WELCH COMMUNITY HOSPITAL

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for West Virginia are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 06/04/2010.

Administration

Post Nurse Staffing Information. Inspection Date: 02/13/2008 Correction Date: 02/13/2008
Follow All Laws and Professional Standards. Inspection Date: 02/13/2008 Correction Date: 03/21/2008
Post Nurse Staffing Information. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Follow All Laws and Professional Standards. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Hire a Qualified Activities Director. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Post Nurse Staffing Information. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Be Administered in a Way That Leads to the Highest Possible Level of Well Being for Each Resident. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Follow All Laws and Professional Standards. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Keep Clinical Information Safe, So That It Will Not Be Lost, Destroyed or Used by the Wrong Person. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Set Up or Keep a Group of People to Review and Ensure Quality. Inspection Date: 06/04/2010 Correction Date: 08/18/2010

Environmental

Put Firmly Secured Handrails on Each Side of Hallways. Inspection Date: 02/13/2008 Correction Date: 02/13/2008
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 04/10/2009 Correction Date: 09/17/2009
Have a Program to Keep Infection from Spreading. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Have a Program to Keep Infection from Spreading. Inspection Date: 06/04/2010 Correction Date: 09/10/2010
Keep All Essential Equipment Working Safely. Inspection Date: 06/04/2010 Correction Date: 09/10/2010
Make Sure That a Working Call System is Available in Each Resident's Room or Bathroom and Bathing Area. Inspection Date: 06/04/2010 Correction Date: 08/18/2010

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Inspection Date: 02/13/2008 Correction Date: 03/05/2008
Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Protect Each Resident from All Abuse, Physical Punishment, and Being Separated from Others. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Inspection Date: 06/04/2010 Correction Date: 08/18/2010

Nutrition and Dietary

Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 02/13/2008 Correction Date: 03/07/2008
Make Sure That the Attending Doctor Orders Special Diets. Inspection Date: 02/13/2008 Correction Date: 03/07/2008
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 02/13/2008 Correction Date: 02/28/2008
Hire Enough Skilled Workers to Carry out Dietary Service. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Make Sure That Residents Are Well Nourished. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 04/10/2009 Correction Date: 09/17/2009
Make Sure That the Attending Doctor Orders Special Diets. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 04/10/2009 Correction Date: 10/07/2009
Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 06/04/2010 Correction Date: 08/18/2010

Pharmacy Service

1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 02/13/2008 Correction Date: 03/07/2008
Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%. Inspection Date: 02/13/2008 Correction Date: 03/28/2008
Make Sure That Residents Are Safe from Serious Medication Errors. Inspection Date: 02/13/2008 Correction Date: 03/28/2008
At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes. Inspection Date: 02/13/2008 Correction Date: 03/07/2008
Properly Mark Drugs and Other Similar Products. Inspection Date: 02/13/2008 Correction Date: 03/28/2008

Quality Care

Develop/Implement Required Procedures for the Administration of Immunizations. Inspection Date: 02/13/2008 Correction Date: 03/27/2008
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 04/10/2009 Correction Date: 09/17/2009
Make Sure That Each Resident's Nutritional Needs Were Met. Inspection Date: 04/10/2009 Correction Date: 09/17/2009
Have Enough Nurses to Care for Every Resident in a Way That Maximizes the Resident's Well Being. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Provide Activities to Meet the Needs of Each Resident. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Make Sure That Each Resident Gets Help to Keep Vision and Hearing. Inspection Date: 06/04/2010 Correction Date: 08/18/2010

Resident Assessment

Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 02/13/2008 Correction Date: 03/07/2008
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations. Inspection Date: 04/10/2009 Correction Date: 09/17/2009
Do a New Assessment After Any Major Change in a Resident's Physical or Mental Health. Inspection Date: 04/10/2009 Correction Date: 10/07/2009
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 04/10/2009 Correction Date: 09/17/2009
Electronically Record and Report Resident Status Assessments in a Timely Manner As Required in Order to Monitor Resident Health and Progress. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 06/04/2010 Correction Date: 08/18/2010

Resident Rights

Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help. Inspection Date: 02/13/2008 Correction Date: 02/13/2008
Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey. Inspection Date: 02/13/2008 Correction Date: 02/13/2008
Tell the Resident or the Resident's Representative in Writing How Long the Nursing Home Will Hold the Resident's Bed when the Resident Temporarily Leaves the Facility. Inspection Date: 02/13/2008 Correction Date: 03/05/2008
Give the Resident's Legal Representative the Same Rights As the Resident. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
1) Protect Current or Future Residents from Giving Up Their Medicaid or Medicare Benefits; or 2) Follow Federal Rules for Admissions. Inspection Date: 04/10/2009 Correction Date: 07/03/2009
Properly Hold, Secure and Manage Each Resident's Personal Money Which is Deposited with the Nursing Home. Inspection Date: 06/04/2010 Correction Date: 08/18/2010
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 06/04/2010 Correction Date: 08/18/2010

The table below lists incident reports by the nursing staff or administration for Welch Community Hospital, as well as complaints by residents or their family in the previous three years.

Environmental

Have a Program to Keep Infection from Spreading. Complaint Filed: 07/10/2008 Correction Date: 08/08/2008
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Complaint Filed: 07/03/2009 Correction Date: 09/17/2009

Mistreatment

1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents. Complaint Filed: 07/03/2009 Correction Date: 09/17/2009
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Complaint Filed: 07/03/2009 Correction Date: 09/17/2009

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way. Complaint Filed: 07/10/2008 Correction Date: 08/08/2008

Pharmacy Service

Properly Mark Drugs and Other Similar Products. Complaint Filed: 07/10/2008 Correction Date: 08/08/2008

Quality Care

Give Each Resident Enough Fluids to Keep Them Healthy and Prevent Dehydration. Complaint Filed: 07/10/2008 Correction Date: 08/08/2008
Use a Registered Nurse at Least 8 Hours a Day, 7 Days a Week. Complaint Filed: 07/10/2008 Correction Date: 08/08/2008

Resident Rights

Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Complaint Filed: 07/10/2008 Correction Date: 08/08/2008

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Welch Community Hospital had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 05/27/2010.

Building Construction

A Two-Hour-Resistant Firewall in Common Walls. Inspection Date: 02/12/2008 Correction Date: 03/05/2008

Electrical

Properly Installed Electrical Wiring and Equipment. Inspection Date: 02/12/2008 Correction Date: 04/01/2008

Exits and Egress

Exits That Are Accessible at All Times. Inspection Date: 05/14/2009 Correction Date: 05/21/2009

Fire Alarm Systems

An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems. Inspection Date: 05/14/2009 Correction Date: 06/30/2009

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 05/27/2010 Correction Date: 06/16/2010

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour. Inspection Date: 02/12/2008 Correction Date: 03/05/2008
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour. Inspection Date: 05/27/2010 Correction Date: 06/16/2010