Inspection Reports for Kanawha Place

WV, 25304

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Deficiencies (last 19 years)

Deficiencies (over 19 years) 11.1 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

23% worse than West Virginia average
West Virginia average: 9 deficiencies/year

Deficiencies per year

16 12 8 4 0
2004
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025

Census

Latest occupancy rate 45 residents

Based on a November 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

0 30 60 90 120 Feb 2004 Jan 2012 Jan 2015 Jul 2017 Apr 2021 Jun 2023 Nov 2025
Inspection Report Complaint Investigation Census: 45 Deficiencies: 0 Nov 4, 2025
Visit Reason
Investigation of Complaint #40240 conducted from 2025-11-03 to 2025-11-04.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #40240 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 45
Inspection Report Follow-Up Census: 42 Deficiencies: 0 Jun 4, 2025
Visit Reason
Follow-up to the Annual Survey to verify correction of previous citations.
Findings
The citations identified in the prior annual survey were corrected as of the follow-up visit.
Report Facts
Census: 42
Inspection Report Annual Inspection Census: 42 Deficiencies: 6 Apr 3, 2025
Visit Reason
Annual survey conducted from 03/31/25 to 04/03/25 to assess compliance with regulatory requirements for resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including inaccurate and outdated functional needs assessments and service plans for residents, inadequate housekeeping and maintenance, failure to ensure registered nurse oversight for medication administration and resident care, and inaccurate documentation of resident code status. Corrective actions and education plans were implemented with completion dates by 05/19/25.
Severity Breakdown
Class I: 2 Class II: 3
Deficiencies (6)
DescriptionSeverity
Failed to ensure functional needs assessments and service plans were updated annually or as indicated by significant change for residents #5, #8, #36, and #38.Class II
Failed to ensure adequate housekeeping and maintenance including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink.
Failed to ensure quarterly medication pass observations were conducted by the authorized Approved Medication Assistive Personnel (AMAP) Registered Nurse for five AMAP employees.Class I
Failed to maintain accurate documentation of resident code status, with discrepancies between face sheets and Physician Orders for Scope of Treatment (POST) forms for residents #5, #8, and #38.Class II
Failed to ensure registered nurse developed, documented, and updated residents' service plans within seven days of admission and with significant changes for residents #8, #34, #36, and #38.Class I
Failed to ensure registered nurse saw residents with nursing care needs weekly and documented progress notes for seven residents including #33, #6, #9, #4, #34, #36, and #5.Class II
Report Facts
Census: 42 Sample Size: 5 Number of AMAP employees reviewed: 5 Number of residents with nursing care needs reviewed: 7 Number of residents with inaccurate code status documentation: 3
Employees Mentioned
NameTitleContext
Employee #9Licensed Practical Nurse (LPN)Completed service plans for residents #8, #34, #36, and #38
Director of Nursing (DON)Licensed Practical Nurse (LPN)Conducted quarterly medication pass observations for AMAP employees
Executive Director (ED)Provided education and discussed findings related to service plans, code status, and audits
Regional Director of Operations (RDO)Provided education on medication administration and service plan requirements
AMAP Registered Nurse (RN)Approved Medication Assistive Personnel RNConducted medication pass observations and provided re-education
AdministratorInterviewed regarding RN and LPN roles in resident assessments and documentation
Inspection Report Annual Inspection Census: 42 Deficiencies: 0 Mar 31, 2025
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with regulatory standards.
Findings
The annual inspection found no deficiencies cited, indicating the facility met all required standards at the time of the visit.
Report Facts
Census: 42 Deficiencies cited: 0
Inspection Report Complaint Investigation Census: 53 Deficiencies: 0 Oct 4, 2024
Visit Reason
Investigation of Complaint #34143 conducted from 2024-10-02 to 2024-10-04.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #34143 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 53
Inspection Report Follow-Up Census: 44 Deficiencies: 0 Jul 11, 2024
Visit Reason
First follow-up to annual survey to verify correction of previously cited deficiencies.
Findings
The citations from the prior annual survey were cleared as of the follow-up visit on 07/11/2024.
Report Facts
Census: 44
Inspection Report Annual Inspection Census: 42 Deficiencies: 4 May 30, 2024
Visit Reason
Annual survey conducted from 05/27/24 to 05/30/24 to assess compliance with health and safety regulations and medication administration standards.
Findings
Deficiencies were cited related to incomplete tuberculosis testing documentation for employees, inadequate medication storage security, incomplete medication administration records, and housekeeping and maintenance issues including damaged carpet and missing bathroom fixtures.
Severity Breakdown
Class I: 2
Deficiencies (4)
DescriptionSeverity
Failed to ensure each employee's record contained results of a complete tuberculosis test upon hire for three employees.
Failed to keep medications in a locked room, cabinet, or storage accessible only to responsible staff; an unlocked medication cart was observed.Class I
Failed to ensure each resident's medication administration records were completed with the signature of the person who administered each medication for four residents.Class I
Failed to ensure adequate housekeeping and maintenance; findings included 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
Census: 42 Employees with incomplete tuberculosis testing: 3 Residents with incomplete medication administration records: 4
Employees Mentioned
NameTitleContext
Executive DirectorExecutive Director (ED)Provided education and discussed deficiencies related to tuberculosis testing, medication storage, and medication administration records.
Resident Wellness DirectorResident Wellness DirectorReceived education on medication storage and administration record requirements; responsible for conducting audits.
Business Office ManagerBusiness Office ManagerReceived education on importance of ensuring completed tuberculosis tests upon hire.
Inspection Report Annual Inspection Census: 39 Deficiencies: 0 May 30, 2024
Visit Reason
Annual environmental inspection conducted to assess the facility's compliance with health and safety regulations.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 39 Deficiencies cited: 0
Inspection Report Follow-Up Census: 40 Deficiencies: 1 Mar 18, 2024
Visit Reason
First follow-up visit to Complaint #30174 to verify correction of previously identified deficiencies.
Findings
The deficiency cited in the complaint investigation was corrected as of the follow-up survey date.
Complaint Details
Complaint #30174 triggered the visit; deficiency was corrected.
Deficiencies (1)
Description
Deficiency related to Complaint #30174 was corrected.
Report Facts
Census: 40
Inspection Report Complaint Investigation Census: 39 Deficiencies: 2 Feb 6, 2024
Visit Reason
Investigation of Complaint #30174 regarding resident care and facility conditions.
Findings
The complaint was substantiated with one related deficiency cited. The facility failed to ensure residents received appropriate monitoring and timely medical care, specifically for Resident #1 who had malnutrition, failure to thrive, and dehydration. Additionally, the facility failed to maintain adequate housekeeping and maintenance in the residence.
Complaint Details
Complaint #30174 was substantiated. Resident #1 had diarrhea for 5 days, was lethargic, had low blood pressure, and was sent twice to the hospital including for a gastrointestinal bleed. Documentation and staff interviews revealed lack of proper monitoring and documentation of Resident #1's condition and interventions.
Deficiencies (2)
Description
Failed to ensure residents received appropriate monitoring and timely medical care, including lack of updated resident assessments and service plans for Resident #1.
Failed to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink.
Report Facts
Census: 39 Sample Size: 5 Days of diarrhea: 5
Employees Mentioned
NameTitleContext
Care Services Nurse #14Documented and communicated Resident #1's condition and hospital transfers; involved in deficient monitoring.
Resident Wellness DirectorReviewed and updated resident assessments and service plans as part of plan of correction.
Executive DirectorProvided education to staff on resident assessments and monitoring.
Inspection Report Complaint Investigation Census: 37 Deficiencies: 0 Oct 25, 2023
Visit Reason
Investigation of Complaint #29519 conducted from 10/24/23 to 10/25/23.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #29519 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 37
Inspection Report Follow-Up Census: 6 Deficiencies: 1 Jun 1, 2023
Visit Reason
The onsite revisit on 06/01/23 was conducted to verify correction of a previously cited deficiency related to safety and supervision in the adolescent residential program.
Findings
The revisit found that the previously cited safety deficiency regarding lack of awake-night supervision on weekends and unsecured doors was 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 awake-night supervision on weekends and unsecured outside doors.
Report Facts
Center census: 6 Sample size: 3
Inspection Report Annual Inspection Census: 27 Deficiencies: 13 Jun 1, 2023
Visit Reason
Annual survey conducted to assess compliance with regulatory requirements for the assisted living facility.
Findings
The facility was found deficient in multiple areas including employee training, staffing levels, housekeeping and maintenance, documentation of resident health assessments, and policy development. Several residents' service plans and health assessments were incomplete or outdated. Staffing on night shifts was insufficient to meet resident care needs. Employee orientation and annual training requirements were not fully met.
Severity Breakdown
Class I: 1 Class II: 5 Class III: 5
Deficiencies (13)
DescriptionSeverity
Failed to maintain health records containing annual tuberculosis screening for employees.Class III
Failed to provide documentation that activities did or did not take place.Class III
Failed to ensure functional needs assessment and service plans reflect current resident needs and are updated.Class II
Failed to promptly notify resident's responsible party or next of kin of major incidents or significant changes.Class I
Failed to document release of resident belongings and funds to estate administrator or executor upon resident death.Class III
Failed to provide and maintain record of new employee orientation training prior to unsupervised work and within 15 days of employment.Class II
Failed to document name of person to whom resident's body was released upon death.Class III
Failed to develop and adopt written policies and procedures consistent with regulatory requirements.Class III
Failed to maintain record of annual in-service training to all staff on required topics including resident rights and infection control.Class II
Failed to provide required Alzheimer's disease and related dementias training to new and current employees within required timeframes.Class II
Failed to have written, signed, and dated annual health assessments for residents including tuberculosis screening.Class II
Failed to ensure adequate staffing on night shifts with at least one additional direct care staff for every 18 residents with two or more special care needs.
Failed to ensure adequate housekeeping and maintenance including cleaning and repair of physical environment.
Report Facts
Census: 27 Deficiencies cited: 12 Staffing requirement: 3 Staffing actual: 1 Staffing actual: 2 Residents with 2 or more special care needs: 12
Employees Mentioned
NameTitleContext
Employee #1Executive Director / Registered Nurse (RN)Named in multiple findings including employee training, documentation, and staffing
Employee #3Care Services Manager / Registered Nurse (RN)Named in findings related to documentation and training
Employee #10Named in findings related to missing annual training
Employee #17Named in findings related to missing orientation and dementia training
Employee #21Named in findings related to missing tuberculosis screening and dementia training
Inspection Report Renewal Census: 25 Deficiencies: 2 May 16, 2023
Visit Reason
The inspection was conducted as a re-licensure survey to assess compliance with regulatory requirements and ensure the facility meets standards for continued licensure.
Findings
The facility was found deficient in having an adequate call system accessible from each bed and other areas, with a call light cord improperly wrapped and not functioning correctly. Additionally, housekeeping and maintenance issues were noted, including damaged carpet, missing bathroom fixtures, and cleanliness concerns.
Severity Breakdown
Class II: 1
Deficiencies (2)
DescriptionSeverity
The residence failed to have a call system that is audible to staff and accessible from each bed and other necessary areas, with the call light cord wrapped around the ADA handrail preventing activation.Class II
Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage (iron burn and bleach spots), torn chair, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Census: 25 Sample Size: 80 Tags Cited: 2
Employees Mentioned
NameTitleContext
Regional Director of Care ServicesRegional Director of Care ServicesProvided education to Executive Director regarding call light cord compliance
Executive DirectorExecutive DirectorAcknowledged deficiency and received education on call light cord compliance
Inspection Report Complaint Investigation Census: 32 Deficiencies: 0 Feb 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation for Complaint #27489 at an assisted living facility.
Findings
No deficiencies were cited during the complaint investigation conducted on February 7, 2023.
Complaint Details
Complaint #27489 was investigated from 8:00 AM to 10:15 AM on 02/07/23. No deficiencies were cited.
Report Facts
Census: 32
Inspection Report Complaint Investigation Census: 32 Deficiencies: 0 Feb 7, 2023
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #27839) at an assisted living facility.
Findings
No citations were cited during the complaint investigation. The Ombudsman was notified.
Complaint Details
Complaint #27839 was investigated with entry on 2023-02-06 at 10:00 AM and exit on 2023-02-07 at 10:15 AM. No citations were cited.
Report Facts
Census: 32
Inspection Report Complaint Investigation Census: 32 Deficiencies: 3 Feb 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to an allegation of abuse, exploitation, or neglect involving a caregiver and a resident.
Findings
The facility failed to notify the licensing agency within 72 hours of an allegation of abuse and did not forward documentation of the investigation results. Observations also noted deficiencies in the physical environment and housekeeping of the residence.
Complaint Details
The complaint involved an allegation that a caregiver (Employee #8) improperly lifted a resident (Resident #1) by yanking her hands instead of using proper technique. The allegation was investigated and found unsubstantiated. The facility failed to notify the licensing agency timely and did not submit investigation results as required.
Severity Breakdown
Class III: 1
Deficiencies (3)
DescriptionSeverity
Failure to notify licensing agency within 72 hours of an allegation of abuse and failure to forward investigation documentation.Class III
The adolescent girls' bedrooms had outside doors without alarms or locking mechanisms, and staff were not awake on weekend nights to monitor safety.
Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and dirty sink.
Report Facts
Census: 32 Sample Size: 3 Audit Timeframes: 60 Completion Date: Apr 20, 2023
Employees Mentioned
NameTitleContext
Employee #8Caregiver alleged to have improperly lifted a resident
Employee #14Executive DirectorProvided interview regarding investigation and corrective actions
Regional Director of Care ServicesProvided education to Executive Director on reporting requirements
Inspection Report Complaint Investigation Census: 27 Deficiencies: 0 Sep 27, 2022
Visit Reason
The inspection was a complaint follow-up visit conducted to verify correction of deficiencies cited during a prior complaint investigation that occurred from 05/18/22 to 05/20/22.
Findings
The deficiencies identified during the complaint investigation were corrected by the time of the follow-up visit on 09/27/22. The census was 27 residents during both visits.
Complaint Details
Complaint #26872 was substantiated during the initial investigation from 05/18/22 to 05/20/22. The follow-up visit on 09/27/22 confirmed that the deficiencies were corrected.
Report Facts
Census: 27
Inspection Report Follow-Up Census: 25 Deficiencies: 0 Aug 25, 2022
Visit Reason
Follow-up annual inspection to verify correction of previous deficiencies and assess compliance.
Findings
The follow-up annual inspection found that all previous citations were cleared and no new citations were issued.
Report Facts
Census: 25
Inspection Report Follow-Up Census: 26 Deficiencies: 4 Jun 28, 2022
Visit Reason
Follow-up to annual survey conducted to assess compliance with previously cited deficiencies related to administrative admission and discharge, employee orientation and training, and housekeeping and maintenance.
Findings
The facility was found to have recurring deficiencies including lack of addendums in resident contracts regarding policies and medication handling, inadequate employee in-service training documentation, and housekeeping and maintenance issues such as damaged carpet, missing bathroom fixtures, and unclean areas. Plans of correction were provided with deadlines for compliance.
Deficiencies (4)
Description
No addendum to inform residents and families where to find the residence's policies and procedures.
No addendum addressing medication storage, handling, distribution, disposition, and responsibility for payment in resident contracts.
Failure to provide and maintain records of annual in-service training for employees on resident rights, confidentiality, abuse prevention, infection control, fire safety, evacuation plans, and specialty care.
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
Census: 26 Sample Size: 3 Employee Identifiers: 5 Dates for Plan of Correction Completion: Aug 15, 2022
Employees Mentioned
NameTitleContext
Employee #1Care Service NurseLacked documented annual education on specialty care, resident rights, provision of group and individual activities, and confidentiality.
Employee #6Executive DirectorLacked documented annual education on specialty care, resident rights, provision of group and individual activities, and confidentiality.
Employee #9Qualified Medication AideLacked documented annual education on specialty care, provision of group and individual activities, and confidentiality.
Employee #15HousekeeperLacked documented annual education on specialty care and provision of group and individual activities.
Employee #18Director of NursingLacked documented annual education on specialty care, resident rights, and provision of group and individual activities.
Inspection Report Complaint Investigation Census: 27 Deficiencies: 2 May 18, 2022
Visit Reason
The inspection was conducted in response to a complaint (#26872) regarding water leaks and mold contamination in the facility, which led to residents being moved to the second floor.
Findings
The facility was found to have significant water damage and mold contamination throughout multiple areas including resident rooms, administrative offices, and common areas. The licensee failed to report these major incidents timely and did not maintain the facility in a safe, sanitary, and well-maintained condition.
Complaint Details
Complaint #26872 was substantiated. The complaint involved water leaks and mold contamination leading to resident relocation and was confirmed by observations and third-party lab testing.
Severity Breakdown
Class I: 1 Class III: 1
Deficiencies (2)
DescriptionSeverity
Failure to report major incidents related to water leaks and mold contamination to the Office of Health Facility Licensure and Certification as required.Class III
Failure to maintain the interior and exterior of the facility in a clean, safe, and sanitary condition, including presence of mold, water damage, rust, and pest issues in multiple areas.Class I
Report Facts
Facility census: 27 Sample size: 3 Dates residents moved: Residents moved to second floor on 04/15/22 and 04/25/22 Date survey completed: Survey completed on 05/20/22
Employees Mentioned
NameTitleContext
Executive DirectorInterviewed regarding water leaks, mold contamination, and failure to report major incidents
Facility Maintenance DirectorInterviewed and provided information about mold discovery and remediation efforts
Operations SupervisorParticipated in tours and observations related to facility conditions
Treatment CoordinatorParticipated in tours and observations related to facility conditions
Inspection Report Annual Inspection Census: 26 Deficiencies: 10 Mar 10, 2022
Visit Reason
Annual survey conducted to assess compliance with state regulations for an assisted living facility.
Findings
The facility was found deficient in multiple areas including personnel records lacking required documentation, incomplete employee training records, inadequate housekeeping and maintenance, missing resident admission information, and incomplete policies and procedures related to abuse reporting and medication management.
Deficiencies (10)
Description
Failed to have proof of eligibility fitness determination or variance from WV CARES for two employees.
Failed to provide health records containing results of annual TB screenings for three employees.
Failed to specify the type of resident population the residence was licensed to serve in the admissions packet.
Failed to provide information on how medications were stored, handled, distributed, and disposed of within the admissions contract and house rules.
Failed to have names, addresses, and telephone numbers of residents' dentists in resident records.
Policies and procedures lacked complete and consistent abuse and neglect reporting instructions, including missing hotline numbers and timelines.
Personnel records lacked employee social security numbers and proof of age for two employees.
Failed to provide and maintain records of annual in-service training on required topics for eight employees.
Failed to maintain records of residents' religious preferences for three residents.
Inadequate housekeeping and maintenance observed, including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink.
Report Facts
Facility Census: 26 Personnel files reviewed: 9 Employees lacking WV CARES proof: 2 Employees lacking TB screening: 3 Residents missing dentist info: 3 Employees lacking social security number: 2 Employees lacking annual training: 8 Residents missing religious preference: 3
Inspection Report Annual Inspection Census: 26 Deficiencies: 1 Mar 7, 2022
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with health and safety regulations and physical facility maintenance standards.
Findings
The facility failed to maintain the kitchen heat and air system discharge vent, which was rusted and in disrepair. Maintenance was performed to correct this issue, and ongoing audits and education were planned to ensure the community remains safe, sanitary, and accident-free.
Deficiencies (1)
Description
The kitchen heat and air system discharge vent was rusted and in disrepair.
Report Facts
Census: 26 Tags cited: 450
Employees Mentioned
NameTitleContext
Executive DirectorExecutive Director (ED)Educated maintenance team and responsible for ongoing audits
Maintenance teamConducted servicing of kitchen heat and air system and audits of the community
Facility administratorVerified and acknowledged the maintenance deficiency during exit interview
Inspection Report Follow-Up Census: 33 Deficiencies: 0 Nov 10, 2021
Visit Reason
Revisit to Complaint 25571 to verify correction of previously cited deficiencies.
Findings
The revisit inspection cleared Tags 260, 268, and 450 with no new citations noted.
Complaint Details
This visit was a follow-up to a complaint investigation (Complaint 25571).
Report Facts
Tags cleared: 3
Inspection Report Complaint Investigation Census: 32 Deficiencies: 0 Oct 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID 25680 on October 4, 2021.
Findings
The deficiencies identified during the complaint investigation were corrected by the time of the inspection.
Complaint Details
Complaint ID 25680 was investigated on 10/04/21 from 11:30 a.m. to 1:15 p.m. The deficiencies cited were corrected.
Report Facts
Census: 32
Inspection Report Re-Inspection Census: 32 Deficiencies: 0 Oct 4, 2021
Visit Reason
Revisit of Complaint #25245 to verify correction of previously cited deficiencies.
Findings
The revisit inspection found that the deficiencies cited in the prior complaint investigation were cleared.
Complaint Details
Complaint #25245 was revisited and deficiencies were cleared.
Report Facts
Census: 32
Inspection Report Follow-Up Census: 33 Deficiencies: 0 Sep 20, 2021
Visit Reason
This was a 1st follow-up visit related to complaint number 25144 to verify correction of previous deficiencies.
Findings
The inspection found that all citations from the prior complaint investigation have been cleared.
Complaint Details
Complaint number 25144 was investigated and found to have all citations cleared at this follow-up visit.
Report Facts
Complaint number: 25144 Census: 33
Inspection Report Complaint Investigation Census: 33 Deficiencies: 5 Jul 28, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a substantiated complaint regarding housekeeping, maintenance, and staffing issues at the facility.
Findings
The facility failed to maintain a safe, sanitary, and well-maintained environment, including presence of insects and vermin, dirty air vents, damaged carpets, and inadequate housekeeping. Staffing levels on evening shifts did not meet regulatory requirements for residents with special care needs. The facility acknowledged these deficiencies and implemented corrective actions including education, audits, and maintenance work orders.
Complaint Details
Complaint Survey Complaint ID: 25680, Start/End Date: 2021-07-28 06:45 to 15:15, Census: 33, Complaint substantiated.
Severity Breakdown
Class III: 1 Class II: 1
Deficiencies (5)
DescriptionSeverity
Failed to keep the residence free of insects, rodents, and vermin; spider web and spider observed in dining room.Class III
Failed to provide maintenance and housekeeping to maintain a safe, sanitary, and accident-free living environment; presence of small black droppings, opening/crevice in resident's bedroom.
Failed to maintain adequate staffing on evening shifts; only one direct care staff present when two or more were required for residents with special care needs.
Failed to keep interior and exterior clean and in good repair; dirty air return vent observed.Class II
Physical environment issues including damaged carpet, missing towel bars, toilet paper holders, and dirty sink.
Report Facts
Facility census: 33 Residents with two or more special care needs: 15 Residents receiving medications between 8:00 p.m. and 11:00 p.m.: 16 Days with inadequate evening staffing: 8 Medications administered during evening shift: 61
Employees Mentioned
NameTitleContext
Regional Executive DirectorInterviewed regarding staffing and maintenance issues
Employee #10Interviewed about staffing levels on evening/night shifts
Employee #9Interviewed about staffing levels on evening/night shifts
Inspection Report Follow-Up Census: 32 Deficiencies: 4 Jul 28, 2021
Visit Reason
The visit was a follow-up survey conducted from 07/26/21 to 07/28/21 to assess compliance with previously identified deficiencies and complaint #25245.
Findings
The facility was found deficient in maintaining an accurate resident register, providing complete activity calendars, ensuring adequate housekeeping and maintenance, and ensuring medications and treatments were administered by appropriately licensed personnel. Plans of correction included education, audits, and scheduled repairs such as carpet replacement.
Complaint Details
Complaint #25245 triggered the follow-up survey conducted from 07/26/21 to 07/28/21 with a census of 32 residents.
Deficiencies (4)
Description
Failed to maintain a register of all residents showing last day in residence and transfer locations.
Failed to provide a monthly calendar listing type, time, and duration of social and recreational activities with documentation.
Failed to ensure resident care was provided by appropriately licensed health care professionals and medications administered as required by law.
Failed to keep the interior and exterior of the residence clean and in good repair.
Report Facts
Facility census: 32 Deficiencies cited: 4 Audit frequency: 4 Audit frequency: 4 Audit frequency: 1
Employees Mentioned
NameTitleContext
Regional Employee #36Interviewed regarding AMAP #12 status and medication administration deficiency.
Administrative AssistantAdministrative Assistant (AA)Updated resident transfer information in the register.
Regional Director of Clinical ServicesRDCSProvided education on maintaining resident register, activity calendar requirements, and AMAP credentialing.
Executive DirectorEDReceived education and responsible for audits related to activity calendar and housekeeping.
Care Service ManagerCSMReceived education and conducted audits related to AMAP personnel files and housekeeping.
Life Enrichment CoordinatorLECReceived education on activity calendar requirements.
Maintenance ManagerConducted audits of interior and exterior cleanliness and repair.
Inspection Report Follow-Up Census: 32 Deficiencies: 0 Jul 28, 2021
Visit Reason
The visit was a follow-up survey conducted to verify correction of previously cited deficiencies.
Findings
The deficiencies previously cited were corrected as of the follow-up survey conducted from 7/26/21 to 7/28/21.
Report Facts
Census: 32
Inspection Report Complaint Investigation Census: 33 Deficiencies: 3 Jul 27, 2021
Visit Reason
Complaint survey conducted on 07/27/21 to investigate substantiated complaints regarding staffing levels, employee training, and maintenance/housekeeping issues at the facility.
Findings
The facility failed to provide required employee orientation and training for 11 agency employees, did not maintain adequate housekeeping and maintenance resulting in unsafe and unsanitary conditions, and failed to meet evening shift staffing requirements for residents with two or more special care needs. Deficiencies were substantiated and plans of correction were provided.
Complaint Details
Complaint ID 25571 investigated on 07/27/21; deficiencies cited and complaint substantiated.
Severity Breakdown
Class I: 1 Class II: 1
Deficiencies (3)
DescriptionSeverity
Failed to provide and maintain a record of training to new employees prior to scheduling them to work unsupervised, and no later than within the first 15 days of employment, including emergency procedures, resident rights, abuse prevention, and infection control for 11 agency employees.Class II
Failed to provide maintenance and housekeeping to maintain a safe, sanitary, and accident-free living environment; observations included personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, dirty sink, and evidence of mice in a resident's bedroom.Class I
Failed to ensure adequate evening shift staffing; only one direct care staff plus one licensed practical nurse or medication assistive personnel were scheduled on multiple days despite 15 residents requiring two or more special care needs.
Report Facts
Census: 33 Agency employees lacking training: 11 Residents with 2 or more special care needs: 15 Medications administered evening shift: 61 Days with insufficient evening staffing: 8
Inspection Report Complaint Investigation Census: 34 Deficiencies: 11 Apr 30, 2021
Visit Reason
Complaint investigation conducted due to concerns about housekeeping, maintenance, staffing, activities, medication administration, and infection control at the facility.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and sanitary environment, inadequate staffing leading to missed showers and insufficient supervision, lack of required employee training and documentation, failure to provide scheduled activities, and poor infection control practices. Numerous physical maintenance issues and cleanliness problems were observed throughout the facility.
Complaint Details
Complaint #25245 substantiated. Facility census 34. Investigation conducted April 12 to April 30, 2021.
Deficiencies (11)
Description
Failed to get results of pre-employment tuberculosis screening for Executive Director prior to hire.
Failed to ensure adequate housekeeping and maintenance required to carry out services; observed personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bars and toilet paper holders, dirty sink.
Failed to provide a monthly calendar listing type, time, and duration of social and recreational activities; no activities provided for April.
Failed to ensure employees obtained and maintained food handler training within 30 days of hire as required by Kanawha County.
Failed to ensure medication administration by appropriately licensed professionals; missing evidence of high school diploma for AMAP #60; missing quarterly reviews for AMAP #58 and #59.
Failed to provide minimum seven hours per week of scheduled activities appropriate for residents.
Failed to provide all resident care and services in accordance with current standards of practice using appropriate infection control techniques; dirty commodes, overflowing trash, soiled laundry, heavily soiled carpet, offensive odors.
Executive Director failed to have proof of required education on file.
Failed to maintain sufficient number of qualified employees on duty to provide required care and services including showers and supervision; multiple missed showers and 28 unwitnessed falls reported.
Failed to provide maintenance and housekeeping to maintain a safe, sanitary, and accident-free living environment; trip hazards, holes in walls and doors, stained carpets, overflowing trash, soiled floors, missing light covers and bulbs.
Failed to keep interior and exterior of residence clean and in good repair; rusty ceiling grid, food debris on floors, stained and worn carpets, damaged walls, missing light covers and bulbs.
Report Facts
Facility census: 34 Missed showers: 34 Unwitnessed falls: 28
Employees Mentioned
NameTitleContext
Executive DirectorExecutive DirectorNamed in deficiency for lack of tuberculosis screening and proof of education.
AMAP #60Approved Medication Assistive PersonnelMissing evidence of high school diploma or GED.
AMAP #58Approved Medication Assistive PersonnelMissing quarterly review.
AMAP #59Approved Medication Assistive PersonnelMissing quarterly review.
Resident Care Provider #47Resident Care ProviderObserved playing cards with residents during survey.
Licensed Practical Nurse #55Licensed Practical NurseInterviewed regarding food handler card requirement.
Resident Care Provider #52Resident Care ProviderInterviewed regarding food handler card requirement.
Inspection Report Complaint Investigation Census: 34 Deficiencies: 3 Apr 19, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to assist a resident in finding alternative placement after transfer to a hospital and issues related to discharge notification and resident safety.
Findings
The facility failed to provide the required 30-day written notice prior to discharge and did not assist the resident or hospital in finding appropriate alternative placement. Additionally, the facility had inadequate housekeeping and maintenance, including damaged carpets, missing bathroom fixtures, and unclean conditions. Staff were not fully aware of their obligations regarding discharge procedures and resident placement assistance.
Complaint Details
Complaint Number: 24770. Substantiated complaint regarding failure to assist resident #CR1 with discharge notification and placement assistance after transfer to hospital. Resident was medically cleared but facility refused to readmit without psych evaluation and did not provide required notices or assistance.
Deficiencies (3)
Description
Failure to provide 30-day written notice prior to discharge and failure to assist resident in finding alternative placement as required by regulation.
Inadequate housekeeping and maintenance including iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Unsafe environment due to lack of alarm on outside doors and inadequate awake-night supervision on weekends.
Report Facts
Resident census: 34 Sample size: 3 Date of survey completion: Apr 19, 2021 Plan of correction completion date: Jun 15, 2021
Employees Mentioned
NameTitleContext
Regional Director of Clinical ServicesRDCSProvided education on discharge notice requirements and placement assistance
Care Service ManagerCSMReceived education on discharge notice requirements
Administrative AssistantAAReceived education on discharge notice requirements
Director of NursingDoNInvolved in decision to not readmit resident and communication with hospital
Executive DirectorEDResponsible for auditing resident discharge records for compliance
Social Worker #68Social WorkerReviewed resident chart and communicated with Medical Power of Attorney
RN Case Manager #67RN Case ManagerReported facility did not assist in placement and communication issues
Inspection Report Complaint Investigation Census: 34 Deficiencies: 3 Apr 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with staffing, safety, housekeeping, and personnel record requirements following allegations of inadequate supervision and other deficiencies.
Findings
The facility was found to have multiple deficiencies including failure to ensure awake staff per story during sleeping hours, inadequate housekeeping and maintenance, and failure to obtain required eligibility fitness determination for the Executive Director prior to hire. These issues had the potential to affect all 34 residents.
Complaint Details
Substantiated complaint investigation conducted from 2021-04-12 to 2021-04-19. Issues included staffing shortages, missed showers, and 28 unwitnessed falls reported in the first quarter of 2021.
Deficiencies (3)
Description
Failure to ensure a multi-story residence had at least one awake staff per story at all times while residents were sleeping unless residents were certified by a physician as not needing sleep time supervision.
Failure to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Failure to ensure the Executive Director received an eligibility fitness determination or variance from WVCARES prior to hire.
Report Facts
Facility census: 34 Unwitnessed falls: 28 Residents with physician order for sleep time supervision: 25 Residents requiring two-person assist: 3 Missed showers: 12
Employees Mentioned
NameTitleContext
Executive DirectorExecutive Director (ED)Named in deficiency for failure to obtain WVCARES eligibility fitness determination prior to hire
Regional Director of Care ServicesRDCSProvided education on staffing requirements and WVCARES compliance
Care Service ManagerCSMRevised staffing schedule to meet awake staff requirements
Director of NursingDONProvided information on residents' supervision needs and staffing challenges
Inspection Report Complaint Investigation Census: 34 Deficiencies: 0 Apr 19, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a complaint numbered WV00025058.
Findings
The complaint investigation was completed with no substantiation of the complaint. The report includes initial comments and notes the census at the time of inspection.
Complaint Details
Complaint number WV00025058 was investigated and found to be not substantiated.
Report Facts
Census: 34
Inspection Report Routine Census: 38 Deficiencies: 0 Dec 23, 2020
Visit Reason
The inspection was conducted as an Infection Control Survey to assess compliance with infection control standards at the facility.
Findings
The survey found no deficiencies or tags cited related to infection control. The census was 38 residents, and the survey sample size was 100%. No complaints were substantiated.
Report Facts
Sample size: 100 Census: 38
Inspection Report Complaint Investigation Census: 41 Deficiencies: 0 Sep 14, 2020
Visit Reason
Revisit of Complaint #24056 to verify correction of previously cited deficiencies.
Findings
The deficiencies cited in the complaint were corrected as of the revisit inspection on 09/14/2020.
Complaint Details
Complaint #24056 was revisited and deficiencies were found to be corrected.
Report Facts
Census: 41
Inspection Report Annual Inspection Census: 41 Deficiencies: 0 Sep 14, 2020
Visit Reason
Revisit to annual inspection to verify correction of previously cited deficiencies.
Findings
The deficiencies identified in the prior inspection were corrected as of the revisit on 09/14/2020.
Report Facts
Census: 41
Inspection Report Complaint Investigation Census: 48 Deficiencies: 3 Jul 30, 2020
Visit Reason
Complaint survey conducted due to a substantiated complaint regarding failure to maintain proper infection control and housekeeping standards.
Findings
The facility failed to keep the residence free of insects, rodents, and vermin as evidenced by mouse droppings found in multiple dining and resident areas. Additionally, the facility did not consistently follow infection control protocols, specifically missing resident and employee temperature recordings during the COVID-19 pandemic. Housekeeping and maintenance deficiencies were also noted, including damaged carpets, missing bathroom fixtures, and unclean areas.
Complaint Details
Complaint Survey: 2405607/27/20 at 9:00 AM; Census 48; Complaint substantiated.
Severity Breakdown
Class III: 1 Class I: 1
Deficiencies (3)
DescriptionSeverity
Failure to keep the residence free of insects, rodents, and vermin with mouse droppings found in dining rooms and resident closets.Class III
Failure to provide all resident care and services in accordance with current standards of practice using appropriate infection control techniques, including missing temperature recordings for residents and employees during COVID-19.Class I
Inadequate housekeeping and maintenance including personal belongings left inappropriately, carpet damage, missing bathroom towel bars and toilet paper holders, and dirty sinks.
Report Facts
Facility census: 48 Deficiencies cited: 3 Missing resident temperatures: 48 Mouse droppings observations: 4
Employees Mentioned
NameTitleContext
Executive Director #61Executive DirectorDemonstrated computerized method of documenting employee temperatures and COVID-19 screening.
Director of Nursing #62Director of NursingExpressed surprise at the number of missing resident temperature recordings.
Inspection Report Annual Inspection Census: 48 Deficiencies: 4 Jul 30, 2020
Visit Reason
Annual survey conducted from 07/27/20 to 07/30/20 to assess compliance with health and safety regulations, medication administration, personnel licensing, and housekeeping standards.
Findings
The facility failed to ensure proper medication administration documentation for insulin and blood glucose monitoring, maintain current nursing licenses for two employees, and uphold adequate housekeeping and maintenance standards. No ill effects were noted from medication errors. Corrective actions and staff education plans were implemented.
Severity Breakdown
Class I: 2
Deficiencies (4)
DescriptionSeverity
Failed to ensure medications and treatments were administered as required by law, including lack of training for medication assistive personnel on blood glucose monitoring.Class I
Failed to provide current nursing licenses for two employees; licenses on file were expired.
Failed to keep a record of all medications given to residents, with missed insulin doses documented for two residents.Class I
Failed to maintain adequate housekeeping and maintenance, including damaged carpet, missing towel bars, and dirty sinks.
Report Facts
Census: 48 Number of residents with medication issues: 8 Number of employees with expired licenses: 2 Number of employees certified AMAP: 4 Number of residents with missed insulin documentation: 2
Employees Mentioned
NameTitleContext
Employee #15Licensed Practical NurseInterviewed regarding medication administration and training
Employee #2AMAP Registered NurseInterviewed regarding training of AMAPs on blood glucose monitoring
Employee #17AMAPInterviewed regarding lack of fingerstick training
Registered Nurse #1Executive Director / RNResponsible for license verification and interview regarding personnel files
Licensed Practical Nurse #31LPNPersonnel file missing current license
Inspection Report Annual Inspection Census: 47 Deficiencies: 2 Jul 28, 2020
Visit Reason
Annual environmental inspection conducted to assess compliance with physical facility standards including cleanliness, maintenance, and pest control.
Findings
The facility was found to have deficiencies related to failure to keep the residence free of insects, rodents, and vermin, as well as failure to maintain the interior and exterior of the residence clean and in good repair. Specific issues included dead insects, small flies, sticky floors, stained ceiling tiles, dusty air vents, and damaged furnishings.
Severity Breakdown
Class III: 1 Class II: 1
Deficiencies (2)
DescriptionSeverity
Failure to keep the residence free of insects, rodents, and vermin.Class III
Failure to keep the interior and exterior of the residence clean and in good repair.Class II
Report Facts
Facility census: 47 Deficiencies cited: 2
Employees Mentioned
NameTitleContext
Maintenance DirectorRemoved dead insects and replaced stained ceiling tile immediately upon notification
Dietary ManagerCleaned serving area and trash cans, and food storage area immediately upon notification
Executive DirectorResponsible for re-educating housekeeping and dietary staff and monitoring facility cleanliness and repair
Inspection Report Plan of Correction Census: 6 Deficiencies: 2 Dec 13, 2019
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations in a behavioral health facility, focusing on the safety and appropriateness of the environment for adolescent consumers.
Findings
The facility was found to have safety deficiencies including lack of alarms on outside doors in adolescent girls' bedrooms and an unlocked outside door in the TV room. Staffing patterns did not provide awake night supervision on weekends, posing safety risks.
Deficiencies (2)
Description
Adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor safety.
An outside door in the TV room does not lock, compromising security.
Report Facts
Center census: 6 Sample size: 3
Inspection Report Complaint Investigation Census: 6 Deficiencies: 1 Dec 11, 2019
Visit Reason
The inspection was conducted in response to a complaint identified as #WV00023531.
Findings
The complaint was investigated and found to be unsubstantiated. The report includes observations regarding safety concerns in the adolescent residence, such as lack of alarms on outside doors and insufficient awake staff on weekend nights.
Complaint Details
Complaint #WV00023531 was investigated and found to be unsubstantiated.
Deficiencies (1)
Description
The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers, including unsecured outside doors and lack of awake staff on weekend nights.
Report Facts
Center census: 6 Sample size: 3
Inspection Report Complaint Investigation Census: 54 Deficiencies: 0 Dec 11, 2019
Visit Reason
The inspection was conducted as a complaint survey in response to Complaint # WV00023528.
Findings
No deficiencies were cited during the complaint survey, and the complaint was found to be unsubstantiated.
Complaint Details
Complaint # WV00023528 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 54
Inspection Report Complaint Investigation Census: 54 Deficiencies: 0 Dec 11, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID# WV0023530.
Findings
No deficiencies were cited during the complaint survey conducted from December 10 to December 11, 2019. The complaint was found to be unsubstantiated.
Complaint Details
Complaint ID# WV0023530 was investigated and found to be unsubstantiated.
Report Facts
Census: 54
Inspection Report Follow-Up Census: 55 Deficiencies: 0 Oct 22, 2019
Visit Reason
Follow-up annual survey visit to assess compliance and verify correction of previous deficiencies.
Findings
No deficiencies were cited during this follow-up annual survey visit.
Report Facts
Census: 55
Inspection Report Complaint Investigation Census: 55 Deficiencies: 1 Oct 22, 2019
Visit Reason
The inspection was conducted as a complaint survey related to a resident complaint about staff behavior and failure to respond to the complaint in writing within the required timeframe.
Findings
The licensee, administrator, and registered nurse failed to resolve a complaint and respond in writing within four days after the complaint was filed for one resident. The investigation substantiated neglect by Employee #21, who was suspended and later terminated. Staff were re-educated on complaint policies and procedures.
Complaint Details
Complaint ID#: WV00023004. Resident #29 complained about staff rudeness and failure to change her wet bed after she used the call light. The complaint was not investigated or responded to in writing within four days as required. Investigation substantiated neglect by Employee #21, who was terminated.
Severity Breakdown
Class III: 1
Deficiencies (1)
DescriptionSeverity
Failure to respond to a resident complaint in writing within four days as required.Class III
Report Facts
Census: 55 Complaint ID: WV00023004
Employees Mentioned
NameTitleContext
Employee #21Named in complaint for neglect and rude behavior; suspended and terminated following investigation.
Licensed Practical Nurse #15Licensed Practical Nurse (LPN)Reported the complaint to the administrator but was unsure if it was investigated.
Interim Executive DirectorConducted interviews, submitted APS report, suspended Employee #21, and oversaw corrective actions.
Inspection Report Follow-Up Census: 55 Deficiencies: 0 Oct 22, 2019
Visit Reason
Follow-up visit to Complaint Survey related to Complaint ID# WV00022672 to verify correction of previously cited deficiencies.
Findings
Deficiencies identified in the prior complaint survey were corrected as of the follow-up visit on 10/22/2019.
Complaint Details
Complaint ID# WV00022672; deficiencies corrected as of follow-up visit.
Report Facts
Census: 55
Inspection Report Annual Inspection Census: 55 Deficiencies: 6 Jul 22, 2019
Visit Reason
Annual Survey and Unsubstantiated Complaint Investigation #22944 conducted from 07/22/19 to 07/24/19 at Kanawha Place.
Findings
The facility failed to ensure admission agreements contained all required information, including licensed nursing coverage, medication management, resident funds management, house rules, and emergency evacuation procedures. Additionally, deficiencies were found in housekeeping and maintenance, failure to notify licensed health care professionals after resident accidents, and failure to report significant weight changes to physicians.
Complaint Details
The inspection included an unsubstantiated complaint investigation #22944.
Severity Breakdown
Class I: 2 Class III: 1
Deficiencies (6)
DescriptionSeverity
Admission agreements lacked required information on licensed nursing coverage, medication storage and distribution, and management of resident funds.
Admission agreements did not include house rules, resident bill of rights, personal property protection, medical examination requirements, assistance with appointments, and access to residence policies.
Failure to notify an appropriately licensed health care professional after a resident accident resulting in injury or illness, and failure to document incident reports and 24-hour monitoring.Class I
Failure to report unplanned weight gain or loss of five or more pounds to the resident's physician.Class III
Failure to provide and document emergency evacuation training to residents within 24 hours of admission.Class I
Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sinks.
Report Facts
Census: 55 Residents affected: 55 Resident identifier: 37 Resident identifier: 32 Completion dates: Sep 27, 2019
Employees Mentioned
NameTitleContext
Employee #1AdministratorAcknowledged admission agreements lacked required information.
Employee #4Business Office Manager/AMAPVerified no notification to resident's physician after accident and no notification of weight changes.
Employee #16AMAPInvolved in care of Resident #37 after accident; gave resident juice and food but failed to notify licensed health care professional.
Inspection Report Annual Inspection Census: 56 Deficiencies: 0 Jul 22, 2019
Visit Reason
The visit was conducted as an Annual Licensure Survey focusing on the annual environmental inspection of the facility.
Findings
No deficiencies were cited during this annual environmental licensure survey.
Report Facts
Census: 56 Deficiencies cited: 0
Inspection Report Complaint Investigation Census: 54 Deficiencies: 5 Jun 27, 2019
Visit Reason
The inspection was conducted as a complaint investigation regarding a major incident involving a bed bug infestation affecting Resident #33.
Findings
The facility failed to report a major incident of bed bug infestation in a timely manner, did not maintain proper legal representative documentation for Resident #33, failed to prepare a proper transfer summary for Resident #33's hospital visit, and did not notify the resident's physician about the bed bug infestation. Additionally, housekeeping and maintenance deficiencies were noted in the facility environment.
Complaint Details
Complaint Investigation #22672 conducted from 06/25/19 to 06/27/19. Allegation substantiated regarding failure to report bed bug incident timely and other related deficiencies.
Severity Breakdown
Class I: 1 Class II: 1 Class III: 2
Deficiencies (5)
DescriptionSeverity
Failed to report a major incident of bed bug infestation involving Resident #33 within the required timeframe.Class III
Failed to keep a copy of the document granting legal authority to a legal representative for Resident #33 in the resident's record.Class III
Failed to prepare a transfer summary including medical history and other required information for Resident #33's hospital transfer.Class II
Failed to promptly notify the resident's physician or licensed health care professional about the bed bug infestation.Class I
Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink.
Report Facts
Facility census: 54 Days delay in incident reporting: 36 Resident blood sugar level: 569
Employees Mentioned
NameTitleContext
RN/CSM #02Registered Nurse/Care Services ManagerVerified failure to report bed bug incident timely and completed Major Incident Report late
Executive Director #01Executive DirectorVerified notification procedures and lack of legal representative documentation
LPN #15Licensed Practical NurseReported initial knowledge of bed bug incident and spoke with resident's guardian
AMAP #16Approved Medication Assistive PersonnelResponsible for transfer form during hospital transfer of Resident #33
Inspection Report Complaint Investigation Census: 54 Deficiencies: 0 Jan 22, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID WV00021822 during January 22-23, 2019.
Findings
No deficiencies were found during the complaint investigation.
Complaint Details
Complaint ID WV00021822 was investigated and found to have no deficiencies.
Report Facts
Census: 54
Inspection Report Complaint Investigation Census: 50 Deficiencies: 0 Dec 18, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID WV00021692 during December 18-19, 2018.
Findings
No deficiencies were cited during this complaint investigation.
Complaint Details
Complaint ID WV00021692 was investigated with no deficiencies cited.
Report Facts
Census: 50
Inspection Report Complaint Investigation Census: 47 Deficiencies: 0 Nov 29, 2018
Visit Reason
The inspection was conducted as a complaint investigation from November 27-29, 2018, related to complaint ID WV00021433.
Findings
No deficiencies were cited during this complaint investigation.
Complaint Details
Complaint ID WV00021433 was investigated with no deficiencies cited.
Report Facts
Census: 47
Inspection Report Follow-Up Census: 52 Deficiencies: 0 Sep 5, 2018
Visit Reason
This was a follow-up survey conducted to verify correction of previous deficiencies noted during the July 16-18, 2018 inspection.
Findings
No deficiencies were cited during the follow-up survey conducted on September 5, 2018, indicating that previous issues had been addressed.
Report Facts
Census: 52 Census: 57
Inspection Report Routine Census: 57 Deficiencies: 1 Jul 18, 2018
Visit Reason
The inspection was conducted to assess compliance with health care standards, specifically regarding medication orders and administration, as well as overall facility safety and housekeeping.
Findings
The facility failed to ensure that prescriptions or verbal orders were properly obtained and documented for medication administration for two residents, resulting in missed doses. Additionally, there were deficiencies in housekeeping and maintenance affecting the physical environment.
Severity Breakdown
CLASS I: 1
Deficiencies (1)
DescriptionSeverity
Failure to obtain and keep copies of prescriptions or written orders for altering, discontinuing, and administering medications for two residents.CLASS I
Report Facts
Census: 57 Missed insulin doses: 34 Potential missed doses: 16 Audit frequency: 5 Audit frequency: 3 Audit frequency: 1
Employees Mentioned
NameTitleContext
Care Services ManagerCare Services Manager (CSM)Notified physician of missing insulin doses and involved in staff re-training
Executive DirectorExecutive Director (ED)Conducted staff re-training and responsible for auditing MARs
Director of NursingDirector of NursingInterviewed regarding unawareness of medication orders
Registered NurseSupervising Registered Nurse (RN)Interviewed and stated inability to locate completed and signed orders
Inspection Report Annual Inspection Census: 58 Deficiencies: 0 Jul 18, 2018
Visit Reason
The visit was conducted as an annual licensure survey including an annual environmental inspection.
Findings
No deficiencies were cited during the inspection. The Fire Marshal report dated 01/31/18 noted no recommendations, while the Sanitarian report dated 12/21/17 included four noncritical recommendations.
Report Facts
Recommendations: 4
Inspection Report Complaint Investigation Census: 54 Deficiencies: 0 Jan 22, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID WV00021712 during January 22-23, 2018.
Findings
No deficiencies were cited during this complaint investigation.
Complaint Details
Complaint ID WV00021712 was investigated with no deficiencies cited.
Report Facts
Census: 54
Inspection Report Annual Inspection Census: 46 Deficiencies: 0 Jul 26, 2017
Visit Reason
The visit was conducted as an annual licensure survey focusing on environmental conditions at the facility.
Findings
The inspection found no deficiencies or technical assistance needs during the annual licensure survey.
Report Facts
Census: 46
Inspection Report Annual Inspection Census: 45 Deficiencies: 3 Jul 13, 2017
Visit Reason
The inspection was conducted as an annual licensure survey of the facility to assess compliance with health care standards and regulatory requirements.
Findings
The survey found deficiencies related to failure to ensure residents were seen weekly by a registered nurse with proper documentation, inadequate housekeeping and maintenance of the facility environment, and failure to release residents' belongings and funds to the estate administrator or executor upon a resident's death.
Severity Breakdown
CLASS II: 1 CLASS III: 1
Deficiencies (3)
DescriptionSeverity
Failure to ensure residents were seen weekly by the registered nurse and documentation of progress notes reflecting residents' status and changes.CLASS II
Failure to ensure adequate housekeeping and maintenance required to carry out services, including damaged carpet, missing bathroom fixtures, and unclean sink.
Failure to release all of the resident's belongings and funds to the estate administrator or executor upon a resident's death.CLASS III
Report Facts
Census: 45 Deficient residents: 5 Deficient deceased residents: 3
Employees Mentioned
NameTitleContext
Executive DirectorNamed in plan of correction to conduct weekly audits on RN documentation and meet with LPNs regarding documentation of estate administrator/executor
Customer Service ManagerR.N.Named in plan of correction to meet with LPNs regarding documentation of estate administrator/executor
Inspection Report Annual Inspection Census: 45 Deficiencies: 1 Jul 10, 2017
Visit Reason
The inspection was conducted as an annual licensure survey of the facility from July 10-13, 2017.
Findings
Deficiencies were cited during the annual licensure survey. A follow-up survey on September 6, 2017, with a census of 48, confirmed that the deficiencies were corrected.
Deficiencies (1)
Description
Deficiencies cited during the annual licensure survey
Report Facts
Census: 45 Census: 48
Inspection Report Complaint Investigation Census: 46 Deficiencies: 0 Jun 14, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID WV00018003 from June 12-14, 2017.
Findings
No deficiencies were found during the complaint investigation conducted at the facility.
Complaint Details
Complaint ID WV00018003 was investigated and found to have no deficiencies.
Report Facts
Census: 46
Inspection Report Plan of Correction Census: 49 Deficiencies: 4 Dec 27, 2016
Visit Reason
The inspection was a follow-up survey to verify correction of previous deficiencies related to physical facilities, housekeeping, and safety in the residence.
Findings
The facility was found deficient in maintaining a safe and appropriate environment, including issues with awake-night supervision on weekends, unsecured doors, and inadequate housekeeping and maintenance such as carpet damage, missing bathroom fixtures, and laundry area cross-contamination risks. The facility administrator and maintenance manager acknowledged the findings and corrective actions were planned.
Severity Breakdown
CLASS II: 3
Deficiencies (4)
DescriptionSeverity
Adolescent girls' bedrooms have outside doors without alarms and lack awake-night supervision on weekends; an outside door in the TV room does not lock.
Interior of the residence was not kept clean and in good repair, including carpet burns and bleach spots, torn furniture, missing bathroom towel bars and toilet paper holders, and dirty sinks.CLASS II
Laundry area lacks physical barriers to separate soiled and clean laundry, risking cross contamination.CLASS II
Hot water tank room lacks outside make-up air for combustion.CLASS II
Report Facts
Census: 49 Sample Size: 3 Completion Date: 2017
Employees Mentioned
NameTitleContext
Operations SupervisorParticipated in residence tour and interview regarding safety and housekeeping findings
Treatment CoordinatorParticipated in residence tour and interview regarding housekeeping findings
Maintenance ManagerPresent during inspection and agreed findings needed correction
Facility AdministratorAware of facility issues and working with contractors to resolve problems
Inspection Report Follow-Up Census: 49 Deficiencies: 0 Dec 27, 2016
Visit Reason
Follow-up visit to verify correction of previous deficiencies related to laundry separation and hot water heater make-up air.
Findings
All previously cited deficiencies have been corrected at the time of this follow-up survey. No new deficiencies were noted.
Report Facts
Census: 49
Inspection Report Follow-Up Census: 50 Deficiencies: 0 Dec 20, 2016
Visit Reason
The visit was a follow-up survey conducted to verify correction of deficiencies identified during the Change of Ownership (CHOW) survey conducted November 7-10, 2016.
Findings
The follow-up survey found that the previously cited deficiencies were corrected as of December 21, 2016.
Report Facts
Census: 50 Residents Out of Facility (OOF): 2
Inspection Report Routine Census: 50 Deficiencies: 4 Nov 10, 2016
Visit Reason
The inspection was conducted as a Change of Ownership (CHOW) survey from November 7-10, 2016, to assess compliance with employee orientation and training requirements.
Findings
The facility failed to provide and maintain records of required training for new employees prior to scheduling them to work unsupervised and failed to provide annual in-service training on topics including emergency procedures, resident rights, confidentiality, abuse prevention, infection control, fire safety, and Alzheimer's disease training. Multiple employees were found to have training completed late by significant timeframes.
Severity Breakdown
Class II: 3
Deficiencies (4)
DescriptionSeverity
Failed to provide and maintain records of training on emergency procedures, disaster plans, complaint procedures, resident rights, confidentiality, abuse prevention, and infection control for new employees within 15 days of employment.Class II
Failed to provide and maintain records of annual in-service training on resident rights, confidentiality, abuse prevention, infection control, and fire safety for all staff.Class II
Failed to provide training to all new employees within 15 days of employment and annual training thereafter on Alzheimer's disease and related dementias.Class II
Failed to ensure adequate housekeeping and maintenance in the facility, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink.
Report Facts
Census: 50 Days late for training: 7 Days late for training: 54 Days late for annual training: 165 Days late for annual training: 571 Days late for annual training: 598
Employees Mentioned
NameTitleContext
Employee #23Failed to complete required training on emergency procedures and Alzheimer's disease within required timeframe; no longer employed at the facility.
Employee #28Failed to complete required training on emergency procedures and Alzheimer's disease within required timeframe.
Employee #29Failed to complete required training on emergency procedures and Alzheimer's disease within required timeframe.
Employee #33Failed to complete required training on emergency procedures and Alzheimer's disease within required timeframe.
Employee #10Failed to complete annual training on fire safety, infection control, resident rights, confidentiality, abuse prevention, and Alzheimer's disease on time.
Employee #15Failed to complete annual training on fire safety, infection control, resident rights, abuse prevention, and Alzheimer's disease on time.
Employee #16Failed to complete annual training on fire safety, infection control, resident rights, abuse prevention, resident activities, and Alzheimer's disease on time.
Employee #25Failed to complete annual training on fire safety, infection control, resident rights, and Alzheimer's disease on time.
Employee #34Failed to complete annual training on fire safety, infection control, resident rights, confidentiality, and Alzheimer's disease on time.
Inspection Report Change Of Ownership Census: 51 Deficiencies: 10 Oct 24, 2016
Visit Reason
The inspection was conducted as a Change of Ownership (CHOW) survey to assess compliance with physical facility standards and maintenance requirements.
Findings
The facility was found deficient in maintaining a safe, sanitary, and accident-free environment, including issues with kitchen flooring, suspended ceilings, slide bolts on restroom doors, storage blocking emergency access, lack of proper combustion air for hot water tanks, dirty and damaged carpeting, improper storage in sprinkler valve room, missing furnace filters, unsecured electrical boxes, and inadequate separation of soiled and clean laundry.
Severity Breakdown
Class I: 2 Class II: 1 Class III: 7
Deficiencies (10)
DescriptionSeverity
Kitchen flooring was made up of mutable ceramic tile and patchwork cement, making sanitation impossible.Class I
Suspended ceiling in food service area did not meet aluminum grid and washable tile requirements.Class I
Slide bolt installed on outside of restroom doors, posing risk of residents being locked in.Class III
Elevator pump room and hot water tank room were cluttered with storage blocking emergency access and violating electrical code clearance.Class III
Hot water tank lacked access to free outside air required for gas-fired appliances.Class III
Large stain on carpeting on second floor stairwell landing.Class III
Main sprinkler valve room used as storage and found dirty with painting supplies and spider webs.Class III
Furnace in sprinkler valve room had no filter installed.Class III
Electrical 'handy box' hanging by flex cable, not secured to wall as required.Class III
Laundry facilities lacked physical barriers to separate soiled and clean laundry, risking cross contamination.Class II
Report Facts
Census: 51 Deficiencies cited: 3
Inspection Report Complaint Investigation Census: 49 Deficiencies: 0 Apr 21, 2016
Visit Reason
The inspection was conducted as a complaint investigation from April 18-21, 2016.
Findings
The report documents a complaint investigation at Kanawha Place with a census of 49 residents. Specific deficiencies or findings are not detailed in the provided text.
Complaint Details
Complaint investigation conducted from April 18-21, 2016, with a census of 49 residents. No substantiation status or detailed complaint findings are provided.
Report Facts
Census: 49
Inspection Report Follow-Up Census: 48 Deficiencies: 0 Mar 31, 2016
Visit Reason
The visit was a follow-up survey conducted to verify correction of deficiencies identified during the annual licensure survey conducted January 25-27, 2016.
Findings
The report summarizes the annual licensure survey and the subsequent follow-up survey, noting census counts of 51 and 48 respectively. Specific deficiencies or findings are not detailed in the provided text.
Report Facts
Census: 51 Census: 48
Inspection Report Complaint Investigation Census: 47 Deficiencies: 1 Feb 15, 2016
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #: WV00015052) regarding failure to notify a resident and their representative at least 72 hours prior to a room change.
Findings
The facility failed to provide the required 72-hour advance notification to Resident #C1 and their legal representative about a room change. Documentation and interviews revealed no prior written or documented verbal notification before the move on October 5, 2015.
Complaint Details
Complaint #: WV00015052. The complaint alleged failure to notify a resident and their legal representative at least 72 hours prior to a room change. The investigation found the licensee did not meet this requirement for Resident #C1.
Severity Breakdown
Class III: 1
Deficiencies (1)
DescriptionSeverity
Failure to notify the resident and his or her representative at least seventy-two (72) hours prior to a change in room or roommate assignment unless an emergency situation occurs.Class III
Report Facts
Census: 47 Days prior notification required: 72 Date of room change: Oct 5, 2015
Inspection Report Complaint Investigation Census: 47 Deficiencies: 1 Feb 15, 2016
Visit Reason
The inspection was conducted as a complaint investigation for complaint number WV00015052 from February 15-17, 2016.
Findings
The report documents deficiencies related to safety and supervision in the facility, including lack of awake staff on weekend nights and unsecured doors in adolescent bedrooms and common areas.
Complaint Details
Complaint #: WV00015052 investigated from February 15-17, 2016 with a census of 47 at the time of investigation.
Deficiencies (1)
Description
The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers, including unsecured outside doors and lack of awake staff on weekend nights.
Report Facts
Census: 47
Inspection Report Annual Inspection Census: 51 Deficiencies: 3 Jan 27, 2016
Visit Reason
The inspection was conducted as an Annual Licensure Survey from January 25-27, 2016, to assess compliance with state regulations and resident rights.
Findings
The inspection found deficiencies related to failure to report neglect or abuse immediately and complete required adult protective services forms within 48 hours, as well as failure to resolve resident complaints promptly with timely written responses. Additionally, there were issues with housekeeping and maintenance observed during the facility tour.
Complaint Details
The complaint involved alleged verbal abuse of Resident #59 by a licensed practical nurse on August 22, 2015. Documentation included statements from a personal care assistant, a housekeeper, and the resident, describing the verbal abuse. The alleged perpetrator was terminated. The facility failed to report the incident to Adult Protective Services immediately, with the report submitted nine days after the incident. Additional complaints involved pharmacy billing issues and other resident concerns, with delayed written responses beyond the required four days.
Severity Breakdown
Class I: 1 Class III: 1
Deficiencies (3)
DescriptionSeverity
Failure to ensure staff report neglect or abuse immediately and complete adult protective services reporting form within 48 hours for one resident.Class I
Failure to ensure complaints by residents are resolved promptly and a written response provided within four days for three of four complaints.Class III
Failure to ensure adequate housekeeping and maintenance required to carry out services, including presence of personal belongings behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and unclean sink.
Report Facts
Census: 51 Complaint count: 4 Days late for APS report: 9 Days late for complaint response: 9 Days late for complaint response: 15
Employees Mentioned
NameTitleContext
Licensed Practical Nurse (LPN)Named as the employee involved in verbal abuse of Resident #59; employee no longer works at the facility
Personal Care Assistant (PCA)Provided a signed statement describing the verbal abuse incident; no longer works at the facility
HousekeeperProvided a signed statement regarding observation of verbal abuse incident
AdministratorFailed to ensure timely reporting of abuse and complaints; completed APS reporting form
Business Office ManagerProvided information about employee training on abuse and neglect reporting
Inspection Report Annual Inspection Census: 42 Deficiencies: 3 Jan 13, 2016
Visit Reason
Annual licensure survey conducted to assess environmental conditions and compliance with physical facility regulations.
Findings
The facility was found deficient in maintaining the interior and exterior of the residence clean and in good repair, including excessive grease and dust buildup and rodent droppings in the kitchen area.
Deficiencies (3)
Description
Ceiling and sprinkler heads next to the kitchen hood had an excessive build up of grease and dust.
Air grill to the air conditioner in the kitchen had an excessive build up of dust.
Rodent droppings found on the floor in the air condition room in the kitchen.
Report Facts
Census: 42 Deficiencies cited: 2
Inspection Report Complaint Investigation Census: 51 Deficiencies: 0 Dec 16, 2015
Visit Reason
The inspection was conducted as a complaint follow-up visit related to complaint number WV 00014838 from December 14-16, 2015.
Findings
The report documents a follow-up inspection to address the complaint, but no specific findings or deficiencies are detailed in the provided text.
Complaint Details
Complaint # WV 00014838 was investigated during the follow-up visit on December 14-16, 2015. No substantiation status is provided.
Report Facts
Census: 51
Inspection Report Complaint Investigation Census: 52 Deficiencies: 0 Apr 16, 2015
Visit Reason
The inspection was conducted as a complaint investigation at Kanawha Place from April 14-16, 2015.
Findings
The report does not provide detailed findings or deficiencies related to the complaint investigation; the summary section is blank.
Complaint Details
Complaint investigation conducted from April 14-16, 2015, with a census of 52 residents. No substantiation status or specific complaint details are provided.
Report Facts
Census: 52
Inspection Report Annual Inspection Census: 57 Deficiencies: 5 Feb 2, 2015
Visit Reason
The inspection was conducted as an annual licensure survey of Quarry Manor Assisted Living to assess compliance with state regulations.
Findings
The facility was found deficient in several areas including failure to review and update the disaster and emergency preparedness plan annually, inadequate housekeeping and maintenance, lack of annual emergency preparedness drills, poor kitchen cleanliness, lack of preventive maintenance for equipment, and inadequate laundry facility design to prevent cross contamination.
Severity Breakdown
CLASS I: 2 CLASS II: 1 CLASS III: 2
Deficiencies (5)
DescriptionSeverity
Failure to review and update the disaster and emergency preparedness plan on an annual basis and sign and date the plan to verify review.CLASS III
Failure to rehearse the disaster and emergency preparedness plan with all staff from each shift annually and maintain documentation of the rehearsal.CLASS I
Failure to provide maintenance and housekeeping to maintain a safe, sanitary, and accident free living environment; kitchen area in serious need of cleaning.CLASS I
Failure to establish and conduct a program of preventive maintenance for all equipment as recommended by the manufacturer; hot water tank and mixing valve malfunctioning.CLASS III
Laundry facilities do not adequately provide design space to prevent cross contamination of soiled and clean linens.CLASS II
Report Facts
Deficiencies cited: 5 Facility census: 57 Residents out to hospital: 1 Water temperature: 113 Laundry facility size: 80
Employees Mentioned
NameTitleContext
Facility AdministratorDiscussed findings related to disaster preparedness, housekeeping, kitchen cleanliness, equipment maintenance, and laundry facility design during exit interview
Maintenance SupervisorDiscussed findings related to disaster preparedness, housekeeping, equipment maintenance, and laundry facility design during exit interview
Director of Dining ServicesResponsible for ensuring kitchen area cleaning and daily cleaning schedule
Executive Director (ED)Responsible for disaster preparedness plan updates, kitchen cleaning oversight, preventive maintenance program, and review of logs
Maintenance DirectorResponsible for developing preventive maintenance program and maintaining water temperature logs
Inspection Report Annual Inspection Census: 57 Deficiencies: 4 Feb 2, 2015
Visit Reason
Annual licensure survey conducted to assess compliance with health, safety, and facility maintenance regulations.
Findings
The facility was found deficient in several areas including failure to review and update the disaster and emergency preparedness plan annually, failure to conduct annual disaster preparedness drills with all staff, inadequate preventive maintenance of equipment such as the hot water tank, and inadequate laundry facility design leading to potential cross contamination of soiled and clean linens. Housekeeping and maintenance issues were also noted.
Severity Breakdown
CLASS I: 1 CLASS II: 1 CLASS III: 2
Deficiencies (4)
DescriptionSeverity
Failure to review and update the disaster and emergency preparedness plan annually and sign and date the plan to verify review.CLASS III
Failure to rehearse the disaster and emergency preparedness plan with all staff from each shift annually and maintain documentation of the rehearsal.CLASS I
Hot water tank and mixing valve are very old and not functioning properly; lack of preventive maintenance program and no documentation of water temperature logs.CLASS III
Laundry facilities do not adequately provide design space to prevent cross contamination of soiled and clean linens.CLASS II
Report Facts
Deficiencies cited: 5 Facility census: 57 Follow-up date: Mar 18, 2015 Completion dates: Apr 10, 2015 Hot water temperature: 113 Laundry facility size: 80
Inspection Report Complaint Investigation Census: 56 Deficiencies: 0 Jan 21, 2015
Visit Reason
The inspection was conducted as a complaint investigation for facility Kanawha Place on January 20-21, 2015.
Findings
The report documents a complaint investigation with no detailed findings or deficiencies explicitly stated in the provided text.
Complaint Details
Complaint investigation WV00012842 conducted January 20-21, 2015 with census of 56. No substantiation status or detailed complaint findings provided.
Report Facts
Census: 56
Inspection Report Annual Inspection Census: 56 Deficiencies: 4 Jan 7, 2015
Visit Reason
Annual licensure survey conducted from January 5-7, 2015 to assess compliance with state regulations and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to resolve resident complaints timely, inadequate housekeeping and maintenance, incomplete medication administration oversight, and failure to obtain monthly resident weights as required.
Complaint Details
The complaint investigation revealed multiple unresolved complaints including missing personal items, inadequate responses, and lack of documentation of outcomes or timely written responses to complainants.
Severity Breakdown
Class I: 1 Class III: 2
Deficiencies (4)
DescriptionSeverity
Failure to ensure complaints by residents are resolved and a written response provided within four days for nine of eleven instances involving eight residents.Class III
Failure to ensure adequate housekeeping and maintenance required to carry out services, including damaged carpet, missing bathroom fixtures, and unclean conditions.
Failure to ensure medications given to residents are administered as required by applicable federal and state law for one employee, including lack of documented education verification and missed quarterly medication pass observations.Class I
Failure to obtain monthly weights for forty-five of fifty-six residents as required, with missing documentation for multiple months in 2014.Class III
Report Facts
Census: 56 Complaints unresolved: 9 Residents involved in complaints: 8 Residents missing monthly weights: 45 Residents total: 56 Medication pass observations missed: 2
Employees Mentioned
NameTitleContext
Employee #18Medication Assistive PersonnelNamed in deficiency related to medication administration and lack of documented education and quarterly observations
Employee LLNamed in plan of correction for quarterly review completed by RN
Employee #19PRN Registered NurseNamed as needing to complete medication pass observations
Inspection Report Annual Inspection Census: 56 Deficiencies: 0 Jan 5, 2015
Visit Reason
The inspection was conducted as an annual licensure survey from January 5-7, 2015, with a follow-up survey on February 19, 2015.
Findings
The report documents the annual licensure survey and a follow-up survey with census counts of 56 and 58 respectively. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 56 Census: 58
Inspection Report Complaint Investigation Census: 55 Deficiencies: 0 Nov 24, 2014
Visit Reason
The inspection was conducted as a complaint investigation for facility Kanawha Place during November 24-25, 2014.
Findings
The report does not provide detailed findings or deficiencies related to the complaint investigation; only the census and dates are stated.
Complaint Details
Complaint Investigation CI: WV0001236 conducted November 24-25, 2014 with census of 55 residents.
Report Facts
Census: 55
Inspection Report Complaint Investigation Census: 57 Deficiencies: 0 Sep 17, 2014
Visit Reason
The inspection was conducted as a complaint investigation identified as Complaint #WV00012020.
Findings
The report documents a complaint investigation at Kanawha Place with a census of 57 residents. No specific findings or deficiencies are detailed in the provided text.
Complaint Details
Complaint #WV00012020 was investigated on September 17, 2014. No substantiation status or detailed findings are provided.
Report Facts
Census: 57
Inspection Report Annual Inspection Census: 54 Deficiencies: 2 Jan 9, 2014
Visit Reason
Annual licensure survey conducted from January 6-9, 2014 to assess compliance with health care standards and medication administration protocols.
Findings
The facility failed to ensure medications were administered according to physician's orders for four residents, with multiple missed doses and lack of physician notification. Deficiencies in housekeeping and maintenance were also noted, including damaged carpets, missing bathroom fixtures, and unclean areas.
Severity Breakdown
CLASS I: 1
Deficiencies (2)
DescriptionSeverity
Failure to administer medications as ordered for four residents, including missed doses and lack of physician notification.CLASS I
Inadequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sink.
Report Facts
Resident census: 54 Missed medication doses: 18 Missed medication doses: 13 Missed medication doses: 12 Number of medications: 10
Inspection Report Annual Inspection Census: 54 Deficiencies: 0 Jan 6, 2014
Visit Reason
The inspection was conducted as an annual licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The report documents the annual licensure survey conducted from January 6-9, 2014, with a census of 54 residents. A follow-up survey was conducted on February 25, 2014, with a census of 57. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 54 Census: 57
Inspection Report Routine Census: 53 Deficiencies: 1 Dec 17, 2013
Visit Reason
The inspection was conducted to assess the physical facilities and ensure maintenance and housekeeping were adequate to maintain a safe, sanitary, and accident-free living environment.
Findings
The facility failed to maintain the necessary fire/smoke separation between the main storage room and the rest of the building, including the absence of a self-closing door and unsealed openings around piping and wiring.
Severity Breakdown
CLASS I: 1
Deficiencies (1)
DescriptionSeverity
Failed to maintain necessary fire/smoke separation between the main storage room and the rest of the building; door leading from dining/laundry corridor to main warehouse is not self-closing and openings around door frame and wall are not sealed.CLASS I
Report Facts
Deficiencies cited: 1 Technical Assistance Given: 5
Inspection Report Routine Census: 53 Deficiencies: 1 Dec 17, 2013
Visit Reason
Routine inspection conducted to assess compliance with health and safety regulations at Kanawha Place.
Findings
One deficiency was cited during the inspection, with technical assistance provided in five areas. The overall findings indicate some areas needing improvement but no detailed severity levels were provided.
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 supervision on weekends.
Report Facts
Deficiencies cited: 1 Technical Assistance Given: 5
Inspection Report Complaint Investigation Census: 6 Deficiencies: 2 Mar 30, 2013
Visit Reason
The inspection was conducted as a complaint investigation related to the safety and appropriateness of the environment for adolescent consumers at the facility.
Findings
The facility was found not to have implemented programs in a safe and appropriate environment for consumers, with specific issues including unsecured outside doors and lack of awake staff supervision on weekend nights. The complaint was ultimately unsubstantiated.
Complaint Details
Complaint investigation #WV00007800 was conducted and found to be unsubstantiated.
Deficiencies (2)
Description
The adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumers, compromising safety.
An outside door in the TV room does not lock, posing a safety risk.
Report Facts
Center Census: 6 Sample Size: 3
Inspection Report Annual Inspection Census: 55 Deficiencies: 4 Jan 10, 2013
Visit Reason
Annual licensure survey conducted January 8-10, 2013 to assess compliance with resident rights, medication administration, dietary services, and housekeeping standards.
Findings
The facility was found deficient in ensuring residents' rights to prompt complaint resolution, proper medication administration according to physician orders, maintenance of adequate food temperatures, and adequate housekeeping and maintenance of the physical environment.
Severity Breakdown
Class I: 1 Class II: 1 Class III: 1
Deficiencies (4)
DescriptionSeverity
Failure to ensure residents have the right to prompt action to resolve complaints and provide written responses within four days.Class III
Failure to administer medications according to physician's orders for multiple residents, with missed doses documented.Class I
Failure to maintain adequate food temperatures in compliance with Division of Health rules.Class II
Failure to ensure adequate housekeeping and maintenance, including presence of personal belongings inappropriately stored, damaged carpet, missing bathroom fixtures, and unclean sink.
Report Facts
Census: 55 Missed medication doses: 13 Missed medication doses: 6 Missed medication doses: 5 Missed medication doses: 6 Missed medication doses: 6
Employees Mentioned
NameTitleContext
Deborah DodrillSurveyorConducted the annual licensure survey
Elizabeth SmithSurveyorConducted the annual licensure survey
Inspection Report Annual Inspection Census: 57 Deficiencies: 0 Jan 3, 2013
Visit Reason
Annual licensure survey conducted to assess compliance with health and safety regulations.
Findings
No deficiencies were cited during the inspection. Technical assistance was provided.
Report Facts
Census: 57
Employees Mentioned
NameTitleContext
John U. StephensHFS ISurveyor conducting the annual licensure survey
Inspection Report Complaint Investigation Census: 57 Deficiencies: 0 Nov 13, 2012
Visit Reason
The inspection was conducted as a complaint investigation at Kanawha Place.
Findings
The complaint investigation was partially substantiated, but no deficiencies were cited. Technical assistance was provided during the visit.
Complaint Details
Partially substantiated complaint with no deficiencies cited.
Report Facts
Census: 57
Employees Mentioned
NameTitleContext
Pam MartinRN, HFNSIISurveyor conducting the complaint investigation
Inspection Report Complaint Investigation Census: 54 Deficiencies: 2 Jul 18, 2012
Visit Reason
The inspection was conducted as a complaint investigation from June 5-13, 2012, followed by a complaint follow-up visit on July 18, 2012.
Findings
The complaint investigation identified deficiencies related to safety and supervision in the facility, including lack of awake staff on weekend nights and unsecured doors. The follow-up visit noted that deficiencies were corrected and technical assistance was given.
Complaint Details
Complaint investigation #WV00007131 conducted June 5-13, 2012 with census 55; follow-up on July 18, 2012 with census 54. Deficiencies were corrected and technical assistance was provided.
Deficiencies (2)
Description
The adolescent girls' bedrooms downstairs have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumers, compromising safety.
An outside door in the TV room does not lock, posing a safety risk.
Report Facts
Census: 55 Census: 54
Employees Mentioned
NameTitleContext
Betty MarineLSW, HFS IISurveyor for complaint investigation June 5-13, 2012
Deborah DodrillHFS IISurveyor for complaint follow-up July 18, 2012
Inspection Report Complaint Investigation Census: 55 Deficiencies: 6 Jun 5, 2012
Visit Reason
The inspection was conducted as a complaint investigation from June 5-13, 2012, to review allegations related to resident care, medication administration, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to implement individualized service plans, improper medication administration, inadequate infection control practices, failure to update nursing assessments and service plans after significant changes, and unsafe storage of toxic substances. Housekeeping and maintenance issues were also noted.
Complaint Details
The complaint investigation was triggered by concerns about inadequate resident care, including failure to follow service plans, improper medication administration, infection control issues, and unsafe storage of toxic substances. The investigation substantiated these deficiencies.
Severity Breakdown
Class I: 5 Class II: 1
Deficiencies (6)
DescriptionSeverity
Failure to ensure staff implement the service plan for one resident, including bathing and showering.Class II
Failure to administer medications as required by state law for three residents, including not observing residents taking medications and improper handling of dropped pills.Class I
Failure to provide resident care and services in accordance with current standards of practice using appropriate infection control techniques for two residents.Class I
Failure to perform and document nursing assessments within 24 hours of admission and update assessments after significant changes for one resident.Class I
Failure to develop and update service plans to meet nursing and medical needs within seven days of admission and after significant changes for one resident.Class I
Failure to store toxic substances in locked storage facilities separate from food and drugs, risking resident safety.Class I
Report Facts
Census: 55 Residents with medication administration issues: 3 Residents with infection control issues: 2 Residents with nursing assessment and service plan issues: 1 Confused residents: 23 Wandering residents: 7
Employees Mentioned
NameTitleContext
Betty MarineLSW, HFS II SurveyorSurveyor conducting the complaint investigation
TBLicensed Practical Nurse (LPN)Named in medication administration deficiencies
DMSupervising Registered Nurse (RN)Named in service plan review and deficiencies
Inspection Report Annual Inspection Census: 54 Deficiencies: 5 Jan 6, 2012
Visit Reason
The inspection was conducted as an Annual Licensure Survey from January 3-6, 2012 to assess compliance with state regulations for resident rights, health care standards, medication administration, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to address resident complaints timely, inadequate housekeeping and maintenance, outdated service plans not available for staff use, and medication administration errors including unclear physician orders and incorrect insulin dosing.
Severity Breakdown
Class I: 2 Class II: 1 Class III: 1
Deficiencies (5)
DescriptionSeverity
Failure to ensure all resident complaints are addressed and responded to within four days as required.Class III
Inadequate housekeeping and maintenance including personal belongings left behind furniture, carpet damage, missing bathroom fixtures, and dirty sinks.
Service plans for multiple residents were outdated and not available for staff use as a guide for resident care.Class II
Medication administration records contained unclear or incomplete physician orders, including PRN medications without symptom instructions and incorrect transcription of medication dosages.Class I
Medication administration errors including failure to administer insulin as ordered and incorrect insulin dosages given to residents.Class I
Report Facts
Census: 54 Sample Size: 3 Months with missing resident council minutes: 5 Months with blank old business documentation: 5 Residents with outdated service plans: 6 Residents with medication order issues: 8 Residents with medication order transcription errors: 3
Employees Mentioned
NameTitleContext
Deborah DodrillHFSII SurveyorConducted the annual licensure survey
Donna WilliamsonHFNSII SurveyorConducted the annual licensure survey
MMActivities DirectorProvided information about resident council meetings and complaint processes
DMRegistered Nurse (RN)Interviewed regarding service plan updates and medication administration
Inspection Report Annual Inspection Census: 66 Deficiencies: 0 Jan 4, 2012
Visit Reason
The visit was conducted as an annual licensure survey to assess compliance with regulatory requirements.
Findings
No deficiencies or technical assistance were identified during the annual licensure survey.
Report Facts
Census: 66
Employees Mentioned
NameTitleContext
Keith CarpenterSurveyorConducted the annual licensure survey
Inspection Report Annual Inspection Census: 54 Deficiencies: 0 Jan 3, 2012
Visit Reason
The inspection was conducted as an annual licensure survey from January 3-6, 2012, with a follow-up survey on February 28, 2012, to verify correction of deficiencies.
Findings
The initial annual licensure survey identified deficiencies which were subsequently corrected by the follow-up survey conducted on February 28, 2012.
Report Facts
Census during annual survey: 54 Census during follow-up survey: 53
Employees Mentioned
NameTitleContext
Deborah DodrillHFSIISurveyor during the annual licensure survey
Donna WilliamsonHFNSIISurveyor during the annual licensure survey
Pam MartinRN, HFNSIISurveyor during the follow-up survey
Inspection Report Complaint Investigation Census: 57 Deficiencies: 1 Apr 6, 2011
Visit Reason
The inspection was conducted as a complaint investigation based on allegation #WV00006334 regarding concerns about dietary services, specifically food temperature and resident preferences.
Findings
The investigation substantiated one allegation resulting in a Class III deficiency related to failure to ensure residents were served meals considering individual preferences, including food temperature. Observations and interviews revealed food was often served not hot enough, and temperature checks were not documented as required.
Complaint Details
Substantiated one allegation - class III deficiency cited - No follow-up needed on class III deficiencies.
Severity Breakdown
Class III: 1
Deficiencies (1)
DescriptionSeverity
Failure to ensure residents are served meals with consideration of individual resident preferences, including temperature of foods served.Class III
Report Facts
Census: 57 Resident sample size: 10 Complaint meetings: 3 Food temperature limits: 41 Food temperature limits: 140 Completion date for monitoring process: 2011 Completion date for training documentation: 2011
Employees Mentioned
NameTitleContext
Deborah DodrillHFSII SurveyorConducted the complaint investigation.
CSAdministratorProvided statements regarding food temperature complaints and corrective actions.
MTDietary SupervisorInterviewed about food temperature checks and procedures.
MCDietary AideInterviewed about buffet bar temperature control and food delivery.
RHHousekeeper/Dietary AideInterviewed about buffet bar preparation before meals.
DJDietary AideInterviewed about hot bar covers and temperature settings.
ANMarketing DirectorInterviewed about resident complaints regarding food temperature.
SHCookInterviewed about past complaints of food temperature.
Inspection Report Annual Inspection Census: 59 Deficiencies: 0 Jan 25, 2011
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental compliance and overall facility conditions.
Findings
No deficiencies or technical assistance needs were identified during the survey.
Report Facts
Census: 59
Employees Mentioned
NameTitleContext
Keith CarpenterSurveyorConducted the annual licensure survey
Inspection Report Annual Inspection Census: 59 Deficiencies: 7 Dec 15, 2010
Visit Reason
Annual licensure survey conducted to assess compliance with health and safety regulations, staffing requirements, employee training, personnel records, health care standards, and proper handling of resident belongings upon death.
Findings
The facility was found deficient in multiple areas including inadequate staffing with current CPR and first aid certifications, failure to provide timely and complete employee training on required topics, delayed tuberculosis screenings for employees, incomplete documentation of medication assistive personnel credentials and quarterly reviews, inadequate housekeeping and maintenance, and failure to properly document disposition of resident belongings upon death.
Severity Breakdown
Class I: 2 Class II: 2 Class III: 1
Deficiencies (7)
DescriptionSeverity
Failure to ensure at least one employee on duty at all times with current first aid and CPR certification for 8 of 14 applicable employees.Class I
Failure to provide and maintain annual in-service training on resident rights, confidentiality, abuse prevention, infection control, fire safety, and evacuation plans for 7 of 7 tenured employees.Class II
Failure to provide annual training on Alzheimer's disease and related dementias for 7 of 7 tenured employees.Class II
Failure to complete tuberculosis screening timely for 7 of 11 employees reviewed.
Failure to ensure resident care and treatment is provided by appropriately credentialed unlicensed personnel; lack of current first aid and CPR certification documentation for 4 of 5 medication assistive personnel; and overdue quarterly reviews for 2 of 5 AMAPs.Class I
Failure to maintain documentation verifying disposition of personal belongings upon resident death in 3 of 4 applicable records.Class III
Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink.
Report Facts
Employees lacking current CPR and first aid certification: 8 Tenured employees lacking annual training on required topics: 7 Employees with delayed tuberculosis screening: 7 Medication assistive personnel lacking current certification: 4 Medication assistive personnel overdue quarterly reviews: 2 Residents with undocumented disposition of belongings: 3 Facility census: 59
Employees Mentioned
NameTitleContext
KMNo evidence of current CPR certification
HMNo evidence of current first aid certification; no longer employed
JSNo evidence of current first aid certification
WHNo evidence of current first aid certification
CNCPR certification expired March 2009; overdue quarterly review
THCPR certification expired April 2010; overdue quarterly review
JMFirst aid and CPR certification expired April 2010; no documentation of first aid training
CMCPR certification expired April 2010; first aid training done by LPN not RN
MFBusiness Office ManagerInterviewed regarding CPR training cancellations and TB screening tracking
Inspection Report Annual Inspection Census: 57 Deficiencies: 4 Jan 6, 2010
Visit Reason
The annual licensure survey was conducted to assess compliance with health care standards, medication administration, and housekeeping/maintenance requirements at the facility.
Findings
The survey found deficiencies in ensuring residents had current annual health assessments, incomplete and unclear medication orders, improper medication administration including insulin dosing errors, and inadequate housekeeping and maintenance such as damaged carpet, missing bathroom fixtures, and unclean areas.
Severity Breakdown
CLASS I: 2 CLASS II: 1
Deficiencies (4)
DescriptionSeverity
Failure to ensure each resident had a current annual health assessment signed and dated by a physician.CLASS II
Failure to ensure medications and treatments were administered as required by law, including incomplete and unclear medication orders.CLASS I
Failure to ensure proper medication administration, including incorrect insulin dosing and missing documentation.CLASS I
Failure to maintain adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks.
Report Facts
Census: 57 Deficiency count: 4 Sample size: 8 Medication administration errors: 5 Medication administration omissions: 7
Employees Mentioned
NameTitleContext
Deborah DodrillHFSII SurveyorNamed as a surveyor conducting the annual licensure survey
Donna WilliamsonHFNSII SurveyorNamed as a surveyor conducting the annual licensure survey
Inspection Report Annual Inspection Census: 57 Deficiencies: 0 Jan 4, 2010
Visit Reason
The inspection was conducted as an annual licensure survey of the facility.
Findings
The report documents the annual licensure survey conducted January 4-6, 2010, with a census of 57 residents. A follow-up survey on March 15, 2010, with a census of 50, confirmed that deficiencies were corrected.
Report Facts
Census: 57 Census: 50
Employees Mentioned
NameTitleContext
Deborah DodrillHFSIISurveyor during the annual licensure survey
Donna WilliamsonHFNSIISurveyor during the annual licensure survey
Pam MartinRN, HFNSIISurveyor during the follow-up survey
Inspection Report Annual Inspection Census: 59 Deficiencies: 0 Dec 15, 2009
Visit Reason
The visit was conducted as an annual licensure survey to assess the environment of the facility.
Findings
The inspection found no deficiencies and no technical assistance was required.
Report Facts
Census: 59
Employees Mentioned
NameTitleContext
Keith CarpenterNamed in relation to the annual licensure survey
Inspection Report Complaint Investigation Census: 57 Deficiencies: 0 Nov 16, 2009
Visit Reason
The inspection was conducted as a complaint investigation on October 13-14, 2009, followed by a survey follow-up on November 17, 2009, to verify correction of deficiencies.
Findings
The complaint investigation identified deficiencies related to the facility's environment and safety measures. A follow-up survey confirmed that the deficiencies were corrected.
Complaint Details
Complaint investigation #WV00005249 conducted October 13-14, 2009 with a census of 57 residents. Follow-up survey on November 17, 2009 with census 60 confirmed deficiencies corrected.
Report Facts
Census: 57 Census: 60
Employees Mentioned
NameTitleContext
Becky DunnHFNSII SurveyorSurveyor during complaint investigation
Pamala MartinHFNSI SurveyorSurveyor during follow-up survey
Sharon KirkProgram ManagerSurveyor during follow-up survey
Inspection Report Complaint Investigation Census: 57 Deficiencies: 7 Oct 13, 2009
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to comply with facility policies and procedures, specifically related to resident falls, injury notifications, and staff training.
Findings
The facility failed to ensure staff compliance with policies on injury notification, resident monitoring after falls, and updating service plans to reflect current resident needs. There were deficiencies in housekeeping and maintenance. One resident suffered a fall resulting in a hip fracture, and the family was not promptly notified. Staff training and documentation were inadequate.
Complaint Details
Complaint investigation #WV00005249 conducted October 13-14, 2009. The complaint involved failure to notify family of a resident fall on September 5, 2009, resulting in a hip fracture. The family was not notified until September 7, 2009. Staff failed to document and monitor the resident properly after the fall. The LPN involved was a new employee and lacked adequate training.
Severity Breakdown
Class I: 1 Class II: 5
Deficiencies (7)
DescriptionSeverity
Failure to notify resident representative/family after injury or fall and incomplete documentation of incident reports.Class II
Failure to protect the physical well-being of a resident who fell and was not sent to hospital promptly.Class II
Failure to provide adequate housekeeping and maintenance in the facility.
Failure to provide sufficient employee orientation and training prior to unsupervised work.Class II
Failure to update resident service plans to reflect current needs, including fall precautions.Class II
Failure to monitor and document resident condition at least every eight hours for 24 hours after an accident.Class II
Failure to promptly notify responsible party or next of kin of significant change in resident condition.Class I
Report Facts
Census: 57 Incident count: 10 Fall incidents for resident #C1: 1 Fall incidents for resident #3: 4 Fall incidents for resident #15: 10 Fall incidents for resident #16: 2 Work order completion timeframe: 30
Employees Mentioned
NameTitleContext
ACLPNNamed in findings related to failure to notify family, incomplete documentation, and insufficient training.
Becky DunnHFNSII SurveyorSurveyor conducting the inspection.
Inspection Report Annual Inspection Census: 58 Deficiencies: 1 Feb 19, 2009
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with health care standards and facility regulations.
Findings
The facility was found deficient in medication security practices, specifically failing to keep the medication cart locked and accessible only to authorized staff. Additionally, observations noted inadequate housekeeping and maintenance issues in the adolescent residential areas.
Severity Breakdown
CLASS I: 1
Deficiencies (1)
DescriptionSeverity
The medication cart was left unlocked and unattended during medication passes, violating medication security requirements.CLASS I
Report Facts
Census: 58 Sample Size: 3 Completion Date: Feb 26, 2009
Employees Mentioned
NameTitleContext
Deborah DodrillHFSIISurveyor
Rebecca DunnHFNSIISurveyor
Pamela MartinHFNSISurveyor
Sharon KirkProgram ManagerSurveyor
Inspection Report Annual Inspection Census: 58 Deficiencies: 1 Feb 17, 2009
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with regulatory requirements for the facility.
Findings
The report includes findings from the annual licensure survey conducted February 17-19, 2009, with a census of 58 residents. A follow-up survey on March 30, 2009, with a census of 57, indicated that deficiencies were corrected and only technical assistance was provided.
Deficiencies (1)
Description
Deficiency Corrected
Report Facts
Census: 58 Census: 57
Employees Mentioned
NameTitleContext
Deborah DodrillHFSIISurveyor during annual licensure and follow-up surveys
Rebecca DunnHFNSIISurveyor during annual licensure survey
Pamela MartinHFNSISurveyor during annual licensure survey
Sharon KirkProgram ManagerSurveyor during annual licensure survey
Pam MartinRN, HFNSISurveyor during follow-up survey
Inspection Report Annual Inspection Census: 58 Deficiencies: 0 Feb 5, 2009
Visit Reason
The visit was conducted as an annual licensure survey to assess the facility's compliance with regulatory requirements.
Findings
The inspection found no deficiencies or technical assistance needs in the environment of the facility.
Report Facts
Census: 58
Inspection Report Follow-Up Census: 55 Deficiencies: 0 Jun 17, 2008
Visit Reason
The visit was a follow-up survey to verify correction of deficiencies identified in a prior Change of Ownership (CHOW) survey conducted in February 2008.
Findings
The follow-up survey found that deficiencies identified in the initial survey were corrected, and technical assistance was provided during the prior inspection.
Report Facts
Census: 55 Census: 58
Employees Mentioned
NameTitleContext
Ernie ChafinRN, HFNS IISurveyor for both initial and follow-up surveys
Deborah DodrillHFS IISurveyor for initial survey
Louise HallRN, HNFS IISurveyor for initial survey
Betty MarineHFS IISurveyor for initial and follow-up surveys
Kathy BeauchampHFNS IISurveyor for follow-up survey
Inspection Report Follow-Up Census: 55 Deficiencies: 6 Apr 22, 2008
Visit Reason
Follow-up survey conducted to verify correction of previously identified deficiencies and compliance with licensing standards.
Findings
The facility was found to have multiple deficiencies related to employee orientation and training, complaint resolution and documentation, resident condition monitoring after accidents, dietary services including therapeutic diet compliance and menu planning, and housekeeping and maintenance issues. Several deficiencies were repeated from prior surveys. Plans of correction were in place with specified completion dates.
Complaint Details
The complaint investigation revealed that residents and family members had repeatedly complained about food quality without receiving written responses within the required 4-day timeframe. The executive director acknowledged verbal complaints but failed to respond in writing. Follow-up showed continued failure to provide timely written responses and document complaint resolution.
Severity Breakdown
Class I: 1 Class II: 2 Class III: 2
Deficiencies (6)
DescriptionSeverity
Failed to ensure new employees received required orientation and training within 15 days, including emergency procedures, resident rights, abuse prevention, and infection control.Class II
Failed to take prompt action and provide written responses within 4 days to resident and family complaints, including food quality complaints.Class III
Failed to monitor and document resident condition at least every 8 hours for 24 hours following an accident or illness, with specific assessments related to injuries.Class II
Failed to maintain physician's orders for therapeutic or modified diets and prepare diets according to written instructions including types and amounts of food.Class I
Failed to encourage resident participation in menu planning and consider resident food preferences.Class III
Failed to maintain adequate housekeeping and maintenance, including presence of personal belongings, damaged carpet, missing bathroom fixtures, and unclean sink.
Report Facts
Census: 58 Census: 55 Deficiencies cited: 7 Completion date: 2008
Employees Mentioned
NameTitleContext
KALPNCompleted resident assessment after fall but documentation was incomplete regarding injury specifics
SKNew employee lacking documented orientation training within 15 days
MFEmployee responsible for providing training to new hires, acknowledged lack of documentation and written content
TDDietary staffUnaware of correct serving sizes for therapeutic diets and lacked proper measuring utensils
Executive DirectorFailed to respond in writing to complaints and ensure timely complaint resolution
Inspection Report Routine Census: 58 Deficiencies: 12 Feb 20, 2008
Visit Reason
Routine inspection conducted to assess compliance with health, safety, employee training, medication administration, resident care, dietary services, and physical facility regulations.
Findings
The facility was found deficient in multiple areas including failure to report major incidents timely, inadequate employee orientation and annual training, incomplete resident service plans, failure to provide updated resident contracts, inadequate complaint resolution, incomplete transfer summaries, medication administration errors, insufficient monitoring after resident injuries, dietary service issues, lack of resident participation in menu planning, and unsecured storage of toxic substances.
Severity Breakdown
Class I: 1 Class II: 3 Class III: 4
Deficiencies (12)
DescriptionSeverity
Failure to report major incidents to the Office of Health Facility Licensure and Certification as required.Class III
Failure to provide adequate employee orientation and training within required timeframes and content.Class II
Failure to maintain updated resident service plans reflecting current care needs.Class II
Failure to have a written contract with residents that includes all required information.Class III
Failure to respond in writing to resident complaints within four days.Class III
Failure to ensure transfer summaries accompany residents at transfer or discharge.
Failure to ensure medication orders are accurately transcribed and medications are available for administration.
Failure to monitor and document resident condition for 24 hours following injury.Class II
Failure to prepare therapeutic or modified diets according to physician orders and written instructions.Class I
Failure to encourage resident participation in menu planning and consider resident preferences.Class III
Failure to secure toxic substances in locked storage inaccessible to residents.
Failure to ensure adequate housekeeping and maintenance, including physical environment issues such as damaged carpet, missing bathroom fixtures, and cleanliness.
Report Facts
Residents with missing training documentation: 7 Residents with missing annual training documentation: 6 Residents with missing dementia training documentation: 6 Residents with incomplete service plans: 5 Residents with missing transfer summaries: 10 Residents with medication administration discrepancies: 18 Residents with incomplete injury monitoring: 4 Residents with missing therapeutic diet orders or incorrect diet served: 1
Employees Mentioned
NameTitleContext
KALPNNamed in failure to report major incidents finding.
SMRegistered NurseNamed in injury monitoring deficiency.
SBRegistered NurseNamed in injury monitoring deficiency.
MSRegistered NurseNamed in injury monitoring deficiency.
Ernie ChafinRN, HFNS IISurveyor
Deborah DodrillHFS IISurveyor
Louise HallRN, HNFS IISurveyor
Betty MarineHFS IISurveyor
Inspection Report Census: 56 Deficiencies: 0 Feb 14, 2008
Visit Reason
The survey was conducted as a Change of Ownership (CHOW) survey to assess the environment of the facility.
Findings
No deficiencies were found during the survey. Only technical assistance was provided.
Report Facts
Census: 56
Employees Mentioned
NameTitleContext
Keith CarpenterSurveyorNamed as the surveyor conducting the Change of Ownership survey
Inspection Report Plan of Correction Census: 6 Deficiencies: 1 Feb 11, 2004
Visit Reason
The inspection was conducted as a behavioral health survey to assess the safety and appropriateness of the environment for adolescent consumers.
Findings
The center failed to implement programs in a safe and appropriate environment, specifically noting that adolescent girls' bedrooms had outside doors without alarms and staff were not awake on weekend nights to monitor consumers. A plan of correction was proposed to provide awake-night supervision during weekend shifts by July 1, 2004.
Deficiencies (1)
Description
Adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumers.
Report Facts
Center census: 6 Sample size: 3 Plan of correction implementation date: Jul 1, 2004
Inspection Report Plan of Correction Census: 6 Deficiencies: 1 Feb 11, 2004
Visit Reason
The inspection was conducted as a behavioral health survey to assess the safety and appropriateness of the environment for adolescent consumers.
Findings
The center failed to provide a safe environment as adolescent girls' bedrooms had outside doors without alarms, and staff were not awake on weekend nights to monitor consumers. A plan of correction was proposed to provide awake-night supervision during weekend shifts by July 1, 2004.
Deficiencies (1)
Description
The adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumers.
Report Facts
Center census: 6 Sample size: 3

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