Deficiencies (last 18 years)
Deficiencies (over 18 years)
9.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than West Virginia average
West Virginia average: 9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
39 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Oct 29, 2025
Visit Reason
Investigation of Complaint #40049 conducted from 10/28/25 to 10/29/25.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #40049 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 39
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Oct 29, 2025
Visit Reason
Investigation of Complaint #40003 conducted from 10/28/25 to 10/29/25.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #40003 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 39
Inspection Report
Follow-Up
Census: 41
Deficiencies: 0
Apr 29, 2025
Visit Reason
Follow-up to Complaint #37379 to verify correction of cited deficiencies.
Findings
The citation related to the complaint was corrected as of the follow-up inspection.
Complaint Details
Complaint #37379 was investigated and the citation was corrected.
Report Facts
Census: 41
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 3
Mar 6, 2025
Visit Reason
Investigation of Complaint #37379 conducted from 03/05/25 to 03/06/25 regarding medication administration issues.
Findings
The Licensee failed to ensure all residents received their medications exactly as ordered for three residents (IDs 5, 9, and 19). Missed medications were due to unavailable medications, pharmacy delivery delays, and failure to document during a power outage. The complaint was substantiated and deficiencies were cited.
Complaint Details
Complaint #37379 was substantiated. The investigation found medication administration deficiencies for three residents. The Director of Nursing provided education and implemented auditing and corrective actions.
Deficiencies (3)
| Description |
|---|
| Resident #5 did not receive Levothyroxine 75 MCG on multiple dates due to medication unavailability and failure to document on paper MAR during power outage. |
| Resident #9 did not receive Collagen Powder Helix3, Allopurinol 100 MG, and Potassium CL ER 10 MEQ on specified dates due to pharmacy delays and unavailability. |
| Resident #19 did not receive Magnesium Glycinate 4 capsules on 02/14/25 due to pharmacy non-delivery. |
Report Facts
Missed medication dates for Resident #5: 7
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided education on missed medications, auditing, and corrective actions related to medication administration deficiencies. |
| Licensed Practical Nurse | Licensed Practical Nurse (LPN) | Noticed Resident #5's Levothyroxine had been held since 01/30/25. |
Inspection Report
Follow-Up
Census: 37
Deficiencies: 0
Dec 18, 2024
Visit Reason
Follow-up to the annual survey to verify correction of previously identified deficiencies.
Findings
The deficiencies identified in the prior annual survey were corrected as of the follow-up inspection.
Report Facts
Census: 37
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 0
Nov 14, 2024
Visit Reason
Annual environmental inspection of the facility to assess compliance with health and safety standards.
Findings
No deficiencies were cited during the inspection. The facility has a sprinkler type 13 system and is connected to city sewer.
Report Facts
Census: 42
Sprinkler Type: 13
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 5
Nov 13, 2024
Visit Reason
Annual survey conducted from 11/11/24 to 11/13/24 to assess compliance with health and safety regulations, service plans, medication administration, and record-keeping.
Findings
The facility was found deficient in updating resident service plans to reflect current needs, proper administration of medications as ordered, and maintaining complete resident records including marital status. Additionally, housekeeping and maintenance issues were noted in the adolescent residence.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure each resident's service plan reflected current needs, including medical devices and wound care for Resident #39. | Class II |
| Failed to ensure medications were administered as ordered for Residents #15 and #39, including incorrect start and stop dates. | Class I |
| Failed to ensure resident records contained marital status for Resident #11. | — |
| Failed to provide a safe and appropriate environment for adolescent consumers, including lack of awake night staff on weekends and unsecured doors. | — |
| Failed to ensure adequate housekeeping and maintenance, including damaged carpet, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Census: 39
Residents with medication deficiencies: 2
Residents with service plan deficiencies: 1
Residents with record deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #65 | Interviewed regarding unawareness of service plan and medication issues for Resident #39 and missing marital status for Resident #11 | |
| Executive Director | Interviewed and unaware of medication administration deficiencies | |
| Director of Nursing | Interviewed and unaware of medication administration deficiencies |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Oct 28, 2024
Visit Reason
Investigation of Complaint #34829 regarding facility conditions and care.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #34829 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 37
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 0
Mar 27, 2024
Visit Reason
Revisit to Annual Survey to verify correction of previous deficiencies.
Findings
All citations from the prior inspection were cleared during this revisit.
Report Facts
Census: 37
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 12
Jan 23, 2024
Visit Reason
Annual survey inspection conducted to assess compliance with state regulations and standards for facility operation and resident care.
Findings
The facility was found deficient in multiple areas including management and control of resident funds, medication administration documentation, staff training and certification, housekeeping and maintenance, resident records completeness, and nursing care documentation for dialysis residents. Several deficiencies were noted with plans of correction provided.
Severity Breakdown
Class I: 3
Class II: 2
Class III: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to have a surety bond to cover resident funds handled by the facility. | Class III |
| Failed to ensure adequate housekeeping and maintenance; issues included personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
| Failed to have a physician's order for self-administration of medications for a resident. | Class I |
| Failed to ensure all Approved Medication Assistive Personnel were certified in CPR. | Class I |
| Failed to include address and telephone number of resident's dentist in medical record. | — |
| Failed to ensure at least one employee with current first aid and CPR training was on duty at all times. | — |
| Failed to provide annual in-service training for staff on required topics. | — |
| Failed to include admission and annual tuberculosis screening in resident medical records. | Class II |
| Failed to manage resident funds at the written request of residents. | Class III |
| Failed to include residents' religious preferences in records. | — |
| Failed to ensure staff initialed medication administration records for all medications given to residents. | Class I |
| Failed to document weekly nursing care notes for residents with dialysis ports. | Class II |
Report Facts
Census: 43
Residents with funds handled: 4
Resident funds amount: 536
Employees with current CPR and first aid training: 2
Residents with missing dentist info: 1
Residents with missing tuberculosis screening: 2
Residents with dialysis ports: 2
Residents with missing physician order for self-medication: 1
Residents with missing religious preference: 2
Residents with missing medication initials: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #11 | Approved Medication Assistive Personnel | Did not have current CPR certification |
| Business Office Director | Counted resident funds and involved in plan of correction for fund management | |
| Director of Nursing | Director of Nursing | Interviewed regarding medication orders, CPR training, and nursing care documentation |
| Executive Director | Executive Director | Interviewed regarding CPR training, medication administration, and fund management |
Inspection Report
Re-Inspection
Census: 43
Deficiencies: 0
Jan 16, 2024
Visit Reason
Revisit to Complaint #29693 conducted from 01/15/24 to 01/16/24 to verify correction of previous deficiencies.
Findings
All citations from the previous complaint investigation were cleared during this revisit inspection.
Complaint Details
Complaint #29693 was the basis for the revisit inspection; all citations were cleared.
Report Facts
Census: 43
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 0
Jan 15, 2024
Visit Reason
Annual environmental inspection conducted to assess the facility's compliance with health and safety regulations.
Findings
No deficiencies were cited during the inspection. The facility has a sprinkler system type 13 and is connected to city sewer.
Report Facts
Census: 42
Sprinkler Type: 13
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Dec 7, 2023
Visit Reason
Investigation of Complaint #29793 conducted from 12/06/23 to 12/07/23.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #29793 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 44
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 4
Nov 9, 2023
Visit Reason
The inspection was conducted as an investigation of Complaint #29693, which was substantiated during the survey.
Findings
The facility failed to report a major incident involving a medication error within the required timeframe and failed to properly label resident medications. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.
Complaint Details
Complaint #29693 was investigated from 11/08/23 to 11/09/23. The complaint was substantiated and deficiencies were cited related to medication errors and reporting failures.
Severity Breakdown
Class I: 2
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Licensee failed to report a major incident to the Office of Health Facility Licensure and Certification within the required timeframe involving Resident #50 receiving an unprescribed dose of insulin. | Class III |
| Licensee failed to properly label Resident #44's Lantus insulin pen with required information including resident name, strength, manufacturer, lot number, and expiration date. | Class I |
| Licensee failed to ensure medications were administered as required by federal and state laws; Resident #50 was given medication not prescribed. | Class I |
| Facility failed to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Resident census: 44
Medication dose: 21
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #8 | Registered Nurse | Named in medication error finding for administering insulin to wrong resident |
| Director of Nursing #28 | Director of Nursing | Interviewed regarding medication labeling deficiency |
| Approved Medication Assistive Personnel #13 | Approved Medication Assistive Personnel | Interviewed regarding medication labeling deficiency |
| Executive Director / Registered Nurse #8 | Executive Director / Registered Nurse | Interviewed regarding medication labeling deficiency and medication error |
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 1
Jun 1, 2023
Visit Reason
The inspection was conducted as a complaint survey (#28367) to investigate an allegation.
Findings
The complaint allegation was found to be unsubstantiated. The report includes a summary of deficiencies from a prior behavioral health survey conducted in 2004, noting safety concerns related to staff supervision and unsecured doors.
Complaint Details
Complaint survey #28367 was conducted from 05/31/23 to 06/01/23. The only allegation was 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 lack of alarms on outside doors and insufficient awake staff on weekend nights. |
Report Facts
Center census: 6
Sample size: 3
Inspection Report
Follow-Up
Census: 47
Deficiencies: 0
May 4, 2023
Visit Reason
This visit was a first revisit inspection to verify correction of previously cited deficiencies related to a complaint investigation (Complaint ID: 28252).
Findings
The citations from the prior complaint investigation were corrected as of this revisit inspection conducted from 05/03/23 to 05/04/23.
Complaint Details
Complaint ID: 28252; this was a first revisit inspection with citations corrected.
Report Facts
Census: 47
Inspection Report
Follow-Up
Census: 6
Deficiencies: 1
May 3, 2023
Visit Reason
This was a 2nd follow-up visit to the Annual Survey to verify correction of previously identified deficiencies.
Findings
The deficiency related to safety and supervision was corrected as of the follow-up visit on 05/03/23.
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 staff on weekend nights and unsecured outside doors. |
Report Facts
Center census: 6
Inspection Report
Re-Inspection
Census: 37
Deficiencies: 6
Mar 23, 2023
Visit Reason
Revisit to Annual Survey conducted from 03/21/23 to 03/23/23 to verify compliance with medication administration regulations and facility housekeeping standards.
Findings
The facility failed to ensure that medications were administered according to state regulations, with missing documentation on medication administration records (MAR) including diagnosis, medication order date, route of administration, and physician phone numbers. Additionally, the facility had housekeeping and maintenance deficiencies such as damaged carpet, missing bathroom fixtures, and unclean areas.
Deficiencies (6)
| Description |
|---|
| Residents #14, #21, and #9 lacked documentation for the diagnosis for which medication was ordered on the MAR. |
| Residents #9 and #15 lacked the date the medication was ordered on the MAR. |
| Resident #9 lacked the route of medication on the MAR. |
| Residents #9, #12, #14, #15, #21, #32, and #33 lacked the physician's phone number on the MAR. |
| Housekeeping and maintenance deficiencies including iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
| Lack of awake night staff supervision on weekends and unsecured outside doors in adolescent girls' bedrooms and TV room. |
Report Facts
Census: 37
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | AMAP Registered Nurse / Executive Director | Interviewed regarding medication administration record deficiencies. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 8
Mar 23, 2023
Visit Reason
Complaint investigation conducted at Seasons Place from 03/21/23 to 03/23/23 with a census of 37 residents.
Findings
The facility was found deficient in multiple areas including personnel records lacking volunteer eligibility verification, failure to report a major incident timely, inadequate housekeeping and maintenance, insufficient staffing for direct care and ancillary services, malfunctioning resident call pendants, lack of scheduled activities especially on weekends, and failure to provide snacks meeting residents' needs and preferences.
Complaint Details
Complaint #28252 was substantiated following investigation at Seasons Place from 03/21/23 to 03/23/23 with a census of 37.
Severity Breakdown
Class I: 2
Class II: 1
Class III: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to have evidence that each assisted living residence volunteer received eligibility fitness determination from WV CARES. | — |
| Failed to report a major incident to the Office of Health Facility Licensure and Certification as soon as possible and no later than the next business day. | Class III |
| Failed to provide adequate housekeeping and maintenance to maintain a safe and appropriate environment; issues included personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
| Failed to provide minimum seven hours per week of scheduled activities requested by residents, especially weekend activities. | — |
| Failed to have a minimum of one direct care staff person 24 hours per day who can read and write and sufficient qualified employees on duty to provide required care and services. | Class I |
| Failed to have sufficient staff to meet laundry, food service, housekeeping, and maintenance requirements. | Class II |
| Resident call pendants were not functioning correctly, with multiple instances of pendants going off for extended periods without response. | Class I |
| Failed to ensure residents were offered snacks that meet their needs and choices; residents requested more accessible snacks and later evening snacks. | — |
Report Facts
Census: 37
Volunteer hours: 37
Call light pendant activation durations: Multiple residents' call pendants activated for durations ranging from minutes to several hours on various dates in March 2023.
Completion dates for corrective actions: Apr 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Activity Director | Employee #9 worked every other weekend and had 37 scheduled hours a week; involved in activity scheduling and volunteer coordination. | |
| Executive Director / Registered Nurse | Employee #6 provided education on timely reporting of major incidents and was aware of call light system issues. | |
| Resident Care Person | Employee #13 reported inability to assist residents due to workload and call light issues. | |
| Regional Director of Care Services | Provided education to Executive Director on reporting and staffing requirements. | |
| Dietary Service Manager | Employee #25 discussed snack availability and resident food council concerns. |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 7
Jan 4, 2023
Visit Reason
Annual survey conducted to assess compliance with health, safety, medication administration, housekeeping, dietary, and administrative standards at Seasons Place facility.
Findings
The inspection identified multiple deficiencies including failure to administer medications as ordered resulting in missed doses for Resident #36, inadequate housekeeping and maintenance with damaged carpet and unclean areas, incomplete admission agreements lacking resident fund management information, missing transfer/discharge summaries for residents, incomplete annual health assessments, and failure to report significant weight changes to physicians for residents #20 and #36.
Severity Breakdown
Class I: 1
Class II: 1
Class III: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Medications and treatments were not administered as ordered for Resident #36, resulting in multiple missed doses. | Class I |
| Facility failed to ensure adequate housekeeping and maintenance; observed damaged carpet, bleach spots, torn furniture, missing towel bars, and dirty sinks. | — |
| Admission agreement did not contain information regarding management of resident funds. | — |
| Transfer/discharge summaries for residents #29 and #36 lacked required information including medical history, advanced directives, service plans, physician orders, allergies, and progress notes. | — |
| Resident #36 lacked a complete annual health assessment; physical exam section incomplete and addendum not immediately available in medical record. | Class II |
| Facility failed to maintain a safe, sanitary, and accident-free environment in kitchen; grease build-up and unclean areas observed. | — |
| Failure to report unplanned weight loss or gain of five pounds or more to resident's physician for residents #20 and #36. | Class III |
Report Facts
Missed medication doses: 11
Missed medication doses: 3
Missed medication doses: 4
Missed medication doses: 3
Missed medication doses: 4
Missed medication doses: 4
Missed medication doses: 4
Missed medication doses: 4
Missed medication doses: 7
Missed medication doses: 3
Missed medication doses: 3
Missed medication doses: 3
Missed medication doses: 4
Missed medication doses: 4
Missed medication doses: 4
Resident census: 36
Weight gain: 38
Weight loss: 21.5
Carpet replacement deadline: Sep 30, 2004
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 2
Dec 20, 2022
Visit Reason
The inspection was an annual environmental survey conducted to assess the facility's compliance with health, safety, maintenance, and housekeeping standards.
Findings
The facility was found to have deficiencies related to maintenance and housekeeping, including a sewage backup in the back corridor, unclean and damaged areas such as carpet burns and bleach spots, missing bathroom fixtures, and general cleanliness issues. Repairs and corrective actions were planned and initiated, including removal of the construction wall, sewage line repairs, and ongoing audits to ensure compliance.
Deficiencies (2)
| Description |
|---|
| Failed to keep the interior and exterior of the facility clean and in good repair, including sewage backup in the back corridor. |
| Miscellaneous small personal belongings behind dresser, iron burn and bleach spots on carpet, chair with tears, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Deficiencies cited: 1
Facility census: 42
Sprinkler Type: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Clinical Services | RDCS | Provided education to Executive Director on maintaining facility safety and sanitation |
| Executive Director | ED | Completed full house audit and ongoing inspections to ensure facility compliance |
| Operations Supervisor | Participated in tour and inspection of residence and rooms | |
| Treatment Coordinator | Participated in tour and inspection of residence and rooms |
Inspection Report
Follow-Up
Census: 41
Deficiencies: 0
Jun 8, 2022
Visit Reason
This was a 1st follow-up visit to verify correction of previously identified deficiencies at the facility.
Findings
The report documents a follow-up inspection conducted on June 8, 2022, with a census of 41 residents. The deficiencies from the prior survey are being reviewed for correction, but specific findings or outcomes are not detailed in this page.
Report Facts
Census: 41
Inspection Report
Follow-Up
Census: 41
Deficiencies: 0
Jun 8, 2022
Visit Reason
This was a 3rd follow-up/revisit to the annual survey to verify correction of previous deficiencies.
Findings
Deficiencies previously cited were corrected or cleared, and no new deficiencies were identified during this visit.
Report Facts
Census: 41
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 2
Mar 1, 2022
Visit Reason
This was a 2nd revisit to the annual survey conducted to verify compliance with nursing and medical service plan requirements and other regulatory standards.
Findings
The facility failed to have a registered nurse develop and document a service plan to meet identified nursing and medical needs of Resident #23. Additional findings included inadequate housekeeping and maintenance issues such as damaged carpet, missing bathroom fixtures, and unclean sinks.
Severity Breakdown
Class I: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to have a registered nurse develop and document a service plan to meet identified nursing and medical needs of Resident #23. | Class I |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Census: 31
Sample Size: 3
Completion Date: Mar 8, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Care Service Manager | Registered Nurse | Interviewed regarding service plan deficiencies |
| Executive Director | Re-educated Care Services Manager and responsible for audits |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Feb 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to fully disclose all costs associated with the use of an outside pharmacy in the resident contract and issues related to medication storage and housekeeping.
Findings
The facility failed to ensure full disclosure of pharmacy-related costs in the resident contract, charged an additional fee for use of a non-preferred pharmacy, and left a medication cart unlocked accessible to unauthorized persons. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.
Complaint Details
Complaint #26548 was entered on 02/28/22 and exited on 03/01/22. The complaint involved failure to disclose pharmacy costs and medication storage issues. The complaint was investigated during the survey.
Severity Breakdown
Class I: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure full disclosure of all costs associated with the use of an outside pharmacy in the resident contract. | — |
| Medication cart left unlocked in the hallway accessible to unauthorized persons. | Class I |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bars and toilet paper holders, and dirty sink. | — |
Report Facts
Facility census: 31
Additional pharmacy fee points: 10
Medication cart audit frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #71 | Licensed Practical Nurse | Named in medication cart left unlocked finding |
| Executive Director | Witnessed medication cart left unlocked and addressed the issue with staff | |
| Care Services Manager | Provided re-education to nurse #71 and other nursing staff regarding medication storage and accessibility |
Inspection Report
Follow-Up
Census: 40
Deficiencies: 6
Dec 30, 2021
Visit Reason
This was a follow-up visit to the annual survey conducted at Seasons Place to assess compliance with health care standards, assessment and service plans, nursing care documentation, and housekeeping/maintenance requirements.
Findings
The facility failed to ensure that functional needs assessments and service plans were updated to reflect residents' current needs, failed to complete required transfer summaries, did not have annual health assessments completed for some residents, lacked proper documentation of registered nurse visits, and failed to maintain adequate housekeeping and maintenance. Several deficiencies were identified related to care planning, nursing documentation, and environmental safety and cleanliness.
Severity Breakdown
Class II: 3
Class III: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure service plans reflected residents' current needs and were updated for three of four resident records reviewed. | Class II |
| Failed to prepare a summary for one resident when transferred to a local hospital including advanced directives, functional needs/service plans, and current physician orders. | — |
| Failed to ensure resident had an annual health assessment completed by a licensed health care professional for one of three resident records reviewed. | Class II |
| Failed to maintain a record with an entry for each registered nurse visit including date, time in/out, duties performed, concerns, and signature. | Class III |
| Failed to document a weekly progress note reflecting the status and any changes in condition for one resident requiring nursing care. | Class II |
| Failed to ensure adequate housekeeping and maintenance required to carry out services, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
Report Facts
Facility census: 40
Sample size: 4
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #83 | Licensed Practical Nurse | Interviewed regarding resident #23's catheter status and annual assessment |
| Regional Care Specialist #92 | Regional Care Specialist | Interviewed regarding care plan audits and training |
| Regional Care Specialist #101 | Regional Care Specialist | Interviewed regarding RN visit documentation and resident care |
| Corporate Employee #92 | Registered Nurse, Regional Care Specialist | Interviewed regarding RN log implementation and documentation |
| Executive Director | Executive Director | Interviewed regarding health assessment completion and transfer form issues |
| Administrative Specialist #74 | Administrative Specialist | Interviewed regarding transfer form completion |
Inspection Report
Follow-Up
Census: 526
Deficiencies: 5
Nov 30, 2021
Visit Reason
This was a 1st follow-up environmental survey conducted to verify correction of previously cited deficiencies related to fire safety, disaster preparedness, housekeeping, and maintenance.
Findings
The facility failed to document and rehearse the disaster and emergency preparedness plan annually, and there were ongoing issues with housekeeping and maintenance such as soiled kitchen utensils, pests, and damaged furnishings. A rehearsal and staff training were conducted on 11/30/21 to address these issues, with ongoing monitoring planned.
Severity Breakdown
Class I: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to document and rehearse the disaster and emergency preparedness plan annually. | Class I |
| Soiled containers for packaged coffee and other coffee utensils. | — |
| Improper sanitizer concentration in wiping cloth buckets. | — |
| Pests observed flying in grill area. | — |
| Floors and walls soiled throughout kitchen, especially near dishwasher. | — |
Report Facts
Deficiencies cited: 3
Sample size: 100
Census: 526
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Named in relation to disaster preparedness rehearsal and training |
| Maintenance Technician | Maintenance Technician (MT) | Named in relation to disaster preparedness rehearsal and training |
| Regional Director of Care Services | Regional Director of Care Services (RDCS) | Conducted training on disaster preparedness requirements |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Oct 21, 2021
Visit Reason
The inspection was conducted in response to a complaint (Complaint number 26122) at Seasons Place.
Findings
The report documents findings related to the complaint investigation at Seasons Place, with a census of 43 residents during the visit. Specific deficiencies or detailed findings are not provided in the available text.
Complaint Details
Complaint number 26122 was investigated during the visit from 10/18/21 to 10/21/21.
Report Facts
Census: 43
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 10
Oct 21, 2021
Visit Reason
Annual survey conducted to assess compliance with health and safety regulations, medication administration, resident care, and facility maintenance.
Findings
The facility had multiple deficiencies including late updates of functional needs assessments and health assessments for residents, inadequate documentation of medication orders and refusals, lack of food handler cards for staff involved in food service, insufficient housekeeping and maintenance, incomplete resident records especially for transfers, and failure to document weekly nursing care progress notes for residents with special needs.
Severity Breakdown
Class I: 2
Class II: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Functional needs assessments and service plans were not updated annually for five residents. | Class II |
| Medication orders were not obtained for discontinuing medications after refusals for two residents. | Class I |
| Approved Medication Assistive Personnel (AMAP) failed to receive timely quarterly reviews. | Class I |
| Resident records lacked dentist contact information for five residents. | — |
| Resident transfer summaries lacked required medical history, functional needs, orders, and progress notes for multiple residents. | — |
| Annual health assessments were not completed timely for five residents. | — |
| Resident capable of self-administering medications was not properly documented; resident was self-administering without physician authorization. | — |
| Facility staff involved in food handling lacked required food handler cards. | — |
| Registered nurse failed to document weekly progress notes for resident with nursing care needs. | — |
| Housekeeping and maintenance deficiencies observed including damaged carpet, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Residents with late functional needs assessments: 5
Facility census: 43
Residents with missing dentist information: 5
Residents with incomplete transfer documentation: 5
Residents with late annual health assessments: 5
Employee files reviewed for food handler cards: 10
Residents with nursing care needs lacking weekly progress notes: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #82 | Licensed Practical Nurse | Mentioned in relation to medication refusals and lack of physician notification |
| Executive Director | Executive Director | Interviewed regarding multiple deficiencies and plans of correction |
| Regional Care Specialist | Regional Care Specialist | Provided education to staff on various compliance requirements |
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 3
Oct 19, 2021
Visit Reason
Annual environmental inspection conducted to assess compliance with fire safety, disaster preparedness, physical facilities, and housekeeping standards.
Findings
The facility was found deficient in several areas including failure to show new residents emergency evacuation procedures within 24 hours of admission, failure to maintain the interior and exterior of the facility in good repair and cleanliness, and failure to document and rehearse the disaster and emergency preparedness plan annually. Specific issues included broken floor tiles, dust accumulation, and lack of documentation for emergency drills.
Severity Breakdown
Class I: 2
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed within 24 hours of admission to show all new residents how to evacuate the residence in an emergency and document this in the residents' records. | Class I |
| Failed to keep the interior and exterior of the residence clean and in good repair, including broken floor tiles and dust on ceiling supply and tiles. | Class II |
| Failed to rehearse the disaster and emergency preparedness plan annually and keep documentation including critique of the rehearsal. | Class I |
Report Facts
Facility census: 43
Deficiencies cited: 3
Date of Fire Marshal report: Aug 20, 2019
County Sanitarian report date: Jul 21, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Verified findings related to emergency evacuation and disaster preparedness documentation; involved in corrective actions and audits. |
| Maintenance Technician | Maintenance Technician | Involved in conducting disaster preparedness rehearsal and maintenance issues. |
| Regional Director of Care Services | Regional Director of Care Services | Provided education and training on emergency preparedness requirements. |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Apr 29, 2021
Visit Reason
The inspection was conducted in response to Complaint #25257 to investigate allegations at the facility.
Findings
The complaint investigation was completed and found to be unsubstantiated.
Complaint Details
Complaint #25257 was investigated from 04/28/21 at 8:30 AM to 04/29/21 at 12:30 PM and was determined to be unsubstantiated.
Report Facts
Complaint number: 25257
Census: 39
Inspection Report
Follow-Up
Deficiencies: 0
Jan 6, 2021
Visit Reason
This was a second revisit inspection to verify correction of previously cited deficiencies at Seasons Place.
Findings
The deficiency cited in the prior inspection was cleared as of this revisit conducted from January 4 to January 6, 2021.
Report Facts
Inspection visit dates: Entrance on 2021-01-04 and exit on 2021-01-06
Inspection Report
Routine
Census: 39
Deficiencies: 0
Jan 6, 2021
Visit Reason
The inspection was conducted as an Infection Control Survey at Seasons Place AL from January 4 to January 6, 2021.
Findings
No deficiencies were identified during the infection control survey.
Report Facts
Census: 39
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 6, 2021
Visit Reason
The inspection was conducted in response to Complaint #24883 to investigate allegations at the facility.
Findings
The complaint was found to be unsubstantiated following the investigation conducted from 01/04/21 to 01/06/21.
Complaint Details
Complaint #24883 was investigated and determined to be unsubstantiated.
Report Facts
Complaint number: 24883
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 2
Oct 27, 2020
Visit Reason
This was a revisit to the annual survey to verify compliance with previously cited deficiencies related to activity documentation and facility environment.
Findings
The facility failed to provide a monthly calendar listing the time and duration of social and recreational activities for residents, affecting all 45 residents. Additionally, deficiencies in housekeeping and maintenance were noted, including damaged carpet, missing bathroom fixtures, and cleanliness issues.
Severity Breakdown
Class III: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide a monthly calendar that lists the type, time, and duration of all social and recreational activities for residents. | Class III |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bar and toilet paper holder, dirty sink, and torn chair. | — |
Report Facts
Residents affected: 45
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #4 | Director of Nurse | Stated calendar only needed to show activity name |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 5
Aug 19, 2020
Visit Reason
Annual survey conducted from 08/17/20 to 08/19/20 to assess compliance with health, safety, and administrative regulations for the facility.
Findings
The facility was found deficient in documenting social and recreational activities, responding in writing to complaints within required timeframes, maintaining accurate POST forms for residents, and completing annual health assessments timely. Housekeeping and maintenance issues were also noted, including damaged carpets and missing bathroom fixtures.
Complaint Details
The complaint investigation revealed failure to respond in writing to five complainants within four days. Complaints involved telephone issues, rude staff, missing clothing, dietary issues, and housekeeping concerns. The facility staff were unaware that written responses were required.
Severity Breakdown
Class III: 2
Class II: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide a monthly calendar documenting that social and recreational activities did or did not take place, potentially affecting 45 residents. | Class III |
| Failed to respond in writing to five complainants within four days after complaints were filed. | Class III |
| Failed to maintain accurate records and reports; POST forms were incomplete or missing preparer's signature, printed name, and date for four residents (#10, #16, #25, #42). | Class II |
| Failed to ensure annual health assessments were completed, signed, and dated by a licensed health care professional for one resident (#42), with the assessment 97 days past due. | Class II |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Residents affected: 45
Complaints not responded to in writing timely: 5
Residents with incomplete POST forms: 4
Days past due for annual health assessment: 97
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director #13 | Executive Director | Unaware that complaints had to be responded to in writing; involved in complaint findings and plan of correction. |
| Registered Nurse #4 | Registered Nurse | Unaware that complaints had to be responded to in writing; involved in complaint findings. |
| Life Enrichment Coordinator (LEC) | Life Enrichment Coordinator | Received training on documenting social and recreational activities. |
| Regional Director of Operations | Regional Director of Operations | Educated Executive Director on complaint process. |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 2
Jul 28, 2020
Visit Reason
Annual environmental inspection conducted to assess the physical condition and compliance of the facility.
Findings
The licensee failed to keep the interior and exterior of the facility clean and in good repair, including damaged laundry room floor tiles and missing tiles on the outside patio area. These deficiencies were verified by staff and acknowledged by the Executive Director.
Deficiencies (2)
| Description |
|---|
| Laundry room floor tile damaged and peeling up off of the floor. |
| Missing tiles located on the outside side patio area. |
Report Facts
Facility census: 42
Deficiencies cited: 1
Date of Fire Marshal report: Aug 20, 2019
County Sanitarian report date: Oct 21, 2019
Sprinkler Type: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified findings of damaged floor and missing tiles | |
| Executive Director | Acknowledged findings at exit interview and responsible for monitoring grounds and facilities |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Jul 31, 2019
Visit Reason
The inspection was conducted in response to a complaint identified by Complaint ID WV00022480.
Findings
No deficiencies were cited during the complaint investigation conducted from July 29-31, 2019.
Complaint Details
Complaint ID WV00022480 was investigated and found to have no deficiencies cited.
Report Facts
Census: 37
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 0
Jul 31, 2019
Visit Reason
The inspection was conducted as an annual survey of the facility.
Findings
No deficiencies were cited during the annual survey conducted from 07/29/19 to 07/31/19. The census at the time of inspection was 37 residents.
Report Facts
Census: 37
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Jul 29, 2019
Visit Reason
The inspection was conducted as a follow-up to a complaint investigation identified by Complaint ID WV00022517 to verify correction of previously cited deficiencies.
Findings
The deficiencies identified in the complaint investigation were corrected as of the date of this follow-up inspection.
Complaint Details
Complaint ID WV00022517; deficiencies corrected.
Report Facts
Census: 37
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Jul 6, 2019
Visit Reason
The visit was conducted as an annual licensure survey to assess the facility's compliance with environmental and health safety standards.
Findings
No deficiencies were cited during the annual licensure survey. The fire marshal and sanitarian inspections reported no recommendations or concerns.
Report Facts
Sprinkler Type: 13
Date of Fire Marshal report: Jun 13, 2019
Sanitarian Date: Jun 4, 2019
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 3
May 16, 2019
Visit Reason
The inspection was conducted as a complaint investigation at Seasons Place to evaluate allegations related to medication administration and resident care.
Findings
The facility failed to ensure resident care was provided by appropriately licensed health care professionals, with deficiencies in medication administration records, including failure to sign MARs, incomplete physician orders, and improper handling of telephone orders. Additionally, staff failed to monitor and document residents' conditions following medication errors. Housekeeping and maintenance deficiencies were also noted from prior observations.
Complaint Details
Complaint investigation conducted from 05-15-2019 to 05-16-2019 with Complaint ID 6KQY11. Deficiencies cited related to medication administration and resident monitoring after medication errors.
Severity Breakdown
CLASS I: 1
CLASS II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure resident care was provided by appropriately licensed health care professionals and proper medication administration as required by law. | CLASS I |
| Failure to monitor and document resident's condition at least once every eight hours for 24 hours following medication errors. | CLASS II |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Census: 40
Sample Size: 3
Medication Administration Records reviewed: 3
Medication errors: 2
Plan of Correction Completion Date: 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #32 | Registered Nurse/Care Service Manager/AMAP Registered Nurse Supervisor | Named in medication administration deficiencies for failing to sign MARs and improper handling of telephone orders; provided training and audits. |
| Employee #30 | Licensed Practical Nurse | Took unauthorized telephone orders and missed a resident's medication dose. |
| Employee #18 | Approved Medication Assistive Personnel (AMAP) | Involved in medication error for Resident #41 and lacked knowledge of required monitoring. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Jul 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation at Seasons Place.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
No deficiencies cited.
Report Facts
Census: 40
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 10
Jul 11, 2018
Visit Reason
Annual licensure survey conducted July 9-11, 2018 to assess compliance with state regulations for Seasons Place.
Findings
The facility was found deficient in multiple areas including employee orientation and training, housekeeping and maintenance, personnel records, health care standards including resident assessments and service plans, staff training on special care needs, resident weight monitoring, and proper release of resident belongings upon death.
Severity Breakdown
Class I: 1
Class II: 3
Class III: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to provide and maintain training records for new employees within 15 days of employment including emergency procedures, resident rights, and complaint procedures. | Class II |
| Failed to ensure adequate housekeeping and maintenance; observed personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bars and toilet paper holders, and dirty sink. | — |
| Failed to provide and maintain records of annual in-service training for staff on resident rights, confidentiality, abuse prevention, infection control, and fire safety. | Class II |
| Failed to maintain confidential personnel records including tuberculosis screening for employees. | — |
| Failed to ensure residents had written, signed, and dated annual health assessments including tuberculosis screening documented in medical records. | Class II |
| Failed to ensure staff had access to updated service plans and used them as a guide for resident care. | — |
| Failed to provide staff training on colostomy care, CPAP machine, wound care, blood thinners, and diabetes management. | — |
| Failed to ensure registered nurse performed and documented nursing assessments within 24 hours of admission and updated assessments with changes in condition. | Class I |
| Failed to release resident belongings only to estate administrator or executor upon resident death. | — |
| Failed to weigh residents monthly, document weights, and notify physician of unplanned weight loss or gain of 5 pounds or more. | Class III |
Report Facts
Census: 42
Weight loss: 9
Weight loss: 47
Weight gain: 9
Weight loss: 35
Weight loss: 18
Weight: 218
Weight: 209
Weight: 167
Weight: 127
Weight: 212
Weight: 221
Weight: 282
Weight: 247
Weight: 120
Weight: 102
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #8 | Named in deficiency for lack of training on oxygen, Hoyer lift, and complaint procedures | |
| Employee #10 | Named in deficiency for lack of training on oxygen, Hoyer lift, and complaint procedures | |
| Employee #13 | Named in deficiency for lack of training on complaint procedures | |
| Employee #2 | Named in deficiency for lack of annual in-service training and tuberculosis screening | |
| Employee #9 | Named in deficiency for lack of annual in-service training and tuberculosis screening | |
| Employee #22 | Named in deficiency for lack of tuberculosis screening and staff training | |
| Administrator | Interviewed regarding multiple deficiencies and corrective actions | |
| Care Services Manager | RN/Designee | Responsible for staff training, audits, and corrective actions |
| Executive Director | E.D. | Responsible for oversight and ensuring compliance |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 0
Jul 9, 2018
Visit Reason
The inspection was conducted as an annual licensure survey of the facility to assess compliance with regulatory requirements.
Findings
The annual licensure survey identified deficiencies which were subsequently corrected during a follow-up survey conducted in September 2018.
Report Facts
Census during annual survey: 42
Census during follow-up survey: 44
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 0
Jul 9, 2018
Visit Reason
Annual licensure survey conducted to assess environmental and facility compliance.
Findings
No deficiencies were cited during the annual licensure survey. Fire Marshal and Sanitarian reports included recommendations, with one critical and one non-critical noted by the Sanitarian.
Report Facts
Census: 42
Deficiencies cited: 0
Fire Marshal report date: Date of Fire Marshal report: 2018-06-13
Sanitarian report date: Date of Sanitarian report: 2018-03-07
Sanitarian recommendations: 2
Sprinkler Type: 13
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 4
Apr 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation from April 23-27, 2018, to evaluate allegations related to staffing and care deficiencies at Seasons Place.
Findings
The facility failed to ensure adequate staffing levels, particularly on the day shift, resulting in insufficient direct care staff to meet residents' needs. Numerous care deficiencies were noted including residents not being fed, inadequate assistance with activities of daily living, poor housekeeping and maintenance, and delayed medication administration. Staff and family interviews confirmed these issues and fear of retaliation was reported.
Complaint Details
Complaint ID WV00020081. The investigation was triggered by complaints regarding inadequate staffing, poor resident care, and facility maintenance issues. Deficiencies were cited based on observations, interviews, and record reviews.
Deficiencies (4)
| Description |
|---|
| Failure to have one additional direct care staff on the day shift for each ten residents with two or more care needs, resulting in inadequate staffing for 23 residents. |
| Inadequate housekeeping and maintenance including personal belongings left behind furniture, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
| Residents not receiving adequate assistance with eating, toileting, bathing, and activities; some found with dried feces in briefs; showers not completed as scheduled; meals not served timely; clothes frequently lost in laundry. |
| Medication administration workload excessive for nursing staff, with one LPN responsible for 405 medications in the morning and 205 medications in the evening, causing delays and interruptions. |
Report Facts
Residents dependent on staff for two or more care needs: 23
Medications administered at 8:00 a.m. and 9:00 a.m.: 405
Medications administered at 8:00 p.m.: 205
Direct care staff required on day shift: 3.5
Direct care staff on duty on day shift: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #20 | Licensed Practical Nurse (LPN) | Observed volunteering to assist with medication pass and reported no instruction to work overtime; responsible for medication administration and direct care duties. |
| Employee #21 | Licensed Practical Nurse (LPN) | Reported having no time for direct care duties due to workload. |
| Administrator | Provided resident roster and staffing schedules; acknowledged staffing deficiencies and delays in medication assistive personnel training. | |
| Executive Director/Designee | Educated on staffing requirements and responsible for reviewing direct care staff schedules to ensure compliance. |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Apr 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation from April 23-27, 2018, related to Complaint ID WV00020081.
Findings
Deficiencies were cited during the complaint investigation. A follow-up visit on June 12, 2018, with a census of 41 and 1 out of facility (OOF) resident, confirmed that the deficiency was corrected.
Complaint Details
Complaint Investigation conducted April 23-27, 2018 for Complaint ID WV00020081. Deficiencies were cited and subsequently corrected by follow-up on June 12, 2018.
Deficiencies (1)
| Description |
|---|
| Deficiencies cited during the complaint investigation. |
Report Facts
Census: 43
Census: 41
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Mar 20, 2018
Visit Reason
The inspection was conducted as a complaint investigation for Complaint ID WV00019943 during March 20-21, 2018.
Findings
No deficiencies were cited during this complaint investigation.
Complaint Details
Complaint ID WV00019943 was investigated with no deficiencies cited.
Report Facts
Census: 46
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Oct 18, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID WV00018967 from October 16-18, 2017.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint ID WV00018967 was investigated and found to have no deficiencies cited.
Report Facts
Census: 22
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 1
Aug 2, 2017
Visit Reason
The inspection was conducted as an annual licensure survey of the facility Seasons Place to assess compliance with regulatory requirements.
Findings
Deficiencies were cited during the annual licensure survey conducted from July 31 to August 2, 2017. A follow-up survey on September 13, 2017, confirmed that both deficiencies were corrected.
Deficiencies (1)
| Description |
|---|
| Deficiencies cited during the annual licensure survey |
Report Facts
Deficiencies cited: 2
Census: 39
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 3
Aug 2, 2017
Visit Reason
Annual licensure survey conducted from July 31 to August 2, 2017, to assess compliance with staffing, housekeeping, maintenance, and resident belongings release regulations.
Findings
The facility was found deficient in ensuring all employees had current first aid and CPR training, maintaining adequate housekeeping and maintenance, and properly releasing residents' personal belongings and funds to authorized estate representatives upon death.
Severity Breakdown
Class I: 1
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure at least one employee on duty at all times had current first aid and CPR training, with three of five employees lacking current certification. | Class I |
| Inadequate housekeeping and maintenance including personal belongings left behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and dirty sink. | — |
| Failure to release residents' personal belongings and funds to the estate administrator or executor upon death for two residents. | Class III |
Report Facts
Census: 39
Deficiency count: 3
Days without CPR/first aid trained staff: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #18 | Resident Care Partner | Lacked current first aid and CPR training |
| Employee #19 | Licensed Practical Nurse | Lacked current CPR training; received inservice training completed August 18, 2017 |
| Employee #24 | Resident Care Partner | Lacked current first aid and CPR training |
| Employee #22 | Licensed Practical Nurse | Interviewed regarding failure to release residents' belongings to authorized estate representatives |
| Employee #29 | Spoke with administrator about resident's brother retrieving belongings |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 0
Jul 5, 2017
Visit Reason
The facility underwent an annual licensure survey focused on environmental conditions.
Findings
No deficiencies were cited during the annual licensure survey conducted on July 5, 2017.
Report Facts
Census: 36
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 7
Jun 13, 2017
Visit Reason
The inspection was conducted as a complaint investigation from June 5-13, 2017, triggered by concerns regarding staffing, resident care, medication administration, resident rights, dietary services, and housekeeping.
Findings
The facility was found deficient in multiple areas including inadequate staffing levels, failure to ensure RN oversight and weekly resident assessments, improper medication cart security, failure to provide residents with full dietary requirements at evening meals, inadequate housekeeping and maintenance, and failure to provide sanitary hand drying methods in resident bathrooms. Resident rights violations were also noted regarding access to common bathrooms and feeding practices.
Complaint Details
Complaint ID WV00018041. The investigation was based on multiple complaints including staffing shortages, resident care concerns, dietary issues, and infection control problems.
Deficiencies (7)
| Description |
|---|
| Failure to ensure adequate staffing levels on day, evening, and night shifts based on residents' functional needs. |
| Failure to ensure RN oversight and weekly progress notes for residents as required. |
| Medication cart was found unlocked and unattended, posing a risk to medication security. |
| Evening meals did not consistently include required protein, vegetables, fruits, and whole grain products on multiple days. |
| Resident rights violations including denial of access to common bathrooms and feeding residents in rooms without adequate justification. |
| Inadequate housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and unclean sinks. |
| Toilet and bathing facilities lacked sanitary hand drying methods; cloth towels were used instead of paper towels, raising infection control concerns. |
Report Facts
Residents with two or more care needs: 22
Days with insufficient day shift staffing: 10
Days with insufficient night shift staffing: 19
Residents census: 39
Days with deficient evening meal nutrition: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #22 | Licensed Practical Nurse (LPN) | Named in findings related to colostomy care delegation and assessment responsibilities. |
| Employee #4 | Licensed Practical Nurse (LPN) | Responsible for medication cart found unlocked; required re-education on medication security. |
| Executive Director | Named in multiple findings related to staffing, resident rights, and corrective actions. |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Jun 5, 2017
Visit Reason
The inspection was conducted as a complaint investigation for Complaint ID WV00018041 from June 5-13, 2017, followed by a complaint follow-up visit on August 2-3, 2017.
Findings
The complaint investigation identified deficiencies which were subsequently corrected as noted in the follow-up visit. The census during both visits was 39 residents.
Complaint Details
Complaint ID WV00018041 was investigated from June 5-13, 2017, with a follow-up on August 2-3, 2017 confirming that deficiencies were corrected.
Report Facts
Census: 39
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
May 1, 2017
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint # WV00017770 from May 1-3, 2017.
Findings
No deficiencies were found during the complaint investigation conducted at Seasons Place.
Complaint Details
Complaint # WV00017770 was investigated from May 1-3, 2017, with no deficiencies found and no substantiation stated.
Report Facts
Census: 36
Number of Deficiencies: 0
Inspection Report
Census: 32
Deficiencies: 0
Nov 10, 2016
Visit Reason
The inspection was conducted as a Change of Ownership (CHOW) Survey from November 7 to 10, 2016.
Findings
No deficiencies were identified during this Change of Ownership survey.
Report Facts
Census: 32
Number of Deficiencies: 0
Inspection Report
Census: 36
Deficiencies: 0
Oct 24, 2016
Visit Reason
The inspection was conducted as a Change of Ownership (CHOW) survey for Seasons Place in Lewisburg, WV.
Findings
The survey found no citations or deficiencies during the Change of Ownership inspection.
Report Facts
Census: 36
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Apr 11, 2016
Visit Reason
The inspection was conducted as a complaint investigation based on allegations regarding inadequate staffing and care at the facility.
Findings
The facility was found to be chronically understaffed, failing to meet minimum staffing requirements for residents with multiple care needs. Residents and family members reported long wait times for assistance, missed showers, and inadequate response to call bells. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.
Complaint Details
Complaint # WV00015495 was investigated from April 11-13, 2016. The complaint was substantiated with findings of inadequate staffing and care delays reported by residents and family members.
Severity Breakdown
Class I: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure one additional direct care staff on the day shift for each ten residents with two or more care needs. | Class I |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks. | — |
Report Facts
Residents with two or more care needs: 11
Census: 39
Staffing levels: 1
Wait times: 20
Wait times: 45
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Apr 11, 2016
Visit Reason
The inspection was conducted as a complaint investigation for Complaint # WV00015495 from April 11-13, 2016, with a follow-up visit on June 1, 2016.
Findings
The report documents a complaint investigation and a follow-up related to the complaint. Specific findings are not detailed in the provided text.
Complaint Details
Complaint # WV00015495 was investigated from April 11-13, 2016, with a follow-up on June 1, 2016. Census was 39 during the initial investigation and 36 during the follow-up.
Report Facts
Census during initial complaint investigation: 39
Census during complaint follow-up: 36
Residents out of facility during initial complaint investigation: 2
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Jan 18, 2016
Visit Reason
The purpose of the visit was to conduct the annual licensure survey and environmental survey of the facility.
Findings
The survey found no deficiencies. The fire marshal report dated January 30, 2015, included 5 recommendations, all of which were corrected. The sanitation report dated October 9, 2015, showed zero critical and zero non-critical issues.
Report Facts
Recommendations: 5
Critical deficiencies: 0
Non-critical deficiencies: 0
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Oct 12, 2015
Visit Reason
The inspection was conducted as a complaint investigation from October 12-14, 2015.
Findings
The report does not provide specific findings or deficiencies related to the complaint investigation.
Complaint Details
Complaint investigation conducted; no substantiation status or detailed findings provided in the report.
Report Facts
Census: 42
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 2
Feb 11, 2015
Visit Reason
The visit was conducted as an annual licensure survey of the facility.
Findings
The survey included a review of the facility environment and programs to ensure safety and appropriateness for consumers. Specific deficiencies were noted related to safety measures in the residence, including lack of alarms on outside doors and insufficient awake staff supervision on weekend nights.
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. |
| An outside door in the TV room does not lock. |
Report Facts
Sample Size: 3
Inspection Report
Annual Inspection
Census: 43
Deficiencies: 0
Feb 2, 2015
Visit Reason
The purpose of the visit was to conduct the annual licensure survey of the Seasons facility.
Findings
The survey found no deficiencies or technical assistance needs. The facility was compliant with health and safety standards, with no recommendations noted.
Report Facts
Critical deficiencies: 2
Non-critical deficiencies: 0
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Jan 18, 2015
Visit Reason
The inspection was conducted as an annual licensure survey of the facility.
Findings
The report summarizes the annual licensure survey conducted from January 18-20, 2015, with a census of 39 residents. No specific deficiencies or severity levels are detailed in the provided document.
Report Facts
Census: 39
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Jan 30, 2014
Visit Reason
The inspection was conducted as a complaint investigation survey from January 27 to January 30, 2014.
Findings
The report documents a complaint investigation survey with no detailed findings or deficiencies explicitly stated in the provided text.
Complaint Details
Complaint Survey WV00009745 conducted January 27-30 with a census of 31.
Report Facts
Census: 31
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 0
Jan 29, 2014
Visit Reason
The inspection was conducted as an annual licensure survey of the facility Seasons Place.
Findings
The report summarizes the annual licensure survey conducted from January 27-29, 2014, with a census of 31 residents. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 31
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 0
Dec 26, 2013
Visit Reason
The inspection was conducted as an annual licensure survey focusing on environmental conditions at the facility.
Findings
The survey found no deficiencies or issues requiring technical assistance during the inspection.
Report Facts
Census: 30
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 13
Jul 31, 2013
Visit Reason
Complaint investigation conducted from July 22-31, 2013, triggered by concerns including medication administration, staffing shortages, resident care, and complaint handling.
Findings
The facility failed to ensure adequate staffing, proper medication administration, timely incident reporting, appropriate infection control, resident rights protection, and an effective activity program. Multiple deficiencies were found related to resident care, medication errors, housekeeping, and complaint resolution.
Complaint Details
Complaint investigation WV00008420 conducted July 22-31, 2013, with census 35. Multiple complaints included staffing shortages, medication errors, missing items, inadequate complaint responses, and poor resident care.
Severity Breakdown
Class I: 6
Class II: 3
Class III: 3
: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failure to protect physical and mental well-being of residents, including delayed treatment and inadequate monitoring of a resident's injury. | Class II |
| Failure to report major incidents to the Office of Health Facility Licensure and Certification within required timeframe. | Class III |
| Insufficient number of qualified staff on duty to administer medications timely and meet residents' care needs. | Class I |
| Failure to ensure one employee on duty each shift with current CPR training. | Class I |
| Failure to ensure no resident is neglected, including inadequate response to injury and poor housekeeping. | Class I |
| Failure to resolve complaints and respond to complainants in writing within four days. | Class III |
| Service plans did not reflect current needs of residents or include necessary precautions and assistance details. | Class II |
| Failure to administer medications according to physician's orders for multiple residents, including missing documentation and medication availability issues. | Class I |
| Failure to assess and document resident capability for self-administration of medications. | Class II |
| Medications were not kept in locked areas accessible only to staff responsible for administering medications; medications found in residents' rooms. | Class I |
| Failure to provide care and services using appropriate infection control techniques, including lack of hand sanitizers in resident rooms and borrowing gloves from residents. | Class I |
| Failure to provide an activity program promoting the highest level possible in all dimensions of life; activities were inadequate and not inclusive. | Class III |
| Failure to ensure adequate housekeeping and maintenance, including presence of personal belongings in inappropriate places, damaged carpet, missing bathroom fixtures, and dirty sinks. | — |
Report Facts
Residents with 2 or more care needs: 21
Medications to be administered on day shift: 394
Medications to be administered on evening shift: 213
Medications to be administered on night shift: 15
Days with only one LPN on 8:00 p.m. shift: 12
Days with no nurse on 11:00 p.m. to 7:00 a.m. shift: 5
Residents incontinent: 14
Blanks with no documentation on MAR: 82
Residents in facility: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #42 | Licensed Practical Nurse | Completed incident report regarding Resident #27 injury |
| Employee #44 | Physical Therapist | Interviewed regarding Resident #27's fracture and therapy |
| Employee #5 | Reported power outage on July 12, 2013 | |
| Director of Nursing | Reviewed incident report and involved in resident care and communication | |
| Administrator | Responsible for staffing, incident reporting, complaint handling, and corrective actions |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Jul 22, 2013
Visit Reason
The inspection was conducted as a complaint investigation regarding failure to administer medications according to physician's orders and documentation issues related to medication administration.
Findings
The facility failed to ensure medications were administered in accordance with physician's orders for multiple residents, with numerous instances of missing documentation, medications not available, and medications administered without proper orders. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas.
Complaint Details
The complaint investigation was substantiated, revealing failure by the administrator and registered nurse to ensure medications were administered as prescribed for twelve residents, with multiple documentation and medication availability issues.
Severity Breakdown
Class I: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to administer medications according to physician's orders for twelve residents, including missing documentation and medications not available. | Class I |
| Inadequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and dirty sinks. | — |
Report Facts
Census: 35
Medication administration blanks: 82
Medication administration blanks: 13
Medication administration blanks: 12
Medication administration blanks: 9
Medication administration blanks: 9
Medication administration blanks: 5
Medication administration blanks: 4
Medication administration blanks: 4
Medication administration blanks: 3
Medication administration blanks: 5
Medication administration blanks: 30
Medication administration blanks: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Named in medication administration audit and deficiencies | |
| Administrator | Named in failure to ensure medications administered per physician's orders |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 5
Jan 23, 2013
Visit Reason
The annual licensure survey was conducted to assess compliance with staffing requirements, employee orientation and training, health care standards, and housekeeping and maintenance standards at Seasons Place.
Findings
The facility was found deficient in ensuring adequate staffing for medication administration, providing sufficient employee training on special care needs, maintaining comprehensive service plans for residents with special care needs, and ensuring adequate housekeeping and maintenance of the physical environment.
Deficiencies (5)
| Description |
|---|
| Administrator failed to ensure sufficient number of qualified staff to administer medications, with only one LPN on duty during the 8:00 p.m. medication pass on multiple days. |
| Failure to provide and maintain adequate employee orientation and training on specialty care needs for five employees. |
| Failure to maintain service plans addressing all resident needs, including guidance on signs and symptoms for anticoagulant therapy, seizure management, and insulin use for nine residents. |
| Registered nurse failed to provide needed training or recommend appropriate training for staff regarding when to contact the nurse about changes in resident condition. |
| Inadequate housekeeping and maintenance observed, including personal belongings behind furniture, carpet damage, torn chair, missing towel bars and toilet paper holders, and dirty sink. |
Report Facts
Medications to be administered during 8:00 p.m. pass: 206
Days with only one LPN on duty: 10
Census: 45
Employees lacking specialty care training documentation: 5
Residents with incomplete service plans: 9
Completion date for carpet replacement: Sep 30, 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW, HFS II | Surveyor conducting the annual licensure survey. |
| Beverly Randolph | HFNS I | Surveyor conducting the annual licensure survey. |
| TE | Employee lacking documentation of specialty care training. | |
| LW | Employee lacking documentation of specialty care training. | |
| AL | Employee lacking documentation of specialty care training. | |
| SC | Employee lacking documentation of specialty care training. | |
| CC | Employee lacking documentation of specialty care training. |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 1
Jan 22, 2013
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental and physical facility compliance.
Findings
The facility was found deficient in maintaining adequate storage space for linens, maintenance and housekeeping supplies, equipment, and food supplies. Specifically, storage items and equipment were found on the floor around and in front of the toilet in the bathing facility.
Deficiencies (1)
| Description |
|---|
| The residence failed to maintain adequate storage for linens, maintenance and housekeeping supplies, equipment, and food supplies, with items found on the floor around and in front of the toilet in the bathing facility. |
Report Facts
Census: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Robinson | Life Safety Surveyor | Surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 0
Jan 22, 2013
Visit Reason
Annual licensure survey conducted to assess environmental compliance and overall facility conditions.
Findings
The report documents an annual licensure survey with environmental focus and a follow-up survey to verify correction of deficiencies. Deficiencies were corrected as noted in the follow-up.
Report Facts
Census: 45
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Robinson | Life Safety Surveyor | Surveyor for annual licensure survey |
| Mark Lubic | Surveyor for follow-up survey | |
| John Stephens | Surveyor for follow-up survey |
Inspection Report
Annual Inspection
Census: 45
Deficiencies: 0
Jan 21, 2013
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with regulatory requirements for the facility.
Findings
The survey identified deficiencies which were later corrected as noted in the follow-up visit. Technical assistance was also provided during the follow-up.
Report Facts
Census at initial survey: 45
Census at follow-up survey: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW, HFS II | Surveyor during the annual licensure survey |
| Beverly Randolph | HFNS I | Surveyor during the annual licensure survey |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Nov 20, 2012
Visit Reason
The visit was conducted as a complaint investigation based on two complaints, #WV00007367 and #WV00007415.
Findings
The complaint investigation found that complaint #WV00007367 was unsubstantiated and technical assistance was provided. Complaint #WV00007415 was substantiated but no deficiencies were cited.
Complaint Details
Complaint #WV00007367 was unsubstantiated with technical assistance provided. Complaint #WV00007415 was substantiated but no deficiencies were cited.
Report Facts
Census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW, HFS II | Surveyor conducting the complaint investigation |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 3
Feb 16, 2012
Visit Reason
Annual licensure survey conducted January 16-18, 2012, with a follow-up survey on February 16, 2012, to assess compliance with state regulations including resident rights and medication administration.
Findings
The facility was found deficient in timely written responses to resident complaints and in maintaining accurate medication administration records (MARs) with correct routes of administration for multiple residents. Additionally, housekeeping and maintenance issues were noted from prior surveys.
Complaint Details
Review of 2011 complaint files revealed multiple complaints with delayed written responses ranging from 6 to 12 days after filing. The administrator acknowledged investigations were started promptly but not always documented in writing.
Severity Breakdown
Class I: 1
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Administrator failed to ensure written responses to complaints were provided within four days in six of nine instances. | Class III |
| Medication administration records (MARs) lacked routes of administration for medications for multiple residents, a repeat deficiency from prior surveys. | Class I |
| Inadequate housekeeping and maintenance including personal belongings left behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Census: 42
Census: 40
Number of residents with MAR route deficiencies: 10
Number of residents with MAR route deficiencies: 9
Number of complaints with delayed responses: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFSII Surveyor | Surveyor during annual and follow-up surveys |
| Donna Williamson | HFNSII Surveyor | Surveyor during annual licensure survey |
| KF | Registered Nurse | Interviewed regarding MAR deficiencies and corrective actions |
| NH | Administrator | Interviewed regarding complaint investigations and deficiencies |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 0
Jan 23, 2012
Visit Reason
Annual licensure survey conducted to assess environmental compliance and overall facility conditions.
Findings
No deficiencies or technical assistance needs were identified during the environmental annual licensure survey.
Report Facts
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Named in the report as a contact or representative |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 3
Jan 18, 2012
Visit Reason
The inspection was conducted as an annual licensure survey of the facility Seasons Place to assess compliance with state regulations.
Findings
The survey identified deficiencies including failure to provide timely written responses to resident complaints, inadequate housekeeping and maintenance issues, and incomplete medication administration records lacking routes of administration for multiple residents.
Severity Breakdown
Class I: 1
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Administrator failed to ensure written responses to complaints were provided within four days in six of nine instances. | Class III |
| Inadequate housekeeping and maintenance including personal belongings left behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and dirty sink. | — |
| Medication administration records (MARs) for ten residents lacked routes of administration for multiple medications. | Class I |
Report Facts
Census: 42
Complaints with delayed written response: 6
Residents with MAR deficiencies: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFSII Surveyor | Named as surveyor conducting the inspection |
| Donna Williamson | HFNSII Surveyor | Named as surveyor conducting the inspection |
| KF | Interviewed and acknowledged medication record issues |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 0
Jan 16, 2012
Visit Reason
The facility underwent an annual licensure survey conducted from January 16-18, 2012, with a follow-up survey on March 28, 2012, to verify correction of deficiencies.
Findings
The report documents the annual licensure survey and a follow-up survey with noted deficiencies that were corrected by February 16, 2012. Specific deficiencies are not detailed in the provided text.
Report Facts
Census: 42
Census: 41
Census: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFSII | Surveyor during annual licensure survey and follow-up |
| Donna Williamson | HFNSII | Surveyor during annual licensure survey |
| Donna Williamson | RN, HFNS II | Surveyor during follow-up survey |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 2
Jan 13, 2011
Visit Reason
The visit was conducted as an annual licensure survey to assess the environment and compliance with physical facility standards.
Findings
The inspection found that the interior of the residence was not kept clean, specifically noting unclean floor surfaces in the walk-in freezer and cooler, and accumulation of debris under work tables and around the kitchen floor perimeter.
Deficiencies (2)
| Description |
|---|
| The floor surface in the walk-in freezer and cooler were unclean. |
| There was an accumulation of debris under work tables, and the perimeter of the kitchen floor that was not being cleaned during normal housekeeping procedures. |
Report Facts
Census: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Surveyor | Conducted the annual licensure survey |
| Food Service Director (FSD) | Responsible for implementing cleaning schedule and audits |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 2
Jan 13, 2011
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess the facility's compliance with health and safety regulations.
Findings
The facility was found deficient in maintaining a clean environment, specifically the interior of the residence including unclean floor surfaces in the walk-in freezer and cooler, and accumulation of debris under work tables and around the kitchen floor perimeter. A follow-up survey confirmed these deficiencies persisted.
Severity Breakdown
CLASS II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to keep the interior of the residence clean, including unclean floor surfaces in the walk-in freezer and cooler. | CLASS II |
| Accumulation of dust and debris under work tables and around the perimeter of the kitchen floor not removed during normal housekeeping. | CLASS II |
Report Facts
Census: 38
Census: 41
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Surveyor | Conducted the annual licensure survey and follow-up survey |
| Food Service Director (FSD) | Responsible for implementing cleaning schedules and auditing compliance | |
| Maintenance Director | Performed deep cleaning of kitchen areas during follow-up |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 0
Jan 13, 2011
Visit Reason
Annual licensure survey conducted to assess the environment and compliance of the facility.
Findings
The report documents an annual licensure survey with follow-up visits, noting census counts and that deficiencies identified were corrected by the final follow-up.
Report Facts
Census: 38
Census: 41
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Surveyor | Conducted the annual licensure survey and follow-up surveys |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 5
Dec 15, 2010
Visit Reason
Annual licensure survey conducted to assess compliance with state regulations including staffing, health assessments, dietary services, and housekeeping.
Findings
The facility was found deficient in multiple areas including failure to conduct abuse registry checks prior to hiring, inadequate staffing on day shifts, incomplete resident health assessments, failure to provide ordered therapeutic diets, and inadequate housekeeping and maintenance.
Severity Breakdown
Class I: 2
Class II: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure nurse aide abuse registry checks were completed prior to hiring new employees. | Class II |
| Failure to consistently staff the residence on the day shift as required by state regulations. | Class I |
| Failure to maintain documentation of admission and annual physical exams for residents. | Class II |
| Failure to provide a resident with a pureed diet as ordered for the first two days after hospitalization. | Class I |
| Failure to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Census: 42
New employee files reviewed: 3
Residents requiring assistance with 2 or more ADLs: 25
Days with inadequate staffing in November: 15
Days with inadequate staffing in December: 6
Residents' records reviewed for physical exams: 5
Residents without required physical exams: 4
Residents requiring pureed diet: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DM | Employee whose nurse aide abuse registry check was completed after hire date. | |
| WR | Employee whose nurse aide abuse registry check was completed after hire date. | |
| DK | Employee whose nurse aide abuse registry check was completed after hire date. | |
| Kathy Beauchamp | HFNSII Surveyor | Surveyor conducting the annual licensure survey. |
| MD | Executive Director | Interviewed regarding weekend staffing and resident care. |
| KF | Wellness Director | Interviewed regarding weekend staffing and resident care. |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 1
Dec 13, 2010
Visit Reason
The inspection was conducted as an annual licensure survey of the facility Seasons Place to assess compliance with regulatory requirements.
Findings
The annual licensure survey identified deficiencies which were later corrected as confirmed by a follow-up survey. Technical assistance was provided during the follow-up visit.
Deficiencies (1)
| Description |
|---|
| Deficiencies were cited during the annual licensure survey conducted December 13-15, 2010. |
Report Facts
Census at annual survey: 42
Census at follow-up survey: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Beauchamp | HFNSII Surveyor | Surveyor for both the annual licensure survey and the follow-up survey |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 5
Jul 22, 2010
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration and record-keeping practices at the facility.
Findings
The facility failed to maintain accurate medication records and ensure medications were administered per physician orders for multiple residents. Additionally, medications were not securely stored, and narcotics were unaccounted for. Housekeeping and maintenance deficiencies were also noted from a prior behavioral health survey.
Complaint Details
Complaint Investigation #WV00005784 conducted July 21-22, 2010. Census at time of survey was 43. Surveyors were Ernie Chafin, HFNS II and Betty Marine, LSW, HFS II.
Severity Breakdown
Class I: 2
Class II: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to maintain accurate medication records for Resident #28, including unaccounted narcotics. | Class II |
| Failure to administer medications per physician's orders for three residents. | — |
| Failure to keep medications accessible only to responsible staff; narcotics not securely stored and medication cart unlocked. | Class I |
| Failure to store Schedule II drugs securely with two locks as required. | Class I |
| Housekeeping and maintenance deficiencies including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Resident census: 43
Unaccounted narcotics: 20
Medication delivery: 60
Medication administration records reviewed: 43
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernie Chafin | HFNS II | Surveyor for complaint investigation |
| Betty Marine | LSW, HFS II | Surveyor for complaint investigation |
| Director of Nurses | DON | Named in findings related to medication administration and narcotics security |
| Administrator | Named in findings related to medication administration and narcotics security | |
| Registered Nurse | RN | Named in findings related to medication administration and narcotics security |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Jul 21, 2010
Visit Reason
The inspection was conducted as a complaint investigation for complaint #WV00005784 during July 21-22, 2010.
Findings
The complaint investigation identified deficiencies which were later corrected as confirmed by a follow-up visit on August 23, 2010. Technical assistance was provided during the follow-up.
Complaint Details
Complaint #WV00005784 was investigated on July 21-22, 2010 with a census of 43. A follow-up visit on August 23, 2010 with a census of 38 confirmed all deficiencies were corrected.
Report Facts
Census at complaint investigation: 43
Census at follow-up: 38
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernie Chafin | HFNS II | Surveyor during complaint investigation |
| Betty Marine | LSW, HFS II | Surveyor during complaint investigation |
| Kathy Beauchamp | HFNS II | Surveyor during complaint follow-up |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 0
Jan 13, 2010
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 related to the environment during the annual licensure survey.
Report Facts
Census: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Named as the surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 0
Jan 7, 2010
Visit Reason
The visit was conducted as an annual licensure survey of the facility.
Findings
No deficiencies were found during the survey, and technical assistance was provided.
Report Facts
Census: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Beauchamp | HFNSII Surveyor | Surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Feb 19, 2009
Visit Reason
The visit was conducted as an annual licensure survey of the facility Seasons Place.
Findings
No deficiencies were found during the survey, and technical assistance was provided.
Report Facts
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Beauchamp | HFNSII Surveyor | Surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Jan 14, 2009
Visit Reason
The visit was conducted as an annual licensure survey to assess the facility's environment and compliance with regulatory standards.
Findings
No deficiencies were cited during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason Lintner | Surveyor | Named as a surveyor conducting the annual licensure survey |
| Keith Carpenter | Surveyor | Named as a surveyor conducting the annual licensure survey |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Oct 27, 2008
Visit Reason
The inspection was conducted as a complaint investigation for facility Seasons Place located at 177 Holt Lane, Lewisburg, WV.
Findings
The complaint investigation found no deficiencies at the facility during the inspection.
Complaint Details
Complaint Investigation #WV00004419 conducted on October 27, 2008 with a census of 33. No deficiencies were found.
Report Facts
Census: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Beauchamp | HFNS II | Surveyor during complaint investigation |
| Betty Marine | LSW, HFS II | Surveyor during complaint investigation |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Aug 20, 2008
Visit Reason
The inspection was conducted as a complaint investigation identified by complaint number WV00004290.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint investigation #WV00004290 was unsubstantiated.
Report Facts
Census: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Beauchamp | HFNSII Surveyor | Surveyor conducting the complaint investigation |
Inspection Report
Follow-Up
Census: 46
Deficiencies: 0
Jun 3, 2008
Visit Reason
The document reports on a follow-up survey conducted to verify correction of deficiencies identified in prior inspections, including a Change of Ownership (CHOW) survey and environmental assessments.
Findings
The follow-up survey conducted on June 3, 2008, found that previously cited deficiencies were corrected. The census was stable at 46 residents during the inspections.
Report Facts
Census: 46
Census: 45
Census: 46
Inspection Report
Follow-Up
Census: 45
Deficiencies: 1
Apr 28, 2008
Visit Reason
This was a follow-up survey to verify correction of deficiencies identified in a prior change of ownership (CHOW) survey conducted on March 20, 2008.
Findings
All deficiencies were corrected except for one related to physical facilities (tag E251) concerning ADA accessibility compliance in the common use toilet and bathing areas, which remained deficient and was scheduled for follow-up after May 19, 2008.
Severity Breakdown
CLASS I: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Renovations in the common use toilet and bathing area fail to comply with ADA accessibility requirements, including improper mounting height and placement of grab bars, lack of mirror over sink, absence of shower chair or fold down seat, and inappropriate door hardware. | CLASS I |
Report Facts
Census: 46
Census: 45
Deficiency completion timeframe: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Surveyor | Conducted Change of Ownership (CHOW) Survey |
| Keith Carpenter | Surveyor | Conducted Survey Follow-Up |
Inspection Report
Follow-Up
Census: 43
Deficiencies: 0
Apr 17, 2008
Visit Reason
The visit was a follow-up survey conducted to verify correction of deficiencies identified during a prior Change of Ownership (CHOW) survey conducted February 5-7, 2008.
Findings
The follow-up survey found that the previously cited deficiencies were corrected as of the April 17, 2008 visit.
Report Facts
Census: 44
Census: 44
Census: 43
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII | Surveyor during Change of Ownership and follow-up surveys |
| Kathy Beauchamp | HFNSII | Surveyor during Change of Ownership and follow-up surveys |
Inspection Report
Follow-Up
Census: 44
Deficiencies: 4
Mar 25, 2008
Visit Reason
The visit was a follow-up survey conducted to assess compliance after a Change of Ownership (CHOW) survey conducted February 5-7, 2008, focusing on correction of previously identified deficiencies.
Findings
The facility was found to have ongoing deficiencies related to housekeeping, maintenance, updating resident service plans after significant changes, notification of licensed healthcare professionals regarding resident conditions, and ensuring 24-hour accessibility to a registered nurse. Plans of correction were in place with specified completion dates.
Severity Breakdown
Class I: 2
Class II: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure adequate housekeeping and maintenance, including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
| Failure to update resident service plans after significant changes, including elopement and fractured ribs with pain management. | Class II |
| Failure to notify an appropriately licensed health care professional of a resident's new complaint of pain following hospital evaluation after a fall. | Class I |
| Failure to ensure consistent 24-hour accessibility between residence staff and a registered nurse, including inability to contact RN on call during a resident's high blood sugar event. | Class I |
Report Facts
Census: 44
Sample Size: 3
Deficiency Completion Dates: 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII Surveyor | Surveyor conducting the inspection |
| Kathy Beauchamp | HFNSII Surveyor | Surveyor conducting the inspection |
| Customer Care Director | Named in plan of correction for holding service plan meetings and inservice trainings | |
| Director of Nursing | DON | Mentioned regarding RN on call issues and staffing |
Inspection Report
Census: 46
Deficiencies: 4
Mar 20, 2008
Visit Reason
The survey was conducted as a Change of Ownership (CHOW) environmental survey to assess compliance with health, safety, and physical facility regulations.
Findings
The facility was found deficient in multiple areas including failure to review and update disaster and emergency preparedness plans annually, inadequate disaster drill participation across all shifts, non-compliance with ADA accessibility requirements in renovations, and unsafe, unsanitary living conditions including clutter, damaged furnishings, and unsafe oxygen equipment use. Several maintenance and housekeeping issues were noted, and plans of correction with completion dates were provided.
Severity Breakdown
Class I: 3
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to review and update disaster and emergency preparedness plans annually with no signature or date verifying review since January 14, 2007. | Class III |
| Failure to rehearse disaster and emergency preparedness plan annually with all staff from each shift; disaster drill on February 11, 2008 did not include evening and midnight shifts. | Class I |
| Renovations in common use toilet and bathing area fail to comply with ADA accessibility requirements including improper mounting heights of grab bars, lack of mirror, shower chair, and lever door hardware. | Class I |
| Failure to maintain a safe, sanitary, and accident-free living environment including clutter creating tripping and fire hazards, wall damage and soiled floors in bathrooms, unsafe oxygen refill system in resident room, and standing water in common use bathroom floor. | Class I |
Report Facts
Census: 46
Completion Date: Apr 7, 2008
Completion Date: May 19, 2008
Completion Date: Apr 20, 2008
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Garry Taylor | Surveyor | Conducted the Change of Ownership (CHOW) environmental survey |
| Administrator | Named in findings related to failure to review disaster plans and conduct drills | |
| Maintenance Supervisor | Named in review of disaster and emergency preparedness plans | |
| Operations Supervisor | Involved in observations during tour of residence and rooms | |
| Treatment Coordinator | Involved in observations during tour of residence and rooms | |
| Director of Nursing | Called Home Health Care Services to remove unsafe oxygen refill system |
Inspection Report
Change Of Ownership
Census: 44
Deficiencies: 7
Feb 7, 2008
Visit Reason
The survey was conducted as a Change of Ownership (CHOW) inspection for Seasons Place.
Findings
The inspection identified multiple deficiencies including inadequate employee orientation and training, failure to update resident service plans after significant changes, failure to follow physician orders, inadequate housekeeping and maintenance, and lack of 24-hour accessibility to a registered nurse.
Severity Breakdown
Class I: 2
Class II: 4
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to provide adequate training to new employees within 15 days on abuse prevention, reporting requirements, ombudsman role, and specialty care based on individualized resident needs. | Class II |
| Failure to provide annual in-service training on resident rights, confidentiality, abuse prevention, infection control, and fire safety. | Class II |
| Failure to update resident service plans to reflect significant changes, such as elopement risk. | Class II |
| Failure to follow physician orders regarding use of gel cushion for resident with recurrent skin breakdown. | Class I |
| Failure to provide resident care in accordance with accepted standards, including inadequate assessment and documentation of injury after resident fall. | Class II |
| Failure to ensure 24-hour accessibility between residence staff and a registered nurse, including failure to contact RN on call during a diabetic emergency. | Class I |
| Failure to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and dirty sink. | — |
Report Facts
Census: 44
Number of employees reviewed: 8
Number of residents with special care needs: 4
Number of residents with updated service plans: 4
Number of deficiencies cited: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII Surveyor | Surveyor conducting the Change of Ownership survey. |
| Kathy Beauchamp | HFNSII Surveyor | Surveyor conducting the Change of Ownership survey. |
| Mike Dolin | Administrator | Named in abuse and neglect reporting procedures. |
| Customer Care Director | Responsible for monitoring service plan meetings, staff education, and in-service training. | |
| Director of Nursing | Named in relation to RN on call accessibility and nursing care deficiencies. | |
| Wellness Coordinator | Named in relation to employee training and abuse reporting. |
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