Inspection Reports for Harmony at White Oaks

The inspection was conducted as an annual licensure survey of the facility.

The survey found no deficiencies or tags cited during the inspection of the assisted living and memory care units.

Follow-up to Complaint #39882 to verify correction of previously identified deficiencies.

The deficiency identified in the prior complaint investigation was corrected as of the follow-up visit.

Complaint #39882; the deficiency was corrected.

Investigation of Complaint #40143 conducted from 2025-10-07 to 2025-10-08 to determine the validity of the complaint.

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

Complaint #40143 was investigated and found to be unsubstantiated with no deficiencies cited.

Investigation of Complaint #39882 regarding a resident elopement incident that occurred on 08/06/25.

The complaint was substantiated. The facility failed to ensure adequate staffing and supervision, resulting in one resident eloping without staff knowledge. Deficiencies in housekeeping and maintenance were also noted.

Complaint #39882 was substantiated. Resident #53 eloped from the facility on 08/06/25. The resident had a history of exit-seeking and a wander management system was in place. Staff failed to monitor the resident adequately during the incident.

Follow-up to Complaint #37513 to verify correction of previously cited deficiencies.

The deficiencies identified in the prior complaint investigation were corrected as of the follow-up visit.

Complaint #37513 was investigated and deficiencies were found; this follow-up visit confirmed the deficiencies were corrected.

Investigation of Complaint #38454 conducted from 04/22/25 to 04/23/25 at Harmony at White Oaks.

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

Complaint #38454 was investigated and found to be unsubstantiated with no deficiencies cited.

Second follow-up to Complaint #35017 to verify correction of previously identified deficiencies.

The deficiencies identified in the prior complaint investigation were corrected as of the follow-up visit.

Complaint #35017; deficiencies were corrected as of the follow-up visit.

Follow-up to Complaint #36304 to verify correction of previously identified deficiencies.

The deficiencies identified in the prior complaint investigation were corrected as of the follow-up visit.

Complaint #36304 was investigated and deficiencies were found; this follow-up visit confirmed the deficiencies were corrected.

The inspection was conducted as an investigation of Complaint #37513 from 04/02/25 to 04/03/25.

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

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

Investigation of Complaint #37033 regarding the assisted living and memory care facility.

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

Complaint #37033 was substantiated, and no deficiencies were cited.

First follow-up to Complaint #35017 conducted from 01/20/25 to 01/27/25 to verify correction of previous deficiencies and identify any new issues.

One deficiency was corrected, one deficiency was re-cited, and additional unrelated deficiencies were cited. Deficiencies included failure to ensure Memory Care Coordinator met training requirements, failure to maintain confidentiality of resident medical information, expired food handler cards for kitchen staff, unlocked medication carts, and inadequate housekeeping and maintenance resulting in unsafe and unsanitary conditions.

This was a follow-up to Complaint #35017. The survey was conducted to verify correction of cited deficiencies and to identify any new issues. One deficiency was corrected, one was re-cited, and additional unrelated deficiencies were cited.

Investigation of Complaint #36304 conducted from 01/20/25 to 01/27/25 at Harmony at White Oaks, an assisted living and memory care facility.

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

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

Investigation of Complaint #35845 conducted from 2024-12-09 to 2024-12-10.

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

Complaint #35845 was investigated and found to be unsubstantiated with no deficiencies cited.

Follow-up to Complaint #34325 to verify correction of previously identified deficiencies.

The deficiencies identified in the prior complaint investigation were corrected as of the follow-up visit.

Complaint #34325 was the reason for the follow-up visit; deficiencies were found previously but were corrected by the time of this inspection.

This is a re-inspection visit to verify correction of previously cited deficiencies from the environmental survey conducted on September 25, 2024.

All previously cited deficiencies (0446, 0450, 0462, and 0496) were corrected as of the re-inspection on October 30, 2024, with the exception of a pending waiver decision on deficiency 0462.

The inspection was conducted as an investigation of Complaint #35017, which was substantiated. The visit aimed to assess compliance with regulations and address the complaint allegations.

The facility failed to ensure the Memory Care Coordinator met minimum qualifications, and failed to monitor and document a resident's condition every eight hours for 24 hours following an accident. Additionally, inadequate housekeeping and maintenance issues were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.

Complaint #35017 was investigated from 2024-10-29 to 2024-10-30. The complaint was substantiated, and unrelated deficiencies were cited.

Investigation of Complaint #34798 conducted from 2024-10-28 to 2024-10-30 at Cedar Grove Assisted Living.

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

Complaint #34798 was investigated and found to be unsubstantiated with no deficiencies cited.

Follow-up to the annual survey to verify correction of previously cited deficiencies.

The deficiencies identified in the prior annual survey were corrected as of the follow-up visit.

Follow-up to Complaint #33183 to verify correction of previously identified deficiencies.

The deficiency identified in the prior complaint investigation was corrected as of the follow-up visit.

Complaint #33183 was the basis for the follow-up visit; the deficiency was corrected.

The visit was conducted as an annual survey of Cedar Grove Assisted Living to assess compliance with regulatory standards.

The annual survey found no deficiencies cited at the facility during the inspection period from September 23 to September 25, 2024.

The inspection was conducted to evaluate compliance with health, safety, housekeeping, maintenance, and physical facility regulations at Cedar Grove Assisted Living.

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

The inspection was conducted as an investigation of Complaint #34325 regarding medication administration and storage practices at Cedar Grove Assisted Living.

The facility failed to ensure a resident was documented as capable of self-administering medications prior to self-administration, and medications were left accessible on a resident's bedside table without staff supervision. Additionally, medications were not kept in a locked storage accessible only to responsible staff. The complaint was substantiated and deficiencies were cited.

Investigation of Complaint #34325 on 09/25/24. The complaint was substantiated and deficiencies were cited related to medication administration and storage.

The inspection was conducted as an annual survey of the assisted living and memory care facility to assess compliance with health, safety, and regulatory requirements.

The survey identified multiple deficiencies including failure to maintain proof of pet vaccinations for five pets, inaccurate resident records for one resident, use of unauthorized visual and auditory monitoring devices in resident apartments, and inadequate housekeeping and maintenance issues such as damaged carpets and missing bathroom fixtures.

The inspection was conducted as a license renewal survey to determine if the residence is in substantial compliance with state requirements.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to substantially meet the State requirements with no deficiencies cited.

Investigation of Complaint #33183 regarding delayed response to residents' call lights and staffing issues at the assisted living and memory care facility.

The facility failed to ensure residents' call lights were answered timely, with documented delays ranging from 31 to 55 minutes. Staffing shortages were reported by multiple anonymous employees, impacting timely response to residents' needs. The complaint was substantiated and deficiencies were cited.

Complaint #33183 was substantiated. The investigation covered the period 07/08/24 to 07/16/24. Census at the time was Assisted Living-67 and Memory Care-24.

Investigation of Complaint #31469 at Cedar Grove Assisted Living.

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

Complaint #31469 was investigated and substantiated; however, no deficiencies were cited.

Second follow-up to annual survey to verify correction of previously identified deficiencies.

The deficiency identified in the prior annual survey was corrected as of the follow-up visit.

The visit was conducted as a follow-up to verify correction of previous deficiencies related to safety and supervision at Cedar Grove Assisted Living.

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

Investigation of Complaint #29988 at Harmony at White Oaks, including Assisted Living and Memory Care units.

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

Complaint #29988 was investigated from 12/06/23, found unsubstantiated with no deficiencies cited.

The annual survey was conducted from 12/04/23 to 12/06/23 to assess compliance with regulatory requirements for Cedar Grove Assisted Living.

The facility was found deficient in documenting the name of the person to whom a resident's body was released upon death for two residents, and failed to ensure required documentation accompanied residents upon transfer for three residents. Deficiencies were cited related to resident death documentation and transfer/discharge records.

Annual environmental inspection conducted to assess compliance with health and safety regulations.

No deficiencies were cited during the inspection. The facility has a sprinkler type 13 system and is connected to city sewer.

The inspection was conducted to assess staffing requirements and compliance with regulations regarding night shift staffing levels for residents with two or more special care needs.

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

Investigation of Complaint #29702 at Harmony at White Oaks assisted living and Alzheimer's care facility.

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

Complaint #29702 was investigated on 11/06/23. The complaint was found to be unsubstantiated with no deficiencies cited.

Investigation of Complaint #29445 at Harmony at White Oaks, including Memory Care and Assisted Living units.

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

Complaint #29445 was investigated on 10/24/2023 from 9:00 AM to 3:00 PM. The complaint was found to be unsubstantiated with no deficiencies cited.

First revisit to complaint #28750 to verify correction of previously cited deficiencies.

Deficiencies cited in the prior complaint were cleared and corrected. No new deficiencies were cited during this revisit inspection.

Complaint #28750 was investigated and deficiencies were cleared/corrected as of the revisit on 10/19/2023.

The inspection was an annual recertification survey conducted to assess compliance with regulatory requirements and review the correction of previously cited deficiencies.

The survey found deficiencies related to tags 0445 and 0450, which were addressed and corrected by the follow-up survey on the same day. Additional reports included a Fire Marshall requirement and a Health Department violation.

Investigation of Complaint #28925 at Cedar Grove Assisted Living.

The complaint was investigated during the visit on 08/28/23 to 08/29/23. The complaint was found to be unsubstantiated with no citations issued.

Complaint #28925 was investigated and found unsubstantiated with no citations.

Investigation of Complaint #28924 conducted from 08/28/23 to 08/29/23.

The complaint was unsubstantiated with no citations issued during the investigation.

Complaint #28924 was investigated and found to be unsubstantiated with no citations.

Investigation of Complaint #28920 conducted from 08/28/23 to 08/29/23.

The complaint was unsubstantiated with no citations issued during the investigation.

Complaint #28920 was investigated and found to be unsubstantiated with no citations.

Annual survey conducted to assess compliance with state regulations for assisted living and memory care residents.

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

The inspection was an Environmental Annual survey conducted to assess compliance with health, safety, maintenance, housekeeping, and emergency preparedness regulations at Harmony at White Oaks.

The facility failed to maintain a safe, sanitary, and accident-free living environment, including issues such as stained ceiling tiles, dust accumulation, lack of keypad directions, and inadequate housekeeping. Additionally, the licensee failed to document and rehearse the disaster and emergency preparedness plan annually.

Investigation of Complaint #28750 at Cedar Grove Assisted Living from 07/25/23 to 08/02/23, involving allegations related to resident safety, incident reporting, and facility maintenance.

The investigation substantiated three allegations, including failure to monitor and document a resident's condition for 24 hours after an accident, failure to maintain accurate incident reports, and inadequate maintenance and housekeeping leading to unsafe conditions in the facility.

Investigation of Complaint #28750 from 07/25/23 to 08/02/23 at Cedar Grove Assisted Living. Three allegations were substantiated, including failure to monitor and document resident condition post-accident, failure to maintain accurate incident reports, and inadequate facility maintenance and housekeeping.

Investigation of Complaint #28794 from 07/25/23 to 08/02/23 regarding allegations at Cedar Grove Assisted Living.

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

Investigation of Complaint #28794 found 1 allegation substantiated with no deficiencies.

The document is a plan of correction submitted in response to a behavioral health survey conducted February 9-11, 2004, addressing deficiencies related to safety and supervision in the facility.

The facility was found not to have implemented programs in a safe and appropriate environment for adolescent consumers, specifically noting lack of alarms on outside doors and insufficient awake staff supervision on weekend nights.

The inspection was conducted as a complaint investigation based on allegations concerning the facility's maintenance, housekeeping, and safety conditions.

The facility was found to have multiple deficiencies related to maintaining a safe, sanitary, and accident-free living environment, including black substance in HVAC closet, food debris in Memory Care area, stained ceiling tiles, missing ceiling tiles, damaged carpet, and incomplete fire watch documentation. Two allegations were substantiated and one was unsubstantiated.

Complaint investigation with 2 allegations substantiated and 1 unsubstantiated. Tags cited were 0450 and 0452.

The inspection was conducted due to a complaint investigation with substantiated and unsubstantiated allegations regarding facility concerns.

The complaint investigation found 2 allegations substantiated and 1 unsubstantiated. A follow-up revisit confirmed all deficiencies were corrected.

Complaint investigation with 2 allegations substantiated and 1 unsubstantiated. Follow-up visit confirmed all deficiencies corrected.

The inspection was conducted in response to Complaint #27845, with entrance on 02/01/23 and exit on 02/02/23.

The complaint was investigated and found to be unsubstantiated. The report includes observations about safety concerns related to staff supervision and unsecured doors, with a plan to provide awake-night supervision on weekends by July 1, 2004.

Complaint #27845 was investigated from 02/01/23 to 02/02/23 and was found to be unsubstantiated.

Follow-up to the annual inspection conducted to verify compliance and corrective actions.

The report documents a follow-up visit to Cedar Grove Assisted Living with a census of 52 residents. The inspection was conducted to assess ongoing compliance following the annual survey.

Annual environmental inspection of Cedar Grove Assisted Living conducted on November 29, 2022.

No deficiencies were cited during this annual environmental inspection.

The annual survey was conducted to assess compliance with health care standards, nursing care requirements, and housekeeping/maintenance standards at Cedar Grove Assisted Living.

The facility failed to ensure proper completion of resident transfer/discharge summaries for three residents, and failed to ensure weekly nursing assessments and documentation for six residents with nursing care needs. Additionally, inadequate housekeeping and maintenance issues were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.

This was a 1st follow-up/revisit to the annual survey to verify correction of previously cited deficiencies.

No new deficiencies were cited during this follow-up visit, and previously cited deficiencies were corrected or cleared.

The visit was a follow-up survey conducted to verify correction of previously cited deficiencies from the August 23, 2022 environmental survey.

All deficiencies cited during the August 23, 2022 survey were corrected by the October 18, 2022 follow-up survey.

Revisit to a complaint #26899 to verify correction of previous deficiencies.

All deficiencies identified in the prior complaint investigation were cleared during this revisit inspection.

Complaint #26899 triggered the revisit inspection; all deficiencies were cleared.

The inspection was conducted as a complaint investigation (#27173) from August 30, 2022 to September 1, 2022.

No deficiencies were cited related to the allegation during the complaint investigation.

Complaint Investigation: #27173. No Deficiencies Cited Related to the Allegation.

The inspection was conducted as a complaint investigation from August 30, 2022, to September 1, 2022.

The complaint investigation was completed and the complaint was found to be unsubstantiated.

Complaint ID 27260 was investigated and found to be unsubstantiated.

Annual survey of Harmony at White Oaks assisted living and memory care facility to assess compliance with regulatory requirements.

The facility was found deficient in multiple areas including staff training on Alzheimer's care, housekeeping and maintenance issues, incomplete personnel records including tuberculosis screening, incomplete resident assessments and service plans, failure to document release of resident belongings upon death, inadequate documentation of resident condition monitoring post-accident, incomplete employee orientation and annual training records, unlocked medication cart, and failure to notify physicians of significant resident weight changes.

The inspection was conducted as an environmental survey of the facility to assess compliance with health, safety, housekeeping, laundry, maintenance, and physical environment regulations.

The facility was found to have deficiencies related to the physical environment, including failure to post directions for keypad exit locks, inadequate housekeeping and maintenance such as soiled floors, dust on high touch surfaces, improper laundry storage, and damaged furnishings. Corrective actions and staff re-education were planned and initiated.

Complaint investigation conducted from 08/15/22 to 08/17/22 regarding allegations of resident abuse and failure to maintain proper resident records and assessments.

The facility failed to ensure resident safety resulting in physical abuse of Resident #5 by Resident #9, inadequate nursing assessments and documentation, failure to maintain accurate resident registry and transfer summaries, and inadequate housekeeping and maintenance in the facility.

Complaint ID 27255 investigated from 08/15/22 to 08/17/22 involving allegations of resident abuse and failure to maintain proper documentation and assessments.

The inspection was conducted in response to complaint #27130 to investigate the allegations made against Cedar Grove Assisted Living.

The complaint was investigated and found to be unsubstantiated. No deficiencies or violations were noted in relation to the complaint.

Complaint #27130 was investigated from 08/01/22 1:00 PM to 08/02/22 12:00 PM and was determined to be unsubstantiated.

Revisit inspection conducted to verify correction of previous deficiencies identified under complaint investigation CI#c 26628.

The revisit inspection found that all citations from the prior complaint investigation were cleared.

Revisit of complaint investigation CI#c 26628; all citations cleared.

The inspection was conducted as a complaint survey (#26628) to investigate concerns related to facility maintenance, housekeeping, and resident care at Cedar Grove Assisted Living.

The facility was found deficient in maintaining safe and sanitary conditions, including issues with toilet and bathing facilities, laundry storage, service plan updates, and physical maintenance such as carpet stains and cleanliness. These deficiencies were verified by observation, employee interviews, and record reviews.

Complaint survey number 26628 was conducted with a census of 48 residents. The complaint focused on sanitation, maintenance, and care plan deficiencies.

Complaint survey conducted from 06/01/22 to 06/03/22 due to concerns about staffing adequacy and resident care, specifically regarding Resident #6 having to sleep overnight in her wheelchair due to insufficient staff assistance.

The facility failed to meet staffing requirements for day, evening, and night shifts based on residents' care needs, resulting in inadequate assistance for residents, including Resident #6 who required 2-3 staff for transfers but often had insufficient staff available. Additionally, the facility failed to maintain adequate housekeeping and maintenance, with issues such as damaged carpet, missing bathroom fixtures, and unclean sinks observed.

Complaint survey #26899 focused on Resident #6's care, specifically her having to sleep overnight in her wheelchair due to insufficient staff assistance. The complaint was substantiated by interviews and review of staffing records and service plans.

The visit was a revisit inspection to verify correction of previously cited deficiencies at Harmony at White Oaks, an assisted living and memory care facility.

The inspection found that previously cited deficiencies were cleared during this revisit inspection conducted on March 16, 2022.

The inspection was conducted as a behavioral health survey to assess the safety and appropriateness of the environment for adolescent consumers.

The facility was found not to have implemented programs in a safe and appropriate environment for consumers, with specific issues including lack of alarms on outside doors and inadequate awake-night supervision on weekends.

The inspection was conducted in response to Complaint #26352 to investigate allegations at the facility.

The complaint was investigated and found to be unsubstantiated.

Complaint #26352 was investigated from 01/12/22 to 01/13/22 and was determined to be unsubstantiated.

The inspection was conducted as a complaint survey related to Complaint ID WV00026323, occurring from January 4, 2022, 2:00 p.m. to January 5, 2022, 1:30 p.m.

No deficiencies were cited during the complaint investigation survey at Cedar Grove Assisted Living.

Complaint ID WV00026323 was investigated and found to have no deficiencies cited.

This was a first follow-up visit to a complaint survey identified by Complaint ID WV00026089 to verify correction of previously cited deficiencies.

The deficiencies identified in the prior complaint survey were corrected as of the follow-up visit on January 5, 2022.

Complaint ID WV00026089 triggered the visit. The deficiencies were corrected as noted in the report.

Complaint investigation survey conducted from 11/29/21 to 12/08/21 regarding allegations of neglect and inadequate maintenance and housekeeping at Harmony at White Oaks Assisted Living and Alzheimer's Unit.

The licensee failed to ensure compliance with mandatory abuse and neglect reporting policies and failed to maintain a safe, sanitary, and accident-free living environment. Resident #29 was found neglected with soiled clothing, urine and fecal matter on furniture and bedding, and a blood-stained carpet that was not replaced timely. Maintenance issues such as a broken toilet handle and clutter in another resident's closet were also noted. Staff were instructed to report abuse only to management, discouraging direct reporting to authorities.

Complaint ID 25824 was unsubstantiated. The investigation revealed failures in abuse reporting procedures and maintenance/housekeeping deficiencies affecting residents, particularly Resident #29 and ALZ Resident #6.

The inspection was conducted as a complaint investigation survey for Complaint ID WV00025974, occurring from November 29, 2021 to December 8, 2021.

The survey identified deficiencies related to safety and supervision, including lack of awake staff on weekend nights and unsecured outside doors in the adolescent residence.

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

Complaint investigation survey conducted due to allegations of abuse and failure to ensure appropriate sanctions and actions to prevent recurrence of abuse at Harmony at White Oaks assisted living and Alzheimer's unit.

The licensee failed to ensure appropriate sanctions were invoked or actions taken to prevent recurrence of abuse involving ALZ Resident #6 and AL Resident #2, who exhibited physical and verbal abuse. Staff were ordered to force ALZ Resident #6 to visit her abusive husband despite her resistance and distress. Additionally, inadequate housekeeping and maintenance issues were observed in the adolescent consumer residence.

Complaint ID 26046 was substantiated. The investigation revealed that AL Resident #2 physically and verbally abused his wife, ALZ Resident #6. Despite staff concerns and resident resistance, management ordered forced visits between the couple. The Executive Director acknowledged the abuse but maintained visitation rights for AL Resident #2. The Ombudsman was notified.

The inspection was conducted in response to Complaint #26118 to investigate concerns at Cedar Grove Assisted Living.

The report documents the complaint investigation process including entry, exit conference, and phone conversation. Specific deficiencies or findings are not detailed in the provided text.

Complaint #26118 was investigated with entry on 11/09/21 at 9:30 AM, exit conference on 11/09/21 at 4:30 PM, and a phone conversation on 11/10/21 at 1:00 PM.

This was a 1st follow-up complaint investigation visit related to complaint WV00025558 to verify correction of previous deficiencies.

All previously cited deficiencies were cleared with no new citations issued. The Ombudsman was notified and an exit conference was held with facility leadership.

Follow-up to complaint WV00025558. All tags cleared and no new citations found.

The inspection was conducted to review credible evidence related to Complaint #25562 and to determine if citations were warranted.

On 10/26/21, a review of credible evidence was completed and all citations related to Complaint #25562 were cleared.

Complaint #25562 was investigated and all citations were cleared.

The inspection was conducted as a complaint investigation following an incident where a resident eloped from the facility without prompt notification to the responsible party or next of kin.

The facility failed to promptly notify the resident's responsible party after a major incident involving elopement. Additionally, the facility did not conduct a resident head count after a door alarm sounded, risking resident safety. Housekeeping and maintenance deficiencies were also noted.

Complaint ID: 26089. The complaint was substantiated based on findings that the facility failed to promptly notify the responsible party and failed to count residents after a door alarm sounded during the elopement incident.

Follow-up to complaint #WV00025841 to verify compliance and address previous concerns.

The inspection found no deficiencies during the follow-up visit conducted on 09/29/21.

Follow-up to complaint #WV00025841. No deficiencies were found, indicating the complaint was addressed.

Follow-up survey conducted to verify correction of previously cited deficiencies at Cedar Grove Assisted Living.

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

The inspection was conducted as a complaint survey in response to Complaint ID WV00025842 from August 16 to August 19, 2021.

The complaint investigation found no substantiated issues during the survey period. The census included 37 assisted living and 19 Alzheimer’s residents.

Complaint ID WV00025842 was investigated from 08/16/21 to 08/19/21 and was found to be unsubstantiated.

The inspection was conducted as a complaint investigation related to regulatory compliance at Harmony at White Oaks Assisted Living and Alzheimer's Unit.

The facility was found to have a violation where the Executive Director served as a legal representative for a resident without the required familial relationship. Additionally, there was a failure to ensure adequate housekeeping and maintenance, and a resident was found to have full-length bed side rails contrary to regulations.

Complaint ID WV00025841 was investigated and found to be unsubstantiated.

The inspection was conducted as a complaint survey from 08/16/21 to 08/18/21 regarding concerns about staff training and resident rights violations at Harmony at White Oaks.

The facility failed to ensure adequate staff training on Alzheimer's care for agency employees, did not maintain proper housekeeping and maintenance, and failed to protect the physical and mental well-being of a resident whose husband was improperly exerting control over her. The facility took corrective actions including staff re-education and relocating the resident.

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

The inspection was conducted as a complaint survey based on Complaint ID WV00025867 from August 16-18, 2021.

No deficiencies were cited during the complaint survey conducted at the facility.

Complaint ID WV00025867 was investigated from 08/16/21 to 08/18/21. No deficiencies were found, indicating the complaint was not substantiated.

Follow-up to annual survey to verify correction of previous deficiencies.

The follow-up survey found that previous citations were cleared and no new citations were identified during the visit.

The inspection was conducted in response to Complaint #25416, entered on 08/16/21, to investigate allegations at the facility.

The report documents the complaint investigation at Harmony at White Oaks, which includes assisted living and memory care residents. Specific findings or deficiencies are not detailed in the provided text.

Complaint #25416 was entered on 08/16/21 at 12:45 PM and the exit date was 08/18/21 at 12:00 PM. The census at the time was 37 Assisted Living and 19 Memory Care residents.

The inspection was conducted in response to an unsubstantiated complaint (#25825) regarding the facility's compliance and care.

The report notes the census of 37 Assisted Living and 19 Memory Care residents. The complaint was found to be unsubstantiated. No specific deficiencies or severity levels are detailed in the provided text.

Unsubstantiated Complaint #25825

The visit was a follow-up inspection to verify correction of previously cited deficiencies related to maintenance and housekeeping at Cedar Grove Assisted Living.

The facility failed to fully correct previously cited deficiencies related to maintenance and housekeeping, including dusty vents, missing light covers, worn paint, peeling finishes, cobwebs, black/brown substances near sinks and showers, improper storage of paper products, and a tripping hazard on an exit ramp. The facility acknowledged these findings and planned corrective actions including cleaning, repairs, audits, and staff in-service training.

The inspection was conducted as a complaint survey investigation triggered by substantiated complaints regarding the facility's compliance with assessments and plans of care for residents in the Alzheimer's/Dementia unit.

The facility failed to assemble an interdisciplinary team to complete assessments and service plans within seven days of admission for two residents, and failed to review and complete quarterly assessments and care plans when a resident's health condition changed. Additionally, the facility lacked a Registered Nurse on site, relying on Licensed Practical Nurses to sign off on care plans.

Complaint Survey Investigation WV00025558 with substantiated deficiencies related to assessments and plans of care for residents #24 and #34. Unrelated deficiency also cited. The complaint was substantiated.

The inspection was conducted as a complaint survey investigation (WV00025807) from July 27 to July 29, 2021.

The complaint investigation found the complaint to be unsubstantiated. The census at the time was 53 residents on the Assisted Living side and 18 residents on the Alzheimer’s side.

Complaint Survey Investigation WV00025807 was unsubstantiated.

Annual survey conducted from 07/06/21 to 07/08/21 to assess compliance with staffing requirements, housekeeping, maintenance, and personnel records.

The facility failed to meet staffing requirements for day shifts based on resident care needs, had inadequate housekeeping and maintenance issues including damaged carpet and missing bathroom fixtures, and lacked complete pre-employment tuberculosis screening records for three employees.

The inspection was a routine survey conducted to assess compliance with physical facilities, fire safety, disaster and emergency preparedness, and housekeeping standards at Cedar Grove Assisted Living.

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

The inspection was a complaint revisit (#24769) conducted to verify correction of previously identified deficiencies.

The deficiency cited in the prior complaint investigation was cleared during this revisit inspection.

Complaint Revisit #24769; deficiency cleared upon revisit.

Routine infection control inspection conducted at Cedar Grove Assisted Living on January 13, 2021.

The report contains initial comments related to infection control with no specific deficiencies or severity levels noted.

The inspection was conducted as an Infection Control Survey at Harmony At White Oaks.

No deficiencies were cited during the infection control survey conducted on January 11, 2021.

The inspection was conducted as a complaint investigation at Harmony at White Oaks on January 11, 2021.

The report contains initial comments related to the complaint investigation but does not provide detailed findings or deficiencies in the provided text.

Complaint #: WV00024950. The investigation visit occurred on 01/11/21 from 10:45 a.m. to 3:00 p.m.

The inspection was conducted as a complaint survey in response to Complaint ID WV00024763 from December 7 to December 9, 2020.

No deficiencies were cited during the complaint survey conducted at Cedar Grove Assisted Living.

Complaint ID WV00024763 was investigated from 12/07/20 to 12/09/20, and no deficiencies were found.

The inspection was conducted as a complaint survey following Complaint ID WV00024769 from December 7 to December 9, 2020.

The facility failed to ensure that the registered nurse maintained a complete and accurate visit log including date, time in/out, duties performed, identified concerns, recommended actions, and signatures. The RN did not sign in and out on numerous occasions from November to December 2020. The complaint was substantiated.

Complaint ID WV00024769 was substantiated. The complaint survey was conducted from 12/07/20 to 12/09/20. The RN failed to maintain required documentation for visits during November and December 2020.

Follow-up survey visit to verify correction of previously identified deficiencies at Cedar Grove Assisted Living.

Deficiencies identified in prior inspections were corrected as of the follow-up visit on 11/24/2020.

Annual environmental inspection of Harmony at White Oaks facility in Bridgeport, WV.

No deficiencies were cited during the annual environmental inspection conducted on November 16, 2020.

The annual survey was conducted to assess compliance with regulatory requirements including service plans, resident records, dietary services, and housekeeping/maintenance.

The facility failed to ensure service plans were updated annually or as needed, service plans were not developed within seven days of admission for several residents, resident records were not kept in safe storage for at least five years, and staff failed to report unplanned weight changes to physicians. Additionally, housekeeping and maintenance deficiencies were observed including damaged carpets, missing bathroom fixtures, and unclean areas.

The inspection was conducted as a complaint survey from August 10 to August 12, 2020, in response to complaint ID WV00024275.

No deficiencies were cited during the complaint investigation, and the complaint was determined to be unsubstantiated.

Complaint ID WV00024275 was investigated and found to be unsubstantiated with no deficiencies cited.

Follow-up visit to the annual survey to verify correction of previous deficiencies.

The follow-up survey conducted from 07/13/20 to 07/15/20 cleared all previously cited tags from the initial survey conducted in January 2020.

The inspection was conducted as an environmental survey of Cedar Grove Assisted Living to assess compliance with health and safety regulations.

The facility was found to have no deficiencies during the environmental survey conducted on June 8, 2020.

Routine inspection survey conducted to assess compliance with regulations including assessments, plans of care, housekeeping, employee training, and incident monitoring at Harmony at White Oaks Alzheimer's Unit.

The facility failed to ensure timely interdisciplinary assessments and care plans for residents, adequate monitoring and documentation of resident conditions after incidents, proper housekeeping and maintenance, and timely employee orientation training. Corrective actions and education plans were implemented with ongoing quality assurance monitoring.

Routine entrance and exit inspection conducted on 01/06/2020 to assess compliance with health and safety regulations at Harmony at White Oaks (ALR/ALZ).

No deficiencies were identified during the inspection visit on 01/06/2020.

The inspection was conducted as a complaint investigation following a complaint numbered 23345.

The report documents a complaint investigation visit to Cedar Grove Assisted Living, with no detailed findings or deficiencies explicitly stated in the provided page.

Complaint investigation related to complaint number 23345 conducted from 10/21/19 to 10/23/19.

The document is an annual licensure survey conducted to assess compliance with regulatory requirements for Cedar Grove Assisted Living.

No deficiencies were cited during the annual licensure survey conducted on May 28-29, 2019.

The visit was conducted as an annual licensure survey focusing on environmental conditions at the facility.

No environmental deficiencies were cited during the annual licensure survey conducted on May 15, 2019.

The inspection was conducted as a complaint investigation from April 29 to May 3, 2019, related to complaint IDs WV00022367, WV00022368, and WV00022379.

No deficiencies were cited during the complaint investigation.

Complaint investigation conducted with no deficiencies cited.

The visit was conducted as an annual licensure survey to assess compliance with environmental and safety regulations at Cedar Grove Assisted Living.

The facility was found deficient for failing to install thermostatic mixing valves on hot water tanks exceeding eighty gallons, which is required for safety. The deficiency was confirmed during the inspection and a plan of correction was provided.

The visit was conducted as an annual licensure survey of Cedar Grove Assisted Living to assess compliance with regulatory requirements.

No deficiencies were cited during the annual licensure survey conducted on May 7-8, 2018.

The visit was conducted as an annual licensure survey and a first follow-up survey to verify compliance.

The annual licensure survey and follow-up found no deficiencies cited at the facility during the inspection period.

The inspection was conducted as a complaint investigation for complaint number WV00018103 at Cedar Grove Assisted Living.

No deficiencies were cited during the complaint investigation conducted on June 20-21, 2017.

Complaint #: WV00018103. No deficiencies cited.

The inspection was conducted as an annual licensure survey to assess compliance with health and safety regulations at Cedar Grove Assisted Living.

The licensee failed to protect the physical and mental well-being of eleven residents due to unsecured bedside rails posing a risk of injury. Immediate corrective actions included removal of the rails and staff education on safety. Additional findings from a prior behavioral health survey noted safety and environmental concerns requiring corrective actions.

The inspection was conducted as a complaint investigation based on complaint number WV00017839.

The complaint investigation conducted on May 9-10, 2017, found no deficiencies at Cedar Grove Assisted Living.

Complaint Number: WV00017839; No deficiencies were found during the investigation.

The visit was conducted as an annual licensure survey to assess environmental conditions and compliance at Cedar Grove Assisted Living.

The survey found no deficiencies cited during the inspection.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living from February 6 to 8, 2017.

No deficiencies were cited during this complaint investigation.

Complaint investigation conducted with no deficiencies cited.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living from September 19-21, 2016.

No deficiencies were found during the complaint investigation at the facility.

Complaint investigation conducted with no deficiencies found; substantiation status not explicitly stated.

The visit was conducted as an annual licensure survey of Cedar Grove Assisted Living to assess compliance with health care standards and regulatory requirements.

The licensee failed to ensure resident belongings were properly released to the estate administrator or executor upon a resident's death for four residents. Documentation issues and lack of verification of estate administrators were noted. A plan of correction including staff education and monthly audits was implemented.

Annual licensure survey conducted from May 16-18, 2016 to assess compliance with regulatory requirements for Cedar Grove Assisted Living.

The report includes an annual licensure survey and a follow-up survey conducted on July 25, 2016, with census counts noted. Deficiencies identified during the annual survey were corrected by the follow-up visit.

The inspection was conducted as an annual licensure survey to assess compliance with assisted living residence environmental standards.

The facility was found to be in compliance with guidelines for assisted living residence environmental standards, with no deficiencies noted during the survey.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living from August 31 to September 1, 2015.

The report documents a complaint investigation with no detailed findings or deficiencies explicitly stated in the provided text or image.

Complaint investigation conducted from August 31 to September 1, 2015, with a census of 59 residents. No substantiation status or specific complaint details are provided.

The visit was a follow-up survey conducted to verify compliance after a prior Change of Ownership (CHOW) survey conducted in June 2015.

The report summarizes the follow-up survey conducted from August 10-12, 2015, with a census of 63 residents. No specific deficiencies or severity levels are detailed in the provided document.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living on July 1-2, 2015.

The report does not provide specific findings or deficiencies related to the complaint investigation.

Complaint investigation WV00013913 conducted July 1-2, 2015 with a census of 65.

The inspection was conducted as an annual licensure survey to assess compliance with health, safety, and physical facility regulations.

The facility was found deficient in maintaining a safe and sanitary environment, including improper use of power strips, unlocked electrical panels, inadequate oxygen cylinder labeling, broken bathroom fans, holes in ceiling tiles, missing hardware on furniture, cigarette littering in smoking areas, and hot water temperatures exceeding regulatory limits.

Routine inspection conducted June 1-4, 2015, including review of medication administration, staffing, housekeeping, resident rights, and health care standards.

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

The visit was conducted as an annual licensure survey to assess compliance with regulatory requirements, including review of fire safety inspections.

The inspection found no requirements from the recent Fire Marshal report dated 11/07/14. The Administrator noted a recent Fire Marshal inspection in the week of 6/3/15 with no report back yet. A plan of correction was established to ensure ongoing review and documentation of inspection reports.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living.

The report documents deficiencies identified during the complaint investigation, but specific findings or deficiencies are not detailed in the provided text.

Complaint investigation WV00013689 conducted on May 26, 2015 with a census of 68.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living.

The report provides a summary statement of deficiencies related to the complaint investigation but does not detail specific findings in the provided text.

Complaint investigation identified by tag E 004 with census noted as 66 on April 13, 2014. No substantiation status or detailed complaint findings are provided.

The inspection was conducted as a complaint investigation regarding the adequacy and functionality of the call system for residents at Cedar Grove Assisted Living.

The facility failed to have a call system that was audible to staff, as staff did not respond to call bells when doors were closed or when staff were not in the immediate area. Staff interviews confirmed the call bell system was difficult to hear, and a family member reported frequent non-response to call bells.

The complaint investigation was substantiated by observations and interviews revealing the call bell system was inadequate and staff frequently did not respond to call bells.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living on March 22-23, 2015.

The report documents a complaint investigation and a follow-up related to the facility. Specific deficiencies or findings are not detailed in the provided text.

The visit was a complaint investigation (E 004) and a complaint follow-up (E 006) with census noted as 66. No substantiation status is provided.

The inspection was conducted as a complaint investigation to evaluate the facility's compliance with physical facilities maintenance and safety standards.

The facility failed to ensure that the electrical system was installed and operating according to the National Electrical Code, with numerous wiring issues observed in the older sections of the building. Maintenance and housekeeping deficiencies were also noted, including broken switch and receptacle covers, open grounds, reverse polarity circuits, and other electrical hazards.

The visit was complaint-related, investigating issues with the facility's physical environment and electrical system. The deficiencies were confirmed with the Facility Director and Maintenance Supervisor at exit.

The inspection was conducted as a complaint investigation to evaluate the physical facilities and ensure maintenance and housekeeping were adequate to maintain a safe, sanitary, and accident-free living environment.

The facility failed to ensure the electrical system was installed and operating according to the National Electrical Code, with numerous wiring issues observed in the older sections of the building. Deficiencies included broken switch and receptacle covers, improperly installed flex conduit, loose receptacles, missing ground pins, and circuits with open grounds and reverse polarity.

Complaint investigation conducted on 03/19/2015 revealed multiple electrical safety issues confirmed with the Facility Director and Maintenance Supervisor at exit.

The visit was a follow-up survey conducted on September 29, 2014, to verify corrections after the annual licensure survey conducted August 5-7, 2014.

The report summarizes the annual licensure survey and the subsequent follow-up survey, noting census counts of 60 and 57 respectively. Specific deficiencies or findings are not detailed in this document.

The visit was conducted as an annual licensure survey to assess environmental compliance and overall facility conditions.

The survey found no deficiencies cited during the inspection, indicating compliance with applicable regulations.

The inspection was conducted as an annual licensure survey of Cedar Grove Assisted Living to assess compliance with health care standards and regulatory requirements.

The facility was found deficient in maintaining complete resident records, including missing medical diagnoses, allergies, and health assessments. Additionally, tuberculosis screenings were not completed for some residents, and staff training on recognizing changes in resident conditions was inadequate. Housekeeping and maintenance issues were also noted, including damaged carpets, missing bathroom fixtures, and unclean areas.

The inspection was conducted as a complaint investigation regarding the protection of residents' physical and mental well-being, accurate record keeping, complaint response timeliness, housekeeping and maintenance, pest control, and adequate supply of linens.

The facility failed to protect two residents at risk of elopement, maintain accurate records for 44 of 63 residents, respond to complaints in writing within four days, ensure adequate housekeeping and maintenance, keep the facility free of vermin, and provide an adequate supply of towels and washcloths for residents.

The complaint investigation was triggered by concerns about resident safety, specifically elopement incidents involving two residents, inadequate showering and feeding, and lack of written complaint responses. The investigation confirmed these issues and found additional deficiencies.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living on June 23-24, 2014.

The report documents a complaint investigation and a subsequent complaint follow-up visit. The census was 63 during the initial investigation and 57 during the follow-up. Specific deficiencies or findings are not detailed in the provided text.

Complaint investigation conducted June 23-24, 2014 with a follow-up on August 25, 2014. Census was 63 at initial investigation and 57 at follow-up.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living.

The report summarizes deficiencies identified during the complaint investigation, but specific findings are not detailed in the provided text.

Complaint investigation WV00011212 conducted on May 5, 2014, with a census of 68 residents.

The inspection was conducted as a complaint investigation based on multiple incident reports of resident falls and injuries occurring between September and December 2013, involving staff assistance failures and safety concerns.

The facility failed to protect the physical and mental well-being of seven residents, with nine documented incidents of falls or injuries during staff assistance. Deficiencies included inadequate staff training on ambulation and mechanical lift use, insufficient staffing during lifts, lack of a formal policy for mechanical lift operation, and housekeeping and maintenance issues affecting safety.

The complaint investigation revealed nine incidents of resident falls or injuries from September to December 2013, involving staff assistance failures. Interviews indicated insufficient staff training and supervision, with some staff failing to follow safety protocols. The complaint was substantiated with findings of inadequate protection of residents.

The inspection was conducted as a complaint investigation at Cedar Grove Assisted Living.

The report documents deficiencies identified during the complaint investigation and a subsequent complaint follow-up visit. The census increased from 64 during the complaint investigation to 69 at the follow-up.

Complaint investigation conducted December 17-18, 2013 with census 64; followed by a complaint follow-up on January 30, 2014 with census 69.

The visit was conducted as an annual licensure survey of Cedar Grove Assisted Living to assess compliance with regulatory requirements.

The report documents the annual licensure survey conducted from August 19 to 21, 2013, with a census of 62 residents. No specific deficiencies or severity levels are detailed in the provided text.

The annual licensure survey was conducted to evaluate the facility's compliance with health and safety regulations, including environmental conditions and hot water temperature controls.

The facility was found deficient in maintaining safe hot water temperatures, with several resident bathrooms exceeding the maximum allowed temperature, posing a risk of scalding. Additionally, housekeeping and maintenance issues were noted, including damaged carpets, missing bathroom fixtures, and inadequate environmental monitoring.

Annual licensure survey conducted to assess environmental conditions and compliance of Cedar Grove Assisted Living facility.

The survey included an environmental review and a follow-up survey. The census was 64 during the annual survey and 62 during the follow-up. No specific deficiencies or severity levels were detailed in the report.

The visit was a follow-up survey to verify correction of deficiencies identified during the annual licensure survey conducted on September 13, 2012.

The follow-up survey found that the previously cited deficiencies were corrected.

The visit was conducted as an annual licensure survey to assess compliance with physical facility requirements and environmental safety standards at Cedar Grove Assisted Living.

The inspection found deficiencies related to maintenance and housekeeping, including missing extension pipes on hot water tanks, mold near the dish machine, rusting chemical storage cabinet, fly problems in the food service area, plastic door hangers interfering with door closure, and excess storage blocking mechanical room access.

The visit was conducted as an annual licensure survey and a follow-up survey to verify correction of previous deficiencies at Cedar Grove Assisted Living.

The annual licensure survey was conducted from May 29-31, 2012 with a census of 70, followed by a survey follow-up on July 26, 2012 with a census of 75. The follow-up survey found that deficiencies identified previously were corrected.

The annual licensure survey was conducted to assess compliance with state regulations regarding medication administration, resident monitoring, housekeeping, maintenance, and documentation of resident conditions following accidents or sudden illness.

The facility was found deficient in timely administration of medications, monitoring and documenting residents' conditions after accidents or illness, and following policies for head injury documentation. Additionally, housekeeping and maintenance issues were noted, including damaged carpets, missing bathroom fixtures, and unclean areas.

The inspection was conducted as a complaint investigation regarding the facility's failure to report a major incident involving a resident elopement.

The licensee failed to report a major incident where a resident eloped from the facility and staff were unaware until the resident was returned. The facility was cited for deficient practice related to incident reporting and required to conduct staff training on reporting requirements.

Complaint investigation WV00006775 found the licensee failed to report a major incident involving Resident #45 eloping from the facility on October 15, 2011. The incident was not reported because the director of nursing was unaware of reporting requirements. The complaint was substantiated as Class III with no follow-up required.