Inspection Reports for Nella’s at Autumn Lake Healthcare
499 ferguson road, WV, 26241
Back to Facility ProfileDeficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 10, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with Federal and State Life Safety Code requirements and the Facility Emergency Preparedness Plan.
Findings
The facility was found to be without waivers and in compliance with all Federal and State Life Safety Code requirements as well as the Facility Emergency Preparedness Plan.
Inspection Report
Annual Inspection
Census: 21
Deficiencies: 0
May 20, 2025
Visit Reason
An onsite revisit for the annual recertification, annual relicensure survey, and complaint investigation survey concluding on 03/12/25 took place on 05/20/25.
Findings
Lakin Hospital is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility is in substantial compliance with the previously cited deficient practices.
Report Facts
Facility census: 21
Inspection Report
Deficiencies: 0
Apr 22, 2025
Visit Reason
The inspection was conducted to review the facility's compliance with emergency preparedness requirements and other regulatory provisions.
Findings
The facility was found to be without waivers and in compliance with all Federal and State requirements regarding the Facility Emergency Preparedness Plan.
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 13
Mar 12, 2025
Visit Reason
Annual recertification, re-licensure, facility reported incidents, and complaint survey conducted at Lakin Hospital.
Findings
The facility had multiple deficiencies including failure to notify residents of menu changes, failure to report and prevent resident abuse, failure to follow medication orders, inadequate staffing, failure to maintain infection control standards, failure to update care plans and PASARR assessments, failure to provide grievance forms access, failure to ensure resident visitation rights, and failure to ensure resident safety during transport.
Complaint Details
Complaint #33116 substantiated with citations for multiple deficiencies including abuse, neglect, medication errors, and infection control.
Severity Breakdown
SS=E: 10
SS=D: 3
SS=J: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to notify residents of menu changes affecting nutritional adequacy. | SS=E |
| Failure to report and prevent sexual abuse by a resident with predatory behavior, and failure to provide adequate supervision. | SS=E |
| Failure to follow physician medication orders including missed and late medications for multiple residents. | SS=E |
| Failure to transfer a resident with required assistance, resulting in neglect. | SS=E |
| Failure to secure resident with seatbelt during transport, causing resident to slide out of seat. | SS=E |
| Failure to provide grievance forms accessible to residents for anonymous filing. | SS=D |
| Failure to allow resident visitation in rooms, restricting visits to lobby or common areas. | SS=D |
| Failure to develop and update comprehensive care plans including activity plans and PASARR assessments. | SS=D |
| Failure to provide sufficient nursing staff to meet resident needs and supervision requirements. | SS=E |
| Failure to report all allegations of abuse and neglect to appropriate state agencies. | SS=E |
| Failure to ensure proper infection control practices including PPE use during incontinence care and maintaining contact/droplet precautions during influenza outbreak. | SS=E |
| Failure to ensure residents receive thickened liquids as ordered. | SS=J |
| Failure to complete required yearly in-service training for nurse aides, with evidence of falsified training records. | SS=E |
Report Facts
Facility census: 61
Missed medications: 24
Staffing levels: 7
Staffing levels: 5
Staffing levels: 5
Staffing levels: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NA #107 | Nurse Aide | Named in neglect finding for improper resident transfer and infection control breach. |
| NA #94 | Nurse Aide | Named in neglect finding for failure to secure resident with seatbelt during transport. |
| NA #93 | Nurse Aide | Named in neglect finding for failure to secure resident with seatbelt during transport. |
| LPN #134 | Licensed Practical Nurse | Named in multiple medication administration neglect findings and terminated for vaping and talking on phone during medication pass. |
| Director of Nursing | Administrator | Interviewed regarding multiple deficiencies including staffing, abuse, and infection control. |
| Social Worker | Social Services Director | Named in abuse reporting and PASARR deficiencies. |
| Activity Director | Activities Director | Named in care plan and activities program deficiencies. |
Inspection Report
Life Safety
Census: 61
Deficiencies: 1
Mar 4, 2025
Visit Reason
The inspection was conducted to assess compliance with NFPA 110 standards for emergency and standby power systems, specifically regarding the maintenance and presence of a remote manual stop station for the emergency generator.
Findings
The facility failed to maintain a remote manual 'emergency stop' station for the outdoor emergency standby generator as required by NFPA 110. The generator enclosure lacked an accessible and properly identified manual stop station external to the weatherproof enclosure.
Deficiencies (1)
| Description |
|---|
| Failure to maintain a remote manual 'emergency stop' station accessible to all staff for the outdoor emergency standby generator, in accordance with NFPA 110. |
Report Facts
Facility census: 61
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Jan 13, 2025
Visit Reason
An unannounced complaint investigation was conducted at Lincoln Healthcare Center on 01/13/25.
Findings
The complaint investigation found that Complaint #36483 was unsubstantiated.
Complaint Details
Complaint #36483 was unsubstantiated.
Report Facts
Complaint number: 36483
Inspection Report
Follow-Up
Deficiencies: 0
Oct 1, 2024
Visit Reason
An unannounced revisit was conducted at Mountain View Care Center from September 30, 2024 to October 1, 2024 to verify correction of previously cited deficient practices from the annual survey concluding on August 16, 2024.
Findings
The facility was found to have corrected the previously cited deficient practices, as reflected on the CMS-2567B.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 28, 2024
Visit Reason
The document is a plan of correction related to a previous investigation survey concluding on 07/04/24, accepted in lieu of an onsite revisit.
Findings
The facility, Nella's At Autumn Lake Healthcare, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed.
Report Facts
Investigation survey conclusion date: Jul 4, 2024
Inspection Report
Routine
Census: 54
Deficiencies: 4
Aug 20, 2024
Visit Reason
Routine inspection to evaluate compliance with fire safety, smoking regulations, emergency preparedness, and advance directives requirements at Jackie Withrow Hospital.
Findings
The facility failed to maintain the sprinkler system according to NFPA 25 standards, lacked an updated smoking policy and proper signage, did not have a current community-based risk assessment for emergency preparedness, and failed to conduct required emergency preparedness exercises within the past year. These deficiencies could affect all residents, staff, and visitors.
Severity Breakdown
SS=C: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure automatic sprinkler and standpipe systems were maintained in accordance with NFPA 25, including missing 5-year internal inspection documentation. | SS=C |
| Failure to adopt and follow a smoking policy in accordance with NFPA 101, including lack of required signage and presence of used cigarettes in prohibited areas. | SS=C |
| Failure to develop and maintain an emergency preparedness plan based on a documented, facility-based and community-based risk assessment utilizing an all-hazards approach. | SS=C |
| Failure to conduct required emergency preparedness exercises, including full-scale or community-based exercises with critique, within the previous twelve months. | SS=C |
Report Facts
Facility census: 54
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding sprinkler system inspection, emergency preparedness findings, and smoking policy deficiencies | |
| Administrator | Acknowledged findings at exit interview and involved in corrective action plans | |
| Maintenance Supervisor | Interviewed and verified findings related to sprinkler system and smoking regulations |
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 8
Aug 16, 2024
Visit Reason
An unannounced annual and complaint investigation was conducted at Jackie Withrow Hospital from 08/12/24 to 08/14/24, including review of complaints and facility compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to update and implement person-centered care plans, neglect of residents leading to prolonged soiling, improper use of physical restraints, failure to maintain a safe and homelike environment, inadequate infection control signage, and improper food storage practices.
Complaint Details
FRIs #33432 part 1 was substantiated; FRIs #33432 part 2 and #32133 were unsubstantiated.
Severity Breakdown
SS=D: 5
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to update and implement a person-centered comprehensive care plan to meet resident preferences and goals, and address medical, physical, mental and psychosocial needs for Residents #26 and #48. | SS=D |
| Resident #48 was left visibly soiled for an extended period in the dining room without staff intervention, constituting neglect. | SS=D |
| Failure to properly investigate an allegation of injury of unknown origin for Resident #55. | SS=D |
| Wall in Resident room C-316 was in poor repair, exposing rough plaster and creating an unsafe, unclean environment. | SS=D |
| Failure to ensure residents did not have Activities of Daily Living (ADL) decline unless unavoidable; Resident #48 was physically restrained in a geri chair with a lap tray, limiting mobility and independence. | SS=D |
| Resident #48 was physically restrained with a lap tray without proper consent documentation and without evidence of release every two hours as ordered. | SS=E |
| Failure to maintain an effective infection control program by not properly identifying Enhanced Barrier Precaution (EBP) isolation rooms for Residents #26, #45, and #307. | SS=E |
| Failure to store food in accordance with professional standards; spoiled, undated, and expired food items were found in walk-in refrigerator, reach-in refrigerator, and walk-in freezer. | SS=E |
Report Facts
Facility census: 51
Deficiency count: 8
Residents on Enhanced Barrier Precautions: 18
Residents with EBP signage deficiency: 3
Residents with ADL decline audit: 25
Falls for Resident #48: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #103 | Licensed Practical Nurse | Provided information about Resident #48's restraint and mobility |
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews and information about care plans, restraints, and investigations |
| Nurse Aide #8 | Nurse Aide | Observed neglect of Resident #48 and failure to provide care |
| Nurse Aide #57 | Nurse Aide | Observed neglect of Resident #48 and failure to provide care |
| Recreation Specialist #69 | Recreation Specialist | Observed Resident #48 soiled and failed to notify staff |
| Hospital Support Services Supervisor | Support Services Supervisor | Responsible for food safety and storage, removed spoiled and expired food |
| Infection Control Nurse #34 | Infection Control Nurse | Provided information on EBP signage and infection control practices |
| Director of Social Work | Director of Social Work | Conducted investigations and audits related to abuse and PASRR |
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 4, 2024
Visit Reason
The document is a Plan of Correction related to deficiencies identified during a prior inspection at Nella's at Autumn Lake Healthcare.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Jul 4, 2024
Visit Reason
An unannounced complaint survey was conducted at Nella's at Autumn Lake Healthcare from 07/02/24 to 07/03/24 following complaint #33187 which was substantiated.
Findings
The facility failed to maintain resident room temperatures between 71 to 81 degrees Fahrenheit, with multiple rooms reported as too hot and malfunctioning air conditioning units. Additionally, a leaking air conditioning unit in room 112 was not maintained in safe operating condition, posing a risk to residents.
Complaint Details
Complaint #33187 was substantiated based on observations, resident and staff interviews, and review of facility documentation.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure resident room temperatures were maintained between 71 to 81 degrees Fahrenheit. | SS=E |
| Failed to maintain a functioning room air conditioner when water was leaking from the unit in room 112. | SS=D |
Report Facts
Facility census: 87
Room temperature: 83
Temperature range: 71
Temperature range: 81
Outdoor temperature: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #44 | Nurse Aide | Interviewed regarding resident #72 sleeping naked in hot room 124 A |
| Registered Nurse #42 | Registered Nurse | Interviewed about building temperature on 06/29/24 |
| Maintenance Director | Responsible for addressing air conditioning issues and maintenance | |
| Administrator (NHA) | Nursing Home Administrator | Provided request for documents and was informed about AC issues |
| Maintenance Helper | Unclogged tube and replaced filter in leaking AC unit in room 112 |
Inspection Report
Follow-Up
Census: 58
Deficiencies: 0
Jun 5, 2024
Visit Reason
An unannounced revisit was conducted at Wyoming Healthcare Center from 06/03/24 to 06/05/24 for the annual licensure/complaint investigation survey concluding on 03/27/24.
Findings
The facility was found to have corrected the previously cited deficient practices, as reflected on the CMS-2567B.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
May 12, 2024
Visit Reason
An unannounced Complaint/Facility Reported Incident (FRI) investigation was conducted at Jackie Withrow Hospital on 05/12/2024.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rule. Facility Reported Incident 35152 was unsubstantiated.
Complaint Details
Facility Reported Incident 35152 was unsubstantiated.
Report Facts
Facility census: 49
Inspection Report
Deficiencies: 0
Apr 15, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to the facility's compliance with Emergency Preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 19
Mar 27, 2024
Visit Reason
An unannounced Annual Survey was conducted at Wyoming Healthcare Center from 03/25/24 to 03/27/24, including an extended survey. The survey included observations, record reviews, interviews, and staff interviews to assess compliance with regulatory requirements.
Findings
The facility was cited for multiple deficiencies including failure to accurately document diagnoses on assessments and PASARR, failure to ensure dignified treatment of residents, medication administration errors, failure to employ qualified dietary staff, incomplete care plans, failure to investigate and report abuse, incomplete medical records, unsafe food storage and handling, incomplete neurological assessments, failure to notify physicians of elevated blood sugars, and failure to maintain a clean environment.
Severity Breakdown
SS=D: 11
SS=E: 4
SS=F: 3
SS=L: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to accurately reflect diagnosis of schizoaffective disorder on quarterly Minimum Data Set (MDS) for Resident #20. | SS=D |
| Failed to ensure residents were treated in a dignified manner; medication administered in dining room and resident taken to activities wearing soiled clothing. | SS=D |
| Failed to employ qualified dietary staff; dietary aide employed without food handlers card. | SS=F |
| Failed to revise care plan when use of vest for positioning was discontinued for Resident #36. | SS=D |
| Failed to ensure residents were free from physical, sexual, and verbal abuse; multiple incidents involving Resident #213 were not investigated or reported. | SS=L |
| Failed to maintain accurate and complete medical records; Resident #19 had incorrect transfer date and Resident #26 had undated POST form. | SS=D |
| Failed to store food safely and maintain sanitary equipment; incomplete temperature logs, expired food items, dented cans, and dirty microwave observed. | SS=F |
| Failed to investigate allegations of abuse from Resident #213 to other residents; no investigations or reports completed. | SS=E |
| Failed to update PASARR for Resident #6 after diagnosis of major depressive disorder. | SS=D |
| Failed to assess Resident #213 for bed rails use; bed rails present but no safety evaluation or care plan. | SS=D |
| Failed to implement fall interventions for Resident #31 and Resident #213; bed bolsters not in place and wanderguard orders delayed. | SS=D |
| Failed to ensure medication error rate was 5% or less; LPN #35 made multiple medication administration errors for Resident #36 including failure to flush feeding tube and check gastric residual volume. | SS=F |
| Failed to ensure licensed nurses had competencies for feeding tube care; LPN #35 lacked documented competency for PEG tube medication administration. | SS=D |
| Failed to develop and implement comprehensive care plans for multiple residents including 1:1 visits, diagnoses, bed rails, psychosocial needs, and tube feeding. | SS=E |
| Failed to maintain a clean, comfortable, and homelike environment; dirty ceiling around vent in dining room. | SS=E |
| Failed to provide proper foot care; Resident #29's toenails were thick, yellow, and curled, and facility failed to arrange for outside podiatry services. | SS=D |
| Failed to have appropriate members attend Quality Assessment and Assurance Committee meetings; Medical Director absent from second quarter 2023 meeting. | SS=F |
| Failed to provide quality of care; incomplete neurological assessments for Resident #213 and #31, failure to notify physician of elevated blood sugars for Resident #8, and failure to administer medication per order for Resident #49. | SS=D |
| Failed to provide appropriate treatment and services for dementia; Resident #213's worsening behaviors were not reported to physician until surveyor intervention. | SS=D |
Report Facts
Facility census: 55
Medication error rate: 16.67
Missed medication doses: 4
Missing neurological assessments: 10
Missing neurological assessments: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #35 | Licensed Practical Nurse | Named in medication administration errors and feeding tube care |
| Director of Nursing | Interviewed regarding multiple deficiencies and care plans | |
| Unit Manager #5 | Interviewed regarding Resident #213 behaviors and abuse | |
| Corporate Nurse #85 | Registered Nurse | Interviewed regarding diagnosis and care plans |
| Social Worker | Involved in PASARR and care plan updates | |
| Culinary Director | Interviewed regarding dietary staff and food safety | |
| Executive Director | Oversight and in-service coordinator for multiple deficiencies | |
| Activities Director | Named in care plan deficiencies for 1:1 visits | |
| Director of Plant Maintenance | Interviewed regarding facility cleanliness |
Inspection Report
Census: 55
Deficiencies: 1
Mar 26, 2024
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Utilities - Gas and Electric standards, specifically evaluating the maintenance of electrical equipment within the facility.
Findings
The facility failed to maintain electrical equipment properly, as evidenced by an exposed hot bus bar in a circuit distribution panel located in the attic service hallway exit. The issue was immediately addressed and repaired, and measures were implemented to prevent recurrence.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Circuit distribution panel (breaker box) located in the service hallway exit in the attic with an exposed hot bus bar. | SS=F |
Report Facts
Facility census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Plant Manager | Verified findings and performed immediate repair of the exposed hot bus bar | |
| Maintenance Director | Participated in exit interview verifying findings | |
| Administrator | Participated in exit interview verifying findings | |
| Maintenance Technician | Will perform monthly visual inspections of the attic breaker box | |
| Executive Director | Will check monthly documentation and report audit results to QA/QI committee |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 30, 2024
Visit Reason
The visit was conducted as an investigation survey triggered by a complaint, with a review of plans of correction and credible evidence accepted in lieu of a second onsite revisit.
Findings
The facility, Nella's at Autumn Lake Healthcare, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.
Complaint Details
Investigation survey concluding on 10/04/23 with acceptance of plans of correction and credible evidence in lieu of a second onsite revisit.
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 1
Dec 12, 2023
Visit Reason
An unannounced revisit was conducted on 12/11/23 and 12/12/23 for the annual recertification/licensure survey concluding on 11/08/23, including follow-up on previous citations and issuance of a new citation.
Findings
The facility failed to complete neurological checks after an unwitnessed fall of Resident #350 on 11/28/23, resulting in delayed detection of a brain bleed and subsequent resident death. The facility implemented corrective actions including staff education and ongoing audits to prevent recurrence.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to complete neuro checks after an unwitnessed fall for Resident #350. | SS=D |
Report Facts
Resident census during revisit survey: 79
Facility census at time of incident: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to perform neurological checks and responsible for staff education and audit implementation. |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 11
Nov 8, 2023
Visit Reason
An unannounced annual recertification survey was conducted to assess compliance with federal regulations related to resident care, safety, and facility operations.
Findings
The survey identified multiple deficiencies including inaccurate resident assessments, failure to report alleged abuse, inadequate grievance procedures, resident-to-resident sexual aggression, improper food utensil storage, incomplete PASRR screening, inadequate supervision during medication administration, unsafe furniture, incomplete staff training on abuse prevention, and inadequate pain management.
Severity Breakdown
SS=E: 5
SS=D: 6
Deficiencies (11)
| Description | Severity |
|---|---|
| Inaccurate Minimum Data Set (MDS) assessments for five residents regarding restraints and feeding tubes. | SS=E |
| Failure to report an allegation of sexual abuse involving Resident #132 and Resident #59 to the State Survey Agency and other authorities. | SS=D |
| Failure to consider resident council concerns as grievances and lack of accessible grievance forms for residents. | SS=E |
| Resident #59 exhibited sexually aggressive behavior toward other residents, creating an immediate jeopardy situation. | SS=E |
| Improper storage of kitchen utensils, with utensils not stored in a sanitary manner. | SS=E |
| Failure to ensure Pre-Admission Screening and Resident Review (PASRR) accurately reflected mental health diagnoses for Resident #26. | SS=D |
| Inadequate supervision during medication administration, leaving medications unattended with Resident #55. | SS=D |
| Unsafe furniture condition with Resident #17's over the bed table trim loose and hanging. | SS=D |
| Failure to provide required training on abuse, neglect, exploitation, misappropriation of resident property, dementia management, and resident abuse prevention to some staff. | SS=D |
| Failure to medicate for pain in a timely manner and failure to evaluate pain using a pain scale for Residents #132 and #181. | SS=E |
| Incorrect posting of nurse staffing data, with inaccurate number of nurse aides reported. | SS=D |
Report Facts
Facility census: 79
Deficiencies cited: 11
Residents with inaccurate MDS: 5
Residents audited weekly for assessment accuracy: 5
Residents audited weekly for behavior monitoring: 5
Residents audited weekly for pain assessment: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding inaccurate assessments, abuse reporting, pain management, and supervision during medication administration | |
| Social Worker | Provided witness statements and complaint documentation related to abuse allegation | |
| Licensed Practical Nurse #22 | Observed leaving medications unattended and interviewed about medication supervision | |
| Licensed Practical Nurse #36 | Received abuse report call and provided statement | |
| Nurse Aide #23 | Reported resident's complaint of sexual assault | |
| Activity Assistant #28 | Aware of resident complaint of sexual remarks | |
| Human Resources/Payroll Manager #65 | Reviewed employee files and confirmed lack of required training for staff |
Inspection Report
Routine
Census: 79
Deficiencies: 8
Nov 7, 2023
Visit Reason
The inspection was a routine survey conducted to assess compliance with various NFPA safety codes and regulatory requirements for the healthcare facility.
Findings
The facility was found deficient in multiple areas including emergency lighting testing, cooking equipment placement, electrical receptacle safety, fire/smoke damper testing, emergency generator maintenance, electrical equipment testing, oxygen cylinder storage, and emergency preparedness planning. Corrective actions and systemic changes were planned or implemented for each deficiency.
Severity Breakdown
SS=E: 3
SS=D: 3
SS=F: 2
SS=C: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure required emergency lighting was tested and maintained in accordance with NFPA 101. | SS=E |
| Failed to properly install and maintain cooking equipment protected by kitchen hood extinguishing system per NFPA 96. | SS=D |
| Failed to ensure electrical wiring and equipment complied with NFPA 70; unsecured electrical receptacles found on kitchen floor. | SS=D |
| Failed to ensure fire and smoke dampers were installed and maintained per NFPA 90A; no documentation of 4-year testing. | SS=D |
| Failed to ensure emergency generator was tested and maintained per NFPA 110; no documentation of annual fuel quality test. | SS=F |
| Failed to maintain testing and maintenance requirements for fixed and portable patient-care electrical equipment per NFPA 101; whirlpool testing not documented. | SS=E |
| Failed to ensure oxygen cylinders were stored and maintained in accordance with NFPA 99; improper segregation and storage near combustibles. | SS=F |
| Failed to develop and maintain a comprehensive emergency preparedness program utilizing an all-hazards approach; no full-scale community based functional exercise conducted in previous 12 months. | SS=C |
Report Facts
Facility census: 79
Emergency lighting test duration: 90
Emergency generator fuel test last date: Apr 5, 2022
Whirlpool testing interval: 12
Fire/smoke damper testing interval: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Verified multiple findings during interviews | |
| Administrator | Acknowledged findings at exit interview | |
| Maintenance Director | Performed corrective actions and responsible for quality assurance reporting | |
| Administrator | Reviewed and updated emergency preparedness plan |
Inspection Report
Deficiencies: 0
Nov 6, 2023
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with Federal and State requirements, specifically regarding the Facility Emergency Preparedness Plan.
Findings
The facility was found to be without waivers and in compliance with all Federal and State requirements related to the Facility Emergency Preparedness Plan.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 8
Oct 4, 2023
Visit Reason
An unannounced annual recertification/licensure survey was conducted at Lincoln Healthcare Center from 10/02/23 to 10/04/23 to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found out of substantial compliance with multiple deficiencies including incorrect oxygen flow rates for residents, incomplete Physician's Order for Scope of Treatment (POST) forms, unsanitary kitchen conditions, incomplete PASARR assessments, lack of comprehensive care plans for weight loss, ineffective pest control, inadequate infection control signage, and failure to obtain weights as ordered for a resident.
Severity Breakdown
SS=D: 5
SS=E: 2
: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide respiratory care at correct oxygen flow rates for two residents (#158 and #29). | SS=D |
| Incomplete POST forms missing physician's phone number for residents #13 and #4. | SS=D |
| Unsanitary kitchen conditions including dirty walk-in freezer floor and dusty racks holding cups, bowls, and thermal warmers. | — |
| Failed to complete new PASARR for resident #14 after addition of psychiatric diagnosis. | SS=D |
| Failed to develop comprehensive care plan related to weight loss for resident #24 despite significant weight loss. | SS=D |
| Failed to maintain effective pest control; uncovered trash can in dining room attracted gnats. | SS=E |
| Infection control signage for Enhanced Barrier Precautions (EBP) not placed at entrance of resident rooms for residents #16, #22, #45, and #51. | SS=E |
| Failed to obtain weekly weights as ordered for resident #2 on three Sundays. | SS=D |
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Facility census: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director for Clinical Operations | Verified oxygen flow rate deficiencies and infection control signage issues; involved in corrective actions. | |
| Director of Plant Maintenance | Removed uncovered trash can and coordinated pest control. | |
| Dietary Manager | Addressed kitchen sanitation deficiencies and educated dietary staff. | |
| Social Services Supervisor | Reviewed and updated PASARR assessments. | |
| Clinical Care Specialist | Involved in care plan updates and weight monitoring. | |
| Infection Preventionist | Corrected infection control signage placement. |
Inspection Report
Life Safety
Census: 58
Capacity: 60
Deficiencies: 1
Oct 3, 2023
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 96 standards for ventilation control and fire protection of commercial cooking operations, specifically regarding the proper installation and maintenance of kitchen hood extinguishing system equipment.
Findings
The facility failed to properly install and maintain kitchen cooking appliances protected by the hood extinguishing system, as the wheeled cooking appliances were not tethered or returned to approved design locations after maintenance and cleaning. This deficiency could affect staff but not residents.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to properly install and maintain equipment protected by the kitchen hood extinguishing system; wheeled cooking appliances were not tethered or returned to approved design locations after maintenance and cleaning. | SS=C |
Report Facts
Facility capacity: 60
Census: 58
Deficiency count: 1
Plan of correction duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Service Supervisor | Environmental Service Supervisor (ESS) | Ensured appliances were hardwired and tethered, conducted audit, and responsible for daily review of appliance tethering and wiring |
| Food Service Supervisor | Food Service Supervisor (FSS) | Communicates with ESS to ensure appliances remain tethered, hardwired, and returned to approved locations |
| Maintenance Director | Maintenance Director | Verified the finding during exit interview |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2023
Visit Reason
The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Findings
Wyoming Healthcare Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.
Complaint Details
The complaint investigation concluded on 2023-09-11, and the facility was found to be in substantial compliance with previously cited deficiencies.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 1
Sep 11, 2023
Visit Reason
An unannounced complaint investigation survey was conducted at Wyoming Healthcare Center on 09/11/23 based on Complaint #28940.
Findings
The facility failed to offer an eligible resident (Resident #39) the pneumococcal immunization Prevnar 20 vaccine, despite the resident being eligible and the last pneumococcal vaccine received over five years ago.
Complaint Details
Complaint #28940 triggered the investigation. The complaint was substantiated based on the finding that Resident #39 was not offered the Prevnar 20 vaccine as required.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to offer an eligible resident the pneumococcal immunization Prevnar 20 vaccine. | SS=D |
Report Facts
Resident reviewed for immunizations: 5
Facility census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated the facility failed to offer Resident #39 the Prevnar 20 vaccine |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Sep 11, 2023
Visit Reason
An unannounced complaint investigation survey was conducted at Nella's At Autumn Lake Healthcare from 9/11-9/13/2023.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules. Complaints #28010 and #28797 were unsubstantiated.
Complaint Details
Complaints #28010 and #28797 were investigated and found to be unsubstantiated.
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 7, 2023
Visit Reason
The document is a plan of correction related to a prior survey for Jackie Withrow Hospital, addressing previously cited deficiencies and demonstrating substantial compliance with regulatory requirements.
Findings
Jackie Withrow Hospital is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with credible evidence accepted in lieu of an onsite revisit for the survey concluding on 08/29/2023.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility must inform residents orally and in writing of their rights, rules, and services including Medicaid-related information prior to or upon admission and during stay. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 6, 2023
Visit Reason
An unannounced complaint investigation survey was conducted at Jackie Withrow Hospital on 09/06/23.
Findings
The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #27472 was unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaint #27472 was unsubstantiated with no related or unrelated deficiencies cited.
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Aug 28, 2023
Visit Reason
An unannounced complaint investigation and a focused infection control survey were conducted at Jackie Withrow Hospital from 08/28/23 to 08/29/23 based on complaints received.
Findings
The facility failed to provide a dignified dining experience for four of 50 residents, with delays in tray delivery and staff not seated while feeding residents. Additionally, the facility failed to maintain a safe, clean, comfortable, and homelike environment due to missing and cracked floor tiles and an unsecured handrail in dining areas.
Complaint Details
Complaint #28669 is substantiated. Complaint #27747 is unsubstantiated with unrelated deficiency.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide a dignified dining experience for residents, including delayed tray delivery and staff not seated while feeding residents. | SS=D |
| Failure to maintain a safe, clean, comfortable, and homelike environment due to missing and cracked floor tiles and an unsecured handrail. | SS=D |
Report Facts
Facility census: 50
Residents affected: 4
Complaints: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #70 | Nurse Aide | Involved in passing lunch trays during dining deficiency |
| Nurse Aide #88 | Nurse Aide | Involved in passing lunch trays during dining deficiency |
| Hospital Administrator Assistant #62 | Hospital Administrator Assistant | Notified of dining tray passing issues |
| Health Service Assistant #12 | Health Service Assistant | Observed standing while feeding resident |
| Recreation Specialist #34 | Recreation Specialist | Observed standing while feeding resident |
| Nurse III | Nurse III | Confirmed incidents of delayed tray delivery |
| Building Grounds Manager #4 | Building Grounds Manager | Confirmed physical environment issues |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 13
Jul 19, 2023
Visit Reason
An unannounced complaint, annual re-certification, and annual re-licensure survey was conducted at Lakin Hospital from 07/17/23 to 07/19/23.
Findings
The survey identified multiple deficiencies including failure to complete discharge assessments, inadequate supervision leading to resident falls, inaccurate PASARR screening, incomplete neurological checks after falls, inaccurate narcotic medication record keeping, missing attendance signatures for QAA meetings, worn recliner chairs, improper oxygen therapy administration, inaccurate MDS assessments, improper medication storage temperatures, lack of resident privacy during treatments, inadequate pain management documentation, and incomplete infection prevention and control monitoring.
Complaint Details
Complaint #27666 substantiated with citations F684 and F689. Complaint #28529 substantiated with citations F684, F695, and F689.
Severity Breakdown
SS=D: 10
SS=E: 3
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to complete discharge assessment for Resident #43. | SS=D |
| Failed to implement adequate supervision to prevent accidents for Resident #45 who fell in the shower. | SS=D |
| Failed to ensure accurate PASARR screening for Resident #16 with missing updated diagnosis. | SS=D |
| Failed to complete neurological checks as ordered for Resident #45 after unwitnessed falls. | SS=D |
| Failed to maintain accurate narcotic medication records and reconciliation for 3 medication carts. | SS=E |
| Failed to maintain attendance signature sheets for Quality Assessment and Assurance (QAA) committee meetings. | SS=E |
| Failed to maintain recliner chairs in good repair, with worn areas making chairs unclean. | SS=D |
| Failed to provide respiratory care consistent with physician orders; Resident #18 received oxygen at 3L instead of 2L. | SS=D |
| Failed to accurately code Minimum Data Set (MDS) assessment for Resident #45 regarding falls with major injury. | SS=D |
| Failed to maintain medication refrigerator temperature within manufacturer recommended range (36-46°F); observed temperatures as low as 32°F. | SS=D |
| Failed to ensure resident privacy during enteral feeding for Resident #32; privacy curtain did not block view from roommate. | SS=D |
| Failed to ensure pain management assessment and documentation for Resident #7; pain scale not documented and pain not assessed regularly. | SS=D |
| Failed to maintain an effective infection prevention and control program; lacked water system diagram and routine water temperature monitoring to prevent Legionella growth. | SS=E |
Report Facts
Facility census: 59
Dates of neuro checks incomplete: 4
Medication refrigerator temperature: 32
Medication refrigerator temperature: 34
Oxygen liter flow: 3
Oxygen liter flow ordered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #101 | Registered Nurse | Admitted missing discharge assessment for Resident #43 |
| DON | Director of Nursing | Reviewed care plan and supervision orders for Resident #45; confirmed fall incident and oxygen order discrepancy |
| LPN #109 | Licensed Practical Nurse | Documented Resident #45 fall incident |
| LPN #17 | Licensed Practical Nurse | Described narcotic record keeping process on C West medication cart |
| RN #21 | Registered Nurse | Observed medication storage room refrigerator temperature and privacy breach during enteral feeding |
| LPN #153 | Licensed Practical Nurse | Verified oxygen order discrepancy for Resident #18 |
| Maintenance Director | Maintenance Director | Discussed water system and Legionella risk; ordered water testing supplies |
| Administrator | Facility Administrator | Discussed QAA meeting attendance and documentation |
Inspection Report
Deficiencies: 0
Jul 19, 2023
Visit Reason
The inspection was conducted as an annual recertification, annual relicensure survey, and complaint investigation.
Findings
Lakin Hospital was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The facility was in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
The visit included a complaint investigation concluding on 07/19/2023; the facility was found in substantial compliance.
Inspection Report
Routine
Census: 59
Deficiencies: 6
Jul 18, 2023
Visit Reason
The inspection was conducted to assess compliance with fire safety codes, maintenance of cooking equipment, sprinkler systems, smoke barriers, fire doors, and emergency preparedness as part of a routine regulatory survey.
Findings
The facility was found deficient in multiple areas including improper installation and maintenance of cooking equipment, penetrations in smoke barriers, dust and wiring issues on sprinkler heads, gaps in smoke barrier doors, lack of documentation for emergency plan drills, and painted-over fire door labels. Corrective actions were planned or implemented for each deficiency.
Severity Breakdown
SS=D: 1
SS=F: 2
SS=C: 3
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to properly install and maintain cooking equipment protected by the kitchen hood extinguishing system. | SS=D |
| Failed to ensure smoke barriers were constructed and maintained to the appropriate fire resistance rating. | SS=F |
| Failed to ensure automatic sprinkler and standpipe systems were maintained in accordance with NFPA 25, including dust/debris on sprinkler heads and wiring on sprinkler lines. | SS=F |
| Failed to maintain smoke barrier doors in accordance with NFPA 101, including gaps between smoke doors. | SS=C |
| Failed to conduct and document required emergency plan exercises and after action reports. | SS=C |
| Failed to maintain fire doors in accordance with NFPA 101 and 80, including painted-over door labels. | SS=C |
Report Facts
Facility census: 59
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and verified multiple findings related to cooking equipment, smoke barriers, sprinkler systems, smoke doors, and fire doors. | |
| Administrator | Acknowledged findings upon exit interview on 07/18/23. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 4
Mar 1, 2023
Visit Reason
An unannounced complaint investigation survey was conducted at Wyoming Nursing and Rehabilitation Center from February 27 to March 1, 2023, based on complaints #28011 and #27595.
Findings
The survey substantiated complaint #28011 with deficiencies related to provision of medically related social services and reporting of alleged violations, and found an unrelated deficiency related to accuracy of assessments. Complaint #27595 was unsubstantiated but resulted in a deficiency related to accuracy of assessments. Key findings included inaccurate Minimum Data Set coding for falls, failure to provide appropriate social services and healthcare surrogate appointment for Resident #57, and failure to timely report allegations of financial exploitation to state agencies.
Complaint Details
Complaint #28011 was substantiated with related deficiencies cited at F745 and F609. Complaint #27595 was unsubstantiated with no related deficiencies cited but an unrelated deficiency cited at F641.
Severity Breakdown
SS=D: 3
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure the Minimum Data Set (MDS) accurately reflected resident's falls, specifically Resident #53's MDS was incorrectly coded. | SS=D |
| Facility failed to provide medically related social services to enable Resident #57 to attain or maintain the highest practicable well-being, including failure to appoint the appropriate healthcare surrogate and failure to involve family member FM #1. | SS=D |
| Facility failed to ensure all allegations of misappropriation of resident funds and/or financial exploitation were reported to all state agencies as required, specifically regarding Resident #57. | SS=D |
| Facility failed to provide residents with notice of rights, rules, services, and charges in accordance with regulations. | SS=C |
Report Facts
Facility Census: 55
Number of falls reported incorrectly: 4
Room and board daily rate: 389
Refund amount: 6058.55
Payment amount: 33918.55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reviewed and confirmed MDS coding errors for Resident #53 and educated RN Assessment Coordinator. |
| Registered Nurse Assessment Coordinator | Registered Nurse Assessment Coordinator | Corrected MDS coding errors and was educated on accurate coding. |
| Social Service Supervisor | Social Service Supervisor | Conducted audits and investigations related to healthcare surrogate appointment and exploitation allegations. |
| Executive Director | Executive Director | Provided education to Social Service Supervisor and reported allegations of exploitation to Ombudsman and OHFLAC. |
| Social Worker | Social Worker | Involved in healthcare surrogate appointment and investigation of financial exploitation. |
| Nursing Home Administrator | Nursing Home Administrator | Confirmed failure to report exploitation allegations timely. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 1, 2023
Visit Reason
The visit was conducted as a complaint investigation survey concluding on 03/01/2023 to review previously cited deficient practices.
Findings
Wyoming Nursing and Rehabilitation Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility is in substantial compliance with the previously cited deficient practices based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
Complaint investigation survey concluded on 03/01/2023 with substantial compliance found; no deficiencies cited in this report.
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 1, 2022
Visit Reason
The document is a plan of correction submitted in response to a prior survey for Jackie Withrow Hospital, addressing previously cited deficient practices and demonstrating substantial compliance.
Findings
Jackie Withrow Hospital is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules. The plan of correction and credible evidence were accepted in lieu of an onsite revisit for the survey concluding on 09/21/2022.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by 483.10(b)(5)-(10), including providing notice in a language the resident understands and written acknowledgment. | SS=C |
Report Facts
Survey completion date: Nov 1, 2022
Prior survey conclusion date: Sep 21, 2022
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 26, 2022
Visit Reason
The document is a plan of correction and statement of deficiencies related to a previous survey concluding on 09/28/2022, accepted in lieu of an onsite revisit.
Findings
Wyoming Nursing and Rehabilitation Center is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. The facility addressed previously cited deficient practices as evidenced by accepted plans of correction and credible evidence.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility must inform residents orally and in writing of their rights, rules, services, and charges, including Medicaid-related information, prior to or upon admission and during their stay. | Level C |
Report Facts
Survey completion date: Oct 26, 2022
Previous survey date: Sep 28, 2022
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 4
Sep 28, 2022
Visit Reason
An unannounced recertification and annual relicensure survey was conducted at Wyoming Nursing and Rehabilitation Center from September 26-28, 2022.
Findings
The survey identified deficiencies including failure to notify the ombudsman of all resident transfers to hospital, inaccurate care plan revisions for pressure ulcers, failure to follow physician medication parameters and neurological assessments, and inaccurate documentation of controlled substance administration.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to notify the ombudsman of all resident transfers to hospital. | SS=D |
| Failure to accurately revise the comprehensive care plan for pressure ulcers. | SS=D |
| Failure to follow physician's orders for medication parameters and neurological assessments. | SS=D |
| Failure to maintain accurate documentation for administration and dispensing of pain medication. | SS=D |
Report Facts
Facility census: 53
Residents reviewed for hospital transfers: 4
Residents reviewed for pressure ulcers: 2
Residents reviewed for medication parameters: 15
Residents affected by neurological assessment deficiency: 3
Residents affected by medication documentation deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #64 | Licensed Practical Nurse | Named in medication documentation discrepancies and disciplinary action |
| Administrator | Interviewed regarding ombudsman notification and documentation issues | |
| Director of Nursing | Director of Nursing | Interviewed and involved in audits, education, and disciplinary actions |
| Clinical Care Supervisor | Clinical Care Supervisor | Involved in care plan corrections, physician notifications, education, and audits |
| Unit Charge Nurse | Unit Charge Nurse | Responsible for medication administration and neurological assessments; received education |
Inspection Report
Life Safety
Deficiencies: 0
Sep 27, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and applicable Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 15
Sep 21, 2022
Visit Reason
An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Jackie Withrow Hospital from September 19-21, 2022.
Findings
The survey identified multiple deficiencies including failure to provide dignified dining experience, neglect in use of lifts causing injury, failure to report and investigate emotional abuse allegations, inaccurate assessments, incomplete care plans, failure to apply ordered hipsters, unsafe medication storage, improper food temperatures, lack of assistive eating devices, unsanitary food storage, and inaccurate medication administration records.
Complaint Details
Complaint #27411 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #27215 was substantiated with no related or unrelated deficiencies cited. Complaint #27125 was substantiated with related deficiencies cited at F600, F609, F610, F697, F842.
Severity Breakdown
SS=D: 14
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to provide a dignified dining experience for Resident #28 when administering medications while the resident was eating in the dining room. | SS=D |
| Neglected to use a lift to transfer Resident #18 resulting in a fractured foot and failed to provide pain medication timely. | SS=D |
| Failed to report an allegation of emotional abuse within the appropriate timeframe for Resident #18. | SS=D |
| Failed to investigate an allegation of emotional abuse for Resident #18. | SS=D |
| Failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for Resident #47. | SS=D |
| Failed to develop and implement a comprehensive care plan addressing wandering behavior for Resident #29. | SS=D |
| Failed to revise care plan to include use of hipsters as a safety intervention for Resident #23. | SS=D |
| Failed to ensure hipsters were applied per physician's order for Resident #23. | SS=D |
| Failed to ensure resident environment was free from accident hazards; medication left unattended at bedside of Resident #38. | SS=D |
| Failed to maintain appropriate storage procedures for BiPap mask for Resident #43. | SS=D |
| Failed to provide pain management to Resident #18 when the resident complained of pain. | SS=D |
| Failed to serve foods at safe and appetizing temperatures; test tray temperatures were below acceptable levels. | SS=D |
| Failed to provide appropriate assistive eating device (maroon spoon) for Resident #21 to maintain independent eating. | SS=D |
| Failed to store, prepare, distribute and serve food in accordance with professional standards; flour and sugar bags undated and dirty shelving unit in kitchen. | SS=D |
| Failed to ensure Resident #18's medication administration record accurately reflected administration of Tylenol as documented in nursing notes. | SS=D |
Report Facts
Facility census: 51
Deficiencies cited: 14
Dates of survey: 2022-09-19 to 2022-09-21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #30 | Licensed Practical Nurse | Named in medication administration finding for Resident #28 |
| RN #15 | Unit Manager Registered Nurse | Interviewed regarding medication administration during dining |
| Nurse Aide #92 | Nurse Aide | Involved in transfer causing injury to Resident #18 |
| Nurse Aide #73 | Nurse Aide | Involved in transfer causing injury to Resident #18 |
| Social Worker #27 | Social Worker | Interviewed regarding abuse allegations for Resident #18 |
| RN #66 | Registered Nurse | Observed BiPap mask improperly stored for Resident #43 |
| Director of Nursing | Director of Nursing | Interviewed regarding pain medication administration and other findings |
| Dietary Manager | Dietary Manager | Interviewed regarding food temperature and food storage findings |
| RN #15 | Registered Nurse | Verified assistive feeding device order for Resident #21 |
Inspection Report
Census: 50
Deficiencies: 1
Sep 21, 2022
Visit Reason
The inspection was conducted to review the facility's compliance with emergency preparedness testing requirements, specifically the requirement to conduct exercises to test the emergency plan at least annually.
Findings
The facility failed to conduct the required emergency preparedness exercises for the previous twelve months, which could affect all patients, staff, and visitors. This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to conduct required exercises to test the emergency plan at least annually. | SS=C |
Report Facts
Facility census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Verified the finding of failure to conduct emergency preparedness exercises | |
| Administrator | Acknowledged the finding at the exit interview |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Sep 20, 2022
Visit Reason
An unannounced complaint investigation survey was conducted at Nella's at Autumn Lake Healthcare from September 19-20, 2022.
Findings
The facility was in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. Three complaints (#27368, #27002, #26468) were investigated and all were unsubstantiated with no related or unrelated deficiencies cited.
Complaint Details
Complaint #27368 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #27002 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #26468 was unsubstantiated with no related or unrelated deficiencies cited.
Report Facts
Complaint investigations: 3
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 14, 2022
Visit Reason
The visit was conducted as an annual recertification and annual survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.
Inspection Report
Life Safety
Deficiencies: 0
May 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code 2012, and applicable Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 7
May 16, 2022
Visit Reason
An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Lincoln Nursing and Rehabilitation Center from May 15-16, 2022.
Findings
The survey identified multiple deficiencies including incomplete or incorrect completion of West Virginia Physician Orders for Scope of Treatment (POST) forms for six residents, failure to notify the State Long-Term Care Ombudsman of resident transfers, incomplete or outdated care plans for falls and pressure ulcers, lack of discharge summaries, improper staff assistance during resident transfers, and incorrect oxygen concentrator settings.
Complaint Details
Complaint #25823 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #25995 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #26132 was unsubstantiated with no related or unrelated deficiencies cited.
Severity Breakdown
SS=E: 2
SS=D: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Six residents had incomplete or incorrectly completed POST forms, including missing signatures and incomplete patient information. | SS=E |
| Failure to notify the Office of the State Long-Term Care Ombudsman of transfers for four residents discharged to hospital. | SS=E |
| Failure to develop a comprehensive care plan for Resident #51 for accidents/falls after actual falls occurred. | SS=D |
| Failure to revise Resident #5's care plan when pressure ulcers resolved. | SS=D |
| Failure to provide a discharge summary for Resident #54 at time of discharge. | SS=D |
| Resident #20 was transferred without proper staff assistance; bed mobility documented as requiring two-person assist but only one person assist provided on multiple occasions. | SS=D |
| Resident #2's oxygen concentrator was set at 4 LPM instead of the physician ordered 2 LPM. | SS=D |
Report Facts
Residents affected by POST form deficiency: 6
Residents affected by transfer notification deficiency: 4
Residents reviewed for care plans: 13
Facility census: 57
Days for audit of POST forms: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in multiple findings including POST form deficiencies, transfer notification deficiencies, care plan deficiencies, and oxygen setting correction |
| Registered Nurse Assessment Coordinator | Registered Nurse Assessment Coordinator | Named in care plan review and update for falls and pressure ulcers |
| Clinical Care Supervisor | Clinical Care Supervisor | Named in care plan review and discharge summary review |
| Licensed Practical Nurse #55 | Licensed Practical Nurse | Confirmed incorrect oxygen concentrator setting for Resident #2 |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 16, 2022
Visit Reason
The visit was conducted as an annual recertification survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rules.
Findings
Lakin Hospital was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.
Inspection Report
Deficiencies: 0
Mar 15, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements and to evaluate the safety and preparedness of the environment for residents.
Findings
The facility was found to be providing and maintaining a safe environment for residents. The Facility Emergency Preparedness Plan complied with all Federal and State requirements.
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 7
Mar 14, 2022
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Lakin Hospital from 03/14/22 to 03/16/22 to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies including failure to provide privacy for residents exhibiting sexual behavior, incomplete advance directives documentation, failure to follow physician orders for assistive devices, unsafe smoking environment, oxygen administration without physician order, improper nurse staffing posting, and infection control lapses including lack of PPE doffing stations and contamination during medication administration.
Severity Breakdown
SS=D: 5
SS=B: 1
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide privacy to resident exhibiting sexual self-pleasuring behavior in public areas and failure to shave female resident's facial hair. | SS=D |
| Incomplete Physician Orders for Scope of Treatment (POST) forms and failure to maintain code status documentation. | SS=D |
| Failure to follow physician order for safe ambulation related to use of Ankle Foot Orthosis (AFO) braces. | SS=D |
| Failure to ensure safe smoking environment due to absence of fire extinguisher in designated smoking area. | SS=D |
| Oxygen administration without a physician order. | SS=D |
| Failure to post nurse staffing information in a prominent and accessible location on multiple wings. | SS=B |
| Infection prevention and control deficiencies including lack of PPE doffing station in transmission-based precaution room, failure to don PPE prior to room entry, leaking pipe in clean laundry area, and contamination of medications during administration. | SS=E |
Report Facts
Facility census: 56
Deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #22 | Licensed Practical Nurse | Named in medication contamination deficiency during medication administration |
| Director of Nursing | Director of Nursing | Interviewed and involved in multiple findings including privacy, advance directives, oxygen order, nurse staffing posting, and infection control |
| Nurse Aide #3 | Nurse Aide | Mentioned in relation to PPE doffing station deficiency |
| Nurse Aide #139 | Nurse Aide | Observed resident ambulation and smoking area |
| Registered Nurse #10 | Registered Nurse | Observed failing to don PPE prior to room entry |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 8, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on September 8-9, 2021.
Findings
The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Aug 31, 2021
Visit Reason
An unannounced complaint investigation was conducted at Nella's Autumn Lake Healthcare on August 30-31, 2021.
Findings
The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Complaint Details
Complaint #25027 was unsubstantiated with no related or unrelated deficiencies cited.
Inspection Report
Monitoring
Census: 67
Deficiencies: 10
Jul 30, 2021
Visit Reason
An unannounced Federal Monitoring Survey was conducted at Nella's Inc from July 27, 2021 through July 30, 2021 to assess compliance with 42 CFR Part 483, subpart B, Requirements for Long Term Care.
Findings
The facility was found not in compliance with multiple requirements including failure to offer advance directives to residents, inaccurate resident assessments, incomplete care plan revisions after falls, inadequate pressure ulcer assessment and treatment, failure to investigate falls thoroughly, improper respiratory equipment maintenance, lack of physician documentation for medication dose reductions, failure to acknowledge resident food preferences, unsanitary food storage and preparation conditions, and failure to follow infection control practices during wound care.
Severity Breakdown
SS=D: 8
SS=E: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to offer 2 of 35 sampled residents an opportunity to formulate an advance directive. | SS=D |
| Failed to ensure accurate minimum data set regarding bed mobility for 1 of 1 resident reviewed. | SS=D |
| Failed to revise care plans with interventions to prevent further falls for 2 of 4 residents reviewed and failed to update care plan regarding alternate sleeping location for 1 of 35 residents. | SS=D |
| Failed to adequately assess and document pressure ulcers for 2 of 35 residents sampled. | SS=D |
| Failed to do a complete and thorough investigation regarding falls for 2 of 35 sampled residents. | SS=D |
| Failed to ensure respiratory equipment was free from infections and failed to post oxygen in use signage for 2 residents. | SS=D |
| Failed to document justification for no gradual dose reduction for 3 residents on psychotropic medications. | SS=D |
| Failed to acknowledge resident's food preferences for 1 resident. | SS=D |
| Failed to ensure foods and cooking equipment were stored under sanitary conditions and dietary worker wore hair restraint. | SS=E |
| Failed to perform appropriate hand hygiene techniques during wound care for 1 resident. | SS=D |
Report Facts
Census: 67
Sample size: 35
Pressure ulcer size: 1
Pressure ulcer size: 2
Oxygen flow rate: 2
Clozapine dose: 300
Seroquel dose: 450
Lexapro dose: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E 21 | Nurse | Completed fall incident report for Resident 15 but was not interviewed |
| E 22 | Nursing Assistant | Found Resident 15 on floor after fall but was not interviewed or asked for written statement |
| Director of Nursing | Responsible for care plan oversight and acknowledged failure to audit care plans for fall interventions | |
| Medical Director | Failed to properly assess and document wound infection for Resident 4 and failed to document rationale for no gradual dose reduction | |
| Wound Care Nurse | Performed wound care on Resident 4 without proper hand hygiene | |
| Infection Control Nurse | Observed wound care on Resident 4 and acknowledged hand hygiene requirements | |
| Certified Dietary Manager | Observed unsanitary food storage and confirmed hair restraint policy | |
| Employee 14 | Dietary Worker | Confirmed facility policy on hotdogs and grilled cheese and food preferences of Resident 39 |
| Registered Dietitian | Acknowledged unsanitary food storage and kitchen cleanliness issues | |
| Pharmacist | PharmD | Explained drug regimen review process and documentation |
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 0
Jul 27, 2021
Visit Reason
An unannounced revisit was conducted at Wyoming Nursing and Rehabilitation Center on July 26-27, 2021 for the annual recertification and relicensure survey concluding on 06/16/2021.
Findings
The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Jul 26, 2021
Visit Reason
An unannounced complaint investigation was conducted at Wyoming Nursing and Rehabilitation Center on July 26-27, 2021.
Findings
The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.
Complaint Details
Complaint #25371 was unsubstantiated with no related or unrelated deficiencies cited.
Inspection Report
Life Safety
Census: 66
Capacity: 100
Deficiencies: 0
Jun 16, 2021
Visit Reason
A Life Safety Code Comparative Federal Monitoring Survey was conducted by CMS on June 16, 2021 following a West Virginia Department of Health survey on June 2, 2021 to assess compliance with Life Safety Code and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with Medicare/Medicaid participation requirements at 42 CFR 483.90(a) for Life Safety from Fire and 42 CFR 483.73 for Emergency Preparedness. The facility is a one-story, fully sprinklered building with supervised smoke detection and a generator tied to fire safety systems.
Report Facts
Certified beds: 100
Census: 66
Inspection Report
Life Safety
Census: 54
Deficiencies: 1
Jun 15, 2021
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 fire drill requirements, specifically to verify that fire drills are held at unexpected times under varying conditions, at least quarterly on each shift.
Findings
The facility failed to ensure that fire drills were held at unexpected times under varying conditions on each shift quarterly as required by NFPA 101. Fire drills were found to be conducted within one hour of each other on the same shift, not meeting the requirement for varying times.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure fire drills are held at unexpected times under varying conditions, at least quarterly on each shift in accordance with NFPA 101. | SS=C |
Report Facts
Facility census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Interview verified findings related to fire drills | |
| Dietary Director | Interview verified findings related to fire drills | |
| Administrator | Acknowledged findings at exit interview | |
| Environmental Supervisor | In-serviced regarding NFPA 101 compliance procedure for fire drills and responsible for documenting fire drill times | |
| Executive Director or designee | Responsible for monitoring fire drill times and reporting compliance to QA committee |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 14
Jun 14, 2021
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Wyoming Nursing and Rehabilitation Center from June 14-16, 2021.
Findings
The survey identified multiple deficiencies including failure to date POST forms, failure to investigate resident injuries, failure to complete significant change MDS assessments timely, failure to follow physician orders regarding aspiration precautions, failure to provide ordered ice cream, incorrect oxygen settings, incomplete pain medication administration and evaluation, inaccurate nurse staffing counts, incomplete drug regimen review documentation, psychotropic medication management issues, incomplete medical records, and improper catheter care.
Severity Breakdown
SS=D: 9
SS=J: 1
SS=C: 2
SS=E: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Facility failed to ensure the resident's responsible party dated the Physician Orders for Scope of Treatment (POST) form when completed. | SS=D |
| Facility failed to investigate an incident of unknown origin involving resident injuries and failed to document or report the incident. | SS=D |
| Facility failed to complete a significant change Minimum Data Set (MDS) within 14 days after resident's physical condition changed. | SS=D |
| Facility failed to ensure residents received treatment and care in accordance with professional standards, specifically failed to follow 'no straws' order for resident at high risk of aspiration, resulting in immediate jeopardy. | SS=J |
| Facility failed to provide ordered ice cream to resident. | SS=D |
| Facility failed to ensure proper catheter care, including failure to support catheter tubing, cleanse properly, and use barrier when emptying catheter bag. | SS=D |
| Facility failed to ensure a resident's oxygen setting matched physician's order. | SS=D |
| Facility failed to consistently evaluate and administer pain medication for residents, including failure to administer pain medication timely and document pain assessments. | SS=D |
| Facility failed to follow physician orders regarding blood pressure measurement in arm with AV fistula and failed to properly monitor bruit and thrill of AV fistula. | SS=D |
| Facility failed to ensure the resident's attending physician provided documentation as to why a gradual dose reduction (GDR) was clinically contraindicated for a medication on the Beers list. | SS=C |
| Facility failed to ensure psychotropic PRN drugs were not given beyond 14 days without documented rationale. | SS=E |
| Facility failed to maintain accurate and complete medical records, including incorrect diagnosis on antibiotic orders and inaccurate nursing assessments regarding catheter presence. | SS=D |
| Facility failed to maintain an infection prevention and control program, including failure of nurse aide to follow appropriate infection control procedures during catheter care. | SS=D |
| Facility failed to maintain correct nurse staffing counts by including the Director of Nursing in the registered nurse count. | SS=C |
Report Facts
Facility census: 53
Deficiencies cited: 14
Weight loss percentage: 10.86
Pain scale scores: 5
Pain scale scores: 3
Oxygen liters ordered: 4
Oxygen liters observed: 1.5
Medication administration delay: 21
Dates with incorrect nurse staffing counts: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing Services | Interviewed and provided education on multiple deficiencies |
| NA #41 | Nurse Aide | Failed to follow infection control procedures during catheter care |
| NA #31 | Nurse Aide | Provided straw to resident against physician order |
| RN #7 | Registered Nurse | Interviewed regarding pain management and AV fistula monitoring |
| RN #69 | Director of Nursing | Interviewed regarding pain management and resident interviews |
| RN #89 | Clinical Care Supervisor | Checked AV fistula bruit and thrill and confirmed absence |
| LPN #82 | Licensed Practical Nurse | Interviewed regarding missed pain medication |
| Speech Therapist #54 | Speech Therapist | Confirmed aspiration risk and no straw order for resident |
| Unit Charge Nurse #60 | Unit Charge Nurse | Observed oxygen setting discrepancy |
| Executive Director #21 | Executive Director | Confirmed nurse staffing count errors |
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 3
Jun 2, 2021
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Nella's Inc. from June 1-2, 2021.
Findings
The survey identified deficiencies related to resident self-determination regarding meal preferences, incomplete Physician Orders for Scope of Treatment (POST) forms, and improper storage and labeling of medications including expired and undated drugs.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure resident #59 received meal preferences, resulting in weight loss and dissatisfaction with meals served. | SS=E |
| Facility failed to complete Physician Orders for Scope of Treatment (POST) form correctly for resident #60, missing legally required surrogate information. | SS=D |
| Facility failed to ensure drugs and biologicals were stored and labeled properly; expired medications and undated opened medications were found. | SS=E |
Report Facts
Resident census: 67
Weight loss percentage: 11.57
Weight loss percentage: 5.57
Deficiencies cited: 3
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 2, 2021
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility, Nella's Inc., was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Report Facts
Facility ID: 515196
Inspection Report
Life Safety
Deficiencies: 0
Jun 2, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and applicable Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of the NFPA 101, Life Safety Code, 2012, and all applicable Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 3
Jun 2, 2021
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Nella's Inc. from June 1-2, 2021.
Findings
The survey identified deficiencies related to resident self-determination regarding meal preferences, incomplete Physician Orders for Scope of Treatment (POST) forms, and improper storage and labeling of medications including expired drugs and undated opened medications.
Severity Breakdown
SS=E: 2
SS=D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure resident #59's meal preferences were honored, resulting in weight loss and dissatisfaction with meals served. | SS=E |
| Facility failed to complete Physician Orders for Scope of Treatment (POST) form correctly for resident #60, missing legally required surrogate information. | SS=D |
| Facility failed to ensure drugs and biologicals were stored and labeled properly; expired medications found and opened medications not dated. | SS=E |
Report Facts
Resident census: 67
Weight loss percentage: 11.57
Weight loss percentage: 5.57
Number of residents reviewed for POST forms: 18
Number of medication storage rooms inspected: 2
Number of medication carts inspected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #45 | Registered Nurse | Confirmed POST form was not completed in its entirety |
| LPN #14 | Licensed Practical Nurse | Verified expired medications and undated opened medications in medication storage and carts |
| Dietary Manager | Reported resident #59 receives regular tray first and breakfast item added only after complaint | |
| Administrator | Confirmed resident #59 would get scrambled eggs and bacon after complaint | |
| RN #13 | Registered Nurse | Stated resident #59 should have received eggs and bacon if that was preference |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 2, 2021
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations, with plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Life Safety
Deficiencies: 0
Jun 2, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and met all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 24, 2021
Visit Reason
The survey was conducted as a Focused Infection Control survey to assess compliance with infection control regulations and CMS/CDC recommended practices for COVID-19 preparation.
Findings
Lakin Hospital was found to be in substantial compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. The facility's plans of correction and credible evidence were accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 7
Feb 23, 2021
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Lincoln Nursing and Rehabilitation Center from February 16-23, 2021.
Findings
The facility was found deficient in multiple areas including failure to protect resident health information, inaccurate completion of minimum data set assessments, improper nephrostomy care, inadequate catheter care, respiratory care deficiencies, incomplete medical records, and infection prevention and control issues.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to protect Resident #1's health information by posting unapproved signs on resident room door. | SS=D |
| Failure to accurately complete minimum data set (MDS) assessments in nutrition and behavior for Residents #25, #51, and #27. | SS=D |
| Failure to ensure appropriate nephrostomy care for Resident #54; site exposed without dressing and signs of infection present. | SS=D |
| Failure to maintain appropriate urinary catheter care for Residents #54, #31, and #26; catheters not properly secured, drainage bags touching floor. | SS=E |
| Failure to provide appropriate respiratory hygiene, equipment maintenance, and oxygen administration for Resident #54; oxygen equipment not labeled or maintained, no physician order for oxygen. | SS=D |
| Failure to complete accurate medical record for Resident #1 regarding positioning during tube feeding; head of bed order was nurse's discretion but care plan required aspiration precautions. | SS=D |
| Failure to maintain an infection prevention and control program including respiratory hygiene, nephrostomy care, wound care, and laundry room infection control; mop heads dried in soiled room, exhaust fan not working, improper hand hygiene during wound care. | SS=E |
Report Facts
Facility census: 57
Residents reviewed for MDS accuracy: 26
Residents with catheter care issues: 3
Residents with nephrostomy care issues: 1
Residents reviewed for respiratory care: 2
Tube feeding flow rate: 220
Oxygen flow rate: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #74 | Licensed Practical Nurse | Verified oxygen supply bag labeling and disposed of incorrect bag; instructed to maintain oxygen concentrator |
| RN #78 | Registered Nurse | Observed nephrostomy care for Resident #54 and noted improper care |
| RN #98 | Registered Nurse | Observed catheter care for Resident #31 and repositioned drainage bag |
| LPN #33 | Licensed Practical Nurse | Observed wound care for Resident #1 and failed to perform proper hand hygiene |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including nephrostomy care, catheter care, respiratory care, and infection control |
| Administrator | Facility Administrator | Interviewed and informed of findings |
| Laundry worker #91 | Laundry Worker | Observed mop heads drying in soiled room |
| Environmental Supervisor | Environmental Supervisor | Confirmed mop heads drying location and exhaust fan malfunction |
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 23, 2021
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with long term care facility regulations.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. Plans of correction and credible evidence were accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.
Inspection Report
Deficiencies: 1
Feb 19, 2021
Visit Reason
The inspection was conducted based on observation, facility tour, and document review to assess the facility's environment and emergency preparedness compliance.
Findings
The facility was found to be providing and maintaining a safe environment for residents. The Facility Emergency Preparedness Plan was in compliance with all Federal and State requirements.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility must inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay, including Medicaid benefits and charges for services. | Level C |
Inspection Report
Abbreviated Survey
Census: 56
Deficiencies: 2
Jan 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and CMS/CDC recommended practices related to COVID-19.
Findings
The facility was found out of compliance with infection control regulations, including failure to secure disinfectant cleaning supplies from resident access and improper handling of isolation gowns, which posed risks for resident safety and infection spread.
Severity Breakdown
Level E: 1
Level D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure disinfectant cleaning supplies were securely stored and inaccessible to residents, found on two of four halls. | Level E |
| Facility failed to ensure proper infection control measures to minimize spread of microorganisms including COVID-19, specifically re-use of disposable isolation gowns. | Level D |
Report Facts
Facility census: 56
Number of disinfectant supplies found unsecured: 5
Number of used disposable gowns observed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #200 | Interviewed regarding disinfectant storage; removed disinfectants and locked them | |
| Nurse Aide #201 | Interviewed regarding disinfectant storage; removed disinfectants and locked them | |
| Director of Nursing (DON) | Interviewed regarding disinfectant storage and gown use policies | |
| Employee #102 | Interviewed about gowns hanging in 'C' unit; unaware of ownership | |
| Employee #101 | Interviewed about gowns hanging in 'C' unit; stated gowns should be discarded after each shift |
Inspection Report
Abbreviated Survey
Census: 51
Deficiencies: 0
Jan 5, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency from January 4, 2021 to January 5, 2021.
Findings
The facility was found in compliance with infection control regulations under 42 CFR 483.80 and related requirements, as well as CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 51
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on December 8, 2020.
Findings
The facility was found in compliance with 42 CFR infection control regulations, related emergency preparedness requirements, and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 37
Inspection Report
Abbreviated Survey
Census: 63
Deficiencies: 0
Nov 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on November 16, 2020.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19. There were zero positive residents and one positive staff member on 11/9/2020. No deficient practices were identified.
Report Facts
Positive staff cases: 1
Positive resident cases: 0
Inspection Report
Routine
Census: 67
Deficiencies: 0
Nov 4, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on November 4, 2020.
Findings
The facility was found in compliance with 42 CFR infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 67
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Oct 29, 2020
Visit Reason
An unannounced complaint investigation was conducted at Jackie Withrow Hospital on 10/29/20 to investigate allegations.
Findings
The allegations were unsubstantiated with no related or unrelated deficiencies cited. The facility was in substantial compliance with applicable federal and state regulations.
Complaint Details
Complaint #24635 is unsubstantiated with no Federal/State citations.
Inspection Report
Abbreviated Survey
Census: 70
Deficiencies: 0
Sep 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 70
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 0
Aug 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 71
Inspection Report
Abbreviated Survey
Census: 50
Deficiencies: 0
Jul 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 50
Inspection Report
Abbreviated Survey
Census: 73
Deficiencies: 0
Jul 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on July 1-2, 2020.
Findings
The facility was found in compliance with infection control regulations under 42 CFR §483.80 and related CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census upon entry: 73
Inspection Report
Routine
Census: 71
Deficiencies: 0
Jun 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on June 22-24, 2020.
Findings
The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census upon entry: 71
Inspection Report
Routine
Census: 54
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on June 16, 2020.
Findings
The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to emergency preparedness, and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 54
Inspection Report
Abbreviated Survey
Census: 71
Deficiencies: 0
Jun 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.
Findings
The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 71
Inspection Report
Deficiencies: 0
Apr 15, 2020
Visit Reason
The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 14, 2020
Visit Reason
The visit was conducted as an annual recertification and relicensure survey for the facility.
Findings
The facility, Nella's Inc., was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The review was based on plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 13
Feb 26, 2020
Visit Reason
Annual Long-term Survey Process (LTCSP) conducted from 02/23/2020 to 02/26/2020 to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to ensure dignity during dining, failure to notify resident representatives of treatment changes, inaccurate Minimum Data Set assessments, incomplete care plans, medication administration errors, respiratory care issues, lack of 8-hour RN coverage, inadequate controlled substance tracking, incomplete medical records, unnecessary medications, food safety violations, infection control lapses, and incomplete vaccination screening documentation.
Severity Breakdown
SS=D: 7
SS=E: 4
SS=F: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure dignity during dining for one resident due to delayed meal tray delivery. | SS=D |
| Failure to notify resident representative of new treatment for one resident. | SS=D |
| Inaccurate Minimum Data Set assessments for three residents. | SS=D |
| Failure to develop and implement comprehensive care plan for one resident regarding use of Hoyer lift. | SS=D |
| Failure to provide treatment and care in accordance with professional standards for two residents, including insulin administration errors and missed blood sugar testing. | SS=E |
| Failure to provide respiratory care consistent with professional standards for three residents, including improper BiPAP use and oxygen flow rate. | SS=E |
| Failure to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week on two days. | SS=F |
| Failure to maintain adequate system for tracking and control of controlled substances, including lack of narcotic counts and documentation. | SS=E |
| Failure to maintain complete and accurate medical records for multiple residents, including discrepancies in medication administration records and physician orders. | SS=E |
| Failure to ensure residents were free from unnecessary medications for one resident. | SS=D |
| Failure to store food in accordance with professional standards, including unlabeled and undated food items and improper freezer maintenance. | SS=E |
| Failure to maintain infection prevention and control program, including lack of hand hygiene during medication administration and improper storage of respiratory equipment. | SS=D |
| Failure to document screening for potential medical contraindications for influenza vaccination for one resident. | SS=D |
Report Facts
Census: 76
Survey sample size: 19
Deficiencies cited: 13
Narcotic count frequency: 2
Hand hygiene audit frequency: 30
Food safety compliance checks: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #67 | Licensed Practical Nurse | Named in dignity during dining and infection control findings |
| Licensed Practical Nurse #13 | Licensed Practical Nurse | Named in notification of changes and care plan findings |
| Director of Nursing | Director of Nursing | Named in multiple findings including MDS accuracy, medication administration, respiratory care, RN coverage, controlled substances, and medical records |
| Licensed Practical Nurse #87 | Licensed Practical Nurse | Named in controlled substances count and medication administration |
| Assistant Kitchen Supervisor #11 | Assistant Kitchen Supervisor | Named in food safety findings |
| Licensed Practical Nurse #20 | Licensed Practical Nurse | Named in vaccination consent documentation finding |
| Registered Nurse #43 | Registered Nurse | Named in respiratory care findings |
Inspection Report
Life Safety
Census: 76
Deficiencies: 4
Feb 25, 2020
Visit Reason
The inspection was conducted to assess compliance with NFPA life safety codes, including means of egress, cooking facilities, sprinkler system installation, and smoke barrier doors.
Findings
The facility failed to maintain unobstructed means of egress due to door obstructions, did not ensure cooking equipment was properly cleaned and protected per NFPA 96, had sprinkler heads improperly installed near light fixtures violating NFPA 13, and failed to maintain smoke barrier doors that did not close completely. These deficiencies could affect all residents, staff, and visitors.
Severity Breakdown
SS=E: 2
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Means of egress doors obstructed by weather stripping and astragal preventing proper opening. | SS=E |
| Cooking equipment not cleaned semi-annually as required by NFPA 96; last cleaning documented in 2018. | SS=D |
| Sprinkler heads located less than 12 inches from light fixtures exceeding maximum allowable distance per NFPA 13. | SS=E |
| Smoke barrier doors would not close completely due to bowed door frame. | SS=D |
Report Facts
Facility census: 76
Deficiency completion date: Mar 31, 2020
Deficiency completion date: Feb 28, 2020
Deficiency completion date: Apr 15, 2020
Deficiency completion date: Apr 30, 2020
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Verified findings related to door obstructions, cooking equipment cleaning, sprinkler head placement, and smoke barrier door issues | |
| Assistant Administrator | Acknowledged findings during exit interview |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Jan 15, 2020
Visit Reason
An unannounced complaint investigation was conducted at Lakin Hospital on 01/14/20 to 01/15/20 to investigate allegations.
Findings
The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable federal and state regulations.
Complaint Details
Complaint #23518 was unsubstantiated with no related or unrelated deficiencies cited.
Report Facts
Complaint number: 23518
Inspection Report
Abbreviated Survey
Census: 37
Deficiencies: 0
Jan 5, 2020
Visit Reason
An unannounced focused infection control survey was conducted at Wyoming Nursing and Rehabilitation Center.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 13, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations, with credible evidence accepted in lieu of an onsite revisit. Previously cited deficient practices were corrected.
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 9, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.
Findings
Jackie Withrow Hospital was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 19, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rules.
Findings
Lakin Hospital was found to be in substantial compliance with the applicable federal and state regulations based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 4
Oct 30, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Lincoln Nursing and Rehabilitation Center from 10/28/19 through 10/30/19.
Findings
The survey identified deficiencies including failure to notify the Ombudsman of resident hospital transfers, inaccurate completion of nutritional assessments, improper labeling of medications, and incomplete dental care documentation in resident records.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide the Ombudsman with notices of a resident's emergency transfers to an acute care hospital on two occasions. | SS=D |
| Failure to accurately complete the nutritional section of the minimum data set (MDS) assessment by entering an erroneous weight. | SS=D |
| Failure to label medications in accordance with professional principles, including unlabeled insulin pen and multi-use vial of Tubersol. | SS=D |
| Failure to ensure complete and accurate medical records; specifically, the Nutrition Profile and Review was incomplete regarding missing or broken teeth. | SS=D |
Report Facts
Facility census: 54
Dates of resident hospitalizations not reported to Ombudsman: 2
Weight recorded on MDS: 183
Weight measurement: 183.9
Insulin pen count: 1
Multi-use vials of Tubersol: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to notify Ombudsman and medication labeling issues | |
| Registered Nurse Assessment Coordinator #46 | RNAC | Agreed weight rounding error on MDS assessment for Resident #32 |
| Licensed Nurse #74 | Observed with unlabeled insulin pen | |
| Registered Nurse #41 | RN | Confirmed missing or broken teeth for Resident #24 and incomplete Nutrition Profile |
| Food Service Supervisor | Corrected Nutrition Profile and Review for Resident #24 and conducted audits |
Inspection Report
Life Safety
Deficiencies: 0
Oct 29, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 7
Oct 2, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted from 09/30/19 through 10/02/19 at Jackie Withrow Hospital. The survey included observations, clinical record reviews, interviews, and documentation review.
Findings
The facility had deficiencies including failure to send discharge notices to the Ombudsman for hospital transfers, incomplete significant change MDS assessments, inaccurate MDS assessments regarding hospice prognosis and height measurements, incomplete comprehensive care plans for anticoagulant medication, fall risk, and fluid restrictions, medication administration errors including incorrect timing and formula for tube feedings, and failure to revise care plans timely.
Complaint Details
Complaint #23229 and Complaint #23248 were unsubstantiated with no related or unrelated deficiencies cited.
Severity Breakdown
SS=C: 1
SS=D: 4
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to send discharge/transfer hospital notice to the Ombudsman for residents transferred to the hospital. | SS=C |
| Failure to complete a significant change Minimum Data Set (MDS) after resident experienced decline due to terminal illness. | SS=D |
| Inaccurate MDS assessments regarding hospice prognosis and height measurements for multiple residents. | SS=E |
| Failure to develop comprehensive care plans for anticoagulant medication, fall risk, and fluid restrictions for several residents. | — |
| Failure to revise comprehensive care plan timely for enteral feeding and fluids when orders changed. | SS=D |
| Failure to ensure residents receive treatment and care in accordance with professional standards for medication administration errors including incorrect timing of phenytoin and warfarin, and incorrect tube feeding formula administration. | SS=D |
| Failure to ensure residents are free of significant medication errors related to warfarin administration time. | SS=D |
Report Facts
Residents reviewed: 20
Residents affected: 3
Residents affected: 5
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
Facility census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Acknowledged failure to send discharge notices to Ombudsman and medication administration errors |
| Director of Nursing | Director of Nursing | Confirmed missing transfer/discharge notices and care plan deficiencies |
| LPN #135 | Licensed Practical Nurse | Administered incorrect tube feeding formula to Resident #55 |
| RN #6 | Registered Nurse | Administered medication to Resident #10 including warfarin |
| CEO | Chief Executive Officer | Educated care plan team and staff on care plan and medication procedures |
Inspection Report
Routine
Census: 72
Deficiencies: 2
Oct 1, 2019
Visit Reason
The inspection was conducted to evaluate compliance with NFPA standards regarding sprinkler system maintenance and electrical equipment usage, including power cords and extension cords, as part of a routine facility inspection.
Findings
The facility failed to maintain automatic sprinkler systems according to NFPA 25 standards and improperly used extension cords and power strips in patient care areas, including decorations attached to sprinkler lines and power strips used for medical equipment. Corrective actions were implemented promptly.
Severity Breakdown
SS=C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Halloween lights were attached to sprinkler lines, violating NFPA 25 maintenance requirements. | SS=C |
| Improper use of extension cords and power strips in patient care areas, including medical rooms and nurse stations, violating NFPA 99 standards. | SS=C |
Report Facts
Facility census: 72
Deficiency completion date: Oct 15, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Building Maintenance Director | Verified findings related to sprinkler system and electrical equipment deficiencies | |
| Administrator | Acknowledged findings at exit interview | |
| CEO | In-serviced department heads and staff regarding compliance with electrical equipment and decoration policies |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 8
Sep 12, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Lakin Hospital from 09/09/19 through 09/12/19.
Findings
The facility was found deficient in multiple areas including failure to honor resident privacy during medication administration, failure to prevent resident-to-resident psychological and verbal abuse, failure to investigate allegations of neglect, failure to implement comprehensive care plans for several residents, failure to evaluate effectiveness of PRN pain medication, failure to implement non-pharmacological interventions prior to psychotropic medication administration, failure to maintain secure storage for controlled medications awaiting disposal, and failure to implement gradual dose reduction for psychotropic medication.
Severity Breakdown
SS=D: 6
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to honor Resident #70's privacy while administering insulin injection in a hallway. | SS=D |
| Failure to ensure residents #21, #22, #11, and #66 were free from psychological and verbal abuse and failure to prevent Resident #51 from wandering into other resident rooms and causing disturbances. | SS=E |
| Failure to implement written policies and procedures to investigate allegations of neglect for Residents #54, #4, and #64. | SS=D |
| Failure to develop and implement comprehensive person-centered care plans for Residents #51, #60, #58, and #63. | SS=E |
| Failure to evaluate effectiveness of PRN pain medication administered to Resident #1. | SS=D |
| Failure to provide non-pharmacological interventions prior to administering psychotropic medication to Resident #51. | SS=D |
| Failure to maintain secure storage for controlled medications awaiting final disposition. | SS=D |
| Failure to implement gradual dose reduction for psychotropic medication for Resident #33. | SS=D |
Report Facts
Facility census: 75
PRN Tramadol doses administered: 14
Ativan doses administered: 42
Controlled medication cards awaiting disposal: 74
Residents reviewed for care plans: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #34 | Licensed Practical Nurse | Observed administering insulin injection without privacy |
| Staff Development Nurse | Provided education on medication administration and resident privacy | |
| Charge Nurse #34 | Confirmed insulin injection should have been administered in resident's room | |
| Employee #22 | Licensed Practical Nurse | Observed Resident #51 wandering and did not redirect |
| Employee #115 | Housekeeper | Observed Resident #51 in other resident's room and told resident to leave |
| Social Work Supervisor #56 | Interviewed regarding resident behaviors and neglect allegations | |
| Director of Nursing | DON | Interviewed regarding Resident #51 behaviors and medication administration |
| Employee #131 | Minimum Data Set Nurse | Reviewed care plans and MDS for Resident #51 |
| Health Service Assistant #171 | Filed complaint regarding neglect of residents #54, #4, and #64 | |
| Health Services Worker #145 | Provided statement regarding neglect allegations | |
| Health Services Worker #134 | Provided statement regarding neglect allegations | |
| Assistant Director of Nursing | ADON | Interviewed regarding neglect allegations and medication storage |
Inspection Report
Life Safety
Deficiencies: 0
Sep 10, 2019
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing for compliance with NFPA 101, Life Safety Code, 2012, and applicable Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 6, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey for Wyoming Nursing and Rehabilitation Center to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the regulatory requirements, and the plans of correction and credible evidence were accepted in lieu of an onsite revisit. Previously cited deficient practices were corrected.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Aug 20, 2019
Visit Reason
An unannounced complaint investigation was conducted at Nella's Inc. from 08/19/19 to 08/20/19.
Findings
The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.
Complaint Details
Complaint #23084 was unsubstantiated with no related or unrelated deficiencies cited.
Report Facts
Complaint number: 23084
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 6
Jul 31, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Wyoming Nursing and Rehabilitation Center from 07/29/19 through 07/31/19.
Findings
The survey identified multiple deficiencies including failure to promptly notify a physician of a resident's elevated blood sugar, failure to develop and update comprehensive care plans for residents, failure to maintain complete medical records including missing radiology reports, inaccurate medication orders, and infection control issues related to improper handling of clean mop heads.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to promptly notify Resident #18's physician when blood sugar was greater than 350. | SS=D |
| Failed to develop a comprehensive care plan for non-pharmacological interventions for anxiety for Resident #35. | SS=D |
| Failed to update Resident #24's comprehensive care plan related to renal failure. | SS=D |
| Failed to maintain Resident #15's radiology report in the medical record. | SS=D |
| Failed to ensure Resident #33's medication order was accurate and complete. | SS=D |
| Failed to maintain infection prevention and control by hanging a clean mop head in the dirty laundry room. | SS=E |
Report Facts
Deficiency citations: 6
Facility census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed findings related to notification delays, care plan deficiencies, and medication order inaccuracies. | |
| Environmental Services Staff #59 | Observed hanging clean mop head in dirty laundry room and acknowledged re-washing it. |
Inspection Report
Life Safety
Deficiencies: 0
Jul 30, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code, 2012, and applicable Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Apr 23, 2019
Visit Reason
An unannounced complaint revisit was conducted at Nella's Inc. on April 23, 2019, to assess compliance with previously cited deficient practices.
Findings
The facility was found to be in substantial compliance with the previously cited deficient practices based on observations, clinical record reviews, interviews, and documentation review.
Complaint Details
Complaint reference: #22065. The revisit was conducted to verify correction of previously cited deficiencies.
Report Facts
Survey sample size: 5
Inspection Report
Deficiencies: 0
Apr 4, 2019
Visit Reason
The document is a statement of deficiencies and plan of correction related to a facility survey, including compliance with emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 20, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations, with plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 4
Mar 11, 2019
Visit Reason
An unannounced complaint survey was conducted from 03/11/19 to 03/14/19 based on complaint #22065 which was substantiated with related and unrelated deficiencies cited.
Findings
The facility was found deficient in maintaining resident assessments, providing quality care related to a resident's change in condition and hydration, posting nurse staffing information daily, and maintaining accurate and legible resident records. Resident #72 experienced harm due to failure to notify the physician of significant condition changes and inadequate documentation.
Complaint Details
Complaint #22065 was substantiated with a related deficiency cited at F684 and unrelated deficiencies cited at F639, F732, and F842.
Severity Breakdown
SS=D: 2
SS=G: 1
SS=C: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Admission Minimum Data Set (MDS) for Resident #65 was not available in the active medical record for staff accessibility. | SS=D |
| Failure to provide treatment and care in accordance with professional standards for Resident #72 who had a change in condition related to fluid intake and bladder incontinence, resulting in hospitalization. | SS=G |
| Failure to post nurse staffing data daily at the beginning of each shift. | SS=C |
| Resident records were not complete, accurately documented, or legible, including Nurse Aide Monthly Reports with illegible and crossed-out entries for Resident #72. | SS=D |
Report Facts
Facility census: 73
Fluid intake measurements: 1378
Fluid intake measurements: 102.7
Lab values: 62
Lab values: 3.7
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #46 | Licensed Practical Nurse and MDS Coordinator | Named in deficiency related to missing MDS and failure to notify physician of Resident #72's condition |
| Director of Nursing #18 | Director of Nursing | Named in deficiencies related to staff in-service and oversight of MDS placement and notification responsibilities |
| LPN #13 | Licensed Practical Nurse | Interviewed regarding hydration policy and Resident #72's condition |
| LPN #54 | Licensed Practical Nurse | Documented Resident #72's fluid intake and condition |
| LPN #83 | Licensed Practical Nurse | Documented Resident #72's fluid intake and condition |
| LPN #15 | Licensed Practical Nurse | Documented Resident #72's condition on 02/19/19 |
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 14, 2019
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations, with plans of correction and credible evidence accepted in lieu of an onsite revisit. The facility was in substantial compliance with previously cited deficient practices.
Inspection Report
Deficiencies: 0
Feb 8, 2019
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to a facility survey conducted to assess compliance with federal, state, and local Emergency Preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements. No deficiencies were cited in this area.
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 11
Jan 30, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted from 01/28/19 through 01/30/19 to assess compliance with federal regulations.
Findings
The facility was found deficient in multiple areas including resident dignity and attire, comprehensive care planning especially for non-pharmacological interventions and oxygen therapy, physical restraint care plans and physician orders, accident hazards due to unsecured chemicals, respiratory care practices, food safety and sanitation, infection control including oxygen tubing management, quality assurance committee attendance, immunization practices, and environmental maintenance issues in resident rooms.
Severity Breakdown
C: 1
D: 3
E: 7
Deficiencies (11)
| Description | Severity |
|---|---|
| Resident #38 was observed wearing a hospital gown during the day and had torn bed linens, failing to ensure dignity. | C |
| Care plans for residents #45, #30, #55 lacked non-pharmacological interventions for behaviors; Resident #74 lacked care plan for oxygen therapy. | E |
| Care plan for Resident #45 did not include monitoring and frequency of releasing physical restraint (meri walker). | D |
| Physician's order for Resident #45 did not specify medical symptom or frequency for releasing the meri walker restraint. | D |
| Kitchenette door unlocked with hazardous chemicals accessible to residents. | E |
| Oxygen tubing for residents #11 and #50 was not dated and tubing was found on the floor. | E |
| Opened and undated resident food items found in A-Hall Kitchenette; dirty ice machine and drip pan; missing trash can near hand washing sink; refrigerator light not working. | E |
| Quality Assessment and Assurance committee failed to have Medical Director attend two of four quarterly meetings. | E |
| Facility failed to provide respiratory care consistent with professional standards; oxygen tubing not dated or changed timely. | E |
| Facility failed to provide pneumococcal vaccines according to CDC guidelines for residents #21 and #38. | D |
| Resident rooms had scratched walls, bent/broken blinds, cracked caulking, missing paint, leaking faucet, and other maintenance issues. | E |
Report Facts
Residents reviewed: 22
Facility census: 77
Deficiency citations: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Social Worker #265 | Licensed Social Worker | Involved in staff in-service and corrective actions related to resident attire, linen management, infection control, and kitchenette food safety |
| Director of Nursing | Director of Nursing | Verified findings related to resident attire, care plans, restraint care, and environmental issues |
| Care Plan Coordinator #26 | Care Plan Coordinator | Revised care plans for residents with behavioral and respiratory needs |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Verified resident attire, oxygen tubing issues, and assisted with corrective actions |
| Maintenance Supervisor #204 | Maintenance Supervisor | Responsible for securing kitchenette door, replacing bulbs, and repairing resident rooms |
| Certified Dietary Manager #243 | Certified Dietary Manager | Responsible for food safety, ice machine cleaning, and environmental monitoring |
| Infection Control Nurse #32 | Infection Control Nurse | Monitored oxygen tubing changes and infection control practices |
| Licensed Social Worker #35 | Licensed Social Worker | Provided QAA attendance sheets and verified Medical Director attendance |
| Medical Director | Medical Director | Failed to attend two of four QAA meetings; notified to improve attendance |
Inspection Report
Life Safety
Census: 79
Deficiencies: 10
Jan 29, 2019
Visit Reason
The inspection was conducted to assess compliance with NFPA life safety codes including exit discharge, emergency lighting, hazardous area enclosures, fire alarm system testing, sprinkler system installation and maintenance, portable fire extinguishers, smoke barrier doors, utilities wiring, and HVAC systems.
Findings
The facility was found deficient in multiple life safety areas including obstructed exit doors, lack of emergency lighting testing documentation, missing door closures on hazardous area doors, missing fire alarm sensitivity testing records, sprinkler heads improperly located near light fixtures, wiring and conduit improperly supported on sprinkler pipes, fire extinguishers installed too high, bowed and binding smoke barrier doors, exposed wiring and missing junction box covers, and untested smoke dampers tied to the fire alarm system.
Severity Breakdown
SS=F: 2
SS=D: 6
SS=C: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Exit discharge doors obstructed by astragal preventing proper opening. | SS=F |
| Emergency lighting systems not tested monthly or annually as required. | SS=D |
| Hazardous area doors missing self-closing devices. | SS=D |
| Fire alarm system sensitivity testing not documented for previous two years. | SS=C |
| Sprinkler heads located less than 12 inches from light fixtures exceeding allowable distance. | SS=C |
| Communication wiring and conduit improperly supported on sprinkler pipes. | SS=C |
| Portable fire extinguishers installed with tops greater than 5 feet above floor. | SS=C |
| Smoke barrier doors bowed and binding exceeding 1/8 inch clearance requirement. | SS=F |
| Exposed wiring and missing junction box covers in attic areas. | SS=D |
| Smoke dampers tied to fire alarm system not tested every four years as required. | SS=D |
Report Facts
Facility census: 79
Deficiencies cited: 11
Fire extinguisher installation height: 5
Smoke damper testing frequency: 4
Emergency lighting test duration: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Verified multiple findings including exit door obstruction, emergency lighting testing, hazardous area door closures, fire alarm sensitivity testing, sprinkler system issues, wiring deficiencies, smoke barrier door conditions, and smoke damper testing | |
| Assistant Administrator | Acknowledged findings during exit interview |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 12
Jan 17, 2019
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Lincoln Nursing and Rehabilitation Center from 01/14/19 through 01/17/19.
Findings
The survey identified multiple deficiencies including failure to report alleged abuse timely, inaccurate resident assessments, failure to follow care plans, environmental safety hazards, improper oxygen administration, incomplete nurse staffing postings, laboratory service delays, dietary staffing issues, menu substitutions without approval, food served at unsafe temperatures, and food safety violations including unlabeled food and incomplete dish machine temperature logs.
Severity Breakdown
SS=D: 6
SS=E: 2
SS=F: 2
SS=B: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to report an allegation of suspected abuse for one resident. | SS=D |
| Failed to ensure accuracy of a minimum data set assessment for one resident. | SS=D |
| Failed to provide respiratory care in accordance with the resident's care plan for one resident. | SS=D |
| Failed to provide treatment and care in accordance with professional standards and resident's choice for one resident. | SS=D |
| Failed to ensure the environment was free from accident hazards by leaving a key in the mechanical room door. | SS=D |
| Failed to ensure respiratory care was provided consistent with professional standards and physician's orders for one resident. | SS=D |
| Failed to ensure nurse staffing postings were complete and included census numbers for each shift. | SS=B |
| Failed to provide or obtain laboratory services to meet the needs of residents; one resident had a lab test not completed as ordered. | SS=D |
| Failed to employ sufficient qualified dietary staff to carry out food and nutrition services during the absence of the Certified Dietary Manager. | SS=F |
| Failed to follow menus and ensure menu substitutions met nutritional needs of residents; substitution logs lacked approval and signatures. | SS=E |
| Failed to ensure food was served at safe and palatable temperatures; food items served were below safe temperature standards. | SS=E |
| Failed to maintain kitchen in a safe and sanitary manner; unlabeled food found in freezer, ice buildup on freezer fan, and incomplete dish machine temperature logs. | SS=F |
Report Facts
Facility census: 59
Deficiency citations: 12
Oxygen flow rate: 2
Oxygen flow rate observed: 2.5
Melatonin dosage: 3
Ambien dosage: 5
Dish machine log blanks: 41
Dish machine log blanks: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #26 | Registered Nurse | Acted as Director of Nursing and involved in abuse allegation reporting |
| SSS #25 | Social Services Supervisor | Involved in abuse allegation investigation and complaint form completion |
| RN #83 | Registered Nurse | Involved in lab order follow-up and abuse allegation reporting |
| RNAC #84 | Resident Nursing Assessment Coordinator | Confirmed inaccurate MDS assessment for Resident #7 |
| DNS | Director of Nursing Services | Provided education and audits related to oxygen therapy and sleep interventions |
| CCS | Clinical Care Supervisor | Involved in oxygen therapy correction and sleep intervention audits |
| ESS | Environment Services Supervisor | Replaced mechanical room door lock and removed ice buildup in freezer |
| CDM #27 | Certified Dietary Manager | On leave during survey, no backup designated |
| CDM #89 | Certified Dietary Manager | Temporary coverage during CDM #27 leave |
| DSA #16 | Dietary Services Assistant | Witnessed mechanical room door key and involved in food temperature testing |
| DSA #68 | Dietary Services Assistant | Tested food temperatures during meal service |
| Administrator | Facility Administrator | Interviewed regarding staffing, abuse reporting, and dietary management |
Inspection Report
Routine
Census: 59
Deficiencies: 2
Jan 15, 2019
Visit Reason
The inspection was conducted to assess compliance with fire safety codes and electrical equipment maintenance requirements at the facility.
Findings
The facility failed to maintain corridor doors in accordance with NFPA 101 standards, with doors bowed beyond the allowable 1/8 inch clearance, and failed to maintain required electrical testing for a whirlpool in the Shower Room. Both deficiencies were acknowledged by staff and corrective action plans were established.
Severity Breakdown
SS=C: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Corridor doors in B-Hall were bowed at the top and exceeded the 1/8 inch clearance requirement. | SS=C |
| No documentation of electrical resistance, current leakage, or touch current testing for a cord connected whirlpool in the Shower Room was provided. | SS=D |
Report Facts
Facility census: 59
Inspection Report
Renewal
Deficiencies: 0
Sep 25, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The Wyoming Nursing and Rehabilitation Center was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficiencies.
Report Facts
Survey completion date: Sep 25, 2018
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 10, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules.
Findings
Lakin Hospital was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Follow-Up
Census: 72
Deficiencies: 1
Sep 4, 2018
Visit Reason
The visit was conducted to follow up on the facility's compliance with testing and maintenance requirements for fixed and portable patient-care electrical equipment as indicated in the approved plan of correction.
Findings
The facility failed to provide documentation of electrical resistance or touch current testing for patient beds, vital signs monitors, nebulizers, and concentrators as required. These findings were verified by the Building Maintenance Director during the inspection and exit interview.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain testing and maintenance requirements for fixed and portable patient-care electrical equipment in accordance with NFPA 99. | SS=F |
Report Facts
census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Building Maintenance Director | Verified findings related to electrical equipment testing during interview and exit interview | |
| Maintenance Supervisor | Responsible for testing documentation and corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 1
Aug 30, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.
Findings
Jackie Withrow Hospital was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming substantial compliance with previously cited deficient practices.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay, including Medicaid benefits and charges for services. | Level C |
Report Facts
Deficiency ID: 156
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 12
Aug 1, 2018
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Wyoming Nursing and Rehabilitation Center from 07/30/18 through 08/01/18.
Findings
The facility was found deficient in multiple areas including safe and homelike environment, transfer and discharge documentation, comprehensive assessments, care plan development and implementation, quality of care including pressure ulcer prevention, pain management, drug regimen review, infection control, and immunization documentation.
Severity Breakdown
Level D: 11
Level E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| The facility failed to ensure a homelike environment for two rooms due to poor repair of heating/cooling units and dust on exhaust vents. | Level D |
| The facility failed to communicate appropriate information to the receiving hospital during resident transfer. | Level D |
| The facility failed to complete accurate minimum data set (MDS) assessments reflecting correct diagnoses. | Level D |
| The facility failed to develop and implement comprehensive person-centered care plans for multiple residents in areas including pain management, pressure ulcer care, oxygen therapy, psychotropic medication monitoring, infections, and activities of daily living. | Level E |
| The facility failed to revise care plans timely for residents when weights were discontinued and regarding current pressure ulcers. | Level D |
| The facility failed to ensure proper positioning of a resident at the dining table to allow easy access to food. | Level D |
| The facility failed to provide nail care for a dependent resident. | Level D |
| The facility failed to provide care and services to promote healing of pressure ulcers and ensure residents were turned and repositioned as ordered. | Level D |
| The facility failed to ensure non-pharmacological interventions for pain management were implemented and documented prior to administration of PRN pain medication. | Level D |
| The facility failed to ensure the drug regimen was free from irregularities; a multivitamin was prescribed for an incorrect diagnosis. | Level D |
| The facility failed to implement an ongoing infection control program to prevent the spread of infection; ice scoop was observed touching the rim of water pitcher lids. | Level D |
| The facility failed to ensure pneumococcal immunization consent was complete for a resident. | Level D |
Report Facts
Residents reviewed: 18
Residents transferred: 5
Survey sample: 18
Facility census: 54
Pressure ulcers: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN Assessment Coordinator | Registered Nurse Assessment Coordinator | Named in multiple findings related to MDS assessments, care plan development and revisions |
| Director of Nursing Services | Director of Nursing | Named in multiple findings related to staff education, audits, and care plan oversight |
| Clinical Care Supervisor | Clinical Care Supervisor | Named in findings related to pain management, care plan audits, and staff education |
| Employee #87 | Unable to provide discharge information for Resident #2 transfer | |
| RN #27 | Registered Nurse | Provided wound care and described pressure ulcer status for Resident #16 |
| NA #8 | Certified Nursing Assistant | Provided nail care for Resident #47 |
| NA #200 | Nurse Aide | Observed improperly passing ice touching water pitcher rims |
| DON | Director of Nursing | Interviewed multiple times regarding care practices and deficiencies |
Inspection Report
Life Safety
Census: 54
Deficiencies: 1
Jul 31, 2018
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 fire drill requirements, specifically to verify that fire drills are held at unexpected times under varying conditions, at least quarterly on each shift.
Findings
The facility failed to ensure that fire drills were held at unexpected times under varying conditions on each shift quarterly as required by NFPA 101. Multiple fire drills were held outside of expected timeframes and shifts, potentially affecting all residents, staff, and visitors.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure fire drills are held at unexpected times under varying conditions, at least quarterly on each shift in accordance with NFPA 101. | SS=C |
Report Facts
Facility census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facilities Services Director | Verified findings on 07/31/18 at approximately 12:00 p.m. | |
| Administrator | Verified findings at time of exit on 07/31/18 | |
| Environmental Supervisor | In-serviced regarding NFPA 101 compliance procedure for fire drills | |
| Executive Director or designee | Will monitor fire drill times of all fire safety drills |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 9
Jul 19, 2018
Visit Reason
An unannounced annual re-certification and annual re-licensure survey was conducted at Lakin Hospital from July 16, 2018 through July 19, 2018.
Findings
The survey identified multiple deficiencies including failure to notify resident representatives of condition changes, failure to protect resident privacy, maintenance issues, failure to notify Ombudsman of transfers, inaccurate assessments, incomplete care plan revisions, failure to follow physician orders, unsafe environment hazards, and infection control lapses.
Severity Breakdown
Level D: 4
Level E: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to notify an incapacitated resident's medical power of attorney of a change in condition. | Level D |
| Failed to protect personal privacy and confidentiality of residents; treatments left unattended in bath/shower rooms. | Level E |
| Failed to provide maintenance services for six of forty-three rooms; scratched and missing paint on dining and lounge room doors. | — |
| Failed to notify Ombudsman of resident transfer to acute care facility. | Level D |
| Failed to complete accurate minimum data set (MDS) assessments for four residents; miscoding of restraints and diagnoses. | Level E |
| Failed to revise and evaluate effectiveness of care plan interventions for fall prevention for two residents. | Level D |
| Failed to follow physician orders for residents; fall mat not in place, improper use of mobility equipment, and failure to monitor vital signs before medication administration. | Level D |
| Failed to maintain a resident environment free of accident hazards; medication cart left unlocked and unattended, used needles improperly disposed, and unsecured chemicals and razors in shower room. | Level E |
| Failed to prevent development and transmission of infection; nurse did not change gloves appropriately or use barrier during wound dressing change. | Level E |
Report Facts
Residents sampled: 22
Facility census: 79
Deficiency citations: 9
Falls without injury: 3
Pulse rate below 60 bpm: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #151 | Licensed Practical Nurse | Named in findings related to medication cart left unlocked, improper needle disposal, and infection control during dressing change |
| ADON | Assistant Director of Nursing | Interviewed regarding notification failures, care plan issues, and vital sign monitoring |
| Employee #48 | Registered Nurse | Interviewed regarding inaccurate MDS coding and care plan revisions |
Inspection Report
Census: 79
Deficiencies: 1
Jul 17, 2018
Visit Reason
The inspection was conducted to review the facility's compliance with fire safety maintenance requirements, specifically the maintenance and testing of the automatic sprinkler and standpipe systems in accordance with NFPA 25 standards.
Findings
The facility failed to provide evidence of a five-year internal inspection of the sprinkler system piping as required by NFPA 25, which could potentially affect all residents, staff, and visitors. The facility acknowledged the deficiency and scheduled corrective actions including an inspection and incorporation of this inspection into their preventive maintenance program.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide evidence of a five-year internal inspection of the sprinkler system piping in accordance with NFPA 25. | SS=C |
Report Facts
Facility census: 79
Completion date for corrective action: Sep 5, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Verified findings during interview on 07/17/18 | |
| Administrator | Acknowledged findings at exit interview on 07/17/18 |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 10
Jul 12, 2018
Visit Reason
An unannounced annual re-certification, annual re-licensure survey and three complaint investigations were conducted at Jackie Withrow Hospital from July 9, 2018 through July 12, 2018.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations for residents, failure to protect personal privacy and confidentiality of medical records, failure to maintain a safe, clean, and homelike environment, failure to prevent abuse and neglect, failure to ensure accurate assessments and comprehensive care plans, failure to provide care in accordance with professional standards, failure to maintain a safe environment free of hazards, and failure to maintain an effective infection control program.
Complaint Details
Three complaint investigations were conducted. Complaint #20719 and #20449 were unsubstantiated with no deficiencies cited. Complaint #19673 was substantiated with one related deficiency cited at F600 regarding abuse and neglect.
Severity Breakdown
SS=D: 6
SS=E: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide services with reasonable accommodation for residents; over the bed light cords were too short for residents to reach. | SS=D |
| Failed to protect personal privacy and confidentiality of medical records; an unlocked computer monitor was left unattended revealing resident information. | SS=D |
| Failed to maintain a safe, clean, comfortable, and homelike environment; multiple rooms had scratched walls, missing paint, damaged cabinets, dirty light fixtures, cracked floor tiles, broken screens, and rusted ceiling tiles. | SS=E |
| Failed to protect a resident's right to be free from abuse; facility failed to recognize and address abuse allegations involving staff and resident. | SS=D |
| Failed to ensure a complete and accurate Minimum Data Set (MDS); resident's anticoagulant medication was not accurately reflected. | SS=D |
| Failed to develop and implement comprehensive care plans; care plans lacked measurable goals and person-centered interventions for anxiety and communication. | SS=D |
| Failed to revise care plan timely; care plan did not reflect resident's assistance needs with activities of daily living (ADLs). | SS=D |
| Failed to ensure treatment and care in accordance with professional standards; pain assessments were not performed every shift as ordered. | SS=E |
| Failed to provide an environment free from accident hazards; medication cart was unlocked and unattended in hallway. | SS=D |
| Failed to maintain an effective infection prevention and control program; medication boxes and blood glucose machines were placed directly on resident surfaces without barriers, and blood glucose machines were cleaned with 70% alcohol which is not effective against viral bloodborne pathogens. | SS=E |
Report Facts
Survey sample: 19
Deficiency count: 9
Pain assessment times: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #140 | Licensed Practical Nurse | Named in findings related to privacy breach and unlocked medication cart |
| SW #10 | Social Service Supervisor | Involved in abuse investigation and interview |
| HSW #59 | Healthcare Service Worker / Nursing Aide | Named in abuse allegation and investigation |
| RN #13 | Registered Nurse / MDS Nurse | Named in findings related to inaccurate MDS and care plan development |
| RN #150 | Unit Manager Registered Nurse | Named in care plan and pain assessment findings |
| Employee #67 | Nurse | Named in infection control training and findings |
| Employee #97 | Nurse | Named in infection control training and blood glucose testing findings |
Inspection Report
Routine
Census: 72
Deficiencies: 11
Jul 11, 2018
Visit Reason
Routine inspection of Jackie Withrow Hospital to assess compliance with NFPA 101 fire safety codes, electrical systems, emergency preparedness, and other regulatory requirements.
Findings
The facility had multiple deficiencies including failure to test emergency lighting, maintain fire barriers, protect hazardous areas, maintain sprinkler systems, properly install fire extinguishers, cover electrical junction boxes, test elevators monthly, maintain electrical receptacles and patient-care equipment, and update emergency preparedness plans. Corrective actions and plans of correction were submitted with completion dates mostly by August 2018.
Severity Breakdown
SS=C: 4
SS=D: 2
SS=E: 1
SS=F: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure required emergency lighting systems were tested monthly and annually as per NFPA 101. | SS=C |
| Failure to maintain fire barriers with appropriate fire resistance rating, including penetrations above fire barrier doors. | SS=D |
| Failure to protect hazardous areas with proper door closures and separation as required by NFPA 101. | SS=D |
| Failure to maintain sprinkler system installation clearance requirements and improper sprinkler head placement near light fixtures. | SS=E |
| Failure to maintain and test automatic sprinkler and standpipe systems in accordance with NFPA 25, including wiring and conduit laying on sprinkler lines. | SS=F |
| Failure to ensure portable fire extinguishers were installed and maintained with tops no more than 5 feet above the floor. | SS=C |
| Failure to ensure electrical wiring and equipment complied with NFPA 70, including missing covers on junction boxes and exposed wiring. | SS=F |
| Failure to ensure periodic testing and inspection of elevators including monthly operation of Firefighter's Service. | SS=C |
| Failure to maintain and test electrical receptacles at patient bed locations in accordance with NFPA 101. | SS=F |
| Failure to maintain testing and maintenance requirements for fixed and portable patient-care electrical equipment including beds, nebulizers, and concentrators. | SS=F |
| Failure to develop and maintain a comprehensive emergency preparedness plan that includes all-hazards risk assessment, shelter in place policies, volunteer use, communication plans, and annual exercises. | SS=C |
Report Facts
Facility census: 72
Deficiencies cited: 11
Completion dates: Aug 30, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Building Maintenance Director | Interviewed and verified multiple findings related to fire safety, electrical, and sprinkler deficiencies | |
| Administrator | Acknowledged findings at exit interview on 07/11/2018 | |
| Maintenance Supervisor | Responsible for corrective actions, in-service training, and preventive maintenance program implementation | |
| CEO | Involved in oversight of emergency preparedness plan updates and corrective action reviews | |
| COOP Coordinator | Responsible for updating emergency preparedness plans and communication |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 26, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rule.
Findings
The facility was found to be in substantial compliance with the cited regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 1
Mar 23, 2018
Visit Reason
An unannounced revisit was conducted from March 19, 2018 to March 23, 2018 for the annual survey concluding on December 7, 2018.
Findings
The facility was found to remain out of compliance with deficiency F867 related to pneumonia and influenza immunizations. The facility failed to ensure residents were properly assessed and offered pneumonia vaccinations according to facility policy and CDC guidelines.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents and/or their representatives were offered pneumonia vaccinations according to facility policy and CDC guidelines, with residents not assessed for prior pneumonia vaccinations or refusals. | SS=E |
Report Facts
Facility census: 79
Revisit survey sample: 12
Residents reviewed for pneumonia vaccination: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing/Social Worker (DON/SW) | Interviewed regarding pneumonia vaccination practices | |
| Infection Control Nurse | Interviewed regarding pneumonia vaccination practices and facility policy | |
| Risk Manager | Interviewed regarding pneumonia vaccination practices |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 15, 2018
Visit Reason
The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.
Findings
The facility was found to be in substantial compliance with the applicable federal and state regulations, with previously cited deficient practices corrected as evidenced by accepted plans of correction and credible evidence.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Feb 28, 2018
Visit Reason
An unannounced complaint investigation was conducted from February 27, 2018 to February 28, 2018 at Nella's Inc. for Complaint Reference #17912.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 and West Virginia Nursing Home Licensure Rules.
Complaint Details
The complaint allegations were unsubstantiated with no deficient practices identified.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 22, 2018
Visit Reason
The inspection was conducted as a complaint investigation concluding on 12/27/2017, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Findings
Jackie Withrow Hospital was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules, with previously cited deficient practices corrected.
Complaint Details
Complaint investigation concluded on 12/27/2017 with substantial compliance found; complaint reference number #18970.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Feb 2, 2018
Visit Reason
An unannounced annual recertification and relicensure survey was conducted at Lincoln Nursing and Rehabilitation Center from January 30, 2018 through February 2, 2018.
Findings
The survey identified deficiencies including failure to discard an influenza vaccine multi-dose vial within 28 days after opening and failure to date oxygen concentrator water reservoirs, which posed potential risks to residents.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to discard an influenza vaccine multi-dose vial within 28 days after opening. | Level D |
| Oxygen concentrator water reservoir was not dated when initiated for one resident. | Level D |
Report Facts
Survey sample size: 15
Facility census: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Present when expired influenza vaccine vial was discovered and confirmed no date on oxygen concentrator water reservoir |
| Employee #49 | Interviewed regarding lack of date on oxygen concentrator water reservoir |
Inspection Report
Life Safety
Deficiencies: 0
Jan 31, 2018
Visit Reason
The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code, 2013, and to review compliance with Federal, State, and local Emergency Preparedness requirements.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2013, and all applicable Emergency Preparedness requirements.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 3
Dec 26, 2017
Visit Reason
An unannounced complaint survey was conducted at Jackie Withrow Hospital on December 26-27, 2017, triggered by complaint #18970 which was substantiated with related deficiencies cited.
Findings
The facility failed to provide a prompt response to a resident grievance regarding a stolen purse, and failed to store and serve food in accordance with professional food safety standards, including improper food storage, undated and unlabeled food items, and serving food at unsafe temperatures.
Complaint Details
Complaint #18970 was substantiated. Resident #68 reported her purse stolen on 12/10/17, but the facility failed to investigate or respond promptly. Social Services Supervisor was unaware of the concern until surveyor inquiry. The Social Worker signed off on the note but admitted not reading it. The administrator found no documentation of investigation prior to survey.
Severity Breakdown
SS=D: 1
SS=F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide a prompt response to a resident grievance regarding a stolen purse. | SS=D |
| Failure to store foods in the kitchen and resident food pantry according to professional food service safety standards, including undated and unlabeled food items and unsanitary conditions. | SS=F |
| Failure to serve food at acceptable temperatures, with hot foods served below 140 degrees and cold foods above 50 degrees, risking foodborne illness. | SS=F |
Report Facts
Facility census: 75
Complaint sample size: 14
Food temperatures: 104.1
Food temperatures: 119.4
Food temperatures: 122.5
Food temperatures: 122.1
Food temperatures: 50.1
Food temperatures: 102.5
Food temperatures: 100.9
Food temperatures: 53.7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #24 | Social Services Supervisor | Unaware of resident #68's concern about stolen purse on 12/10/17. |
| Employee #37 | Social Worker | Signed off on resident #68's note but admitted not reading it. |
| Employee #71 | Food Service Employee | Discarded thawing ham and turkey, cleaned containers, and placed thermometers in refrigerators. |
| Employee #141 | Licensed Practical Nurse | Observed pantry conditions and food storage issues on second floor. |
| Employee #81 | Dietary Employee | Obtained food temperatures during lunch on 12/26/17. |
| Employee #15 | Food Service Employee | Verified milk cooler had no thermometer and observed food storage issues. |
| Administrator | Facility Administrator | Unable to find documentation of investigation into resident #68's concern prior to survey. |
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 10
Dec 7, 2017
Visit Reason
Unannounced annual recertification and relicensure surveys were conducted to assess compliance with regulatory requirements, including resident care, abuse prevention, medication management, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to prevent resident-to-resident abuse, inadequate behavioral health care and individualized care plans, incomplete and inaccurate resident records, failure to properly document hospice services, medication regimen review deficiencies, improper medication storage and administration practices, incomplete immunization education and documentation, inadequate infection control practices, and failure to maintain a comprehensive facility assessment addressing wandering residents and staffing needs.
Severity Breakdown
SS=G: 1
SS=D: 5
SS=E: 4
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to prevent resident-to-resident abuse and neglect, including inadequate investigation and reporting of abuse allegations and insufficient interventions to protect residents from aggressive behaviors. | SS=G |
| Failure to develop and implement comprehensive person-centered care plans addressing behavioral health needs, including individualized goals and interventions for residents with dementia and aggressive behaviors. | SS=D |
| Failure to maintain complete, accurate, and accessible resident medical records, including missing psychiatric consults, incorrect documentation, and incomplete consent forms. | SS=D |
| Failure to ensure hospice services documentation and care plans were complete and updated to reflect resident status and facility admission. | SS=D |
| Failure to maintain an effective medication regimen review program with timely communication and action on pharmacist recommendations. | SS=E |
| Failure to secure medications properly during administration, leaving medication cups unsecured and out of nurse's sight. | SS=E |
| Failure to provide education on influenza immunization benefits and side effects to residents or their representatives using current CDC Vaccine Information Statements. | SS=E |
| Failure to develop and implement a facility assessment that identifies wandering residents, physical environment interventions, and appropriate staffing to prevent resident-to-resident abuse. | SS=D |
| Failure to maintain an effective infection prevention and control program, including failure to use barriers when administering multi-dose medications. | SS=E |
| Failure to properly dispose of garbage and refuse, with overflowing dumpsters and unsecured lids. | SS=D |
Report Facts
Facility census: 87
Survey dates: 2017-12-04 to 2017-12-07
Survey sample size: 18
Narcotic reconciliation missing signatures: 2
Hospice nursing visits: 2
Hospice nursing visits documented: 2
Medication administration observations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activities Director #30 | Activities Director | Named in relation to resident abuse allegations and failure to report. |
| Licensed Practical Nurse #31 | LPN | Reported resident #84's behaviors and medication issues. |
| Licensed Practical Nurse #15 | LPN | Reported on resident #84's behavioral health needs and care plan deficiencies. |
| Licensed Practical Nurse #25 | Infection Control Nurse | Confirmed outdated immunization education materials. |
| Registered Nurse #42 | RN | Observed unsecured medication cups during medication administration. |
| Social Worker #7 | Social Worker | Reported lack of reporting abuse and inadequate monitoring of wandering residents. |
| Director of Nursing | DON | Provided information on hospice care plan, medication regimen review, and facility assessment. |
Inspection Report
Routine
Census: 86
Deficiencies: 5
Dec 5, 2017
Visit Reason
The inspection was conducted to assess compliance with various National Fire Protection Association (NFPA) codes and federal regulations related to emergency lighting, HVAC systems, fire drills, electrical systems, and patient-care related electrical equipment.
Findings
The facility was found deficient in maintaining emergency lighting, providing combustion air for fuel-fired equipment, conducting fire drills at unexpected times, maintaining electrical wiring, and completing electrical testing for portable patient-care related equipment. The facility acknowledged these deficiencies and submitted plans of correction including training, risk assessments, equipment testing, and scheduled maintenance.
Severity Breakdown
SS=C: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to maintain emergency lighting in accordance with NFPA 101; no evidence of required 90-minute annual emergency light testing and monthly 30-second testing. | SS=C |
| Failed to provide combustion air for fuel-fired equipment in laundry room as required by NFPA 101. | SS=C |
| Failed to hold fire drills at unexpected times and under varying conditions as required by NFPA 101. | SS=C |
| Failed to maintain electrical wiring according to NFPA standards; exposed wiring and flexible metallic conduit hanging from junction box. | SS=C |
| Failed to complete electrical testing for portable patient-care related electrical equipment; no evidence of testing and missing safety stickers. | SS=C |
Report Facts
Facility census: 86
Deficiency completion dates: Various completion dates for plans of correction ranging from 2017-12-18 to 2018-02-13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Manager | Present during inspection and acknowledged deficiencies | |
| Administrator | Present during inspection and acknowledged deficiencies | |
| Maintenance Supervisor | Provided in-service training on emergency lighting testing and responsible for quarterly equipment checks | |
| Assistant Administrator | Responsible for quarterly checks to ensure equipment stays up to date | |
| Director of Nursing | Involved in training on fire drills and documentation |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 10, 2017
Visit Reason
The document is a plan of correction submitted in response to previously cited deficiencies during the Quality Indicator and Licensure Surveys concluding on 06/13/17.
Findings
The Wyoming Nursing and Rehabilitation Center is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with credible evidence accepted in lieu of an onsite revisit. The facility is in substantial compliance with previously cited deficient practices.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 8
Jun 13, 2017
Visit Reason
Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Wyoming Nursing and Rehabilitation Center from July 7, 2017 through July 13, 2017.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of changes in resident condition, inaccurate and incomplete assessments, failure to develop or revise comprehensive care plans, medication errors including failure to follow physician orders for diabetes management and anemia treatment, failure to obtain and report laboratory tests timely, failure to provide care and treatment for pressure ulcers, and failure to serve food at proper temperatures.
Severity Breakdown
SS=E: 4
SS=D: 4
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to notify physician and resident representative of significant changes in resident condition for two residents. | SS=E |
| Failure to ensure comprehensive assessments accurately reflected resident status, including dental status and medication injections. | SS=D |
| Failure to develop and revise comprehensive care plans reflecting current resident needs and preferences, including urinary continence and pressure ulcer care plans. | SS=D |
| Failure to provide care and services consistent with physician orders for diabetes management and anemia treatment. | SS=E |
| Failure to provide pharmaceutical services ensuring medication availability and administration as ordered. | SS=D |
| Failure to obtain laboratory services timely and failure to notify physicians promptly of abnormal lab results. | SS=E |
| Failure to maintain complete and accurate medical records, including inaccurate resident weight documentation. | SS=D |
| Failure to serve food at proper temperatures to residents, with multiple resident complaints about cold food and coffee. | — |
Report Facts
Facility census: 55
Survey dates: 7
Residents in survey sample: 22
Blood sugar readings: 537
Blood sugar readings: 50
Procrit doses held: 3
Pressure ulcer size: 1.5
Pressure ulcer size: 0.7
Food temperature: 87.2
Food temperature: 128.4
Weight: 176.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed multiple findings including failure to notify physician, medication errors, and inaccurate assessments |
| Registered Nurse Assessment Coordinator #91 | RNAC | Interviewed regarding assessment and care plan deficiencies |
| Clinical Care Supervisor #92 | CCS | Provided information on pressure ulcer staging and care plan issues |
| Dietary Services Assistant #63 | DSA | Provided food temperature measurements |
| Dietary Manager #93 | DM | Provided food temperature measurements and standards |
| Licensed Practical Nurse #69 | LPN | Obtained physician order for Coumadin dose change |
| Registered Nurse #95 | RN | Documented physician notification of lab results |
Inspection Report
Census: 58
Deficiencies: 2
Jun 12, 2017
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 99 standards related to electrical systems and equipment maintenance in the facility.
Findings
The facility failed to install the Essential Electric System Alarm Annunciator according to NFPA 99 and failed to test and maintain electrical equipment as required by NFPA 99. These deficiencies were discussed with facility leadership and corrective actions were implemented.
Severity Breakdown
SS=C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to install the Essential Electric System Alarm Annunciator in accordance with NFPA 99. | SS=C |
| Failed to test and maintain electrical equipment in accordance with NFPA 99. | SS=C |
Report Facts
Facility census: 58
Completion date of corrective action: Jun 13, 2017
Completion date of corrective action: Jun 23, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Harry | Performed relocation and inspection of the Remote Annunciator |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 0
May 18, 2017
Visit Reason
Unannounced annual Quality Indicator Survey, State Licensure Survey and Complaint Investigation #17186 were conducted from May 15, 2017 to May 18, 2017 at Lakin Hospital.
Findings
The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. No deficiencies were cited.
Complaint Details
Complaint Investigation #17186 was conducted during the survey period; no deficiencies were cited.
Report Facts
Survey sample residents: 14
Inspection Report
Census: 92
Deficiencies: 4
May 16, 2017
Visit Reason
The inspection was conducted to assess compliance with NFPA (National Fire Protection Association) standards related to building safety, electrical systems, and patient care equipment maintenance.
Findings
The facility failed to maintain corridor doors in accordance with NFPA 101 due to louvered doors allowing smoke passage, failed to conduct a formal documented risk assessment of building systems per NFPA 99, failed to maintain and test electrical receptacles at patient bed locations, and failed to maintain patient-care related electrical equipment according to NFPA 99 standards.
Severity Breakdown
SS=C: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| NFPA 101 Corridor - Openings: Louvered doors in bathroom corridor doors on resident wings A, B, C, and D allowed passage of smoke. | SS=C |
| NFPA 101 Fundamentals - Building System Categories: Failure to conduct a formal documented risk assessment of building systems. | SS=C |
| NFPA 101 Electrical Systems - Maintenance and Testing: Failure to conduct maintenance and testing of hospital-grade receptacles at patient bed locations. | SS=C |
| NFPA 101 Electrical Equipment - Testing and Maintenance: Failure to maintain patient-care related electrical equipment in accordance with NFPA 99. | SS=C |
Report Facts
Facility Census: 92
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to corrective actions for deficiencies including ordering plates to cover door louvers, conducting audits, completing risk assessments, ordering testing equipment, and monitoring testing. | |
| Administrator | Discussed deficiencies with surveyors and agreed on needed corrections. | |
| Building and Grounds Manager | Discussed deficiencies with surveyors and agreed on needed corrections. |
Inspection Report
Plan of Correction
Deficiencies: 1
May 8, 2017
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey for Jackie Withrow Hospital, addressing previously cited deficient practices and confirming substantial compliance.
Findings
Jackie Withrow Hospital is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules. The plan of correction and credible evidence were accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 04/06/17.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility must inform residents orally and in writing of their rights, rules, services, and charges in a language they understand, including Medicaid-related information and legal rights. | Level C |
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 14
Apr 6, 2017
Visit Reason
Unannounced annual Quality Indicator Survey, State Licensure Surveys, and Complaint Investigation #17076 were conducted at Jackie Withrow Hospital from 03/27/17 through 04/06/17.
Findings
The facility was found deficient in multiple areas including failure to provide dentures to Resident #84 despite dentures being delivered to the facility, failure to maintain residents' dignity during meal service and catheter care, failure to ensure call lights were accessible to residents, maintenance and housekeeping deficiencies, incomplete and inaccurate medical records, failure to monitor medication effectiveness and vital signs as ordered, improper medication storage and labeling, infection control lapses including improper hand hygiene and linen handling, and failure to follow up on pharmacist recommendations for medication dose reductions.
Complaint Details
Complaint investigation #17076 was substantiated with related deficiencies at F224 and F225. The complaint involved neglect related to missing dentures for Resident #84, which were not located or provided to the resident for 299 days despite being delivered to the facility.
Severity Breakdown
SS=D: 11
SS=E: 4
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to provide dentures to Resident #84 despite dentures being delivered to the facility on 06/09/16 and not located until surveyor intervention on 04/03/17. | SS=D |
| Failure to maintain residents' dignity: uncovered catheter bag visible from hallway and residents at same table not served meals at the same time. | SS=D |
| Failure to ensure call light was accessible to Resident #79; call light was dangling out of reach. | SS=D |
| Maintenance and housekeeping deficiencies including buckling paint, chipped paint, broken window blinds, dirty heating/cooling units, stained toilets, and dirty shower rooms. | SS=D |
| Failure to ensure accuracy of comprehensive assessment related to depression for Resident #38; depression diagnosis not coded despite medication orders. | SS=D |
| Failure to revise care plans related to nutrition, pain, lab refusals, and colostomy care for multiple residents. | SS=D |
| Failure to monitor effectiveness of pain medication for Resident #79 and failure to obtain vital signs prior to administering Metoprolol for Resident #38 as ordered. | SS=E |
| Failure to provide necessary dental services as evidenced by failure to secure and deliver dentures to Resident #84 for 299 days. | SS=D |
| Failure to store medications properly including undated insulin vials, open and undated purified protein derivative vials, and improperly labeled eye drops. | SS=D |
| Failure to maintain effective infection control program including improper hand hygiene during medication administration, improper linen handling, and inadequate antibiotic stewardship. | SS=D |
| Failure to maintain sanitary and comfortable transfer equipment; wheelchair arms for Resident #89 were torn and needed replacement. | SS=D |
| Failure to maintain complete and accurate medical records related to documentation of meal intake and nutritional supplements for Resident #26. | SS=E |
| Failure to follow physician orders to assess vital signs prior to administration of antihypertensive medications and failure of the quality assurance program to identify and correct this repeated deficiency. | SS=D |
| Failure to store, prepare, distribute, and serve food in a sanitary manner including uncovered food in freezer and refrigerator, improper storage of flour and salt, and dirty kitchen window and blinds. | SS=E |
Report Facts
Residents affected: 1
Survey sample size: 40
Facility census: 90
Deficiency counts: 15
Weight loss percentage: 9.1
Medication refusal days: 12
Medication administration missing vital signs: 4
Meal intake omissions: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #105 | Unit Manager | Interviewed regarding Resident #84 dentures and care plan. |
| LPN #28 | Licensed Practical Nurse | Observed administering medications without hand hygiene. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including dentures, vital signs, infection control. |
| Employee #146 | Resident Accounts employee who described denture delivery process. | |
| Employee #157 | Resident Accounts employee who confirmed denture invoice and Medicaid payment. | |
| Dietary Supervisor #114 | Interviewed regarding kitchen food storage deficiencies. | |
| Dietary Manager #154 | Interviewed regarding kitchen food storage deficiencies. | |
| HSW #11 | Health Service Worker | Interviewed regarding Resident #84 denture care. |
| Pharmacist | Interviewed regarding failure to recommend gradual dose reduction for Resident #12. |
Inspection Report
Routine
Census: 90
Deficiencies: 19
Mar 29, 2017
Visit Reason
Routine inspection of Jackie Withrow Hospital to assess compliance with fire safety, electrical, and facility maintenance regulations.
Findings
The facility was found to have multiple deficiencies including obstructed means of egress, non-functioning emergency lighting and exit signage, improperly enclosed vertical openings, hazardous areas not maintained, fire alarm system issues, sprinkler system maintenance deficiencies, fire extinguisher servicing lapses, corridor door malfunctions, HVAC exhaust fan problems, elevator penthouse storage violations, exposed electrical wiring, missing GFCI receptacles near water sources, incomplete generator battery testing, incomplete electrical equipment testing, and improper storage and training related to medical gas cylinders.
Severity Breakdown
SS=C: 18
Deficiencies (19)
| Description | Severity |
|---|---|
| Means of egress obstructed by laundry cart, wheelchair scales, and beds. | SS=C |
| Emergency lighting not functioning at main entrance and snack bar. | SS=C |
| Exit and directional signs not maintained; multiple exit lights not working. | SS=C |
| Vertical openings (dumbwaiter doors) not properly enclosed or sealed. | SS=C |
| Hazardous areas with door closer missing and door wedged open. | SS=C |
| Cooking facilities' fire suppression system not properly maintained or tested. | SS=C |
| Fire alarm control panel in trouble state due to phone line failure. | SS=C |
| Fire alarm system smoke detector sensitivity testing incomplete; failed detector not replaced. | SS=C |
| Sprinkler system gauges not calibrated or replaced; wires taped and zip tied to sprinkler pipes. | SS=C |
| Fire extinguishers in elevator penthouses not serviced since 2014. | SS=C |
| Corridor doors not closing properly; gaps and missing door coordinators. | SS=C |
| HVAC rooftop exhaust fans missing covers and not working. | SS=C |
| Elevator penthouses used for storage of items unrelated to elevator function. | SS=C |
| Electrical systems with missing junction box covers, exposed wiring, and hanging receptacles. | SS=C |
| Water fountains lacking ground fault circuit interrupting (GFCI) receptacles. | SS=C |
| Generator battery electrolyte testing incomplete; only one cell tested. | SS=C |
| Portable patient-care electrical equipment not tested or tagged as required. | SS=C |
| Medical gas cylinders (acetylene and oxygen) stored together without proper separation. | SS=C |
| Lack of safety and usage training for staff handling medical gas cylinders. | SS=C |
Report Facts
Census: 90
Deficiencies cited: 18
Fire extinguisher last serviced: 2014
Date of inspection: Mar 29, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Maintenance Director | Present during multiple findings and agreed on needed corrections | |
| Assistant Maintenance Supervisor | Responsible for monitoring compliance, maintaining logs, and overseeing corrective actions | |
| NHA | Nursing Home Administrator | In-serviced department managers and involved in compliance monitoring |
| Maintenance Staff | Performed corrective actions such as moving obstructions, repairing equipment, and replacing fire extinguishers | |
| Electrician | Replaced electrical components and GFCI receptacles |
Inspection Report
Life Safety
Deficiencies: 0
Nov 30, 2016
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2012.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012.
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Nov 28, 2016
Visit Reason
An unannounced complaint investigation was conducted at Lincoln Nursing and Rehabilitation Center from November 28, 2016 to October 30, 2016.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Complaint Details
The investigation was complaint-related and the facility was found to be in substantial compliance.
Report Facts
Sample size: 23
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Sep 9, 2016
Visit Reason
An unannounced complaint investigation was conducted from September 5, 2016 to September 8, 2016 at Nella's Inc. for Complaint Reference #16303.
Findings
Elements of the complaint were substantiated for an occurrence in 2014; however, at the time of investigation, the facility was in substantial compliance with applicable regulations.
Complaint Details
Elements of the complaint were substantiated for an occurrence in 2014.
Report Facts
Sample size: 11
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 0
Aug 22, 2016
Visit Reason
An unannounced revisit was conducted at Wyoming Nursing and Rehabilitation Center from August 22, 2016 to August 24, 2016 for the Quality Indicator Survey concluding on June 23, 2016.
Findings
The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.
Report Facts
Revisit survey sample: 19
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 28, 2016
Visit Reason
The inspection was conducted as a complaint investigation, including a Quality Indicator Survey, State Licensure Survey, and Complaint Investigation concluding on 05/12/16.
Findings
The facility, Nella's Inc., was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. Plans of correction and credible evidence were accepted in lieu of an onsite revisit.
Complaint Details
Complaint Reference: #15535. The facility was found in substantial compliance with previously cited deficient practices.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 7
Jun 23, 2016
Visit Reason
Unannounced annual Quality Indicator and State Licensure Surveys were conducted from June 21, 2016 through June 23, 2016 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance, care and services for highest well-being related to tube feeding, timely physician visits, call light response times, infection control practices, and accuracy of clinical records. Immediate jeopardy was identified related to inadequate care for a resident with tube feeding and failure of physician face-to-face visits.
Severity Breakdown
Level E: 1
Level J: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide effective housekeeping and maintenance services for eleven resident rooms with cosmetic imperfections such as rusted light fixtures, peeling paint, missing hooks, and water stains. | Level E |
| Failed to provide necessary care and services to maintain highest practicable well-being for a resident with tube feeding, including inaccurate feeding orders, failure to increase feeding despite weight loss, and inaccurate height and BMI documentation. | Level J |
| Failed to deploy sufficient nursing staff to ensure timely response to call lights for three residents. | — |
| Failed to ensure physician made required face-to-face visits every 60 days after first 90 days; visits were delegated to nurse practitioner without proper physician involvement for multiple residents. | — |
| Failed to ensure oxygen tubing was dated when last changed, posing infection control risk. | — |
| Failed to ensure call light was functioning for one resident. | — |
| Failed to maintain complete and accurate clinical records for a resident, including inaccurate height, BMI, and enteral feeding orders. | — |
Report Facts
Facility census: 59
Residents with delayed call light response: 3
Weight loss: 18.7
Tube feeding rate: 30
Tube feeding rate increased: 32
Call light response delays for Resident #6: 14
Call light response delays for Resident #79: 17
Call light response delays for Resident #82: 2
Physician visits missed: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CFNP #99 | Certified Family Nurse Practitioner | Managed care of Resident #15 and other residents, made physician visits but did not accurately assess or document Resident #15's status |
| Director of Nursing | Director of Nursing | Interviewed regarding call light response issues, physician visit compliance, and resident care |
| Corporate Licensed Dietitian #101 | Licensed Dietitian | Evaluated Resident #15's nutritional status and made recommendations |
| Attending Physician | Physician/Medical Director | Misinterpreted physician visit requirements, failed to see residents timely, corrected practice after notification |
| LPN #24 | Licensed Practical Nurse | Observed unhooking and rehooking of Resident #15's feeding tube |
| Nurse Aide #77 | Nurse Aide | Unhooked Resident #15's feeding tube without authorization |
| Nurse Aide #81 | Nurse Aide | Reported Nurse Aide #77 unhooked Resident #15's feeding tube |
| Registered Nurse #47 | Registered Nurse | Interviewed about documentation of resident fluid intake |
| Social Worker | Social Worker | Investigated Resident #6's complaint about call light response |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 0
May 23, 2016
Visit Reason
An unannounced complaint investigation was conducted from 05/23/16 to 05/25/16 at Lakin Hospital for Complaint Reference #15575.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with applicable federal and state nursing home regulations.
Complaint Details
Complaint Reference #15575 was investigated and found unsubstantiated with no deficiencies identified.
Report Facts
Sample size: 5
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 11
May 12, 2016
Visit Reason
Unannounced annual Quality Indicator and State Licensure Surveys were conducted from May 2, 2016 through May 12, 2016. Complaint #15535 was investigated at the time of the annual surveys.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance, comprehensive assessments, care planning, provision of care and services, infection control, medication regimen review, and clinical record maintenance. Specific issues included failure to maintain sanitary conditions, inaccurate resident assessments, incomplete care plans, inadequate monitoring of residents especially those on dialysis, improper wound care techniques, improper incontinence care, unsanitary food preparation equipment, and incomplete medical records.
Complaint Details
Complaint #15535 was substantiated with one unrelated deficiency.
Severity Breakdown
E: 4
D: 5
B: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to provide effective housekeeping and maintenance services for five resident rooms with damaged walls, peeling paint, scrapes on floors, unpainted areas, and missing curtain hooks. | E |
| Failed to accurately assess three residents' diagnoses on Minimum Data Set (MDS) assessments. | D |
| Failed to develop a comprehensive care plan addressing advance directive implementation for one resident receiving hospice care. | D |
| Failed to reassess and revise plan of care to meet needs of a resident refusing fingerstick blood sugars and insulin coverage. | — |
| Did not provide necessary care and services to attain highest practicable well-being for residents, including inadequate monitoring of dialysis patients and failure to address diabetes care needs. | E |
| Failed to provide care service to promote healing of existing pressure ulcers and prevent infection, including improper wound care technique and handling of soiled linens. | D |
| Did not provide incontinence care in a manner to prevent urinary tract infections, including improper cleansing technique and failure to use soap or antimicrobial cleanser. | D |
| Dietary staff did not ensure food preparation equipment was kept clean and sanitary, including accumulation of food debris on drip pan under range top. | B |
| Pharmacist failed to report irregularities regarding administration of psychotropic medications for one resident. | D |
| Facility did not maintain an effective infection control program to prevent transmission and spread of infection; staff used improper hand hygiene and handled soiled laundry improperly. | E |
| Facility did not maintain clinical records that were complete, accurately documented, and systematically organized, including inaccurate pneumonia vaccine documentation and missing dialysis records. | D |
Report Facts
Residents in survey sample: 24
Residents in complaint sample: 14
Facility census: 86
Rooms with housekeeping deficiencies: 5
Residents with inaccurate assessments: 3
Residents with incomplete care plans: 1
Days resident refused insulin or fingerstick checks: 34
Opportunities with no dialysis communication form: 30
Pressure ulcer size: 4
Pressure ulcer size: 0.3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #22 | MDS Coordinator | Named in inaccurate assessment and medication diagnosis findings |
| LPN #61 | Licensed Practical Nurse | Named in findings related to refusal of insulin and fingerstick blood sugar monitoring |
| RN #4 | Registered Nurse | Named in findings related to refusal of insulin and fingerstick blood sugar monitoring |
| LPN #11 | Licensed Practical Nurse | Named in dialysis communication and monitoring findings |
| LPN #102 | Licensed Practical Nurse | Named in dialysis communication and monitoring findings |
| LPN #67 | Licensed Practical Nurse | Named in dialysis communication and monitoring findings |
| DON | Director of Nursing | Named in multiple findings including dialysis monitoring, wound care, infection control, and record keeping |
| LPN #89 | Licensed Practical Nurse | Named in wound care findings for improper technique |
| NA #52 | Nurse Aide | Named in infection control findings for improper hand hygiene and linen handling |
| NA #67 | Nurse Aide | Named in infection control findings for improper incontinence care technique |
| NA #42 | Nurse Aide | Named in infection control findings for improper incontinence care technique |
| RN #1 | Registered Nurse | Named in medication regimen review findings |
| LPN #1 | Licensed Practical Nurse | Named in medication regimen review findings |
Inspection Report
Routine
Census: 86
Deficiencies: 4
May 9, 2016
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including sprinkler system maintenance, smoking regulations, emergency generator maintenance, and electrical wiring safety.
Findings
The facility was found deficient in maintaining sprinkler systems free of obstructions, providing proper smoking containers, monitoring emergency generator battery electrolyte levels, and securing multi-tap electrical plugs. Maintenance staff acknowledged these issues and corrective actions were planned or underway.
Severity Breakdown
SS=C: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Sprinkler piping had wires and cables draped over them and sprinkler heads were covered with insulation batting. | SS=C |
| Facility failed to provide a metal container with self-closing cover device in the designated smoking area. | SS=C |
| Emergency generator battery electrolyte levels were not monitored and recorded weekly as required. | SS=C |
| Multi-tap electrical plugs were not secured to electrical outlets in multiple resident rooms. | SS=C |
Report Facts
Facility census: 86
Deficiencies cited: 4
Inspection Report
Annual Inspection
Deficiencies: 0
Apr 12, 2016
Visit Reason
The visit was conducted as an annual recertification Quality Indicator Survey (QIS) to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules.
Findings
Lakin Hospital was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 4
Mar 10, 2016
Visit Reason
An unannounced annual Quality Indicator Survey was conducted at Lakin Hospital from March 7, 2016 through March 10, 2016 to assess compliance with regulatory requirements.
Findings
The survey identified deficiencies including failure to complete quarterly minimum data sets (MDS) timely and accurately, failure to revise care plans after significant weight loss, and failure to maintain fluid restrictions for residents as ordered by physicians.
Severity Breakdown
E: 2
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to complete quarterly minimum data sets (MDS) within 14 days of the assessment reference date for multiple residents. | E |
| Failure to accurately reflect diagnoses in MDS assessments for residents receiving antipsychotic medications. | D |
| Failure to revise care plan to reflect significant weight loss for Resident #68. | — |
| Failure to provide care and services to maintain or attain highest practicable well-being by not adhering to fluid restrictions for Residents #93 and #34. | E |
Report Facts
Facility census: 96
Residents in survey sample: 22
Residents with late MDS assessments: 4
Weight loss: 15.8
Fluid intake exceedance: 560
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator #78 | MDS Coordinator | Named in findings related to incomplete and untimely MDS assessments. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding MDS completion and fluid restriction compliance. |
| Registered Dietitian #16 | Registered Dietitian | Interviewed regarding care plan updates and fluid restriction compliance. |
| Licensed Practical Nurse (LPN) #22 | Licensed Practical Nurse | Interviewed regarding fluid intake provided to Resident #93. |
| Assistant Director of Nursing (ADON) #44 | Assistant Director of Nursing | Interviewed regarding fluid intake monitoring and compliance. |
Inspection Report
Deficiencies: 0
Mar 10, 2016
Visit Reason
The Quality Indicator Survey was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Findings
Jackie Withrow Hospital was found to be in substantial compliance with the previously cited deficient practices and the applicable federal requirements for long term care facilities.
Report Facts
Survey completion date: Mar 10, 2016
Quality Indicator Survey end date: Feb 3, 2016
Inspection Report
Census: 114
Deficiencies: 5
Mar 7, 2016
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to facility safety, fire drills, smoking regulations, and generator maintenance.
Findings
The facility was found deficient in multiple areas including failure to provide at least two smoke compartments on sleeping floors with more than 30 patients, failure to maintain hazardous storage areas with proper self-closing doors, failure to conduct fire drills at varied times, failure to meet smoking regulations, and failure to perform required generator load testing.
Severity Breakdown
SS=C: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide at least two smoke compartments on every sleeping room floor for more than 30 patients. | SS=C |
| Failed to maintain hazardous storage area with self-closing door as required. | SS=C |
| Failed to conduct fire drills at varied times as required. | SS=C |
| Failed to meet smoking regulations including absence of metal container with self-closing cover in designated smoking area. | SS=C |
| Failed to meet generator inspection and load testing requirements. | SS=C |
Report Facts
Facility census: 114
Deficiencies cited: 5
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 7
Feb 3, 2016
Visit Reason
An unannounced annual Quality Indicator Survey was conducted at Jackie Withrow Hospital from January 26, 2016 through February 3, 2016.
Findings
The survey identified multiple deficiencies including failure to conduct accurate comprehensive assessments, failure to develop and implement care plans for urinary incontinence and vision care needs, failure to follow medication administration protocols, unsafe storage of controlled medications, unsanitary medication room conditions, and incomplete clinical records related to bowel movements.
Severity Breakdown
Level B: 1
Level D: 4
Level E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Resident #91's admission comprehensive assessment did not identify active diagnoses for which the resident was being treated. | Level D |
| Facility failed to ensure a care plan was developed with measurable goals and interventions for residents with urinary incontinence and vision care needs (Residents #73 and #75). | Level D |
| Staff failed to follow a care plan intervention for Resident #25 directing the resident's pulse rate be checked prior to administration of Clonidine. | Level D |
| Facility failed to ensure physician's orders were followed for Resident #78's bowel protocol related to opioid medication use. | Level D |
| Controlled medications were not stored in a separately locked, permanently affixed compartment in the first and third floor medication rooms. | Level E |
| Second floor medication room was found to be soiled, including refrigerator, countertop, and floor. | Level E |
| Facility failed to maintain a complete, accurately documented clinical record for Resident #78 regarding bowel movements. | Level B |
Report Facts
Residents sampled: 14
Facility census: 83
Fentanyl patches: 5
Lorazepam tabs: 30
Alprazolam tabs: 30
Tramadol tabs: 30
Phenobarbital tabs: 30
Lorazepam tabs: 60
Lyrica tabs: 30
Tramadol tabs: 30
Diazepam tabs: 30
Morphine Sulfate tabs: 30
Alprazolam tabs: 30
Clonazepam tabs: 60
Hydrocodone/Acetaminophen tabs: 120
Nurse aide flow records missing: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #106 | Present during observation of unsecured controlled medications on first floor | |
| Licensed Practical Nurse #159 | Present during observation of unsecured controlled medications on third floor | |
| Licensed Practical Nurse #173 | Present during observation of soiled second floor medication room | |
| Director of Nursing | DON | Interviewed regarding missing vital signs, bowel movement documentation, and medication storage |
| MDS Coordinator | Interviewed regarding incomplete assessments and care plans |
Inspection Report
Routine
Census: 83
Deficiencies: 7
Jan 27, 2016
Visit Reason
The inspection was conducted as a routine building and life safety code survey to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain corridor doors that resist smoke passage, unsealed smoke barriers, incomplete fire drill documentation, inadequate maintenance of sprinkler systems, fire extinguishers, emergency generator, and electrical wiring issues such as missing junction box covers.
Severity Breakdown
SS=C: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to protect corridor openings with doors capable of resisting passage of smoke; resident room doors failed to latch and had gaps exceeding one half inch. | SS=C |
| Facility failed to maintain smoke barrier walls to provide at least one half hour fire resistance rating; openings around conduits and piping not sealed properly. | SS=C |
| Facility failed to conduct fire drills quarterly on each shift; missing records for multiple shifts and quarters in 2015. | SS=C |
| Facility failed to maintain sprinkler system in reliable operating condition; no record of gauge calibration within five years and missing sprinkler testing for fourth quarter 2015. | SS=C |
| Facility failed to maintain and inspect portable fire extinguishers; 53 of 111 fire extinguishers overdue for six year maintenance, some not checked monthly, and one needed recharging. | SS=C |
| Facility failed to maintain emergency generator; failed to test and record battery electrolyte fluid specific gravity weekly. | SS=C |
| Facility failed to maintain electrical wiring and equipment; missing junction box covers at nurses station and basement electrical boxes. | SS=C |
Report Facts
Facility census: 83
Fire extinguishers overdue maintenance: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| maintenance supervisor | Discussed and agreed on corrections needed for multiple deficiencies including door latching, smoke barriers, fire drills, sprinkler system, fire extinguishers, generator, and electrical issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 18, 2015
Visit Reason
The inspection was conducted as a complaint investigation concluding on 2015-11-04 to review previously cited deficient practices at Jackie Withrow Hospital.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
Complaint Reference: 14662. The complaint investigation concluded with the facility in substantial compliance and no new deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 14, 2015
Visit Reason
The document is a plan of correction submitted in response to a Quality Indicator Survey concluding on 2015-10-29, accepted in lieu of an onsite revisit.
Findings
The facility, Lincoln Nursing and Rehabilitation Center, LLC, is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with previously cited deficient practices addressed through the plan of correction.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 483.10(b)(5) - (10), 483.10(b)(1) NOTICE OF RIGHTS, RULES, SERVICES, CHARGES: The facility must inform residents of their rights and services in writing and orally in a language they understand, including Medicaid-related information and charges. | SS=C |
Report Facts
Survey completion date: Dec 14, 2015
Quality Indicator Survey conclusion date: Oct 29, 2015
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 1
Nov 4, 2015
Visit Reason
An unannounced complaint survey was conducted at Jackie Withrow Hospital from November 2, 2015 to November 4, 2015, triggered by Complaint #14662 which was unsubstantiated.
Findings
The facility failed to ensure that Resident #91 received a pneumococcal immunization after the responsible party was educated and consented. The vaccine was not ordered or administered due to an oversight, despite consent being obtained.
Complaint Details
Complaint #14662 was unsubstantiated with an unrelated deficiency cited. The complaint sample consisted of 9 residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure Resident #91 received pneumococcal immunization after consent was given. | SS=D |
Report Facts
Residents sampled for infection control review: 6
Residents identified with pneumonia: 6
Facility census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #112 | Person designated as responsible for infection control who acknowledged the omission of vaccine administration | |
| Director of Nursing (DON) | Re-educated licensed nursing staff on obtaining physician's orders and vaccine administration |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 3
Oct 29, 2015
Visit Reason
An unannounced annual Quality Indicator Survey was conducted at Lincoln Nursing and Rehabilitation Center from October 26, 2015 through October 29, 2015.
Findings
The facility was found deficient in multiple areas including failure to implement care plans for residents, improper wound care techniques leading to potential contamination, failure to provide proper incontinence care increasing risk of urinary tract infections, and lack of staff knowledge regarding dietary restrictions for residents. Deficiencies were based on observations, record reviews, and staff interviews.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to implement care plan and knowledge of care for two residents; skin care not performed as required and lack of knowledge of renal diet. | SS=D |
| Failure to provide treatment and services to prevent and heal pressure sores for two residents; improper wound care techniques observed. | SS=D |
| Failure to provide incontinence care to prevent urinary tract infections; improper technique observed increasing risk of infection. | SS=D |
Report Facts
Residents in survey sample: 17
Facility census: 56
Pressure ulcer measurement: 1.1
Pressure ulcer measurement: 2
Pressure ulcer measurement: 1
Pressure ulcer measurement: 3.3
Pressure ulcer measurement: 1.5
Urinary tract infection lab results: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #10 | Unit Charge Nurse-Licensed Practical Nurse | Named in findings related to improper wound care and incontinence care |
| DON | Director of Nursing | Provided interviews confirming improper care and expectations for staff |
| CCS | Clinical Care Supervisor | Observed and assisted with wound care and incontinence care |
| Nurse Aide #52 | Interviewed regarding knowledge of resident dietary restrictions | |
| LPN #33 | Interviewed regarding knowledge of resident dietary restrictions and wound care | |
| LPN #69 | Interviewed regarding knowledge of resident dietary restrictions | |
| Dietary Manager | Interviewed regarding resident diet and staff awareness |
Inspection Report
Life Safety
Deficiencies: 0
Oct 28, 2015
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Oct 15, 2015
Visit Reason
An unannounced complaint investigation was conducted from October 13, 2015 to October 15, 2015 at Jackie Withrow Hospital for Complaint Reference #14011 and #14494.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.
Complaint Details
The allegations were unsubstantiated and no related or unrelated deficient practices were identified.
Report Facts
Sample size: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 9, 2015
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey for Wyoming Nursing and Rehabilitation Center, LLC, accepted in lieu of an onsite revisit.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected as evidenced by the accepted plan of correction and credible evidence.
Report Facts
Survey completion date: Jul 9, 2015
Previous survey date: Jun 4, 2015
Inspection Report
Life Safety
Deficiencies: 0
Jun 9, 2015
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 2
Jun 1, 2015
Visit Reason
Unannounced annual Quality Indicator and Licensure Surveys were conducted at Wyoming Nursing and Rehabilitation Center from June 1, 2015 through June 4, 2015.
Findings
The survey identified deficiencies including inaccurate resident assessments related to thyroid disorder documentation and unsafe storage of controlled medications requiring refrigeration. The facility submitted plans of correction addressing these issues.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Quarterly MDS assessment did not accurately reflect a diagnosis of hypothyroidism for Resident #12. | SS=D |
| Controlled medications subject to abuse requiring refrigeration were stored in a clear box not permanently affixed to the refrigerator. | SS=D |
Report Facts
Residents reviewed in survey sample: 30
Medication count: 17
Medication count: 28
Medication count: 1
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
May 20, 2015
Visit Reason
An unannounced complaint investigation was conducted from May 18, 2015 to May 20, 2015 at Jackie Withrow Hospital for Complaint Reference #13626.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with applicable regulations.
Complaint Details
The complaint allegations were unsubstantiated.
Report Facts
Sample size: 8
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 25, 2015
Visit Reason
The document is a plan of correction submitted in response to previously cited deficiencies during the Quality Indicator and Licensure Surveys concluding on 03/03/15.
Findings
The facility, Nella's at Autumn Lake Healthcare, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Report Facts
Survey completion date: Mar 25, 2015
Survey conclusion date: Mar 3, 2015
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 0
Mar 23, 2015
Visit Reason
An unannounced complaint investigation was conducted at Jackie Withrow Hospital for Complaint Reference 12691.
Findings
The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with applicable regulations.
Complaint Details
The complaint allegations were unsubstantiated.
Report Facts
Sample size: 6
Inspection Report
Life Safety
Deficiencies: 0
Mar 11, 2015
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 5
Mar 3, 2015
Visit Reason
Unannounced annual Quality Indicator and State Licensure Surveys were conducted from February 24, 2015 through March 3, 2015 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to conduct abuse registry checks prior to employment for some staff, incomplete care plans for residents, improper hand hygiene and infection control practices, and unsecured storage of refrigerated controlled substances. Corrective actions and staff inservices were planned or implemented.
Severity Breakdown
Level C: 1
Level D: 1
Level E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure State nurse aide registry checks were completed prior to employment for five employees (#70, #96, #11, #35, #61). | Level C |
| Failure to develop comprehensive care plans addressing monitoring of dialysis site for Resident #101 and individualized non-pharmacological interventions for Resident #61. | Level D |
| Failure to ensure staff served food in a sanitary manner; employee failed to wash/sanitize hands between resident contacts affecting Residents #20 and #32. | Level E |
| Failure to store refrigerated controlled substances in permanently affixed locked compartments; medication boxes were removable. | Level E |
| Failure to follow infection control practices during medication pass; nurse contaminated medications by touching with bare hands affecting Residents #21 and #34. | Level E |
Report Facts
Facility census: 86
Survey dates: 8
Survey sample size: 16
Employees with missing registry checks: 5
Residents with deficient care plans: 2
Residents observed during medication pass: 7
Residents affected by medication pass deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #70 | Maintenance Employee | Identified as lacking prior abuse registry check |
| Employee #96 | Tech Support Person | Identified as lacking prior abuse registry check |
| Employee #11 | Tech Support Person | Identified as lacking prior abuse registry check |
| Employee #35 | Dietary Manager | Identified as lacking prior abuse registry check |
| Employee #61 | Licensed Practice Nurse | Identified as lacking prior abuse registry check |
| Nurse Aide #46 | Nurse Aide | Failed to wash/sanitize hands between resident contacts during meal service |
| Employee #18 | Licensed Practical Nurse | Broke infection control protocol during medication pass by contaminating medications |
| Registered Nurse #92 | Registered Nurse | Reported lack of documentation for dialysis site monitoring |
| Office Assistant #5 | Office Assistant | Assisted with personnel record review and acknowledged failure to complete registry checks |
| Licensed Practical Nurse #36 | Licensed Practical Nurse | Discovered unsecured medication storage and notified maintenance |
| Registered Nurse #29 | Registered Nurse | Confirmed unsecured medication storage and reported it |
| Director of Nursing | Director of Nursing | Acknowledged findings and provided policies |
Inspection Report
Re-Inspection
Census: 89
Deficiencies: 0
Feb 9, 2015
Visit Reason
An unannounced revisit was conducted at Lakin Hospital from February 9, 2015 to February 11, 2015 for the Quality Indicator Survey concluding on January 14, 2014.
Findings
The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.
Report Facts
Revisit survey sample: 5
Inspection Report
Routine
Census: 92
Deficiencies: 2
Jan 21, 2015
Visit Reason
The inspection was conducted as a routine survey to assess compliance with life safety code standards and other regulatory requirements at Lakin Hospital.
Findings
The facility failed to maintain a metal container with a self-closing cover for ashtrays in the patient smoking area and had several missing 'J' box covers from electrical boxes with improperly installed data/phone cables along sprinkler piping, indicating non-compliance with NFPA 101 Life Safety Code and NFPA 70 National Electrical Code.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain a metal container with self-closing cover device into which ashtrays can be emptied in the patient smoking area. | SS=D |
| Several 'J' box covers missing from electrical boxes over drop ceilings and data/phone cables improperly installed over and along sprinkler piping. | SS=F |
Report Facts
Facility census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Discussed findings regarding smoking area container and electrical issues | |
| Facility Director | Discussed findings at exit interview |
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 4
Jan 14, 2015
Visit Reason
An unannounced annual Quality Indicator Survey was conducted at Lakin Hospital from January 12, 2015 through January 14, 2015 to assess compliance with regulatory requirements.
Findings
The survey identified deficiencies including failure to provide meaningful activities for residents, failure to revise nutrition care plans in response to weight loss, failure to implement care plans for activities and fall prevention, and failure to maintain nutritional status for a resident with significant weight loss.
Severity Breakdown
SS=D: 3
SS=G: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to provide a meaningful activity program for one resident (#40), including lack of one-on-one activities and failure to cover units when activity staff were ill. | SS=D |
| Facility failed to review and revise nutrition care plan for resident (#66) with significant weight loss and frequent meal refusals. | SS=D |
| Facility failed to implement care plans for two residents (#40 and #15), including activities and fall prevention interventions (hipsters). | SS=D |
| Facility failed to maintain nutritional status for resident (#66) with severe weight loss of 14.3% over three months without appropriate interventions. | SS=G |
Report Facts
Facility census: 89
Survey sample size: 28
Weight loss: 19
Weight loss percentage: 14.3
Meal refusals: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health Service Trainee #141 | Interviewed regarding lack of resident #40 participation in activities | |
| Activity Staff #129 | Interviewed regarding activity coverage and documentation for resident #40 | |
| Director of Nursing Staff #6 | Director of Nursing | Verified activity staff responsibilities and lack of coverage for resident #40 activities |
| Dietary Manager Staff #47 | Dietary Manager | Reviewed nutrition care plan and weight loss for resident #66 |
| Health Service Worker #147 | Reported resident #66 meal refusals and eating behavior | |
| Health Service Trainee #137 | Interviewed about resident #15 fall interventions and hipster use | |
| Health Service Trainee #68 | Interviewed about resident #15 hipster availability and use | |
| Laundry Worker #23 | Interviewed about hipster laundry and inventory for resident #15 | |
| Director of Nursing | Director of Nursing | Unaware of hipster shortages for resident #15 and weight loss identification for resident #66 |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 6, 2015
Visit Reason
The document is a plan of correction related to a previous Quality Indicator and Licensure Survey for Jackie Withrow Hospital, addressing previously cited deficient practices.
Findings
Jackie Withrow Hospital is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with credible evidence accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 12/03/14.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility as required by 483.10(b)(5)-(10), 483.10(b)(1). | SS=C |
Report Facts
Survey completion date: Jan 6, 2015
Previous survey date: Dec 3, 2014
Inspection Report
Life Safety
Deficiencies: 0
Dec 11, 2014
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 7
Dec 3, 2014
Visit Reason
An unannounced annual Quality Indicator Survey was conducted at Jackie Withrow Hospital from December 1, 2014 through December 3, 2014.
Findings
The facility was found deficient in several areas including failure to notify a resident of a roommate change, failure to promote a homelike dining environment, failure to conduct comprehensive assessments for physical restraints, failure to assess and document restraint use properly, failure to promote dignity during meal times, failure to update and revise a resident's nutrition care plan, and failure to maintain nutritional status by re-weighing a resident after significant weight loss and providing ordered nutritional supplements.
Severity Breakdown
SS=D: 6
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to notify one resident of a roommate change prior to the change. | SS=D |
| Failed to promote a homelike dining environment; meals served on trays with items not removed and milk served in cartons. | SS=E |
| Failed to conduct comprehensive assessments for physical restraints for two residents. | SS=D |
| Failed to ensure one resident was restrained only as required to treat medical symptoms; no assessment for bed rails. | SS=D |
| Failed to promote dignity and respect during meal times; residents pulled backwards in wheelchairs and staff fed residents while standing. | SS=D |
| Failed to review and revise one resident's nutrition care plan to include nutritional supplements. | SS=D |
| Failed to maintain nutritional status; resident not re-weighed after significant weight loss and did not receive ordered nutritional supplements. | SS=D |
Report Facts
Deficiencies cited: 7
Facility census: 93
Survey dates: 2014-12-01 to 2014-12-03
Weight loss: 29.3
Weight loss percentage: 13.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HSW #69 | Health Service Worker | Mentioned in relation to weights and nutritional supplement administration for Resident #93 |
| HSW #14 | Health Service Worker | Mentioned in relation to bed rail removal and resident mobility for Resident #69 |
| Resident #98 | Resident involved in roommate change notification deficiency | |
| Resident #69 | Resident involved in physical restraint and bed rail assessment deficiencies | |
| Resident #93 | Resident involved in nutrition care plan and nutritional status deficiencies | |
| Resident #47 | Resident involved in physical restraint and wheelchair assessment deficiencies | |
| Resident #81 | Resident involved in dignity and respect during meal times deficiency | |
| Resident #33 | Resident involved in dignity and respect during meal times deficiency | |
| Resident #10 | Resident involved in dignity and respect during meal times deficiency | |
| Resident #23 | Resident involved in dignity and respect during meal times deficiency | |
| Resident #16 | Resident involved in dignity and respect during meal times deficiency | |
| Resident #63 | Resident involved in dignity and respect during meal times deficiency | |
| Resident #72 | Resident involved in dignity and respect during meal times deficiency | |
| Nurse #36 | Nurse | Mentioned in relation to restorative therapy and wheelchair evaluations |
| Nurse #58 | Nurse | Mentioned in relation to restraint use and assessments |
| NA #39 | Nursing Assistant | Mentioned in relation to dignity and respect during meal times deficiency |
| NA #44 | Nursing Assistant | Mentioned in relation to dignity and respect during meal times deficiency |
| NA #95 | Nursing Assistant | Mentioned in relation to dignity and respect during meal times deficiency |
| Nurse #31 | Nurse | Mentioned in relation to dignity and respect during meal times deficiency |
| Administrator #10 | Administrator | Mentioned in relation to multiple deficiencies and interviews |
| Director of Nursing #124 | Director of Nursing | Mentioned in relation to multiple deficiencies and interviews |
| Unit Manager #156 | Unit Manager | Mentioned in relation to multiple deficiencies and interviews |
| Social Worker #49 | Social Worker | Mentioned in relation to roommate change notification deficiency |
| Dietary Manager | Mentioned in relation to dining environment and resident wishes | |
| Activities Director | Mentioned in relation to dining environment and resident wishes | |
| NHA | Nursing Home Administrator | Mentioned in relation to staff in-service and policy enforcement |
| DON | Director of Nursing | Mentioned in relation to staff in-service and policy enforcement |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 21, 2014
Visit Reason
The document is a plan of correction related to a Quality Indicator and Licensure Survey for Lincoln Nursing and Rehabilitation Center, LLC, addressing previously cited deficient practices.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights and rules in a language they understand as required by 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Report Facts
Survey completion date: Oct 21, 2014
Plan of correction acceptance date: Feb 9, 2026
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Oct 9, 2014
Visit Reason
An unannounced revisit was conducted at Lakin Hospital on 10/09/14 for the complaint survey concluding on 07/23/14.
Findings
The facility was found to have corrected the deficient practices identified in the prior complaint survey.
Complaint Details
The revisit survey was conducted following a complaint survey (11657) and found the facility had corrected the deficiencies.
Report Facts
Revisit survey sample size: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 17, 2014
Visit Reason
The inspection was conducted as a complaint investigation, reviewing plans of correction and credible evidence in lieu of an onsite revisit for complaint reference 11437.
Findings
Jackie Withrow Hospital was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules, with no new deficiencies cited during this investigation.
Complaint Details
Complaint Reference: 11437. The facility was in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence accepted in lieu of onsite revisit.
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 4
Sep 11, 2014
Visit Reason
Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Lincoln Nursing and Rehabilitation Center, LLC from September 8, 2014 through September 11, 2014.
Findings
The facility was found deficient in accurately completing resident assessments and honoring resident preferences. Specifically, Resident #70's preference for showers was not honored, and the admission MDS was inaccurately coded. Resident #18's MDS assessment failed to reflect dialysis treatments, and the care plan did not include special precautions for the resident's AV fistula.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to accurately complete an admission minimum data set (MDS) assessment for Resident #70 regarding bathing preferences; resident preferred showers but never received one. | SS=D |
| Failed to ensure Resident #70's bathing preference was honored; resident expressed desire for showers but was only given bed baths. | SS=D |
| Failed to ensure accuracy in coding MDS assessment for Resident #18; dialysis treatments not reflected in assessment. | SS=D |
| Failed to develop a comprehensive care plan for Resident #18 addressing special treatment precautions related to AV fistula in left upper arm. | SS=D |
Report Facts
Survey sample size: 31
Facility census: 60
Residents reviewed: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #9 | Nursing Assistant | Interviewed regarding Resident #70's bathing preference and care |
| Employee #27 | Nursing Assistant | Interviewed regarding Resident #70's bathing preference and care |
| Employee #39 | Nursing Assistant | Interviewed regarding Resident #70's bathing preference and care |
| Employee #69 | Nursing Assistant | Interviewed regarding Resident #70's bathing preference and care |
| Employee #21 | Licensed Practical Nurse | Interviewed regarding Resident #70's bathing preference and care |
| Employee #72 | Director of Nursing | Interviewed regarding Resident #70's bathing preference and care |
| Employee #71 | Registered Nurse Assessment Coordinator | Interviewed regarding MDS assessment accuracy and care plan for Resident #18 |
Inspection Report
Life Safety
Deficiencies: 0
Sep 10, 2014
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 5
Jul 29, 2014
Visit Reason
An unannounced complaint survey was conducted at Jackie Withrow Hospital from July 29, 2014 to July 31, 2014, triggered by complaint #11437 which was substantiated with related deficiencies cited.
Findings
The facility was found deficient in multiple areas including failure to accurately assess and document pressure ulcers, insufficient nursing staff to meet residents' needs especially during meal times, and failure to serve food at proper temperatures. Deficiencies included inaccurate resident assessments, inadequate wound care documentation, insufficient feeding assistance, and cold food service.
Complaint Details
Complaint #11437 was substantiated based on observations, resident and family interviews, staff interviews, and medical record reviews. The complaint sample consisted of 8 residents.
Severity Breakdown
SS=D: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to complete an accurate pressure ulcer assessment for Resident #43, with wound measurements carried over from previous assessments and no current assessment documented. | SS=D |
| Failed to timely assess and monitor pressure ulcers in accordance with the comprehensive assessment and plan of care for Resident #43. | SS=D |
| Failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed meal assistance and staff using cell phones during work hours. | SS=E |
| Failed to serve food at proper temperatures; test tray temperatures for meatballs were below 120°F at point of service. | SS=E |
| Failed to maintain clinical records that accurately reflected Resident #43's current status, with insufficient documentation of pressure ulcers and wound care. | SS=D |
Report Facts
Facility census: 93
Residents in complaint sample: 8
Pressure ulcers reviewed: 3
Temperature of whole meatball: 107.4
Temperature of pureed meatball: 110
Time from tray arrival to feeding start: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #60 | Registered Nurse (RN) | Confirmed pressure ulcers were measured weekly by unit managers but acknowledged inaccurate documentation for Resident #43 |
| Employee #19 | Licensed Practical Nurse (LPN) | Stated no residents currently had pressure ulcers and did not measure wounds during dressing changes |
| Employee #56 | Unit One Manager, Registered Nurse (RN) | Confirmed lack of sufficient wound assessment documentation for Resident #43 |
| Employee #27 | Nursing Assistant (NA) | Observed using cell phone during lunch meal service, delaying resident feeding |
| Employee #206 | Nursing Assistant (NA) | Reported only two nurse aides on evening shift to assist 10 residents needing feeding assistance |
| Employee #97 | Nursing Assistant (NA) | Assisted with serving trays and feeding residents during meal observations |
| Employee #137 | Dietary Supervisor | Measured food temperatures on test tray and confirmed temperatures below 120°F |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 3
Jul 23, 2014
Visit Reason
An unannounced complaint survey was conducted at Lakin Hospital from 07/21/14 through 07/23/14 based on Complaint #11657. The complaint investigation included observations, clinical record reviews, staff interviews, and facility documentation review.
Findings
The facility was found deficient in maintaining resident privacy during toileting, failing to implement care plan interventions including the use of a personal alarm for a resident at risk, and inadequate fall prevention measures resulting in a resident's fall with injury. The complaint was unsubstantiated but related and unrelated deficiencies were identified.
Complaint Details
Complaint #11657 was unsubstantiated with related and unrelated deficiencies identified during the investigation.
Severity Breakdown
Level D: 2
Level G: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to maintain resident privacy during toileting; bathroom door left open exposing resident below the waist. | Level D |
| Failure to implement care plan intervention for use of personal alarm for resident in wheelchair. | Level D |
| Failure to ensure resident environment was free of accident hazards and provide adequate supervision and assistance devices to prevent falls, resulting in a fall with injury. | Level G |
Report Facts
Complaint sample size: 5
Resident census: 94
Fall risk score: 14
Date of fall incident: Jul 5, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #107 | Observed resident privacy issue and closed bathroom door | |
| Licensed Practical Nurse (LPN) #25 | Acknowledged resident should have personal alarm in use | |
| Director of Nursing (DON) | Confirmed care plan and fall risk findings, acknowledged delays in interventions and occupational therapy evaluation |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 16, 2014
Visit Reason
The visit was conducted as a complaint investigation related to complaint reference 10773, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Findings
The facility, Nella's at Autumn Lake Healthcare, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rule, with no new deficiencies cited during this investigation.
Complaint Details
Complaint Reference: 10773. The complaint investigation concluded on 04/03/14 with the facility in substantial compliance and previously cited deficient practices corrected.
Report Facts
Complaint Reference Number: 10773
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 3, 2014
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference 14031 / 9540.
Findings
Jackie Withrow Hospital was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The review included plans of correction and credible evidence accepted in lieu of an onsite revisit.
Complaint Details
Complaint investigation concluded on 02/25/2015 with the facility found in substantial compliance with previously cited deficient practices.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 3
Apr 1, 2014
Visit Reason
An unannounced complaint survey was conducted from April 1 to April 3, 2014, based on Complaint #10773 which was substantiated with related and unrelated deficiencies cited.
Findings
The facility failed to promptly notify a resident's legal representative of a skin impairment with potential for physician intervention, failed to provide necessary treatment and services to prevent and promote healing of pressure ulcers for two residents, and failed to maintain an effective infection control program, including improper hand hygiene and contamination risks during wound care.
Complaint Details
Complaint #10773 was substantiated with related and unrelated deficiencies cited based on observations, record reviews, and interviews.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to promptly notify resident's legal representative of a skin impairment with potential for physician intervention. | SS=D |
| Failed to ensure residents received necessary treatment and services to prevent and heal pressure sores, including deterioration of a Stage 1 to Stage 4 pressure ulcer requiring surgery. | SS=D |
| Failed to maintain an infection control program; nurse did not implement standard practices for barriers and hand hygiene during wound dressing changes, and contaminated supplies were handled improperly. | SS=E |
Report Facts
Facility census: 82
Pressure ulcer size: 5
Pressure ulcer size: 7
Number of residents reviewed for pressure ulcers: 4
Number of residents observed for infection control: 4
Number of residents with infection control issues: 3
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Mar 25, 2014
Visit Reason
An unannounced complaint survey was conducted at Lakin Hospital from March 24, 2014 through March 25, 2014 to investigate complaint #10297/14026.
Findings
The complaint was investigated through observations, review of clinical records, interviews with residents, family, and staff, and review of facility documentation. The complaint was found to be unsubstantiated.
Complaint Details
Complaint #10297/14026 was investigated and found to be unsubstantiated.
Report Facts
Survey sample size: 6
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Feb 24, 2014
Visit Reason
An unannounced complaint investigation was conducted at Jackie Withrow Hospital for Complaint Reference 9540 / 14031 due to allegations related to medication errors and timely acquisition and administration of medications.
Findings
The facility failed to ensure timely acquisition and administration of medications, resulting in 35 of 85 residents missing doses of prescribed medications because the medications were not available from the pharmacy when due. The errors were substantiated and attributed to pharmacy failures.
Complaint Details
Substantiated complaint record with related citation regarding medication errors and failure to provide medications on time due to pharmacy errors.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure timely acquisition and administration of medications, resulting in missed doses for 35 residents due to pharmacy errors. | SS=E |
Report Facts
Residents missing doses: 35
Census: 85
Sample size: 40
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 11
Jan 10, 2014
Visit Reason
Annual Quality Indicator and Licensure Survey conducted from 01/06/14 to 01/10/14 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant resident changes, improper conveyance of resident funds upon death, inadequate surety bond coverage for resident funds, maintenance issues in resident rooms, inaccurate resident assessments, incomplete care plans, unnecessary medication administration, failure to act on pharmacist recommendations, infection control lapses, and incomplete medical records.
Severity Breakdown
SS=D: 9
SS=E: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to notify physician of significant weight loss for Resident #69. | SS=D |
| Failure to convey Resident #83's personal funds to the estate within 30 days of death. | SS=D |
| Failure to maintain a surety bond sufficient to cover resident funds, with account balances exceeding bond coverage. | SS=E |
| Maintenance issues in six resident rooms including peeling paint, holes, missing tile, and uncovered screws. | SS=E |
| Failure to accurately code dialysis treatments in annual and quarterly MDS assessments for Resident #13. | SS=D |
| Failure to ensure assessment accuracy and certification by registered nurse for Resident #13. | SS=D |
| Failure to develop a comprehensive care plan with monitoring parameters for hypertension medication for Resident #52. | SS=D |
| Failure to ensure drug regimen free from unnecessary drugs; Resident #52 received Toprol XL despite vital signs outside physician parameters. | SS=D |
| Failure to act on pharmacist recommendation to change medication monitoring parameters for Resident #52. | SS=D |
| Failure to implement infection control measures; lack of visible isolation signage for Resident #58 with MRSA. | SS=D |
| Failure to maintain complete and accurate medical records; incorrect diagnosis on physician order for Resident #69 and conflicting weights for Resident #13. | SS=D |
Report Facts
Facility census: 53
Weight loss: 10.9
Weight loss percentage: 8.3
Surety bond amount: 28000
Resident funds balance: 27063.75
Days delay: 79
Deficiency count: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #79 | Registered Nurse Assessment Coordinator | Confirmed failure to accurately code dialysis treatments and incomplete care plan |
| Employee #47 | Director of Nursing | Confirmed failure to notify physician of resident weight loss and lack of action on pharmacist recommendations |
| Employee #76 | Nursing Home Administrator | Discussed infection control signage issue |
| Employee #77 | Director of Nursing Services | Confirmed inaccurate medical records and infection control signage issue |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 10, 2014
Visit Reason
The visit was conducted as a Quality Indicator and Licensure Survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.
Report Facts
Survey completion date: Feb 13, 2014
Inspection Report
Life Safety
Deficiencies: 0
Jan 7, 2014
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 9, 2013
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Lakin Hospital.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 25, 2013
Visit Reason
The inspection was conducted as a complaint investigation based on two complaint references: 13246/8957 and 13247/8958.
Findings
Both complaint investigations were unsubstantiated with no citations issued.
Complaint Details
Complaint Reference: 13246/8957 - Unsubstantiated complaint record with no citations. Complaint Reference: 13247/8958 - Unsubstantiated complaint record with no citations.
Report Facts
Complaint References: 2
Inspection Report
Routine
Census: 87
Deficiencies: 11
Oct 22, 2013
Visit Reason
Quality Indicator and Licensure Surveys conducted from 10/15/13 to 10/22/13 to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of resident injuries, inadequate housekeeping and maintenance, inaccurate resident assessments, failure to develop comprehensive care plans, dignity and respect issues during dining, medication errors, unsafe smoking practices, inadequate infection control, and failure to provide timely dental services.
Severity Breakdown
SS=C: 1
SS=D: 7
SS=E: 3
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to notify physician of resident injury from cigarette burn. | SS=C |
| Failure to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior, including stained ceiling tiles and rusted door in dining room. | SS=E |
| Failure to conduct comprehensive assessments accurately, including dental status and range of motion. | SS=D |
| Failure to maintain dignity and respect of residents during dining, including delayed meal service and lack of assistance. | SS=E |
| Failure to develop comprehensive care plans addressing resident safety and dental needs. | SS=D |
| Failure to ensure residents are free of significant medication errors; resident given twice the ordered dose of Dilantin. | SS=D |
| Failure to maintain food under sanitary conditions including lack of trash can with step-on lid and no internal thermometer in ice cream freezer. | SS=F |
| Failure to provide or obtain routine and emergency dental services for residents with dental needs. | SS=D |
| Failure to establish and maintain an infection control program to prevent spread of infection; residents not provided opportunity to wash hands prior to meals. | SS=D |
| Failure to identify and evaluate risks for resident with unsafe smoking habits and failure to complete smoking assessment. | SS=D |
| Failure to provide range of motion services to resident's affected left hand as specified in care plan. | SS=D |
Report Facts
Facility census: 87
Medication administration opportunities: 25
Medication error count: 1
Dates of survey: 10/15/2013 to 10/22/2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #179 | Licensed Practical Nurse (LPN) | Interviewed regarding resident burn injury and smoking assessment |
| Employee #27 | Licensed Practical Nurse (LPN) | Observed medication administration and interviewed about medication error |
| Employee #6 | Director of Nursing (DON) | Interviewed regarding multiple deficiencies including burn injury, dining issues, and smoking assessment |
| Employee #110 | Nurse Assessment Coordinator | Interviewed regarding inaccurate dental assessment |
| Employee #2 | Licensed Practical Nurse (LPN) | Interviewed regarding resident denture issues |
| Employee #60 | Program Manager | Interviewed regarding range of motion services |
| Employee #64 | Health Service Assistant | Interviewed regarding range of motion services |
| Employee #155 | Health Service Worker | Interviewed regarding range of motion services |
| Employee #129 | Health Service Worker | Interviewed regarding range of motion services |
| Employee #1 | Licensed Nurse | Interviewed regarding hand washing practices |
| Employee #55 | Nutritionist | Interviewed regarding dietary sanitation issues |
Inspection Report
Life Safety
Deficiencies: 0
Oct 22, 2013
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Life Safety
Census: 93
Capacity: 102
Deficiencies: 2
Oct 18, 2013
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 10 Standard for Portable Fire Extinguishers and NFPA 99 Standards for Health Care Facilities regarding fire extinguisher maintenance and medical gas storage safety.
Findings
The facility failed to ensure that 8 of 25 fire extinguishers had monthly documented inspections as required, and failed to properly secure and segregate oxygen cylinders, including failure to mark empty cylinders and secure freestanding cylinders.
Severity Breakdown
SS=C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Eight of twenty-five fire extinguishers lacked required monthly documented checks for various months in 2013. | SS=C |
| Medical gas storage areas failed to secure free standing cylinders, did not segregate empty cylinders from full cylinders, and did not mark empty cylinders to avoid confusion and delay. | SS=C |
Report Facts
Fire extinguishers inspected: 25
Fire extinguishers lacking monthly checks: 8
Facility census: 93
Facility capacity: 102
Oxygen cylinders freestanding: 6
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 10, 2013
Visit Reason
The inspection was conducted as a Quality Indicator and Licensure Survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.
Findings
The facility, Nella's at Autumn Lake Healthcare, was found to be in substantial compliance with applicable federal and state regulations during the survey conducted from 10/07/13 to 10/10/13.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 29, 2013
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint numbers 8533 / 13181.
Findings
The complaint was unsubstantiated and no citations were issued during the investigation.
Complaint Details
Complaint Reference: 8533 / 13181. The complaint was unsubstantiated with no citations.
Inspection Report
Census: 73
Deficiencies: 1
Aug 15, 2013
Visit Reason
The inspection was conducted to assess compliance with NFPA 99 standards for medical gas storage and administration areas, specifically focusing on oxygen storage safety.
Findings
The facility's oxygen storage did not meet NFPA 99 standards, with evidence of smoking within 20 feet of the oxygen storage building and lack of proper signage and marked no-smoking areas.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Oxygen storage did not meet NFPA 99 standards including lack of proper signage and smoking observed within 20 feet of the oxygen storage building. | SS=F |
Report Facts
Facility census: 73
Date of survey completion: Aug 15, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 25, 2013
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Jackie Withrow Hospital.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Annual Inspection
Census: 74
Deficiencies: 8
Jun 25, 2013
Visit Reason
The inspection was conducted as part of Quality Indicator and Licensure Surveys from 06/17/13 to 06/25/13.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for medication administration parameters, failure to provide care according to plans, unsafe storage of chemicals, improper food storage and handling, failure to monitor drug regimens and report irregularities, failure to discard expired medications, and inaccurate clinical record documentation regarding pressure ulcers.
Severity Breakdown
SS=C: 1
SS=D: 4
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to develop comprehensive care plans for residents related to medication use and parameters for administration. | SS=C |
| Failure to ensure licensed nursing staff provided care in accordance with the care plan for obtaining blood pressure/pulse prior to medication administration. | SS=D |
| Failure to ensure the resident environment was free from accident hazards; chemicals accessible to residents. | SS=D |
| Failure to store, distribute and serve food under sanitary conditions; undated condiments and outdated food found; improper hand hygiene during meal service. | SS=E |
| Failure to ensure drug regimens were free from unnecessary drugs; inadequate monitoring of anti-hypertensive medications and psychotropic drugs. | SS=D |
| Failure to ensure drug regimen reviewed monthly by pharmacist and irregularities reported and acted upon. | SS=E |
| Failure to ensure injectable medication vials were dated after opening and expired medications discarded. | SS=E |
| Failure to maintain accurate clinical records; inaccurate documentation of pressure ulcers upon discharge and readmission. | SS=D |
Report Facts
Facility census: 74
Days medication administered without verification: 47
Days blood pressure obtained: 8
Days pulse recorded: 20
Days blood pressure recorded: 25
Days pulse not monitored: 25
Days blood pressure not monitored: 30
Number of pressure ulcers: 7
Expiration days for opened vial: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #113 | MDS Coordinator | Named in care plan development and medication administration findings |
| Employee #118 | Assistant Director of Nursing | Verified failures in medication administration and monitoring |
| Employee #120 | RN Unit Manager | Informed about chemical hazard and removal |
| Employee #5 | Housekeeper | Left Lysol spray in resident's room |
| Employee #53 | Nursing Assistant | Observed not washing hands during meal service |
| Employee #142 | Dietary Manager | Confirmed undated spices in kitchen |
| Employee #134 | Dietary Assistant | Confirmed undated spices in kitchen |
| Employee #87 | Director of Nursing | Assisted medication room inspection |
| Employee #118 | Registered Nurse, Assistant Director of Nursing | Confirmed expired medication and monitoring failures |
| Employee #9 | Administrator | Confirmed policy noncompliance and pharmacist reporting failures |
| Employee #52 | Registered Nurse | Confirmed lack of behavior monitoring for psychotropic medication |
Inspection Report
Routine
Census: 73
Deficiencies: 8
Jun 19, 2013
Visit Reason
Routine inspection to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements for the facility.
Findings
Multiple deficiencies were found related to life safety code violations including corridor doors not properly closing or latching, vertical openings lacking required fire resistance, smoke barriers with unprotected penetrations, hazardous areas not properly protected, smoking regulation violations, obstructed means of egress, privacy curtains lacking fire resistant labeling, and oxygen storage areas not meeting NFPA 99 standards.
Severity Breakdown
SS=C: 5
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Corridor doors held open or not latching properly, including doors propped open by chairs or wedges. | SS=C |
| Vertical openings within the facility did not have a 1-hour fire resistance rating. | SS=C |
| Smoke barriers did not meet the required fire resistance rating with unprotected penetrations. | SS=C |
| Hazardous areas not protected as required; doors to file storage rooms found open or door closures disconnected. | SS=F |
| Facility did not adhere to smoking regulations; cigarette butts near oxygen storage, flammable wipes in smoking room, oxygen tanks in patient rooms without 'No Smoking' signs. | SS=F |
| Means of egress obstructed by chairs, equipment, and exercise tables in auditorium emergency exit path. | SS=C |
| Privacy curtains in resident rooms lacked fire resistant labeling and were not treated with fire resistant chemicals after washings. | SS=C |
| Oxygen storage did not meet NFPA 99 standards; storage rooms lacked required signage, combustible materials stored near oxygen cylinders, evidence of smoking near oxygen storage, and full and empty cylinders co-mingled. | SS=F |
Report Facts
Facility census: 73
Deficiencies cited: 8
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 5, 2013
Visit Reason
The document is a Plan of Correction related to deficiencies identified during a prior inspection of Lincoln Healthcare Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 3
Apr 25, 2013
Visit Reason
The inspection was conducted as part of a Quality Indicator and Licensure Survey to assess compliance with regulatory requirements.
Findings
The facility failed to provide diets as ordered for two residents with swallowing difficulties, serving whole pork chops instead of ground meats, and failed to provide supervision during meals, creating a risk of choking. Additionally, hazardous cleaning wipes were found stored in a resident's room, accessible to residents.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide diets as ordered for residents with swallowing difficulties, serving whole pork chops instead of ground meats. | SS=D |
| Failure to provide adequate supervision during meals for residents with swallowing difficulties. | SS=D |
| Hazardous cleaning wipes stored in a resident's room, accessible to residents. | SS=D |
Report Facts
Residents reviewed: 16
Residents with swallowing difficulties: 2
Facility census: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #72 | Registered Nurse | Interviewed about assistance required by Resident #55 |
| Employee #73 | Care Plan Nurse | Verified physician orders and care plans for Residents #55 and #56 |
| Employee #42 | Nursing Assistant | Interviewed about meal service and diet verification |
| Employee #71 | Director of Nursing Services | Acknowledged hazardous wipes should not be in resident rooms and removed them |
| Employee #28 | Environmental Services Supervisor | Provided Material Safety Data Sheet for cleaning wipes |
Inspection Report
Life Safety
Deficiencies: 0
Apr 23, 2013
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 28, 2013
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Jackie Withrow Hospital.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 27, 2013
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint numbers 13062 / 7847.
Findings
The complaint was found to be unsubstantiated with no citations issued.
Complaint Details
Complaint Reference: 13062 / 7847. The complaint was unsubstantiated with no citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 15, 2013
Visit Reason
The inspection was conducted in response to a complaint (Reference: 7425 / 12260).
Findings
The complaint was found to be unsubstantiated with no citations issued.
Complaint Details
Complaint Reference: 7425 / 12260. The complaint record was unsubstantiated with no citations.
Report Facts
Complaint Reference Number: 7425
Complaint Reference Number: 12260
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 9
Feb 14, 2013
Visit Reason
The inspection was conducted as a substantiated complaint investigation with citations related to care planning, physician visits, medication regimen review, and resident safety.
Findings
The facility was found deficient in multiple areas including failure to develop and revise comprehensive care plans for residents with behavioral and medical needs, failure to implement care plan interventions, untimely physician visits, failure to notify physicians promptly of lab results, inadequate supervision and assistive devices to prevent accidents, and inaccurate documentation in medical records.
Complaint Details
The visit was complaint-related with substantiated complaints and citations issued.
Severity Breakdown
SS=C: 1
SS=D: 7
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to develop a comprehensive care plan addressing behavioral problems for Resident #55. | SS=C |
| Failure to review and revise care plan for Resident #20 after change in ambulatory status. | SS=D |
| Failure to implement care plan interventions for Resident #24 exhibiting behaviors. | SS=D |
| Failure to provide necessary care and services to maintain well-being for Resident #55, including delayed notification of elevated ammonia levels and failure to respond to low body temperature. | SS=D |
| Failure to ensure adequate supervision and assistive devices to prevent accidents for Resident #24 who fell and sustained a laceration. | SS=D |
| Failure to ensure timely physician visits for Residents #7, #16, #19, #20, and #55. | SS=E |
| Failure to ensure pharmacist's recommendations were reported to attending physician for Resident #19. | SS=D |
| Failure to promptly notify physician of lab results for Resident #55. | SS=D |
| Failure to maintain accurate and consistent clinical records for Resident #24; behavior monitoring sheets did not correlate with nurse's notes. | SS=D |
Report Facts
Facility census: 103
Deficiencies cited: 9
Physician visit intervals: 30
Physician visit intervals: 60
Lab ammonia levels: 201
Lab ammonia levels: 225
Resident temperature: 90.6
Resident temperature: 88.8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #113 | Director of Nursing | Confirmed lack of care plan for behaviors and untimely physician visits |
| Employee #10 | Administrator | Confirmed lack of care plan for behaviors and untimely physician visits |
| Employee #121 | Assistant Director of Nursing | Confirmed lack of care plan revision and untimely physician visits |
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 27, 2012
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Lakin Hospital.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Report Facts
Deficiency ID: 156
Inspection Report
Routine
Census: 95
Deficiencies: 14
Aug 17, 2012
Visit Reason
Routine Quality Indicator Survey conducted from 08/13/12 to 08/17/12 to assess compliance with federal regulations related to resident rights, dignity, care planning, infection control, nutrition, medication management, and pest control.
Findings
The facility was found deficient in multiple areas including failure to safeguard resident property, failure to report abuse allegations, lack of dignity and respect during meal service and interactions, incomplete and inaccurate care plans, failure to monitor and justify medication use, poor infection control practices, ineffective pest control program, and inaccurate clinical records.
Severity Breakdown
SS=D: 12
SS=E: 2
SS=F: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to safeguard resident's personal property by not investigating missing dentures. | SS=D |
| Failed to report allegation of physical abuse to proper state agencies. | SS=D |
| Failed to maintain dignity and respect for residents during meal service and interactions. | SS=E |
| Failed to honor resident's request for male assistance with bathing. | SS=D |
| Failed to conduct accurate comprehensive assessments; pressure ulcer not identified on MDS. | SS=D |
| Failed to revise care plans to reflect current treatment needs for multiple residents. | SS=D |
| Failed to ensure services were provided by qualified persons per care plan. | SS=D |
| Resident received unnecessary medication (Levothyroxine) without diagnosis or monitoring. | SS=D |
| Failed to provide food that is palatable and attractive; pureed foods blended together on plate. | SS=D |
| Failed to offer substitutes of similar nutritive value when residents refused food served. | SS=D |
| Failed to maintain effective infection control practices; same hairbrush used on multiple residents, improper handwashing, and use of soiled clothing protectors to clean spills. | SS=D |
| Failed to maintain effective pest control program; flies observed in kitchen, resident rooms, and dining areas. | SS=F |
| Failed to ensure nursing assistant was registered with the state nursing assistant registry; employee worked with expired registration. | SS=D |
| Failed to maintain complete, accurate, and accessible clinical records; inaccurate meal intake and dental assessment documentation. | SS=D |
Report Facts
Facility census: 95
Residents affected: 10
Residents affected: 45
Residents affected: 95
Nursing assistant registry expiration date: 2012
Weight: 115.2
Weight: 113
Weight: 101
Meal refusal count: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding missing dentures, abuse reporting, and care plan issues | |
| Assistant Director of Nursing | Interviewed regarding dignity issues and care plan revisions | |
| Dietary Supervisor | Interviewed regarding dining observations and resident utensils | |
| Licensed Practical Nurse | Observed improper handwashing and interviewed about medication administration | |
| Health Service Worker | Observed using same hairbrush on multiple residents | |
| Registered Nurse | Interviewed about MDS assessment and medication monitoring | |
| Administrative Service Manager, Human Resources | Verified nursing assistant registry documents |
Inspection Report
Life Safety
Deficiencies: 0
Aug 17, 2012
Visit Reason
The inspection was conducted to review the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 27, 2012
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Wyoming Healthcare Center.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents of their rights, rules, services, and charges as required. | Level C |
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 11, 2012
Visit Reason
Onsite revisit to recertification survey.
Findings
All citations found to be in compliance during the revisit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 26, 2012
Visit Reason
The inspection was conducted in response to a complaint referenced as 7179 / 12114.
Findings
The complaint was investigated and found to be unsubstantiated.
Complaint Details
Complaint Reference: 7179 / 12114. The complaint was unsubstantiated following the investigation conducted from 06/25/12 to 06/26/12.
Inspection Report
Life Safety
Deficiencies: 0
Jun 8, 2012
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Routine
Census: 58
Deficiencies: 4
Jun 7, 2012
Visit Reason
The inspection was a Quality Indicator and Licensure Survey conducted from 06/04/12 to 06/07/12 to assess compliance with regulatory requirements.
Findings
The facility failed to develop a comprehensive care plan for a resident with increased urinary incontinence, did not implement measures to restore bladder function or prevent urinary tract infections, and failed to provide individualized toileting plans. Additionally, the facility did not properly document or monitor the use of psychoactive medications for a resident, including failure to identify targeted behaviors and monitor side effects, and the pharmacist did not report these irregularities to the physician.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop a care plan for a resident with increased urinary incontinence. | SS=D |
| Failed to implement measures to prevent urinary tract infections and restore bladder function for a resident. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs; lacked documentation and monitoring of psychoactive medications. | SS=D |
| Failed to ensure pharmacist reported irregularities in drug regimen to physician and director of nursing. | SS=D |
Report Facts
Facility Census: 58
Sampled residents: 22
Resident #40 admission date: Jan 23, 2012
Resident #40 initial MDS assessment date: Jan 29, 2012
Resident #40 quarterly MDS assessment date: Apr 27, 2012
Resident #66 admission date: Jan 20, 2012
Medication prescription dates and dosages: Seroquel 100 mg daily 01/21/12, Seroquel 50 mg daily 05/15/12, Ativan 0.5 mg twice daily 04/06/12, Ativan 1 mg daily 04/07/12
Pharmacist drug regimen review dates: 01/30/12, 02/28/12, 03/26/12, 04/26/12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #75 | Care Conference Nurse | Interviewed regarding lack of individualized care plan for Resident #40 |
| Employee #76 | Director of Nursing | Interviewed regarding psychoactive medication monitoring and documentation |
| Employee #77 | Clinical Care Coordinator | Interviewed regarding psychoactive medication monthly flow records and pharmacist reporting |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 1, 2012
Visit Reason
Revisit to Immediate Jeopardy at F323 to verify correction of previous deficiencies.
Findings
All citations related to the Immediate Jeopardy at F323 were cleared during this revisit inspection.
Inspection Report
Annual Inspection
Deficiencies: 20
May 11, 2012
Visit Reason
Traditional Recertification Survey conducted from 05/07/12 to 05/11/12 to assess compliance with federal regulations for nursing home care.
Findings
The facility was found to have widespread deficiencies including failure to maintain a safe environment, inadequate hydration leading to dehydration, failure to promote resident rights and freedom from restraints, incomplete assessments and care plans, failure to provide quality care and services, unsanitary dietary practices, ineffective infection control, incomplete and inaccurate clinical records, and lack of effective quality assurance processes. Specific issues included improper use of restraints, failure to provide timely psychiatric and physical therapy services, inadequate monitoring of psychotropic medications, unsafe water temperatures, malfunctioning wander guard alarms, and failure to provide adequate personal care and hygiene.
Severity Breakdown
SS=E: 10
SS=D: 4
SS=F: 5
Deficiencies (20)
| Description | Severity |
|---|---|
| Failure to ensure residents were provided the opportunity to exercise their voting rights; Social Worker unable to provide evidence of voter education or assistance. | SS=E |
| Failure to maintain resident privacy and confidentiality; exposure of resident's genitals in presence of visitor; medical records labeled with resident names and code status visible in hallway. | SS=D |
| Failure to ensure residents were free from physical restraints unless medically necessary; cognitively intact residents restrained without assessment or less restrictive measures; conflicting documentation regarding restraint use. | SS=E |
| Failure to provide care and services in a manner that maintains dignity and respect; unauthorized entry into resident rooms and verbal reports of resident status in presence of others; verbal abuse of resident by staff; improper use of safety devices on residents. | SS=E |
| Failure to allow residents to make choices regarding activities, schedules, and health care; restrictions on smoking and outdoor access; resident with capacity denied discharge options. | SS=E |
| Failure to provide medically-related social services including discharge planning and advocacy for restraint alternatives; delay in psychiatric consult; failure to assist residents with voting rights; improper handling of deceased resident funds. | SS=E |
| Failure to complete annual comprehensive assessment for resident R14; computer software error cited as cause. | SS=D |
| Failure to develop individualized comprehensive care plans with measurable objectives and revisions based on resident needs; care plans not updated after falls or changes in condition; generic interventions used regardless of effectiveness. | SS=E |
| Failure to follow physician orders for lab follow-up and diet consistency; failure to provide liquids at proper consistency; thickened liquids inconsistently prepared. | SS=D |
| Failure to provide necessary assistance with activities of daily living including toileting and bathing; residents left without showers for extended periods; call lights inaccessible or improperly managed; inadequate staffing observed. | SS=E |
| Failure to provide timely treatment and services for resident with mental/psychosocial difficulties; delay in psychiatric evaluation after suicidal ideation; lack of suicide watch policy; failure to monitor psychotropic medication side effects. | SS=D |
| Failure to maintain a safe environment free of hazards; unsafe water temperatures; malfunctioning wander guard alarms; inadequate fall prevention and supervision; unsafe use of side rails and beds; gaps between mattresses and headboards not addressed. | SS=E |
| Failure to provide foods at proper palatable temperature; food served lukewarm; temperature logs showed unsafe temperature ranges at point of service. | SS=E |
| Failure to ensure food procured, stored, prepared, and served under sanitary conditions; sanitizer levels not monitored or maintained; improper sanitizer use in dishwashing. | SS=F |
| Failure to properly dispose of garbage and refuse; dumpsters left open with overflowing trash and litter around area. | SS=F |
| Failure to maintain an effective infection control program; failure to prevent spread of MRSA between roommates; personal supplies stored unsanitarily on bathroom floors; hydration pass conducted unsanitarily. | SS=E |
| Failure to provide effective administration to ensure residents attain or maintain highest practicable well-being; failure to implement corrective actions from previous surveys; administration allowed risk management company to dictate policies. | SS=F |
| Failure to provide nurse aide in-service education based on performance reviews and identified weaknesses; same training topics repeated for multiple years. | SS=F |
| Failure of Medical Director to participate in policy development and quality assurance meetings; failure to respond promptly to physician consult requests. | SS=F |
| Failure to maintain complete, accurate, and accessible clinical records; conflicting and altered documentation related to restraint assessments; incomplete restraint elimination reviews; inconsistent documentation of resident condition and care. | SS=E |
Report Facts
Residents restrained: 20
Residents sampled: 19
Temperature of tub water: 120
Temperature of wash cycle: 148
Temperature of rinse cycle: 138
Temperature of test tray turkey: 82
Temperature of test tray dressing: 82
Temperature of test tray green beans: 85
Temperature of test tray fruit cocktail: 60
Temperature of test tray milk: 52
Fluid intake: 1445
Fluid intake: 1980
Fluid intake: 1660
Fluid intake: 1840
Hospital lab BUN: 156
Hospital lab Creatinine: 8.9
Hospital lab BUN: 54
Hospital lab Creatinine: 2
Number of CNAs reviewed: 6
Number of residents with psychotropic meds: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN59 | Licensed Practical Nurse | Named in findings related to privacy violation and restraint use |
| LPN17 | Licensed Practical Nurse | Named in findings related to restraint assessment and psychiatric consult |
| LPN45 | Licensed Practical Nurse | Named in findings related to psychiatric consult and hydration monitoring |
| RN37 | Registered Nurse Wound Care Nurse | Named in findings related to MRSA wound care |
| CNA85 | Certified Nursing Assistant | Named in findings related to bathing refusals and ADL assistance |
| CDM71 | Certified Dietary Manager | Named in findings related to food temperature and sanitizer monitoring |
| DON | Director of Nursing | Named in multiple findings related to care planning, restraint documentation, and QA process |
| MD1 | Medical Director | Named in findings related to lack of involvement in policy and delayed consult response |
| LPN49 | Licensed Practical Nurse | Named in findings related to care planning and restraint documentation |
| LPN5 | Licensed Practical Nurse | Named in findings related to fall follow-up and lab follow-up |
| Tech42 | Dietary Technician | Named in findings related to hydration cart contamination |
| E16 | Facility Staff | Named in findings related to malfunctioning wander guard alarms |
| LPN34 | Licensed Practical Nurse | Named in findings related to restraint use and resident statements |
| LPN18 | Licensed Practical Nurse | Named in findings related to restraint use |
| LPN21 | Certified Nursing Assistant | Named in findings related to restraint use |
| LPN73 | Licensed Practical Nurse | Named in findings related to resident interview and restraint use |
| LPN48 | Licensed Practical Nurse | Named in findings related to verbal abuse of resident |
| LPN34 | Licensed Practical Nurse | Named in findings related to restraint use and resident statements |
| LPN55 | Licensed Practical Nurse | Named in findings related to diet consistency |
| RN81 | Registered Nurse | Named in findings related to bathing refusals and ADL assistance |
| LPN21 | Certified Nursing Assistant | Named in findings related to restraint use |
| LPN18 | Licensed Practical Nurse | Named in findings related to restraint use |
| LPN49 | Licensed Practical Nurse | Named in findings related to restraint use and care planning |
| LPN17 | Licensed Practical Nurse | Named in findings related to restraint use and psychiatric consult |
| LPN5 | Licensed Practical Nurse | Named in findings related to fall follow-up |
| LPN45 | Licensed Practical Nurse | Named in findings related to hydration and psychiatric consult |
| Tech42 | Dietary Technician | Named in findings related to hydration cart contamination |
| CDM75 | Certified Dietary Manager | Named in findings related to food temperature and sanitizer monitoring |
| DON | Director of Nursing | Named in findings related to QA process and documentation |
| Administrator | Facility Administrator | Named in findings related to QA process and mattress replacement |
| MD2 | Physician | Named in findings related to resident capacity and medical decision making |
Inspection Report
Life Safety
Census: 92
Capacity: 102
Deficiencies: 2
May 10, 2012
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on smoke barrier walls and generator equipment maintenance.
Findings
The facility failed to maintain smoke barrier walls to provide the required one half hour fire resistance rating in Wing A, with unsealed penetrations observed. Additionally, the battery powered emergency lighting in the generator transfer switch room was found to be inoperable.
Severity Breakdown
SS=E: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Smoke barriers in Wing A had unsealed penetrations compromising the required fire resistance rating. | SS=E |
| Battery powered emergency lighting in the generator transfer switch room was inoperable. | SS=C |
Report Facts
Facility census: 92
Total capacity: 102
Inspection date: May 10, 2012
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Apr 20, 2012
Visit Reason
The inspection was conducted as a complaint investigation related to resident safety and care plan compliance, specifically addressing concerns about resident elopement risks and environmental safety hazards.
Findings
The facility failed to update a resident's care plan to include a watchlet device intervention, and the environment was not free of accident hazards due to inadequate audible alarms on emergency exit doors and stairwells, creating an immediate jeopardy situation for residents at risk of elopement.
Complaint Details
Complaint Reference ID: #12054 / ACTS #7001. The complaint was unsubstantiated but unrelated citations were issued. The investigation focused on resident safety related to elopement risks and environmental hazards.
Severity Breakdown
SS=D: 1
SS=K: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure one resident's care plan was updated to reflect the use of a watchlet bracelet as an intervention for elopement risk. | SS=D |
| Failed to ensure the resident environment was free of accident hazards; emergency exit door alarms were not audible at nursing stations, and the WanderGuard system was not functioning properly, creating an immediate jeopardy situation. | SS=K |
Report Facts
Facility census: 84
Residents at risk with Watchlet devices: 3
Residents with access to fire doors/stairwells: 68
Exit seeking behaviors: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #33 | Registered Nurse/Program Services | Amended Resident #82's care plan to include the watchlet device intervention. |
| Employee #14 | Administrator | Notified of resident elopement and involved in investigation and corrective actions. |
| Employee #60 | Registered Nurse/Unit Manager | Managed unit where Resident #53 eloped and reported alarm malfunction. |
| Employee #78 | Information Systems Representative | Reported WatchMate monitoring system malfunction and tested alarm systems. |
| Employee #174 | Maintenance Director | Reported WatchMate system failure due to lightning strike and monitored emergency exit doors. |
| Employee #71 | Maintenance Staff | Tested fire exit doors and confirmed lack of audible alarms at nursing stations. |
| Employee #180 | Maintenance Staff | Assisted in testing fire exit doors. |
| Employee #115 | Assistant Director of Nursing | Interviewed regarding elopement incident and care plan compliance. |
| Employee #91 | Director of Nursing | Participated in discussion regarding immediate jeopardy situation. |
| Employee #16 | Assistant Administrator | Participated in discussion regarding immediate jeopardy situation. |
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 2, 2012
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Jackie Withrow Hospital.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to inform residents of their rights, rules, services, and charges as required. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 24, 2012
Visit Reason
Onsite revisit for QIS and licensure survey and complaint investigations 11340 and 11345 conducted from 02/21/12 to 02/24/12.
Findings
The document is a statement of deficiencies and plan of correction related to regulatory compliance, including notification of residents' rights and services. Specific deficiencies are not detailed on this page.
Complaint Details
The visit was triggered by complaint investigations numbered 11340 and 11345.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 22
Dec 8, 2011
Visit Reason
Complaint investigations 11340 and 11345 were conducted; complaint 11340 was substantiated with no deficiencies, complaint 11345 was unsubstantiated. The survey included review of resident care, facility policies, and environment.
Findings
The facility was cited for multiple deficiencies including failure to prominently display Medicare/Medicaid information on one unit, failure to notify physician and legal representative of a new pressure ulcer, failure to ensure resident access to personal funds after hours, failure to make survey results accessible, incorrect bed-hold policy information, improper use of physical restraints, neglect of residents by sleeping staff, failure to maintain resident dignity during meals, failure to honor resident food preferences, environmental maintenance issues, incomplete care plans, failure to monitor pain and respond to pharmacist recommendations, improper medication storage, infection control lapses, malfunctioning call light systems, pest control issues, unsecured fire exit doors, and failure to ensure safe medication administration.
Complaint Details
Complaint 11340 was substantiated with no deficiencies; complaint 11345 was unsubstantiated.
Severity Breakdown
SS=F: 3
SS=E: 9
SS=D: 5
SS=C: 3
Deficiencies (22)
| Description | Severity |
|---|---|
| Failure to prominently display written information about how to apply for and use Medicare and Medicaid benefits on one unit. | SS=C |
| Failure to immediately inform physician and legal representative of a new Stage II pressure ulcer for Resident #7. | SS=E |
| Failure to ensure residents had access to personal funds after business hours and on weekends. | SS=E |
| Failure to make survey results and plan of correction readily accessible to residents. | SS=C |
| Failure to provide correct information regarding bed-hold policy and appeal contacts to residents transferred or on therapeutic leave. | SS=C |
| Failure to ensure Resident #35 was free from physical restraints imposed for staff convenience during meals and failure to attempt alternative measures. | SS=D |
| Failure to ensure residents on behavioral unit were monitored; staff found sleeping while residents were unsupervised. | SS=E |
| Failure to provide care in an environment that maintained resident dignity during meals; residents waited long periods for assistance and some were isolated or positioned improperly. | SS=E |
| Failure to ensure Resident #2 could make choices about meals significant to him; care plan and tray card did not reflect his food preferences. | SS=D |
| Failure to maintain sanitary, orderly, and comfortable environment; floors, walls, fixtures, and heating units in disrepair; persistent odors noted. | SS=E |
| Failure to develop, review, and revise comprehensive care plans to reflect significant changes in resident condition and preferences for four residents. | SS=E |
| Failure to ensure nursing staff provided care within professional standards; failure to document and communicate assessment data and failure to maintain resident dignity in documentation. | SS=E |
| Failure to ensure consistent communication between facility and dialysis center for Resident #28 receiving outpatient dialysis. | SS=D |
| Failure to assess and monitor pain and explore alternative pain relief methods for Resident #52 with respiratory distress risk from narcotics. | SS=D |
| Failure to provide necessary services to maintain good grooming and oral hygiene for three residents; one resident not assisted with teeth brushing, two residents observed with long chin hairs. | SS=D |
| Failure to ensure emergency fire exit doors were secured with functional delayed egress systems and alarms to prevent resident exit without warning. | SS=E |
| Failure to ensure hazardous chemicals were contained in a locked unit; cleaning cart with hazardous supplies found in unlocked laundry storage room; failure to follow resident identification procedures during medication administration. | SS=E |
| Failure to maintain an infection control program to prevent spread of infection; improper use of personal protective equipment and inadequate policies for cleaning contact isolation rooms with C-Diff. | SS=F |
| Failure to ensure call light systems functioned properly for two residents; call lights did not illuminate above resident doors. | SS=E |
| Failure to maintain an effective pest control program; live roach found on resident's breakfast tray. | SS=E |
| Failure to ensure medications were stored in a safe and orderly manner; opened medications found improperly stored and undated. | SS=E |
| Failure to ensure food items in kitchen and nourishment pantries were sealed, dated, and stored under sanitary conditions; missing thermometers and unlabeled food items found. | SS=F |
Report Facts
Facility census: 90
Deficiencies cited: 20
Stage II sample size: 38
Medication doses: 7
Medication doses without effectiveness documentation: 2
Staples for laceration: 20
Resident age: 93
Resident age: 59
Resident age: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #59 | Registered Nurse Unit Manager | Confirmed no documentation of pressure ulcer assessment and notification |
| Employee #122 | Unit Charge Nurse | Unable to produce documentation of pharmacist recommendation response |
| Employee #10 | Administrator | Informed of multiple deficiencies and facility issues |
| Employee #147 | Nursing Assistant | Observed improper PPE use during incontinence care |
| Employee #140 | Nursing Assistant | Observed improper PPE use during incontinence care |
| Employee #83 | Facility Monitor | Found sleeping while residents unsupervised |
| Employee #81 | Staff Feeding Residents | Observed inattentive during meal assistance |
| Employee #100 | Social Worker | Unaware of psychiatrist report for Resident #1 |
| Employee #115 | Assistant Director of Nursing | Confirmed failure to write pain monitoring order |
| Employee #122 | Unit Charge Nurse | Verified behavior monitoring flow record issues |
| Employee #109 | Registered Nurse Unit Director | Observed nourishment pantry issues |
| Employee #117 | Registered Nurse Unit Director | Observed nourishment pantry issues |
| Employee #38 | Housekeeper | Reported live roach found on resident's breakfast tray |
| Employee #126 | Monitor / Nursing | Confirmed call light malfunction |
| Employee #161 | Nursing Staff | Confirmed call light malfunction |
| Employee #175 | Maintenance Supervisor | Reported fire door delayed egress system malfunction |
| Employee #42 | Infection Control Nurse | Provided infection control manual |
| Employee #91 | Director of Nursing | Provided education on smoking apron safety |
| Employee #176 | Licensed Practical Nurse | Reported Resident #2 food preferences |
| Employee #74 | Health Service Worker | Reported Resident #2 food preferences |
| Employee #151 | Recreation Staff | Provided one-on-one activities to Resident #42 |
| Employee #19 | Recreation Staff | Provided one-on-one activities to Resident #42 |
| Employee #160 | Licensed Practical Nurse | Reported smoking apron incident for Resident #23 |
| Employee #23 | Housekeeper / Monitor | Reported smoking apron incident for Resident #23 |
| Employee #147 | Nursing Assistant | Reported smoking apron incident for Resident #23 |
| Employee #139 | Dietary Manager | Provided Resident #2 tray card |
| Employee #152 | Nurse | Failed to identify resident prior to medication administration |
| Employee #156 | Nurse | Failed to identify resident prior to medication administration |
Inspection Report
Life Safety
Census: 90
Deficiencies: 15
Nov 28, 2011
Visit Reason
The inspection was a Life Safety Code Recertification survey conducted to assess compliance with fire safety and related regulatory standards.
Findings
The facility failed to maintain fire barriers, corridor doors, vertical openings, smoke barriers, smoke barrier doors, hazardous area doors, exit accessibility, exit signs, fire alarm system testing, smoke detector sensitivity testing, sprinkler system coverage and inspections, prohibition of portable space heaters in patient rooms, generator maintenance, and electrical junction box covers in accordance with applicable NFPA and CMS regulations.
Severity Breakdown
SS=F: 6
SS=B: 5
SS=C: 3
SS=D: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Fire barrier walls had unsealed/incompletely sealed penetrations around wires and conduits. | SS=B |
| Corridor doors were obstructed or failed to latch properly. | SS=C |
| Vertical openings were not enclosed with construction having a one-hour fire resistance rating. | SS=C |
| Smoke barrier walls had unsealed/incompletely sealed penetrations. | SS=F |
| Smoke barrier doors failed to close completely under the power of the self-closing device. | SS=F |
| Hazardous area doors failed to close and latch with the self-closing device. | SS=B |
| Exits were not readily accessible due to missing instructional signage and improper locking devices. | SS=D |
| Exit signs failed to provide continuous illumination. | SS=B |
| Fire alarm system was not inspected and tested annually as required. | SS=F |
| Smoke detectors were not sensitivity tested within the last two years as required. | SS=D |
| Automatic sprinkler system did not provide coverage to all portions of the facility. | SS=F |
| Sprinkler system inspections were not conducted quarterly as required. | SS=F |
| Portable space heaters were found in resident rooms, which is prohibited. | SS=F |
| Generator emergency lighting was inoperable. | SS=B |
| Electrical junction boxes were missing covers. | SS=B |
Report Facts
Census: 90
Sample Size: 80
Number of tags cited: 15
Inspection duration: 3
Sprinkler inspection reports available: 2
Fire alarm inspection reports available: 2
Number of resident rooms with portable heaters observed: 15
Number of electrical junction boxes without covers: 3
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 2
Oct 26, 2011
Visit Reason
The inspection was conducted as a complaint investigation related to refusal of treatment and medication administration practices at Jackie Withrow Hospital.
Findings
The facility failed to assess and document reasons for residents' refusal to wear identification bracelets during medication administration, and did not educate residents on the consequences of refusal. Additionally, unrelated deficiencies in housekeeping and maintenance were noted.
Complaint Details
Complaint reference #11260 was unsubstantiated with unrelated deficiencies cited. The complaint involved refusal of treatment related to residents not wearing identification bracelets during medication administration.
Deficiencies (2)
| Description |
|---|
| Facility failed to assess reasons for residents' refusal to wear identification bracelets and did not educate residents on consequences of refusal. |
| Facility failed to document each resident's refusal related to the use of identification bracelets with the medication administration pass. |
Report Facts
Facility census: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) - Employee #60 | Reported that many residents refused to wear identification bracelets and that no documentation of refusals existed. |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 5
Sep 7, 2011
Visit Reason
The inspection was conducted concurrently with the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.
Findings
The facility was found deficient in several areas including failure to verify employee background checks prior to hire, unsanitary conditions in the central shower room, failure to maintain palatability of food served, improper food storage in the nutrition pantry, and failure to discard expired medications in a timely manner.
Complaint Details
Complaint reference #11228 was unsubstantiated with no related deficiencies cited. The complaint investigation was conducted concurrently with the annual inspection.
Severity Breakdown
SS=D: 1
SS=E: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to verify prior to hire that one employee had no findings entered into the State nurse aide registry concerning abuse, neglect, mistreatment, or misappropriation. | SS=D |
| Failed to ensure the central shower room was kept clean and comfortable; feces found on the floor of a shower stall. | SS=E |
| Failed to prepare marinated chicken in a manner that maintained palatability for five residents; chicken was too tough to eat. | SS=E |
| Failed to assure food in the nutrition pantry was stored in a sanitary manner; open bags of cookies not sealed or dated, nacho cheese spread container open and not labeled/dated. | SS=E |
| Failed to discard expired medications in a timely manner; 32 acetaminophen suppositories expired since April 2011 found in medication storage room. | SS=E |
Report Facts
Facility census: 60
Employees reviewed: 5
Expired medications found: 32
Residents affected by food palatability: 5
Open bags of cookies: 6
Inspection Report
Life Safety
Deficiencies: 0
Sep 1, 2011
Visit Reason
The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2000, based on review of documentation, staff interviews, observations, and performance testing.
Findings
The facility was found to be without waivers and in compliance with the provisions of the NFPA 101, Life Safety Code, 2000.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 30, 2011
Visit Reason
The inspection was conducted in response to complaint reference #11213.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the inspection.
Complaint Details
Complaint reference #11213 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
May 10, 2011
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Jackie Withrow Hospital.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Apr 5, 2011
Visit Reason
The inspection was conducted as a complaint investigation referenced by complaint #11057, which was found to be unsubstantiated but resulted in unrelated deficiencies being cited.
Findings
The facility failed to revise the care plan for one resident (#85) to reflect a new structured visitation schedule implemented on 02/14/11 until 04/04/11. Additionally, the consultant pharmacist did not complete monthly medication regimen reviews for any residents during February 2011, affecting all residents including five sampled residents (#25, #80, #37, #15, and #35).
Complaint Details
Complaint reference #11057 was unsubstantiated, but unrelated deficiencies were cited during the investigation.
Severity Breakdown
Level D: 1
Level F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to revise the care plan for Resident #85 to reflect a structured visitation schedule implemented on 02/14/11 until 04/04/11. | Level D |
| Failure to ensure the consultant pharmacist completed monthly medication regimen reviews for all residents in February 2011. | Level F |
Report Facts
Facility census: 92
Residents affected by medication review deficiency: 5
Residents sampled for care plan revision: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #102 | Social Worker | Confirmed Resident #85's care plan was not updated to reflect the new visitation schedule until 04/04/11 |
| Director of Nursing | Confirmed the pharmacist had not visited the facility or reviewed medication regimens in February 2011 |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 10, 2011
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Lakin Hospital.
Findings
The report identifies a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 20, 2011
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #11014.
Findings
The complaint was substantiated; however, no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #11014 was substantiated but resulted in no deficiencies cited.
Inspection Report
Life Safety
Deficiencies: 0
Jan 19, 2011
Visit Reason
The inspection was conducted to review the facility's compliance with the NFPA 101, Life Safety Code, 2000, based on documentation review, staff interview, observations, and performance testing.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Jan 12, 2011
Visit Reason
The inspection was conducted as a substantiated complaint investigation (#10369) concurrently with the facility's annual Medicaid certification resurvey.
Findings
The facility failed to provide adequate supervision to prevent an avoidable choking accident involving Resident #83, who was served the wrong diet contrary to physician orders. Additionally, the facility failed to identify and dispose of expired medications in two medication rooms, posing a risk to residents.
Complaint Details
Complaint reference #10369 was substantiated with deficiencies cited related to supervision and medication management.
Severity Breakdown
SS=G: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide adequate supervision to prevent an avoidable choking accident to Resident #83 due to serving a mechanically altered diet contrary to physician order for a pureed diet. | SS=G |
| Failed to identify and dispose of expired medications in medication rooms on D and C Wings, including multiple medications with outdated expiration dates. | SS=E |
Report Facts
Facility census: 90
Residents reviewed for swallowing problems: 4
Residents involved in diet error: 2
Medications with outdated expiration dates: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding Resident #83's condition and incident | |
| Director of Nursing | Interviewed regarding Resident #83's condition, incident, and medication storage policies | |
| Licensed Practical Nurse (Employee #156) | Observed medication room on D Wing with expired medications | |
| Licensed Practical Nurse (Employee #27) | Observed medication room on C Wing with expired medications |
Inspection Report
Routine
Census: 86
Deficiencies: 1
Dec 2, 2010
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations and other facility requirements during a routine survey.
Findings
The facility failed to assure all medications were maintained in a safe and secure storage manner, affecting two of four sampled residents. The Director of Nursing removed unsecured medications and implemented staff in-service and monitoring plans to ensure compliance.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications (Vitamin A&D ointment and Collagenase) were found unsecured in residents' rooms. | SS=B |
Report Facts
Facility census: 86
Sampled residents affected: 2
Sampled residents reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Withrow | Director of Nursing | Removed unsecured medications and conducted staff in-service on proper medication storage |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 2
Oct 22, 2010
Visit Reason
The inspection was conducted as a complaint investigation, including substantiated and unsubstantiated complaints regarding the facility's care and notification practices.
Findings
The facility failed to promptly notify the resident's physician and legal representative of a significant decline in the resident's health condition, resulting in delayed medical intervention and harm. Specifically, Resident #31 experienced decreased fluid intake, decreased level of consciousness, and no urinary output, leading to hospitalization for dehydration and renal failure.
Complaint Details
Complaint reference #10263 was substantiated with deficiencies cited. Complaint references #10295 and #10269 were unsubstantiated with no related deficiencies.
Severity Breakdown
Level C: 1
Level G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to promptly notify the resident's physician and legal representative of a significant change in physical condition and deterioration in health. | Level C |
| Failure to obtain timely medical intervention for a resident exhibiting decreased fluid intake, decreased level of consciousness, and no urinary output, resulting in harm. | Level G |
Report Facts
Facility census: 58
Resident weight: 130
Fluid intake requirement: 1776
Fluid intake: 1020
Fluid intake: 1100
Fluid intake: 890
Fluid intake: 0
Blood urea nitrogen: 116
Creatinine level: 6
Intravenous fluid rate: 125
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding resident's fluid requirements and condition. | |
| Registered Nurse (RN - Employee #68) | Documented nursing notes including no urinary output and physician contact. | |
| Licensed Practical Nurse (LPN - Employee #61) | Interviewed regarding family notification and resident condition on 09/16/10. | |
| Treating Physician | Interviewed regarding expectations for notification of resident condition. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 6
Oct 7, 2010
Visit Reason
Complaint investigation triggered by multiple complaint references regarding heating system failure and resident safety.
Findings
The facility failed to maintain safe and comfortable ambient air temperatures due to a malfunctioning heating boiler system that was red-tagged and not repaired in time for cold weather. Sixteen residents experienced drops in body temperature placing them at risk for hypothermia. Immediate jeopardy was identified and abated after portable heaters were provided and a temporary boiler was approved. Additional deficiencies included unsecured medication access and lack of a detailed disaster and evacuation plan.
Complaint Details
Complaint references #10274 and #10275 substantiated with deficiencies cited. Complaint reference #10264 substantiated with no deficiencies cited. Complaint references #10249 and #10287 unsubstantiated with no deficiencies cited.
Severity Breakdown
Immediate Jeopardy: 2
Level F: 2
Level D: 1
Substandard Quality of Care: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to provide a reliable source of heat to maintain safe indoor temperatures, placing residents at risk of hypothermia. | Immediate Jeopardy |
| Failure to maintain comfortable and safe temperature levels between 71 and 81 degrees Fahrenheit throughout the facility. | Substandard Quality of Care |
| Unsecured medication cart with resident access, posing accident hazard. | Level D |
| Failure to maintain heating boilers in safe operating condition. | Level F |
| Failure of governing body to ensure timely repair or replacement of heating system, resulting in immediate jeopardy. | Immediate Jeopardy |
| Lack of detailed written disaster and emergency evacuation plan including evacuation from the building. | Level F |
Report Facts
Residents affected by hypothermia risk: 16
Facility census: 81
Occupied rooms below 70 degrees F: 58
Occupied rooms below 65 degrees F: 19
Occupied rooms below 70 degrees F: 44
Occupied rooms below 65 degrees F: 20
Portable space heaters purchased: 56
Ambient room temperatures: 59
Ambient outdoor temperature: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding heating system failure and resident temperature monitoring. | |
| Maintenance Director | Interviewed regarding heating boiler system status and repair plans. | |
| Licensed Practical Nurse (Employee #158) | Accompanied LSC surveyor during ambient air temperature measurements. | |
| Director of Nursing (Employee #87) | Provided three-month summary of residents' body temperatures. | |
| Nurse (Employee #168) | Left medication unattended on cart, which was accessed by resident. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 5
Sep 22, 2010
Visit Reason
The inspection was conducted as a substantiated complaint investigation related to resident care, infection control, and facility administration.
Findings
The facility was found deficient in multiple areas including failure to provide care with dignity and respect, lack of an assembled suction machine readily available during emergencies, ineffective infection control program with multiple residents contracting nosocomial UTIs, failure to employ a qualified dietary manager, and failure of the quality assessment and assurance committee to address ongoing quality deficiencies.
Complaint Details
Complaint reference #10241 was substantiated with deficiencies cited related to resident dignity, emergency preparedness, infection control, dietary management, and quality assurance.
Severity Breakdown
Level D: 1
Level K: 2
Level F: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide care in a manner that maintains resident dignity and respect, evidenced by an LPN's inappropriate comment to a resident. | Level D |
| Failure to ensure an assembled suction machine was present and readily available on the crash cart during a choking emergency, placing residents at immediate jeopardy. | Level K |
| Failure to maintain an effective infection control program, including failure to investigate and address a high number of nosocomial urinary tract infections among residents. | Level F |
| Failure to administer the facility effectively, including failure to employ a qualified dietary manager during the absence of the dietary supervisor. | Level K |
| Failure of the Quality Assessment and Assurance (QAA) committee to develop and implement appropriate plans of action to correct identified quality deficiencies related to nosocomial UTIs. | Level F |
Report Facts
Facility census: 58
Residents with swallowing problems: 14
Minutes elapsed to locate suction machine: 7.5
Residents contracting nosocomial UTIs: 14
Last inservice date for perineal care: 2009
Dietary supervisor absence start date: 2010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #52 | Licensed Practical Nurse (LPN) | Named in dignity and respect deficiency for inappropriate comment |
| Employee #56 | Licensed Practical Nurse (LPN) | Involved in emergency response and failure to locate suction machine |
| Employee #47 | Records Information Systems Clerk | Assisted in locating suction machine |
| Employee #46 | Environmental Services Staff | Located unassembled suction machine |
| Employee #16 | Nursing Assistant (NA) | Observed providing improper perineal care |
| Employee #66 | Director of Nursing (DON) | Provided infection control policy and inservice evidence |
| Employee #33 | Dietary Services Assistant | Acting dietary supervisor without certification |
| Employee #37 | Dietary Services Supervisor | On maternity leave since August 2010 |
| Employee #68 | Administrator | Responsible for facility operation and QAA committee |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 31, 2010
Visit Reason
The inspection was conducted in response to complaint reference #10232.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #10232 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 10, 2010
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference #10122.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #10122 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Mar 31, 2010
Visit Reason
The inspection was conducted as a complaint investigation related to substantiated complaints with deficiencies cited.
Findings
The facility was found deficient in promoting resident dignity, as evidenced by a resident seated at an improperly sized table affecting her ability to eat with dignity. Additionally, the facility failed to promptly initiate contact precautions for a resident diagnosed with Clostridium difficile infection, delaying isolation by two days after positive lab results.
Complaint Details
Complaint reference #10077 was substantiated with deficiencies cited.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to promote care for residents in an environment that enhances dignity, demonstrated by a resident unable to eat properly due to table height. | Level D |
| Failure to follow infection control policy by not initiating contact precautions immediately after a resident tested positive for C. difficile. | Level D |
Report Facts
Resident census: 60
Doses of Kaopectate: 13
Days delay in contact precautions: 2
Duration of Flagyl treatment: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Social Worker | Interviewed regarding resident seating and dignity issues | |
| Director of Nursing | Interviewed regarding infection control and initiation of contact precautions |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 31, 2010
Visit Reason
The inspection was conducted in response to complaint reference #10085.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #10085 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Mar 17, 2010
Visit Reason
The inspection was conducted as a complaint investigation related to substantiated complaints of non-compliance with Medicaid certification requirements and State nursing home licensure rules.
Findings
The facility failed to support residents' rights to voice grievances, failed to register and respond to complaints filed by family or legal representatives of residents #94, #95, and #96, and failed to immediately report and thoroughly investigate allegations of abuse and neglect involving residents #94 and #96 to appropriate State agencies.
Complaint Details
Complaint reference #10061. The complaint was substantiated with deficiencies cited for non-compliance with Medicaid certification requirements and State nursing home licensure rules. The investigation involved review of records, resident and family interviews, and staff interviews. Specific complaints included failure to address concerns about resident safety, communication, and care, including allegations of resident abuse and neglect that were not reported or investigated properly.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to support residents' right to voice grievances and failed to actively seek resolution or keep residents or representatives apprised. | SS=D |
| Failed to investigate and report allegations of abuse, neglect, or mistreatment to State agencies and failed to prevent further potential abuse during investigations. | SS=D |
Report Facts
Facility census: 92
Number of residents sampled: 3
Date of survey completion: Mar 17, 2010
Inspection Report
Plan of Correction
Deficiencies: 3
Mar 4, 2010
Visit Reason
The visit was conducted to review the facility's compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the maintenance and inspection of the automatic sprinkler system.
Findings
The facility had not fully corrected previously cited deficiencies related to the automatic sprinkler system, including lack of internal inspections of alarm valves and check valves, and failure to flow test the private fire main within the last five years. The assistant administrator stated that corrections had been scheduled but delayed due to weather.
Deficiencies (3)
| Description |
|---|
| Alarm valves and associated trim internally inspected past five years? Answered 'no' with no explanation or date given. |
| Check valves internally inspected in the last five years? Answered 'no' with no explanation or date given. |
| Private fire main has not been flow tested in the last five years. Answered 'no' with no explanation or date given. |
Report Facts
Years since last inspection: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| assistant administrator | Stated that corrections have been scheduled but delayed due to weather |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 2, 2010
Visit Reason
The inspection was conducted in response to complaint references #10032 and #10045.
Findings
The complaint records were unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint references #10032 and #10045 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 25, 2010
Visit Reason
The inspection was conducted in response to complaint reference #10040.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #10040 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 13
Jan 20, 2010
Visit Reason
The inspection was conducted as a complaint investigation (complaint #9292) which was unsubstantiated, concurrently with the facility's annual Medicaid certification resurvey and State licensure inspection.
Findings
The facility was cited for multiple deficiencies including failure to provide accurate transfer/discharge notices, improper use and care planning of physical restraints, failure to check nurse aide abuse registry upon hire, lack of dignity during dining, inaccurate or incomplete comprehensive assessments and care plans, failure to monitor vascular access sites for a dialysis resident, inadequate infection control program, and improper food temperature maintenance.
Complaint Details
Complaint #9292 was unsubstantiated with no related deficiencies cited.
Severity Breakdown
C: 1
D: 3
E: 6
F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Facility failed to provide accurate information in the uniform notice regarding residents' right to appeal transfer/discharge decisions. | C |
| Facility failed to assure physical restraints were used only for treatment of medical symptoms and failed to perform assessments, care planning, and monitoring for six residents using restraints. | E |
| Facility failed to check nurse aide abuse registry upon initial hire for three employees. | E |
| Facility failed to assure dignity and respect during dining, including institutional dining environment and improper feeding practices. | E |
| Facility failed to assure accuracy of minimum data set assessments and failed to complete comprehensive assessments for residents using physical restraints. | E |
| Facility failed to develop comprehensive care plans with measurable objectives and timetables for seven residents. | E |
| Facility failed to revise care plan as needed when changes occurred in the use of physical restraints for one resident. | D |
| Facility failed to ensure a dialysis resident with two vascular access sites received necessary care and monitoring to prevent complications. | E |
| Facility failed to ensure one resident was evaluated for visual appliances despite documented vision decline. | D |
| Facility failed to ensure one resident with an indwelling Foley catheter received appropriate care to prevent urinary tract infections; catheter tubing was observed dragging on the floor. | D |
| Facility failed to assure foods were served at proper temperatures on one food cart, with temperatures below safe levels. | E |
| Facility failed to assure foods were prepared and served under sanitary conditions, including improper dishwashing practices and lack of soap in dishwasher. | F |
| Facility failed to establish and implement an effective infection control program including isolation procedures and infection tracking, resulting in potential spread of MRSA infection between roommates. | F |
Report Facts
Facility census: 93
Number of sampled residents: 27
Number of residents with restraint deficiencies: 6
Number of employees with abuse registry check deficiencies: 3
Number of residents with care plan deficiencies: 7
Number of UTIs for Resident #7: 3
Food temperature: 116
Food temperature: 119
Food temperature range: Array
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Employee #49, interviewed regarding restraint use for Resident #87 | |
| Nurse | Employee #16, acknowledged restraint use left out of care plan | |
| Nurse | Employee #41, discussed restraint monitoring | |
| Restorative Nurse | Interviewed regarding self-release belt restraints | |
| Director of Nursing | Interviewed regarding restraint care planning and infection control | |
| Social Worker | Interviewed regarding restraint assessments and resident vision | |
| Care Plan Nurse | Acknowledged care plan deficiencies for dialysis resident | |
| Dietary Manager | Interviewed regarding food temperature and food cart repair | |
| Infection Control Nurse | Interviewed regarding infection control and catheter care | |
| Employee #46 | Completed nurse aide abuse registry checks during survey |
Inspection Report
Life Safety
Census: 93
Deficiencies: 2
Jan 12, 2010
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on the maintenance, inspection, and testing of the facility's automatic sprinkler system and emergency power supply system (generator).
Findings
The facility failed to maintain, inspect, and test the sprinkler system according to NFPA 25 standards, with inspection reports overdue by approximately seven months and incomplete documentation. Additionally, the emergency power supply system was not exercised under load as required by NFPA 110, with generator logs indicating 'not tested under load' and a non-functioning block heater, as well as a warning light for low engine temperature.
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain, inspect, and test the sprinkler system in accordance with NFPA 25, including overdue inspections and incomplete reports. | SS=F |
| Failure to maintain and exercise the emergency power supply system (generator) under load as required by NFPA 110, including lack of amp readings, non-working block heater, and low engine temperature warning. | SS=F |
Report Facts
Facility census: 93
Months overdue for sprinkler inspection: 7
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 11
Jan 7, 2010
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations governing nursing facilities, including resident rights, care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to properly inform residents of rights, inadequate assessment and application of physical restraints, insufficient employee background checks, incomplete comprehensive assessments after significant changes, unclear standing orders for constipation treatment, inadequate assistance with eating for dependent residents, unsecured hazardous materials, improper food sanitation practices, untimely physician visits, and incomplete or inaccurate medical records.
Severity Breakdown
SS=D: 7
SS=C: 1
SS=E: 2
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to assure determination of incapacity for resident #9 was completed according to State law. | SS=D |
| Failure to ensure physical restraint was adequately assessed and applied correctly for resident #42. | SS=D |
| Failure to ensure two employees were adequately screened for abuse or neglect history. | SS=D |
| Failure to conduct a comprehensive assessment after significant change for resident #32. | SS=D |
| Facility's standing orders for constipation treatment were unclear and inaccurate. | SS=C |
| Failure to provide necessary assistance with eating for resident #43 with poor oral intake. | SS=D |
| Unsecured cabinet in shower room containing hazardous materials accessible to residents. | SS=E |
| Failure to ensure medication regimen was free from unnecessary drugs; milk of magnesia given without indication to resident #9. | SS=D |
| Failure to assure food was prepared and served under sanitary conditions; multiple sanitation infractions observed in dietary department. | SS=F |
| Failure to ensure timely physician visits for residents #39 and #32 within required time frames. | SS=E |
| Failure to maintain complete and accurate medical records for five residents (#39, #29, #12, #4, #10). | SS=D |
Report Facts
Facility census: 60
Sampled residents: 13
Employees sampled: 10
Deficiencies cited: 11
Days between physician visits: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #6 | Licensed Practical Nurse | Failed background check screening for abuse/neglect history |
| Employee #75 | Failed background check screening for abuse/neglect history and criminal background | |
| Director of Nursing | Director of Nursing | Interviewed regarding restraint application, medication errors, and physician visit timeliness |
| Employee #59 | Business Office Assistant | Assisted in personnel file review for background checks |
| Employee #70 | Clinical Care Supervisor | Interviewed regarding comprehensive assessment for resident #32 |
Inspection Report
Life Safety
Deficiencies: 0
Jan 7, 2010
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.
Inspection Report
Life Safety
Deficiencies: 0
Jan 5, 2010
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be in compliance without waivers with the Life Safety Code provisions.
Inspection Report
Routine
Census: 88
Deficiencies: 8
Dec 10, 2009
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding resident rights, dignity, care planning, medication administration, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide beauty and barber services, maintain comfortable temperature levels, conduct comprehensive assessments after significant resident changes, revise care plans accordingly, administer medications correctly, and maintain infection control practices.
Severity Breakdown
E: 2
D: 6
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide beauty and barber services as needed by residents after the beautician quit. | E |
| Failure to maintain comfortable and safe temperature levels, with temperatures often below the required range. | E |
| Failure to conduct a comprehensive assessment within 14 days after a significant change in a resident's condition. | D |
| Failure to evaluate and revise a resident's care plan as the resident's status changed. | D |
| Failure to provide and/or dispense medications in accordance with physician's orders and manufacturer's recommendations, including incorrect eye drop strength and improper timing. | D |
| Failure to follow physician's order for Lidocaine Patch application and removal times. | D |
| Failure to provide pharmaceutical services assuring accurate acquiring, receiving, dispensing, and administering of drugs, including failure to obtain medication at prescribed concentration. | D |
| Failure to maintain infection control practices, including improper handling of resident's treatment supplies leading to potential infection transmission. | D |
Report Facts
Facility census: 88
Medication administration opportunities: 42
Residents sampled: 18
Residents sampled: 15
Deficiencies cited: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding beauty shop services, care plan implementation, and medication order discrepancies | |
| Medication Nurse (Employee #113) | Observed administering eye drops with incorrect timing and strength | |
| Nurse (Employee #99) | Confirmed pharmacy medication strength discrepancy and initiated clarification | |
| Health Services Worker (Employee #82) | Observed transporting resident and unable to recall care plan intervention | |
| Nurse (Employee #105) | Observed applying Lidocaine patch incorrectly | |
| Nurse (Employee #106) | Observed placing resident's jar of cream on the floor during treatment |
Inspection Report
Life Safety
Census: 60
Deficiencies: 1
Nov 17, 2009
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the maintenance and operation of the facility's automatic sprinkler system.
Findings
The facility failed to maintain all components of the sprinkler system in reliable operating condition as required by NFPA 25. A solid shower curtain obstructing the spray pattern of a sprinkler head in the storage room near the activities room was observed.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| A solid shower curtain hanging on a ceiling mounted track obstructed the spray pattern for a sprinkler head in the storage room near the activities room. | SS=B |
Report Facts
Facility census: 60
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 1
Nov 17, 2009
Visit Reason
The inspection was conducted in response to complaint reference #9313 regarding an allegation of neglect involving a resident who was found unresponsive after a fall.
Findings
The facility failed to immediately report an allegation of neglect involving one resident who was found unattended after an unwitnessed fall. The allegation was not reported to State agencies until nine days after the incident. The facility's internal investigation later found the resident was not left unattended as originally alleged.
Complaint Details
Complaint reference #9313 was unsubstantiated with unrelated deficiencies cited. The allegation involved Resident #72 who was found on the floor after an unwitnessed fall on 10/21/09 and was allegedly left unattended by staff when ambulance arrived. The incident was not reported to State agencies until 10/30/09. The facility's internal investigation included witness statements that the resident was not left unattended.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately report an allegation of neglect involving a resident found unattended after an unwitnessed fall. | SS=D |
Report Facts
Facility census: 83
Complaint reference number: 9313
Days delay in reporting: 9
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 8
Oct 23, 2009
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for nursing facilities, including care planning, medication administration, infection control, food service, and laboratory services.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans with measurable objectives, licensed practical nurses acting outside their scope of practice, failure to provide necessary care to maintain residents' well-being, improper medication administration via gastrostomy tubes, food served at improper temperatures, unsanitary food service conditions, inadequate infection control practices, and untimely laboratory testing.
Severity Breakdown
SS=D: 6
SS=E: 2
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to develop comprehensive care plans with measurable objectives and relevant services for residents #5 and #36. | SS=D |
| Licensed practical nurses failed to notify RN or physician of resident #26's change in condition, acted outside scope of practice by ordering/administering medication, and failed to document medication refusal for resident #23. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable physical well-being for residents #26 and #57, including inappropriate administration of laxatives and delayed antibiotic treatment. | SS=D |
| Failure to properly position resident #2 during gastrostomy tube medication administration to avoid choking and aspiration. | SS=E |
| Failure to serve food at proper temperature for palatability, with food items below 120 degrees Fahrenheit at point of service. | SS=E |
| Failure to maintain sanitary food service conditions, including open trash can without lid and wet nesting of glasses and bowls. | SS=F |
| Failure to ensure licensed nursing staff washed or sanitized hands prior to administering medications via gastrostomy tubes for residents #2 and #42. | SS=D |
| Failure to provide or obtain laboratory services in a timely manner for residents #12, #23, and #26, including delayed stool specimen collection and processing. | SS=D |
Report Facts
Facility census: 59
Deficiency count: 9
Food temperature: 108.1
Food temperature: 109.9
Laxative administration days: 6
Antibiotic delay: 2
Laboratory specimen delay: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #31 | Licensed Practical Nurse | Named in medication refusal documentation deficiency for Resident #23 |
| Employee #82 | Director of Nursing | Interviewed regarding nursing scope of practice and laboratory testing delays |
| Employee #84 | Registered Nurse | Notified about missing laboratory results for Resident #26 |
| Employee #13 | Nurse | Observed improperly positioning Resident #2 during gastrostomy medication administration and failing to wash hands |
| Employee #6 | Nurse | Observed failing to wash hands prior to gastrostomy medication administration for Resident #42 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 6, 2009
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #9166.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #9166 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 3, 2009
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #9213.
Findings
The complaint was substantiated; however, no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #9213 was substantiated with no deficiencies cited.
Inspection Report
Life Safety
Census: 80
Deficiencies: 9
Jul 9, 2009
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including fire safety, smoke barriers, exit components, fire alarm systems, sprinkler systems, HVAC shutdown devices, and emergency generator testing.
Findings
The facility failed to maintain several life safety code requirements including fire door latching, smoke barrier door ratings, exit stairway egress, continuous illumination of exit signs, fire alarm system testing, sprinkler system inspections, HVAC shutdown device testing, and emergency generator load testing.
Severity Breakdown
SS=B: 2
SS=C: 7
Deficiencies (9)
| Description | Severity |
|---|---|
| 90-minute door separating A-wing from B-wing lacked mechanical locking device, only magnetic lock present, not compliant with NFPA 80. | SS=B |
| Smoke barrier doors near room B117 dragged at meeting edges, failing to close tightly and reducing fire resistance rating. | SS=B |
| Soiled utility and store room doors lacked effective positive latching devices to keep doors closed. | SS=C |
| B-Unit exit stairway door stuck closed due to damage; 1-C exit stairway door required excessive force to open, impeding egress. | SS=C |
| Exit and directional signs failed to maintain continuous illumination at multiple locations. | SS=C |
| Fire alarm system lacked documentation of quarterly testing as required by NFPA 72. | SS=C |
| Sprinkler system inspections were not conducted quarterly; missing second quarter 2009 inspection. | SS=C |
| HVAC system shutdown devices were not tested annually as required by NFPA 90-A. | SS=C |
| Emergency generator was not exercised under load for 30 minutes each month as required. | SS=C |
Report Facts
Facility census: 80
Annual fire alarm inspection: 1
Sprinkler system inspections: 3
Emergency generator load test duration: 30
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 7
Jul 2, 2009
Visit Reason
The inspection was conducted concurrently with complaint investigations #9155 and #9164, the facility's annual Federal Medicaid certification resurvey, and State licensure inspection.
Findings
The facility was found deficient in multiple areas including failure to post complete contact information for State advocacy agencies, failure to report and investigate allegations of neglect for a transferred resident, failure to accommodate a resident's need for a larger chair, failure to develop and implement comprehensive care plans for certain residents, failure to maintain a safe environment by leaving a janitor's closet unlocked, failure to ensure drug regimens were free from unnecessary drugs, and failure to properly post daily nurse staffing information.
Complaint Details
Complaint references #9155 and #9164 were unsubstantiated with unrelated deficiencies cited. The complaint investigations were conducted concurrently with the annual inspection.
Severity Breakdown
SS=C: 2
SS=D: 4
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to post all complete contact information for all applicable State advocacy agencies. | SS=C |
| Failed to report and investigate allegations of neglect involving a resident transferred to another facility. | SS=D |
| Failed to accommodate a resident's need for a larger chair after weight gain. | SS=D |
| Failed to develop and implement comprehensive care plans for residents including one receiving Ativan for insomnia and one with dietary needs. | SS=D |
| Failed to ensure the locked unit was kept safe and free from accident hazards; janitor's closet was left unlocked allowing resident access to hazardous chemicals. | SS=E |
| Failed to ensure the drug regimen of a resident was free from unnecessary drugs; resident received excessive dose of Ativan with adverse consequences. | SS=D |
| Failed to ensure daily nursing staffing posting was complete and compliant with regulatory requirements. | SS=C |
Report Facts
Facility census: 81
Resident sample size: 14
Resident falls: Resident #74 had frequent falls since admission
Ativan dose: 3
Unit census: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #24 | Assistant Director of Nursing | Confirmed resident #74 was receiving Ativan for insomnia |
| Employee #111 | Health Services Worker | Observed and locked janitor's closet after surveyor found it unlocked |
| Employee #14 | Housekeeping Supervisor | Provided material safety data sheets for chemicals in janitor's closet |
| Employee #163 | Reported resident #74 had frequent falls |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 27, 2009
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference #9127.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #9127 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 18, 2009
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference #9057.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #9057 was substantiated with no deficiencies cited.
Inspection Report
Follow-Up
Census: 100
Deficiencies: 0
Feb 2, 2009
Visit Reason
Follow-up/re-visit to a complaint investigation to determine if previously cited deficiencies were corrected.
Findings
The facility had corrected the deficiency cited at F323 and was found to be in compliance with the regulations. No new tags were cited during this visit.
Complaint Details
Complaint number #2-8284; substantiation status: N/A.
Report Facts
Sample size: 5
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Dec 10, 2008
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse and neglect concerning the care of Resident #69.
Findings
The facility was found to have failed to ensure that Resident #69, who required a mechanical lift for transfers, was assisted with this device during a transfer from a shower chair to her bed, resulting in a fractured leg that required surgical repair.
Complaint Details
Complaint reference #2-8284 was substantiated with deficiencies cited related to neglect in transferring Resident #69 without the required mechanical lift, leading to a fractured leg.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure one resident who required a mechanical lift for transfers received assistance with the device during transfer, resulting in injury. | SS=G |
Report Facts
Facility census: 99
Sampled residents: 5
Resident involved: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #148 | Nursing Assistant | Involved in the transfer of Resident #69 without using the mechanical lift as required |
| Assistant Director of Nursing | ADON | Provided information about Resident #69's mobility status and transfer requirements |
| Director of Nursing | DON | Reported that the nursing assistant should have known the resident required mechanical lift use and explained documentation issues |
Inspection Report
Life Safety
Census: 100
Deficiencies: 4
Nov 13, 2008
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including corridor door safety, hazardous area protections, fire alarm system maintenance, and generator maintenance.
Findings
The facility failed to maintain corridor doors to close and latch without impediment, improperly charged electric wheelchair batteries outside hazardous areas, did not fully inspect and test fire alarm system components, and failed to maintain battery-powered emergency lighting in the generator location and transfer switch room.
Deficiencies (4)
| Description |
|---|
| Corridor door to treatment room had a hooking device impeding door closure. |
| Electric wheelchair batteries were charged in a resident room not protected as a hazardous area. |
| Fire alarm inspection report lacked evidence of testing accessory equipment (automatic telephone dialer). |
| No battery powered emergency lighting observed in generator location building or transfer switch room. |
Report Facts
Facility census: 100
Deficiency completion dates: Various deficiencies have completion dates ranging from 01/13/09 to 03/13/09
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 5
Nov 7, 2008
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-8313, which was unsubstantiated, concurrently with the facility's annual Federal Medicaid certification resurvey and State licensure inspection.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, failure to revise care plans to reflect changes in resident status, improper communication and clarification of therapeutic diet orders, unsanitary food storage and serving conditions, and improper labeling and storage of medications.
Complaint Details
Complaint reference #2-8313 was unsubstantiated with no related deficiencies cited. The complaint investigation was conducted concurrently with the annual certification resurvey and licensure inspection.
Severity Breakdown
SS=D: 3
SS=E: 1
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to conduct an accurate assessment of resident #28 by incorrectly indicating deterioration when improvement occurred. | SS=D |
| Facility failed to revise the care plan for resident #28 to reflect actual improvement and medication changes. | SS=D |
| Facility failed to ensure physician's therapeutic diet orders were clarified and accurately communicated to dietary for residents #64 and #97. | SS=D |
| Facility failed to ensure foods were stored and served under sanitary conditions in the kitchen and diet kitchen. | SS=F |
| Facility failed to ensure all medications were properly labeled and securely stored to prevent dispensing errors. | SS=E |
Report Facts
Facility census: 100
Sampled residents: 17
Random residents: 1
Dates: Nov 7, 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Two nurses (Employees #80 and #97) interviewed regarding inaccurate MDS coding and care plan revision for resident #28 | ||
| Dietary manager interviewed regarding diet order clarifications and diet manual | ||
| Social worker (Employee #15) and nurses (Employees #26 and #97) interviewed regarding diet order communication | ||
| Nurse (Employee #47) confirmed unsanitary food storage observations | ||
| Server (Employee #131) interviewed regarding meal service and food handling | ||
| Medication nurse accompanying surveyor when unlabeled ophthalmic solution was found |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 2, 2008
Visit Reason
The inspection was conducted in response to complaint reference #2-8258.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8258 was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 8
Sep 18, 2008
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations governing nursing facilities, including resident rights, care, medication management, infection control, and record keeping.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints, failure to report injuries of unknown origin, lack of comprehensive assessments after significant resident changes, incomplete care plans, unnecessary drug use without adequate monitoring, failure of pharmacist to report drug irregularities, poor infection control practices during wound care, and inconsistent documentation of residents' code status.
Severity Breakdown
SS=D: 6
SS=E: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to properly utilize and release physical restraints according to physician orders and care plans for Resident #9. | SS=D |
| Failure to follow policy for investigating and reporting injuries of unknown origin for Resident #28. | SS=D |
| Failure to conduct a comprehensive assessment after significant change in Resident #9's condition. | SS=D |
| Failure to develop comprehensive care plans including measurable objectives and interventions for Resident #52's insomnia. | SS=D |
| Use of unnecessary drugs without adequate monitoring or indications for Residents #46, #59, #19, #55, and #52. | SS=E |
| Failure of pharmacist to identify and report drug irregularities for Residents #46 and #19. | SS=D |
| Failure to follow infection control practices during wound treatment, including placing treatment records on resident's bed and placing wound cleanser on the floor. | SS=E |
| Inaccurate and inconsistent documentation of residents' code status for Residents #33 and #52. | SS=D |
Report Facts
Facility census: 59
Number of sampled residents: 15
Number of residents with deficiencies related to unnecessary drugs: 5
Number of residents with inconsistent code status documentation: 2
Number of residents with physical restraint deficiency: 1
Number of residents with injury reporting deficiency: 1
Inspection Report
Life Safety
Deficiencies: 0
Sep 16, 2008
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.
Inspection Report
Life Safety
Deficiencies: 0
Sep 9, 2008
Visit Reason
The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Findings
Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 10
Aug 28, 2008
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with federal regulations regarding resident rights, physical restraints, staff treatment, activities, resident assessments, care plans, medication safety, food sanitation, pharmacy services, and administrative compliance.
Findings
The facility was found deficient in multiple areas including improper use and lack of reduction plans for physical restraints, failure to prevent neglect during night shifts, inadequate individualized activities, inaccurate resident assessments, incomplete care plans, unsecured medication carts, unsanitary food preparation conditions, unsupervised access to medication rooms, and failure to provide employees with required Central Abuse Registry information.
Severity Breakdown
SS=B: 1
SS=D: 5
SS=E: 3
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to assure residents were free from unnecessary physical restraints and lack of plans to reduce restraint use for residents #35, #71, and #30. | SS=D |
| Failure to implement procedures to prevent neglect of residents needing assistance during night shift, specifically Resident #15. | SS=D |
| Failure to immediately report and investigate allegations of neglect involving Resident #15. | SS=D |
| Failure to provide an ongoing individualized activities program for Resident #35, who was restrained and expressed interest in activities using his hands. | SS=D |
| Failure to accurately reflect Resident #35's use of physical restraint in the Minimum Data Set assessment. | SS=D |
| Failure to develop and revise comprehensive care plans addressing resident-specific needs including pressure ulcers, restraint reduction, nutritional status, psychoactive drug use, and behavioral issues for multiple residents. | SS=E |
| Failure to secure medication cart during medication administration, leaving it unlocked and unsupervised. | SS=E |
| Failure to maintain sanitary conditions in food preparation, with dishwashing machine rinse temperature too high to properly sanitize dishware. | SS=F |
| Failure to ensure medications were kept safe, with unauthorized personnel (housekeeper) left unsupervised in medication room. | SS=D |
| Failure to ensure compliance with State code regarding providing Central Abuse Registry information to all current employees. | SS=B |
Report Facts
Facility census: 98
Sampled residents: 17
Sampled residents: 20
Residents affected: 21
Residents affected: 36
Employees affected: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #100 | Reported seeing Resident #35 walking without restraint | |
| Employee #96 | Verified inaccuracies in Resident #35's MDS and care plans for multiple residents | |
| Employee #3 | Activity Director | Confirmed no individualized activity plan for Resident #35 |
| Employee #110 | Nurse | Observed leaving medication cart unlocked during medication administration |
| Employee #99 | Nurse | Unaware of housekeeper unsupervised in medication room |
| Employee #13 | Acknowledged failure to provide Central Abuse Registry information to current employees |
Inspection Report
Life Safety
Census: 98
Deficiencies: 1
Aug 28, 2008
Visit Reason
The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically the maintenance and testing of the facility's fire alarm system.
Findings
The facility failed to maintain all components of the fire alarm system in accordance with NFPA 72. During testing, the automatic dialing system did not send a required 'trouble' signal to the fire alarm annunciator panel when the primary phone line was disconnected.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain all components of the facility fire alarm system in accordance with NFPA 72, including failure to send a 'trouble' signal to the fire alarm annunciator panel during testing. | SS=F |
Report Facts
Facility census: 98
Inspection Report
Routine
Census: 59
Deficiencies: 4
Aug 21, 2008
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, quality of care, sanitary conditions in food preparation, and clinical record documentation at Wyoming Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to properly assess and document an infected gastrostomy site for one resident, unsanitary conditions in the dietary department affecting food storage and preparation, and inaccurate clinical record documentation related to infection treatment.
Severity Breakdown
SS=C: 1
SS=D: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure the infected gastrostomy site for one resident was assessed and documented properly. | SS=D |
| Failure to store, prepare, and distribute food under sanitary conditions in the dietary department. | SS=F |
| Failure to maintain accurate and complete clinical records for one resident. | SS=D |
| Failure to inform residents of their rights and facility rules in writing and orally. | SS=C |
Report Facts
Facility census: 59
Sampled residents: 13
Days antibiotic prescribed: 10
Area of redness: 10
Date of survey completion: Aug 21, 2008
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 17, 2008
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference #2-8209.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8209 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 3, 2008
Visit Reason
The inspection was conducted in response to complaint reference #2-8104.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8104 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 5
May 6, 2008
Visit Reason
The inspection was conducted as a comprehensive annual survey of Jackie Withrow Hospital to assess compliance with federal regulations regarding resident care, medication management, sanitary conditions, laboratory services, and emergency preparedness.
Findings
The facility was found deficient in multiple areas including incomplete care plans addressing resident falls, unnecessary use of hypnotic drugs without proper re-evaluation, unsanitary conditions with coffee cups containing dried food debris, failure to obtain ordered laboratory tests, and failure to conduct required annual disaster drills.
Severity Breakdown
SS=D: 3
SS=B: 1
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Care plan for Resident #34 failed to address falls from bed, only addressing falls from wheelchair. | SS=D |
| Resident #6 was receiving the hypnotic drug Serax 10 mg at bedtime for an excessive duration without re-evaluation despite decline in health. | SS=D |
| Coffee cups used for residents had dried food debris inside, indicating unsanitary conditions. | SS=B |
| Facility failed to obtain electrolyte labs as ordered for Resident #37. | SS=D |
| Facility failed to rehearse disaster plan annually; no disaster drill conducted within the past year. | SS=F |
Report Facts
Facility census: 79
Falls experienced: 2
Medication dose: 10
Lab order frequency: 3
Inspection Report
Census: 78
Deficiencies: 4
May 6, 2008
Visit Reason
The inspection was conducted to assess compliance with fire safety codes, life safety standards, and facility maintenance requirements, including smoke barrier integrity, delayed egress door signage, sprinkler system maintenance, and emergency generator functionality.
Findings
The facility was found deficient in maintaining smoke barrier walls with proper fire resistance, lacked proper signage on delayed egress doors, failed to maintain sprinkler systems with timely inspections and cleaning, and did not maintain the emergency generator and its monitoring annunciator according to NFPA standards.
Severity Breakdown
SS=C: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to maintain smoke barrier walls to provide at least one-half hour fire resistance rating; multiple penetrations through smoke barriers were not sealed. | SS=C |
| Not all delayed-egress doors were identified with the proper sign indicating door release within 15 seconds after pressure applied to panic bar. | SS=C |
| Required automatic sprinkler systems were not continuously maintained in reliable operating condition; inspections and testing were not conducted quarterly as required; sprinkler heads were covered with dust/dirt. | SS=C |
| Emergency generator annunciator was not located in a continuously monitored area; exhaust vent stack was rusted and allowed rainwater to enter the motor. | SS=C |
Report Facts
Facility census: 78
Sprinkler inspection dates: 3
Sprinkler heads observed dirty: 18
Delayed egress door tests: 7
Delayed egress door release time: 30
Inspection Report
Deficiencies: 0
Apr 10, 2008
Visit Reason
The inspection visit was conducted on 04/10/2008 as an entrance and exit survey for regulatory compliance at Jackie Withrow Hospital.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights, services, charges, and Medicaid benefits. No specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 19, 2008
Visit Reason
This document is a plan of correction related to a paper revisit inspection of Lincoln Healthcare Center.
Findings
The report references a deficiency related to the facility's obligation to inform residents of their rights and services in writing and orally, but no detailed findings or severity levels are provided.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Report Facts
Provider/Supplier Identification Number: 515171
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 17, 2008
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-8043.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8043 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 3
Feb 15, 2008
Visit Reason
The inspection was conducted in response to substantiated complaints regarding lack of hot water and related quality of life issues for residents, as well as concerns about sanitary conditions in food preparation and maintenance of essential equipment.
Findings
The facility failed to provide hot water to multiple units affecting 43 residents, resulting in inability to shower regularly and dependence on staff for personal hygiene. Water temperatures fluctuated and were often too cold. The dietary department had inadequate sanitization practices and insufficient hot water and water pressure at hand sinks. The facility also failed to maintain hot water heating equipment in safe operating condition, with delayed ordering of necessary repair parts.
Complaint Details
Complaint references #2-8038, #2-8045, and #2-8051 were substantiated with deficiencies cited related to lack of hot water and quality of life issues for residents.
Severity Breakdown
E: 1
F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide hot water to Units 1B, 2B, and 3B affecting 43 residents, resulting in inability to shower and maintain personal hygiene. | E |
| Failure to maintain sanitary conditions in food preparation, including inadequate sanitization of dishes and insufficient hot water and water pressure at hand sinks. | F |
| Failure to maintain essential mechanical equipment in safe operating condition, including broken steam coil in hot water tank and delayed repair parts ordering. | F |
Report Facts
Residents affected by no hot water: 43
Facility census: 82
Water temperature: 108.7
Water temperature range: 69
Water temperature range: 108
Dish machine rinse temperature: 160
Dish machine rinse temperature: 164
Date parts ordered for instant steam converter water heater: Feb 15, 2008
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 5, 2008
Visit Reason
The visit was conducted as a complaint investigation referenced as #2-8024.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-8024 was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 5
Jan 31, 2008
Visit Reason
The inspection was conducted concurrently with a complaint investigation and the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.
Findings
The facility was found to have multiple deficiencies including failure to ensure joint medical decision-making by appointed medical powers of attorney, inadequate monitoring and documentation of PRN medication use, unsanitary food storage conditions, medication availability issues, and incomplete clinical record documentation.
Complaint Details
Complaint reference #2-8013 was unsubstantiated with no related deficiencies cited.
Severity Breakdown
Level B: 1
Level D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to have both appointed medical powers of attorney jointly make medical decisions for resident #3. | Level D |
| Failure to adequately monitor and document the use of the anti-anxiety medication Ativan for resident #12. | Level D |
| Failure to store food items such as thickener powder under sanitary conditions, risking contamination affecting eight residents. | Level B |
| Failure to ensure medications were available for administration as ordered; resident #11 missed eight doses of Carafate due to unavailability. | Level D |
| Failure to maintain complete and accurate clinical records; Carafate medication order for resident #11 was not carried forward in monthly recapitulation. | Level D |
Report Facts
Resident census: 59
Medication doses missed: 8
PRN medication administrations: 24
Residents affected by thickener powder storage: 8
Sampled residents: 13
Inspection Report
Life Safety
Deficiencies: 0
Jan 29, 2008
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 20, 2007
Visit Reason
This document is a plan of correction related to a paper revisit survey conducted at the facility.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand. No other specific findings are detailed.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Follow-Up
Deficiencies: 1
Sep 6, 2007
Visit Reason
The visit was a paper revisit to review the facility's compliance with previously cited deficiencies.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, but no specific findings or severity levels are detailed in this excerpt.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Inspection Report
Life Safety
Census: 98
Deficiencies: 1
Aug 24, 2007
Visit Reason
The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the testing and maintenance of the fire alarm system and smoke detector sensitivity.
Findings
The facility failed to conduct required sensitivity testing of smoke detectors as mandated by NFPA 72. Review of fire alarm inspection reports from 2001 to 2007 showed no evidence of sensitivity testing, and the maintenance director confirmed no such tests had been performed.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Smoke detectors were not tested for sensitivity as required by NFPA 72. | SS=F |
Report Facts
Facility census: 98
Inspection date: Aug 24, 2007
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility maintenance director | Stated no sensitivity test has been conducted |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 4
Aug 23, 2007
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify physicians of significant changes in resident conditions, unsafe resident environment, infection control lapses, and inaccurate clinical records.
Findings
The facility failed to timely notify physicians of worsening pressure ulcers, maintain a safe environment by securing hazardous items, consistently implement infection control practices, and accurately document clinical records regarding use of a leg rest for a resident.
Complaint Details
The investigation found substantiated complaints regarding lack of timely physician notification of resident condition changes, unsafe environment hazards, infection control breaches, and inaccurate clinical documentation.
Severity Breakdown
SS=G: 1
SS=E: 2
SS=A: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to notify physician timely of worsening pressure ulcers and changes in resident condition. | SS=G |
| Resident environment not free of accident hazards; unsecured cabinets with razors, mop handle hazard, and unsecured external use items accessible to residents. | SS=E |
| Infection control program deficiencies with staff contaminating gloves and treatment items, risking transfer of organisms to residents. | SS=E |
| Clinical records did not accurately reflect use of leg rest as ordered; leg rest was not used though documented as used. | SS=A |
Report Facts
Facility census: 92
Number of wounds documented for Resident #931: 4
Temperature: 102.4
Dates of wound measurements: Multiple wound size measurements from 06/06/07 to 07/25/07 documented
Inspection Report
Routine
Census: 94
Deficiencies: 10
Aug 16, 2007
Visit Reason
Routine inspection of Nella's at Autumn Lake Healthcare to assess compliance with federal regulations related to resident rights, protection of resident funds, physical restraints, care plans, accident prevention, drug regimen, therapeutic diets, sanitary conditions, infection control, and clinical records.
Findings
The facility was found deficient in multiple areas including improper handling of resident funds, inadequate surety bond coverage, inappropriate use of physical restraints (bed rails) without proper evaluation and care planning, incomplete care plans related to bed rail safety, unsafe side rail netting and padding, unnecessary use of psychotropic drugs without adequate monitoring or gradual dose reduction, failure to provide therapeutic diets as ordered, unsanitary food storage and equipment conditions, and inaccurate clinical records related to bed safety assessments.
Severity Breakdown
SS=B: 2
SS=D: 3
SS=E: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to deposit resident funds in an account completely separate from facility funds. | SS=B |
| Facility failed to assure the security of all personal funds of residents by not securing a surety bond adequate to cover resident funds. | SS=B |
| Physical restraints in the form of bed rails were used without proper medical indication or care planning for residents #37 and #95. | SS=D |
| Care plans did not accurately reflect needs related to bed rail use and safety precautions for residents with seizure disorders (#95, #92, #16). | SS=D |
| Facility failed to assure an environment free of accident hazards due to disrepair and improper securing of side rail netting and foam padding affecting multiple residents. | SS=E |
| Resident drug regimens included unnecessary psychoactive drugs without adequate indications, monitoring, or attempts at gradual dose reduction for residents #1 and #52. | SS=E |
| Therapeutic diets were not provided as ordered for multiple residents; regularly seasoned potatoes and gravy served instead of low sodium, low fat, or calorie controlled items. | SS=E |
| Food was stored under unsanitary conditions including undated opened containers and crumbly substance on refrigerator shelves. | SS=E |
| Equipment such as bed side rails and geri chairs were not maintained in a sanitary manner, with dirt, grime, torn padding, and loose netting posing infection risks. | SS=E |
| Clinical records were incomplete and inaccurate, specifically bed safety assessments that did not reflect resident's actual mobility status. | SS=D |
Report Facts
Facility census: 94
Surety bond amount: 32000
Psychotropic drug orders: 3
Psychotropic drug orders: 2
Number of residents affected by unsafe side rail netting/padding: 20
Number of residents affected by therapeutic diet errors: 9
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 2, 2007
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of Lakin Hospital.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Census: 108
Deficiencies: 1
Jul 12, 2007
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to social services and resident rights in the facility.
Findings
The facility failed to ensure that one of fourteen sampled residents received a psychological consultation as requested. Specifically, Resident #71 had a consultation request dated 05/11/07 that had not been completed by the time of review.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure one resident received a psychological consultation as requested. | SS=D |
Report Facts
Facility census: 108
Sampled residents: 14
Residents with deficiency: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 27, 2007
Visit Reason
The visit was conducted as a complaint investigation referenced as #2-7134.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-7134 was unsubstantiated with no deficiencies cited.
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 25, 2007
Visit Reason
The visit was a paper revisit to follow up on previously identified deficiencies.
Findings
The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. Specific deficiencies are noted but detailed findings are not fully provided in the excerpt.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Report Facts
Provider/Supplier Identification Number: 515164
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 6
Jun 11, 2007
Visit Reason
Complaint investigation related to substantiated complaint record with deficiencies cited regarding care plans, quality of care, pressure sores, accident hazards, and clinical records.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents with pressure ulcers, inadequate nursing care and monitoring especially related to pneumonia and pressure ulcers, failure to provide ordered pressure-relieving devices, unsafe environment due to unlocked mechanical room, and inaccurate clinical record documentation.
Complaint Details
Complaint reference #2-7118. Substantiated complaint record with deficiencies cited.
Severity Breakdown
C: 1
D: 1
E: 2
G: 2
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to develop comprehensive care plans for residents with pressure ulcers or requiring treatment for existing pressure ulcers. | C |
| Failure to assure licensed nursing staff provided care within their scope, specifically unclear standing orders for PRN laxatives. | E |
| Failure to provide appropriate assessments, monitoring, and evaluation for a resident with pneumonia leading to decline and death. | G |
| Failure to assess and monitor pressure ulcers on a consistent weekly schedule and failure to provide ordered devices to relieve pressure and promote healing. | G |
| Failure to maintain a resident environment free of accident hazards; unlocked mechanical room with dust and debris posing risk. | E |
| Failure to maintain accurate and complete clinical records, including documentation of application of pressure-relieving devices. | D |
Report Facts
Facility census: 93
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 4.9
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 0.01
Pressure ulcer surrounding area measurements: 12.9
Pressure ulcer surrounding area measurements: 8.2
Resident age: 64
Resident age: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Present during interview regarding care plan formulation for Resident #100's pressure ulcer |
Inspection Report
Plan of Correction
Deficiencies: 1
May 23, 2007
Visit Reason
This document is a plan of correction submitted by Lincoln Healthcare Center following a survey completed on May 23, 2007.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Inspection Report
Routine
Census: 59
Deficiencies: 4
May 23, 2007
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, quality of care, drug regimen review, infection control, and other care standards at Wyoming Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to appoint legal representatives for residents, failure to provide necessary care such as pressure relief and repositioning, failure to act on pharmacist recommendations, and poor infection control practices during medication administration and wound care.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to assure legal representatives were appointed for two residents in accordance with State law. | SS=D |
| Failure to provide necessary care including pressure relief and repositioning for three residents. | SS=D |
| Failure to act on pharmacist's recommendation for gradual dose reduction of antipsychotic medication for one resident. | SS=D |
| Failure to maintain proper infection control practices during medication administration and wound treatment affecting two residents. | SS=D |
Report Facts
Facility census: 59
Sample size: 13
Residents with legal representative deficiency: 2
Residents with care deficiencies: 3
Residents with infection control deficiencies: 2
Date of pharmacist recommendation: Feb 8, 2007
Inspection Report
Life Safety
Census: 59
Deficiencies: 2
May 21, 2007
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically regarding smoking regulations and maintenance of the facility's emergency power supply (generator).
Findings
The facility failed to provide metal containers with self-closing covers in all designated smoking areas and failed to maintain all components of the emergency power supply, including a defective generator muffler and a 'high battery' indicator light signaling a servicing need.
Severity Breakdown
SS=B: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide metal containers with self-closing covers in all areas where smoking is permitted. | SS=B |
| Facility failed to maintain all components of the emergency power supply (generator), including a defective muffler with a hole and a 'high battery' red light indicator. | SS=C |
Report Facts
Facility census: 59
Hole size in muffler: 4
Inspection Report
Annual Inspection
Census: 108
Deficiencies: 18
May 16, 2007
Visit Reason
The inspection was conducted as a substantiated complaint investigation concurrent with the facility's annual Federal Medicaid certification survey and State licensure inspection.
Findings
The facility was found deficient in multiple areas including failure to discontinue physical restraints as ordered, failure to prevent resident-to-resident abuse, inadequate staff treatment of residents, lack of privacy and dignity, failure to provide self-determination and participation, inadequate social services, incomplete resident assessments and care plans, failure to monitor side effects of antipsychotic medications, insufficient nursing staff, failure to post accurate nurse staffing data, inadequate dietary services including failure to individualize diets and maintain sanitary food preparation, and failure to obtain and communicate laboratory results timely.
Complaint Details
Complaint references #2-7095 and #2-7107 were substantiated with deficiencies cited related to physical restraints and abuse.
Severity Breakdown
Level C: 2
Level D: 6
Level E: 6
Level F: 2
Level G: 2
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to discontinue physical restraint after physician's order. | Level C |
| Failure to prevent physical abuse of resident #18 by resident #81. | Level G |
| Failure to develop and implement policies to protect residents during abuse investigations. | Level E |
| Failure to respect residents' privacy and dignity in bathroom use and addressing residents by preferred names. | Level E |
| Failure to ensure residents' self-determination and participation in significant life choices. | Level D |
| Failure to provide medically-related social services to address behavioral issues and psychosocial programming. | Level G |
| Failure to complete comprehensive assessments and triggered resident assessment protocols (RAPs) properly. | Level E |
| Failure to complete a significant change assessment after major decline in resident #1's condition. | Level E |
| Failure to develop comprehensive care plans addressing abuse, aggression, and psychosocial programming for multiple residents. | Level E |
| Failure to ensure swallowing precautions were implemented as ordered for residents #3, #7, and #22. | Level D |
| Failure to ensure antipsychotic drug side effects were adequately monitored for residents #1, #2, #3, #85, and #87. | Level E |
| Failure to maintain sufficient nursing staff on Unit D to prevent resident-to-resident and resident-to-staff abuse. | Level C |
| Failure to post nurse staffing data in a clear, readable, and accessible manner and failure to update postings timely. | Level D |
| Failure to plan individualized diet for resident #7 requiring six small meals daily. | Level D |
| Failure to assure foods were well seasoned and pureed foods were attractive and had form. | Level F |
| Failure to assure food preparation and service under sanitary conditions, including greasy debris and dried food on containers. | Level F |
| Failure to obtain monthly Depakote level for resident #7 as ordered. | Level D |
| Failure to promptly notify attending physician of lab results for resident #1. | Level D |
Report Facts
Facility census: 108
Residents reviewed: 21
Residents with insufficient care plans: 7
Residents requiring swallowing precautions: 3
Residents monitored for antipsychotic side effects: 5
HSWs scheduled on Unit D: 3
HSWs observed on Unit D: 2
Meals per day ordered: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #109 | Assistant Minimum Data Set (MDS) Assessment Nurse | Interviewed regarding care plans and assessments |
| Employee #88 | Acting Director of Nursing | Confirmed lack of protective plans for abuse and care plan deficiencies |
| Employee #20 | Social Services Supervisor | Interviewed about placement attempts and abuse investigations |
| Employee #158 | Health Service Worker | Interviewed about bathroom privacy and staffing |
| Employee #151 | Health Service Worker | Interviewed about monitoring antipsychotic side effects |
| Employee #128 | Health Service Worker | Interviewed about monitoring antipsychotic side effects |
| Employee #136 | Health Service Worker | Observed leaving unit for medical transport |
| Employee #145 | Health Service Worker | Observed leaving facility during shift |
| Employee #118 | Health Service Worker | Interviewed about staffing and van trip |
| Dietary Manager | Dietary Manager | Confirmed inadequate seasoning and food preparation issues |
Inspection Report
Life Safety
Census: 109
Deficiencies: 1
May 10, 2007
Visit Reason
The inspection was conducted to assess compliance with NFPA 10 standards for portable fire extinguishers in the hospital.
Findings
The hospital failed to maintain and test fire extinguishers in accordance with NFPA 10. Fifteen fire extinguishers dated 2001, 2003, 2004, and 2006 were found without the required verification collars.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain and test fire extinguishers in accordance with NFPA 10, specifically missing verification collars on fifteen fire extinguishers. | SS=C |
Report Facts
Fire extinguishers missing verification collars: 15
Facility census: 109
Inspection Report
Plan of Correction
Deficiencies: 1
May 3, 2007
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Jackie Withrow Hospital.
Findings
The document includes a summary statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights and services in writing and orally.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. | SS=C |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 23, 2007
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified during a prior survey.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights and services, including Medicaid-related information, but does not provide detailed findings within this excerpt.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | SS=C |
Inspection Report
Re-Inspection
Deficiencies: 1
Apr 19, 2007
Visit Reason
This document is a paper revisit (re-inspection) survey of Jackie Withrow Hospital conducted to follow up on previous deficiencies.
Findings
The report includes a statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights and services in writing and orally.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. | Level C |
Report Facts
Deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 1
Apr 16, 2007
Visit Reason
The document is a paper revisit inspection conducted to follow up on previously identified deficiencies at Jackie Withrow Hospital.
Findings
The report includes a statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights, services, charges, and Medicaid benefits. No detailed findings or severity levels are provided in the excerpt.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents orally and in writing of their rights, rules, services, charges, and Medicaid benefits as required. | Level C |
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Apr 6, 2007
Visit Reason
The inspection was conducted as a complaint investigation related to a substantiated complaint record with both related and unrelated deficiencies cited.
Findings
The facility failed to ensure a safe resident environment by improperly installing side rails and air mattresses for eleven residents, resulting in an incident with Resident #21. Additionally, the facility failed to obtain timely laboratory services for Resident #27 as ordered by the physician.
Complaint Details
Complaint reference #2-7090 was substantiated with related and unrelated deficiencies cited.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide each resident with a safe bed system; improper installation of side rails and air mattresses for eleven residents. | SS=E |
| Failed to assure timely laboratory services for one resident; no evidence of urine culture and sensitivity obtained as ordered. | SS=D |
Report Facts
Residents with air mattresses: 11
Facility census: 102
Sampled residents: 11
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
Apr 5, 2007
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to report and investigate an allegation of attempted rape involving a resident, as well as concerns about staff treatment of residents.
Findings
The facility failed to report and investigate an allegation of attempted rape affecting one resident and failed to ensure nursing staff spoke respectfully to residents, potentially affecting another resident. The allegation was not reported timely, and staff made inappropriate comments about a resident's behavior.
Complaint Details
The complaint investigation found that the facility failed to report and investigate an allegation of attempted rape involving Resident #68. The resident initially reported a male resident was trying to rape her, but later denied making the accusation. The allegation was brought to the administrator's attention late and was not reported as required. Additionally, a nursing staff member was observed speaking disrespectfully about Resident #7's behavior.
Severity Breakdown
SS=A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report and investigate an allegation of attempted rape affecting one resident. | SS=A |
| Failure to assure that a nursing staff member spoke in a respectful manner related to a resident's behavior. | SS=A |
Report Facts
Facility census: 102
Sampled residents: 3
Residents affected: 1
Inspection Report
Life Safety
Census: 60
Deficiencies: 1
Mar 28, 2007
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on the maintenance and operation of the facility's emergency generator and transfer switch.
Findings
The facility failed to maintain the emergency generator and transfer switch in accordance with NFPA 110 standards, as evidenced by the absence of the required battery emergency illumination light at the emergency generator transfer switch location.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide the required battery emergency illumination light at the emergency generator transfer switch. | SS=C |
Report Facts
Facility census: 60
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 5
Mar 26, 2007
Visit Reason
The survey team conducted an unannounced annual survey and a concurrent complaint investigation due to a substantiated complaint record with deficiencies cited.
Findings
The facility was found deficient in maintaining a clean and homelike environment due to persistent urine odor, failure to complete significant change assessments for residents, inaccurate pressure ulcer assessments, development of clinically avoidable pressure ulcers, and failure to appoint a licensed administrator or emergency permit for the acting administrator.
Complaint Details
Complaint reference #2-7018 was substantiated with deficiencies cited related to environmental odor, resident assessments, pressure ulcer care, and administrative oversight.
Severity Breakdown
Level C: 1
Level D: 1
Level F: 1
Level G: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean, comfortable, and homelike atmosphere due to persistent urine odor in common areas. | Level C |
| Facility failed to complete a significant change Minimum Data Set (MDS) within 14 days after a resident experienced decline in mood/behavior and continence. | Level D |
| Facility failed to ensure accurate assessment of pressure ulcers for a resident, including size and stage for appropriate treatment. | Level G |
| Facility failed to prevent development of clinically avoidable pressure ulcers and failed to provide timely incontinence care and pressure relief interventions for residents at risk. | Level G |
| Governing body failed to appoint a licensed administrator or obtain an emergency permit for the acting administrator, who was also the director of nurses, violating state licensing rules. | Level F |
Report Facts
Facility census: 60
Licensed capacity: 60
Pressure ulcer size: 7
Pressure ulcer size: 0.5
Pressure ulcer size: 1
Pressure ulcer size: 2
Administrator absence duration: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Made initial pressure ulcer assessment for Resident #37 and was treatment nurse for Resident #38 |
| DON | Director of Nurses | Acting administrator without emergency permit during administrator's absence |
| LPN-C | Licensed Practical Nurse | Interviewed regarding pressure ulcer staging, unable to accurately describe stages |
| LPN-D | Licensed Practical Nurse | Interviewed regarding pressure ulcer staging, unable to accurately describe stages |
| LPN-E | Licensed Practical Nurse | Interviewed regarding pressure ulcer staging, unable to accurately describe stages |
| CNA-B | Certified Nurse Aide | Assigned to Resident #4, reported placing two cloth incontinent pads over urine-soaked sheet due to lack of assistance |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Mar 22, 2007
Visit Reason
The inspection was conducted as a complaint investigation following complaint reference #2-7046, which was substantiated with deficiencies cited.
Findings
The facility failed to assure that meals served were acceptable to residents, with dissatisfaction expressed regarding menu choices and food preparation affecting 10 residents. Additionally, the facility failed to provide adequate housekeeping services in restrooms on 'B' Hall, resulting in persistent odors affecting 44 residents and visitors.
Complaint Details
Complaint reference #2-7046 was substantiated with deficiencies cited related to food service and housekeeping.
Severity Breakdown
Level B: 1
Level E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to assure meals served were acceptable to residents, with dissatisfaction regarding menu choices and food preparation. | Level B |
| Failure to provide housekeeping services in restrooms on 'B' Hall, resulting in persistent odors. | Level E |
Report Facts
Facility census: 94
Residents affected by food service deficiency: 10
Residents affected by housekeeping deficiency: 44
Number of restrooms cleaned: 2
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 7
Mar 15, 2007
Visit Reason
Complaint investigation related to substantiated complaint record with related and unrelated deficiencies at Jackie Withrow Hospital.
Findings
The facility was found deficient in multiple areas including dignity and respect during care, accommodation of resident needs, quality of care including hydration and positioning, pharmacy services with improper antibiotic scheduling, nurse aide proficiency in care techniques, and timely laboratory services.
Complaint Details
Complaint reference #2-7062 substantiated with related and unrelated deficiencies.
Severity Breakdown
SS=E: 5
SS=D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Residents were not served meals at the same time, Styrofoam saucers were used, and one resident was excessively exposed during incontinence care. | SS=E |
| Residents were not provided reasonable accommodation of needs such as proper tray support, positioning for feeding and comfort. | SS=E |
| Facility failed to provide necessary care and services to maintain highest practicable well-being; one resident showed signs of fluid deficit and was not attended while awaiting emergency personnel; another resident lacked ordered positioning and catheter care. | SS=E |
| Facility failed to ensure sufficient fluid intake to maintain proper hydration; multiple residents had intakes less than estimated needs and inadequate monitoring of fluid balance. | SS=E |
| Facility failed to assure antibiotics were administered at times to maintain blood levels for optimal effect; antibiotics scheduled at 9:00 a.m. and 5:00 p.m. instead of every 12 hours. | SS=E |
| Nurse aides lacked competency in care skills; a health service worker provided incontinence care leaving resident excessively exposed, skin not rinsed, and foreskin not retracted. | SS=D |
| Laboratory services were not provided in a timely manner; a lab test ordered every 4 weeks was not completed when due in February 2007. | SS=D |
Report Facts
Facility census: 95
Fluid intake deficit: 11220
Fluid intake deficit: 13725
Fluid intake deficit: 3550
Fluid intake deficit: 2170
Inspection Report
Re-Inspection
Deficiencies: 2
Mar 12, 2007
Visit Reason
A revisit was conducted on 03/12/07 to verify correction of previously cited deficiencies related to life safety code standards, including sprinkler system coverage and elevator repairs.
Findings
The sprinkler system was found to be properly installed and maintained except the sun porch remained unsprinklered. Elevator repairs were not completed at the time of the revisit.
Severity Breakdown
SS=E: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Sun porch attached to the building structure was not sprinklered. | SS=E |
| Repairs to the facility elevators were not completed. | SS=C |
Report Facts
Deficiency completion date: Mar 30, 2007
Deficiency completion date: Jun 12, 2007
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| maintenance supervisor | Interviewed regarding elevator repairs not completed |
Inspection Report
Follow-Up
Deficiencies: 0
Mar 1, 2007
Visit Reason
The visit was a paper revisit to review compliance and corrective actions following a prior inspection.
Findings
The document is a statement of deficiencies and plan of correction for Jackie Withrow Hospital, indicating a paper revisit was conducted. Specific deficiencies or findings are not detailed in the provided text.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 2, 2007
Visit Reason
Complaint investigation related to complaint reference #2-7018.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-7018 was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 9
Feb 1, 2007
Visit Reason
Complaint investigation triggered by allegations of neglect and poor care at Jackie Withrow Hospital nursing facility.
Findings
The facility was found to have substantiated deficiencies including failure to investigate neglect allegations, failure to maintain resident dignity, failure to ensure residents attended medical appointments, failure to provide necessary care to prevent skin ulcers and infections, failure to assist with toileting, inappropriate use and monitoring of antipsychotic medication, failure to post nurse staffing data properly, and failure to prevent recurrent urinary tract infections.
Complaint Details
Complaint references #2-7019 and #2-7021 were substantiated with deficiencies cited related to neglect and poor care.
Severity Breakdown
SS=D: 4
SS=G: 3
SS=C: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to investigate an allegation of neglect regarding Resident #106 who was found with fecal contamination and a skin ulcer. | SS=D |
| Did not provide care to maintain dignity for Resident #38 who was observed wearing soiled clothing and having body odor. | SS=D |
| Failed to ensure two residents (#25 and #125) attended scheduled medical appointments. | — |
| Failed to identify and provide wound care for a skin ulcer on Resident #106, resulting in transfer for whirlpool treatments. | — |
| Failed to provide necessary perineal care to Resident #106 to prevent skin alterations and infections. | SS=G |
| Failed to assist Resident #56 with toileting from 7:00 a.m. until after 11:30 a.m., resulting in resident sitting in wet brief. | SS=D |
| Inappropriate use and inadequate monitoring of antipsychotic medication (Haldol) for Resident #56 without adequate diagnosis or behavioral interventions. | SS=D |
| Failed to post nurse staffing data daily at the beginning of each shift as required by Medicare BIPA of 2000. | SS=C |
| Failed to prevent recurrent urinary tract infections for Resident #106, who had ten UTIs in one year. | SS=G |
Report Facts
Facility census: 104
Number of urinary tract infections: 10
Deficiencies with severity SS=D: 4
Deficiencies with severity SS=G: 3
Deficiencies with severity SS=C: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident #106 family member | Provided testimony about neglect and condition of Resident #106. | |
| Administrator | Interviewed regarding neglect investigation and staffing. | |
| Director of Nurses | Director of Nurses | Interviewed regarding medication use and urinary tract infections. |
| NA-A | Nurse Aide | Observed and interviewed regarding toileting of Resident #56. |
| NA-B | Nurse Aide | Interviewed regarding toileting of Resident #56. |
Inspection Report
Annual Inspection
Census: 105
Deficiencies: 12
Jan 12, 2007
Visit Reason
The inspection was conducted as part of the annual survey of Jackie Withrow Hospital, a nursing facility, to assess compliance with federal regulations including resident rights, care quality, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to inform residents of incapacity determinations, inadequate transfer and discharge notifications, incomplete abuse investigations, inaccurate resident assessments, failure to implement physician-ordered behavior monitoring, improper urinary incontinence assessments, lack of menu plans for double portions, improper food preparation and sanitation practices, unsafe environmental conditions, unsecured handrails, and failure to obtain ordered laboratory tests.
Severity Breakdown
SS=B: 5
SS=C: 1
SS=D: 4
SS=E: 3
SS=F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to inform residents deemed incapacitated of their status and rights as required by state law. | SS=B |
| Failure to provide required written notice of transfer or discharge rights to residents and families. | SS=B |
| Failure to thoroughly investigate allegations of abuse and neglect and properly report them. | SS=E |
| Incomplete and inaccurate comprehensive resident assessments and failure to complete significant change assessments timely. | SS=B |
| Failure to implement physician-ordered behavior monitoring for tapering antipsychotic medication. | SS=D |
| Failure to assess contributing factors and functional ability related to urinary incontinence decline and failure to implement bladder retraining. | SS=D |
| Lack of a menu plan or directive for double portions despite physician orders for eight residents. | SS=E |
| Food prepared too early and held improperly, including pureed foods prepared a day in advance, risking loss of nutritive value and palatability. | SS=E |
| Improper dishwashing procedures with incorrect order of washing, rinsing, and sanitizing in three-compartment sinks. | SS=F |
| Facility environment not maintained in a sanitary and functional condition with water damaged ceiling tiles, walls, damaged doors, floor coverings, and window blinds. | SS=C |
| Handrails on the 3rd floor auditorium ramp walkways were loose and not firmly secured. | SS=B |
| Failure to obtain ordered laboratory tests (lipid panel and complete metabolic panel) for a resident as prescribed by physician. | SS=D |
Report Facts
Facility census: 105
Residents with incapacity notification issues: 5
Residents lacking discharge information: 3
Allegations of abuse/neglect not thoroughly investigated: 1
Complaints not reported as neglect: 2
Residents with incomplete MDS RAP summaries: 7
Residents with late quarterly assessments: 18
Residents with physician orders for double portions: 8
Damaged window blinds: 9
Loose handrails: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E39 | Registered Nurse | Confirmed laboratory tests for Resident #6 had not been obtained |
| Director of Nursing | Director of Nursing | Interviewed regarding incapacity notification, discharge information, behavior monitoring, and bladder incontinence assessment |
| Dietary Manager | Dietary Manager | Provided policy on double portions and responded to food preparation timing issues |
Inspection Report
Life Safety
Census: 105
Deficiencies: 14
Jan 10, 2007
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards and other related health and safety regulations for the facility.
Findings
The facility was found to have multiple deficiencies related to fire safety, including failure to maintain fire barrier walls and corridor doors, unsealed penetrations, inadequate sprinkler coverage, malfunctioning fire alarm system components, improper storage of oxygen cylinders, and incomplete elevator repairs.
Severity Breakdown
SS=F: 4
SS=E: 1
SS=C: 5
SS=B: 3
Deficiencies (14)
| Description | Severity |
|---|---|
| Fire barrier door at 2A failed to close and latch under self-closing device power. | SS=F |
| Unsealed/incompletely sealed penetrations around wires in fire barrier walls at multiple locations (1A, 2A, 3A, 1B/D, 3B/D). | SS=F |
| Corridor doors had unsealed penetrations at rooms #113, #117, #119, #121, #122, #123, and #124. | SS=F |
| Facility did not maintain all portions of smoke barrier walls to a one-half hour fire rated construction with unsealed penetrations at multiple locations on first, second, and third floors. | SS=B |
| Hazardous room door (1st floor Clean Linen room) did not close and latch with self-closing device. | SS=C |
| Means of egress obstructed by unattended items in corridors on 1st, 2nd, and 3rd floors. | SS=C |
| Exit directional signs did not provide continuous illumination and misidentified egress path. | SS=B |
| Fire alarm annunciator panel had trouble light illuminated with unknown cause. | SS=F |
| Facility failed to inspect and test smoke detectors for sensitivity as required. | SS=F |
| Facility failed to provide automatic sprinkler coverage to all portions of the building, including a Sun Porch room. | SS=E |
| Range hood extinguishing system inspections were not performed semiannually as required. | SS=C |
| Oxygen cylinders stored approximately one foot from combustible materials. | SS=B |
| Facility emergency generator monthly transfer test logs lacked evidence of power supply within required 10-second interval; no battery powered lighting in transfer switch room. | SS=C |
| Elevators had repairs ordered and lacked current compliant certification. | SS=C |
Report Facts
Facility census: 105
Size of Sun Porch room: 320
Number of clean linen carts stored in corridor: 10
Number of patient lifts stored in corridor: 4
Number of empty wheelchairs stored in corridor: 3
Number of oxygen cylinders improperly stored: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding sprinkler coverage, fire alarm system trouble, elevator repairs, and generator maintenance |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 9, 2007
Visit Reason
Paper Revisit to review previously identified deficiencies and the facility's plan of correction.
Findings
The document contains a summary statement of deficiencies related to resident rights and notification requirements, with a focus on informing residents of their rights and services.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility must inform residents orally and in writing of their rights, rules, and services, including Medicaid-related information, prior to or upon admission and during their stay. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 21, 2006
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-6320.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference: #2-6320. Unsubstantiated complaint record with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 4, 2006
Visit Reason
The inspection was conducted in response to complaint references #2-6287 and #2-6307, which were substantiated with deficiencies cited.
Findings
The facility failed to maintain all essential mechanical, electrical, and patient care equipment in safe operating condition, specifically one of three boilers for the heating system was inoperable, impairing the system's efficient operation.
Complaint Details
Complaint references #2-6287 and #2-6307 were substantiated with deficiencies cited.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain all essential mechanical, electrical, and patient care equipment in safe operating condition; one of three boilers for the heating system was inoperable. | SS=F |
Report Facts
Boilers inoperable: 1
Total boilers: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding the inoperable boiler. |
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 27, 2006
Visit Reason
This document is a plan of correction related to a paper revisit survey of Lakin Hospital conducted on November 27, 2006.
Findings
The document includes a statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights, services, and charges in writing and orally.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | SS=C |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 1
Oct 12, 2006
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse and neglect by a nurse aide involving multiple residents.
Findings
The facility was found to have failed to immediately report all allegations of abuse and neglect against a nurse aide involving multiple residents. The facility eventually terminated the nurse aide after investigation and resubmitted all allegations to the state agency after being prompted.
Complaint Details
Complaint reference #2-6254 was substantiated with deficiencies cited. The facility initially filed two reports involving two residents but failed to report additional allegations involving several other residents until prompted by the state agency. The nurse aide was terminated following the investigation.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately report all allegations of abuse and neglect against a nurse aide involving multiple residents. | SS=E |
Report Facts
Resident identifiers involved: 8
Facility census: 105
Follow-up reports: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 4, 2006
Visit Reason
The inspection was conducted in response to complaint references #2-6258 and #2-6261.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited during the inspection.
Complaint Details
Complaint references #2-6258 and #2-6261 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 11, 2006
Visit Reason
The inspection was conducted in response to a complaint referenced as #2-6240.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the inspection.
Complaint Details
Complaint reference: #2-6240. Unsubstantiated complaint record with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 31, 2006
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #2-6186.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-6186 was unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 1
Aug 4, 2006
Visit Reason
The visit was a paper revisit to follow up on previous deficiencies.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, but no specific findings or severity levels are detailed in this excerpt.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. | SS=C |
Report Facts
Provider/Supplier Identification Number: 515171
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 1, 2006
Visit Reason
The inspection was conducted in response to complaint references #2-6183 and #2-6184.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited during the investigation.
Complaint Details
Complaint references #2-6183 and #2-6184 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Census: 58
Deficiencies: 2
Jul 13, 2006
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, sanitary conditions, and pharmacy services in the facility.
Findings
The facility was found deficient in ensuring all garbage receptacles were secured with lids, potentially affecting residents on an oral diet. Additionally, the facility failed to have insulin available for one resident with physician orders for sliding scale insulin, although insulin was available for other residents.
Severity Breakdown
SS=C: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure all garbage receptacles were secured with a closing lid; the garbage can next to the hand-washing sink did not have a lid. | SS=C |
| Facility failed to ensure insulin was available for one resident with physician orders for sliding scale regular insulin. | SS=D |
Report Facts
Facility census: 58
Residents on oral diet: 53
Residents with sliding scale insulin orders: 9
Residents with insulin available: 8
Deficiencies cited: 2
Reorder timeframe for medication supply: 72
Inspection Report
Life Safety
Deficiencies: 0
Jul 12, 2006
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 2000.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2000.
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 4, 2006
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Jackie Withrow Hospital.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally, but does not provide detailed findings beyond this.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 4, 2006
Visit Reason
The inspection was conducted in response to a complaint, reference #2-6149.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the inspection.
Complaint Details
Complaint reference #2-6149 was unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 25, 2006
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified in a prior survey of the facility.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights and services, but does not provide detailed findings beyond this.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to properly inform residents of their rights and services as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Report Facts
Deficiency ID: 156
Inspection Report
Life Safety
Deficiencies: 1
May 24, 2006
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically regarding the proper storage and restraint of medical gas cylinders in the facility.
Findings
The facility failed to store all oxygen cylinders in accordance with NFPA 99 standards. Specifically, one small oxygen cylinder was found unsecured and free standing in the B wing oxygen storage room.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| One small oxygen cylinder was observed free standing and not secured by chain or supported in a proper cylinder stand in the B wing oxygen storage room. | SS=B |
Report Facts
Oxygen cylinder count: 1
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 8
May 18, 2006
Visit Reason
Complaint investigation triggered by complaint reference #2-6017 regarding resident rights, protection of resident funds, notice of bed hold policy, staff treatment of residents, social services, sanitary conditions in food preparation, and infection control.
Findings
The facility was found to have multiple deficiencies including failure to document resident incapacity notification, commingling resident funds, failure to provide bed-hold policy notice at hospital transfer, failure to report alleged abuse to state agencies, inadequate staff knowledge of abuse reporting procedures, failure to provide adequate social services related to resident transfer requests, unsanitary food storage and preparation conditions, and inadequate infection control practices including outdated TB screening and contamination risks.
Complaint Details
Complaint reference #2-6017 was substantiated with deficiencies cited related to resident rights, protection of resident funds, bed-hold policy notice, staff treatment of residents, social services, sanitary conditions, and infection control.
Severity Breakdown
SS=D: 4
SS=F: 3
SS=C: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure residents were informed of determination of incapacity as required by state law. | SS=D |
| Failure to deposit resident funds in interest-bearing accounts and commingling of resident and facility funds. | SS=F |
| Failure to provide written notice of bed-hold policy at time of hospital transfer. | SS=C |
| Failure to report alleged abuse to state survey and nurse aide registry as required. | SS=D |
| Failure to ensure nursing staff were familiar with abuse reporting procedures. | SS=D |
| Failure to provide adequate social services to meet mental and psychosocial needs related to resident transfer requests and failure to involve responsible parties in discharge planning. | SS=D |
| Failure to maintain sanitary conditions in food storage and preparation including malfunctioning freezers and contaminated ice machine. | SS=F |
| Failure to maintain an effective infection control program including inadequate TB screening frequency and failure to prevent contamination of linens and resident environment. | SS=F |
Report Facts
Facility census: 100
Residents affected by commingled funds: 41
Total resident funds amount: 22778.31
Dates of cited deficiencies completion: Various completion dates requested for plans of correction (e.g., 06/15/06, 06/16/06)
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
May 3, 2006
Visit Reason
The inspection was conducted as a complaint investigation following substantiated complaints regarding staff treatment of residents, specifically concerning sexually aggressive behaviors by Resident #93.
Findings
The facility failed to develop and implement adequate interventions and supervision for Resident #93, who exhibited sexually aggressive behaviors towards other residents. Multiple incidents were documented where Resident #93 engaged in inappropriate sexual contact and aggression, and the facility did not have appropriate care plans or staff training to manage these behaviors effectively.
Complaint Details
Complaint reference #2-6097 was substantiated with no related deficiencies cited. Complaint reference #2-6104 was substantiated with deficiencies cited related to staff treatment of residents and failure to prevent abuse.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement interventions to prevent occurrences of sexually aggressive behavior by Resident #93 and failure to provide adequate supervision and monitoring to prevent abuse of other residents. | SS=G |
Report Facts
Facility census: 110
Medication dosage: 150
Medication dosage: 80
Number of residents on locked unit: 28
Staffing: 2
Staffing: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Reported observations of Resident #93's inappropriate behavior and interactions with staff and residents | |
| Employee #2 | Reported Resident #18's allegation of sexual abuse by Resident #93 | |
| Employee #3 | Interviewed regarding Resident #23's report of sexual abuse by Resident #93 | |
| Employee #6 | Interviewed about observations of Residents #93 and #23 and their interactions | |
| Facility Administrator | Administrator | Interviewed regarding awareness and response to Resident #93's sexually aggressive behaviors and facility policies |
| Care Plan Nurse | Nurse | Interviewed and found unaware of any care plan addressing sexually aggressive behaviors |
| Activities Person | Interviewed and found unaware of any care plan addressing sexually aggressive behaviors |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 19, 2006
Visit Reason
This document is a plan of correction related to a paper revisit survey conducted at Lakin Hospital.
Findings
The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally, but no detailed findings are provided in this excerpt.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10), 483.10(b)(1). | Level C |
Inspection Report
Deficiencies: 3
Apr 4, 2006
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, therapeutic diets, and sanitary conditions in food preparation and service at Lakin Hospital.
Findings
The facility was found deficient in accurately communicating physician orders for therapeutic diets to the dietary department, resulting in discrepancies in resident diet administration. Additionally, sanitary violations were observed in the dietary department, including improper food storage, unlabeled refrigerated items, and potential contamination risks with utensils and food scoops.
Severity Breakdown
SS=B: 1
SS=F: 1
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure physician orders for therapeutic diets and nutritional supplements were accurately communicated to the dietary department, affecting four residents (#12, #62, #74, #98). | SS=B |
| Failure to store, prepare, distribute, and serve food under sanitary conditions, including unlabeled refrigerated foods, scoops stored inside food items, wet stacked plates, and improper utensil storage. | SS=F |
| Failure to inform residents of their rights and facility rules in writing and orally in a language they understand. | SS=C |
Report Facts
Resident records reviewed: 12
Residents with diet order issues: 4
Days food items kept after opening: 7
Date of cheese opening: Mar 4, 2006
Date of survey: Apr 4, 2006
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Manager | Present during observations and verified sanitary issues | |
| Nutritionist | Discussed dietary communication issues | |
| Director of Nursing | Discussed dietary communication issues | |
| Administrator | Discussed dietary communication issues |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 8
Feb 16, 2006
Visit Reason
The inspection was conducted as an annual survey of Wyoming Healthcare Center to assess compliance with federal regulations regarding resident rights, physical restraints, resident assessments, care plans, accident prevention, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of significant changes in resident condition, improper use and monitoring of physical restraints for multiple residents, inaccurate resident assessments, incomplete care plans lacking measurable goals especially related to restraint reduction, inadequate supervision leading to resident safety risks, failure to properly assess wound dressings, unclear physician orders for restraints, and improper handling of soiled linens that could spread infection.
Severity Breakdown
SS=D: 7
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to inform physician of significant change in resident condition (Resident #33). | SS=D |
| Failure to ensure residents were free from inappropriate physical restraints and lack of restraint reduction plans (Residents #17, #20, #39, #49). | SS=D |
| Inaccurate Minimum Data Set (MDS) assessment regarding resident falls (Resident #20). | SS=D |
| Care plans lacked measurable goals and did not address restraint reduction or least restrictive alternatives (Residents #17, #20, #39, #49). | SS=D |
| Failure to update care plan to reflect turning schedule for wound care (Resident #39). | SS=D |
| Failure to assure services met professional standards including failure to assess wound dressing and unclear restraint orders (Residents #39, #56). | SS=D |
| Failure to provide adequate supervision to prevent accidents; resident observed eating unsafe items without supervision (Resident #20). | SS=D |
| Failure to handle and transport soiled linens properly, risking spread of infection. | SS=F |
Report Facts
Facility census: 56
Sampled residents: 12
Deficient residents for restraints: 4
Deficient residents for care plan issues: 4
Deficient residents for professional standards: 2
Inspection Report
Life Safety
Deficiencies: 2
Feb 16, 2006
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including the maintenance of fire extinguishing systems and electrical safety in the facility.
Findings
The facility failed to maintain the range hood extinguishing system in accordance with NFPA 96, as the six-year maintenance examination was past due since 1999. Additionally, the electrical ground fault circuit interrupter (GFCI) breaker for several resident rooms failed to trip as designed, indicating non-compliance with NFPA 70 standards.
Severity Breakdown
SS=B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain the range hood extinguishing system in accordance with NFPA 96; six-year maintenance examination of the dry chemical system was past due since 1999. | SS=B |
| Failure to maintain all electrical wall receptacles in accordance with NFPA 70; the electrical GFCI breaker for resident rooms A-10, A-12, A-14, and A-16 failed to trip as designed. | SS=B |
Report Facts
Maintenance interval: 6
Year maintenance last performed: 1999
Inspection date: Feb 14, 2006
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2006
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-6024.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-6024 was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 104
Deficiencies: 9
Jan 26, 2006
Visit Reason
The inspection was an annual survey to assess compliance with federal regulations governing nursing facilities, including resident assessments, dietary services, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to ensure registered nurse certification of resident assessments, incomplete and late submission of resident assessment records, inadequate dietary services including menu planning, food preparation, and therapeutic diet adherence, excessive time between evening meal and breakfast, unsanitary food preparation conditions, and inadequate infection control practices including improper aseptic technique and failure to investigate infection causes.
Severity Breakdown
SS=F: 5
SS=E: 1
SS=D: 1
SS=C: 2
SS=B: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure RN assessment coordinator signed and certified completion of resident assessments. | SS=C |
| Incomplete and late submission of resident assessment records to the state repository. | SS=B |
| Failure to employ a full-time qualified dietary manager; menus not planned or followed; food preparation and serving practices deficient. | SS=F |
| Menus failed to meet nutritional needs and were not followed. | SS=F |
| Food not prepared by methods conserving nutritive value, flavor, and appearance; foods held too long before service; pureed foods too thin. | SS=F |
| Dietary staff failed to assure residents received diets as ordered; multiple residents affected. | SS=E |
| More than 14 hours between evening meal and breakfast. | SS=C |
| Food prepared and served under unsanitary conditions including dirty bowls, greasy shelves, moldy cooler gasket, and uncovered foods. | SS=F |
| Failure to follow aseptic technique during dressing change and inadequate infection control surveillance and investigation. | SS=D |
Report Facts
Facility census: 104
Residents affected by incomplete assessments: 50
Missing or late assessment records: 70
Residents affected by diet order errors: 12
Hours between evening meal and breakfast: 14.75
MRSA positive residents: 12
Inspection Report
Routine
Census: 104
Deficiencies: 2
Jan 25, 2006
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to resident rights and facility safety.
Findings
The facility was found to have multiple trash receptacles exceeding the 32-gallon capacity limit left unattended and not protected as hazardous areas. Additionally, oxygen cylinders were not properly secured or stored according to NFPA 99 standards, with some cylinders located too close to combustible materials and not restrained properly.
Severity Breakdown
SS=C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Trash receptacles greater than 32 gallons left unattended and not protected as hazardous areas throughout multiple wings. | SS=C |
| Oxygen cylinders were free standing, not secured by chain or proper stand, and located too close to combustible materials. | SS=C |
Report Facts
Facility census: 104
Trash receptacle capacity: 32
Trash receptacle capacity observed: 44
Trash receptacle capacity observed: 50
Oxygen cylinder storage distance: 0.5
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 10, 2006
Visit Reason
The inspection was conducted in response to complaint reference #2-6004.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-6004 was unsubstantiated with no deficiencies cited.
Inspection Report
Follow-Up
Deficiencies: 1
Dec 20, 2005
Visit Reason
This follow-up survey was conducted to verify correction of previously cited deficiencies related to the facility's provision of dietary consults by a registered dietitian.
Findings
The facility failed to ensure timely completion of dietary consults for six sampled residents, with physician orders for consults not completed until weeks after the orders were written or not completed at all by the exit date of the survey.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff had not ensured that residents received dietary consults by a registered dietitian in a timely manner or at all for six sampled residents. | SS=F |
Report Facts
Number of residents with delayed dietary consults: 6
Dates of physician orders for dietary consults: Orders dated between 11/01/05 and 12/05/05 for various residents.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 22, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-5270.
Findings
The complaint was substantiated; however, no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-5270 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 124
Deficiencies: 15
Oct 20, 2005
Visit Reason
Complaint investigation related to substantiated complaints with deficiencies cited regarding resident rights, advance directives, notification of changes, staff treatment of residents, dietary services, and clinical records.
Findings
The facility was found deficient in multiple areas including failure to involve residents in CPR decisions, incomplete documentation of incapacity determinations, failure to follow residents' advance directives, failure to notify family of acute changes, inadequate staff screening, insufficient social services, incomplete care plans, inappropriate restrictive diets without dietitian consultation, unnecessary drug use without adequate monitoring, dietary service deficiencies including menu noncompliance, poor food preparation and sanitation, unsafe environmental conditions, and incomplete clinical records.
Complaint Details
Complaint reference #2-5273. Substantiated complaint record with deficiencies cited.
Severity Breakdown
SS=A: 1
SS=C: 3
SS=D: 7
SS=E: 1
SS=F: 4
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to include participation of residents in decisions to decline cardiopulmonary resuscitation without determination of incapacity. | SS=D |
| Failure to ensure physician's determinations of incapacity were reviewed and documented according to state law. | SS=D |
| Failure to ensure resident's known wishes with respect to advance directives were followed. | SS=D |
| Failure to notify resident's family of acute changes in physical condition. | SS=D |
| Failure to screen employee against nurse aide registry in all states of previous employment. | SS=C |
| Failure to provide adequate social services to meet psychosocial needs of grieving resident. | SS=D |
| Failure to develop comprehensive care plans addressing mental and psychosocial needs of residents. | SS=D |
| Failure to assure therapeutic diets were ordered according to current standards encouraging liberal diets; failure to ensure dietitian consultation was completed as ordered. | SS=F |
| Failure to ensure drug regimens were free from unnecessary drugs administered without adequate indication or monitoring. | SS=D |
| Failure to employ competent dietary support personnel familiar with menu standards and sanitation practices. | SS=F |
| Failure to assure menus were followed for any diet served, affecting all residents evaluated. | SS=F |
| Failure to prepare foods by methods conserving nutritive value, flavor, appearance, and palatability; foods were unseasoned, dry, at improper temperatures, and pureed foods lacked form. | SS=E |
| Failure to store, prepare, distribute, and serve food under sanitary conditions; multiple sanitation infractions observed. | SS=F |
| Failure to maintain a safe, functional, sanitary, and comfortable environment; damaged walls, ceilings, and loose heating/cooling unit cover observed. | SS=C |
| Failure to maintain complete and accurately documented clinical records; POST form missing signature of preparer. | SS=A |
Report Facts
Facility census: 124
Residents reviewed: 21
Residents affected by menu noncompliance: 111
Residents on restrictive diets: 44
Employee identifier: 1
Deficiency counts: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Unit Manager | Interviewed regarding resident pain assessment and CPR decision involvement | |
| Certified Dietary Manager (CDM) | Interviewed regarding restrictive diets, menu compliance, food preparation, and sanitation | |
| Social Worker | Interviewed regarding resident capacity determinations, advance directives, and psychosocial needs |
Inspection Report
Life Safety
Census: 124
Deficiencies: 3
Oct 20, 2005
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including fire drills, sprinkler system maintenance, and proper storage of soiled linen and trash receptacles.
Findings
The facility failed to conduct quarterly fire drills on each shift, had multiple corroded sprinkler heads in various locations, and stored soiled linen and trash receptacles exceeding allowed capacity within the means of egress without proper hazardous area protection.
Severity Breakdown
SS=C: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to conduct fire drills quarterly on each shift, specifically missing drills for second and third shifts during the third quarter. | SS=C |
| Multiple sprinkler heads observed to be corroded in various locations including kitchen, nurse station bath, smoking rooms, resident rooms, and employee break room. | SS=C |
| Soiled linen and trash receptacles of 32 gallons located within the means of egress exceeding the 64 sq. ft. area without protection as a hazardous area. | SS=C |
Report Facts
Facility census: 124
Corroded sprinkler heads: 15
Soiled linen/trash receptacles: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 29, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-5261.
Findings
The complaint was substantiated; however, no deficiencies were cited in the report.
Complaint Details
Complaint reference #2-5261 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 28, 2005
Visit Reason
The inspection was conducted in response to complaint references #2-5219 and #2-5243.
Findings
The complaint investigation was substantiated but no deficiencies were cited.
Complaint Details
Complaint references #2-5219 and #2-5243 were substantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 13, 2005
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Lakin Hospital.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges as required by regulation 483.10(b)(5)-(10). | Level C |
Report Facts
Deficiency ID: 156
Inspection Report
Follow-Up
Deficiencies: 1
Aug 29, 2005
Visit Reason
The visit was a paper revisit to review previous deficiencies and corrective actions.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, but no detailed findings or severity levels are provided.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 8, 2005
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-5171, to review substantiated complaints and related deficiencies at Lakin Hospital.
Findings
The facility failed to provide evidence that the required written discharge information, including the reason for transfer, effective date, state agency contact information, and resident rights, was given to Resident #101 at the time of discharge. The social worker confirmed the form was not signed at discharge and was later mailed to the resident without documented evidence in the medical record.
Complaint Details
Complaint reference #2-5171 was substantiated with unrelated deficiencies cited. The complaint investigation focused on the failure to provide required discharge information to Resident #101.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide written discharge information to Resident #101 including reason for transfer, effective date, state agency information, and resident rights. | SS=D |
Report Facts
Complaint reference number: 25171
Date of resident transfer: Jul 8, 2005
Date of social worker interview: Aug 8, 2005
Completion date for plan of correction: Sep 4, 2005
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 1, 2005
Visit Reason
This document is a plan of correction related to a previously identified deficiency regarding resident rights and notification requirements.
Findings
The facility was cited for failing to properly inform residents of their rights, rules, services, and charges as required by regulations.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Inspection Report
Annual Inspection
Census: 95
Deficiencies: 10
Jul 14, 2005
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, safety, infection control, clinical records, and other standards.
Findings
The facility was found deficient in multiple areas including failure to document resident incapacity properly, inadequate surety bond coverage for resident funds, lack of respect for residents' preferences, inaccurate resident assessments, failure to follow dietary menus, improper controlled substance accounting, infection control breaches, unsafe and unsanitary environmental conditions, and incomplete clinical records documentation.
Severity Breakdown
SS=A: 2
SS=B: 1
SS=C: 3
SS=D: 1
SS=E: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to document determination of resident incapacity in accordance with State law for Resident #7. | SS=A |
| Facility failed to maintain a surety bond adequate to cover resident personal funds for 82 residents. | SS=E |
| Failure to respect residents' preferences by unnecessarily awakening them for routine vital signs and lack of privacy during personal care for Resident #51. | SS=C |
| Inaccurate minimum data set (MDS) assessments for four residents (#11, #13, #53, #37). | SS=D |
| Failure to have a planned menu for a resident with a therapeutic renal diet and failure to follow menus for four residents. | SS=E |
| Failure to ensure controlled drugs were accurately accounted for on B wing. | SS=B |
| Infection control breaches including improper use and cleaning of dressing carts and compromised aseptic technique for Residents #7 and #88. | SS=E |
| Tears in wheelchair armrest covers and restraints preventing sanitary maintenance and increasing risk of skin tears. | SS=C |
| Failure to maintain a safe, functional, and sanitary environment including stained caulking and floor tiles, stained ceiling, and dirty floors in resident rooms. | SS=C |
| Failure to maintain complete and accurate clinical records including altered physician determination of capacity and inaccurate intake/output documentation for Residents #7 and #51. | SS=A |
Report Facts
Facility census: 95
Residents with personal funds: 82
Surety bond amount: 25000
Surety bond amount: 50000
Deficiency occurrences: 14
Residents with inaccurate MDS: 4
Residents with menu issues: 4
Residents with therapeutic diet missing menu: 1
Inspection Report
Life Safety
Census: 95
Deficiencies: 7
Jul 13, 2005
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code standards, specifically focusing on the maintenance and condition of the facility's automatic sprinkler system.
Findings
The facility failed to maintain the sprinkler system in accordance with NFPA standards, with multiple sprinkler heads observed to be corroded and storage found within less than the required clearance distance from sprinkler heads in various areas of the facility.
Severity Breakdown
SS=C: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Two sprinkler heads in the kitchen dish washer room were corroded. | SS=C |
| Four sprinkler heads in the laundry (clean side) were corroded. | SS=C |
| Two sprinkler heads in the staff dining room were corroded. | SS=C |
| Two sprinkler heads in the smoking room were corroded. | SS=C |
| Storage was observed within ten inches of sprinkler heads in the storage closet and copier room main office area. | SS=C |
| Storage was observed within twelve inches of sprinkler heads in the center hall linen closet. | SS=C |
| Storage was observed within six inches of sprinkler heads in the side soiled linen room. | SS=C |
Report Facts
Facility census: 95
Sprinkler heads corroded: 10
Storage clearance inches: 6
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 1
Jul 6, 2005
Visit Reason
The inspection was conducted as a complaint investigation related to a substantiated complaint regarding resident safety and wandering incidents.
Findings
The facility failed to ensure a safe environment for a resident with elopement tendencies, as the resident repeatedly left the facility unattended despite monitoring efforts. The facility was in the process of seeking a more secure placement but lacked an effective system to prevent the resident from wandering off the property.
Complaint Details
Complaint reference #2-5141. The complaint was substantiated with deficiencies cited related to resident safety and elopement.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility did not ensure a safe environment for a resident with elopement tendencies who wandered off the facility property multiple times. | SS=D |
Report Facts
Facility census: 118
One-on-one monitoring duration: 5
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 13, 2005
Visit Reason
This document is a plan of correction related to a paper revisit survey conducted at the facility.
Findings
The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as well as providing written descriptions of legal rights. No further findings are detailed.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Report Facts
Deficiency ID: 156
Inspection Report
Complaint Investigation
Deficiencies: 0
May 27, 2005
Visit Reason
The inspection was conducted in response to a complaint, referenced as #2-5131.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-5131 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 8
Apr 28, 2005
Visit Reason
The inspection was conducted based on a complaint investigation regarding resident rights, care planning, resident assessment, quality of care, physical environment, dietary services, infection control, and clinical record accuracy at Lincoln Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to ensure legal surrogate decision-making, incomplete and conflicting care plans, failure to carry out physician orders, inadequate quality of care related to oxygen therapy, unsafe physical environment conditions, unsanitary dietary practices, poor infection control practices, and inaccurate clinical records.
Complaint Details
The visit was complaint-related, investigating issues such as resident rights violations, inadequate care planning, failure to follow physician orders, poor quality of care, unsafe physical environment, unsanitary dietary practices, infection control breaches, and inaccurate clinical records.
Severity Breakdown
SS=D: 5
SS=B: 1
SS=F: 1
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Legal surrogate had not made decisions for an incapacitated resident; successor MPOA acted without proper documentation. | SS=D |
| Care plans lacked measurable objectives and contained conflicting interventions for residents. | SS=D |
| Physician's orders for daily blood pressure monitoring were not carried out or documented properly. | SS=D |
| Resident did not receive care to maintain highest practicable well-being; oxygen therapy was applied without proper evaluation or physician order. | SS=D |
| Facility failed to maintain a safe, functional, sanitary, and comfortable physical environment including non-functional night lights, ceiling damage, and faulty electrical receptacles. | SS=B |
| Dietary services failed to store, prepare, and serve food under sanitary conditions including undated food, dirty equipment, and improper utensil storage. | SS=F |
| Infection control practices were inadequate, including improper handling of feeding tube plugs, contaminated gloves, and improper wound care techniques. | SS=E |
| Clinical records were inaccurate; allergy information was missing and catheter status was incorrectly documented. | SS=D |
Report Facts
Facility census: 58
Number of falls: 6
Deficiencies cited: 8
Inspection Report
Life Safety
Census: 58
Deficiencies: 5
Apr 25, 2005
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including corridor exit width, exit accessibility, sprinkler system maintenance, soiled linen receptacle storage, and medical gas storage.
Findings
The facility failed to maintain corridor exit widths, had obstructions limiting exit access, had tarnished and corroded sprinkler heads, improperly stored soiled linen receptacles exceeding allowed density, and failed to store oxygen cylinders in accordance with NFPA 99 standards.
Severity Breakdown
SS=C: 1
SS=B: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to maintain corridor exit width in accordance with NFPA 101 Life Safety Code - 2000 Existing. | SS=C |
| Facility failed to maintain corridor exits that are readily accessible at all times due to wheelchairs and geri-chair stored in exit egress. | SS=B |
| Required automatic sprinkler systems were tarnished and corroded, failing to maintain reliable operating condition. | SS=B |
| Facility failed to store thirty-two gallon soiled linen receptacles in a room or space not to exceed 0.5 gallon per square foot. | SS=B |
| Facility failed to store oxygen cylinders in accordance with NFPA 99, including proximity to combustibles and inadequate signage. | SS=B |
Report Facts
Facility census: 58
Sprinkler heads tarnished and corroded: 9
Sprinkler heads tarnished and corroded: 2
Soiled linen receptacles: 8
Required area for soiled linen receptacles: 512
Actual area of room storing soiled linen receptacles: 300
Oxygen cylinders observed: 31
Oxygen cylinders near combustibles: 2
Oxygen cylinders near combustibles: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 10, 2005
Visit Reason
The inspection was conducted in response to complaint references #2-5037 and #2-5038.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited during the inspection.
Complaint Details
Complaint references #2-5037 and #2-5038 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 8, 2005
Visit Reason
The inspection was conducted in response to a complaint referenced as #2-5026.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-5026 was unsubstantiated with no deficiencies cited.
Inspection Report
Re-Inspection
Deficiencies: 1
Feb 2, 2005
Visit Reason
The visit was a paper revisit to review compliance and corrective actions following a prior inspection.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, but no specific findings or severity levels are detailed in this excerpt.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and all rules and regulations governing resident conduct and responsibilities during their stay. | Level C |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 5
Jan 27, 2005
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident care, dietary services, and facility administration.
Findings
The facility was found deficient in multiple areas including incomplete care plans for swallowing strategies, lack of staff awareness of resident swallowing guidelines, absence of a prepared menu for a 2000 calorie diet, unsanitary food storage practices, and inaccurate medical record documentation related to diet orders and supplement schedules.
Severity Breakdown
SS=A: 1
SS=C: 1
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility staff had not carried over all portions of swallowing strategy guidelines from physician orders to the care plan for Resident #68. | SS=A |
| Not all nursing staff were aware of swallowing strategy guidelines for Residents #50 and #41. | SS=D |
| Facility-approved menu did not have a menu guideline for 2000 calorie level diets prepared in advance, affecting Resident #32. | SS=D |
| Dietary staff had not always stored and distributed food items under sanitary conditions, including unlabeled and undated food items and improper sanitizer use. | SS=C |
| Medical records contained inaccurate diet orders and supplement distribution schedules, incomplete dietary information, and inaccurate documentation of swallowing precaution orders for Residents #31, #27, and #44. | SS=D |
Report Facts
Residents with swallowing strategies ordered: 15
Residents with swallowing strategy deficiencies: 3
Residents in house: 94
Inspection Report
Routine
Census: 55
Deficiencies: 4
Jan 6, 2005
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal regulations regarding resident rights, self-administration of drugs, resident assessments, insulin injection documentation, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to properly assess a resident's ability to self-administer medications, inaccurate resident assessments, failure to document insulin injection sites, and improper storage of food items in the dietary department.
Severity Breakdown
SS=D: 2
SS=B: 1
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to adequately assess a resident's ability to self-administer medications and failure to follow assessment instructions. | SS=D |
| Resident assessments contained inaccurate information and one assessment was not signed by a registered nurse. | SS=B |
| Failure to record injection sites when administering insulin, increasing risk of tissue trauma. | SS=D |
| Improper storage of thawed hamburger meat without proper dating, risking contamination. | SS=E |
Report Facts
Facility census: 55
Residents sampled: 11
Residents with inaccurate assessments: 5
Residents with insulin injection documentation issues: 3
Inspection Report
Life Safety
Deficiencies: 0
Jan 5, 2005
Visit Reason
The survey was conducted to assess the facility's compliance with the Life Safety Code NFPA 101 - 2000 Existing.
Findings
Based on observation, performance testing, and review of facility documentation during the survey from 01/03/05 to 01/05/05, the facility was determined to be in compliance with the Life Safety Code NFPA 101 - 2000 Existing.
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 5, 2005
Visit Reason
Paper revisit to review the facility's plan of correction following a prior inspection.
Findings
The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on the facility's obligation to inform residents of their rights and services. No new inspection findings are detailed beyond the plan of correction context.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and services in writing and orally as required. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 2, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4378, which was substantiated with deficiencies cited.
Findings
The facility failed to maintain a safe environment for staff, specifically due to standing water and a slimy substance observed in the walkway to the walk-in freezer, creating a potential slip hazard.
Complaint Details
Complaint reference #2-4378 was substantiated with deficiencies cited.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a safe environment for staff due to standing water and a slimy substance in the walkway to the walk-in freezer creating a slip hazard. | SS=F |
Report Facts
Completion date for plan of correction: Dec 31, 2004
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 15
Nov 11, 2004
Visit Reason
The inspection was conducted as a comprehensive annual survey of the facility to assess compliance with federal regulations related to resident rights, quality of care, dietary services, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to notify physicians timely of resident changes, inadequate staff licensure verification, lack of dignified dining experience, insufficient weekend activities, incomplete resident assessments, non-measurable care plan goals, failure to follow physician orders especially regarding diet and fluid restrictions, inadequate dietary services including menu planning and food preparation, unsanitary food service conditions, and inadequate infection control policies and practices.
Severity Breakdown
SS=F: 5
SS=E: 5
SS=D: 4
SS=C: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to notify physician timely for residents #35 and #84 regarding changes in condition. | SS=D |
| Failure to verify nurse aide registry and nursing license status for newly hired staff. | SS=E |
| Failure to provide dignified dining experience for residents #3 and #16. | SS=D |
| Insufficient weekend activities to meet residents' recreational needs. | SS=E |
| Failure to fully utilize the resident assessment instrument (RAI) in the approved format. | SS=C |
| Care plans lacked measurable goals and were inconsistent with medical records for residents #3, #84, #49, #51, #58, and #61. | SS=C |
| Failure to follow physician orders and provide care according to comprehensive care plans for residents #61, #49, and #6, including feeding and fluid restrictions. | SS=E |
| Dietary services failed to provide adequate nutritional services due to lack of frequent dietitian consultation. | SS=F |
| Dietary staff were not competent to carry out dietary functions, including menu adherence and food preparation. | SS=F |
| Menus were not prepared in advance or followed for all diets with physician orders, affecting 21 residents. | SS=E |
| Food was not prepared or served to conserve nutritive value, flavor, appearance, palatability, or proper temperature. | SS=F |
| Facility failed to maintain sanitary conditions in food storage, preparation, and service areas, including improper sink use, contaminated equipment, and poor hygiene. | SS=F |
| Dietary staff served all residents a 2 gram sodium diet regardless of physician orders, unnecessarily restricting residents without sodium restrictions. | SS=E |
| Infection control program failed to prevent contamination risks, including resident access to clean linen carts and lack of specific infection control policies. | SS=D |
| Physician orders were not always correct or clear, risking incorrect treatment for residents #58 and #6. | SS=D |
Report Facts
Facility census: 96
Residents affected by insufficient weekend activities: 7
Residents affected by menu deficiencies: 21
Residents with no added salt diet orders: 23
Days fluid restriction exceeded: 8
Number of newly hired staff without licensure verification: 4
Number of residents with non-measurable care plans: 5
Temperature of pureed hot dogs: 110
Temperature of pureed vegetables: 120
Temperature of mashed potatoes: 130
Inspection Report
Census: 96
Deficiencies: 2
Nov 10, 2004
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and emergency power system maintenance requirements.
Findings
The facility failed to maintain all exits to be readily accessible due to a delayed-egress locking device that did not release as required. Additionally, the facility failed to maintain the emergency power system (generator) in accordance with NFPA 110, lacking documentation of weekly maintenance inspections and monthly load testing for the previous twelve months.
Severity Breakdown
SS=B: 1
SS=C: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Exit door at main entrance had a delayed-egress locking device that did not release when pressure was applied for approximately 30 seconds. | SS=B |
| Facility failed to maintain emergency power system generator with required weekly maintenance inspections and monthly load testing documented for the previous 12 months. | SS=C |
Report Facts
Facility census: 96
Duration of generator load test: 30
Duration pressure applied to door releasing mechanism: 30
Maximum force to release door lock: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding lack of documentation for generator maintenance and testing |
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 5
Sep 23, 2004
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with federal regulations regarding resident rights, protection of resident funds, resident assessments, care planning, quality of care, and safety measures.
Findings
The facility was found deficient in multiple areas including failure to have a surety bond for resident funds, failure to complete significant change assessments and update care plans for residents with declining conditions, failure to provide ordered protective devices and follow medication administration instructions, and inadequate supervision and safety measures for residents.
Severity Breakdown
SS=B: 1
SS=D: 3
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility does not have a surety bond or acceptable equivalent to assure security of resident funds. | SS=B |
| Facility did not assess a resident for a significant change in status and complete a minimum data set assessment (MDS). | SS=D |
| Facility did not update the resident's care plan with a significant change in physical functioning. | SS=D |
| Facility did not provide mesh gloves or pudding thickened liquids for Resident #96, did not follow pharmacy recommendations for medication administration, did not elevate heels of Resident #24, did not provide padded vest for Resident #82, and placed a predated care plan in Resident #1's medical record. | SS=E |
| Facility did not provide safety mats on the floor for Resident #38 and did not provide supervised smoking for Resident #72. | SS=D |
Report Facts
Facility census: 113
Sampled residents: 13
Residents with deficiencies: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 14, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4260.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-4260 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 19, 2004
Visit Reason
The inspection was conducted in response to complaint references #2-4255, #2-4275, and #2-4284.
Findings
The complaint records were found to be unsubstantiated with no deficiencies cited during the investigation.
Complaint Details
Complaint references #2-4255, #2-4275, and #2-4284 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 27, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4230.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-4230 was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 113
Deficiencies: 17
Jul 15, 2004
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident rights, protection of resident funds, staff treatment of residents, quality of life, resident assessments, care planning, quality of care, dietary services, infection control, and administration.
Findings
The facility was found deficient in multiple areas including failure to provide surety bond for resident funds, failure to protect a resident from possible abuse, inadequate policies for abuse investigations, failure to inform residents about food substitutions, failure to honor food preferences, inaccessible call light for a resident, failure to complete updated assessments and care plans after significant changes, failure to follow physician orders, inadequate supervision on dementia unit, failure to meet dietary needs related to allergies, improper handwashing by staff, unsanitary food storage, lack of follow-up TB testing, and lack of contract with home health agency.
Severity Breakdown
SS=A: 1
SS=B: 1
SS=C: 2
SS=D: 10
SS=E: 3
SS=F: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Facility unable to produce a current surety bond to secure resident funds. | SS=B |
| Failure to protect a resident from possible abuse by nursing staff. | SS=D |
| Facility abuse policies did not address protection of residents during abuse investigations. | SS=C |
| Failure to inform residents of availability of food substitutions. | SS=E |
| Failure to honor food preference of a resident at meal. | SS=A |
| Call light inaccessible to resident due to placement and wheelchair size. | SS=D |
| Failure to identify significant change and complete updated assessment after hip fracture. | SS=D |
| Failure to update care plan after significant changes in condition and treatment. | SS=E |
| Care plans did not meet residents' needs or provide appropriate interventions for identified problems. | SS=D |
| Failure to follow physician orders for medication administration and other treatments. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable well-being, including continuous oxygen. | SS=D |
| Failure to ensure adequate supervision and use of chair alarm on dementia unit. | SS=E |
| Failure to meet dietary needs of resident with known food allergies. | SS=D |
| Failure to ensure proper handwashing by nursing assistant. | SS=D |
| Failure to store food under sanitary conditions; undated stock and dented cans. | SS=F |
| Failure to perform follow-up TB testing on resident exposed to tuberculosis. | SS=D |
| Failure to obtain contract with local home health agency before allowing provision of services. | SS=D |
Report Facts
Facility census: 113
Residents sampled: 20
Residents in dementia unit dining room: 13
Residents in dementia unit: 25
Dented cans found: 3
Residents affected by care plan deficiencies: 5
Inspection Report
Life Safety
Census: 113
Deficiencies: 4
Jul 14, 2004
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards related to fire resistance ratings of smoke barriers, smoke barrier doors, hazardous area doors, stairway handrails, and other life safety components.
Findings
The facility failed to maintain smoke barrier walls and doors to the required fire resistance ratings, had doors that failed to close or latch properly, and lacked handrails on stairs in an egress path. These deficiencies reduce the fire safety of the building.
Severity Breakdown
SS=C: 1
SS=B: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to maintain all portions of smoke barrier walls to a one-half hour fire rated construction, with unsealed penetrations around conduits and wires in multiple locations. | SS=C |
| Facility failed to maintain all facility smoke barrier doors to a 20 minute fire resistance rating; specifically, a smoke barrier door failed to close completely under the self-closing device. | SS=B |
| Facility failed to maintain all hazardous room doors to be self-closing; corridor doors to soiled linen holding room and battery charging room failed to close/latch properly. | SS=B |
| Facility failed to maintain handrails on stairs located in an egress path; stairs from 3rd floor auditorium to 1st floor corridor lacked handrails at the top portion. | SS=B |
Report Facts
Facility census: 113
Deficiency completion dates: 2004
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 4
Jul 1, 2004
Visit Reason
The inspection was conducted as a complaint investigation (reference #2-4204) which was substantiated with deficiencies cited.
Findings
The facility failed to follow the posted menus for residents, resulting in altered meals due to lack of beef. Several residents did not receive meals consistent with their prescribed diets. The food served was often unattractive and lacked palatability, with repetitive menu items. Additionally, the facility failed to ensure eggs were fully cooked before serving, posing a food safety risk.
Complaint Details
Complaint reference #2-4204 was substantiated with deficiencies cited related to dietary services and food safety.
Severity Breakdown
Level C: 3
Level D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to follow the posted menus for all residents, altering meals due to lack of beef. | Level C |
| Residents did not receive meals consistent with their prescribed dietary orders (e.g., mechanical soft, low sodium, cardiac diets). | Level C |
| Food served was not attractive or palatable, with repetitive menu items and lack of variety. | Level C |
| Facility failed to ensure fried eggs were fully cooked before serving, posing a risk of food poisoning. | Level D |
Report Facts
Facility census: 118
Beef occurrences on menu: 8
Green beans occurrences: 3
Carrots occurrences: 3
Potatoes occurrences: 7
Potatoes occurrences in cycle menu week 1: 8
Carrots occurrences in cycle menu week 1: 3
Potatoes occurrences in cycle menu week 2: 5
Green beans occurrences in cycle menu week 2: 3
Carrots occurrences in cycle menu week 2: 5
Chicken occurrences in cycle menu week 2: 4
Potatoes occurrences in cycle menu week 3: 6
Carrots occurrences in cycle menu week 3: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
May 13, 2004
Visit Reason
Complaint investigation related to complaint reference #2-4150.
Findings
The complaint was substantiated but no deficiencies were cited.
Complaint Details
Complaint reference #2-4150 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 9
Apr 15, 2004
Visit Reason
Complaint investigation related to resident rights, resident assessment, care planning, quality of care, infection control, and physical environment.
Findings
The facility was found noncompliant in multiple areas including failure to allow a resident to participate in medical decisions, incomplete resident assessment protocols, inaccurate minimum data set assessments, inadequate care plans lacking measurable goals and specific interventions, unsafe environment with unlocked IV cart, inadequate supervision of assistive devices, poor hand hygiene among staff, and incomplete clinical documentation.
Complaint Details
Complaint reference #2-4116 was unsubstantiated with no deficiencies cited related to the complaint itself, but multiple deficiencies were identified during the investigation.
Severity Breakdown
Level C: 1
Level D: 4
Level E: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility did not allow one resident who was alert and oriented to participate in medical care decisions. | Level D |
| Facility failed to complete resident assessment protocols (RAPs) adequately for 8 of 16 sampled residents. | Level E |
| Minimum data set (MDS) assessment did not accurately reflect resident status for Resident #56. | Level D |
| Facility failed to develop comprehensive care plans based on assessments for 9 of 16 sampled residents. | Level E |
| Intravenous therapy treatment cart found unlocked and unattended, accessible to residents. | Level E |
| Facility failed to provide adequate supervision of assistive device (body alarm) for Resident #50. | Level D |
| Staff failed to wash hands after resident contact in multiple observed instances. | Level E |
| Facility failed to maintain a safe, functional, sanitary, and comfortable environment; water leak and out-of-order showers observed. | Level C |
| Facility failed to maintain clinical records meeting professional standards; unsigned dental exams, out-of-sequence physician orders, and incomplete catheter orders. | Level D |
Report Facts
Facility census: 95
Residents sampled: 16
Residents with incomplete RAPs: 8
Residents with inadequate care plans: 9
Nursing assistants observed not washing hands: 6
Inspection Report
Deficiencies: 4
Apr 14, 2004
Visit Reason
The inspection was conducted to assess compliance with various NFPA 101 Life Safety Code standards related to fire safety, hazardous area protections, fire drills, soiled linen receptacle capacity, and medical gas storage and administration.
Findings
The facility was found deficient in multiple areas including failure to maintain self-closing devices on hazardous room doors, inadequate leadership during fire drills, exceeding capacity limits for unattended soiled linen receptacles, and improper storage of oxygen cylinders not secured by chains.
Severity Breakdown
SS=B: 2
SS=C: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to maintain all hazardous room doors with self-closing devices, including the clean linen storage room door. | SS=B |
| Facility failed to exercise leadership during fire drills; staff confusion and lack of response to fire alarm observed. | SS=C |
| Facility failed to comply with capacity limitations for unattended mobile soiled linen receptacles; six receptacles over 32 gallons observed unattended in corridors and service corridor. | SS=C |
| Facility failed to store all oxygen cylinders in accordance with NFPA 99; ten small oxygen cylinders were freestanding and not secured by a chain. | SS=B |
Report Facts
Unattended soiled linen receptacles: 6
Oxygen cylinders: 10
Date of fire drill observation: Apr 13, 2004
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Apr 13, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4117, which was substantiated but unrelated deficiencies were also cited.
Findings
The facility failed to maintain complete and thorough clinical documentation regarding a bruise found on Resident #1's left knee. The bruise was noted a day after a physician visit, but nursing notes lacked documentation of the bruise discovery, size measurements, and monitoring. X-rays confirmed an incomplete tibia fracture.
Complaint Details
Complaint reference #2-4117 was substantiated with unrelated deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain complete and thorough clinical records, specifically no documentation in nursing notes about a bruise found on Resident #1's left knee. | SS=D |
Report Facts
Facility census: 58
Deficiency completion date: May 7, 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the bruise discovery on Resident #1 |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 6
Mar 31, 2004
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, care planning, quality of care, infection control, dietary services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents on Coumadin therapy and those with constipation, failure to follow bowel protocols, inadequate toenail care for residents, improper handwashing technique by staff, and unsanitary food preparation and serving conditions in the dietary department.
Severity Breakdown
C: 1
D: 3
E: 1
F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and facility rules in an understandable language. | C |
| Failure to develop comprehensive care plans with measurable objectives and appropriate interventions for residents receiving Coumadin therapy and those with constipation. | D |
| Failure to implement care plans and follow bowel protocols for residents who had not had a bowel movement within three days. | E |
| Failure to provide necessary toenail care for residents, despite podiatrist visits. | D |
| Failure to ensure proper handwashing technique by nursing staff, contaminating clean hands. | D |
| Failure to store, prepare, distribute, and serve food under sanitary conditions, including presence of dried food debris, greasy residue, soiled lids, and inadequate sanitizing solutions. | F |
Report Facts
Facility census: 59
Residents sampled: 9
Residents with care plan deficiencies: 3
Residents with bowel protocol failures: 2
Residents with toenail care issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies, bowel protocol, toenail care, and handwashing practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 31, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-4038.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-4038 was unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 4, 2004
Visit Reason
This document is a Plan of Correction related to deficiencies identified during a prior inspection of Jackie Withrow Hospital.
Findings
The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to properly inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. | Level C |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 11
Feb 12, 2004
Visit Reason
Complaint investigation related to allegations of abuse, neglect, mistreatment, and failure to follow care protocols at Lincoln Healthcare Center.
Findings
The facility failed to timely report and thoroughly investigate injuries of unknown origin, failed to provide care respecting resident dignity and privacy, did not complete required resident assessments and care plans adequately, failed to follow infection control and medication administration policies, and did not ensure timely physician visits for newly admitted residents. Additionally, dietary services were not provided according to physician orders and sanitary conditions in food preparation were inadequate.
Complaint Details
Complaint reference #2-4030. Complaint was unsubstantiated with no related deficiencies cited.
Severity Breakdown
SS=E: 4
SS=D: 6
SS=F: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to notify state survey agency timely and thoroughly investigate injuries of unknown origin for multiple residents. | SS=E |
| Failure to provide care promoting dignity and respect; resident emotional distress and privacy violations observed. | SS=D |
| Failure to complete comprehensive resident assessments and Resident Assessment Protocols (RAPs) as required. | SS=E |
| Failure to include appropriate non-pharmacologic interventions in care plans for residents with mood and behavior problems. | SS=D |
| Failure to wear gloves during insulin injections as required by facility policy. | SS=D |
| Failure to follow bowel protocol for residents with constipation, including physician notification and treatment interventions. | SS=E |
| Failure to assess need for indwelling urinary catheter and attempts to restore bladder function. | SS=D |
| Failure to provide mechanical soft diet as ordered by physician. | SS=D |
| Failure to maintain sanitary conditions in food preparation area; condensation dripping on food prep area and damaged spice container lids. | SS=F |
| Failure to ensure physician visits every 30 days for newly admitted residents during first 90 days. | SS=D |
| Failure to prepare a clean field and follow proper wound care technique during pressure ulcer dressing change. | SS=D |
Report Facts
Files reviewed: 19
Deficient files: 7
Residents sampled: 14
Residents with assessment deficiencies: 4
Residents with care plan deficiencies: 2
Residents with insulin injection observations: 2
Residents with constipation protocol failures: 5
Residents with missed physician visits: 3
Facility census: 55
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 1
Feb 11, 2004
Visit Reason
The inspection was conducted as a complaint investigation related to complaint reference #2-4081.
Findings
The complaint was substantiated but no deficiencies were cited. However, a behavioral health survey identified safety concerns including lack of alarms on outside doors and insufficient awake staff supervision on weekend nights.
Complaint Details
Complaint reference #2-4081 was substantiated with no deficiencies cited.
Deficiencies (1)
| Description |
|---|
| The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers; specifically, adolescent girls' bedrooms have outside doors without alarms and there is no awake staff on weekend nights to monitor consumers. |
Report Facts
Center census: 6
Sample size: 3
Inspection Report
Life Safety
Deficiencies: 0
Feb 9, 2004
Visit Reason
The inspection was conducted to assess the facility's compliance with the Life Safety Code NFPA 101 - 2000 Existing.
Findings
Based on observation, performance testing, and review of facility documentation from 02/09/04 to 02/10/04, the facility was determined to be in compliance with the Life Safety Code NFPA 101 - 2000 Existing.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 9, 2004
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-3314.
Findings
The complaint was substantiated and deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-3314 was substantiated with deficiencies cited.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Dec 1, 2003
Visit Reason
The inspection was conducted as a complaint investigation based on complaint reference #2-3234 regarding allegations of abuse, neglect, and injuries of unknown origin at the facility.
Findings
The facility failed to immediately report four allegations of abuse/neglect and injuries of unknown origin to the administrator and the State survey and certification agency as required by West Virginia State Code 9-6-11. Incidents occurred in July, September, and November 2003 but were reported late or not at all.
Complaint Details
Complaint reference #2-3234 was substantiated with deficiencies cited related to failure to report abuse/neglect incidents and injuries of unknown origin in a timely manner.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately report allegations of abuse/neglect and injuries of unknown origin to the administrator and State survey agency. | SS=E |
Report Facts
Facility census: 97
Number of unreported incidents: 4
Dates of incidents: Two incidents in July 2003, one injury in September 2003, and one incident in November 2003.
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Dec 1, 2003
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to provide necessary medications to Resident #100 after his return from the hospital.
Findings
The facility failed to provide Resident #100 with ordered medications in a timely manner, resulting in physical harm and mental anguish. The resident exhibited agitation, bruising, and required one-to-one monitoring, but medications were delayed and the physician was not notified of escalating behaviors.
Complaint Details
The complaint investigation found that Resident #100 did not receive medications after hospital return, leading to agitation and physical harm. The resident was blind and nonverbal, and the facility failed to notify the physician of escalating behaviors.
Severity Breakdown
SS=G: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide necessary medications to Resident #100 to avoid physical harm and mental anguish. | SS=G |
Report Facts
Facility census: 97
Medications delayed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Withrow | Named as provider/supplier on the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 16, 2003
Visit Reason
The inspection was conducted in response to two complaint references (#2-3247 and #2-3277).
Findings
Both complaints were found to be unsubstantiated with no deficiencies cited during the investigation.
Complaint Details
Complaint reference #2-3247 and #2-3277 were both unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 13, 2003
Visit Reason
The inspection was conducted in response to complaint reference #2-3252.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-3252 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 3
Oct 23, 2003
Visit Reason
Complaint reference #2-3117 triggered a substantiated complaint investigation with deficiencies cited at Wyoming Healthcare Center.
Findings
The facility was found deficient for employing a certified nursing assistant without a valid nurse aide registration, failing to develop a comprehensive care plan with measurable objectives for one resident, and not following facility policy for checking gastrostomy tube placement during medication administration.
Complaint Details
Complaint reference #2-3117 was substantiated with deficiencies cited related to staff treatment of residents and resident assessment.
Severity Breakdown
Level B: 1
Level D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure one CNA had a current registration with WV Nurse Aide Education and Competency Evaluation Program before employment. | Level B |
| Facility failed to develop a comprehensive care plan including measurable objectives, goals, and timetables for one resident. | Level D |
| Facility did not check for placement of a gastrostomy tube by auscultation per facility policy during medication administration for one resident. | Level D |
Report Facts
Facility census: 66
Sampled residents: 15
Sampled residents: 13
Personnel records reviewed: 4
Inspection Report
Deficiencies: 2
Oct 23, 2003
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically regarding soiled linen container capacity and emergency generator maintenance and testing.
Findings
The facility was found non-compliant with the size and capacity requirements for soiled linen containers, as containers exceeding 32 gallons were in use. Additionally, the emergency generator exercise and testing did not fully comply with NFPA 110 requirements due to lack of documentation on electrical load, exhaust gas temperatures, and absence of an annual load bank test.
Severity Breakdown
SS=C: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Soiled linen or trash collection receptacles exceeded 32 gallon capacity in resident units, violating NFPA 101 Life Safety Code standards. | SS=C |
| Emergency generator exercise and testing did not comply with NFPA 110 due to missing documentation on electrical load, exhaust gas temperatures, and lack of annual load bank test. | SS=F |
Report Facts
Deficiencies cited: 2
Inspection dates: 2
Soiled linen container capacity: 32
Soiled linen containers found: 4
Emergency generator exercise duration: 30
Emergency generator exercise load percentage: 30
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 20, 2003
Visit Reason
The inspection was conducted in response to complaint reference #2-3239.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-3239 was unsubstantiated with no deficiencies cited.
Inspection Report
Routine
Census: 95
Deficiencies: 3
Oct 7, 2003
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, facility environment, and quality of care.
Findings
The facility was found deficient in maintaining a sanitary and comfortable environment with dirty rooms and offensive odors, and failed to provide necessary grooming and oral hygiene services to seven residents who were unable to care for themselves.
Severity Breakdown
SS=C: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable environment; dirty rooms and offensive odors noted throughout the facility. | SS=C |
| Facility failed to provide necessary services to maintain good grooming and personal and oral hygiene for seven residents unable to care for themselves. | SS=C |
| Facility failed to inform residents of their rights and services as required by regulations. | SS=C |
Report Facts
Facility census: 95
Number of residents with grooming deficiencies: 7
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 1
Oct 7, 2003
Visit Reason
The inspection was conducted as a complaint investigation referenced as #2-3229, focusing on substantiated complaints with deficiencies cited related to staff treatment of residents and incident investigations.
Findings
The facility failed to ensure that 20 of 21 incident reports from 07/01/03 to 10/08/03 were thoroughly investigated and reported to required agencies. Incident reports lacked completed investigations and actions to prevent recurrence, with examples including injuries of unknown origin and resident-to-resident altercations.
Complaint Details
Complaint reference #2-3229 was substantiated with deficiencies cited related to incomplete investigations and failure to report incidents to required agencies.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate and report incidents involving injuries of unknown origin, neglect, and abuse as required. | SS=E |
Report Facts
Incident reports not thoroughly investigated: 20
Facility census: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding incomplete incident investigations and failure to report |
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 4
Sep 30, 2003
Visit Reason
The inspection was conducted based on complaints regarding inadequate care and medication management for residents, specifically concerning failure to provide wound dressings and pain medication.
Findings
The facility failed to provide ordered wound care to Resident #101, causing mental anguish and infection risk, and failed to adequately address Resident #40's pain complaints. Additionally, the facility did not develop comprehensive care plans with measurable objectives for these residents and failed to secure medications properly.
Complaint Details
The complaint investigation substantiated that the facility failed to provide necessary wound care and pain management, and failed to secure medications properly, affecting residents' safety and well-being.
Severity Breakdown
G: 2
D: 1
E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide dressings for Resident #101's stage III and IV pressure ulcers as ordered, causing mental anguish and infection risk. | G |
| Failure to provide appropriate interventions for Resident #40 who was screaming in pain and was denied timely pain medication. | G |
| Failure to develop comprehensive care plans with measurable objectives and timetables for Residents #101 and #40. | D |
| Failure to store all drugs and biologicals in locked compartments; medications were left unsecured in Resident #40's room and nursing station. | E |
Report Facts
Facility census: 95
Number of medications left unsecured: 3
Number of ointment tubes left unsecured: 4
Number of antiseptic containers left unsecured: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 29, 2003
Visit Reason
The visit was conducted as a complaint investigation referenced as #2-3166.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaint reference #2-3166 was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 9, 2003
Visit Reason
The inspection was conducted as a complaint investigation identified as #2-3149.
Findings
The document is a statement of deficiencies and plan of correction related to the complaint investigation. Specific deficiencies or findings are not detailed in the provided text.
Complaint Details
Complaint investigation #2-3149
Inspection Report
Life Safety
Deficiencies: 0
Aug 14, 2003
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with the provisions of NFPA 101, Life Safety Code, 1981.
Findings
The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1981.
Inspection Report
Annual Inspection
Census: 101
Deficiencies: 11
Aug 11, 2003
Visit Reason
Annual survey inspection of Lakin Hospital to assess compliance with federal regulations related to resident rights, quality of care, resident assessment, physical environment, dietary services, and clinical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to notify family and physician of resident condition changes, inadequate quality of life accommodations, inaccurate resident assessments, incomplete care plans, improper medication administration, failure to address behavioral issues, inadequate pressure ulcer care, unsecured medication carts, pest control issues, improper food storage, and inconsistent clinical record documentation.
Severity Breakdown
SS=D: 8
SS=C: 2
SS=B: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to notify family or physician of residents' falls or life-threatening condition changes for residents #18 and #54. | SS=D |
| Failure to provide appropriate accommodations and assistive devices for residents #48 and #69 affecting quality of life. | SS=D |
| Resident assessment inaccuracies for resident #18 including bowel/bladder status, mechanical lift use, and behavioral issues. | SS=D |
| Comprehensive care plan did not address falls prevention, constipation, or cognitive changes for residents #18 and #20. | SS=D |
| Failure to maintain professional standards in medication administration including improper insulin injection technique and failure to offer fluids for residents #70 and #53; lack of physician order for Foley catheter for resident #18. | SS=D |
| Failure to provide necessary services to determine cause of verbal outbursts and physically abusive behavior for resident #83, including lack of pain assessment. | SS=D |
| Failure to promote healing of pressure ulcer for resident #18 by not using pressure relief devices when in chair. | SS=D |
| Medication carts left unlocked and unattended on two occasions posing safety hazard. | SS=D |
| Facility did not maintain effective pest control program; flies observed in hallways, dining room, and smoking area. | SS=B |
| Improper storage of raw eggs above raw fruit in kitchen refrigerator risking foodborne illness. | SS=C |
| Clinical records inconsistent and bowel movement documentation incomplete and not easily accessible for all sampled residents. | SS=C |
Report Facts
Facility census: 101
Sampled residents: 18
Falls: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to failure to notify family/physician and care plan deficiencies |
| Licensed Practical Nurse | LPN | Observed administering insulin injection improperly and medication without offering fluids |
| MDS Nurse | MDS Nurse | Verified inaccuracies in Minimum Data Set assessments |
| Care Conference Nurse | Care Conference Nurse | Verified care plan discrepancies and lack of updates |
Inspection Report
Life Safety
Deficiencies: 16
Jun 13, 2003
Visit Reason
The survey was conducted to assess the facility's compliance with NFPA 101 Life Safety Code standards, including fire safety, smoke barriers, sprinkler systems, emergency lighting, fire drills, and other life safety requirements.
Findings
The facility failed to maintain corridor doors with proper latching, maintain smoke barriers with required fire resistance ratings, separate hazardous areas properly, provide adequate emergency lighting, conduct quarterly fire drills, maintain electronically supervised fire alarm and sprinkler systems, provide ventilation according to NFPA 90A, and maintain handrails on designated means of egress. Additionally, delayed egress magnetic locks did not meet code requirements.
Severity Breakdown
SS=B: 12
SS=C: 3
SS=F: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Corridor doors for rooms 102, 104, 106, 108, and 110 lack positive latching mechanisms. | SS=B |
| Restorative therapy room corridor door has louvers not resistant to smoke passage. | SS=B |
| Supply room corridor door near room C-100 held open with wedge, impeding closing. | SS=B |
| Corridor door for room 207 (housekeeping supply) does not close to latch. | SS=B |
| Smoke barriers penetrated by foam pipe insulation and unsealed openings reducing fire resistance rating. | SS=B |
| Smoke barrier doors between rooms C-104 and C-105, and near unit 2C nurses station drag at meeting edges, reducing fire resistance rating. | SS=B |
| Hazardous areas not properly separated; thin sheet metal covering louvers lacks 20-minute fire rating; combustibles in room B-104; storage room corridor doors 307 and 311 have louvers reducing fire resistance rating. | SS=B |
| Emergency lighting fails to illuminate stairwell lights in C-section stairwell and restorative therapy corridor stairwell. | SS=B |
| Facility fails to conduct quarterly fire drills on each shift and lacks documentation of staff familiarization with emergency procedures. | SS=F |
| No fire alarm warning device in basement area near large water storage tank. | SS=B |
| Incomplete sprinkler protection behind stage theme in 3-B auditorium and second floor ice machine room; four sprinkler heads in restorative therapy corridor not side wall type, leaving corridor width uncovered. | SS=B |
| Sprinkler system water flow device failed to alarm during test. | SS=C |
| Main control valve of sprinkler system not electronically supervised; electronic sensor failed to activate alarm when valve closed. | SS=C |
| Ventilation equipment fails to comply with NFPA 90A; fans cause corridors to be exhaust air plenums. | SS=B |
| No handrails on stairs leading from second floor auditorium to first floor corridor. | SS=B |
| Delayed egress magnetic locks on smoke barrier doors entering 3C unit fail to release lock within 15 seconds under pressure; missing required signage. | SS=C |
Report Facts
Fire drill documentation period: 10
Fire drill report review date: Jun 12, 2003
Survey period: 5
Emergency lighting duration: 90
Fire resistance rating: 20
Fire resistance rating: 45
Inspection Report
Annual Inspection
Census: 102
Deficiencies: 12
Jun 13, 2003
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations related to resident rights, quality of care, infection control, medication administration, dietary services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to properly assess and document residents' decision-making capacity, lack of privacy during care, inadequate social services support, inaccurate resident assessments, poor quality of care including failure to follow physician orders, medication errors exceeding 5%, unsanitary conditions in dietary and housekeeping, inadequate infection control practices, and lack of an effective quality assurance program.
Severity Breakdown
SS=D: 7
SS=F: 2
SS=E: 1
SS=C: 1
SS=B: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failure to determine resident's ability to make decisions and complete capacity statements with required signatures for reinstating capacity. | SS=D |
| Failure to provide privacy during medication administration and care. | SS=D |
| Failure to provide medically-related social services to address psychological needs. | SS=D |
| Failure to complete and sign minimum data set (MDS) assessments accurately and timely. | SS=B |
| Failure to develop comprehensive care plans reflecting residents' needs and physician orders. | SS=D |
| Failure to provide necessary care and services including padding siderails, bowel management, maintaining NPO status, and pressure sore prevention. | SS=D |
| Failure to provide adequate supervision and assistance devices to prevent accidents including supervision during smoking and use of bed alarms. | SS=E |
| Failure to maintain medication error rate at or below 5%, including improper medication administration techniques. | SS=D |
| Failure to store, prepare, distribute, and serve food under sanitary conditions, including soiled equipment and unsanitary food storage. | SS=C |
| Failure to establish and maintain an effective infection control program, including improper glove use, hand hygiene, and contamination risks. | SS=F |
| Failure to provide or obtain timely laboratory services as ordered. | SS=D |
| Failure to develop and implement a quality assurance program to identify and correct quality deficiencies. | SS=F |
Report Facts
Sampled residents: 18
Medication error rate: 7.14
Facility census: 102
Missed lab tests: 3
Falls: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Interviewed regarding failure to assess resident capacity and health care surrogate designation | |
| Registered Nurse | Interviewed regarding resident care plans and assessments | |
| Licensed Practical Nurse | Observed administering medication improperly and interviewed about lab testing issues | |
| Clinical Nurse Coordinator | Interviewed regarding lack of infection control program | |
| Quality Assurance/Infection Control Nurse | Interviewed regarding lack of quality assurance program | |
| Housekeeper | Observed handling dirty and clean linens without handwashing |
Inspection Report
Census: 106
Deficiencies: 1
May 16, 2003
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, specifically regarding the administration of a physician-ordered enema for Resident #105.
Findings
The facility failed to ensure that a physician's order for a large volume warm water enema to be given to Resident #105 on 4/2/03 was completed as scheduled. Documentation and staff interviews confirmed the enema was likely not administered.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer a physician-ordered enema to Resident #105 as scheduled. | SS=D |
Report Facts
Census: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN charge nurse | Interviewed regarding missing documentation of enema administration | |
| RN unit 3 supervisor | Interviewed regarding missing documentation and failure to administer enema |
Inspection Report
Annual Inspection
Census: 98
Deficiencies: 17
Feb 28, 2003
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including resident rights and notification, quality of life, dietary services, medication management, infection control, physical environment, and record keeping. Specific issues included failure to notify legal representatives of care plans, inadequate grooming and timely meal service, improper medication dose reductions, unsafe environment, pest control problems, and poor documentation accessibility.
Severity Breakdown
SS=F: 1
SS=E: 3
SS=D: 9
SS=C: 4
SS=B: 1
SS=A: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Allowed someone without legal authority to make health care decisions for a resident. | SS=D |
| Failed to notify legal representative prior to commencing a weight management program for a resident. | SS=D |
| Failed to provide adequate hair grooming for residents unable to care for themselves. | SS=D |
| Failed to provide food of proper consistency and timely meal service for residents. | SS=D |
| Did not perform gradual dosage reductions separately on antipsychotic medications for residents. | SS=E |
| Failed to provide pressure relieving devices as per care plans for residents at risk of skin breakdown. | SS=D |
| Failed to provide necessary grooming services to maintain good hygiene for a resident. | SS=D |
| Did not provide a safe environment and failed to revise care plan after multiple incidents of resident climbing out of bed. | SS=D |
| Failed to assure residents were provided foods as directed on the menu and lacked diet plans for some ordered diets. | SS=E |
| Failed to prepare and serve pureed and regular Harvard beets in an attractive manner. | SS=C |
| Designated smoking room had inadequate ventilation and exposed residents, staff, and visitors to second-hand smoke. | SS=C |
| Failed to provide adequate ventilation in resident bathroom vents on 'A' wing. | SS=C |
| Failed to maintain an effective pest control program; gnats observed in resident rooms. | SS=A |
| Failed to offer substitutes of similar nutritive value for refused food. | SS=D |
| Pharmacist failed to report simultaneous dose reductions of antipsychotic medications as irregularity. | SS=D |
| Failed to assure ice pitchers were free from contamination and staff washed hands after resident care. | SS=F |
| Failed to maintain clinical records including minimum data sets and care plans readily accessible. | SS=B |
Report Facts
Facility census: 98
Residents sampled: 17
Residents affected by dietary issues: 20
Incidents of resident climbing out of bed: 10
Residents observed smoking in designated room: 12
Times smoking room door opened during 15-minute period: 12
Inspection Report
Life Safety
Deficiencies: 1
Feb 25, 2003
Visit Reason
The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically to verify that the fire alarm systems were tested monthly as required.
Findings
The facility failed to produce documentation showing that the fire alarm system was tested monthly, specifically lacking evidence of testing for September 2002.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to test the fire alarm system monthly as required by NFPA 101 Life Safety Code Standard. | SS=C |
Report Facts
Date of missing fire alarm test documentation: 200209
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Feb 19, 2003
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to report or investigate injuries of unknown origin for certain residents and to assess compliance with staff treatment of residents regulations.
Findings
The facility failed to report or investigate injuries of unknown origin for two residents (#68 and #106) and did not initiate or submit a timely five-day follow-up report for another resident (#103). The investigation for resident #103 was initiated eight days after the incident, exceeding the required five working days.
Complaint Details
The complaint investigation found that the facility did not report or investigate injuries of unknown origin for two residents and delayed investigation and reporting for a third resident. Resident identifiers #68, #103, and #106 were involved.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report or investigate injuries of unknown origin for residents #68 and #106. | SS=D |
| Failure to initiate investigation and submit five-day follow-up report in a timely manner for resident #103. | SS=D |
Report Facts
Facility census: 104
Bruise size: 6
Days delayed: 8
Inspection Report
Annual Inspection
Deficiencies: 7
Jan 9, 2003
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident rights, assessments, care planning, quality of care, physical environment, dietary services, and medication management.
Findings
The facility was found deficient in multiple areas including inaccurate resident assessments, incomplete care plans, failure to follow physician orders, inadequate monitoring and dosage reduction of antipsychotic medications, unsafe physical environment conditions, and unclean food service equipment. Specific resident care issues involved inaccurate MDS data, lack of pain management in care plans, improper restraint documentation, and medication management concerns.
Severity Breakdown
SS=B: 3
SS=C: 1
SS=D: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to provide accurate minimum data set assessments (MDS) reflecting residents' conditions. | SS=B |
| Facility failed to address resident problems in care plans and did not reflect standards of current professional practice. | SS=B |
| Facility did not follow physician's orders regarding size of indwelling urinary catheter. | SS=D |
| Facility failed to adequately monitor use of antipsychotic medication with no indication resident needed it. | SS=D |
| Facility did not assess for dosage reduction of antipsychotic medication as required. | SS=D |
| Facility deficient in maintaining a safe physical environment including disabled emergency alarm and damaged surfaces preventing cleaning. | SS=C |
| Facility food service equipment not maintained in a clean condition compromising food service. | SS=B |
Report Facts
Sampled residents: 12
Residents with inaccurate assessments: 5
Residents with incomplete care plans: 6
Pain medications: 3
Medication doses: 0.5
Medication doses: 1
Medication dose: 10
Medication dose: 30
Inspection Report
Life Safety
Deficiencies: 1
Jan 9, 2003
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the construction and maintenance of smoke barriers in the facility.
Findings
The facility was found deficient in maintaining the required construction of smoke barriers, with a two-foot by two-foot section of the barrier apron missing at the front barrier on the dining room side, compromising the smoke barrier.
Severity Breakdown
SS=A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Two-foot by two-foot section of the smoke barrier apron missing at the front barrier on the dining room side. | SS=A |
Inspection Report
Life Safety
Deficiencies: 0
Dec 5, 2002
Visit Reason
The survey was conducted to assess the facility's compliance with the Life Safety Code NFPA 101 - 1981 New.
Findings
Based on observation, performance testing, and review of facility documentation during the survey from 12/04/02 to 12/05/02, the facility was determined to be in compliance with the Life Safety Code NFPA 101 - 1981 New.
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 3
Nov 14, 2002
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with federal regulations regarding resident rights, infection control, and clinical record administration.
Findings
The facility was found deficient in infection control practices related to contamination risk during medication administration via feeding tubes and in the accurate transcription of physician orders onto computer-generated monthly renewals for several residents. Additionally, there were documentation issues with resident medical records not reflecting accurate admission physicals.
Severity Breakdown
SS=D: 1
SS=F: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect the feeding tube from contamination during medication pass for Resident #31. | SS=D |
| Failure to maintain accurate and complete clinical records for Resident #19, including discrepancies in admission physical documentation. | SS=F |
| Failure to ensure physician orders were correctly transcribed onto computer-generated monthly renewals for Residents #5, #16, and #46. | SS=F |
Report Facts
Facility census: 54
Facility census: 56
Number of sampled residents with record issues: 1
Number of residents with transcription errors: 3
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 7
Sep 5, 2002
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Lakin Hospital, a nursing facility.
Findings
The facility was found deficient in multiple areas including failure to report and investigate an allegation of abuse, failure to promote dignity during dining, failure to accommodate resident needs during meals, use of unnecessary drugs without gradual dose reduction, ineffective pest control, failure to provide food substitutes, and inaccurate clinical record coding.
Severity Breakdown
SS=E: 2
SS=D: 4
SS=C: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to report and thoroughly investigate an allegation of abuse involving Resident #104. | SS=D |
| Failure to promote care that maintains residents' dignity during dining; mixing alert residents with disruptive residents and inconsistent meal service times. | SS=E |
| Failure to provide reasonable accommodation for Resident #89 during meal time, seated in a merry walker making it difficult to eat independently. | SS=D |
| Failure to ensure one resident's drug regimen was free from unnecessary drugs; no gradual dose reduction attempted for Risperdal and Restoril. | SS=D |
| Failure to maintain an effective pest control program; flies observed in dining rooms and windows without insect screening. | SS=C |
| Failure to provide substitutes of similar nutritive value for food refused by residents #85 and #96. | SS=D |
| Failure to maintain clinical records accurately; Resident #69's Minimum Data Set (MDS) was incorrectly coded as independent in transfers and ambulation. | SS=E |
Report Facts
Resident census: 99
Sampled residents: 20
Residents not served meals at same time: 11
Residents refusing food: 2
Months MDS miscoded: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding failure to report abuse and medication dose reduction |
| MDS Coordinator | MDS Coordinator | Interviewed regarding inaccurate coding of resident #69's Minimum Data Set |
| Dietary Manager | Interviewed regarding meal service and food substitutes | |
| Nursing Supervisor | Interviewed regarding dining arrangements for residents | |
| Maintenance Supervisor | Interviewed regarding pest control and window screening |
Inspection Report
Life Safety
Deficiencies: 3
Sep 5, 2002
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on maintaining emergency exits free of obstructions for emergency egress.
Findings
The facility was found deficient in maintaining emergency exits free of obstructions. Storage shelves and supplies in the kitchen area reduced emergency egress paths to less than two feet and restricted access to emergency exit doors.
Severity Breakdown
SS=B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Access from the kitchen to the rear corridor door was found to have storage shelves which reduce emergency egress to less than two feet. | SS=B |
| The emergency egress door from the kitchen/staff dining corridor was found to have storage shelves and supplies that reduce and/or restrict the path and access to the emergency exit door. | SS=B |
| Furnishings and decorations obstruct exits or visibility of exits. | SS=B |
Report Facts
Width of emergency exit access: 2
Required minimum width of exit access corridors and aisles: 8
Existing width of exit access corridors and aisles: 4
Inspection Report
Deficiencies: 7
Aug 15, 2002
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to fire safety, exit accessibility, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to maintain corridor and smoke barrier doors to required fire resistance ratings, unsealed penetrations in smoke barrier walls, lack of proper signage and accessibility of exit doors, failure to maintain emergency exit lighting, and failure to conduct monthly inspections of the rangehood dry chemical extinguishing system as required.
Severity Breakdown
SS=B: 3
SS=C: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Corridor door to the ice machine room on the 3B unit had a venting grille and lacked a positive latching device. | SS=B |
| Facility smoke barrier walls had unsealed/incompletely sealed penetrations around wires, pipes, and conduits in multiple units. | SS=C |
| Smoke barrier doors for Unit 1B and Unit 1C failed to close completely under the power of self-closing devices. | SS=C |
| Soiled linen rooms corridor doors failed to close and latch under the power of self-closing devices; unsealed penetrations observed in walls above lay-in-ceiling. | SS=C |
| Exit doors had magnetic locking devices but lacked instructional signage on how to release doors in emergencies; exit doors were blocked by furniture. | SS=C |
| Exit signs in the 3C stairwell from the auditorium were not illuminated during emergency power system load test. | SS=B |
| Facility failed to inspect the rangehood dry chemical extinguishing system monthly as required; service tag lacked recent inspection dates and initials. | SS=B |
Report Facts
Date of survey completion: Aug 15, 2002
Deficiency completion dates: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Withrow | Hospital Representative | Named as provider or supplier representative on the report |
| Maintenance supervisor | Interviewed regarding failure to conduct monthly inspections of the rangehood extinguishing system |
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 17
Aug 15, 2002
Visit Reason
Annual inspection of Jackie Withrow Hospital to assess compliance with federal regulations including resident rights, medication administration, care planning, dietary services, physical environment, infection control, and other quality of care standards.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights regarding advance directives, improper medication administration and monitoring, inadequate investigation of incidents, failure to provide ordered assistive devices and therapeutic diets, incomplete care plans, unsafe physical environment conditions, and inadequate infection control practices.
Severity Breakdown
SS=A: 1
SS=C: 3
SS=D: 8
SS=E: 4
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to assure one resident's right to exercise advance directives, including inappropriate inquiries to medical power of attorney. | SS=A |
| Failure to notify medical power of attorney and physician of changes in resident condition and medication administration issues for multiple residents. | SS=D |
| Failure to properly assess resident for self-administration of drugs. | SS=D |
| Failure to report and investigate ten incidents of unknown origin involving resident injuries and bruises. | SS=E |
| Failure to provide assistive devices such as special shoes and wheelchair leg elevation as ordered. | SS=D |
| Failure to develop comprehensive care plans addressing self-injurious behavior and self-administration of medications. | SS=D |
| Failure to follow physician's orders for TED hose and weighted utensils. | SS=D |
| Failure to provide care in accordance with bowel management orders for multiple residents. | SS=E |
| Failure to reposition residents as required to prevent pressure ulcers. | SS=E |
| Failure to properly care for a resident after a fall resulting in hip fracture. | SS=D |
| Failure to maintain emergency electrical power system to provide lighting and fire alarm function. | SS=C |
| Facility environment had unpleasant odors and unsanitary conditions including soiled caulking around commodes. | SS=C |
| Failure to assure therapeutic diets meet residents' needs; low fat diet residents served same chili as regular diet residents without recipe for low fat chili. | SS=E |
| Failure to follow menus resulting in residents receiving incorrect diet portions or types. | SS=E |
| Pharmacist failed to identify irregularities in psychotropic medication use without adequate indication or monitoring. | SS=D |
| Failure to clean shower chairs after use to prevent infection spread. | SS=D |
| Failure to maintain complete, accurate, and accessible clinical records for residents. | SS=E |
Report Facts
Facility census: 118
Residents with no bowel movement: 6
Residents with no bowel movement: 7
Residents with no bowel movement: 5
Residents affected by dietary menu failure: 31
Temperature of chicken served: 120
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Jul 12, 2002
Visit Reason
The inspection was conducted due to complaints regarding reduced staffing levels on weekends and holidays, which potentially affected resident care and well-being.
Findings
The facility implemented a new staffing pattern in June 2002 that reduced staffing on weekends and holidays, leading to concerns about the ability to maintain the highest practicable physical, mental, and psychosocial well-being of residents. Specific issues included insufficient staff to provide care, residents left in bed more frequently, and complaints from family members about resident care.
Complaint Details
The complaint investigation focused on staffing reductions on weekends and holidays, with substantiated concerns from staff and family members about decreased care quality, including residents not being repositioned or turned as often, and increased time spent in bed or chairs. Specific residents (#10 and #15) were highlighted with concerns about care adequacy.
Severity Breakdown
SS=A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Reduction in staffing on weekends and holidays demonstrated potential to detract from staff's ability to maintain highest practicable physical, mental, and psychosocial well-being of residents. | SS=A |
Report Facts
Facility census: 114
Health service workers per unit: 3
Health service workers per unit: 2
Residents in largest unit: 33
Residents in unit 1C: 32
Residents totally dependent on staff in unit 1C: 31
Residents requiring feeding assistance in unit 1C: 18
Previous staffing on 7-3 shift: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 5, 2002
Visit Reason
This document is a plan of correction related to a facility inspection, addressing compliance with resident rights and notification requirements.
Findings
The report states there are no deficiencies identified during the inspection.
Inspection Report
Life Safety
Deficiencies: 1
May 3, 2002
Visit Reason
The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on the design, installation, and use of commercial cooking equipment and its fire-extinguishing system.
Findings
The facility's rangehood wet chemical extinguishing system was found not to be inspected monthly as required by NFPA 17A. The service tag lacked dates and initials for inspections from February to March 2002, and the maintenance supervisor confirmed no inspections were conducted during that period.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility rangehood wet chemical extinguishing system was not inspected monthly as required; service tag lacked date and initials for February to March 2002 inspections. | SS=B |
Report Facts
Inspection date: May 3, 2002
Inspection observation date: Apr 30, 2002
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| maintenance supervisor | Interviewed regarding monthly inspection of rangehood extinguishing system |
Inspection Report
Deficiencies: 2
May 1, 2002
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection control regulations and residents' rights notification requirements.
Findings
The facility failed to establish and maintain an infection control program to prevent infection transmission, specifically placing a resident at risk by improper handling of a Foley catheter collection unit. Additionally, there was a deficiency related to informing residents of their rights and services.
Severity Breakdown
SS=C: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to establish and maintain an infection control program, placing Resident #21 at risk for bladder infection by placing Foley catheter collection unit above the level of the bladder. | SS=D |
| Failure to inform residents orally and in writing of their rights, rules, and services as required. | SS=C |
Report Facts
Resident identifier: 21
Inspection Report
Life Safety
Deficiencies: 0
Mar 19, 2002
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101, Life Safety Code, 1981, based on review of facility documentation, staff interview, observations, and performance testing.
Findings
The facility was found to be without waivers and in compliance with the provisions of the NFPA 101, Life Safety Code, 1981.
Inspection Report
Plan of Correction
Census: 59
Deficiencies: 3
Feb 28, 2002
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction following a survey completed on 02/28/2002 at Lincoln Healthcare Center.
Findings
The facility was found deficient in several areas including lack of a state-approved surety bond for resident funds, failure to screen new employees properly per abuse prohibition policies, and improper storage of frozen hash brown potatoes in the dietary services area.
Severity Breakdown
Level C: 2
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility did not have a surety bond approved by the State Attorney General's Office as required, potentially affecting all residents. | Level C |
| Facility failed to screen four of five new employees per abuse prohibition policy, including lack of reference checks and license verification. | Level C |
| Facility failed to ensure individual portions of frozen hash brown potatoes were properly stored in a sanitary manner, risking contamination. | Level E |
Report Facts
Facility census: 59
New employees not screened: 4
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 8, 2002
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint # 2-2031 at Jackie Withrow Hospital.
Findings
The report includes a statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights and services in writing and orally.
Complaint Details
Complaint # 2-2031 was the reason for the visit. No substantiation status is provided in the report.
Severity Breakdown
Level C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to inform residents both orally and in writing of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. | Level C |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 8, 2002
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's compliance with NFPA 101 Life Safety Code standards, specifically regarding exit access and delayed egress locks.
Findings
The facility failed to ensure that all designated exits were readily accessible. Specifically, magnetic locking devices on corridor double doors and a stairwell exit door on Unit 3-C did not initiate an alarm or release the lock within the required 15 seconds when pressure was applied, violating life safety code requirements.
Complaint Details
Complaint # 2-2031 was investigated. The complaint concerned the failure of magnetic locking devices to function properly on designated exits, compromising exit accessibility and safety.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Magnetic locking devices on corridor double doors and stairwell exit door on Unit 3-C did not initiate an alarm or release the lock within 15 seconds as required. | SS=E |
Report Facts
Date of testing: Feb 5, 2002
Time of interview: 1030
Seconds for lock release: 15
Force limit: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding magnetic locking device functionality |
Inspection Report
Deficiencies: 4
Jan 24, 2002
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations regarding quality of care, resident rights, accident hazards, and specialized rehabilitative services at Jackie Withrow Hospital.
Findings
The facility was found deficient in multiple areas including failure to perform ordered eye examinations, inadequate monitoring and treatment of pressure ulcers, unsafe resident environment related to side rail use and accident hazards, and failure to obtain timely occupational and physical therapy evaluations for a resident at risk of falls.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility did not perform an eye examination when ordered by the physician for one resident. | SS=D |
| Facility did not monitor the progress of pressure ulcers or administer timely treatment for one resident. | SS=D |
| Facility did not assure that the resident's environment was free from accident hazards related to side rails for one resident. | SS=D |
| Facility did not obtain occupational therapy or physical therapy evaluations in a timely manner for one resident. | SS=D |
Report Facts
Falls: 4
Pressure ulcer size: 4
Dates elapsed: 35
Dates elapsed: 7
Dates elapsed: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Withrow | Facility name; no employee role mentioned. | |
| Registered Nurse (RN) | Registered Nurse | Confirmed failure to perform eye exam and described skin assessment procedures. |
| Licensed Practical Nurse (LPN) | Licensed Practical Nurse | Reported on skin assessment and physician notification procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 6, 2001
Visit Reason
The inspection was conducted following a complaint or allegation regarding failure to notify family or physician about a resident's bruise and inadequate supervision of residents.
Findings
The facility failed to notify the responsible family member or physician about a bruise of unknown origin on one resident and failed to report or investigate the injury. Additionally, the facility did not provide adequate supervision to prevent a cognitively impaired resident from exiting the building unsupervised on multiple occasions.
Complaint Details
The complaint investigation revealed that the facility did not notify the medical power of attorney or physician about a bruise on Resident #34 and failed to complete an incident report or investigate the injury. Also, Resident #43 was found outside the building unsupervised on three occasions, and the facility had not addressed this elopement behavior in the care plan.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to notify responsible family member or physician concerning a bruise of unknown origin for one resident. | SS=D |
| Failure to report or investigate a bruise of unknown origin for one resident. | SS=D |
| Failure to provide adequate supervision to prevent a cognitively impaired resident from exiting the building alone. | SS=D |
Report Facts
Sampled residents: 12
Bruise size: 9
Bruise size: 3
Unsupervised exit incidents: 3
Inspection Report
Routine
Census: 59
Deficiencies: 6
Aug 30, 2001
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal regulations regarding resident rights, staff treatment of residents, quality of care, dietary services, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to properly screen employees prior to employment, failure to ensure resident call bells were accessible, inadequate assistance with meals for residents, failure to prepare food in the appropriate form, improper handwashing technique by staff, and failure to properly clean the whirlpool tub, posing potential infection risks.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to assure that the facility's policy and procedure on screening of employees prior to employment was implemented for one employee file reviewed. | SS=D |
| Failure to assure that the resident's call bell was within reach for one resident observed. | SS=D |
| Failure to assure that two residents observed received assistance with meals as needed. | SS=D |
| Failure to assure that food was prepared in a form designed to meet individual needs for one resident observed. | SS=D |
| Failure to assure that handwashing was performed in accordance with professional standards of practice for one individual observed. | SS=D |
| Failure to assure that procedures were implemented to prevent the spread of disease and infection in accordance with facility policy for cleaning of the whirlpool tub. | SS=E |
Report Facts
Facility census: 59
Employee personnel files reviewed: 5
Residents observed for meal assistance: 2
Residents observed for call bell accessibility: 1
Residents observed for food preparation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed and confirmed lack of evidence for employee screening | |
| Licensed Practical Nurse (LPN) | Confirmed call bell was inaccessible and whirlpool tub was dirty | |
| Certified Nursing Assistant (CNA) | Observed performing improper handwashing technique |
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 30, 2001
Visit Reason
The document is a statement of deficiencies and plan of correction related to regulatory compliance of Wyoming Healthcare Center, focusing on facility safety and resident rights.
Findings
The facility was found deficient in providing proper notice of resident rights and in life safety code compliance, specifically lacking an instructional sign on the main exit door with a secure care magnetic locking device.
Severity Breakdown
SS=C: 1
SS=B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide residents with proper notice of rights and rules in writing and orally as required. | SS=C |
| Facility main exit door had a secure care magnetic locking device without the required instructional sign indicating how to release the door. | SS=B |
Report Facts
Date of survey completion: Aug 30, 2001
Inspection Report
Annual Inspection
Deficiencies: 9
Aug 29, 2001
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations related to resident rights, quality of life, resident assessment, physical environment, dietary services, clinical records, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to report abuse investigations timely, failure to promote resident dignity, incomplete and inaccurate resident assessments and care plans, unsafe physical environment conditions, improper food temperature control, incomplete clinical records, and lack of physician participation in the quality assurance committee.
Severity Breakdown
SS=A: 2
SS=C: 3
SS=D: 2
SS=E: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to report the results of abuse investigations to the State survey and certification agency within five working days. | SS=A |
| Failure to promote care for residents in a manner that maintains and enhances dignity, including use of disposable meal service items and posting personal care information above resident's bed. | SS=D |
| Failure to accurately complete resident assessments, including signing MDS before completion. | SS=D |
| Failure to develop and revise comprehensive care plans reflecting residents' current status and needs. | SS=E |
| Failure to maintain essential mechanical and patient care equipment in safe operating condition, including fire alarm panel time/date errors and unclean oxygen concentrator filters. | SS=C |
| Failure to maintain a safe, functional, sanitary, and comfortable physical environment, including equipment storage blocking access, lack of GFCI outlets near water sources, and disorderly storage rooms. | SS=C |
| Failure to serve food under sanitary conditions by serving egg and ham salad sandwiches at potentially hazardous temperatures above 41 degrees. | SS=E |
| Failure to maintain complete and accurate clinical records, including failure to document daily weights as ordered. | SS=A |
| Failure to maintain a quality assurance committee that includes a physician designated by the facility. | SS=C |
Report Facts
Dates weights not documented: 5
Temperature of ham salad sandwiches: 44
Temperature of egg salad sandwiches: 43
Temperature of ham salad sandwiches: 49
Temperature of egg salad sandwiches: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding posting signs above resident beds and care plan accuracy. | |
| Registered Dietitian | Interviewed regarding use of Styrofoam cups and food temperature concerns. | |
| Facility Social Worker | Interviewed regarding failure to report abuse investigation results. |
Inspection Report
Deficiencies: 7
Aug 29, 2001
Visit Reason
The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including fire safety, emergency exit accessibility, and proper notification of resident rights and services.
Findings
The facility was found deficient in maintaining corridor doors serving hazardous areas with proper fire-rated and smoke-resistant construction, maintaining emergency exits free and accessible, ensuring emergency exit doors comply with locking device regulations, identifying oxygen use/storage areas with proper signage, and maintaining fire-resistant waste containers in patient rooms.
Severity Breakdown
SS=A: 4
SS=B: 1
SS=C: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Corridor door to 'D' wing supply room had a louver, not meeting 45 minute fire rated and smoke resistant construction requirements. | SS=A |
| Corridor door serving clean side of laundry had a key operated dead bolt lock instead of a door knob latching assembly, causing potential delay in emergency egress. | SS=C |
| Emergency exit doors equipped with delayed egress locking systems that release in 30 seconds instead of the required 15 seconds. | SS=A |
| Emergency exit door had a dead bolt lock on a door equipped with panic hardware, violating NFPA 1, 4-1.9.6. | SS=A |
| Facility failed to maintain emergency exits free, unobstructed, and accessible at all times. | SS=C |
| Oxygen use or storage areas lacked required notification/warning signs. | SS=B |
| Non-rated plastic waste containers were used in resident rooms instead of fire-resistant containers with UL or FM ratings. | SS=A |
Report Facts
Deficiencies cited: 7
Lock release time: 30
Lock release time: 15
Inspection Report
Deficiencies: 13
Jul 26, 2001
Visit Reason
The inspection was conducted to assess compliance with life safety codes, physical environment standards, and resident rights regulations at Jackie Withrow Hospital.
Findings
The facility was found deficient in multiple areas including corridor and smoke barrier doors not meeting fire safety standards, emergency lighting failures, inadequate staff emergency training, kitchen range hood not meeting fire safety code, damaged furnishings preventing cleaning, lack of self-closing waste containers in common toilets, unsafe smoking lounge conditions, improper storage in handicapped accessible areas, and safety hazards such as taped exit door alarms and unlocked cleaning equipment cabinets.
Severity Breakdown
SS=C: 12
Deficiencies (13)
| Description | Severity |
|---|---|
| Corridor doors not provided with positive latching to secure the door tightly in its frame to resist the passage of smoke in units 2D, 3D, and 4D. | SS=C |
| Smoke barrier doors found not to close in their frames to sufficiently resist the passage of smoke in Wing 1B room #115, Wing 2C room #205, and Wing 4D room #410. | SS=C |
| No emergency lighting found in the 3B auditorium, an area of resident protection/refuge. | SS=C |
| Facility deficient in staff emergency training; unannounced fire drill showed delayed staff response and 19 corridor doors open and unsecured in unit 1B. | SS=C |
| Kitchen range hood duct work not of the gage metal required by code, presenting a fire safety hazard. | SS=C |
| Furnishings with damaged laminated surfaces in multiple utility and pantry areas and nursing stations preventing cleaning. | SS=C |
| Common toilets not provided with self-closing waste containers. | SS=C |
| Floor surface in 2B resident smoking lounge has numerous burns preventing cleaning. | SS=C |
| Corridor door open with resident smoking activity in 3C resident smoking lounge, not containing second hand smoke. | SS=C |
| Handicapped accessible central toilets and showers used for equipment storage, not maintained ready for use. | SS=C |
| Exit door alarm serving unit 1B found taped, preventing staff notification of unauthorized entrance or egress. | SS=C |
| Cleaning equipment cabinets unlocked in all units' shower/tub rooms permitting unauthorized access. | SS=C |
| Washing machine in 3C resident laundry room not provided with back flow prevention, risking facility and municipal water supply. | SS=C |
Report Facts
Number of corridor doors open and unsecured: 19
Emergency lighting duration required: 90
Inspection Report
Plan of Correction
Deficiencies: 19
Jul 26, 2001
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Jackie Withrow Hospital, detailing regulatory compliance issues identified during a survey completed on July 26, 2001.
Findings
The report lists multiple deficiencies related to resident rights, protection of resident funds, notification of rights and services, transfer and discharge requirements, abuse prevention, quality of care, nursing services, infection control, and physical environment. Severity levels range from B to G, with several deficiencies rated as severe (e.g., SS=E and SS=F).
Severity Breakdown
C: 2
D: 9
B: 2
E: 5
G: 1
F: 1
Deficiencies (19)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and facility rules in a language they understand. | C |
| Failure to notify residents or their representatives promptly about accidents or significant changes in condition. | D |
| Inadequate protection and accounting of resident funds. | B |
| Failure to ensure residents' right to free choice of physician and privacy. | D |
| Failure to promptly resolve resident grievances. | E |
| Failure to comply with transfer and discharge notification and documentation requirements. | D |
| Failure to protect residents from physical and chemical restraints used for convenience or discipline. | B and D |
| Failure to protect residents from abuse and mistreatment, and failure to investigate and report allegations properly. | G and E |
| Failure to develop and implement policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property. | E |
| Failure to promote quality of life and dignity for residents. | D |
| Failure to provide services meeting professional standards of quality. | D |
| Failure to provide necessary care and services to maintain highest practicable well-being. | E |
| Failure to provide appropriate treatment for residents with mental or psychosocial adjustment difficulties. | D |
| Failure to maintain a safe environment free of accident hazards. | D |
| Failure to provide adequate supervision and assistance devices to prevent accidents. | D |
| Insufficient nursing staff to provide care according to resident care plans. | E |
| Failure to require staff to wash hands after each direct resident contact as indicated. | D |
| Failure to provide a safe, functional, sanitary, and comfortable environment. | C |
| Failure to establish an infection control program that investigates, controls, and prevents infections. | F |
Report Facts
Survey completion date: Jul 26, 2001
Inspection Report
Plan of Correction
Deficiencies: 5
Jul 26, 2001
Visit Reason
The document is a plan of correction related to deficiencies identified during a prior inspection, addressing compliance with NFPA 101 Life Safety Code standards.
Findings
The facility was cited for multiple deficiencies related to Life Safety Code standards including corridor door fire resistance, smoke barrier door ratings, emergency lighting duration, quarterly fire drills, and commercial cooking equipment compliance.
Severity Breakdown
SS=C: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Corridor doors must be 1 3/4 inch solid bonded wood core doors or have a 20 minute fire resistance rating with proper latching devices. | SS=C |
| Smoke barrier doors are 20 minute rated or 1 3/4 inch solid bonded wood core doors; latching is not required. | SS=C |
| Emergency lighting is provided for 90 minutes (existing 60 minutes). | SS=C |
| Quarterly fire drills are conducted on each shift to familiarize staff with emergency procedures. | SS=C |
| The design, installation, and use of commercial cooking equipment is in accordance with NFPA 96. | SS=C |
Report Facts
Fire drill frequency: 4
Emergency lighting duration: 90
Inspection Report
Routine
Census: 122
Deficiencies: 18
Jul 19, 2001
Visit Reason
Routine inspection of Jackie Withrow Hospital to assess compliance with federal regulations including resident rights, protection of resident funds, quality of care, abuse prevention, and infection control.
Findings
The facility was found deficient in multiple areas including failure to notify residents and legal representatives of transfers and discharges, improper handling of resident funds, inadequate protection from abuse and neglect, insufficient staffing to monitor aggressive behaviors, failure to implement care plans, improper medication administration, inadequate infection control practices, and failure to maintain resident dignity and privacy.
Severity Breakdown
SS=D: 11
SS=B: 2
SS=E: 3
SS=G: 1
SS=F: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to notify resident and legal representative of room change and transfer. | SS=D |
| Failure to deposit resident funds exceeding $50 in interest bearing accounts and failure to convey deceased residents' funds timely. | SS=B |
| Failure to ensure resident participation in advanced directives and free choice of physician. | SS=D |
| Failure to maintain resident privacy during personal care and visits. | SS=D |
| Failure to promptly and adequately address resident grievances. | SS=E |
| Failure to document physician's order for resident discharge and failure to notify legal representative in writing. | SS=D |
| Failure to limit physical restraints to medically warranted circumstances and failure to evaluate ongoing restraint use. | SS=B |
| Failure to ensure resident is free from chemical restraints. | SS=D |
| Failure to protect residents from abuse and neglect, failure to report and investigate abuse allegations, and failure to protect residents during investigations. | SS=G |
| Failure to implement policies prohibiting abuse and failure to remove alleged perpetrators from resident contact during investigations. | SS=E |
| Failure to maintain resident dignity and respect, including failure to ensure proper clothing and hygiene. | SS=D |
| Failure to administer medication according to professional standards. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable well-being, including failure to obtain ordered urinalysis, failure to assess resident after fall, failure to provide ordered elbow protectors, failure to provide thickened liquids, and failure to implement care plan. | SS=E |
| Failure to provide appropriate treatment and services for residents with mental or psychosocial adjustment difficulties, including failure to monitor, reevaluate, and revise behavior plans and failure to intervene appropriately. | SS=D |
| Failure to maintain a safe environment by leaving medication and treatment carts unlocked and unattended in resident areas. | SS=D |
| Failure to provide adequate supervision and assistance devices to prevent accidents for wheelchair bound residents. | SS=D |
| Failure to establish an infection control program that investigates, controls, and prevents infections, including failure to screen new and existing employees for communicable diseases. | SS=F |
| Failure to assure correct handwashing technique by nursing staff. | SS=D |
Report Facts
Residents affected by resident funds deposit issue: 57
Residents affected by delayed conveyance of funds after death: 57
Residents affected by abuse incidents: 38
Residents affected by infection control screening deficiency: 18
Facility census: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Withrow | Hospital/Facility Name | Facility name |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing and abuse investigations |
| Consultant Psychologist | Consultant Psychologist | Interviewed regarding behavior management and resident #36 |
| Social Service Worker | Social Service Worker | Interviewed regarding resident supervision and transfers |
| Licensed Nurse | Licensed Nurse | Interviewed regarding suicide threat reporting and medication administration |
| Certified Nursing Assistant | CNA | Involved in abuse incident and resident care |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding infection control program and employee screening |
| Director of Social Services | Director of Social Services | Interviewed regarding sexual abuse allegations and reporting |
Inspection Report
Life Safety
Deficiencies: 0
Jun 19, 2001
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101:10; Life Safety Code, 1967 New Edition.
Findings
The facility was found to be in compliance with the NFPA 101:10 Life Safety Code, 1967 New Edition based on the review and testing conducted during the visit.
Inspection Report
Annual Inspection
Census: 16
Deficiencies: 15
May 7, 2001
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident privacy, staff treatment of residents, quality of care, infection control, physical environment, and dietary services. Specific issues included lack of privacy during care, improper reporting of abuse, inadequate care planning, poor nutrition and hygiene care, infection control lapses, unsafe environment, and unsanitary food handling practices.
Severity Breakdown
SS=D: 11
SS=E: 2
SS=F: 1
SS=A: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Privacy was not provided during care and treatments for one resident as cubicle curtains were not drawn. | SS=D |
| Facility policies did not meet state law requirements for immediate reporting of abuse allegations. | SS=A |
| Residents were not treated in a manner that maintained dignity and respect; inappropriate staff remarks were made. | SS=D |
| Significant change assessment was not conducted for a resident after decline in decision making and continence status. | SS=D |
| Comprehensive care plans lacked measurable objectives and timetables for medical, nursing, and psychosocial needs. | SS=D |
| Resident was improperly positioned during meals and had long jagged toenails. | SS=D |
| Resident with Foley catheter did not receive appropriate treatment to prevent urinary tract infections; catheter system was contaminated. | SS=D |
| Residents with limited range of motion did not receive appropriate treatment or support to prevent decline. | SS=D |
| Facility failed to ensure resident environment was free of accident hazards by leaving an unlocked, unattended medication cart in hallway. | SS=E |
| Resident was left unattended and unsupervised in beauty shop, risking falls. | SS=D |
| Staff failed to wash hands properly after direct resident contact during incontinence care. | SS=D |
| Resident call light system was not functioning for one resident. | SS=D |
| Strong, persistent urine odor was present in a section of the building, affecting residents. | SS=E |
| Dietary personnel did not have hair effectively restrained and ice pitchers were filled in a manner risking cross contamination. | SS=F |
| Facility failed to maintain an effective infection control program; staff used unclean gloves and improper practices risking infection transmission. | SS=D |
Report Facts
Sampled residents: 16
Residents affected by privacy deficiency: 1
Residents affected by infection control deficiency: 2
Residents with Foley catheter: 4
Residents observed with range of motion issues: 2
Residents observed with environmental hazards: 1
Residents with call light issues: 1
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 15
Mar 15, 2001
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities, including quality of care, resident rights, infection control, dietary services, and physical environment.
Findings
The facility was found deficient in multiple areas including failure to provide required notices to residents, inadequate quality of life and dignity during dining, insufficient social services, improper resident assessments and care, medication administration errors, inadequate supervision to prevent accidents, infection control lapses, unsanitary food handling, and incomplete clinical records.
Severity Breakdown
Level A: 1
Level B: 3
Level C: 1
Level D: 7
Level E: 3
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to provide bed hold policy information at time of transfer to residents or their representatives. | Level C |
| Failed to ensure a safe, secure environment promoting residents' quality of life, including ignoring emergency alarms and undignified dining experiences. | Level D |
| Failed to provide medically related social services to a resident needing dentures and to address roommate issues. | Level D |
| Failed to meet professional standards during resident treatments and medication administration, including improper wound care and insulin injection technique. | Level D |
| Failed to provide necessary care and services to maintain highest practicable well-being, including improper use of side rails and failure to prevent falls. | Level D |
| Failed to provide assistance with eating and personal hygiene to residents unable to perform these activities independently. | Level E |
| Failed to provide adequate supervision and use of assistive devices to prevent accidents, including unlocked wheelchair wheels and improperly used alarms. | Level E |
| Failed to ensure timely availability of parenteral and enteral feeding supplies, resulting in inappropriate feeding solutions and elevated blood sugars. | Level D |
| Failed to require staff to wash hands after each direct resident contact as indicated by accepted professional practice. | Level D |
| Failed to provide a safe, functional, sanitary, and comfortable environment, including persistent urine odor in dining and entrance areas. | Level B |
| Failed to provide substitutes of similar nutritive value to residents who refused food served, including serving incorrect food items. | Level A |
| Failed to provide therapeutic diets as prescribed by the attending physician, including serving contraindicated food items. | Level B |
| Failed to store, prepare, distribute, and serve food under sanitary conditions, including lack of paper towels and bare hand contact with food. | Level B |
| Failed to implement infection control procedures, including improper glove use and cross-contamination during resident care and treatments. | Level D |
| Failed to maintain complete, accurately documented, and systematically organized clinical records, including missing signatures and incomplete transcription of physician orders. | Level E |
Report Facts
Facility census: 59
Residents sampled: 13
Deficiencies cited: 15
Residents involved in bed hold deficiency: 3
Residents involved in quality of life deficiency: 6
Residents involved in social services deficiency: 1
Residents involved in resident assessment deficiency: 4
Residents involved in quality of care deficiency: 4
Residents involved in infection control deficiency: 2
Residents involved in clinical records deficiency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed failing to clean insulin vial top, not washing hands after glove removal, and admitting to medication transcription errors | |
| Certified Nursing Assistant (CNA) | Observed feeding residents, providing personal hygiene care with infection control lapses | |
| Licensed Social Worker (LSW) | Interviewed regarding failure to provide dentures and social services to Resident #52 | |
| Consultant Dietitian | Interviewed regarding delays in obtaining tube feeding supplies |
Inspection Report
Life Safety
Deficiencies: 1
Mar 15, 2001
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the installation of automatic sprinkler systems under exterior roofs or canopies.
Findings
The facility was found not to have automatic sprinkler coverage on all portions of the building, specifically three wooden canopies attached to the building exterior exceeded 4 feet in width and lacked sprinkler installation as required by code.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Not all portions of the facility are provided automatic sprinkler coverage, specifically three wooden canopies attached to the building exterior exceeding 4 ft in width lack sprinklers. | SS=D |
Report Facts
Canopy dimensions: 11
Canopy dimensions: 24
Canopy dimensions: 6
Canopy dimensions: 15
Canopy dimensions: 12
Canopy dimensions: 30
Canopy dimensions: 12
Canopy dimensions: 30
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 10, 2001
Visit Reason
The inspection was conducted as a complaint investigation identified as Complaint Investigation #: 2-0221.
Findings
The facility failed to ensure that a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene, as evidenced by hospital medical record review of Resident #110 showing multiple hygiene and skin issues including decubitus ulcers, severe cradle cap, dry mouth, and ecchymosis.
Complaint Details
Complaint Investigation #: 2-0221. The citation was substantiated based on hospital medical record review and documented findings of poor personal hygiene and skin conditions in Resident #110.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident unable to carry out activities of daily living received necessary services to maintain good personal hygiene. | SS=D |
Report Facts
Deficiency size: 1
Decubitus ulcer size: 5
Decubitus ulcer size: 4.5
Eschar size: 3
Eschar size: 2.5
Heel decubitus ulcer size: 1
Q-tips used: 8
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 3, 2000
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements related to resident rights, dietary services, and infection control.
Findings
The facility was found deficient in informing residents of their rights and services, providing food at proper temperatures, and implementing proper infection control procedures during wound care. Specifically, food temperatures were below acceptable standards and a nurse failed to change gloves before applying a dressing, contaminating the wound.
Severity Breakdown
Level C: 2
Level D: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to inform residents of their rights and services in writing and orally in a language they understand. | Level C |
| Food items were not served at proper temperatures; milk was 56-58 F and meat was 108-112 F, below the acceptable hot food temperature of 120 F. | Level C |
| Failure to implement infection control standards during wound care; nurse applied dressing with contaminated gloves. | Level D |
Report Facts
Residents expressing concern: 2
Food temperature: 56
Food temperature: 108
Food temperature: 58
Food temperature: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Confirmed nurse contaminated dressing by not changing gloves during wound care. |
Inspection Report
Deficiencies: 0
Sep 12, 2000
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing related to compliance with the provisions of 483.70 Physical Environment.
Findings
The facility was determined to be in compliance with the provisions of 483.70 Physical Environment based on the review and observations.
Inspection Report
Life Safety
Deficiencies: 2
Sep 12, 2000
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code standards, specifically evaluating fire/smoke resistant construction and the maintenance of commercial cooking equipment.
Findings
The facility was found deficient in maintaining required fire/smoke resistant construction due to unsealed or incomplete spaces in recessed ceiling lighting fixtures in multiple areas. Additionally, the facility lacked documentation and a contract for inspection and cleaning of the kitchen range hood system as required by NFPA 96.
Severity Breakdown
SS=C: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Unsealed or incompletely sealed spaces in recessed ceiling lighting fixtures in the attic space violating the required one hour fire resistance rating and smoke compartmentation. | SS=C |
| Lack of inspection/cleaning contract and documentation for the kitchen range hood system as required by NFPA 96. | SS=C |
Report Facts
Number of unsealed recessed ceiling lighting fixtures: 30
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 28, 2000
Visit Reason
The inspection was conducted as an annual survey of Wyoming Continuous Care Center to determine compliance with State and Federal regulations.
Findings
Based on the survey conducted from August 28-30, 2000, Wyoming Continuous Care Center was found to be in compliance with all State and Federal regulations.
Inspection Report
Deficiencies: 0
Aug 17, 2000
Visit Reason
The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with the provisions of 483.70 Physical Environment.
Findings
The facility was found to be in compliance with the provisions of 483.70 Physical Environment based on the review.
Inspection Report
Life Safety
Deficiencies: 3
Aug 17, 2000
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code standards, focusing on building construction, fire and smoke resistance, and emergency preparedness.
Findings
The facility was found deficient in maintaining required fire and smoke resistance ratings in mechanical rooms and stairway enclosures, including unsealed penetrations and excessive door undercuts. Additionally, the facility failed to conduct required quarterly fire drills on all shifts for the second quarter of 2000.
Severity Breakdown
SS=C: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility mechanical rooms had unsealed/incompletely sealed ceiling penetrations and openings, failing to meet fire or smoke resistant construction rating. | SS=C |
| Not all vertical openings (stairways) were maintained enclosed to the required fire/smoke resistance rating of at least one hour, including stairway doors with excessive undercuts. | SS=C |
| Fire drills were not conducted for the first and second shifts of the second quarter (April, May, June) of 2000, violating code requirements for quarterly fire drills on each shift. | SS=C |
Report Facts
Fire drills missed: 2
Inspection date: Aug 17, 2000
Inspection Report
Deficiencies: 0
Aug 17, 2000
Visit Reason
The inspection was conducted based on observation and review of facility documentation to assess compliance with Section 483.70 Physical Environment of 42 CFR Part 483.
Findings
The facility was determined to be in compliance with the physical environment requirements of 42 CFR Part 483.
Inspection Report
Life Safety
Deficiencies: 1
Aug 17, 2000
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the maintenance of portable fire extinguishers.
Findings
The facility failed to maintain portable fire extinguishers annually as required by NFPA 10. Inspection revealed that the last service was in March 1998 and had expired in March 1999.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Portable fire extinguishers were not maintained annually per NFPA 10; last service was March 1998 and expired March 1999. | SS=C |
Report Facts
Date of last fire extinguisher service: 199803
Inspection Report
Annual Inspection
Deficiencies: 13
Aug 2, 2000
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations related to resident rights, quality of care, medication management, dietary services, and facility administration.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights were properly exercised and communicated, inadequate notification of legal representatives during hospital transfers, insufficient weekend activity programming, incomplete and outdated care plans, failure to prevent accidents and falls, medication regimen issues including unnecessary drugs and improper administration, unsanitary dietary practices, and incomplete or unclear physician orders.
Severity Breakdown
C: 2
D: 9
E: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to ensure residents' rights were exercised by legal surrogates in accordance with state law and improper notarization of resident signatures. | E |
| Failure to notify legal representatives of resident hospital transfers. | D |
| Failure to provide mail service six days a week as available in the community. | C |
| Failure to properly screen employees and report allegations of abuse. | D |
| Failure to provide ongoing weekend activity programming. | C |
| Failure to update resident care plan to reflect current needs after change in condition. | D |
| Failure to provide necessary care and services to maintain highest practicable well-being, including delayed specialist consultation. | D |
| Failure to ensure adequate supervision and assistive devices to prevent accidents, resulting in resident falls. | D |
| Failure to ensure residents' drug regimens were free from unnecessary drugs and excessive doses, and lack of adequate indicators for medication use. | D |
| Failure to prepare and serve food under sanitary conditions, including inaccurate food temperature monitoring and broken trays. | C |
| Pharmacist failed to report medication irregularities to attending physician and director of nursing. | D |
| Physician orders were not clear, concise, or accurate for multiple residents. | D |
| Failure to maintain complete, accurate, and accessible clinical records. | D |
Report Facts
Residents sampled: 21
Residents affected by rights exercise deficiency: 2
Residents affected by notification deficiency: 2
Residents affected by activity program deficiency: 5
Residents affected by care plan deficiency: 1
Residents affected by quality of care deficiency: 1
Residents affected by supervision deficiency: 1
Residents affected by medication regimen deficiency: 1
Residents affected by medication error: 2
Residents affected by unclear physician orders: 4
Facility census: 101
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 1, 2000
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to immediately consult with a resident's physician upon a significant change in the resident's physical status.
Findings
The facility failed to promptly notify the physician regarding a resident's decreased eating and fluid intake despite standing orders requiring physician contact within 48 hours of a diet change. The resident exhibited decreased appetite and fluid intake over several days, but the physician was only notified once and not again despite ongoing issues.
Complaint Details
Complaint #2-0112. The facility did not notify the resident's physician after 6/13/00 regarding decreased eating and fluid intake despite ongoing decline, which was substantiated by physician interviews and record reviews.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to immediately consult with the resident's physician when there was a significant change in the resident's physical status, specifically decreased eating and fluid intake. | SS=D |
Report Facts
Resident sample size: 4
Resident identifier: 103
Fluid intake: 860
Fluid intake threshold: 800
Date of physician notification: Jun 13, 2000
Inspection Report
Life Safety
Deficiencies: 0
Jun 1, 2000
Visit Reason
The inspection was conducted to assess the facility's compliance with the Life Safety Code NFPA 101 - 1967 New.
Findings
Based on observation and review of facility documentation from May 30, 2000 to June 1, 2000, the facility was determined to be in compliance with the Life Safety Code NFPA 101 - 1967 New.
Inspection Report
Deficiencies: 1
May 30, 2000
Visit Reason
The survey was conducted to assess the functionality of the resident call system and compliance with physical environment requirements.
Findings
The resident call system was found to be inoperable in several resident rooms during performance testing conducted from May 30 to May 31, 2000.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident call system failed to function in rooms A118 (bed #2), A111 (bed #2, #3), A105 (bed #2), A104 (bed #2), and A101 (bed #1, #2). | SS=D |
Report Facts
Date of survey: May 30, 2000
Inspection Report
Capacity: 75
Deficiencies: 0
May 25, 2000
Visit Reason
The inspection was conducted based on a review of facility documentation, staff interviews, observations, and performance testing to assess compliance with physical environment provisions.
Findings
The facility was found to be in compliance with the provisions of 483.70 Physical Environment.
Inspection Report
Life Safety
Capacity: 75
Deficiencies: 1
May 25, 2000
Visit Reason
The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code, specifically evaluating the building construction type and fire/smoke resistant construction.
Findings
The facility was found deficient in maintaining the required fire/smoke resistant construction due to unsealed or incompletely sealed recessed lighting fixtures in the attic space, violating the one hour fire resistance rating and smoke compartmentation.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Unsealed or incompletely sealed recessed lighting fixtures in attic space compromising fire resistance and smoke compartmentation. | SS=C |
Report Facts
Recessed ceiling light fixtures: 30
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 5
May 11, 2000
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with federal regulations regarding resident rights, staff treatment of residents, resident assessments, medication administration, quality of care, and advance directives.
Findings
The facility was found deficient in multiple areas including failure to report abuse allegations, incomplete resident assessments, improper medication administration practices, inadequate supervision to prevent accidents, and a medication error rate exceeding 5%. Specific deficiencies involved failure to report abuse to the Nurse Abuse Registry and Adult Protective Services, incomplete MDS 2.0 RAP summaries for residents, improper handling of liquid medications, failure to supervise a resident with choking risk, and multiple medication administration errors.
Severity Breakdown
SS=D: 3
SS=E: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to report one of two allegations of abuse to the Nurse Abuse Registry and Adult Protective Services. | SS=D |
| Failure to complete the West Virginia approved MDS 2.0 Resident Assessment Protocol Summary for two of thirteen residents. | SS=D |
| Failure to administer medications according to accepted professional nursing standards for two of forty-one medications observed. | SS=D |
| Failure to ensure one resident received adequate supervision and assistance devices to prevent accidents, despite known choking risk. | SS=E |
| Medication error rate of 12%, exceeding the allowable 5% threshold. | SS=E |
Report Facts
Census: 58
Medication error rate: 12
Medication opportunities: 41
Medication errors: 5
Residents in sample: 13
Residents with incomplete RAP summary: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse #2 | Named in medication administration deficiencies for improper handling of liquid medications and incorrect timing of Albuterol inhaler administration | |
| Licensed nurse #1 | Observed crushing and administering enteric coated aspirin against physician's order | |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration errors and confirmed improper practices |
| Social worker | Interviewed regarding failure to report abuse and awareness of resident's unsupervised consumption of gum and candy |
Inspection Report
Annual Inspection
Census: 101
Deficiencies: 12
Apr 14, 2000
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations governing nursing facilities.
Findings
The facility was found deficient in multiple areas including resident privacy violations, improper medication administration, use of physical restraints without orders, denial of resident rights, inadequate activity programming, poor quality of care including hygiene neglect, medication errors, improper food temperature and sanitation, infection control breaches, and incomplete clinical records.
Severity Breakdown
SS=E: 5
SS=D: 4
SS=F: 1
SS=C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to assure residents' rights to confidentiality by posting personal elimination and continence information on the doors of eleven residents' rooms. | SS=E |
| Facility allowed residents incapable of self-administration of drugs to keep medications at bedside without supervision. | SS=E |
| Use of seat belt restraint on a resident without physician's order or medical necessity. | SS=D |
| Facility failed to allow two residents to make choices about significant aspects of their lives, including marriage, due to surrogate decision maker restrictions. | SS=D |
| Facility failed to provide an ongoing program of activities meeting the interests of residents, especially on evenings and weekends. | SS=E |
| Facility failed to provide necessary services to maintain good grooming and personal hygiene for two residents. | SS=D |
| Facility failed to ensure medication error rate was below 5%, with a 6.8% error rate observed. | SS=E |
| Facility failed to serve food at proper temperatures to maintain palatability. | SS=E |
| Facility failed to require staff to wash hands properly before and after resident contact, including medication administration. | SS=D |
| Facility failed to store, prepare, distribute, and serve food under sanitary conditions, including improper food storage and glove use during serving. | SS=F |
| Facility failed to implement infection control techniques during wound care and medication administration. | SS=D |
| Facility failed to maintain clinical records that were complete, accurate, readily accessible, and systematically organized. | SS=C |
Report Facts
Facility census: 101
Medication error rate: 6.8
Number of residents with confidentiality breach: 11
Number of residents observed with improper medication self-administration: 3
Number of residents denied right to marry: 2
Number of residents with hygiene neglect: 2
Number of residents observed with physical restraint without order: 1
Number of residents observed with infection control breaches: 2
Inspection Report
Deficiencies: 0
Dec 13, 1999
Visit Reason
The inspection was conducted based on observation and review of facility documentation from November 29 to December 13, 1999, to determine compliance with Section 483.70 Physical Environment of 42 CFR Part 483.
Findings
The facility was found to be in compliance with the physical environment requirements of 42 CFR Part 483 during the inspection period.
Inspection Report
Life Safety
Deficiencies: 8
Dec 13, 1999
Visit Reason
The survey was conducted to assess compliance with NFPA 101 Life Safety Code standards, focusing on fire barriers, corridor doors, vertical openings, smoke barriers, exit components, and stairways in the facility.
Findings
The facility was found to have multiple deficiencies related to fire safety, including fire barrier walls not maintaining the required two-hour fire resistance rating, corridor doors failing to close tightly, unsealed penetrations in boiler room walls, vertical openings not enclosed to required fire-resistance ratings, and stairways not maintained as smokeproof towers.
Severity Breakdown
SS=C: 7
SS=E: 1
SS=B: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Fire barrier walls not maintained to the required two-hour fire resistance rating; fire door latching mechanism held open and would not latch. | SS=C |
| Facility does not maintain all rooms to the required building construction type II(222) for fire and smoke resistance; unsealed penetrations in boiler room walls and ceiling. | SS=E |
| Corridor doors failed to close tightly in their frames and resist passage of smoke. | SS=B |
| Vertical openings (stairways) not enclosed to required fire-resistance rating of at least one hour. | SS=C |
| Doors in fire walls, hazardous areas, horizontal exits, or smoke barriers held open improperly, not arranged to automatically close upon fire alarm activation. | SS=C |
| Smoke barriers not maintained to one-half hour fire rated construction; unsealed penetrations around pipes and conduit above lay-in-ceiling. | SS=C |
| Exit components (stairways) not maintained to one-hour fire-resistance rating and do not provide protection against fire and smoke. | SS=C |
| Stairs and smokeproof towers not maintained as required by means of egress components standards. | SS=C |
Report Facts
Survey period: 15
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 2, 1999
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Jackie Withrow Hospital, detailing regulatory compliance issues identified during a survey completed on December 2, 1999.
Findings
The facility failed to ensure that the rights of two residents adjudged incompetent were exercised by the legally appointed persons, and failed to provide medically-related social services for one resident, resulting in the resident becoming indebted to the facility for nearly two years of care.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure that the rights of two residents adjudged incompetent were exercised by the person appointed under State law to act on their behalf. | SS=D |
| Failed to provide medically-related social services for one resident, allowing the resident to become indebted to the facility for almost two years of care and services. | SS=D |
Report Facts
Deficiencies cited: 2
Resident sample size: 24
Resident sample size: 4
Outstanding bill amount: 86000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Withrow | Hospital | Named as the provider/supplier in the report header. |
| Director of Social Services | Interviewed regarding residents' committees and health care surrogates. | |
| Director of Social Work Services | Interviewed regarding resident #2's financial and social service situation. |
Inspection Report
Plan of Correction
Deficiencies: 2
Nov 17, 1999
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction following an environmental inspection of the facility.
Findings
The facility was found deficient in maintaining a sanitary environment, including damaged laminated surfaces on twenty-one resident over bed table tops preventing cleaning, and a persistent stale urine odor in resident room CW27.
Severity Breakdown
SS=A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Twenty one resident over bed table tops were observed to have damaged laminated surfaces, preventing cleaning. | SS=A |
| Resident room CW27 was found to have a persistent stale urine odor. | SS=A |
Report Facts
Resident over bed table tops with damaged surfaces: 21
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 16, 1999
Visit Reason
The inspection was conducted on 11/16-17/99 to assess the facility's compliance with regulatory requirements, specifically checking for waivers and adherence to 483.70(a).
Findings
The facility was found to be without waivers and in compliance with 483.70(a) during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 4, 1999
Visit Reason
A recertification survey was completed to assess compliance with OBRA regulations.
Findings
The facility was found to be in compliance with all OBRA regulations during the recertification survey.
Report
File
WV51E137-RFS812-Federal2567.pdf
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