F867 in West Virginia. Pick another state for the same tag.
Against expectation — 2024
West Virginia cites F867 less often than its own record predicts
Versus expected share0.99×
0.99 times the national share — cited less often here than elsewhere.
Share of West Virginia citations0.45%
Of every deficiency written in West Virginia in 2024, this is the portion that was F867.
West Virginia0.45%
National0.45%
Share of all citations that were F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What West Virginia surveyors wrote
F867 findings written in West Virginia, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedNovember 15, 2018
Based on staff interview and policy review, the facility QAA committee failed to identify Licensed Practical Nurses (LPNs) were performing Intravenous (IV) therapy without sufficient training and implement an appropriate plan of action. This resulted in an Immediate Jeopardy. The facility census was 87.
On 11/13/18 at 7:56 PM, the Administrator and Director of Nursing were notified verbally that Immediate Jeopardy began on 10/05/18, when Resident #48 was readmitted with a peripheral inserted central catheter (PICC). In (MONTH) (YEAR), the facility conducted a medication management audit through the Quality Assurance and Performance Improvement (QAPI) committee. …
Based on record review and interviews, the facility's quality assessment and assurance (QAA) committee failed to have a system in place to identify quality of care problems and to develop/implement measures to correct the problems and maintain ongoing compliance with the Code of Federal Regulations. This resulted in a pattern of harm in quality of care areas. The facility census was 96.
Findings include:
On 12/07/18 at approximately 4:40 PM, the Director of Nursing (DON), who was the contact person for the QAA committee, was interviewed in the conference room. She stated issues which require the QAA committee's attention are discussed in the facility's morning meeting. …
D · No harm, potential for more than minimal, isolatedJuly 11, 2024
Based on medical records, facility records and staff interview the facility Quality Assurance and Performance Improvement committee failed to develop corrective actions to effectively change systems level to prevent quality of care and or quality of life problems. The POST forms were not being accurately completed and or modified based on the physician's determination of capacity. All residents had the potential to be affected by this practice. This was discovered during the facilities long term care survey process. Census: 64.
a) Post forms
During a POST form document review of on 07/12/24 at approximately 4:00 PM it was identified that a post form cannot be modified. It is stated on the form that if changes are needed you are to void the form and complete a new POST form. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction