Inspection Reports for Bluestone Health and Rehabilitation

An unannounced revisit was conducted at Bluestone Rehab and Healthcare on 03/19/25 for the annual recertification/licensure survey concluding on 02/15/25.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

An unannounced revisit was conducted at Maples Nursing Home on 03/19/25 for the annual recertification/licensure survey concluding on February 13, 2025.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted as the annual survey to assess compliance with applicable Federal, State, and local Emergency Preparedness requirements.

The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

The survey was conducted in response to complaints regarding pressure ulcer care and readmission practices at Bluestone Health and Rehabilitation.

The facility failed to prevent and properly treat pressure ulcers for Resident #59, resulting in actual harm. Additionally, the facility failed to readmit Resident #60 to an appropriate bed after hospital discharge, causing psychosocial harm. The facility also failed to notify Resident #60's responsible party of a room change prior to moving the resident.

Complaint #36896 and Complaint #32404 were substantiated. Resident #59 developed multiple pressure ulcers during their stay, which were not documented or treated by the facility. Resident #60 was discharged from the facility and was expected to return but was not readmitted despite bed availability, causing psychosocial harm. The responsible party was not notified of a room change for Resident #60.

An unannounced annual recertification, complaint, facility reported incident (FRI) and annual relicensure survey was conducted at Bluestone Health and Rehab from January 7 - 15, 2025.

The survey identified multiple deficiencies including failure to follow physician orders for weights and insulin administration, incomplete care plans, failure to address resident fears related to mechanical lifts, incomplete PASARR documentation, food temperature and preference issues, infection control lapses, inaccurate assessments, incomplete medical records, and failure to implement non-pharmacological interventions for behaviors.

Complaint #33788 was substantiated. Facility Reported Incident (FRI) #31949, and complaints #32697 and #35364 were unsubstantiated.

The inspection was conducted to assess compliance with NFPA standards related to sprinkler system installation, maintenance, electrical systems, and emergency preparedness in the facility.

The facility was found deficient in maintaining an unobstructed sprinkler system, proper securing of sprinkler pipes and wires, electrical wiring issues including unprotected wire splices, and lack of a remote manual stop for the emergency generator. These deficiencies could affect all residents, staff, and visitors.

An unannounced complaint investigation survey was conducted at Maples Nursing Home from 03/05/24 to 03/06/24 based on complaint #31449 which was substantiated.

The facility failed to establish and maintain an infection prevention and control program specifically related to the water management program to reduce Legionella growth and spread. Documentation was lacking for the water systems, control measures, and monitoring, potentially affecting all residents.

Complaint #31449 was substantiated.

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 an onsite revisit.

Maples Nursing Home 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.

Investigation survey concluding on 03/06/24 with acceptance of plans of correction and credible evidence instead of onsite revisit.

An unannounced complaint investigation survey was conducted at Maples Nursing Home from January 9-10, 2024. The visit was triggered by complaint #29996, which was unsubstantiated with unrelated deficiencies cited.

The facility failed to promote dignity during dining as residents were not served lunch trays at the same time as their roommates in their rooms. Additionally, the facility failed to serve food and drink that was palatable and at a safe and appetizing temperature for Resident #54. Both deficiencies had the potential to affect all residents.

Complaint #29996 was unsubstantiated with unrelated deficiencies cited.

The inspection was conducted as an investigation survey triggered by a complaint, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Maples Nursing Home 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.

Investigation survey concluding on 01/10/24 with acceptance of plans of correction and credible evidence instead of onsite revisit.

The document is a plan of correction related to a Focused Infection Control survey and complaint investigation concluding on 08/28/2023, accepted in lieu of an onsite revisit.

Maples Nursing Home 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 addressed.

The plan of correction relates to a complaint investigation concluding on 08/28/2023.

An unannounced complaint investigation and focused infection control survey was conducted based on complaints received, with a complaint sample size of 6.

The facility was found deficient in providing a dignified dining experience by serving meals on Styrofoam dinnerware to second floor residents, failing to offer pneumococcal immunizations per CDC guidelines to some residents, and maintaining a safe, clean, and sanitary environment including issues with kitchen cleanliness, bathroom sanitation, room repairs, and water temperature.

Complaint investigation included three complaints: 28574 (unsubstantiated), 28629 (substantiated with deficiency 584), and 28668 (substantiated with deficiency 921).

An unannounced revisit was conducted at Maples Nursing Home on June 12, 2023 for the annual recertification/licensure survey concluding on April 28, 2023.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

A Comparative Federal Monitoring Survey was conducted on 5/17/23 following a State Agency Annual Survey on 4/25/23 to assess compliance with federal regulations for long term care facilities.

The facility was found noncompliant with several federal requirements including failure to document monthly and annual testing of battery powered emergency lights, failure to conduct the required five-year internal inspection of the sprinkler system piping, and failure to include procedures for integration of State and Federally designated health care professionals in the emergency preparedness plan.

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.

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.

An unannounced annual recertification and complaint investigation survey was conducted at Bluestone Health and Rehabilitation from April 24-26, 2023. The survey included review of complaints, resident care, infection control, and compliance with regulatory requirements.

The facility was found deficient in multiple areas including pressure ulcer care, accident hazard prevention, infection prevention and control, comprehensive care planning, resident privacy, quality of care related to blood glucose management, pneumococcal immunization offering, and catheter care. Deficiencies involved failure to follow professional standards, incomplete care plans, inadequate infection surveillance, and failure to maintain resident privacy during care.

Complaint #27940 was substantiated with a related deficiency cited at F880 (infection prevention and control). Complaint #27608 was unsubstantiated with no related or unrelated deficiencies cited.

The document is a plan of correction submitted in response to a prior survey concluding on 2022-10-12, addressing previously cited deficiencies at Maples Nursing Home.

The facility 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 plan of correction addresses previously cited deficient practices.

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.

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.

An unannounced annual recertification and annual relicensure survey was conducted at Maples Nursing Home from October 10-12, 2022.

The survey identified multiple deficiencies including failure to provide residents' rights to self-determination, failure to report serious bodily injuries, inaccurate resident assessments, incomplete and unimplemented care plans, medication administration errors, expired medications in stock, unsafe food storage practices, incomplete nurse staffing postings, failure to maintain accurate medical records, and failure to notify resident representatives of COVID-19 outbreak.

The document is a plan of correction related to a Special Focus Facility 6-month recertification survey, accepted in lieu of an onsite revisit.

Maples Nursing Home is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through the plan of correction.

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.

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.

An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Maples Nursing Home from April 25-28, 2022.

The survey identified multiple deficiencies including failure to promote dignity during dining, inadequate call light accessibility for a blind resident, failure to honor resident self-determination, inaccurate completion of Physician Orders for Scope of Treatment (POST) forms, failure to provide a homelike environment, failure to report and investigate abuse allegations timely, inaccurate Minimum Data Set (MDS) assessments, failure to administer medications and tube feedings as ordered, failure to maintain safe operating condition of equipment, and infection prevention and control deficiencies.

Complaint #26479 was unsubstantiated with no related or unrelated deficiencies cited. Complaints #26480, #26473, and #26507 were substantiated with related deficiencies cited at F684, F908, and F692.

An unannounced onsite revisit survey was conducted at Maples Nursing Home from March 13-14, 2022 for the annual survey concluding on August 31, 2021.

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.

An unannounced second onsite revisit survey was conducted at the Maples Nursing Home on January 3, 2021 for the annual survey completed on 08/31/2021.

The facility failed to report two unwitnessed falls with major injuries involving residents #6 and #10 to the appropriate state agencies within the required time frames.

An unannounced onsite revisit survey was conducted at Maples Nursing Home from November 2-3, 2021 for the annual survey concluding on August 31, 2021.

The facility was found out of compliance with multiple deficiencies including failure to report alleged abuse within required time frames, improper respiratory care, unsafe food storage and handling, and inadequate infection prevention and control practices.

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.

The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements. One deficiency related to resident rights and notification was cited under F 156.

An unannounced annual re-certification and annual re-licensure survey was conducted from August 23-31, 2021, including complaint investigations.

The facility was found deficient in multiple areas including failure to provide adequate nursing staffing on the third floor, failure to follow physician orders for insulin administration, failure to maintain accurate resident records, failure to properly store and account for controlled substances, failure to maintain sanitary food storage and resident refrigerators, failure to ensure infection control practices, and failure to maintain safe equipment and environment such as loose handrails and leaking ice machine.

Multiple complaints were substantiated with related deficiencies cited at various F-tags including F580, F626, F637, F675, F684, F689, F695, F725, F726, F755, F761, F812, F813, F880, F908, and F924.

The inspection was conducted to assess compliance with testing and maintenance requirements for fixed and portable patient-care electrical equipment in accordance with NFPA 99 standards.

The facility failed to maintain documentation and testing for electrical resistance, current leakage, and touch current testing for patient-care equipment. This was confirmed through record review and staff interviews.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted at Maples Nursing Home by the state survey agency.

The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.

An unannounced revisit was conducted at Maples Nursing Home on 01/06/21 for the complaint investigation survey concluding on 10/28/20.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

Complaint # 24578. The revisit was conducted to investigate this complaint.

An unannounced annual re-certification and annual re-licensure survey was conducted from 10/26/20 through 10/28/20. The survey included observations, clinical record reviews, interviews, and documentation review. Complaint investigations were also included.

The facility was found deficient in transfer and discharge procedures, specifically failing to allow Resident #3 to remain at the facility and discharging him without appropriate cause or safe transition of care. Resident #3 was discharged to a hospital for behavioral evaluation without a discharge summary or plan, and was denied readmission due to ongoing sexually inappropriate and aggressive behaviors. The facility also failed to provide proper notice of transfer and bed hold policy to Resident #3. The facility's plan of correction includes staff education, interdisciplinary review of transfers, and monitoring of compliance.

Complaint #24578 was substantiated with related deficiencies cited. Complaints #23189 and #23442 were not substantiated.

Routine COVID-19 Focus Survey conducted to assess compliance with infection control practices.

No deficient practices were identified related to COVID-19 infection control during the survey.

The inspection was conducted as a complaint investigation based on complaint number 00231534 with a sample size of 80%.

The complaint was substantiated with tags cited during the investigation. All cited tags were corrected by the date of the second visit.

Complaint number 00231534 was substantiated. The investigation included two visits on 09/11/19 and 10/07/19, both confirming the complaint and resulting in cited tags. All tags were corrected by the second visit.

An unannounced revisit was conducted at The Maples on 09/17/19 to 09/18/19 for the annual recertification and relicensure survey concluding on 04/11/19.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted as a complaint investigation (Complaint 0023153) to evaluate concerns related to the facility's electrical system maintenance and testing.

The facility failed to ensure that maintenance and testing of the emergency generator and transfer switches were performed in accordance with NFPA 110 standards. The emergency generator failed to start on 07/29/19 and remained out of service until the date of the inspection.

Complaint 0023153 was substantiated based on findings related to the emergency generator maintenance and testing deficiencies.

An unannounced complaint investigation was conducted at The Maples on 09/05/19 to address allegations related to facility compliance.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.

Complaint #23086 was substantiated during a revisit survey on 07/23/19 with related deficiencies cited at F600, F607, F609, and F610. Complaint #23119 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced revisit was conducted at Maples Nursing Home on 07/22/19 to 07/23/19 for the annual recertification and relicensure surveys concluding on 04/11/19. An extended survey was completed on 07/23/19.

The facility was found to remain out of compliance with multiple tags including F600 (Abuse/Neglect), F609 (Failure to report abuse/neglect), F610 (Failure to complete investigation), F684 (Quality of Care), F697 (Pain Management), F732 (Posted Nurse Staffing Information), F755 (Pharmacy Services), and F867 (QAPI). The facility failed to protect residents from sexual abuse by Resident #13, failed to report and investigate abuse allegations timely and thoroughly, failed to provide care according to physician orders, and had inaccurate nurse staffing postings.

An unannounced annual re-certification and annual re-licensure survey was conducted at Maples Nursing Home from 04/08/19 through 04/11/19. The survey included complaint investigations and review of residents' clinical records, interviews, and facility documentation.

The facility was found deficient in multiple areas including failure to provide accessible resident rights postings, failure to ensure residents were free from neglect and abuse, failure to report and investigate abuse allegations, inaccurate resident assessments, incomplete baseline and comprehensive care plans, failure to provide ADL care, failure to administer medications as ordered, failure to maintain accurate nurse staffing postings, failure to maintain food safety and palatable food temperatures, incomplete facility assessment, and failure to maintain secure handrails in corridors.

Complaint investigation #21846 was substantiated with related tags cited at F600, F677, and F684. Complaint investigation #21797 was substantiated with related tags cited at F609 and F880.

The inspection was conducted to assess compliance with NFPA 101 hazardous areas enclosure requirements and NFPA 90A HVAC standards, including fire safety and air conditioning, heating, and ventilation systems.

The facility failed to ensure hazardous areas were properly protected and separated by fire barriers and door closures as required by NFPA 101, and failed to provide documentation for smoke/fire damper testing as required by NFPA 90A. Door closures in multiple storage rooms were missing or not functioning properly, and the smoke/fire damper inspection documentation was unavailable.

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.

The facility, Maples Nursing Home, 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.

An unannounced annual certification and licensure survey was conducted at Maples Nursing Home from April 2, 2018 through April 5, 2018.

The facility was found deficient in multiple areas including resident dignity and respect, reasonable accommodations, diet and nutrition, advance directives, discharge notices, baseline and comprehensive care planning, pressure ulcer care, medication storage and labeling, infection control, and environmental safety.

The inspection was conducted as a routine facility survey to assess compliance with NFPA 101 fire safety codes and other regulatory requirements.

The facility was found deficient in maintaining emergency lighting, hazardous area enclosures, sprinkler system installation, corridor door compliance, electrical receptacle testing, and electrical equipment safety inspections. All deficiencies were acknowledged by facility leadership and corrective actions were planned or underway.

An unannounced complaint investigation was conducted at The Maples Nursing Home from September 5, 2017 to September 8, 2017 for Complaint Reference #18645, #18648, and #18308.

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.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

An unannounced revisit was conducted at the Maples Nursing Home on 06/06/2017 to 06/07/2017 for the Quality Indicator Survey concluding on 02/09/2017.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

An unannounced complaint investigation was conducted June 7, 2017 to June 8, 2017 at the Maples Nursing Home for Complaint Reference #17343.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with applicable regulations. However, a deficiency was found related to inappropriate incontinence care techniques that could increase the risk of urinary tract infections for two residents.

The complaint investigation was unannounced and conducted over two days. The allegations were unsubstantiated. The census on the first day was 49 residents. The sample size was 8 residents.

An unannounced revisit was conducted from 05/01/17 to 05/04/17 for the Quality Indicator and Licensure Surveys concluding on 02/09/17. The revisit was to verify correction of previous deficiencies.

The facility remained out of compliance with several deficiencies including failure to complete a corrected comprehensive assessment for Resident #42 after a fall with injury, failure to revise a care plan for Resident #30 after discontinuation of sliding scale insulin, failure to ensure Resident #108 had a wheelchair alarm in use as ordered, and failure to act on a pharmacist's recommendation for Resident #36 to rinse mouth after inhaler use.

Unannounced annual Quality Indicator Survey, State Licensure Survey, and subsequent Complaint Investigations were conducted from February 6, 2017 through February 9, 2017.

The facility had multiple deficiencies including failure to notify responsible parties of changes, failure to maintain a clean and safe environment, inaccurate resident assessments, incomplete care plans, medication administration errors, elevated water temperatures posing immediate jeopardy, and infection control issues.

Complaint Investigation #16714 was substantiated with related deficiencies at F253, F309, F312, F323, and F353. Complaint Investigation #17075 was unsubstantiated with an unrelated deficiency at F514.

The inspection was a routine survey to assess compliance with fire safety codes, building construction standards, and other regulatory requirements for the nursing facility.

The facility was found deficient in multiple areas including incomplete sprinkler coverage, stairway maintenance, hazardous area door closures, cooking facility maintenance, fire alarm system maintenance, sprinkler system piping, corridor door smoke resistance, smoke barrier construction, fire drills, and emergency generator maintenance.

The inspection was conducted as a complaint investigation following a complaint referenced as #15882, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Maples Nursing Home, 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 previously cited deficient practices were corrected as evidenced by the accepted plans of correction.

Complaint investigation concluded on 07/29/16 with substantial compliance found and previously cited deficiencies corrected.

An unannounced complaint survey was conducted at Maples Nursing Home from July 25, 2016 to July 28, 2016, based on complaint #15882 which was substantiated with related deficiencies cited.

The facility was found deficient in multiple areas including failure to notify physicians of medication errors, failure to investigate and report allegations of neglect, failure to revise care plans to reflect current resident status, late medication administration, failure to ensure residents received scheduled baths/showers, inaccurate medication documentation, and inaccurate nurse staffing postings.

Complaint #15882 was substantiated based on observations, clinical record reviews, resident and staff interviews, and other facility documentation.

The document is a plan of correction related to a Quality Indicator Survey for Maples Nursing Home, accepted in lieu of an onsite revisit for the survey concluding on 2015-11-12.

The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and with previously cited deficient practices, based on review of plans of correction and credible evidence.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including door closures, fire drills, sprinkler system maintenance, fire extinguisher inspections, and generator maintenance.

The facility failed to maintain corridor and hazardous area doors to close and latch properly, conduct fire drills under varying conditions, maintain sprinkler heads and ceiling tiles properly, perform monthly documented fire extinguisher checks, and ensure weekly generator inspections and documentation. Several deficiencies were acknowledged by the Environmental Director and maintenance staff.

An unannounced annual Quality Indicator Survey was conducted at Maples Nursing Home from November 09, 2015 through November 12, 2015 to assess compliance with regulatory requirements.

The survey identified multiple deficiencies including failure to promptly resolve a resident grievance regarding dentures, inadequate housekeeping and maintenance of dining room chairs, inaccurate resident assessments, failure to maintain resident dignity during dining, medication errors exceeding 5%, failure to administer pneumococcal vaccine, unsafe storage and handling of food and utensils, inadequate infection control practices including improper hand hygiene and PPE use, insufficient dining space in the restorative dining room, and failure to obtain ordered laboratory tests.

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 for the complaint investigation concluding on 2015-10-14.

The facility, Maples Nursing Home, 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 Reference: 14102. The complaint investigation concluded on 2015-10-14 with the facility in substantial compliance and no onsite revisit required.

An unannounced complaint survey was conducted at Maples Nursing Home from October 13, 2015 to October 14, 2015, triggered by Complaint #14102 which was substantiated with a related deficiency cited.

The facility failed to provide care and services to ensure the highest practicable well-being for one resident (#51) by not performing daily blood glucose monitoring as ordered by the physician. The deficiency was substantiated based on clinical record review, resident and staff interviews.

Complaint #14102 was substantiated with a related deficiency cited based on observations, clinical record review, and interviews with residents, family, and staff.

An unannounced revisit was conducted at Maples Nursing Home from November 17, 2014 to November 20, 2014 for the Quality Indicator Survey concluding on September 19, 2014.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including fire safety, emergency systems, and electrical safety in the facility.

The facility failed to maintain several life safety code requirements including self-closing hazardous room doors, exit signs illumination, fire alarm system coverage, range hood extinguishing system maintenance, smoke barrier damper testing, emergency generator testing, and electrical wiring safety. Multiple deficiencies were identified and discussed with facility staff.

An unannounced annual Quality Indicator Survey was conducted at Maples Nursing Home from September 15, 2014 through September 18, 2014.

The survey identified multiple deficiencies including failure to provide residents with information on Medicare and Medicaid benefits, failure to notify residents of roommate changes, inadequate housekeeping and maintenance, incomplete comprehensive assessments, failure to promote dignity and respect, failure to revise care plans, failure to follow care plans, inadequate pain management, improper wound care, lack of toileting programs, inadequate supervision and accident prevention, unnecessary medications, unsanitary food handling, inadequate drug regimen review, and ineffective infection control and pest control programs.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of Bluestone Health and Rehabilitation.

The document includes a summary statement of deficiencies related to resident rights and notification requirements, specifically regarding informing residents of their rights, services, charges, and Medicaid benefits.

The inspection was conducted as a complaint investigation related to allegations of neglect and environmental concerns at the facility.

The facility failed to maintain a safe, sanitary environment as evidenced by worn and unsanitizable furniture in 16 of 31 resident rooms. Additionally, the facility failed to thoroughly investigate and report an allegation of neglect involving Resident #5 and Employee #86, resulting in unreported and uninvestigated neglect cases.

Complaint Reference: 13261 / 9045. The complaint was unsubstantiated but unrelated citations were found. The facility substantiated an allegation of neglect on 07/25/13 involving Employee #86 neglecting Resident #9. However, the facility failed to report or investigate another allegation of neglect involving Resident #5. The social worker and nursing staff did not report or investigate the neglect allegations properly, and the facility did not identify all residents potentially neglected by Employee #86.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Bluestone Health and Rehabilitation.

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).

The inspection was conducted as a complaint investigation based on two unsubstantiated complaints (References: 13179 / 8527 and 13184 / 8572). The facility was entered on 08/11/2013 and exited on 08/13/2013.

The facility failed to ensure proper infection control practices, specifically handwashing and glove changes during dressing changes on residents with wounds and infections. A nurse was observed placing clean gloves in a potentially contaminated uniform pocket and then using them, creating a risk of pathogen transfer. Two residents (#22 and #11) were affected by these deficiencies.

The complaint investigation was unsubstantiated for the complaints referenced (13179 / 8527 and 13184 / 8572), but unrelated citations were issued related to infection control deficiencies.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Bluestone Health and Rehabilitation.

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 federal regulations.

Routine Quality Indicator and Licensure Survey conducted to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including failure to provide written notice of discharge from skilled Medicare services, improper conveyance of personal funds upon resident death, failure to investigate and report allegations of neglect, inaccurate resident assessments, failure to notify residents or representatives of care plan meetings, unsanitary storage of emergency food supplies, failure to act on pharmacist recommendations for medication dose reduction, and improper storage of respiratory equipment.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to fire safety, oxygen storage, and installation of Alcohol Based Hand Rub dispensers in the facility.

The facility was found to have multiple deficiencies including corridor and stair enclosure doors that did not latch or resist smoke passage, improper hold open devices on stair doors, gaps in stair enclosure doors, lack of floor identification signage, improper oxygen cylinder storage and identification, and Alcohol Based Hand Rub dispensers installed above electrical sources.

This document is a plan of correction related to deficiencies identified during a prior inspection of Bluestone Health and Rehabilitation.

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, as required by regulation 483.10(b)(5)-(10).

Complaint investigation related to failure to notify responsible parties of changes in residents' conditions and medication changes, failure to update care plans, failure to follow physician orders for lab tests and medication administration, and failure to maintain nurse aide performance evaluations and competency checklists.

The facility failed to notify legal representatives of changes in residents' conditions and medication changes for three residents, failed to update care plans for a resident receiving anticoagulants, failed to follow physician orders for weekly PT/INR lab tests resulting in a resident's hospitalization and death, failed to have physician-ordered medications available leading to missed doses for two residents, failed to recognize missing lab tests during pharmacist drug regimen reviews, and failed to complete nurse aide performance evaluations and competency checklists for most staff.

Substantiated complaint record with citations related to failure to notify responsible parties, failure to update care plans, failure to follow physician orders, failure to maintain medication availability, and failure to maintain nurse aide evaluations and competencies.

The inspection was conducted as a complaint investigation referenced by complaint number 12269 / 7442.

The complaint was unsubstantiated and no citations were issued during the investigation.

Complaint reference 12269 / 7442 was investigated and found to be unsubstantiated with no citations.

The inspection was conducted as a substantiated complaint investigation (State 12107 / ACTS 7116) from 05/23/12 to 05/24/12 regarding failure to notify the physician and properly monitor a resident with persistent nausea, vomiting, and diarrhea.

The facility failed to notify the treating physician of continued symptoms and the cancellation of a gastroenterologist appointment for Resident #39. The facility also failed to develop a plan to monitor the resident's fluid intake and dehydration risk, and administered stool softeners despite ongoing diarrhea. Documentation and communication deficiencies were noted, contributing to the resident's hospitalization with acute renal failure and dehydration.

Substantiated complaint record with citation related to failure to notify physician and inadequate care for Resident #39 with persistent gastrointestinal symptoms.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Bluestone Health and Rehabilitation.

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).

The inspection was conducted as a substantiated complaint investigation (Complaint Reference: #11356) from 02/06/12 to 02/07/12 regarding nurse aide registry verification and retraining.

The facility failed to ensure registry verification for one of eleven nurse aides prior to hiring. Employee #85 worked without a valid West Virginia nurse aide registration, had not completed the required competency evaluation or reciprocity, and was involved in an incident where a resident fell and broke her wrist due to failure to activate a seatbelt alarm.

Complaint Reference #11356 was substantiated. The complaint involved Employee #85 working without proper nurse aide registration and an incident where a resident fell and broke her wrist due to the employee not activating a seatbelt alarm. The employee was terminated upon discovery of the lack of valid license.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of Bluestone Health and Rehabilitation.

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).

Revisit to QIS and to Complaint #11199 regarding allegations of neglect and other regulatory compliance issues.

The facility was found deficient in multiple areas including failure to report neglect, inadequate accommodation of resident needs, failure to provide medically-related social services, failure to revise care plans, unsafe environment hazards, unsanitary food storage and preparation, and inadequate infection control practices.

The visit was a revisit to a complaint investigation (Complaint #11199) triggered by allegations of neglect and other regulatory concerns.

The inspection was conducted concurrently with the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.

The facility was found deficient in multiple areas including residents' rights to privacy and mail delivery, failure to investigate and report abuse allegations, incomplete employee background checks, inadequate social services, housekeeping and maintenance issues, incomplete assessments and care plans, failure to provide care according to plans, pain management deficiencies, nutrition assistance failures, improper use of safety devices, food sanitation issues, infection control lapses, and incomplete medical records.

Complaint reference #11199 was unsubstantiated with no related deficiencies cited. The complaint investigation was conducted concurrently with the annual inspection.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards related to fire barriers, smoke barriers, fire drills, smoke detectors, soiled linen receptacles, and medical gas storage.

The facility failed to maintain required fire and smoke barriers, did not conduct quarterly fire drills on each shift, lacked documentation of smoke detector sensitivity testing, used soiled linen receptacles exceeding allowed capacity in unprotected areas, and improperly stored oxygen cylinders closer than allowed to a building window.

The inspection was conducted as a complaint investigation related to complaint reference #11069.

The complaint was found to be unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #11069 was unsubstantiated with no deficiencies cited.

This document is a plan of correction related to deficiencies identified during a prior inspection of Bluestone Health and Rehabilitation.

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.

The inspection was conducted as a complaint investigation related to complaint reference #10163, which was found unsubstantiated but resulted in unrelated deficiencies being cited.

The facility was found deficient in housekeeping and maintenance services, failing to maintain a sanitary environment in one resident's room. Additionally, the facility failed to provide necessary care and services to maintain the highest practicable physical well-being for one resident with improperly applied bandages causing swelling, and failed to provide adequate personal hygiene care to two residents who were unable to carry out activities of daily living independently.

Complaint reference #10163 was unsubstantiated, but unrelated deficiencies were cited during the investigation.

The inspection was conducted as a complaint investigation related to complaint reference #9354.

The complaint was substantiated, but no deficiencies were cited during the investigation.

Complaint reference #9354 was substantiated with no deficiencies cited.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including smoke barrier integrity, exit accessibility, and emergency generator maintenance.

The facility failed to maintain smoke barrier walls with the required fire resistance rating, failed to maintain clear access to all exits due to construction blocking an exit path, and failed to properly maintain and test the emergency generator and transfer switch as required by NFPA 110.

The inspection was conducted as part of the annual survey of Bluestone Health and Rehabilitation to assess compliance with federal regulations regarding resident rights, care, medication administration, infection control, and facility operations.

The facility was found deficient in multiple areas including failure to ensure proper determination of resident capacity, inaccurate posting of state licensure information, failure to report incidents of neglect, inadequate provision of medically-related social services, medication administration errors, improper resident positioning, unnecessary use of antipsychotic medication, medication error rate exceeding 5%, unsanitary food handling practices, and inadequate infection control practices.

The inspection was conducted to assess compliance with regulations related to resident rights, activities of daily living care, and accident hazard prevention in the facility.

The facility failed to assist two female residents with removal of chin hair and failed to ensure two residents with orders for thickened liquids received the correct consistency of liquids as ordered by the physician. The facility also lacked a process to ensure staff awareness and responsibility for thickened liquids.

The inspection was conducted as a substantiated complaint investigation (reference #9011) to assess compliance with resident care and safety regulations.

The facility was found deficient in multiple areas including failure to maintain resident dignity by not ensuring clean corrective lenses, failure to prevent and properly treat pressure sores in two residents, and failure to accurately document and analyze accident reports for trend prevention.

Complaint reference #9011 was substantiated with deficiencies cited related to resident dignity, pressure sore prevention and treatment, and incident reporting.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of Bluestone Health and Rehabilitation.

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.

The inspection was a routine survey to assess compliance with life safety codes and other regulatory requirements at Bluestone Health and Rehabilitation.

The facility failed to maintain corridor doors to close and latch properly, failed to maintain hazardous room doors as self-closing, failed to inspect and test smoke detectors according to NFPA 72 standards, and failed to maintain and inspect the range hood extinguishing system as required by NFPA 96.

The inspection was conducted concurrently with the facility's Federal Medicare/Medicaid certification resurvey and annual State licensure inspection.

The facility had multiple deficiencies including failure to complete physician's orders properly, inadequate resident rights notification, failure to convey resident funds timely after death, inadequate posting of survey results, lack of auditory privacy for resident phone calls, dignity issues during dining, failure to accommodate resident needs during meals, environmental concerns, incomplete resident assessments and care plans, medication administration errors, insufficient nursing staff, dietary and sanitation issues, and infection control lapses.

Complaint reference #2-8131 was unsubstantiated with no related deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-7233.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-7233 was unsubstantiated with no deficiencies cited.

This document is a plan of correction related to a statement of deficiencies identified during a facility survey.

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.

This document is a plan of correction related to a paper revisit survey conducted at Bluestone Health and Rehabilitation.

The document 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.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of Bluestone Health and Rehabilitation.

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, including Medicaid-related information.

The inspection was conducted as a substantiated complaint investigation related to allegations of neglect, abuse, and misappropriation of property, concurrently with a revisit to the facility's annual Federal Medicare/Medicaid resurvey.

The facility failed to thoroughly investigate allegations of neglect and abuse, delayed required reporting to the Nurse Aide Registry, and did not follow through on replacing a resident's missing property. Additional deficiencies included failure to maintain resident dignity during dining, improper infection control practices related to ice handling, and failure to maintain a preventive maintenance program to prevent sewer backups into hallways.

Complaint reference #2-7180 was substantiated with deficiencies cited. Allegations included neglect related to Resident #40, delayed abuse investigation follow-up for Resident #19, and misappropriation of property for Resident #7.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident care, medication management, safety, and sanitary conditions.

The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans addressing non-pharmacological interventions for residents receiving psychoactive drugs, unsafe environmental conditions such as loose bed side rails, use of unnecessary drugs without proper monitoring or dose reduction, unsafe food storage and service temperatures, and failure of the pharmacist to identify and report medication irregularities.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to fire safety, emergency preparedness, and electrical safety in the facility.

The facility failed to maintain smoke barrier walls with proper fire resistance, hazardous room doors with self-closing devices, clear exit access, and conduct required fire drills on all shifts quarterly. Additionally, the facility did not maintain the generator according to NFPA 110 standards and failed to ensure electrical receptacles met NFPA 70 requirements.

The inspection was conducted concurrently with the facility's annual Federal Medicare/Medicaid certification survey and State licensure inspection.

The facility was found deficient in multiple areas including failure to provide residents ongoing access to personal funds outside business hours, lack of privacy during resident showers, inadequate investigation of complaints, failure to properly assess and document a gastric tube site wound, unsafe bed side rails, improper use and monitoring of antipsychotic medication, inaccurate nurse staffing postings, failure to maintain safe food temperatures, incomplete nurse aide annual performance reviews, and nursing assistant proficiency issues related to gastric feeding tube care.

Complaint reference #2-7120 was unsubstantiated with no related deficiencies cited. The complaint investigation was conducted concurrently with the annual survey.

The visit was a paper revisit to review the facility's compliance with previously cited deficiencies.

The document contains a statement of deficiencies related to the facility's obligation to inform residents of their rights and services, but no specific findings or severity levels are detailed in this excerpt.

The inspection was conducted as a complaint investigation, substantiated with deficiencies cited related to resident care and facility compliance.

The facility failed to notify the physician and resident's representative of significant weight loss and edema in Resident #7, did not develop an adequate care plan addressing nutritional status, and failed to monitor and document edema and nutritional intake properly. Additionally, clinical records for several residents lacked complete dates and were not systematically organized.

Complaint reference #2-7074 was substantiated with deficiencies cited related to failure to notify physician and representative of resident's significant weight loss and edema, inadequate care planning, and incomplete clinical records.

The visit was a paper revisit to follow up on previous deficiencies.

The document contains a statement of deficiencies related to resident rights and notification requirements, but no detailed findings or severity levels are provided.

Complaint investigation triggered by complaint reference #2-6298 regarding non-compliance with Federal Medicare/Medicaid certification requirements and State nursing home licensure rules.

The facility was found deficient in multiple areas including failure to immediately report and investigate injuries of unknown origin, failure to ensure staff wore identification badges, failure to administer medications as ordered, and failure to provide necessary pressure relieving devices to residents with pressure ulcers or at risk for skin breakdown.

Complaint reference #2-6298 was substantiated with deficiencies cited for non-compliance with Federal Medicare/Medicaid certification requirements and State nursing home licensure rules.

The visit was a paper revisit to review compliance and deficiencies.

The report includes a deficiency related to the facility's obligation to inform residents of their rights and services, specifically regarding notice of rights and charges. No detailed findings or severity levels are provided.

The visit was a revisit conducted on 10/23/2006 to follow up on deficiencies issued on 08/23/2006 related to fire alarm system inspection and smoke detector sensitivity testing.

The facility failed to inspect and test all components of the fire alarm system annually as required by NFPA 72, including incomplete inspection of pull stations and fire alarm annunciator panels. Additionally, the facility did not perform required sensitivity testing of smoke detectors, with no changes made since the prior deficiencies were issued.

This document is a plan of correction related to a paper revisit survey conducted at Bluestone Health and Rehabilitation.

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).

The inspection was conducted as the facility's annual Medicare/Medicaid certification survey and included investigation of a substantiated complaint.

The facility was found deficient in multiple areas including failure to protect resident rights, inadequate grievance follow-up, improper transfer/discharge notifications, incomplete employee screening, inadequate restorative nursing care, medication administration errors, unsanitary food preparation and pest control issues, environmental safety concerns, and lack of staff performance reviews.

Complaint reference #2-6212 was substantiated with deficiencies cited. The complaint was investigated concurrently with the annual certification survey.