Inspection Reports for
Cedar Grove Assisted Living

The complaint was substantiated. Resident #53 eloped from the facility on 08/06/25 without staff knowledge. The resident had a history of exit-seeking and a wander management system was in place. Interviews revealed staff were not adequately monitoring the resident at the time of elopement.

The complaint was substantiated; the facility failed to ensure adequate staffing and supervision, resulting in Resident #53 eloping without staff knowledge. Additional findings included inadequate housekeeping and maintenance issues in the facility.

Investigation of Complaint #37513 from 04/02/25 to 04/03/25. The complaint was unsubstantiated, but deficiencies were cited.

The facility was found deficient in notifying the registered nurse immediately upon admission of a resident with nursing care needs, timely initiation of resident service plans, and performing nursing assessments within 24 hours of admission. The complaint was unsubstantiated but deficiencies were cited.

This inspection was a follow-up to Complaint #35017. One deficiency was corrected, one was re-cited, and additional unrelated deficiencies were cited.

One deficiency was corrected, one deficiency was re-cited, and additional unrelated deficiencies were cited. Deficiencies included failure to ensure the Memory Care Coordinator met training requirements, failure to maintain confidentiality of resident medical information, failure to ensure all dietary staff had valid food handler cards, failure to keep medications locked when unattended, and inadequate housekeeping and maintenance resulting in unsafe and unsanitary conditions.

Complaint #36304 was investigated from 01/20/25 to 01/27/25. The complaint was unsubstantiated but deficiencies were cited.

The facility was found deficient in multiple areas including medication labeling, nursing notifications, record accuracy, housekeeping and maintenance, nursing care documentation, and service plan development. The complaint was unsubstantiated but deficiencies were cited.

Complaint #35017 was investigated from 10/29/24 to 10/30/24. The complaint was substantiated. Resident #24 alleged being hit by Resident #25, but the facility failed to monitor Resident #24's condition as required after the incident.

The complaint was substantiated with deficiencies cited including failure to ensure the Memory Care Coordinator met minimum qualifications and failure to monitor and document a resident's condition every 8 hours for 24 hours following an accident. Additional housekeeping and maintenance deficiencies were noted.

All previously cited deficiencies (0446, 0450, 0462, and 0496) were corrected as of the re-inspection date, with the exception of deficiency 0462 which is awaiting a waiver decision.

The facility was found to have multiple deficiencies including improper storage of soiled laundry, inadequate bedroom floor space, failure to document emergency evacuation training for new residents, and maintenance issues such as dust accumulation on heating/cooling registers, broken floor tiles, and damaged carpets.

Investigation of Complaint #34325 on 09/25/24. The complaint was substantiated and deficiencies were cited.

The facility failed to ensure a resident was documented as capable of self-administering medications prior to self-administration, and medications were left accessible to residents without proper supervision or locked storage. The complaint was substantiated and deficiencies were cited.

Multiple deficiencies were cited including failure to maintain proof of pet vaccinations for 5 pets, inaccurate resident records for one resident, and unauthorized use of visual and auditory monitoring devices in resident apartments. Plans of correction were provided with completion dates ranging from 09/30/24 to 10/08/24.

Investigation of Complaint #33183 from 07/08/24 to 07/16/24. The complaint was substantiated and a deficiency was cited.

The facility failed to ensure residents' call lights were answered timely, with documented delays ranging from 31 to 55 minutes. Staffing shortages were reported by multiple anonymous employees, impacting the ability to respond promptly. The complaint was substantiated and a deficiency was cited.

Credible evidence was accepted in lieu of an onsite revisit, citations were cleared, and the facility was found to be in substantial compliance with the rule.

The facility was found deficient in documenting the name of the person to whom a resident's body was released upon death and in ensuring required documentation accompanied residents upon transfer or discharge. Deficiencies related to housekeeping and maintenance were also noted in a behavioral health survey from 2004, but these are historical and not part of the current survey findings.

The facility failed to maintain adequate staffing levels on the night shift, with 37 days of insufficient staffing out of 37 reviewed days. There were 37 residents with two or more care needs but only two direct care staff scheduled for the night shift on those days.

The survey cited tags 0445 and 0450, with a follow-up survey confirming the correction of these deficiencies. Additional findings included one requirement from the Fire Marshall report and one violation from the Health Department report.

The facility was found deficient in multiple areas including staff training and supervision, resident funds management, medication administration, housekeeping and maintenance, resident assessments, and staffing levels. Several residents' records lacked required documentation and staff failed to meet regulatory requirements for care and safety.

The facility was found to have deficiencies related to maintenance and housekeeping, including stained ceiling tiles, dust accumulation, missing signage, and inadequate documentation of emergency preparedness drills. Corrective actions were planned or implemented to address these issues.

Investigation of Complaint #28750 from 07/25/23 to 08/02/23 at Cedar Grove Assisted Living with census of 60 residents. Three allegations were substantiated with related and unrelated deficiencies cited.

Three substantiated allegations were found including failure to monitor and document a resident's condition for 24 hours following an accident, failure to maintain accurate resident records, and inadequate maintenance and housekeeping resulting in unsafe and unsanitary conditions.

Complaint investigation with 2 allegations substantiated and 1 unsubstantiated.

The facility failed to maintain a safe, sanitary, and accident-free living environment, with observations including black-like substance in HVAC closet, food debris in Memory Care area, stained ceiling tiles, missing ceiling tiles, damaged carpet, and incomplete fire watch documentation. Two allegations were substantiated and one was unsubstantiated.

The facility failed to ensure proper completion of transfer/discharge summaries for three residents and did not maintain weekly nursing documentation for six residents requiring limited and intermittent nursing care. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.

The facility was found deficient in multiple areas including staff training on Alzheimer's care, housekeeping and maintenance issues, incomplete personnel records such as tuberculosis screening, incomplete resident assessments and service plans, failure to document release of belongings upon resident death, inadequate monitoring of residents after accidents, incomplete employee orientation and annual training, unsecured medication storage, and failure to notify physicians of significant resident weight changes.

The facility was found deficient in maintaining a safe and sanitary environment, including issues with key pad exit door signage, improper laundry storage, and inadequate housekeeping and maintenance such as soiled floors, dust accumulation, and damaged furnishings.

Complaint ID 27255 initiated due to allegations of resident abuse and failure to maintain proper documentation and assessments. The complaint investigation confirmed substantiated findings including physical abuse of Resident #5 by Resident #9 and multiple regulatory violations.

The facility failed to maintain accurate resident registries, failed to update functional assessments and service plans after significant changes, failed to notify registered nurses immediately of nursing care needs, and failed to monitor residents adequately after incidents. Resident #5 was physically abused by Resident #9, resulting in a cervical fracture. The facility also failed to prepare transfer summaries and ensure safety of residents in memory care. Housekeeping and maintenance deficiencies were noted. Staff education and corrective actions were planned.

Complaint survey number 26628 was conducted with a census of 48 residents. The complaint focused on housekeeping, maintenance, and sanitary issues, all of which were verified and acknowledged by facility staff during exit interviews.

The facility failed to maintain adequate housekeeping and maintenance, resulting in unsanitary conditions such as disrepair of toilet paper holders, human fecal matter on floors and carpets, improper laundry storage, and incomplete or outdated service plans. Staff education and corrective actions were planned to address these deficiencies.

Complaint survey #26899 initiated due to Resident #6 reporting having to sleep overnight in her wheelchair because staff did not assist her to bed. Investigation revealed staffing shortages and failure to meet care needs as documented in Resident #6's service plan.

The facility failed to provide adequate staffing levels on day, evening, and night shifts according to the number of residents with two or more care needs, resulting in Resident #6 having to sleep overnight in her wheelchair due to insufficient staff to assist with transfers. Additionally, the facility failed to maintain adequate housekeeping and maintenance, including damaged carpet, missing bathroom fixtures, and unclean sinks.

The facility was found not to have implemented programs in a safe and appropriate environment, with specific concerns about lack of alarms on outside doors and insufficient awake staff supervision on weekend nights.

Complaint ID 25824 was unsubstantiated. The investigation revealed failures in mandatory reporting procedures, neglect of resident hygiene and environment, and maintenance deficiencies. Staff were discouraged from reporting abuse directly to authorities. Resident #29 experienced neglect with multiple falls, unclean conditions, and delayed carpet replacement. Maintenance issues included broken toilet handle and cluttered closets.

The licensee failed to ensure compliance with mandatory reporting of suspected abuse and neglect, failed to maintain a safe, sanitary, and accident-free environment, and neglected residents, including Resident #29 who was found in unsanitary conditions with urine and fecal matter on clothing, bedding, and furniture. Maintenance issues such as broken toilet handle and unaddressed carpet stains were also noted. Staff were instructed to report abuse only to management, contrary to state law requiring direct reporting to authorities.

Complaint Investigation Survey Complaint ID: WV00025974. The investigation was conducted from 11/29/21 to 12/08/21. Census at the time was 42 assisted living and 22 Alzheimer’s residents.

The report documents findings related to safety concerns in the facility, including lack of alarms on outside doors in adolescent bedrooms and insufficient awake staff supervision during weekend nights.

Complaint ID 26046 was substantiated. The complaint involved abuse and failure to protect ALZ Resident #6 from her husband's physical and verbal abuse. Staff interviews and observations confirmed the abuse and management's failure to prevent forced visits despite resident's distress.

The investigation found that ALZ Resident #6 was physically and verbally abused by her husband, AL Resident #2, including being punched with a closed fist. Despite staff concerns and resident distress, management ordered staff to force visits between the couple against ALZ Resident #6's wishes. The facility failed to protect the resident from abuse and did not adequately respond to the situation. Additionally, the facility failed to maintain adequate housekeeping and maintenance, with multiple environmental deficiencies observed.

Complaint ID 26089 was substantiated. The complaint investigation was conducted from 10/05/21 to 10/06/21 regarding the elopement incident and failure to notify responsible party timely.

The facility failed to promptly notify the responsible party of a major incident involving Resident #45 eloping. Additionally, the facility failed to count residents after a door alarm sounded, which could have prevented the elopement. Housekeeping and maintenance deficiencies were also noted, including damaged carpet, missing bathroom fixtures, and unclean areas.

All deficiencies identified in the prior survey were corrected except for deficiency E0450. By the date of this re-inspection, all deficiencies were corrected.

Complaint ID 25562 initiated a survey from 08/16/21 to 08/18/21. The complaint involved failure to provide required staff training and failure to protect a resident from verbal abuse by her husband who was not the legal medical power of attorney. The husband was later determined to have lost capacity to make medical decisions. Resident was moved to a Memory Care apartment and staff re-education was planned.

The facility failed to provide required dementia training for three staff agency employees, failed to maintain adequate housekeeping and maintenance, and failed to protect the physical and mental well-being of a resident due to inappropriate behavior by the resident's husband who was not the legal medical power of attorney.

Complaint ID WV00025841 was investigated and found to be unsubstantiated.

The facility was found to have multiple deficiencies including an Executive Director serving as a legal representative for a resident without proper consanguinity, use of full-length bed side rails against regulations, and inadequate housekeeping and maintenance issues such as damaged carpets, missing bathroom fixtures, and unclean sinks.

The facility failed to fully correct multiple maintenance and housekeeping deficiencies noted in the prior inspection, including dusty vents, missing light covers, worn paint, cobwebs, black/brown substances near sinks and showers, improperly stored paper products, and a tripping hazard on an exit ramp. The findings were acknowledged by the Administrator and Maintenance Director.

Complaint IDs WV00025841 and WV00025842 were investigated; WV00025842 was substantiated with deficiencies cited.

The facility failed to assemble an interdisciplinary team to complete assessments and service plans within seven days of admission for two residents (#24 and #34). Additionally, the interdisciplinary team did not review and complete quarterly assessments and care plans when a resident's condition changed (#25). The facility also lacked a Registered Nurse on site, relying on Licensed Practical Nurses, and had housekeeping and maintenance deficiencies noted from a prior 2004 behavioral health survey.

The facility failed to meet staffing requirements for direct care staff on day shifts based on resident care needs, had inadequate housekeeping and maintenance issues including damaged carpets and missing bathroom fixtures, and lacked complete tuberculosis screening documentation for three employees. Plans of correction were provided for staffing, environmental hygiene, and personnel record compliance.

The facility was found deficient in several areas including lack of accessible call systems for residents, inadequate housekeeping and maintenance resulting in physical environment issues, and incomplete emergency preparedness plans lacking an emergency transportation policy and a three-day food supply. Corrective actions and staff education were planned to address these deficiencies.

Complaint ID WV00024769 was substantiated. The complaint survey was conducted from 12/07/20 to 12/09/20 with a census of 62 residents.

The facility failed to ensure the registered nurse maintained a proper visit log including date, time in/out, duties performed, concerns, recommended actions, and signature. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.

The facility failed to ensure service plans were updated annually or within seven days of admission for multiple residents, maintain resident records for at least five years, adequately document and report unplanned weight changes to physicians, and maintain adequate housekeeping and maintenance of the physical environment.

The facility failed to ensure timely completion of initial assessments and care plans by the interdisciplinary team for three residents, failed to monitor and document a memory care resident's condition every four hours for 24 hours following incidents, failed to provide new employee training within 15 days for one employee, and failed to maintain adequate housekeeping and maintenance in the residence.

The facility failed to provide a thermostatic mixing valve to control the temperature of hot water tanks exceeding eighty gallons, which was confirmed during the inspection. A plan of correction was submitted to install the valves and conduct monthly maintenance checks.

The licensee failed to protect the physical and mental well-being of eleven residents due to unsecured bedside rails posing injury risks. Immediate corrective actions were taken to remove the rails, and systemic changes including staff education and ongoing monitoring were implemented.

The licensee failed to ensure resident belongings were properly released to the estate administrator or executor upon a resident's death for four residents. Documentation issues and improper release procedures were identified. A plan of correction was implemented including staff education, audits, and contract addendums.

The report summarizes deficiencies related to health and safety, including lack of awake night staff on weekends and unsecured doors in adolescent residential areas. The provider plans to implement awake-night supervision by July 1, 2004.

The inspection identified multiple deficiencies including unsafe use of power strips, unlocked electrical panels, improper oxygen cylinder storage and signage, maintenance issues such as broken bathroom fans, holes in ceiling tiles, missing hardware on furniture, cigarette littering, and hot water temperature exceeding regulatory limits. Corrective actions and plans of correction were documented with completion dates.

The facility was found deficient in multiple areas including medication administration documentation, staffing with current first aid certification, housekeeping and maintenance, resident rights complaint resolution, infection control practices, resident monitoring post-incident, nursing documentation, dietary orders compliance, and resident weight monitoring.

The complaint investigation found that the call bell system was difficult to hear and staff frequently did not respond to call bells, as confirmed by observations, staff interviews, and a family member's statement.

The facility failed to have a call system that is audible to staff, as staff were unable to hear call bells when resident room doors were closed or when staff were not nearby. Interviews confirmed the call system was inadequate and staff frequently did not respond to call bells.

Complaint investigation conducted based on intake number WV00013216. Deficiencies related to physical facilities and electrical safety were confirmed during the visit.

The facility failed to ensure that the electrical system was installed and operating according to the National Electrical Code, with numerous wiring issues observed. Maintenance and housekeeping deficiencies were also noted, including broken switch covers, loose receptacles, and other safety hazards.

The visit was complaint-related as indicated by the complaint investigation tag E 004 and the focus on physical facilities and safety issues.

The facility failed to ensure the electrical system was installed and operating according to the National Electrical Code, with numerous wiring issues observed including broken switch covers, open grounds, reverse polarity, and loose receptacles. Immediate corrective actions were taken by maintenance staff, and licensed contractors were engaged to complete necessary repairs by May 8, 2015.

The survey found deficiencies related to incomplete resident records, including missing medical diagnoses, allergies, and health assessments, failure to complete tuberculosis screenings, inadequate staff training on resident care needs and when to notify the registered nurse, and housekeeping and maintenance issues observed in the facility.

The complaint investigation was triggered by concerns about resident safety, including elopement incidents involving residents #31 and #40, inadequate showering and feeding, and lack of written complaint responses. The investigation found substantiated deficiencies in these areas.

The licensee failed to protect residents from elopement risks, maintain accurate records for 44 of 63 residents, respond to complaints in writing within four days, ensure adequate housekeeping and maintenance, keep the facility free of vermin, and provide an adequate supply of towels and washcloths. Multiple deficiencies were noted including unsupervised residents at risk of wandering, flies observed in multiple areas, and inadequate linen supplies.

The complaint investigation revealed nine incidents from September to December 2013 where residents suffered falls or injuries while being assisted by staff. Interviews indicated inadequate staff training and supervision, especially regarding the use of mechanical lifts and ambulation assistance. The mechanical lift policy was not formally developed, and staff often worked alone contrary to recommended procedures.

The facility failed to protect the physical and mental well-being of seven residents, with nine incidents of falls or injuries occurring while staff assisted residents. Staff training on safe use of mechanical lifts and ambulation devices was inadequate, and policies regarding mechanical lift use were not formally developed. Housekeeping and maintenance deficiencies were also noted.