MONTGOMERY GENERAL HOSPITAL

Nursing Home Inspector

401 6TH AVENUE
MONTGOMERY, WV 25136
Fayette County
Phone: 304-442-5151
Provider Number: 515081
Last Inspection: 05/17/2017

About the Nursing Home

Number of Beds: 44
Number of Residents: 39
Beds Available: 5
Percent Occupancy: 89%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Other
Within Hospital?: YES

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

60

Facility
27

County
28

WV
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

60

2017
19

2016
40

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/17/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 7/26/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 7/26/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 7/26/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 7/26/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 7/26/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 7/26/2017
 
Failed To: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Isolated : Minimal 3 7/26/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 7/26/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 7/26/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 7/26/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 7/26/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Widespread : Minimal 5 7/26/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 7/26/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 7/26/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 7/26/2017
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 7/26/2017
 

2/19/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 4/18/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 4/18/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 4/18/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 4/18/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 4/18/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 4/18/2016
 

3/4/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide proof that residents' personal money that is deposited with the nursing home is secure. Pattern : Minimal 4 4/15/2015
 
Failed To: 1) Hire only people with 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. Widespread : Potential 4 4/15/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 4/15/2015
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 4/15/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 4/15/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 4/15/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 4/15/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 4/15/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 4/15/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/15/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Minimal 4 4/15/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg WV State Avg
Number of Residents 39 68.17 75.79
Registered Nurses 0.59 0.53 0.71
Licensed Practical / Vocational Nurses 0.79 0.93 0.86
Certified Nursing Assistants 2.01 1.96 2.13
Total Staff Hours 3.39 3.42 3.69

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% WV State Avg%
of high risk long-stay residents with pressure ulcers 1 4 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 91 93 97
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 46 86 96
of long-stay residents experiencing one or more falls with major injury 2 4 4
of long-stay residents who have depressive symptoms 0 3 4
of long-stay residents who lose too much weight 12 7 7
of long-stay residents who received an antianxiety or hypnotic medication 35 32 26
of long-stay residents who received an antipsychotic medication 29 14 15
of long-stay residents who self-report moderate to severe pain 25 6 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 2 17 22
of long-stay residents whose need for help with daily activities has increased 8 17 17
of long-stay residents with a catheter inserted and left in their bladder 5 3 2
of long-stay residents with a urinary tract infection 4 8 5
of low risk long-stay residents who lose control of their bowels or bladder 28 42 43
of short-stay residents assessed and appropriately given the pneumococcal vaccine 81 80 85
of short-stay residents who had an outpatient emergency department visit 26 23 15
of short-stay residents who made improvements in function 46 58 65
of short-stay residents who newly received an antipsychotic medication 0 2 2
of short-stay residents who self-report moderate to severe pain 61 16 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 77 74 83
of short-stay residents who were rehospitalized after a nursing home admission 26 29 23
of short-stay residents with pressure ulcers that are new or worsened 2 45 45