Inspection Reports for Rolling Meadows Place

Complaint #40395 was investigated and found unsubstantiated with no deficiencies cited related to the complaint itself.

The complaint was unsubstantiated and no deficiencies were cited. However, a deficiency was noted regarding failure to maintain accurate resident records for one resident.

The initial survey found that the facility did not provide a safe environment for adolescent consumers, specifically noting lack of alarms on outside doors and insufficient awake staff supervision on weekend nights. The plan of correction was accepted and the deficiency was corrected as of the review date.

One deficiency was re-cited related to failure to ensure each resident received medications as ordered by their physician, specifically for Resident #44. The facility lacked physician orders for certain medications during the survey.

Deficiencies were cited related to administrative requirements including failure to maintain records of annual in-service training for staff, inadequate housekeeping and maintenance, and failure to ensure residents received medications exactly as ordered by their physician.

The licensee failed to maintain a safe, sanitary, and accident-free living environment, with deficiencies including peeling paint, mold or mildew on air registers, stained ceiling tiles, and dust accumulation on air registers and sprinkler heads throughout the facility.

A total of 28 deficiencies were cited during the annual inspection. A first revisit was scheduled for September 2, 2025, at which time all deficiencies were corrected and the facility census was 56.

Complaint #34437 was substantiated with deficiencies cited related to medication administration and storage.

The facility failed to ensure medications were properly administered, stored, and secured, with multiple residents observed having unattended medications in their rooms. Additionally, the facility did not maintain adequate housekeeping and maintenance, with issues such as damaged carpet, missing bathroom fixtures, and unclean sinks observed.

The facility was found deficient in maintaining complete resident records including names, addresses, and telephone numbers of emergency contacts and medical professionals, as well as marital status and religious preference. Additionally, medications were not always secured properly, with an unlocked medication cart observed. Housekeeping and maintenance issues were noted but are from a prior survey and not part of this revisit.

The facility was found deficient in multiple areas including inadequate housekeeping and maintenance, incomplete and inaccurate resident service plans, missing or incomplete employee training records, incomplete documentation of tuberculin skin tests, and missing information in resident admission agreements regarding policies, medication disposition, nursing care services, and CPR procedures.

The facility was found deficient in ensuring functional needs assessments and service plans reflected current resident needs, adequate housekeeping and maintenance, proper documentation of resident deaths, and inclusion of policy access information in admission agreements. Twelve deficiencies were corrected, two were re-cited, and one additional related deficiency was cited during the survey.

This was a first revisit to complaint #28524 conducted from 10/02/23 at 11:15 PM to 10/03/23 at 11:15 PM. The complaint involved medication administration and housekeeping deficiencies. The surveyor found 2 of 2 deficiencies re-cited.

The facility failed to obtain required written or verbal medication orders for 3 of 10 residents reviewed and failed to ensure medications and treatments were administered as required for 5 of 10 residents. Additionally, inadequate housekeeping and maintenance issues were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.

The facility was found deficient in multiple areas including maintaining accurate resident admission registers, documenting activities, updating service plans to reflect current resident needs, releasing resident belongings upon death, providing access to policies and procedures, medication administration oversight, employee training and orientation, housekeeping and maintenance, incident reporting, resident rights posting, transfer summaries, annual assessments, and weekly nursing notes.

Complaint ID WV00028524 initiated a survey from 05/22/23 to 05/23/23 due to medication administration concerns. Deficiencies were cited related to missing physician orders, unavailable medications, and incomplete medication administration records. The complaint was substantiated with findings of noncompliance.

The facility failed to ensure proper medication administration, including missing physician orders and unavailable medications for residents, and inadequate documentation with multiple missing signatures on medication administration records. Additionally, housekeeping and maintenance deficiencies were noted, including damaged carpets, missing bathroom fixtures, and unclean areas.

Complaint #28021 was substantiated. Issues included inadequate staffing, delayed response to call pendants, insufficient showers, and housekeeping deficiencies.

The facility failed to maintain adequate staffing levels, resulting in delayed response times to resident calls, insufficient showers, and staff performing non-care duties. Housekeeping and maintenance were inadequate, with observed damages and cleanliness issues. The facility lacked a full-time receptionist, and door alarms were often unanswered. Plans of correction included staffing adjustments, audits, education, and environmental improvements.

Re-visit to complaint #27055. Surveyor was unable to correct the deficiency during the visit.

The facility failed to ensure proper medication orders for discontinuing medications for one resident and had environmental safety and housekeeping deficiencies. A plan of correction was initiated including audits, education, and maintenance work orders.

Revisit to complaint #27872 regarding staffing inadequacies and resident care concerns.

The facility failed to ensure adequate staffing of Resident Care Partners (RCPs) across all shifts to assist residents with activities of daily living, resulting in long response times to resident calls for help. Additionally, housekeeping and maintenance were inadequate, with observed physical environment issues and staff assigned to ancillary duties rather than resident care.

Complaint survey #27872 with all allegations substantiated, including staffing shortages, medication storage and administration issues, inadequate housekeeping, and dietary concerns.

The facility failed to maintain adequate staffing levels on day, evening, and night shifts to meet residents' care needs. Medication storage and documentation were deficient, with residents self-administering medications without proper locked storage or documentation. Housekeeping and maintenance were inadequate, with physical environment issues noted. Dietary services were inconsistent, with complaints about food quality, temperature, and portion sizes. Resident safety and communication were also concerns, with reports of delayed call light responses and insufficient supervision.

Complaint #27055 was substantiated. The investigation revealed medication errors involving Resident #3, including administering more medication than prescribed for 36 days and missing doses for 8 days. The Executive Director was aware of the errors and notified the resident's physician. No ill effects were noted to the resident. The facility failed to report the medication errors to state nurse licensing boards or regulatory agencies as required.

The facility failed to administer a prescription medication as ordered for one resident, resulting in medication errors over 36 days of overdosing and 8 days of missed doses. Additionally, the facility failed to maintain adequate housekeeping and maintenance in the residence, with issues such as damaged carpet, missing bathroom fixtures, and unclean areas.

The facility failed to maintain accurate resident registry records, with four residents listed as current but discharged. Additionally, service plans for three residents were not established within seven days of admission. Housekeeping and maintenance issues were observed, including damaged carpet, missing bathroom fixtures, and cleanliness concerns. Corrective actions and audits were planned and initiated.

Complaint Investigation Survey #26483 conducted from 06/01/22 to 06/02/22. The complaint involved Resident C#1's care needs exceeding the facility's licensed level, failure to notify or assist with placement, and poor communication with hospital and family. The resident was transferred to hospital on 02/08/22 and subsequently to a psychiatric unit. The facility did not adequately assist in placement or communicate with involved parties.

The licensee failed to ensure that Resident C#1, whose care needs exceeded the facility's licensed level, was properly informed or assisted in securing placement in a more appropriate health care facility. The resident exhibited aggressive and combative behavior, requiring hospitalization. The facility did not adequately communicate with the resident's family or hospital staff, and failed to document efforts to assist with placement. Additionally, the facility failed to maintain adequate housekeeping and maintenance, with multiple physical environment deficiencies noted.

The facility was found deficient in ensuring timely updates of residents' functional needs assessments and service plans, maintaining proof of pet vaccinations, preparing complete transfer documentation, and completing timely health assessments. Additionally, housekeeping and maintenance issues were observed, including damaged carpets, missing bathroom fixtures, and cleanliness concerns.

Complaint #26024 was substantiated. The complaint involved failure to follow COVID-19 policy requiring twice daily temperature checks during an outbreak.

The facility failed to follow its policy requiring twice-daily temperature checks for residents during a COVID-19 outbreak, with four residents testing positive. Interviews revealed staff were unaware of the twice-daily temperature requirement. The facility census was 31 at the time.

This was the first revisit to Complaint #25708 to verify correction of cited deficiencies.

The facility was found to have updated personnel files for agency employees including date of employment and telephone numbers, and provided required training documentation. Housekeeping and maintenance issues were identified but corrective actions and monitoring plans were in place. Ongoing audits and education were planned to ensure compliance.

Complaint ID 25708 initiated due to concerns about resident care, staffing shortages, and facility conditions. Survey conducted from 06/30/21 to 07/07/21 with census of 34 residents. Multiple deficiencies cited.

The facility failed to ensure updated service plans reflecting residents' current needs, adequate housekeeping and maintenance, proper medication orders, sufficient activities, appropriate notification of care cost increases, timely health assessments, prevention of neglect, and adequate staffing levels. Resident #4 experienced multiple falls without proper interventions and neglect in feeding assistance. Staffing shortages were noted especially on evening shifts.

The licensee failed to prepare and retain a complete summary for two residents discharged from the facility, missing key documents such as medical history, functional needs assessment, service plans, physician's orders, advanced directives, allergies, and progress notes. The Executive Director conducted audits and received training to ensure compliance and ongoing monitoring.

The licensee failed to ensure that West Virginia Physician Orders for Scope of Treatment (POST) forms were properly completed for three residents and one resident's POST form was missing. The facility census was 26. A plan of correction was implemented to address these deficiencies.

Complaint Investigation #25112 was substantiated. The complaint involved Resident #C51 exiting the facility without proper discharge procedures and elopement risk management. The investigation included interviews with staff and family, record reviews, and observations.

The facility failed to prepare and retain a discharge summary for Resident #C51, did not provide a 30-day written notice prior to discharge, and failed to assist the resident in securing alternative placement. Resident #C51, assessed as high risk for elopement, eloped during cold weather without appropriate interventions in place. The facility also failed to maintain adequate housekeeping and maintenance standards.

Complaint #25183 was substantiated. The complaint involved neglect of Resident C#1, who had frequent episodes of diarrhea and was found sitting in soiled clothing and bedding. The resident's daughter reported neglect by staff on weekends. The facility acknowledged staffing shortages and housekeeping deficiencies. Resident Care Partner #62 was alleged to be neglectful and is no longer employed at the facility.

The facility was found to have multiple deficiencies including failure to store soiled laundry properly, inadequate housekeeping and maintenance, failure to maintain locked storage for hazardous materials, neglect of a resident with incontinence issues, and insufficient infection control measures including lack of COVID-19 signage and visitor screening.

The facility failed to maintain an accurate Physician Orders for Scope of Treatment (POST) form for one resident, Resident #36. The POST form lacked proper signatures and accurate information, but all other tags were cleared during the survey.

Complaint #WV00024531 triggered the revisit inspection. All tags were cleared except for tag 4.7.4.d (E 294) related to the failure to provide information on medical examinations and treatment orders.

The facility failed to ensure that residents were provided information on the requirements for medical examinations and treatment orders at the time the resident's contract was provided. Documentation review and interviews confirmed the absence of this information in the Resident admission agreement packet.

Complaint number 24531 was substantiated following an investigation from 09/28/20 to 09/30/20. The complaint involved failure to maintain proper resident records, contracts, and housekeeping standards.

The facility failed to maintain proper records and contracts for residents, including missing advanced directives, appointment dates, legal authority documents, and resident contracts. Resident #6 did not receive required paperwork or contracts, including the resident's bill of rights. The facility also failed to provide adequate housekeeping and maintenance, with observations of damaged carpet, missing bathroom fixtures, and unclean sinks. The complaint was substantiated.

The facility was found deficient in multiple areas including incomplete resident records, inadequate housekeeping and maintenance, missing employee background checks and health screenings, incomplete medication administration parameters, failure to document resident deaths properly, lack of timely complaint responses, incomplete employee training, and failure to maintain resident weights and health assessments as required.

The facility was found deficient in documenting timely notification of resident deaths to physicians and next of kin, documenting circumstances of death, conducting timely health assessments including tuberculosis screening, and notifying physicians of significant weight changes in residents. Additionally, housekeeping and maintenance issues were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.

Complaint investigation conducted on July 1, 2019, with substantiated deficiencies related to physical facilities maintenance and housekeeping.

The facility was found deficient in maintaining a safe, sanitary, and accident-free living environment, including propped open laundry room doors, lack of mechanical ventilation in the soiled laundry room, and failure to maintain separation between soiled and clean laundry areas.

Complaint # WV00022761 was substantiated. The complaint involved neglect related to residents not receiving scheduled showers and delayed responses to complaints filed by Resident #12's son.

The facility failed to ensure thirteen residents received scheduled showers, failed to respond timely to complaints, and did not properly separate soiled and clean laundry. Additionally, housekeeping and maintenance deficiencies were noted, including damaged carpets and missing bathroom fixtures.

Complaint ID WV00021191 was investigated and the deficiency was corrected.

The deficiency cited during the complaint investigation was corrected as noted in the report.

Complaint ID WV00021191 was investigated from October 2-4, 2018, regarding inadequate housekeeping and staffing issues.

The facility failed to ensure sufficient housekeeping staff to meet the needs of residents, resulting in multiple apartments with stained carpets, odors, overflowing trash, and dirty bathrooms. Residents, family members, and staff reported dissatisfaction with the cleanliness and housekeeping adequacy.

The facility was found deficient in employee orientation and training, annual resident health assessments, updating service plans, housekeeping and maintenance, and providing needed staff training on resident condition changes. Several residents lacked timely annual assessments and service plans, and some employees had delayed training on oxygen therapy and blood thinners.

The complaint investigation found that the licensee, administrator, and registered nurse failed to ensure weekly progress notes and weekly resident visits by the RN for four insulin-dependent diabetic residents. The RN was unaware of the missing documentation and was working on a booklet to maintain weekly progress notes.

The facility failed to ensure that a registered nurse documented weekly progress notes reflecting residents' status and changes, and failed to see four applicable residents weekly as required. Deficiencies were found in documentation and nursing visits for insulin-dependent diabetic residents.

Complaint investigation conducted June 25-27, 2018 with census 46; follow-up on 08/22/2018 with census 40 confirmed deficiency correction.

The initial complaint investigation identified deficiencies which were subsequently corrected by the follow-up visit on August 22, 2018.

The facility was found deficient in timely resolution and written response to resident complaints, completion and updating of health assessments and service plans within required timeframes, and maintaining adequate housekeeping and maintenance. Several residents had late or missing health assessments and service plans, and physical environment issues were noted.

The survey identified deficiencies related to failure to ensure prompt action and written responses to resident complaints, inadequate housekeeping and maintenance, and failure to administer medications according to physician orders for four residents.

The complaint involved allegations of verbal and physical abuse of residents by employees, failure to report abuse to Adult Protective Services, and failure to properly investigate and document abuse allegations. Interviews with residents, staff, and former employees confirmed these issues. The administrator failed to report abuse incidents and notify the licensing agency as required.

The facility failed to ensure adequate employee training on abuse prevention and mandatory reporting, failed to report abuse allegations to Adult Protective Services (APS) and the licensing agency within required timeframes, and failed to thoroughly investigate and document abuse allegations. Additionally, housekeeping and maintenance deficiencies were noted in the physical environment.

The facility was found deficient in employee orientation and training related to specialty care needs, and in ensuring that resident service plans accurately reflected current care needs for six residents. Deficiencies in housekeeping and maintenance were also noted in a prior behavioral health survey.

The facility was found deficient in multiple areas including failure to obtain required waivers for residents needing nursing care, incomplete transfer/discharge summaries, missing or incomplete health assessments and functional needs assessments, inadequate service plans, medication administration and documentation errors, failure to monitor residents' conditions post-accident or illness, and failure to obtain and document residents' weights monthly.

The inspection found deficiencies in maintaining a sanitary food preparation area, inadequate housekeeping and maintenance in the facility, and unsafe hot water temperatures exceeding regulatory limits. Corrective actions were initiated including cleaning, maintenance scheduling, and adjustment of water temperatures.

The facility was found deficient in multiple areas including failure to report major incidents timely, inadequate housekeeping and maintenance, incomplete resident contracts, failure to provide proper transfer/discharge summaries, medication administration errors including lack of proper orders and documentation, and failure to perform timely nursing assessments after significant resident condition changes.

The inspection found critical deficiencies including black mold growth inside a refrigerator, improper storage of employee drinking containers, moldy produce, and failure to install thermostatic mixing valves on hot water tanks exceeding 80 gallons. Plans of correction were provided with timelines for remediation and monitoring.

The facility was found to have deficiencies related to maintenance and housekeeping, including damaged carpet, missing bathroom fixtures, and unsafe oxygen cylinder refilling practices. The oxygen concentrator unit used to refill cylinders inside a resident's room was identified as a high hazard and not approved for use in the facility.