire, three references, written or verbal will be obtained. Afte… | 2016-03-01 |
| 11215 | 11215 | COLUMBIA ST. FRANCIS HOSPITAL | 515110 | 333 LAIDLEY STREET | CHARLESTON | WV | 25322 | 2009-06-18 | 225 | E | 1 | 0 | 1MWP11 | Part I -- Based on review of facility documents and staff interview, the facility failed to immediately report and thoroughly investigate two (2) allegations of abuse / neglect in accordance with State law. This deficient practice affected two (2) former residents. Resident identifiers: #10 and #11. Facility census: 8. Findings include: a) Resident #10 Review of facility documents found that, on 01/31/09, Resident #10 reported to facility staff he had an incontinence episode because staff did not answer his call light in a timely manner. Further review found no evidence the facility had reported this allegation of neglect to Adult Protective Services or the State survey and certification agency in accordance with State law. The facility documents concerning the allegation did not contain evidence that a thorough investigation was conducted. No statements were obtained from staff members present during the alleged incident, nor was there evidence to reflect the facility attempted to determine if corrective action was needed to prevent future incidents. Interview conducted with Employee #3, on the afternoon of 06/18/09, confirmed the facility could provide no evidence that this allegation of neglect was reported and thoroughly investigated in accordance with State law. b) Resident #11 Review of facility documents found that, on 01/07/09, Resident #11 reported to a facility staff member that a nurse had been rough with her. Further review found no evidence the facility had reported this allegation of neglect to Adult Protective Services or the State survey and certification agency in accordance with State law. Interview conducted with Employee #3, on the afternoon of 06/18/09, confirmed the facility could provide no evidence that this allegation of abuse was reported in accordance with State law. --- Part II -- Based on random observation, staff interview, review of the list of skilled unit employees provided by the facility, review of staffing assignment sheets, and review of sampled employee personnel files, the f… | 2014-07-01 |
| 9694 | 9694 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2010-01-07 | 225 | E | 0 | 1 | 9PJH11 | Part I -- Based on personnel file review and staff interview, the facility failed to obtain statewide criminal background checks for eight (8) of ten (10) sampled employees, and failed to obtain an out of state background check for one (1) employee who had lived and/or worked in another state for many years. Employee identifiers: #19, #12, #59, #39, #30, #7, #72, and #76. Facility census: 72. Findings include: a) Employees #19, #12, #59, #39, #30, #7, #72, and #76 During review of sampled personnel records 01/05/10 at 1:30 p.m., Employee #89 agreed the following eight (8) employees had no evidence of having had a statewide criminal background check through the West Virginia State Police: Employees #19, #12, #59, #39, #30, #7, #72, and #76. Employee #89 confirmed Employee #30 had no out of state criminal background check for another state in which he resided for many years. Employee #19 was a nursing assistant whose services were being obtained through a temporary staffing agency. Her personnel filed contained a card, dated 09/29/09, stating a criminal background check through the West Virginia State Police was in progress with no results. Employee #89 said she would call the agency to obtain results, but nothing more was heard on the subject. These findings were reported to the director of nursing and the administrator at 3:30 p.m. on 01/07/10. No further information was provided. --- Part II -- Based on review of the facility's complaint files and reported allegations of resident abuse / neglect, and staff interview, the facility failed to thoroughly investigate and/or report all allegations of resident abuse / neglect to State agencies as required. Four (4) of nineteen (19) Complaint / Grievance forms reviewed contained allegations of physical and/or verbal abuse, or neglect. Resident identifiers: #79, #78, #77, and #65. Facility census: 72. Findings include: a) Resident #79 1. A Complaint / Grievance form, dated as received on 01/12/09, included: Resident stated, 'The CNA (certified nursing assistant) emptied … | 2015-10-01 |
| 9454 | 9454 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2011-04-28 | 323 | D | 0 | 1 | UJUP11 | Part I -- Based on observation, medical record review, and staff interview, the facility failed to remove side rails from a resident's bed after the physician wrote an order to discontinue the side rails. This was true for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #82. Facility census: 124. Findings include: a) Resident #82 Observation, on 04/20/11 at approximately 2:35 p.m., found Resident #82 lying in bed with bilateral side rails in the up position. A gap measuring approximately 3 inches in width was observed between the mattress's edge and side rails. The acting director of nursing (DON - Employee #109) and the administrator (Employee #81) were summoned to view the resident's side rails. At approximately 3:30 p.m. on 04/20/11, the DON stated the resident had been re-evaluated and the side rails had been discontinued. Review of Resident #82's medical record found a nursing note, dated 02/09/11, stating: Received order to discontinue side rails due to they pose more of a risk than benefit and resident unable to use them on command. Review of the treatment administration record (TAR) revealed the order for the side rails was discontinued on 02/09/11. On 04/26/11 at approximately 5:30 p.m., the DON, when interviewed regarding the above findings, was unable to provide any additional information as to why the side rails were observed in use on the resident's bed on 04/20/11 when the side rails were discontinued by the physician on 02/09/11. --- Part II -- Based on observation and staff interview, the facility failed to ensure the resident's call light system was in good working condition. Observation revealed electrical wires were exposed in the call light in Room 110. Facility census: 124. Findings include: a) Room 110 On 04/20/11 at 2:20 p.m., observation of the interior of Room 110 on North hall, found the call light housing unit was observed pulled out of the wall with electrical wires exposed. On 04/20/11 at 2:25 p.m., a second surveyor verified this same observation - that the… | 2015-11-01 |
| 9287 | 9287 | WEBSTER NURSING AND REHABILITATION CENTER, LLC | 515165 | ERBACON ROAD, PO BOX 989 | COWEN | WV | 26206 | 2012-03-09 | 156 | C | 0 | 1 | LL6H11 | I. Based on the liability notice and beneficiary appeal review and staff interview, the facility failed to ensure three (3) of three (3) residents selected for review had received the appropriate notice when there was a termination of Medicare Part A services. Resident identifiers: #27, #28, and #64. Facility census: 55. Findings include: a) On 03/08/12, at approximately 10:00 a.m., the liability notice and beneficiary appeal review revealed three (3) of three (3) residents discharged from a Medicare Part A skilled service in the past six (6) months did not receive the appropriate notice when there was a termination of Medicare Part A services. Resident #27 received the notice of Medicare provider non-coverage (CMS - - Generic Expedited Determination Notice Fee For Service Beneficiary) on 01/17/12. At that point the facility felt Medicare probably would not continue to pay for her therapy due to her plateau in therapy progress. The facility did not provide the resident / responsible party with the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice - CMS - ). This resident / responsible party should have received this notice to inform the resident of potential financial liability since the resident still had benefit days. Resident #28 received the notice of Medicare provider non-coverage (CMS - - Generic Expedited Determination Notice) on 01/05/11. At that time the facility determined the resident no longer met the criteria for skilled nursing services. The resident / responsible party should have also received the SNFABN (CMS - ). Resident #64 received the notice of Medicare provide non-coverage (CMS - ) on 01/04/12. At that time the resident had used all of her available Medicare Part A days. The facility did not send the Notice of Exclusions from Medicare Benefits Skilled Nursing Facility (CMS - - NEMB - SNF). This notice should have been provided for technical details. The facility did not need to send the generic notice (CMS - ) because the resident had exhausted Medicare Part A benefits. On 03/08/1… | 2016-01-01 |
| 8756 | 8756 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2012-01-11 | 225 | D | 0 | 1 | K0ZK11 | I. Based on review of facility incident / accident reports, and staff interview, it was determined the facility failed to thoroughly investigate and report an injury of unknown origin and an incident of neglect. This was identified for two (2) of thirteen (13) incident / accident reports reviewed involving injuries. A report noted Resident #18 was placed on a bed pan at 5:00 a.m. on 08/30/11. The resident was found sleeping and still on the bed pan at 7:40 a.m. on 08/30/11. Another report included documentation Resident #93 was found with a bruise of unknown origin, below the right eye, after being seen by an ENT (ear, nose and throat) physician. There was no evidence of thorough investigations in effort to determine a perpetrator or cause, and the incidents were not reported to the State survey agency and other agencies as required by law. Resident identifiers: #18 and #93. Facility census: 141. Findings include: a) Resident #18 Review of incident/accident reports revealed, on 08/30/11 at 5:00 a.m., this resident was placed on a bed pan by staff. According to the report, the resident was not taken off the bed pan until 7:40 a.m., at which time she was noted to have a red mark on her left buttock from the bed pan. The incident report also noted the resident had been observed lying on her side with the bed pan full of urine under her. Further review found the resident had been alert. She had stated I don't remember everything but the girl left me on the bed pan and I fell asleep. It was discovered there was no investigation into this allegation of neglect in an effort to determine the perpetrator. There was no evidence this occurrence had been reported to the State survey and certification agency, or other State agencies as required. During an interview with the director of nursing, Employee #73, and the nursing home administrator, Employee #103, on 01/10/12 at 8:45 a.m., they agreed this incident should have been reported and further investigated as an allegation of neglect. b) Resident #93 During the review of i… | 2016-03-01 |
| 8267 | 8267 | RALEIGH CENTER | 515088 | PO BOX 741 | DANIELS | WV | 25832 | 2012-05-03 | 431 | E | 0 | 1 | POUN11 | I. Based on observation and staff interviews, the facility failed to ensure all opened vials of Purified Protein Derivative (PPD), used for tuberculin skin testing, and all opened vials of insulin, were discarded timely after opening. This was evident for one (1) partially used vial of PPD stored in the medication room refrigerator that had no date of opening, and for one (1) partially used vial of regular insulin on the B Hall medication cart that contained no date as to when it had first been opened. This had the potential to affect more than a limited number of residents. Facility census: 64. Findings include: a) Medication storage room Observation of the medication storage room, on 04/30/12 at 12:47 p.m., found there was one (1) partially used vial of Purified Protein Derivative (PPD), that had no date of opening. During an interview with a licensed nurse, Employee #87, at that time, she stated that once opened, the vial of PPD should have been discarded after 30 (thirty) days. She acknowledged there was no date of opening, and it could not be verified how long it had been since the vial had been opened. b) B Hall medication cart Observation of the B Hall medication cart, on 04/30/12, at approximately 1:00 p.m., found one (1) partially used vial of Humulin R insulin with no date of opening. Licensed nurse, Employee #87, said that most insulins are discarded after having been opened for 28 days. She agreed this vial had no date of opening, and it could not be verified how long it had been opened, or which resident it belonged to. During an interview with the Director of Nursing, on 05/03/12 at approximately 10:00 a.m., she said they discard opened vials of injectable medications at 30 (thirty) days after opening, although certain insulins may be stored a short while longer. She further stated that all vials of insulin, and other injectables, were to be dated when opened. II. Based on observation and staff interview, the facility failed to ensure the provision of a medication cart with a functional locking mech… | 2016-07-01 |
| 9095 | 9095 | GOLDEN LIVINGCENTER - GLASGOW | 515118 | PO BOX 350 | GLASGOW | WV | 25086 | 2011-11-16 | 253 | E | 0 | 1 | 8VFF11 | I. Based on observation and staff interview, the facility failed to assure housekeeping services were provided which maintained a sanitary environment for the residents. The floors in the resident rooms and hallways, on both the east and west wings of the facility, were visibly soiled. Dried feces was found on the wall next to the commode in one (1) resident room. The seat portion of the dining room chairs in the main dining room, in the activity room on the east wing of the facility, and in the dining / activity room on the Alzheimer's unit, were noted to have copious amounts of dark staining. This had the potential to affect more than an isolated number of residents residing in the facility. Facility census: 95. Findings include: a) During the initial tour of the facility, on the afternoon of 11/08/11, it was noted the seat portion of the chairs in the main dining room were covered with dark stains. The dining room chairs in the small dining room on the east wing, and in the Alzheimer's wing activity / dining room, were also noted to be covered with dark stains. Further observations noted the floors on the east and west wings of the facility were visibly soiled with dried substances. The floors in resident rooms 24, 126, 128, 115, 213, 129, 114, and 130 were noted to be soiled. The commode in room 133 had brown stained areas with a smear of dried brown substance noted on the wall next to the commode. An interview with the administrator, Employee #48, on 11/09/11 at 3:14 p.m., elicited the facility had contracted a local person to replace the upholstery on the dining room chairs in 01/11. That individual had not performed the work for which the facility had paid. The administrator could provide no evidence of attempts to replace the contractor. On 11/10/11 at 10:10 a.m., the housekeeping supervisor, Employee #90, was interviewed concerning the dirty floors in the facility. Employee #90 stated employees had called off on Saturday, Sunday, and Monday, leaving the housekeeping department short staffed. The facility… | 2016-02-01 |
| 11184 | 11184 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2009-05-20 | 465 | D | 1 | 0 | V0TW11 | Guidelines for Design and Construction of Health Care Facilities 2 Building Systems 2.1 Plumbing 2.1.1 General. Unless otherwise specified herein, all plumbing systems shall be designed and installed in accordance with the International Plumbing Code. 2.1.2 Plumbing and Other Piping Systems 2.1.2.1 Hot water systems. The following standards shall apply to hot water systems: *(1) Capacity. The water-heating system shall have sufficient supply capacity at the temperatures and amounts indicated in the applicable table. Storage of water at higher temperatures shall be permitted. (2) Hot water distribution systems serving patient/resident care areas shall be under constant recirculation to provide continuous hot water. This Standard is Not Met as evidenced by: Based on measured water temperatures, the facility failed to provide continuous hot water at the required temperatures indicated in Table 4.1-3 (95 - 110 degrees Fahrenheit (F)). Facility census: 28. Findings include: a) At approximately 10:50 a.m. on 05/19/09, hot water temperature was measured in the sink serving resident room #630. The hot water temperature at this sink was measured to be 65.9 degrees F after heavily flowing water for four (4) minutes. The hot water temperature at a second sink serving the Ante-room portion of this resident room was measured at 66.0 degrees F initially and rose to 108.0 degrees F after three (3) minutes. The hot water temperature of the first sink was re-measured and found to be 108 degrees F. To conclude, a time frame of seven (7) minutes was required to obtain an acceptable hot water temperature and continuous hot water is not provided. As such, the comfort of the resident is compromised. . | 2014-07-01 |
| 269 | 269 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2018-03-14 | 804 | E | 0 | 1 | YXUB11 | Facility failed to provide palatable, attractive and appetizing and proper temperature of food with complaints from 12 anonymous residents. This failed practice had the potential to affect more than a limited number of residents. Facility census: 56. Finding included: a) Anonymous resident statements, from resident council and resident interviews Statements from random residents during resident interviews and resident council meeting. --The bread is always dry like it's been frozen. --Food is cold and mashed potatoes everyday sometimes twice a day --Too many potatoes --The food is either over cooked or under cooked, potatoes every day, the bread is always dried out. --Sometimes I don't even know what the food is. --Today the chicken and dumplings were cold. --They run out of things a lot, the orange juice don't even taste like juice, the vegetables are either over cooked or under cooked. We have told them in resident council, several of us we don't like that old black gravy on everything. --We have a lot of chicken with fancy names, but it ain't good. Sundays pork chop was so tough you can't cut it. --I eat in my room and the food is cold even though it is in a warmer. --I couldn't eat my lunch dried up lima beans and old chicken again. We all agree that we don't like that old brown goo stuff on our food. My meat needs to be cooked good and done. The chicken and dumplings only had 1 piece of meat in it the size of my finger the rest was dough. b) Temperature check on test tray, On 03/13/18 at 11:28 AM, trays arrived on the floor for the Short hall. Many staff members arrive to dispatch trays. They were asked to get a temperature on the last tray to be served on this food cart. Food Service Manager #20 arrived on the floor with thermometer on 03/13/18 at 11:39 AM, to check temperatures of a test tray. Roast beef 108 degrees Fahrenheit. Food Service Manager #20 agreed the temperature of the roast beef was not high enough to meet safe and palatable standards. c) Interviews with Food Service Manager (FSM) and Adminis… | 2020-09-01 |
| 495 | 495 | ST. JOSEPH'S HOSPITAL | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2018-05-09 | 867 | F | 0 | 1 | VZPJ11 | Deficiency Text Not Available | 2020-09-01 |
| 727 | 727 | HILLTOP CENTER | 515061 | 152 SADDLESHOP ROAD | HILLTOP | WV | 25855 | 2018-08-30 | 772 | D | 0 | 1 | T9WW12 | Deficiency Text Not Available | 2020-09-01 |
| 2028 | 2028 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2018-02-06 | 641 | D | 1 | 0 | 3TSK12 | Deficiency Text Not Available | 2020-09-01 |
| 3034 | 3034 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2018-09-13 | 550 | D | 0 | 1 | GTWI11 | Deficiency Text Not Available | 2020-09-01 |
| 3035 | 3035 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2018-09-13 | 558 | D | 0 | 1 | GTWI11 | Deficiency Text Not Available | 2020-09-01 |
| 3036 | 3036 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2018-09-13 | 584 | D | 0 | 1 | GTWI11 | Deficiency Text Not Available | 2020-09-01 |
| 3037 | 3037 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2018-09-13 | 641 | D | 0 | 1 | GTWI11 | Deficiency Text Not Available | 2020-09-01 |
| 3038 | 3038 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2018-09-13 | 656 | D | 0 | 1 | GTWI11 | Deficiency Text Not Available | 2020-09-01 |
| 3039 | 3039 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2018-09-13 | 684 | D | 0 | 1 | GTWI11 | Deficiency Text Not Available | 2020-09-01 |
| 3040 | 3040 | CARE HAVEN CENTER | 515178 | 2720 CHARLES TOWN ROAD | MARTINSBURG | WV | 25401 | 2018-09-13 | 690 | D | 0 | 1 | GTWI11 | Deficiency Text Not Available | 2020-09-01 |
| 3622 | 3622 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 881 | E | 0 | 1 | HHMR12 | Deficiency Text Not Available | 2020-09-01 |
| 3749 | 3749 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2018-09-21 | 609 | D | 1 | 0 | PCJU12 | Deficiency Text Not Available | 2020-09-01 |
| 3754 | 3754 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2018-09-21 | 835 | D | 1 | 0 | PCJU12 | Deficiency Text Not Available | 2020-09-01 |
| 5724 | 5724 | WORTHINGTON HEALTHCARE CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2015-08-20 | 501 | D | 1 | 0 | 34HG11 | Deficiency Text Not Available | 2018-08-01 |
| 5780 | 5780 | GREENBRIER HEALTH CARE CENTER | 515185 | 1115 MAPLEWOOD AVENUE | LEWISBURG | WV | 24901 | 2015-08-05 | 225 | D | 1 | 0 | 5S9P11 | Deficiency Text Not Available | 2018-08-01 |
| 5784 | 5784 | GREENBRIER HEALTH CARE CENTER | 515185 | 1115 MAPLEWOOD AVENUE | LEWISBURG | WV | 24901 | 2015-08-05 | 441 | D | 1 | 0 | 5S9P11 | Deficiency Text Not Available | 2018-08-01 |
| 5854 | 5854 | ST. MARY'S HOSPITAL | 515113 | 2900 FIRST STREET | HUNTINGTON | WV | 25702 | 2015-01-09 | 329 | D | 0 | 1 | RXZ912 | Deficiency Text Not Available | 2018-07-01 |
| 5856 | 5856 | ST. MARY'S HOSPITAL | 515113 | 2900 FIRST STREET | HUNTINGTON | WV | 25702 | 2015-01-09 | 428 | D | 0 | 1 | RXZ912 | Deficiency Text Not Available | 2018-07-01 |
| 6018 | 6018 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-08-14 | 309 | D | 0 | 1 | K1XR12 | Deficiency Text Not Available | 2018-05-01 |
| 6593 | 6593 | E.A. HAWSE NURSING AND REHABILITATION CENTER | 515173 | 18086 STATE ROUTE 55 | BAKER | WV | 26801 | 2016-09-14 | 272 | D | 0 | 1 | ZHIW11 | Deficiency Text Not Available | 2018-01-01 |
| 6923 | 6923 | SALEM CENTER | 515071 | 255 SUNBRIDGE DRIVE | SALEM | WV | 26426 | 2014-10-22 | 431 | E | 1 | 0 | 134X11 | Deficiency Text Not Available | 2017-10-01 |
| 7163 | 7163 | WORTHINGTON NURSING AND REHABILITATION CENTER | 515047 | 2675 36TH STREET | PARKERSBURG | WV | 26104 | 2014-07-30 | 282 | G | 1 | 0 | 7S3H11 | Deficiency Text Not Available | 2017-07-01 |
| 8092 | 8092 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2013-10-30 | 323 | G | 1 | 0 | 47GE11 | Deficiency Text Not Available | 2016-10-01 |
| 8093 | 8093 | MEADOWBROOK ACRES | 515134 | 2149 GREENBRIER STREET | CHARLESTON | WV | 25311 | 2013-10-30 | 353 | G | 1 | 0 | 47GE11 | Deficiency Text Not Available | 2016-10-01 |
| 8852 | 8852 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2013-03-21 | 323 | G | 1 | 0 | SM2B11 | Deficiency Text Not Available | 2016-03-01 |
| 9085 | 9085 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-02-21 | 309 | J | 1 | 0 | RESW11 | Deficiency Text Not Available | 2016-02-01 |
| 9116 | 9116 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2011-09-22 | 156 | E | 0 | 1 | REFP12 | Deficiency Text Not Available | 2016-02-01 |
| 9273 | 9273 | MANSFIELD PLACE | 515129 | PO BOX 930 | PHILIPPI | WV | 26416 | 2015-02-10 | 317 | G | 0 | 1 | 8Z8911 | Deficiency Text Not Available | 2016-01-01 |
| 9343 | 9343 | PRINCETON CENTER LLC | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2011-06-30 | 327 | G | 0 | 1 | QU2H12 | Deficiency Text Not Available | 2015-11-01 |
| 10480 | 10480 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2009-08-26 | 252 | E | 0 | 1 | O8DH11 | Bases on observations and staff interview, the facility failed to provide a common shower bathing area that was clean. This has the potential to affect all residents on the 200 hallway who use this shower room. Facility census: 57. Findings include: a) Observations, on 08/24/09 at 11:45 a.m. and again at 3:30 p.m., revealed the shower room on the 200 hallway was not clean. The toilet was observed to have rust, feces, and urine stains in the toilet bowl and on the toilet seat. The tub was noted to have visible dirt, debris, stains, and a plastic razor blade cover and a plastic can cover in the bottom of the tub. Observations, on 08/25/09 at 9:45 a.m., revealed the shower room on the 200 hallway was again not clean. The toilet was observed to have rust, feces, and urine stains in the toilet bowl and on the toilet seat. The tub was noted to have visible dirt, debris, stains and a plastic razor blade cover and a plastic can cover in the bottom of the tub. The housekeeper (Employee #48), when interviewed on 08/25/09 at 9:45 a.m., reported the tub was broken and not in use. The housekeeper, who acknowledged being responsible for cleaning the 200 shower room area, reported having cleaned the toilet in the 200 shower room between 1:30 p.m. and 3:00 p.m. on 08/24/09. The 200 shower room was subsequently at 12:40 p.m. on 08/25/09. At that time, the tub and toilet were cleaned and free from stains. . | 2015-03-01 |
| 1713 | 1713 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2018-06-07 | 583 | C | 0 | 1 | 2KKW11 | Based upon the resident group meeting, staff interview and review of facility documents, the facility failed to ensure the residents' right to promptly receive mail, except when there is no regularly scheduled postal delivery and pick-up service. Promptly as defined within the regulation, means: delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service. This had the potential to affect all the resident of the facility. Facility census: 67. Findings included: a) During a group meeting with seven (7) members of the facility resident council on 6/5/17 at 11:00 AM, The group said they did not receive mail on Saturdays. When asked if they had been given a reason for this, they said they had not, they just figured there was no one there on Saturdays to deliver it. b) The Activities Director, #40, who facilitates monthly Resident Council Meetings, was interviewed on 6/7/18 at 11:47 AM. She was asked about residents getting their mail on Saturdays. She said they did not. She said right after she had started working at the facility as Activities Director, about two (2) years ago, the former Administrator told her she had called the Post Office and canceled Saturday deliveries to the facility. c) Review of the Activities Calendars on 6/5/18 at 12:00 PM, it was found there was a notice on the calendars stating Mail delivered Monday thru Friday. d) During an interview on 6/5/18 at 3:00 PM, the Director of Nursing (DON), #77, confirmed the Saturday mail delivery had been canceled by the former Administrator about two years ago. e) Facility Administrator, #60 said on 6/5/18 at 4:00 PM he had contacted the Post Office and Saturday mail delivery would resume on 6/9/18. | 2020-09-01 |
| 3968 | 3968 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 244 | E | 0 | 1 | 25Q611 | Based upon review of resident council meeting minutes, review of complaints and grievances, and staff interview, the facility failed to consider the views of a resident or family group and act promptly upon the grievances voiced by the Resident Council concerning issues of resident care and life in the facility. The facility was not able to demonstrate its responses and rationale for such responses. This had the potential to affect more than a limited number of residents residing in the facility. Facility census: 115. Findings include: a) Review of the Resident Council Meeting Minutes for the previous six (6) months on 06/21/17 at 4:00 p.m. found the record of the meetings began with a form called Resident Council Quality of Life Assessment - Group Interview. For some of the months, the form had two (2) pages, and for others, there were three (3). Not all the issues had responses noted. For those that did, some negative responses were found as follows: -- For the 06/05/17 meeting, for the question, Does the group have input into the rules of the facility? the response was No, because they always give you reason for the rules. The question Does the facility listen to your suggestions? was answered Sometimes. The question Are there places you can go when you want to be with other residents? was answered Not really, need more places. -- For the 05/05/17 meeting, for the question Does the group have input into the rules of the facility? the response was No. The question Does the facility listen to your suggestions? was answered Sometimes. The question Are there places you can go when you want to be with other residents? was answered No. The question Are the temperatures of your foods ok? was answered Sometimes. The question How did staff react? (to a voiced grievance/concern) was answered They listened, but it depends on who it is. -- For the (MONTH) (YEAR) meeting (no specific date was on the minutes), for the question Does the group have input into the rules of the facility? the response was No. The question Are me… | 2020-04-01 |
| 10042 | 10042 | PENDLETON MANOR INC | 515124 | 68 GOOD SAMARITAN DRIVE | FRANKLIN | WV | 26807 | 2009-11-04 | 225 | D | 0 | 1 | FWJG11 | Based upon review of personnel records and staff interview, the facility failed to implement procedures to screen employees for prevention of abuse and neglect, by failing to check appropriate licensing boards and/or registries. This was found for two (2) of ten (10) sampled employees, who were hire within the past twelve (12) months. Employee identifiers: #132 and #19. Facility census: 84. Findings include: a) Employee #132 Review of the personnel record of Employee #132 (the facility's director of nursing), on the afternoon of 11/02/09, revealed she began working at the facility on 12/08/08. There was no evidence that either the West Virginia Board of Examiners for Registered Professional Nurses or the West Virginia Nurse Aide Registry had been checked for findings of resident abuse or neglect that would indicate the employee was unfit for service in a nursing facility. b) Employee #19 Review of the personnel record of Employee #19 (a nursing assistant), on the afternoon of 11/03/09, revealed she had started working on 09/08/09. There was no evidence that the West Virginia Nurse Aide Registry had been checked for findings of abuse or neglect prior to 09/23/09. c) During an interview with the Person in Charge (Employee #107) on 11/04/09 at 11:35 a.m., she confirmed that there was no available verification to reflect these individuals had been properly screened prior to working with facility residents. . | 2015-07-01 |
| 1987 | 1987 | WELLSBURG CENTER | 515123 | 70 VALLEY HAVEN DR | WELLSBURG | WV | 26070 | 2017-09-14 | 249 | E | 0 | 1 | 7HYJ11 | Based upon review of licenses, registrations, and certifications of facility personnel and staff interview, the facility's activity program was not being directed by a qualified professional who was licensed by the state in which they practiced. This had the potential to affect more than a limited number of residents. Facility census: 55. Findings include: a) Copies of current license, registration, and/or certification, as applicable, of the Administrator, Director of Nursing, Social Worker, Activity Director, and Dietary Manager were requested upon entrance on 09/11/17. These documents were provided on 09/13/17 at 9:50 a.m. by Administrator #38. When the documents were provided, there was no certification for the Activities Director. Administrator 338 said Activities Director, #52, was not certified. Administrator #38 said the Certified Activities Director had resigned, and the Acting Director had not yet fully completed the tasks to become certified. | 2020-09-01 |
| 3763 | 3763 | HOPEMONT HOSPITAL | 5.1e+149 | 150 HOPEMONT DRIVE | TERRA ALTA | WV | 26764 | 2017-11-02 | 361 | F | 0 | 1 | 1EPD11 | Based upon review of licenses and certifications and staff interview, the facility failed to employ a food service supervisor with the appropriate competencies and skills to carry out the functions of the food and nutrition service and, in States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers. This has the potential to affect all residents. Facility census: 57. Findings include: a) Review of managers' licenses and certifications on 10/30/17 at 2:00 p.m. found the document provided for the food service supervisor, #18 was for the completion of the Dietary Manger Training Course for Pre-Certification on 5/17/17. b) Facility Administrator, #80, was asked on 10/31/17 at 11:00 if the food service supervisor was a Certified Dietary Manager. He replied she was. c) The food service supervisor #18 was asked on 10/31/17 at 2:00 p.m. if she was certified. She said she was not. She said she had completed the course required to take the examination and she was waiting for the facility to get the examination scheduled. She said the Registered Dietitian visited on a consultant basis weekly. d) West Virginia State Long Term Care Regulation N824 specifies (typed as written): A dietary manager shall be employed if a dietitian is not employed full-time and shall be one of the following: A dietetic technician, registered by the Academy of Nutrition and Dietetics; A certified dietary manager, as certified by the Association of Nutrition and Foodservice Professionals; A graduate of an associate or baccalaureate degree program in foods and nutrition or food service management; or a person enrolled in an approved program to become a certified dietary manager within 60 days of accepting responsibility for the position. This person shall successfully complete the program within the specific timeframes outlined by the enrolled program and shall successfully pass the Certified Dietary Manager (CDM) examination within no more than two month… | 2020-09-01 |
| 8562 | 8562 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2012-05-21 | 225 | E | 0 | 1 | ZPPW11 | Based upon review of facility personnel records and staff interview, the facility failed to complete a thorough investigation of past histories for two (2) of five (5) agency staff prior to allowing them to work at the facility. A state wide criminal background check, as required by State law, was not completed for these agency personnel. Employee identifiers: #71 and #72. This practice had the potential to affect more than an isolated number of residents. Facility census: 54. Findings include: a) Personnel records were reviewed on 05/17/12 at 11:30 a.m. Five (5) records of employees hired within the past four (4) months and five (5) records of staff supplied under contract from an outside staffing agency were reviewed. The review included verifying that required criminal background checks and nurse aide registry checks had been completed prior to staff working with residents in the facility. There was no evidence of statewide criminal background checks for two (2) agency personnel. One was licensed practical nurse (LPN), Employee #72, the other was nursing assistant (NA), Employee #71. These individuals' files had checks done by a commercial online vendor, but no statewide West Virginia State Police check was found. During an interview on 05/21/12 at 11:00 am, the administrator, Employee #42, concurred that although the two (2) individuals had been providing care to residents, the required checks were not available. | 2016-05-01 |
| 3965 | 3965 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2017-06-30 | 161 | E | 0 | 1 | 25Q611 | Based upon review of facility documents and staff interview, the facility failed to have an approved surety bond to ensure the security of the residents' personal funds. This failed practice had the potential to affect one-hundred-six (106) residents having personal funds deposited in the care of the facility, and so had the potential to affect more than a limited number of residents. Facility census: 115. Findings include: a) The review of the facility's surety bond began on 06/28/17 at 9:30 a.m. A copy of the surety bond had been requested upon entrance. The facility provided a certificate listing the names of persons appointed as attorneys-in-fact to act to provide surety up to an amount of $2,000,000.00. There was no mention of the facility or its relationship to all or any portion of the amount specified. Clarification was requested from the Administrator on 06/28/17 at 10:00 a.m. She provided a second document entitled continuation certificate which stated a bond was in force in the amount of $76,000.00 for the facility's resident funds account for the period from 07/01/17 to 07/01/18. An approval of the bond, or a continuation approval of the facility's bond, by the West Virginia Attorney General was requested from the Administrator. She said the facility did not have such a document. She offered to contact the Office of Health Facility Licensure and Certification, the agency which facilitates the process of obtaining the required approval documentation of West Virginia nursing facilities from the Attorney General's office to find out the status of the facility's surety bond. She reported there was no approved surety bond in effect as required by statute due to the fact the bond was not submitted by the parent corporation in accordance with the provisions of the law. | 2020-04-01 |
| 6085 | 6085 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 247 | E | 0 | 1 | ZW4411 | Based upon resident interview, staff interview, policy review, and record review, the facility had no evidence that notice was given before the resident's room or roommate in the facility was changed. This was found for one (1) of 35 residents reviewed in the Quality Indicator Survey sample, and for three (3) randomly reviewed residents who had room changes in December 2013 or January 2014. Resident identifiers: #58, #109, #148, and #141. Facility census: 100. Findings include: a) Review of facility's policy and procedure for room change notification was on 01/13/14 at 3:00 p.m. The Social Services manual stated Notify patients and responsible parties, as directed, about changes such as room or roommate changes. and Notify the patient or responsible responsible party of the change, the reason for the change, and respond to questions. b) The Social worker (agency), Employee #44, was interviewed on 01/14/14 at 12:19 p.m. She said that social workers do notifications of room/roommate changes when they are aware of them, but the notifications were also done by admissions and by nursing. She was asked where the notification would be documented. She said that social workers document the notification as a progress note in the electronic medical record. She felt that admissions and nursing probably did so as well, but could not say for sure. The Administrator, Employee #120, was interviewed on 01/14/14 at 12:40 p.m. She said she thought there was a form designed for documentation of room/roommate change notification. She was asked to provide a list of room/roommate changes for the past two (2) months. c) The list was provided on 01/14/13 at 1:40 p.m. The Administrator said that although notice of room/roommate changes may have been provided, admissions staff and/or nursing were not always documenting that notice was given. d) Resident #58 said during an interview on 01/07/14 at 10:23 a.m., that she was never notified of a room change in October 2013. Review of the records found no evidence that any notice was ever given.… | 2018-05-01 |
| 2834 | 2834 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2019-11-20 | 657 | D | 0 | 1 | Z38K11 | Based upon resident interview, staff interview, and record review, the facility failed to provide notice to a resident regarding the resident's care plan meeting. This was true for one (1) of twenty-three (23) residents care plan reviewed. Resident identifier: #57. Facility census: 127. Findings include: a) Resident #57 During an interview on 11/19/19 at 8:34 AM, Resident #57 stated that he guesses that he attends care plan meetings. Resident #57's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/01/19 noted the resident had a score of Brief Interview for Mental Status (BIMS) of 15. A BIMS score of 15 is the highest score and indicates that the resident is cognitively intact and has capacity. A record review revealed two care plan meeting notes dated 02/08/19 and 02/25/19. The care plan note for 02/08/19, revealed Resident #57's sister was in attendance. The care plan note for 02/25/19 revealed that the resident was present for the care plan meeting. A record review noted the following: -- Nurse's Note 3/5/19 17:43 - Resident was seen on this date 3/5/2019 and was evaluated by (PHYSICIAN NAME), Psychologist who found him to have capacity to make his own medial decisions. A review of Resident #57's care plan history noted that the care plan had updates the following dates: -- 10/8/2019 -- 7/10/2019 -- 4/10/2019 -- 1/15/2019 On 11/21/119 at 8:50 AM, Employee #208, Registered Nurse / Clinical Reimbursement Coordinator (RN / CRC), stated that the care plan meeting schedule is given to the receptionist to send out the invitations to the resident / family / responsible party. On 11/21/19 at 9:03 AM, Employee #79, Receptionist, stated that she delivered the care plan invitations to the residents who had capacity. Employee #79 could not find the copy of the letter for the care plan meeting in (MONTH) 2019. A review of the Careplan review schedule for (MONTH) 2019 noted the care plan meeting for Resident #57 was scheduled for Monday, 10/07/19. On 11/21/19 at 10:06 AM, RN #208 stated that she could not … | 2020-09-01 |
| 10019 | 10019 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2009-10-15 | 520 | E | 0 | 1 | 5DR211 | Based upon record review, staff interview, and policy review, the facility's quality assessment and assurance (QAA) process failed to recognize that resident incidents / accidents were not being properly investigated to assure appropriate follow-up, in accordance with facility policy. This was determined for seventeen (17) of eighty-three (83) incident / accident reports reviewed. Resident identifiers: #7, #11, #12, #15, #17, #30 (two (2) occurrences), #54 (two (2) occurrences), #66 (two (2) occurrences), #78, #82, #88, #96, #97, and #98. Facility census: 92. Findings include: a) A review of the facility "Resident / Patient Incident Report" forms, on 10/15/09 at 11:00 a.m., revealed the reports for Residents #7, #11, #12, #15, #17, #30 (two (2) occurrences), #54 (two (2) occurrences), #66 (two (2) occurrences), #78, #82, #88, #96, #97, and #98 did not have "Incident / Accident Investigation" forms completed as instructed on that form, which stated: "Complete this form in conjunction with the 'Resident / Patient Incident Report' for injuries of known or unknown origin, allegations of abuse or neglect, resident-to-resident incidents, elopements, or any other incident determined to need investigation." Further instruction was found within the facility policy "1.1 Accidents / Incidents" under Section 4, "Documentation and Investigative Action: 4.1 The staff member must document the incident on the Investigation of Incident form and conduct an immediate investigation of the accident or incident." All of these incident reports were signed by the facility's director of nursing and the administrator, indicating their review of the incidents. b) During an interview on 10/15/09 at 11:30 a.m., the administrator (Employee #54), who was a member of the facility's QAA committee, indicated that all incident reports were discussed routinely at every monthly quality assurance meeting as part of "Core Data" that was always on the agenda. The purpose of this quality assurance review was to assure appropriate follow-up, to identify … | 2015-07-01 |
| 10550 | 10550 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2009-10-22 | 225 | D | 0 | 1 | 938011 | Based upon record review, staff interview, and policy review, the facility failed to follow its policy and procedure to ensure allegations of abuse / neglect and/or injuries of unknown source were being properly investigated. This was noted for one (1) of thirteen (13) residents reviewed. Resident identifier: #36. Facility census: 65. Findings include: a) Resident #36 1. A review of the facility's incident reports, conducted on 10/21/09 at 10:40 a.m., revealed an incident report for Resident #36 dated 10/13/09, in which the section of the form headed "Describe exactly what happened ..." contained the following descriptive narrative: "During resident care CNA (certified nursing assistant) observed dark purple bruise to right thigh 3 cm x 2 cm." There was no documentation of how the bruising occurred. Under the section of the form headed "Additional comments and/or steps taken to prevent recurrence" was: "Reapproach resident when she is resistent to care." The report was signed by the facility's administrator (Employee #77) on 10/19/09, and director of nursing (DON - Employee #1) on 10/13/09. 2. A review of the facility's policy and procedure entitled "Abuse Prohibition Policy", conducted on 10/21/09 at 11:00 a.m., found included under the heading "Process": "6. Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse, and determine the direction of the investigation." "7. Upon receiving information concerning a report of abuse, the Administrator or designee will: "7.1 Report it to appropriate agencies as per state requirement and conduct an immediate and thorough investigation. "7.1.1. The investigation will be documented on any state required form, and on CareHaven of Pleasants' investigation form and log. "7.1.2. The form and log will be kept confidential in a file in the Administrator's office. "7.1.3. The investigation will include signed statements from perpetrator, witnesses, and all concerned." 3. A review of facility-provided cases of… | 2015-02-01 |
| 1772 | 1772 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2018-07-12 | 655 | F | 0 | 1 | 3KXQ11 | Based upon record review, staff interview and resident interview, the facility failed to provide the resident or their representative with a written summary of the baseline care plan within 48 hours of admission. This was found for residents #80, #11, #32, #35, #15, #20, #37, and #3, and had the potential to affect all residents in the facility. Census: 30. Findings included: a) Resident #11 Resident #11 was admitted in the month of (MONTH) (YEAR). She is acting as her own responsible party. During an interview on 7/10/18 at 10:00 AM, Resident #11 was asked if the facility had met with her within forty-eight hours of her admission to discuss her care needs and plan the care and services to be provided during her stay, and the desired goals of those services. She said they had not. b) Resident #15 Resident #15 was admitted to the facility in the month of (MONTH) (YEAR). She is acting as her own responsible party. Resident #15 was interviewed on 7/10/18 at 9:19 AM. She was asked if her care needs and the facility's plan to meet them were discussed within 48 hours of her admission, and if she was provided with a written summary of the discussion. She said could not recall discussing or receiving any written copy of a plan regarding her care needs, the care and services to be provided during her stay, or the desired goals of those services. c) Resident #32 Resident #32 was interviewed on 7/10/18 at 9:36 AM. She said she could not recall discussing or receiving any written copy of a plan regarding her care needs, the care and services to be provided during her stay, or the desired goals of those services. d) Resident #35 Resident #35 was interviewed on 7/10/18 at 10:15 AM, and he also said he could not recall discussing or receiving any written copy of a plan regarding his care needs, the care and services to be provided during his stay, or the desired goals of those services. e) Staff Interview The Director of Nursing, Registered Nurse #39, was interviewed on 7/10/18 at 3:30 PM. She said the facility does not furnish… | 2020-09-01 |
| 6933 | 6933 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-10-16 | 353 | F | 1 | 0 | TXTJ11 | Based upon record review, review of staffing postings, staffing assignment sheets, nursing schedules, payroll records, assessed care needs, staff interviews, family interviews, and resident interviews, the facility failed to consistently ensure sufficient nursing staff across all shifts to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. This deficient practice had the potential to affect all residents living in the facility. Facility census: 88. Findings include: a) Complaints received by the Office of Health Facility Licensure and Certification (OHFLAC) led to an on site investigation into allegations, including allegations of insufficient staff to provide needed care during some shifts in August, September, and October 2014. These complaints received by OHFLAC identified some specific shifts when staffing was alleged to be insufficient, and review of the facility's complaint files and abuse/neglect reporting files on 10/06/14 at 9:30 a.m., found additional complaints and allegations related to staffing, delays in care, and neglect. Resident, family, and staff interviews during the investigation of these concerns resulted in additional staffing concerns and other specific dates when insufficient staffing was alleged. The following were sampled for detailed investigation: 1) It was alleged on the 08/29/14 day shift, there were only four (4) nursing assistants working in the facility to care for 87 residents. 2) It was alleged on the 09/08/14 day shift, there were only four (4) nursing assistants working in the facility to care for 86 residents. 3) It was alleged on the 10/03/14 night shift, there was only one (1) nursing assistant working in the facility on the Jackson Court wing to care for 42 of the facility's 89 residents. 4) It was alleged on the 10/03/14 night shift there were only two (2) aides working in the facility on the Nutter Fort Court … | 2017-10-01 |
| 6097 | 6097 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 493 | F | 0 | 1 | ZW4411 | Based upon record review, review of facility policy and procedure, and staff interviews the governing body, and designated administrator, failed to ensure policies regarding the management and operation of the facility were established and implemented. The facility failed to effectively maintain and operationalize policies and procedures. This had the potential to affect all residents. Facility census: 100. Findings include: a) The facility's failure to fully operationalize and maintain effective policies and procedures resulted in deficient practices being cited related to employee screening for abuse prevention. Review of thirteen (13) employees ' personnel files found the files did not contain all State required information, such as signed job descriptions, verification of current license/registration, evidence the nurse aide abuse registry and been checked to make sure the individual was not listed, etc. Three (3) of the thirteen (Employees #40, #119, and #49 did not have evidence of a statewide criminal background check. b) The facility failed to ensure allegations of abuse/neglect were identified, investigated, and reported to the appropriate administrative personnel and State agencies. The facility did not identify the staff member responsible for initiating the reporting process. Seven (7) of forty-three allegations of abuse/neglect were not thoroughly investigated and/or reported. (Resident identifiers: #50, #148, #111, #47, #27, #71, and #25.) c) Following the discovery of the lack of facility specific policies and procedures for abuse/neglect prohibition, a discussion was held with administrator, Employee # 120 on 01/20/14 at 9:00 a.m. She said the corporate owner of the facility had policies and procedures, which were available on the Internet, and these policies and procedures were revised and updated by corporate personnel as needed. There was no evidence that the facility itself had adopted them or that the medical director, administrator, director of nursing, or other department heads had read, re… | 2018-05-01 |
| 5201 | 5201 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2014-09-24 | 247 | E | 0 | 1 | PSV811 | Based upon record review, policy review, resident interview, and staff interview, the facility failed to ensure all residents received notice before getting a new roommate. This was found for two (2) of thirty (30) sample residents sampled residents and two (2) randomly selected residents. Resident identifiers: #40, #66, #36, and #46. Facility census: 60. Findings include: a) Resident #40 In an interview on 09/17/14 at 10:18 a.m., the resident said she has had different roommates, one passed away. She said she does not know she is getting a new roommate until she sees them coming in her room. Review of her medical record, beginning on 09/18/14 at 11:42 a.m., found her Brief Interview for Mental Status (BIMS) score, as assessed on 09/13/14, was 15, indicating she was cognitively intact. She was determined by her physician to possess the capacity to make informed medical decisions and she acted as her own responsible party. Her care plan, dated 09/26/12, included, she doesn't deal well with change. Interventions implemented for this concern included, When a change in routine occurs, explain to resident what is happening and why. The review found a newly admitted resident was placed in the vacant bed in Resident #40's room on 08/30/14. There was no evidence indicating Resident #40 was given any notice prior to getting the new roommate. b) Resident #66 In an interview on 09/17/14 at 10:40 a.m., Resident #66 said she got a new roommate a month ago. Her previous roommate was gone, and a new one was just moved in without notice. Review of her medical record, beginning on 09/18/14 at 11:42 a.m., noted her Brief Interview for Mental Status (BIMS) score, as assessed on 09/5/14, was 15, indicating she was cognitively intact. She was determined by her physician to possess the capacity to make informed medical decisions and acted as her own responsible party. Her care plan, dated 09/11/14, included that she .exhibits psychosocial distress about own well-being and or social relationships The review found a newly admitted resid… | 2019-03-01 |
| 3616 | 3616 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 835 | F | 0 | 1 | HHMR11 | Based upon record review, policy review, and staff interview, the facility was not administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility did not have a Medication Regimen Review policy in place that gave specific instruction regarding urgent recommendations or specific time frames for all the different steps in the process including physician responses. The facility was not providing all aspects of an influenza immunization program as required. These deficient practices had the potential to affect all residents. Facility census: 87 Findings include: a) Deficient practice was cited during the survey for failure to develop an adequate policy and procedure for Medication Regimen Review as required by Federal Regulation. The facility did not have a Medication Regimen Review policy in place that gave specific instruction regarding urgent recommendations or specific time frames for all the different steps in the process including physician responses. b) Deficient practice was cited during the survey for failure to provide all aspects of an influenza immunization program as required. The facility failed to educate each resident and/or their legal representative on the pertinent information regarding immunizations such as the benefits and potential side effects of the influenza vaccine prior to administering the vaccine during the current (YEAR)-2017 flu season. This was found for five (5) of five (5) residents reviewed during the annual Long Term Care Survey Process. Review of the medical records for Residents #20, #14, #84, #18, and #10, on 12/05/17 at 1:30 p.m., revealed all five (5) medical records lacked documentation indicating the residents and/or their legal representatives received current education regarding the benefits and potential side effects of the influenza vaccine prior to administration during the current flu season. Residents #20, #14, #18, and … | 2020-09-01 |
| 3617 | 3617 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 838 | F | 0 | 1 | HHMR11 | Based upon record review, policy review, and staff interview, the facility failed to develop a Facility Assessment that gave consideration the of physical environment interventions to protect residents from identified wanderers with potential to enter other residents' rooms. The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require. This deficient practice had the potential to affect all residents. Facility census: 87. Findings include: a) Deficient practice was cited during the survey for failure to consider any physical environment interventions to protect residents from identified wanderers with potential to enter other residents' rooms, such as stop signs or wander alarms. During an interview on 12/6/17 at 3:00 p.m., Social Worker #7 was unable to identify any environmental interventions in place or under consideration to prevent or discourage wanderers from entering other residents' rooms. b) During an interview on 12/06/17 at 3:00 p.m., Social Worker #7 was unable to describe any systematic assessment process to determine adequate deployment of staff to effectively monitor and redirect identified wanderers. c) The Facility Assessment developed by the facility was reviewed on 12/06/17 at 4:00 p.m. The document identified seventy-seven (77) residents had behavioral health needs. There was no identification of the risk presented by identified wandering residents with behaviors. When asked how many residents exhibited wandering behaviors, the Activity Director, #30, said We have eighty-six (86) residents in the facility so we have eighty-six (86) wanderers. The staffing section of the facility Assessment simply identified the current budgeted staffing levels without any recognition or consideration of the needs of the current population including identified wanderers with behavioral health issues and resulting instances of abuse discovered during the current survey. | 2020-09-01 |
| 4716 | 4716 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2016-04-06 | 492 | D | 0 | 1 | TULX11 | Based upon record review and staff interview, the facility failed to operate and provide services in compliance with all applicable State laws, regulations, and codes. One (1) of ten (10) personnel files did not have license verification for a nurse. Facility census: 92. Findings include: a) Review of ten (10) personnel files on 03/28/16 at 1:30 p.m., found one (1) of the files did not contain a verification of a current professional license for Licensed Practical Nurse #13. During an interview on 03/31/16 at 11:25 a.m., Human Resources/Payroll Manager #78 confirmed the personnel files did not contain all information required by West Virginia State Code Title 64 Series 13. | 2019-08-01 |
| 7999 | 7999 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2013-11-21 | 514 | D | 1 | 0 | G1FX11 | Based upon record review and staff interview, the facility failed to maintain clinical records that could provide accurate documentation of implementation of the plan of care and the services provided to ensure adequate hydration for a dependent resident. This was found for one (1) of three (3) residents reviewed. Resident identifier: #1. Facility census: 95. Findings included: a) Resident #1 The facility was entered on 11/19/13 at 4:55 a.m. A general tour of the entire facility was immediately undertaken. Information was requested from administrator, Employee #117 regarding residents ordered thickened liquids. Upon review, on 11/19/13 at 9:41 a.m., it was found three (3) residents were ordered thickened liquids. These residents were #1, #56, and #87. Resident #56 had documentation that fluids were offered on the night of 11/18/13 - 11/19/13 at 22:18 (10:18 p.m.) and at 10:36 a.m. Resident #87 had documentation that fluids were offered on the night of 11/18/13 - 11/19/13 at 6:18 a.m. and 1:47 a.m. There was no field found in the electronic medical record (EMR) for the nursing assistants to document that fluids were provided to Resident #1. The resident's care plan included (typed as written): Potential for skin breakdown, inadequate oral intake, and weight loss r/t (related to) . and limited mobility, swallowing difficulty AEB (as evidenced by) chart and pt interview/review, and puree with spoon thick liquids. Date Initiated: 3/2/2011 Created on: 3/2/2011 Revision on: 8/28/2012. The facility administrator, Employee #117 was interviewed on 11/19/13 at 10:47 a.m. She said that based upon her care plan, her expectations for Resident #1 would be that fluids would be offered with meals and between meals on all shifts due to her inability to hydrate herself or effectively ask for fluids. She acknowledged there was currently no method in the EMR (electronic medical record) to permit the nursing staff to document when they provided Resident #1 with fluids by spoon feeding thickened liquids in between meals and at night. … | 2016-11-01 |
| 3613 | 3613 | NELLA'S INC | 51A010 | 499 FERGUSON ROAD | ELKINS | WV | 26241 | 2017-12-07 | 756 | E | 0 | 1 | HHMR11 | Based upon record review and staff interview, the facility failed to develop a policy and procedure for Medication Regimen Review (MRR) that gave all specific time frames and expectations for communication of urgent concerns and for timeliness of physician's responses. This had the potential to affect all residents. Facility census: 87. Findings include: a) The facility's policies for Medication Regimen Review were reviewed on 12/7/17 at 8:30 a.m. They were dated 11/2011. There was no specificity regarding urgent recommendations or specific time frames for all the different steps in the process including physician responses. There was a statement regarding urgent communication under section B saying in the event of a problem requiring immediate attention, the physician would be contacted by the consultant pharmacist or the facility. There was also a statement under section H that said When pharmacist is reviewing resident chart and notice that a medication need to be change immediately he will inform the nurse . These two sections did not reflect consistent procedure. During an interview with Director of Nursing #8 on 12/7/17 at 9:40 a.m., she expressed understanding the policy related to MRR was dated 2011, and did not contain the aforementioned detail. A telephone conversation was conducted with Pharmacy Representative #102, for the company contracted by the facility on 12/7/17 at 9:50 a.m. He said the company was finalizing the new policy to reflect the new regulations which was anticipated to be released in (MONTH) (YEAR). | 2020-09-01 |
| 6959 | 6959 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2013-06-25 | 492 | F | 0 | 1 | WVZU11 | Based upon record review and staff interview, the facility failed to comply with with State of West Virginia Hospital Licensure, Code 64CSR12, which requires that the governing authority appoint a full time hospital administrator and that if there is a nursing facility unit with more than sixty (60) resident beds, the governing body shall also appoint a qualified administrator who holds a current valid license or emergency permit issued by the West Virginia Nursing Home Administrator's Licensing Board. This had the potential to result in harm to more than a minimal number of residents. Facility census: 59. Findings include: a) Review of entrance documents and interview with acting administrator, employee #3, on 6/20/13 at 4:00 p.m. found that he was acting as both the full time hospital administrator and as the administrator of the seventy-six (76) bed long term care unit under an emergency permit. He said that the former long term care administrator had quit on 4/19/13, and the position had been vacant for the last two (2) months. He said the vacancy had been advertised, and some applications received, but no applicants had been interviewed or considered. State of West Virginia Hospital Licensure, Code 64CSR12 requires that the governing authority appoint a full time hospital administrator and that if there is a nursing facility unit with more than sixty (60) resident beds, the governing body shall also appoint a qualified administrator who holds a current valid license or emergency permit issued by the West Virginia Nursing Home Administrator's Licensing Board. The hospital administrator voiced understanding that Hospital licensure rules prohibit him from serving in both positions concurrently. | 2017-09-01 |
| 6096 | 6096 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 492 | F | 0 | 1 | ZW4411 | Based upon record review and staff interview conducted for each specific citation, the facility failed to operate and provide services in compliance with all applicable State and local laws, regulations, and codes. There were multiple deficient practices cited for failure to comply with West Virginia Nursing Home Licensure Rule 64CSR13. This had the potential to affect all residents. Facility census: 100. Findings include: a) The facility failed to develop and maintain written policies and procedures, and failed to ensure the policies and procedures were effectively operationalized by the facility as required by 64-13-10.3.d. The facility had not implemented policies and procedures regarding the investigation and reporting of allegations of abuse and neglect. b) The facility failed to maintain personnel files containing all required information as required by 64-13-11.6.a-i. Personnel files did not contain reference verifications, signed job descriptions, verification of current licenses, evidence of criminal background checks, evidence the abuse registry had been checked, and/or evaluations of work performance. c) The facility failed to have a written disaster and emergency preparedness plan that had been approved by the director as required by 64-13-9.11.b. | 2018-05-01 |
| 1656 | 1656 | GLENVILLE CENTER | 515103 | 111 FAIRGROUND ROAD | GLENVILLE | WV | 26351 | 2018-05-17 | 867 | F | 0 | 1 | 2ID911 | Based upon policy review, staff interview, and review of systemic deficient practices being cited during the survey, the facility failed to maintain an effective Quality Assurance program. The facility had not fully implemented an antibiotic stewardship program as required by federal regulations. This deficient practice had the potential to affect all residents. Facility census: 58. Findings included: a) The facility's policy and procedure for the Quality Improvement and Assurance Committee was reviewed on 05/16/18 at 12:50 PM. Included under the committee's activities was that the committee would assess, evaluate, and identify potential improvement opportunities based upon the results and activities of the Infection Prevention and Control System. b) During an interview with Infection control coordinator #69 on 05/16/18 at 9:00 AM, she acknowledged the program had not been implemented and that it should have involved the QAA committee. c) During an interview with the QAA coordinator, Administrator #56 on 05/16/18 at 3:00 PM, she acknowledged the QAA Committee was aware of and involved in the rollout of regulatory changes and should have taken the lead in the implementation of the Antibiotic Stewardship program. | 2020-09-01 |
| 3666 | 3666 | NELLA'S NURSING HOME | 5.1e+35 | 200 WHITMAN AVENUE, CRYSTAL SPRINGS | ELKINS | WV | 26241 | 2018-07-19 | 867 | F | 0 | 1 | 7LQW11 | Based upon policy review, staff interview, and review of deficient practices identified during the survey, the facility failed to maintain an effective Quality Assurance Committee to develop and implement appropriate plans to correct identified quality deficiencies and coordinate the facility's required implementation of all regulatory changes. This had the potential to affect all residents residing in the facility. Facility census: 69. Findings included: a) The current survey found the facility failed to fully implement an antibiotic stewardship program as required by Federal regulations. b) An interview was conducted with the Director of Nursing, Registered Nurse #69 on 7/19/18 at 8:56 AM. He was identified as the person responsible for Quality Assurance. He provided the plan manual, meeting schedules and the participation members for each committee and sub committee. It was stated in the plan he provided the committee is responsible for establishing policies and procedures for the facility, including the Infection Control Policies and Procedures. It was also stated the Committee is responsible to review and implement regulatory requirements. It was discussed that the facility has not fully implemented the antibiotic stewardship program required by recent regulatory changes. He agreed the Quality Assurance Committee for the facility would have responsibility for the planning and implementation of new regulatory requirements such as Antibiotic Stewardship. | 2020-09-01 |
| 1280 | 1280 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2018-10-03 | 867 | F | 0 | 1 | GY7L11 | Based upon policy review, record review, and staff interview, the facility failed to maintain an effective Quality Assurance Committee to develop and implement appropriate plans to correct identified quality deficiencies and coordinate the facility's required implementation of all regulatory changes. The recent requirement to develop a Baseline Care Plan within 48 hours of admission had not been fully implemented, and deficiencies were cited with the facility's Infection Control Program, which has also been cited during each of the last three previous annual surveys. This had the potential to affect all residents residing in the facility. Facility census: 95. Findings include: a) During an interview with the facility's Administrator on 10/02/18 at 3:00 PM, he confirmed, as stated in the Quality Assurance and Performance (QAPI) Policy and Procedure, the QAPI Committee met at least ten months a year. The required members attend, including the Medical Director, the Consultant Pharmacist, and the Infection Control and Prevention Officer. He confirmed the Committee was charged to develop and implement appropriate plans to correct all identified quality deficiencies, including items identified as the result of annual inspection surveys. He specified some items that were designated high risk and were a permanent agenda item for review at every meeting, such as falls, antipsychotic medications, employee turnover, re-hospitalization s, abuse/neglect/grievances, and Infection Control. The Administrator also confirmed one of the functions of the committee was to develop plans to ensure all changes in Long Term Care regulations were recognized and implemented fully and effectively in the facility. b) He had acknowledged earlier, on 09/26/18 at 2:10 PM, the facility had not fully implemented Federal regulatory changes that became effective on 11/28/17 requiring completion of Baseline Care Plans within forty-eight (48) hours of admission, which was cited during the current survey. c) Deficient practices were identified for the… | 2020-09-01 |
| 6098 | 6098 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 496 | E | 0 | 1 | ZW4411 | Based upon personnel file review and staff interview, the facility failed to ensure it had received registry verification that an individual met competency evaluation requirements before allowing an individual to serve as a nurse aide. This was found for two (2) of twenty (20) personnel records reviewed. This had the potential to affect more than a limited number of residents. Employee Identifiers: #37 and #93. Facility census: 100. Findings include: a) Ten (10) personnel files were reviewed on 01/13/14 at 10:00 a.m. The review found the facility failed to obtain registry verification for Employee #37 to ensure the individual met competency evaluation requirements before allowing the employee to serve as a nurse aide. b) During an interview with human resources director, Employee #40, on 01/13/13 at 11:00 a.m., she confirmed that the facility failed to obtain the required registry verification. c) An additional sample of ten (10) nursing assistants' personnel files was chosen at random to supplement the sample for an extended survey. These records were reviewed for registry verification on 01/20/14 at 1:00 p.m. The review found the facility failed to obtain registry verification that Employee #93 met the competency evaluation requirements before allowing the individual to serve as a nurse aide. | 2018-05-01 |
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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 );