Deficiencies per Year
24
18
12
6
0
Severe
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Census: 6
Deficiencies: 1
Feb 9, 2026
Visit Reason
The visit was conducted to review the facility's plan of correction and credible evidence submitted by the facility to address previously identified deficiencies.
Findings
The review found that credible evidence was accepted in lieu of an onsite revisit, and the deficiencies were corrected.
Deficiencies (1)
| Description |
|---|
| The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers, including lack of alarms on outside doors and insufficient awake staff on weekend nights. |
Report Facts
Center census: 6
Sample size: 3
Inspection Report
Follow-Up
Census: 95
Deficiencies: 2
Nov 4, 2025
Visit Reason
First follow-up to the annual survey conducted to verify compliance with previously cited deficiencies related to staffing coordination in the Alzheimer's/dementia special care unit and policies on administering lifesaving medications.
Findings
Two deficiencies were cited: failure to designate a staff member responsible for coordinating the Alzheimer's/dementia special care unit, and failure to have policies related to administering lifesaving medications such as naloxone and epinephrine. Plans of correction were provided with completion dates.
Deficiencies (2)
| Description |
|---|
| Failure to ensure a designated staff member was responsible for the coordination of the Alzheimer's/dementia special care unit. |
| Failure to ensure the facility had a policy related to administering lifesaving medications including naloxone and epinephrine. |
Report Facts
Census: 64
Census: 31
Deficiencies cited: 2
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Nov 4, 2025
Visit Reason
Investigation of Complaint #40209 regarding the assisted living and memory care units at the facility.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #40209 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 63
Census: 31
Inspection Report
Original Licensing
Census: 64
Deficiencies: 0
Aug 11, 2025
Visit Reason
The inspection was conducted as an initial licensure survey for the facility.
Findings
The environmental survey found no deficiencies cited during the inspection.
Report Facts
Census: 64
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 12
Aug 7, 2025
Visit Reason
Annual survey of Harmony at Morgantown Assisted Living and Memory Care units conducted from 08/04/25 to 08/07/25 to assess compliance with regulatory requirements.
Findings
Multiple deficiencies were cited including failure to ensure adequate staff training, incomplete interdisciplinary assessments and care plans, inadequate housekeeping and maintenance, failure to maintain resident register, unauthorized medication administration by unlicensed staff, inadequate staffing levels, delayed reporting of major incidents, and presence of insects in the facility.
Deficiencies (12)
| Description |
|---|
| The coordinator of the Alzheimer's unit failed to complete the required 30-hour training course by a nationally recognized Alzheimer's/dementia care giving resource or association. |
| Facility failed to provide a minimum of eight (8) hours of documented annual training to all staff on required topics. |
| Interdisciplinary team failed to complete initial assessments within seven days of admission for some residents. |
| Interdisciplinary team failed to review, evaluate, and revise resident care plans at least quarterly for some residents. |
| Activities program was not directed by a person meeting all applicable education and training requirements. |
| Administrator/Executive Director failed to participate in eight (8) hours of training related to the operation of a residence annually. |
| Major incidents were not reported to the Office of Health Facility Licensure and Certification (OHFLAC) no later than the next business day. |
| Inadequate staffing levels during the evening shift in Assisted Living, with fewer direct care staff than required on multiple dates. |
| Failed to maintain a register of all residents; 19 residents were living in the facility but not listed on the register. |
| Failed to ensure Approved Medication Administration Personnel (AMAP) manual was maintained according to requirements and unauthorized injections were administered by unlicensed staff. |
| Failed to keep the residence free of insects; tiny black flying insects observed in dining and kitchen areas. |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. |
Report Facts
Census: 65
Census: 27
Sample Size: 3
Dates with inadequate staffing: 4
Residents not on register: 19
Dates of unauthorized injections: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #48 | Alzheimer's Unit Coordinator | Failed to complete required 30-hour training |
| Employee #22 | AMAP employee | Administered unauthorized injections to Resident #16 |
| Employee #49 | AMAP employee | Administered unauthorized injection to Resident #33 |
| Employee #55 | AMAP employee | Administered unauthorized injections to Resident #13 |
| Employee #64 | AMAP employee | Administered unauthorized injections to Resident #61 |
| Employee #77 | AMAP employee | Administered unauthorized injection to Resident #13 |
| Director of Nursing | Unable to provide evidence of training completion; acknowledged training AMAP staff on injections | |
| Executive Director | Administrator | Failed to complete required annual training; responsible for staffing and incident reporting |
| Business Office Manager | Unable to maintain resident register; acknowledged insect issue | |
| Healthcare Director | Acknowledged staffing shortages and insect issue |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 0
Aug 5, 2025
Visit Reason
Investigation of Complaint #39562 regarding the assisted living and memory care units at Harmony at Morgantown.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation conducted on August 4-5, 2025.
Complaint Details
Complaint #39562 was investigated from 08/04/25 to 08/05/25. The complaint was found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 65
Census: 27
Inspection Report
Plan of Correction
Deficiencies: 1
Aug 5, 2025
Visit Reason
Review of the facility's plan of correction and credible evidence was conducted to verify correction of previously cited deficiencies.
Findings
The credible evidence was accepted in lieu of an onsite revisit, and the deficiencies were corrected as of the review date.
Deficiencies (1)
| Description |
|---|
| The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers, including lack of alarms on outside doors and insufficient awake staff on weekend nights. |
Report Facts
Center Census: 6
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 4
Nov 25, 2024
Visit Reason
Investigation of Complaint #35501 regarding compliance with medication administration, personnel records, and facility safety.
Findings
The complaint was substantiated with deficiencies cited related to failure to ensure all Approved Medication Assistive Personnel had current First Aid certification, failure to maintain confidential personnel records including proof of required education, and inadequate housekeeping and maintenance in the facility.
Complaint Details
Complaint #35501 was substantiated. The investigation found deficiencies related to medication administration, personnel records, and facility environment.
Severity Breakdown
Class I: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure all Approved Medication Assistive Personnel employees had current First Aid certification. | Class I |
| Failed to maintain confidential personnel records including proof of required education for one AMAP employee. | — |
| Failed to ensure adequate housekeeping and maintenance required to carry out services, including damaged carpet, missing towel bars, and dirty sink. | — |
| Environment not safe and appropriate for adolescent consumers due to lack of alarms on outside doors and inadequate weekend night supervision. | — |
Report Facts
Census: 96
Sample Size: 3
Employees without current First Aid certification: 2
Inspection Report
Follow-Up
Census: 99
Deficiencies: 0
Oct 22, 2024
Visit Reason
Second follow-up to the annual survey to verify correction of previously cited deficiencies.
Findings
The citations from the prior annual survey were corrected as of the follow-up visit on 10/22/24.
Report Facts
Census: 67
Census: 32
Inspection Report
Re-Inspection
Census: 87
Deficiencies: 5
Sep 4, 2024
Visit Reason
This document reports on a series of environmental inspections and revisits conducted at Harmony at Morgantown, an assisted living and memory care facility, to verify correction of previously cited deficiencies.
Findings
The initial survey on May 6, 2024, identified multiple deficiencies. Subsequent revisits on June 25, July 31, and September 4, 2024, documented partial and full corrections of these deficiencies, with all deficiencies corrected by the third revisit.
Deficiencies (5)
| Description |
|---|
| Deficiency 0445 |
| Deficiency 0450 |
| Deficiency 0452 |
| Deficiency 0457 |
| Deficiency 0496 |
Report Facts
Facility census: 97
Deficiencies cited: 5
Facility census: 87
Facility census: 84
Facility census: 87
Inspection Report
Follow-Up
Census: 66
Deficiencies: 2
Aug 21, 2024
Visit Reason
First follow-up to the Alzheimer's Unit Annual Survey to verify correction of previously cited deficiencies and to assess compliance with training and monitoring requirements.
Findings
The original deficiencies related to annual training for staff on Alzheimer's care were re-cited for four employees lacking documented training. Additionally, a new deficiency was cited regarding the improper use of visual and auditory monitoring devices in resident apartments, which is restricted to common areas only.
Severity Breakdown
Class III: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure all staff received a minimum of eight hours of documented annual training on care of residents with Alzheimer's disease and related dementia for four of five employees reviewed. | — |
| Use of visual and auditory devices to monitor areas of the assisted living residence was not restricted to common areas only; video surveillance signs were observed on apartment doors of two residents. | Class III |
Report Facts
Census: 66
Employees lacking training: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #14 | Named in deficiency for lack of documented annual training on Alzheimer's care. | |
| Employee #21 | Named in deficiency for lack of documented annual training on Alzheimer's care. | |
| Employee #83 | Named in deficiency for lack of documented annual training on Alzheimer's care. | |
| Employee #91 | Named in deficiency for lack of documented annual training on Alzheimer's care. | |
| Healthcare Director #76 | Healthcare Director | Interviewed regarding staff training and monitoring device use. |
Inspection Report
Re-Inspection
Census: 84
Deficiencies: 3
Jul 31, 2024
Visit Reason
This is a re-inspection survey conducted to verify correction of previously cited deficiencies related to housekeeping, laundry storage, physical facilities, and emergency preparedness.
Findings
The facility failed to fully correct deficiencies related to proper storage of soiled laundry, maintenance and housekeeping issues including dust/debris on high touch surfaces, and failure to rehearse and document the disaster preparedness plan annually. Some deficiencies were partially corrected while others remained uncorrected as of the latest revisit.
Deficiencies (3)
| Description |
|---|
| Failure to ensure soiled and clean laundry are stored separately in covered containers or disposable plastic bags. |
| Failure to maintain a safe, sanitary, and accident-free living environment including dust/debris on high touch surfaces and maintenance issues such as carpet damage and missing bathroom fixtures. |
| Failure to rehearse and document the disaster and emergency preparedness plan annually. |
Report Facts
Facility census: 97
Facility census: 87
Facility census: 84
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified findings related to laundry storage and housekeeping deficiencies during interviews and exit interviews | |
| Executive Director | Acknowledged findings during exit interviews and involved in plan of correction |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Jul 3, 2024
Visit Reason
Investigation of Complaint #33102 conducted from 07/01/24 to 07/03/24 at Harmony at Morgantown.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #33102 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 89
Inspection Report
Re-Inspection
Census: 87
Capacity: 97
Deficiencies: 4
Jun 25, 2024
Visit Reason
The visit was a re-inspection conducted on June 25, 2024, to follow up on previously cited deficiencies related to housekeeping, laundry storage, physical facilities maintenance, and disaster preparedness.
Findings
The facility failed to correct multiple deficiencies including improper storage of soiled laundry, inadequate housekeeping and maintenance resulting in dust and debris accumulation, physical damage such as exposed drywall and missing paint, unsecured oxygen cylinders, and failure to rehearse and document the disaster preparedness plan annually. Some deficiencies were partially corrected, but several remained uncorrected at the time of the revisit.
Deficiencies (4)
| Description |
|---|
| Failure to ensure soiled and clean laundry were stored separately in covered containers or disposable plastic bags. |
| Failure to maintain a safe, sanitary, and accident-free living environment, including dust/debris on high touch surfaces and rusty ceiling registers. |
| Failure to keep the interior and exterior of the residence clean and in good repair, including exposed drywall, missing paint, and unsecured oxygen cylinders. |
| Failure to rehearse and document the disaster and emergency preparedness plan annually. |
Report Facts
Facility census at initial survey: 97
Facility census at revisit: 87
Deficiency counts: 5
Deficiency counts: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Acknowledged findings during exit interviews and verified deficiencies | |
| Maintenance Director | Verified findings related to laundry storage, housekeeping, and physical facilities | |
| Healthcare Director | Involved in plan of correction for laundry storage and disaster preparedness | |
| Memory Care Director | Involved in plan of correction for disaster preparedness |
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 11
May 16, 2024
Visit Reason
Annual survey conducted from 05/06/24 to 05/16/24 to assess compliance with state regulations for assisted living and memory care services.
Findings
The facility was found deficient in multiple areas including staff training on Alzheimer's care, personnel records maintenance, employee orientation and in-service training, medication administration compliance, food handler certification, resident health assessments, and physical facility maintenance. Housekeeping and maintenance issues were noted, including unsafe storage of chemicals and damaged carpets.
Deficiencies (11)
| Description |
|---|
| Failed to ensure all staff received minimum 8 hours annual training on care of residents with Alzheimer's disease and related dementia. |
| Failed to maintain confidential personnel records including pre-employment tuberculosis test results for employees. |
| Failed to provide monthly calendar listing duration of all social and recreational activities. |
| Failed to ensure functional needs assessments and service plans reflected residents' current needs and were updated annually or with significant changes. |
| Failed to ensure liability coverage and required education/certifications for Approved Medication Assistive Personnel (AMAPs). |
| Failed to provide and maintain records of employee orientation and training within first 15 days of employment. |
| Failed to provide and maintain records of annual in-service training on resident rights, confidentiality, abuse prevention, infection control, fire safety, and specialty care. |
| Failed to provide training to all new employees within 15 days of employment and annually thereafter on Alzheimer's disease and related dementias. |
| Failed to maintain written, signed, and dated health assessments by a physician or authorized licensed health care professional for residents within required timeframes. |
| Failed to ensure all employees handling food had a food handler's card. |
| Failed to provide maintenance and housekeeping to maintain a safe, sanitary, and accident-free living environment; unsafe storage of chemicals and damaged carpets observed. |
Report Facts
Census: 60
Census: 27
Number of employees lacking required Alzheimer's training: 8
Number of employees lacking tuberculosis test records: 9
Number of AMAP employees lacking liability coverage: 11
Number of employees lacking high school diploma or equivalent: 9
Number of employees lacking CPR or First Aid certification: 8
Number of employees lacking in-service training: 6
Number of employees lacking Alzheimer's training: 5
Number of residents with deficient health assessments: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #14 | Lacked required annual Alzheimer's training and new employee orientation training | |
| Employee #86 | Handled food without food handler's card | |
| Business Office Manager #73 | Business Office Manager | Acknowledged lack of tuberculosis testing records and personnel files for social workers |
| Healthcare Director #71 | Healthcare Director | Acknowledged training deficiencies and lack of physician involvement in resident assessments |
| Dining Services Director #84 | Dining Services Director | Acknowledged food handler card deficiency and scheduled training |
| Executive Director | Executive Director | Uncertain about liability insurance for AMAPs and acknowledged training deficiencies |
| Life Enrichment Director #86 | Life Enrichment Director | Acknowledged deficiencies in activity calendar documentation |
| AMAP RN | Registered Nurse | Acknowledged missing education and certifications for AMAP employees |
Inspection Report
Routine
Census: 97
Deficiencies: 5
May 6, 2024
Visit Reason
The inspection was a routine environmental survey conducted to assess compliance with health, safety, housekeeping, maintenance, and emergency preparedness regulations at Harmony at Morgantown assisted living and memory care facility.
Findings
The facility was found deficient in multiple areas including improper storage of soiled laundry, inaccessible or broken nurse call systems, inadequate housekeeping and maintenance with dirty surfaces and damaged furnishings, unsecured oxygen cylinders, and failure to rehearse and document the disaster and emergency preparedness plan annually.
Severity Breakdown
Class I: 2
Class II: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Soiled laundry stored in perforated hampers with no lids, failing to separate soiled and clean laundry. | Class II |
| Broken or missing nurse call cords near beds in multiple resident rooms, making call system inaccessible. | Class II |
| Failure to maintain a safe, sanitary, and accident-free living environment with dusty high touch surfaces, rusty ceiling registers, and dirty kitchen areas. | Class I |
| Failure to keep the interior and exterior of the residence clean and in good repair, including exposed drywall, missing paint, and unsecured oxygen cylinders. | Class II |
| Failure to rehearse and document the disaster and emergency preparedness plan annually. | Class I |
Report Facts
Facility census: 97
Deficiencies cited: 5
Oxygen cylinders unsecured: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified findings related to laundry storage, nurse call cords, housekeeping, and unsecured oxygen cylinders | |
| Executive Director | Acknowledged findings at exit interview and verified disaster preparedness documentation failure | |
| Healthcare Director | Involved in corrective action plans and verification of findings | |
| Memory Care Director | Involved in corrective action plans and verification of findings |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Jan 2, 2024
Visit Reason
Investigation of Complaint #30076 regarding the facility.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #30076 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 90
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 0
Nov 8, 2023
Visit Reason
Investigation of Complaint #29721 regarding facility conditions and care.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #29721 was investigated from 11/07/23 6:00 PM to 11/08/23 11:00 AM. The complaint was found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 97
Inspection Report
Follow-Up
Census: 84
Deficiencies: 0
Sep 11, 2023
Visit Reason
The visit was a first revisit to the annual survey to verify correction of previously cited deficiencies.
Findings
The revisit found that all previously cited deficiencies were cleared and no new deficiencies were identified.
Report Facts
Census: 84
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Sep 11, 2023
Visit Reason
Second revisit to complaint #28308 to verify correction of previously cited deficiencies.
Findings
The revisit found that the previously cited deficiencies were cleared and no new deficiencies were identified during the inspection.
Complaint Details
Complaint #28308; deficiency cleared upon second revisit.
Report Facts
Census: 53
Census: 31
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 2
Jul 20, 2023
Visit Reason
The inspection was a revisit to Complaint #28308 to investigate deficiencies related to transfer and discharge documentation and facility housekeeping and maintenance.
Findings
The facility failed to prepare complete transfer or discharge summaries including functional needs assessments and pertinent progress notes for residents transferred to hospitals. Additionally, inadequate housekeeping and maintenance issues were observed, such as damaged carpets, missing bathroom fixtures, and unclean sinks.
Complaint Details
This was a first revisit to Complaint #28308. The complaint was substantiated with repeat deficiencies found regarding incomplete transfer documentation and inadequate housekeeping and maintenance.
Deficiencies (2)
| Description |
|---|
| Failed to prepare prior to transfer or discharge a summary including medical history, functional needs assessment, service plans, physician's orders, advanced directives, allergies, and progress notes. |
| Failed to ensure adequate housekeeping and maintenance required to carry out services, including presence of personal belongings behind furniture, carpet damage, missing towel bars and toilet paper holders, and unclean sinks. |
Report Facts
Census: 56
Census: 30
Staff training sign-off: 9
Transfer/discharge forms reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director #52 | Healthcare Director | Interviewed regarding transfer documentation practices and deficiencies |
Inspection Report
Original Licensing
Census: 55
Deficiencies: 0
Jul 5, 2023
Visit Reason
The inspection was conducted as an initial licensure survey for the facility.
Findings
The environmental inspection found no deficiencies cited during the initial licensure survey.
Report Facts
Census: 55
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 5
Jun 29, 2023
Visit Reason
Annual survey conducted from 06/26/23 to 06/29/23 to assess compliance with regulatory requirements for assisted living and memory care residents.
Findings
The facility failed to report major incidents timely, maintain accurate resident records including service plans and health assessments, and ensure proper weight monitoring and reporting. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.
Severity Breakdown
Class III: 2
Class II: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to report major incidents to the Office of Health Facility Licensure and Certification as soon as possible and no later than the next business day. | Class III |
| Failure to maintain accurate records and reports, including missing signatures and dates on service plans. | Class II |
| Failure to ensure written, signed, and dated health assessments by a licensed healthcare professional within required timeframes and maintain documentation. | Class II |
| Failure to provide adequate housekeeping and maintenance, including damaged carpets, missing towel bars and toilet paper holders, and unclean sinks. | — |
| Failure to weigh residents upon admission and monthly thereafter, document weights, and report unplanned weight loss or gain of five pounds or more to the physician. | Class III |
Report Facts
Census: 57
Census: 29
Weight loss: 12.6
Weight gain: 19.8
Weight loss: 12
Weight loss: 10.8
Weight gain: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director #57 | Healthcare Director / Registered Nurse | Named in findings related to failure to report major incidents and maintain accurate records. |
| Executive Director #80 | Executive Director | Named in findings related to failure to report major incidents and oversight of documentation. |
| Former Employee / Registered Nurse | Registered Nurse | Named in relation to failure to report major incidents timely. |
Inspection Report
Census: 6
Deficiencies: 2
Jun 14, 2023
Visit Reason
The inspection was conducted to assess compliance with health and safety standards in a behavioral health facility, focusing on the safety and appropriateness of the environment for adolescent consumers.
Findings
The facility was found not to fully implement programs in a safe and appropriate environment, with specific issues including unsecured outside doors in adolescent girls' bedrooms and the TV room, and lack of awake staff supervision on weekend nights.
Deficiencies (2)
| Description |
|---|
| Adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumers. |
| An outside door in the TV room does not lock. |
Report Facts
Center census: 6
Sample size: 3
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 13, 2023
Visit Reason
The visit was a re-inspection of Harmony at Morgantown to verify compliance and check for deficiencies.
Findings
No deficiencies were cited during this re-inspection visit conducted on June 13, 2023.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Jun 6, 2023
Visit Reason
The inspection was conducted as a complaint survey for Harmony at Morgantown following Complaint ID WV00028425 from June 5 to June 6, 2023.
Findings
No deficiencies were cited during the complaint survey. The Ombudsman was notified via e-mail.
Complaint Details
Complaint ID WV00028425 was investigated during the survey. No deficiencies were found, indicating the complaint was not substantiated.
Report Facts
Census: 81
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 5, 2023
Visit Reason
The visit was the 4th re-visit to a complaint survey for Harmony at Morgantown to verify correction of previously cited deficiencies.
Findings
The deficiency cited in the complaint survey was corrected as of the visit date. The Ombudsman was notified via e-mail.
Complaint Details
Complaint ID WV00026385; the visit was a re-visit to a complaint survey and the deficiency was corrected.
Deficiencies (1)
| Description |
|---|
| Deficiency corrected. |
Report Facts
Complaint ID: WV00026385
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Apr 12, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to ensure proper transfer/discharge documentation accompanied a resident during hospital transfers.
Findings
The licensee failed to ensure that prior to transfer or discharge of a resident, a summary including medical history, functional needs, physician's orders, advanced directives, allergies, and progress notes accompanied the resident. Specifically, one resident's chart lacked transfer/discharge forms for multiple hospital visits.
Complaint Details
Complaint ID 28308 was investigated from 04/10/23 to 04/12/23. The complaint was unsubstantiated. The issue involved missing transfer/discharge forms for Assisted Living Resident #39 during hospital transfers on 02/14/23 and 03/19/23.
Deficiencies (1)
| Description |
|---|
| Failure to ensure transfer/discharge documentation accompanied resident transfers to hospital. |
Report Facts
Resident census: 58
Resident census: 22
Number of residents' charts reviewed: 10
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director | Registered Nurse | Named in relation to findings about transfer documentation and interview on 04/12/23 |
| Certified Nursing Assistant #08 | Certified Nursing Assistant | Documented resident condition and communication attempts |
| Licensed Practical Nurse #13 | Licensed Practical Nurse | Documented resident condition and care |
| Memory Care Unit Director | Licensed Practical Nurse | Documented resident condition and care |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Apr 5, 2023
Visit Reason
Revisit to Complaint ID 26554 Investigation Survey conducted to follow up on previously identified deficiencies.
Findings
The deficiency identified as AL E270 was cleared and corrected during this revisit inspection.
Complaint Details
Revisit to Complaint ID 26554. Deficiency AL E270 was cleared/corrected.
Deficiencies (1)
| Description |
|---|
| Deficiency AL E270 |
Report Facts
Census: 58
Census: 22
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Apr 5, 2023
Visit Reason
Revisit to Complaint ID 27485 Investigation Survey to verify correction of previously cited deficiencies.
Findings
Deficiencies related to AL E331 and AL E426 were cleared and corrected during this revisit inspection.
Complaint Details
Revisit to Complaint ID 27485 Investigation Survey; deficiencies previously cited were cleared/corrected.
Deficiencies (1)
| Description |
|---|
| Deficiencies AL E331 and AL E426 were cited previously but are now cleared/corrected. |
Report Facts
Census AL: 58
Census ALZ: 22
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 2
Mar 22, 2023
Visit Reason
Revisit to Complaint Investigation Survey conducted on 03/22/23 from 9:00 a.m. to 11:00 a.m. to assess compliance with care plan development and facility environment standards.
Findings
The facility failed to ensure the development of a written individualized care plan within twenty-one days of admission for an Alzheimer's/dementia resident. Additionally, observations revealed inadequate housekeeping and maintenance issues including damaged carpet, missing bathroom fixtures, and unclean conditions.
Complaint Details
Revisit to complaint investigation survey. Census at time of visit was Assisted Living 57 and Alzheimer's 23. The complaint involved missing 21-day assessment and care plan for Resident #13. The Executive Director confirmed inability to locate the assessment/care plan.
Deficiencies (2)
| Description |
|---|
| Failure to develop a written individualized care plan within twenty-one days of admission for Alzheimer's/dementia special care unit residents. |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bar and toilet paper holder, dirty sink, and torn chair. |
Report Facts
Census: 57
Census: 23
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Interviewed regarding missing 21-day assessment and care plan for Resident #13 |
Inspection Report
Re-Inspection
Census: 85
Deficiencies: 2
Feb 2, 2023
Visit Reason
The visit was a re-inspection related to Complaint #27401 to follow up on previously identified deficiencies regarding fire safety, disaster preparedness, and facility maintenance.
Findings
The facility failed to provide documentation of annual disaster and emergency preparedness training for all staff, and deficiencies in housekeeping and maintenance were observed, including damaged carpet and missing bathroom fixtures. The Executive Director acknowledged these findings during the exit interview.
Complaint Details
Complaint #27401 was the basis for the revisit inspection conducted from 02/01/23 to 02/02/23. The survey type was a Revisit Complaint. Census at the time was 85 (58 Assisted Living, 27 Memory Care).
Severity Breakdown
Class I: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to rehearse the disaster and emergency preparedness plan with all staff annually and maintain documentation of participation and critique. | Class I |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bar and toilet paper holder, dirty sink, and torn chair. | — |
Report Facts
Census: 85
Sample Size: 3
Completion Date: Mar 24, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed and acknowledged findings related to disaster preparedness and facility deficiencies | |
| Maintenance Director | Responsible for conducting disaster preparedness training and rehearsals | |
| Business Office Manager | Responsible for educating new employees on disaster preparedness plan |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Nov 9, 2022
Visit Reason
Revisit to Complaint Investigation #27003 conducted to verify correction of previously cited deficiencies.
Findings
The revisit inspection found that all previously cited deficiencies were corrected or cleared, and no new deficiencies were cited during this visit.
Complaint Details
Complaint Investigation #27003; deficiencies corrected/cleared; no new deficiencies cited.
Report Facts
Census AL: 58
Census ALZ: 30
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 0
Nov 9, 2022
Visit Reason
Revisit to Complaint Investigation #26864 to verify correction of previously cited deficiencies.
Findings
No new deficiencies were cited during the revisit. The previously identified deficiencies were corrected and cleared.
Complaint Details
Complaint Investigation #26864 was revisited; deficiencies were corrected and cleared with no new deficiencies cited.
Report Facts
Census: 88
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Nov 9, 2022
Visit Reason
The inspection was a 2nd revisit to a complaint investigation survey to assess compliance with training requirements and facility conditions.
Findings
The facility failed to provide required Alzheimer's disease and related dementias training to new and existing employees within the mandated timeframe. Additionally, the facility did not maintain adequate housekeeping and maintenance, including damaged carpets, missing bathroom fixtures, and unclean sinks.
Complaint Details
This was a 2nd revisit to a complaint investigation survey. Deficiency E270 was recited. Deficiencies E261, E268, E327, E379, and Z107 were corrected/cleared.
Deficiencies (2)
| Description |
|---|
| Failure to provide training to all new employees within 15 days of employment and annually thereafter on Alzheimer's disease and related dementias. |
| Inadequate housekeeping and maintenance including iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Census: 58
Census: 30
Employee files reviewed: 4
Residents affected: 30
Employees not trained: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director #01 | Healthcare Director | Had not completed required two-hour annual Alzheimer's training for 2022 |
| CNA #04 | Certified Nursing Assistant | Hired 06/21/22, had not received required two-hour Alzheimer's training |
| Resident Assistant #44 | Resident Assistant | Hired 08/25/22, had not received required two-hour Alzheimer's training |
| Resident Assistant #57 | Resident Assistant | Hired 09/21/22, had not received required two-hour Alzheimer's training |
| Memory Care Director #91 | Memory Care Director | Interviewed and stated new employees had not yet been trained on Alzheimer's/Dementia-related diseases |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Oct 13, 2022
Visit Reason
Complaint investigation conducted from 10/06/22 to 10/13/22 regarding allegations of inadequate food and fluid provision to residents during a COVID outbreak.
Findings
The licensee failed to provide adequate food and fluid to maintain appropriate minimum average weight for three residents (#32, #57, #58) during a COVID outbreak. Documentation and interviews revealed missed meals, delayed food delivery, and lack of clear communication about residents' COVID status among staff. Additionally, housekeeping and maintenance deficiencies were observed in the facility environment.
Complaint Details
Complaint Investigation #27485 was substantiated. The investigation period was from 10/06/22 2:15 p.m. to 10/13/22 12:00 p.m. Census at time of investigation was 60 residents.
Severity Breakdown
Class I: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide each resident with the amount of food and fluid daily necessary to maintain appropriate minimum average weight for three residents during COVID outbreak. | Class I |
| Inadequate housekeeping and maintenance including personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Residents affected: 3
Resident census: 60
Weight loss: 6.5
Meal delivery frequency: 3
Date of survey completion: 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #39 | Licensed Practical Nurse | Documented Resident #32 found on floor and incident details. |
| Dining Services Director #84 | Dining Services Director | Reported meals were delivered to COVID-positive residents three times daily. |
| Director of Nursing / Healthcare Director #2 | Director of Nursing / Healthcare Director | Observed food delivery to COVID-positive residents and provided meal consumption sheets. |
Inspection Report
Routine
Census: 87
Deficiencies: 0
Oct 3, 2022
Visit Reason
The inspection was conducted as a routine visit to assess compliance with regulations for the assisted living and memory care facility.
Findings
The report documents initial comments including census counts for assisted living and memory care. No specific deficiencies or severity levels are detailed in this excerpt.
Report Facts
Census: 57
Census: 30
Inspection Report
Routine
Census: 56
Capacity: 31
Deficiencies: 0
Sep 20, 2022
Visit Reason
The inspection was conducted as a routine survey of the assisted living facility to assess compliance with regulatory requirements.
Findings
The report indicates no citations were issued during the inspection. The census was 56 residents with a licensed capacity of 31 beds.
Report Facts
Census: 56
Total Capacity: 31
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Sep 20, 2022
Visit Reason
The inspection was conducted as a complaint survey to investigate concerns related to medication administration, medication storage, housekeeping, maintenance, and emergency preparedness at the assisted living and memory care facility.
Findings
The facility failed to maintain proper medication administration records and secure medication storage, with medications being left in residents' rooms. Housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean sinks. Additionally, the facility did not ensure all staff participated in disaster and emergency preparedness drills.
Complaint Details
Complaint ID 27401, conducted from 09/19/22 to 09/20/22, census at time of survey was Assisted Living 56 and Memory Care 31.
Severity Breakdown
Class I: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to keep a record of all medications given to each resident including signatures of administering staff; medications were not kept in locked storage and were left in residents' rooms. | Class I |
| Failed to ensure adequate housekeeping and maintenance, including damaged carpets, missing towel bars and toilet paper holders, and dirty sinks. | — |
| Failed to ensure all staff rehearsed the disaster and emergency preparedness plan annually; only 38 of 92 staff participated in elopement drills. | Class I |
Report Facts
Census: 56
Census: 31
Staff participation: 38
Total staff: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health Care Director | Interviewed regarding medication administration and storage issues; recently hired in July. | |
| Memory Care Director | Licensed Practical Nurse | Interviewed regarding medication administration practices and resident self-administration. |
| Executive Director | Responsible for reviewing and signing off on monthly all staff meeting forms related to emergency preparedness training. | |
| Maintenance Director | Responsible for conducting disaster and emergency preparedness rehearsals with staff. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 0
Sep 20, 2022
Visit Reason
The inspection was conducted in response to Complaint #27019 from 9/19/2022 to 9/20/2022 to investigate the complaint allegations.
Findings
No deficiencies were cited during the complaint investigation of the assisted living and memory care facility.
Complaint Details
Complaint #27019 was investigated from 9/19/2022 10:30 A.M. to 9/20/2022 12:15 P.M. No deficiencies were found or cited.
Report Facts
Census: 56
Memory Care Census: 31
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Aug 31, 2022
Visit Reason
The inspection was conducted as a complaint survey based on Complaint ID 27082 from 08/30/22 to 08/31/22.
Findings
No deficiencies were cited during the complaint survey conducted at the facility.
Complaint Details
Complaint ID 27082 was investigated during the survey. No deficiencies were cited, indicating no substantiated issues.
Report Facts
Census: 58
Inspection Report
Follow-Up
Census: 89
Deficiencies: 7
Aug 31, 2022
Visit Reason
This was a 1st follow-up visit to a complaint survey conducted from 08/30/22 to 08/31/22 to assess compliance with previously cited deficiencies related to staffing, employee training, care plans, and housekeeping.
Findings
The facility failed to meet staffing requirements for direct care personnel hours and night shift staffing ratios, did not ensure employee training on service plans and Alzheimer's disease within required timeframes, and failed to maintain adequate housekeeping and maintenance. Additionally, residents did not have access to inspection results as required, and one resident's care plan was not updated to reflect increased needs.
Complaint Details
This was a follow-up visit to complaint ID 26654. The complaint investigation identified multiple deficiencies including staffing shortages, inadequate employee training, failure to update care plans, and housekeeping issues. The follow-up assessed correction of these issues.
Severity Breakdown
Class II: 3
Class III: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide staffing at no less than an average of 2.25 direct care personnel hours per resident per day, and minimum two direct care personnel present when census is greater than five. | — |
| Failed to ensure adequate housekeeping and maintenance, including damaged carpet, missing bathroom fixtures, and unclean sink. | — |
| Failed to update functional needs assessment and service plans to reflect resident's current needs and significant changes. | Class II |
| Failed to make inspection and complaint investigation results accessible to residents. | Class III |
| Failed to provide and maintain record of employee orientation and training prior to unsupervised work and within 15 days of employment. | Class II |
| Failed to provide training on Alzheimer's disease and related dementias within 15 days of employment and annually thereafter. | Class II |
| Failed to ensure night shift staffing met minimum requirements for residents with two or more special care needs. | — |
Report Facts
Resident census: 58
Resident census: 31
Direct care hours per resident per day: 2
Direct care hours per resident per day: 2.06
Staffing shortage hours: 4
Staffing shortage hours: 8
Employee training completion timeframe: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #44 | Did not receive initial Alzheimer's disease training within 15 days of employment | |
| Employee #82 | Did not receive initial Alzheimer's disease training and training on review of service plans within 15 days of employment | |
| Memory Care Director | Interviewed regarding staffing issues and training deficiencies | |
| Health Care Director | Interviewed regarding care plan updates and employee training | |
| Executive Director | Responsible for oversight of staffing, training, and compliance |
Inspection Report
Follow-Up
Census: 58
Deficiencies: 2
Aug 30, 2022
Visit Reason
Follow-up complaint survey conducted as a second visit to verify correction of previous deficiencies related to assessments and plans of care.
Findings
The facility failed to ensure the required signatures on the twenty-one day individualized care plans and failed to make copies of the care plans available to all staff for consistent implementation. Plans of correction were initiated to address these issues.
Complaint Details
Follow-up complaint survey: 2nd visit. Complaint ID: 26395. Survey conducted on 8/30/22 from 8:00 a.m. to 10:00 a.m. Census at time of complaint: 58 Assisted Living residents.
Deficiencies (2)
| Description |
|---|
| Failed to ensure the required signatures of each member of the interdisciplinary team, the resident, and/or the resident's legal representative were recorded on the resident's twenty-one day individualized care plan. |
| Failed to ensure a copy of the twenty-one day care plan was made available to all staff to ensure consistent implementation. |
Report Facts
Facility census: 58
Memory Care census: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Healthcare Director | Named in relation to findings about missing signatures on care plans and care plan availability | |
| Harmony Square Director | Responsible for completing plan of correction related to care plans | |
| Executive Director | Responsible for monitoring and reviewing care plan documentation and completion | |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding missing twenty-one day service plan and printing it for surveyor |
| Memory Care Director #93 | Brought resident's three and seven day service plans with signatures to survey area |
Inspection Report
Follow-Up
Census: 58
Deficiencies: 0
Aug 29, 2022
Visit Reason
The visit was a follow-up survey conducted in response to Complaint ID 26736 to assess compliance and corrective actions.
Findings
The report documents a follow-up survey conducted at Harmony at Morgantown, an assisted living and memory care facility, with a census of 58 residents. The survey was conducted to verify correction of previous deficiencies related to the complaint.
Complaint Details
Complaint ID 26736 triggered the follow-up survey; no substantiation status is provided.
Report Facts
Census: 58
Inspection Report
Follow-Up
Census: 58
Deficiencies: 0
Aug 29, 2022
Visit Reason
Follow-up 3rd visit to the Annual Survey to verify correction of previously cited deficiencies.
Findings
The deficiencies identified in prior inspections were corrected as of the follow-up visit on 08/29/22.
Report Facts
Census: 58
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 5
Jun 23, 2022
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #26960) for Harmony at Morgantown, an assisted living and memory care facility.
Findings
The facility was found to have multiple deficiencies including improper medication storage (medications not stored in original containers and unsecured medications), food safety violations (open containers of pudding left out beyond allowed time), inadequate housekeeping and maintenance (damaged carpets, missing bathroom fixtures, dirty sinks), and unsecured access to kitchen and housekeeping areas posing safety risks.
Complaint Details
Complaint #26960 was entered on 06/18/22 at 8:00 PM and the exit was on 06/23/22 at 10:00 AM. The complaint investigation focused on medication storage, food safety, housekeeping, maintenance, and facility security issues.
Severity Breakdown
Class I: 4
Class II: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Medications were stored outside original containers and improperly labeled, including weekly pill minders and unmarked medicine cups on medication carts. | Class I |
| Medications were not kept in locked storage accessible only to responsible staff; unsecured medications found in medication rooms, resident rooms, and administrator's office. | Class I |
| Food service facilities failed to comply with food safety rules; open containers of vanilla pudding were left out on medication carts beyond the allowed 4-hour time limit. | Class II |
| Facility failed to provide adequate housekeeping and maintenance; findings included damaged carpet (iron burns, bleach spots), torn furniture, missing bathroom fixtures, dirty sinks, and miscellaneous personal belongings improperly stored. | Class I |
| Kitchen and housekeeping closets were left unlocked with access to knives, stove, and cleaning supplies, posing safety risks. | Class I |
Report Facts
Census: 60
Census: 31
Number of weekly pill minders: 7
Number of prescription bottles: 17
Number of unmarked medicine cups: 2
Number of residents potentially affected: 60
Time open for pudding container: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #57 | Licensed Practical Nurse | Named in medication storage findings; acknowledged improper medication storage and lack of awareness of medications being out of proper storage |
| Executive Director #80 | Executive Director | Interviewed regarding unlocked kitchen and medication storage issues |
| Dining Services Director #81 | Dining Services Director | Interviewed regarding unlocked kitchen and food safety issues |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage and food safety findings |
| Administrator | Interviewed regarding unsecured medications found in office and resident rooms |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 4
Jun 23, 2022
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #27003) to assess compliance with health, safety, and emergency preparedness regulations at Harmony at Morgantown Assisted Living and Memory Care facility.
Findings
The facility failed to provide annual in-service training on fire safety and evacuation plans to five of six tenured employees, did not conspicuously post emergency call information near telephones, and failed to educate and document emergency evacuation procedures for new residents within 24 hours of admission. Additionally, housekeeping and maintenance deficiencies were noted, including damaged carpets, missing bathroom fixtures, and unclean areas.
Complaint Details
Complaint #27003 was investigated from 06/18/22 to 06/23/22. The complaint involved concerns about fire safety training, emergency preparedness, and housekeeping/maintenance issues. The complaint was substantiated based on observations, record reviews, and interviews.
Deficiencies (4)
| Description |
|---|
| Failed to provide and maintain a record of annual in-service training on fire safety and evacuation plans for five of six tenured employees. |
| Failed to conspicuously post emergency call information near each telephone in the residence excluding resident rooms. |
| Failed to show all new residents how to evacuate the residence in an emergency within 24 hours of admission and document this in residents' records. |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Residents in Assisted Living: 60
Residents in Memory Care: 31
Tenured employees lacking annual fire safety training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director #80 | Executive Director | Interviewed and stated unawareness of emergency call information posting requirements. |
| Director of Nursing | Director of Nursing | Interviewed and acknowledged being behind on employee training. |
| Harmony Square Director | Licensed Practical Nurse | Interviewed and unaware of requirement to educate and document resident emergency evacuation within 24 hours of admission. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 2
May 18, 2022
Visit Reason
The inspection was conducted as a complaint investigation regarding the failure to provide structured activities for the Alzheimer's/dementia special care unit and program.
Findings
The licensee failed to provide scheduled and structured activities for the Memory Care unit, with multiple observations of activities not occurring as scheduled or lacking leadership. Additionally, inadequate housekeeping and maintenance issues were noted, including damaged carpets, missing bathroom fixtures, and unclean areas.
Complaint Details
Complaint number 26864 triggered the investigation conducted from 05/16/22 to 05/18/22. The complaint involved failure to provide scheduled activities and inadequate staffing for Memory Care residents.
Deficiencies (2)
| Description |
|---|
| Failed to provide activities appropriate to the needs of the Alzheimer's/dementia special care unit residents; activities were not provided as scheduled. |
| Failed to ensure adequate housekeeping and maintenance; observed iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Facility Census: 62
Memory Care Census: 32
Residents observed in activity room: 7
Residents observed in activity room: 11
Residents observed in activity room: 13
Residents observed in activity room: 13
Transporting residents time: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director #9 | Wellness Director | Interviewed regarding activities program and staffing issues |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 12
May 18, 2022
Visit Reason
Complaint survey conducted due to concerns about staffing, resident care, and facility conditions at Harmony at Morgantown assisted living and memory care facility.
Findings
The facility failed to maintain adequate staffing levels, including registered nurse coverage, resulting in delayed medication administration and incomplete nursing assessments. Housekeeping and maintenance were inadequate, with stained carpets and drywall dust in resident areas. Resident care plans and assessments were not consistently updated to reflect current needs. Employee training records were incomplete, and staff lacked training on emergency procedures. Medication administration was often delayed beyond the one-hour window.
Complaint Details
Complaint ID 26654 initiated due to staffing shortages, medication delays, and facility maintenance issues. Survey conducted from 05/09/22 to 05/18/22.
Deficiencies (12)
| Description |
|---|
| Alzheimer's/dementia special care unit failed to provide required staffing hours and minimum direct care personnel. |
| Failed to maintain a register of all residents with required admission and transfer information. |
| Failed to ensure adequate housekeeping and maintenance; observed personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sinks. |
| Failed to ensure adequate staffing ratios for residents with special care needs. |
| Failed to notify Secretary of permanent change in supervising registered nurse within required timeframe. |
| Failed to ensure functional needs assessments and service plans reflected current resident needs and were updated timely. |
| Failed to ensure registered nurse was notified immediately of residents with nursing care needs and to perform timely nursing assessments. |
| Failed to ensure registered nurse provided needed training to staff on when to contact nurse regarding changes in resident condition. |
| Failed to ensure registered nurse assumed responsibility for oversight of nursing care and services; facility lacked RN coverage for extended periods. |
| Failed to provide and maintain employee training records including specialty care based on resident needs and service plans for new hires. |
| Failed to ensure residents were not neglected; seven residents did not receive medications within the required one-hour time frame. |
| Failed to keep interior and exterior of residence clean and in good repair; stained carpets and drywall dust observed in resident areas. |
Report Facts
Resident census: 62
Resident census: 32
Residents with delayed medications: 7
Medication count: 46
Medication count: 16
Medication count: 28
Staffing hours: 1.93
Staffing hours: 1.87
Residents with two or more care needs: 20
Staff hours worked: 19.94
Staff hours worked: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Named in multiple findings related to staffing shortages, notification failures, and corrective action plans | |
| Memory Care Director | Licensed Practical Nurse involved in staffing and care plan deficiencies | |
| Business Office Manager | Involved in resident register maintenance and employee orientation | |
| Regional Director of Operations | Interviewed regarding notification of registered nurse shortage | |
| LPN #24 | Provided nursing notes on residents with colostomy and hypoglycemia | |
| LPN #42 | Night shift nurse involved in medication administration delays and staffing concerns | |
| LPN #25 | Night shift nurse involved in medication administration and staffing concerns | |
| Maintenance Director | Responsible for facility maintenance and cleaning oversight |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
May 11, 2022
Visit Reason
The inspection was conducted in response to a complaint (#26736) regarding the facility's failure to report a major incident involving a resident fall and fracture.
Findings
The licensee failed to report a major incident to the Office of Health Facility Licensure and Certification as required. One resident fell and fractured a femur, but the incident was not reported timely. Additionally, the facility had deficiencies in housekeeping and maintenance, including damaged carpets, missing bathroom fixtures, and unclean areas.
Complaint Details
Complaint #26736 regarding failure to report a major incident involving a resident fall and fracture. The complaint was substantiated by documentation and interviews confirming the incident was not reported as required.
Severity Breakdown
Class III: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report major incidents to the Office of Health Facility Licensure and Certification as soon as possible and no later than the next business day. | Class III |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Facility Census: 62
Facility Census: 32
Sample Size: 3
Completion date for Plan of Correction: Jul 30, 2022
Date of resident fall: Apr 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Harmony Square Director | Interviewed regarding major incident notification process | |
| Executive Director | Responsible for Plan of Correction and providing in-service training | |
| Healthcare Director RN | RN | Responsible for Plan of Correction |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 3
May 10, 2022
Visit Reason
The inspection was a first follow-up to Complaint 26385 conducted to investigate concerns related to assessments, plans of care, and housekeeping/maintenance at the facility.
Findings
The facility failed to complete preliminary care plans within three days of admission and initial interdisciplinary assessments within seven days for four residents admitted in April 2022. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.
Complaint Details
First follow-up to Complaint 26385 conducted from 05/09/22 to 05/10/22.
Deficiencies (3)
| Description |
|---|
| Unit coordinator failed to review immediate care needs and establish preliminary care plans within three days of admission for four residents (#65, #77, #85, #92). |
| Failed to complete initial interdisciplinary assessments within seven days of admission including social history, family supports, ADL functioning, cognitive level, behavioral impairment, and nutritional status for four residents (#65, #77, #85, #92). |
| Inadequate housekeeping and maintenance including personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Resident census: 94
Residents without preliminary care plans: 4
Residents without initial interdisciplinary assessments: 4
Carpet replacement deadline: 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Provided resident rosters, stated no Director of Nursing on staff, and responsible for plan of correction. | |
| Memory Care Coordinator | Licensed Practical Nurse | Admitted residents without interdisciplinary team input and stated service plans were completed in computer but not reviewed or signed by RN. |
| Healthcare Director RN | Healthcare Director RN | Responsible for ensuring care plans and assessments are completed as part of plan of correction. |
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 3
Mar 21, 2022
Visit Reason
The inspection was a 2nd revisit to the annual survey conducted on 03/21/22 to assess compliance with nursing care documentation and housekeeping standards.
Findings
The facility failed to ensure a registered nurse maintained proper documentation for each visit, including date, time, duties, concerns, and signatures. Additionally, the facility lacked a full-time RN for over two months, resulting in incomplete nursing care documentation, especially for residents with special needs such as insulin administration. The facility also failed to maintain adequate housekeeping and maintenance, with issues such as damaged carpet, missing bathroom fixtures, and unclean sinks.
Severity Breakdown
Class III: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a registered nurse maintained a record with date, time in/out, duties, concerns, and signature for each visit. | Class III |
| Failed to ensure a registered nurse saw residents weekly for nursing care needs and documented progress notes reflecting resident status and changes. | Class II |
| Failed to maintain adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks. | — |
Report Facts
Facility census: 78
Sample size: 3
Completion date for carpet replacement: Sep 30, 2004
Plan of Correction completion date: Jul 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Harmony Square Director #89 | Interviewed regarding lack of RN on site and staffing difficulties | |
| Executive Director #79 | Executive Director | Interviewed about RN staffing and hiring a new RN on 03/21/22 |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 5
Jan 26, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to deficiencies in assessments, plans of care, resident rights, and health care standards at Harmony at Morgantown assisted living and memory care facility.
Findings
The facility failed to conduct required assessments within 3 and 7 days of admission for a resident in the memory care unit, denied the resident's Medical Power of Attorney access to medical records, and failed to prepare a summary of documentation to accompany a resident transferred to the emergency room. Additionally, housekeeping and maintenance deficiencies were observed.
Complaint Details
Complaint #26385 was substantiated. The investigation found multiple deficiencies related to resident assessments, rights, and health care standards.
Deficiencies (5)
| Description |
|---|
| Failed to conduct a three-day assessment of a resident upon admission to the memory care unit. |
| Failed to conduct a seven-day interdisciplinary assessment of a resident upon admission to the memory care unit. |
| Failed to grant resident or Medical Power of Attorney access to all medical records and one free copy. |
| Failed to prepare a summary of documentation to accompany a resident to the emergency room during transfer. |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. |
Report Facts
Census: 85
Assisted Living Census: 55
Alzheimer/Dementia Unit Census: 30
Sample Size: 3
Completion Dates for Plans of Correction: Apr 29, 2022
Completion Date for Resident Rights Plan of Correction: Mar 4, 2022
Completion Date for Health Care Standards Plan of Correction: Apr 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director #92 | Executive Director | Named in findings related to failure to conduct assessments, denial of medical records access, and incomplete transfer documentation. |
Inspection Report
Follow-Up
Census: 88
Deficiencies: 8
Dec 21, 2021
Visit Reason
Follow-up to Annual Survey 1st Visit conducted to assess compliance with previously identified deficiencies and regulatory requirements at Harmony at Morgantown Assisted Living and Memory Care facility.
Findings
The facility was found deficient in multiple areas including failure to provide proper 24-hour monitoring documentation following resident incidents, inadequate housekeeping and maintenance, incomplete employee training on Alzheimer's disease and related dementias, improper infection control practices, incomplete nursing documentation and visits, failure to provide residents with access to policies and procedures, and failure to document resident weights and report significant weight changes.
Severity Breakdown
Class I: 1
Class II: 3
Class III: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to provide documentation concerning monitoring six Assisted Living residents at least every eight hours during a 24-hour period following an accident or illness. | Class II |
| Failure to ensure adequate housekeeping and maintenance required to carry out services, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
| Failure to provide residents with information on how to access the residence's policies and procedures in the Alzheimer's/Dementia Special Care Unit written contract. | Class III |
| Failure to provide all resident care and services in accordance with current standards of practice using appropriate infection control techniques; staff observed not wearing masks correctly. | Class I |
| Failure to provide training to all new employees within 15 days of employment and annually thereafter on Alzheimer's disease and related dementias, including maintaining employee training records. | Class II |
| Failure to maintain a record with an entry for each registered nurse visit including date, time in/out, duties performed, concerns, and signature. | Class III |
| Failure of registered nurse to see residents weekly when nursing care needs exist and to document progress notes reflecting resident status and changes. | Class II |
| Failure to provide documentation of resident weights and failure to report unplanned weight loss or gain of five pounds or more to the resident's physician. | Class III |
Report Facts
Resident census: 58
Resident census: 30
Residents monitored: 6
Employees reviewed: 4
Residents with nursing care needs: 9
Missing RN time out entries: 8
Completion date: Feb 28, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Williams | Licensed Practical Nurse | Documented medication error and monitoring directions for Resident #26 |
| Alize Mitchell | Licensed Practical Nurse | Documented vital signs and monitoring directions for Resident #52 |
| Harmony Square Director | Licensed Practical Nurse | Interviewed regarding infection control and monitoring documentation issues |
| Executive Director | Named in multiple interviews regarding facility compliance and Plan of Correction | |
| Business Office Manager | Provided training documentation and interviewed about employee training compliance |
Inspection Report
Follow-Up
Census: 88
Deficiencies: 0
Dec 21, 2021
Visit Reason
Revisit / Follow-up to Complaint Investigation #25508 conducted to verify correction of previously identified deficiencies.
Findings
The inspection was a follow-up visit to a complaint investigation to assess compliance and corrective actions taken by the facility.
Complaint Details
Complaint Investigation #25508 was the basis for the follow-up visit.
Report Facts
Census AL: 58
Census ALZ: 30
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 1
Jun 16, 2021
Visit Reason
The inspection was conducted in response to a substantiated complaint (Complaint 25508) concerning the accuracy of training records and care practices in the Memory Care and Assisted Living units.
Findings
The licensee failed to maintain accurate training records for the Executive Director, who was documented as having 30 hours of Alzheimer's training but admitted to only 4-5 hours. The deficiency potentially affected all 26 Alzheimer's residents. A plan of correction was established to ensure required training completion by August 31, 2021.
Complaint Details
Complaint number 25508 was substantiated. The complaint involved discrepancies in the Executive Director's training records and potential impact on 26 Alzheimer's residents. The inspection was entered on 2021-06-07 and exited on 2021-06-16.
Severity Breakdown
Class II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee failed to maintain accurate records of the Executive Director's Alzheimer's Disease/Dementia training hours. | Class II |
Report Facts
Memory Care Census: 26
Assisted Living Census: 42
Training hours discrepancy: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Named in finding regarding inaccurate training records and required to complete training |
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 23
Jun 16, 2021
Visit Reason
Annual survey of Harmony at Morgantown assisted living and Alzheimer's unit to assess compliance with state regulations.
Findings
The facility was found deficient in multiple areas including failure to complete interdisciplinary assessments and care plans timely, inadequate housekeeping and maintenance, failure to report major incidents timely, lack of RN oversight and documentation, missing resident records, incomplete staff training, and failure to maintain accurate resident weights and transfer documentation.
Deficiencies (23)
| Description |
|---|
| Failure to ensure interdisciplinary team completed initial assessments within seven days of admission for Alzheimer's unit residents. |
| Failure to develop individualized care plans within 21 days of admission for Alzheimer's unit residents. |
| Failure to ensure monthly evaluation by a registered nurse of residents receiving psychotropic medications. |
| Failure to ensure resident's physician documented reassessment every six months for continued use of psychotropic medications. |
| Failure to conduct comprehensive social assessments by licensed social worker or professional counselor for Alzheimer's residents. |
| Failure to report major incidents to the Office of Health Facility Licensure and Certification as soon as possible and no later than the next business day. |
| Failure to ensure individualized care plans reflect current resident needs and are updated annually or with significant changes. |
| Failure to notify registered nurse immediately of resident admissions, readmissions, or nursing care needs. |
| Failure to provide needed training to staff on when to contact registered nurse regarding resident condition changes. |
| Failure to develop and implement a plan for 24-hour accessibility between residence, registered nurse, and emergency personnel. |
| Failure to keep laundry supplies and hazardous materials in locked storage separate from food and drugs. |
| Failure to maintain accurate records and reports as required by regulation. |
| Failure to retain closed resident records in a secure area and make them available for inspection. |
| Failure to provide and maintain records of annual in-service training on required topics for staff. |
| Failure to have annual health assessments signed and dated by a licensed health care professional authorized under state law. |
| Failure to maintain a record of registered nurse visits including date, time in/out, duties performed, concerns, and actions taken. |
| Failure to develop and document service plans within seven days after admission and update with significant changes. |
| Administrator lacked knowledge of regulatory requirements and failed to ensure compliance with laws and policies. |
| Failure to ensure registered nurse participation in admission and discharge decisions for residents with nursing care needs. |
| Failure to include health and nursing care services in the Alzheimer's unit residency agreement. |
| Failure to include notification regarding pets in the Alzheimer's unit residency agreement. |
| Failure to see residents weekly by registered nurse and document progress notes reflecting status and changes. |
| Failure to provide each resident with adequate food and fluid to maintain appropriate weight and document weights monthly. |
Report Facts
Census: 42
Census: 26
Deficiencies cited: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director #49 | Executive Director | Named in findings related to lack of regulatory knowledge and training |
| Health Care Director #26 | Licensed Practical Nurse / Healthcare Director | Named in findings related to assessments and RN notification failures |
| Life Enrichment Director #8 | Life Enrichment Director | Named in findings related to social assessments |
| Licensed Social Worker #58 | Licensed Social Worker | Named in findings related to assessments and care plans |
| HSD #4 | Health Services Director / Licensed Practical Nurse | Interviewed regarding assessments and incident reporting |
| Former RN #63 | Registered Nurse | Named in findings related to lack of notification and documentation |
Inspection Report
Routine
Census: 72
Deficiencies: 2
Jun 8, 2021
Visit Reason
The inspection was conducted as a routine environmental survey to assess compliance with health, safety, housekeeping, laundry, and physical facility maintenance requirements.
Findings
The facility was found to have deficiencies related to improper storage and transport of soiled laundry, inadequate housekeeping and maintenance including dusty vents, dirty surfaces, and damaged furnishings. These issues were acknowledged by the Administrator during the exit interview.
Deficiencies (2)
| Description |
|---|
| Failure to ensure that soiled and clean laundry were stored separately and transported properly, with uncovered laundry containers observed. |
| Failure to maintain the interior and exterior of the residence clean and in good repair, including dusty ceiling vents, dirty kitchen surfaces, damaged carpet, and missing bathroom fixtures. |
Report Facts
Facility census: 72
Facility census: 46
Facility census: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding laundry storage deficiencies and acknowledged findings at exit interview | |
| Executive Director | Responsible for monitoring correction of deficiencies and providing in-service training | |
| Dining Service Director | Involved in plan of correction for cleaning and sanitizing surfaces | |
| CNA #13 | Certified Nursing Assistant | Interviewed regarding laundry transport practices |
Inspection Report
Follow-Up
Census: 22
Deficiencies: 0
Mar 4, 2021
Visit Reason
Follow-up to Complaint 24791 to verify correction of previously cited deficiencies.
Findings
The inspection found that two previously cited tags, Z101 and Z104, were both cleared during this follow-up visit.
Complaint Details
Complaint 24791 was the reason for the follow-up visit; deficiencies related to this complaint were cleared.
Report Facts
Tags cleared: 2
Census: 22
Inspection Report
Routine
Census: 59
Deficiencies: 0
Jan 20, 2021
Visit Reason
The inspection was conducted as an Infection Control Survey at Harmony at Morgantown AL on January 20, 2021.
Findings
No deficiencies were cited during the infection control survey. The facility was found to be in compliance with infection control standards.
Report Facts
Census: 59
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Adkins | Named as the person conducting the infection control survey | |
| Richard Ertter | Contacted the Ombudsman by email |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 2
Dec 17, 2020
Visit Reason
The inspection was conducted as a complaint survey from December 14 to December 17, 2020, triggered by allegations regarding failure to provide monthly educational and family support group meetings and inadequate annual Alzheimer's/Dementia training for staff.
Findings
The facility failed to ensure monthly educational and family support group meetings were offered to residents' families and did not provide the required eight hours of annual Alzheimer's/Dementia training for three staff members. Additionally, housekeeping and maintenance deficiencies were noted in a prior behavioral health survey.
Complaint Details
Complaint Survey #24791 was substantiated. The complaint included failure to conduct family support group meetings for months and failure to provide required annual Alzheimer's/Dementia training to direct care staff.
Deficiencies (2)
| Description |
|---|
| Facility failed to ensure monthly educational and family support group meetings were offered to residents' families. |
| Facility failed to ensure eight (8) hours of annual Alzheimer's/Dementia training was provided for three staff members. |
Report Facts
Census: 49
Staff missing training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lead Cook #11 | Identified as staff missing required annual Alzheimer's/Dementia training. | |
| CNA #16 | Certified Nursing Assistant | Identified as staff missing required annual Alzheimer's/Dementia training. |
| CNA #39 | Certified Nursing Assistant | Identified as staff missing required annual Alzheimer's/Dementia training. |
| Executive Director #9 | Executive Director | Verified the facility had started monthly educational and family support group meetings and acknowledged uncertainty about training documentation. |
| Executive Director #6 | Executive Director | Verified the first family support group meeting since starting in October 2020 and efforts to find creative meeting solutions due to COVID-19. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 17, 2020
Visit Reason
The inspection was conducted as a complaint investigation following complaint number 24781, with the visit occurring from December 14, 2020 to December 17, 2020.
Findings
No related or unrelated citations were found during the complaint investigation.
Complaint Details
Complaint #24781 was investigated from 12/14/20 to 12/17/20 with no related or unrelated citations identified.
Report Facts
Complaint Number: 24781
Inspection Report
Original Licensing
Census: 31
Deficiencies: 0
Jul 13, 2020
Visit Reason
The inspection was conducted as an initial licensure survey for the facility.
Findings
The environmental inspection conducted on July 13, 2020, found no deficiencies cited at the facility with a census of 31.
Report Facts
Census: 31
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 18, 2019
Visit Reason
Revisit desk review to evaluate credible evidence related to previous deficiencies.
Findings
The revisit desk review found credible evidence accepted, indicating follow-up on prior issues. No new deficiencies or severity levels were explicitly stated.
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 2
Aug 15, 2019
Visit Reason
Annual Assisted Living Survey including Alzheimer's Unit Survey conducted from August 12 to August 15, 2019.
Findings
The facility failed to monitor and document residents' conditions at least every eight hours for 24 hours following accidents or illnesses for multiple residents. Additionally, inadequate housekeeping and maintenance issues were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.
Severity Breakdown
Class II: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to monitor and document residents' condition at least every eight hours for 24 hours following accidents or illnesses for residents #7, #9, #13, #14, #16, #17, #23, and #26. | Class II |
| Inadequate housekeeping and maintenance including personal belongings left behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Census: 16
Census: 28
Number of residents with monitoring deficiencies: 8
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 0
Jul 17, 2019
Visit Reason
The inspection was conducted as an annual licensure survey to assess environmental compliance at the facility.
Findings
No deficiencies were cited during the annual licensure survey conducted on July 17, 2019.
Report Facts
Census: 41
Inspection Report
Original Licensing
Census: 3
Deficiencies: 0
Oct 23, 2018
Visit Reason
Initial licensure survey conducted to assess compliance for facility licensing.
Findings
No deficiencies were cited during the initial licensure survey conducted on October 22-23, 2018.
Report Facts
Census: 3
Inspection Report
Original Licensing
Census: 3
Deficiencies: 0
Oct 22, 2018
Visit Reason
Initial licensure survey conducted to evaluate environmental conditions and compliance for licensing of the facility.
Findings
The survey found no deficiencies related to environmental conditions, fire marshal report, sprinkler system, or sanitation as of the inspection date.
Report Facts
Census: 3
Date of Fire Marshal report: Jun 1, 2018
Date of sanitation report: Sep 24, 2018
Sprinkler Type: 13
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