Inspection Reports for Complete Care at Dawnview LLC

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.

The facility, Complete Care At Dawnview LLC, 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.

Investigation survey concluding on 11/06/24 with substantial compliance found and acceptance of plans of correction in lieu of onsite revisit.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine 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.

An unannounced annual recertification, annual relicensure, facility reported incident (FRI) and complaint investigation survey was conducted at Complete Care at Dawnview from November 4 to November 6, 2024.

The survey identified multiple deficiencies including failure to revise care plans timely, incomplete abuse investigations, unsafe storage of wheelchairs, inaccurate resident transfer documentation, improper food storage and labeling, failure to appoint healthcare surrogate properly, and unsecured treatment carts.

The inspection was conducted to assess compliance with fire safety codes, facility policies, and regulatory requirements related to resident rights, hazardous areas, cooking facilities, interior finishes, smoke barriers, and fire alarm system maintenance.

The facility was found deficient in multiple areas including failure to ensure hazardous areas were properly enclosed with door closures, cooking equipment was not maintained in approved locations, smoke barriers had penetrations, and the fire alarm system lacked documentation for semi-annual visual inspections. Corrective actions and audits were planned to address these deficiencies.

An unannounced complaint survey was conducted at Complete Care at Dawn View from 06/11/24 to 06/14/24.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaints and two facility reportable incidents were substantiated with no citations.

Complaints were substantiated with no citations. Facility Reportable Incident #32898 and Facility Reportable Incident #32020 were substantiated with no citation.

An unannounced revisit was conducted at Complete Care at Dawnview on June 14, 2024, to follow up on the complaint survey concluding on April 10, 2024.

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

This visit was a follow-up to a complaint survey. The previously cited deficiencies were corrected.

An unannounced complaint investigation was conducted due to allegations of resident-to-resident sexual abuse and failure to maintain continuous oxygen supply for a resident.

The facility failed to report an allegation of sexual abuse within the required two-hour timeframe and failed to protect a non-communicative resident from sexual abuse. Additionally, the facility failed to ensure a resident maintained a continuous oxygen supply, resulting in oxygen deprivation for approximately 20 minutes.

Complaint investigations #31427 and #31733 were substantiated. The facility failed to report a sexual abuse incident involving Resident #20 and Resident #14 within two hours and failed to protect residents from sexual abuse. The facility also failed to maintain continuous oxygen supply for Resident #50, resulting in oxygen deprivation and emergency intervention.

An unannounced complaint survey was conducted at Complete Care at Dawnview from 09/12/23 to 09/13/23.

The facility was in substantial compliance with applicable regulations. Complaint #28769 was substantiated with no deficient practice, and Complaint #28971 was unsubstantiated with no related or unrelated deficiencies.

Complaint #28769 was substantiated with no deficient practice. Complaint #28971 was unsubstantiated with no related or unrelated deficiencies.

An unannounced complaint investigation survey was conducted at Complete Care at Dawn View from 09/12/23 to 09/13/23.

The facility 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. Complaint #28971 was determined to be unsubstantiated.

Complaint #28971 was unsubstantiated.

An unannounced annual recertification, annual relicensure, and complaint investigation survey was conducted at Complete Care at Dawnview from January 3 - 10, 2023.

The facility had multiple deficiencies including failure to maintain resident dignity, failure to provide appropriate treatment and services, medication regimen review deficiencies, unsafe and unclean environment, infection control issues, failure to maintain respiratory equipment, medication errors, failure to secure resident personal health information, and incomplete care plans for mental and psychosocial needs.

Complaint #27711 was unsubstantiated with an unrelated deficiency cited at F908.

The visit was conducted as an annual recertification and annual relicensure survey for Complete Care at Dawnview LLC.

The facility was found to be 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 review was based on plans of correction and credible evidence accepted in lieu of an onsite revisit.

The inspection was conducted to assess the facility's compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the NFPA 101 Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

The inspection was conducted as a complaint investigation survey concluding on 08/16/2022, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Complete Care at Dawnview LLC, 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.

The complaint investigation survey concluded on 08/16/2022 with the facility in substantial compliance and no new deficiencies cited.

An unannounced complaint investigation survey was conducted at Complete Care at Dawnview from August 15-16, 2022, based on complaints #26270 and #27200 which were substantiated with related deficiencies.

The facility failed to provide medications as ordered by physicians, including failure to administer prescribed topical medications and failure to follow physician orders for pain management medications for two residents. These deficiencies were substantiated through resident interviews, record reviews, and staff interviews.

Complaint #26270 was substantiated with a related deficiency cited at F684. Complaint #27200 was substantiated with related deficiencies cited at F684 and F697.

An unannounced annual re-certification and annual re-licensure survey was conducted at Dawn View Center from September 7-15, 2021.

The survey identified multiple deficiencies including failure to protect resident dignity, failure to honor resident preferences, incomplete advance directive documentation, failure to notify Ombudsman of hospital transfers, inaccurate assessments, medication administration errors, infection control lapses, unsafe equipment, and inadequate staffing postings.

Complaint #24868 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was the annual survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules.

The facility, Dawn View Center, was found to be in substantial compliance with the applicable federal and state regulations based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

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.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency at Dawn View Center.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on December 15, 2020.

The facility was found out of compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted 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.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia state nursing home licensure rules.

The facility, Dawn View Center, was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.

An unannounced annual re-certification and annual re-licensure survey was conducted at Dawn View Center from 06/03/19 through 06/06/19 to assess compliance with federal and state regulations.

The survey identified multiple deficiencies including failure to ensure timely administration of medications, inadequate environment maintenance, inaccurate resident assessments, incomplete care plans, failure to follow physician orders, insufficient staffing, infection control lapses, and incomplete vaccination documentation.

The inspection was conducted to assess the facility's compliance with NFPA 101, Life Safety Code, 2012, and to verify compliance with 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.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia state nursing home licensure rules.

The facility, Dawn View Center, was found to be in substantial compliance with the applicable federal and state regulations. Plans of correction and credible evidence were accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.

An unannounced annual recertification and relicensure survey was conducted at Dawn View Center from February 12, 2018 through February 15, 2018.

The survey identified deficiencies including failure to notify a physician of a high blood sugar reading for a resident, failure to ensure personal privacy during treatments, failure to revise a care plan to include a pressure relieving boot, failure to communicate diabetic shoe recommendations to the physician, failure to provide ordered pressure relieving devices to a resident, and failure to use pasteurized eggs for sunny side up eggs.

The inspection was conducted to assess compliance with NFPA 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

The inspection was conducted as a complaint investigation, including a Quality Indicator Survey, State Licensure Survey, and Complaint survey concluding on 2017-01-06.

The facility, Dawn View Center, 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 accepted plans of correction and credible evidence.

Complaint Reference number #16952 was investigated. The facility was found in substantial compliance with no outstanding deficiencies.

Unannounced off hours annual Quality Indicator Survey, State Licensure Survey, and a Complaint Investigation were conducted at Dawn View Center from 01/02/2017 through 01/05/2017.

The facility was found deficient in timely reporting and thorough investigation of allegations of abuse/neglect involving multiple residents. Additionally, the facility failed to assess and treat pain for a resident with a dislocated shoulder. Plans of correction include staff reeducation and audits to ensure compliance.

Complaint Investigation #16952 was substantiated with related deficiencies involving failure to report and investigate allegations of abuse/neglect for Residents #19, #21, #73, and #4.

Routine inspection of the facility to assess compliance with NFPA 101 Life Safety Code and other regulatory requirements.

The facility was found deficient in multiple areas including exit signage illumination, hazardous area door closures, fire alarm system policies, sprinkler system maintenance, corridor door smoke resistance, smoke barrier construction, fire drill scheduling, and electrical system maintenance. Corrective actions and plans of correction were submitted for each deficiency.

An unannounced complaint investigation was conducted due to Complaint Reference 15153.

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

The complaint allegations were unsubstantiated.

The document is a plan of correction submitted in response to a Quality Indicator Survey concluding on 09/24/2015, accepted in lieu of an onsite revisit.

The facility, Dawn View Center, is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with previously cited deficient practices addressed through plans of correction.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including sprinkler system maintenance, portable heating device prohibition, emergency generator maintenance, and electrical wiring safety.

The facility failed to maintain sprinkler pipes free from external loads, keep sprinkler heads free of paint and debris, ensure sprinkler escutcheons fit properly, maintain required annual sprinkler inspections, prohibit portable space heaters in resident areas, maintain emergency generator testing and documentation, and ensure all electrical junction boxes had covers.

An unannounced annual Quality Indicator Survey was conducted at Dawn View Center from September 21, 2015 through September 24, 2015 to assess compliance with federal regulations through observations, record reviews, interviews, and facility documentation.

The facility was found deficient in multiple areas including inaccurate comprehensive assessments for residents, incomplete care plans, failure to implement care plans, inadequate infection control practices, improper food handling and storage, incomplete clinical records, and failure to follow physician orders related to blood sugar monitoring and medication assessments.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for a long term care facility, accepted in lieu of an onsite revisit.

The facility, Dawn View Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Dawn View Center from June 25, 2014 through July 9, 2014.

The survey identified multiple deficiencies including failure to involve a resident in advance directive decisions, failure to secure surety bond for resident funds, unsanitary housekeeping conditions, inaccurate comprehensive assessments, failure to maintain dignity of residents, incomplete care plans, unnecessary medications without proper monitoring, medication errors including crushing extended release tablets, improper infection control practices including failure to maintain isolation, and incomplete medical records.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code, 2000.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.

The inspection was conducted as a complaint investigation based on complaint references 13285 and 9268 from 12/30/13 to 01/02/14.

The complaint investigation was unsubstantiated with no citations issued.

Complaint Reference: 13285 / 9268. The complaint was unsubstantiated with no citations.

This document is a Plan of Correction related to deficiencies identified during a regulatory inspection of the facility.

The facility was cited for deficiencies related to informing residents of their rights, rules, services, and charges in accordance with regulatory requirements.

The inspection was an annual quality indicator and licensure survey conducted to assess compliance with federal regulations for nursing facilities.

The facility was cited for multiple deficiencies including failure to notify a physician when medication was withheld, failure to provide dignified dining experiences, incomplete comprehensive care plans, failure to revise care plans after falls, improper food storage, failure to properly store and dispose of medications, inadequate infection control signage for a resident with a multi-drug resistant organism, and incomplete and inaccurate medical records related to wound care orders.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards related to smoke barriers, fire alarm system maintenance, sprinkler system installation, and overall fire safety in the facility.

The facility failed to maintain smoke barrier walls with the required fire resistance rating due to unsealed penetrations and missing sheet rock. The fire alarm system's smoke detector sensitivity testing was not conducted or documented as required. Additionally, sprinkler piping was improperly used to support nonsystem components such as cables.

The inspection was conducted as a complaint investigation based on complaint reference numbers 12259 / 7424.

The complaint was unsubstantiated and no citations were issued as a result of the investigation.

Complaint reference 12259 / 7424 was investigated and found to be unsubstantiated with no citations.

The inspection was conducted as a complaint investigation based on complaint reference 12143 / 7178.

The complaint was found to be unsubstantiated with no deficiencies cited in the report.

Complaint Reference: 12143 / 7178. The complaint was unsubstantiated according to the report.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The inspection was conducted concurrently with the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection, including investigation of two unsubstantiated complaints.

The facility was found deficient in several areas including failure to adequately address the care needs of a dialysis resident in the comprehensive care plan, failure to ensure timely Level II evaluations for residents with mental illness or mental retardation, and medication errors including a medication error rate exceeding 5% and significant medication errors related to antihypertensive medications.

Complaint references #11095 and #11066 were investigated concurrently and found unsubstantiated with no related deficiencies cited.

The inspection was conducted in response to complaint reference #10328.

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

Complaint reference #10328 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The inspection was conducted as an annual survey to assess the facility's compliance with regulatory requirements related to resident rights, care planning, medication management, and professional standards of care.

The facility was found deficient in multiple areas including failure to ensure residents' rights were exercised by legally appointed representatives, inadequate comprehensive care plans addressing psychoactive medication use, failure to meet professional standards in medication administration, and medication regimens containing unnecessary drugs.

The inspection was conducted as a complaint investigation related to allegations concerning the facility's failure to provide proper notice and procedures regarding a resident's discharge.

The facility failed to provide a written thirty-day advance notice of discharge to Resident #22, did not notify the resident or her responsible party in a timely manner, and discharged the resident without proper communication or opportunity to appeal. This resulted in actual harm to the resident, who experienced mental anguish upon losing her bed and belongings.

Complaint reference #2-8343 was substantiated with deficiencies cited. The complaint involved Resident #22 being discharged without proper notice or opportunity to appeal, causing mental anguish.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for the facility Complete Care at Dawnview LLC.

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 to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically focusing on the fire alarm system's installation, testing, and maintenance.

The facility's annual fire alarm inspection report was found to be incomplete. The report did not confirm the existence or functional status of magnetic locking devices on exit doors, the auto-dialer, or the monitoring entity. Additionally, the report did not state the date and time the system was returned to normal operation.

The inspection was conducted as a substantiated complaint investigation (#2-8236) concurrently with the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.

The facility was found deficient in multiple areas including failure to report allegations of neglect for two residents, failure to provide timely reasonable accommodations after a resident's request for a bedside commode following falls, failure to ensure accurate and complete assessments for a resident undergoing outpatient dialysis, and failure to maintain sanitary food storage and serving conditions in the kitchen.

Complaint reference #2-8236 was substantiated with deficiencies cited. The complaint investigation was conducted concurrently with the annual certification resurvey and state licensure inspection.

This document is a Plan of Correction submitted by the facility in response to cited deficiencies during a prior inspection.

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 deficiency is identified as F 156 with a severity of SS=C.

This document is a Plan of Correction submitted by the facility in response to cited deficiencies during a prior inspection.

The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges as required by regulations.

This document is a plan of correction related to deficiencies identified in a prior inspection of the facility Complete Care at Dawnview LLC.

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).

Follow-up visit after the Federal Monitoring Survey conducted on 03/13/08 to assess compliance with previously cited deficiencies and identify any new deficiencies.

The facility was found to be in compliance with nine of the previous eleven deficiencies but remained out of compliance with two previously cited deficiencies (F309 and F314) and one new deficiency (F441). Deficiencies involved failure to monitor laboratory results and follow-up, failure to maintain aseptic technique during wound dressing changes, and infection control issues.

The inspection was conducted as a complaint investigation referenced as #2-8113, substantiated with deficiencies cited related to failure to notify the physician of changes in a resident's condition.

The facility failed to notify the physician timely about Resident #1653's worsening edema and erythema, resulting in delayed treatment and harm. The resident was hospitalized after a delay in medical intervention despite multiple nurse assessments and physician notifications. The facility also failed to conduct a thorough assessment on 03/26/08 and did not properly document communication with the physician.

Complaint reference #2-8113 was substantiated with deficiencies cited related to failure to notify the physician and delayed treatment causing harm to Resident #1653.

A Federal Monitoring Survey was conducted at Dawn View Center from March 11-13, 2008 to assess compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care.

The facility was found non-compliant with multiple requirements including failure to monitor blood sugar levels, failure to follow physician orders, improper wound care technique, duplicate drug therapy, medication errors, improper food temperature, infection control breaches, and incomplete clinical documentation.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101 Life Safety Code, 2000 Existing Edition.

The inspection was conducted to review medical records, facility policies and documentation, observations, resident and family interviews, and staff interviews to determine compliance with state licensure and federal Medicare/Medicaid certification requirements.

The facility was found to be in compliance with both state licensure and federal Medicare/Medicaid certification requirements based on the review and interviews conducted.

The visit was a paper revisit to review previous deficiencies and the facility's plan of correction.

The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on the facility's compliance with informing residents of their rights and services.

The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including failure to immediately report an injury of unknown source, failure to complete significant change assessments, inaccuracies in minimum data set (MDS) assessments, incomplete care plans, failure to comply with pre-admission screening requirements, delays in electronic submission of MDS data, failure to carry out physician's lab orders, and incomplete clinical records.

The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

This document is a plan of correction submitted in response to a prior inspection, specifically a paper revisit.

The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on informing residents of their rights and services in writing and orally.

The inspection was conducted as a complaint investigation referenced as #2-6228, which was substantiated with deficiencies cited.

The facility was found to have a deficiency related to the required training and registry verification of nursing aides. Specifically, one nurse aide worked with an expired registration for five days, which had the potential to affect residents receiving care from this individual.

Complaint reference #2-6228 was substantiated with deficiencies cited.

This document is a plan of correction submitted in response to a prior deficiency statement related to resident rights and notification requirements.

The facility was cited for failing to properly inform residents of their rights, rules, services, and charges as required by regulations.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on the maintenance and testing of the facility's emergency electrical generator system.

The facility failed to provide documentation that the diesel-powered emergency generator was exercised monthly with the required electrical load and annually with supplemental loads at 25%, 50%, and 75% of the rated capacity as required by NFPA standards. The current load test report lacked evidence of testing with a resistive load bank and did not meet the required testing intervals and load percentages.

Annual inspection of Complete Care at Dawnview LLC nursing facility to assess compliance with federal regulations including resident assessments, care planning, medication management, dietary services, and sanitary conditions.

The facility was found deficient in multiple areas including incomplete resident assessment protocols, failure to complete significant change assessments, inaccurate behavior recording, inadequate care planning, unnecessary drug use, dietary and food service deficiencies including improper meal portions, food preparation, and sanitation, and failure to act on pharmacist recommendations.

The inspection was conducted as part of the facility's annual licensure survey to assess compliance with federal, state, and local regulations and professional standards.

The facility was found to have failed to employ a qualified dietary manager as required by West Virginia Nursing Home Licensure Rule 64CSR13. The current dietary manager did not meet any of the qualifications specified by the rule.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The inspection was conducted as a complaint investigation referenced as #2-4188.

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

Complaint reference #2-4188 was substantiated with no deficiencies cited.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was determined to be in compliance with the Life Safety Code.

Complaint reference #2-3207; the investigation was conducted to determine the validity of the complaint.

The complaint was unsubstantiated with no deficiencies cited related to it. However, multiple deficiencies were found related to quality of care, physician services, and medication management, including failure to implement a pressure ulcer care plan, lack of gradual dose reduction for antipsychotic medication, and undated physician progress notes and telephone orders.

Complaint reference #2-3207 was unsubstantiated with no deficiencies cited related to the complaint.

The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to dietary services, resident rights, and food safety in the facility.

The facility was found deficient in several areas including failure to follow menus as planned, improper food preparation and storage temperatures, failure to provide special eating equipment to a resident, and inadequate notification of resident rights. These deficiencies had the potential to affect all 65 residents.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 1973 New Edition.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was determined to be in compliance with the Life Safety Code.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with the Fire Safety Survey Report as it pertains to NFPA 101; Life Safety Code, 1973 New Edition.

The facility was found to be in compliance with the provisions of the Fire Safety Survey Report Short Form related to NFPA 101; Life Safety Code, 1973 New Edition.

The inspection was conducted to assess compliance with health and safety regulations, including dietary staffing qualifications, at Complete Care at Dawnview LLC.

The facility failed to employ a qualified dietary manager as required by regulations. The dietary manager did not meet the qualifications defined by the relevant standards.

The inspection was conducted to investigate complaints related to resident rights, staff treatment of residents, and the facility's compliance with policies and procedures regarding resident care and abuse reporting.

The facility was found deficient in several areas including failure to provide required capacity evaluations before DNR orders, failure to report alleged abuse to appropriate state agencies, incomplete reference checks for new employees, and failure to develop comprehensive care plans with measurable objectives for residents with specific medical needs.

The complaint investigation revealed that a CNA spoke harshly to Resident #11 when she asked for assistance, and this complaint was not reported to the appropriate State agencies as required by law.

The inspection was conducted based on a review of facility documentation, staff interviews, observations, and performance testing to assess compliance with the provisions of 483.70 Physical Environment.

The facility was determined to be in compliance with the provisions of 483.70 Physical Environment.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101:12, Life Safety Code, 1973 New.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was determined to be in compliance with the Life Safety Code.

The inspection was conducted to assess compliance with federal regulations regarding residents' rights, quality of life, activities program, and dietary services at the facility.

The facility failed to provide reasonable accommodations for residents' individual needs regarding closet space, did not ensure an adequate activities program on Saturdays and evenings, and failed to maintain sanitary conditions in the dietary department, with dust, food debris, and spider webs observed on food preparation surfaces.