Inspection Reports for St. Barbara’s Memorial Nursing Home

The inspection was conducted as an investigation survey following a complaint, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, St. Barbara's Memorial Nursing Home, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The previously cited deficient practices were corrected as evidenced by the accepted plans of correction.

Investigation survey concluding on 05/07/2025 with plans of correction accepted in lieu of onsite revisit. Facility found in substantial compliance with previously cited deficiencies.

An unannounced annual complaint survey was conducted at St Barbara's Memorial Nursing Home on 05/07/2025. The visit was triggered by a complaint alleging physical abuse by a staff member.

The facility was found out of substantial compliance due to failure to thoroughly investigate an alleged physical abuse incident involving a Feeding Assistant hitting a resident. The investigation lacked gathering witness statements from staff and residents present during the incident.

Complaint 34318 was investigated and found unsubstantiated. The allegation involved a Feeding Assistant (#200) hitting Resident #1 on the shoulder on 10/14/2024. The staff member was suspended immediately and the incident was reported to appropriate agencies. However, the facility failed to conduct a thorough investigation by not interviewing all staff and residents present at the time.

The inspection was conducted as an investigation survey concluding on 10/11/23, related to previously cited deficient practices.

St. Barbara's Memorial Nursing Home is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia state nursing home licensure rules. The facility was accepted as compliant based on plans of correction and credible evidence without an onsite revisit.

The visit was an investigation survey related to previously cited deficient practices, with substantial compliance found and no new deficiencies cited.

The document is a Plan of Correction related to a facility inspection, addressing deficiencies identified during the survey.

The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements. One deficiency related to resident rights and notification was cited.

An unannounced annual recertification/licensure survey was conducted at St Barbara's Memorial Nursing Home from 10/10/23 to 10/11/23 to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found out of substantial compliance with deficiencies related to incomplete medical records, improper food safety practices, failure to coordinate PASARR assessments, unsafe environment hazards, inadequate hospice care collaboration, and infection control lapses including improper medication handling and incontinence care. Pain management practices were also found deficient.

The inspection was conducted to evaluate the facility's compliance with NFPA 101 life safety code requirements, including smoke barriers, sprinkler system maintenance, and corridor door protections.

The facility was found deficient in maintaining smoke barriers with appropriate fire resistance, cleaning sprinkler heads, and ensuring corridor doors resist the passage of smoke. Corrective actions were planned and initiated to address these issues.

An unannounced complaint survey was conducted at St. Barbara's on 09/04/23.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #28520 is unsubstantiated with no related or unrelated deficiencies cited.

Complaint #28520 is unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the applicable federal and state regulations, with no new deficiencies cited. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced annual recertification and annual relicensure survey was conducted at St. Barbara's Memorial Nursing Home from November 28 - December 1, 2022.

The survey identified multiple deficiencies including failure to document physician rationale for medication regimen reviews, untimely Medicare non-coverage notices, insufficient appealing meal options, inadequate weekend nursing staffing, failure to maintain grooming and hygiene for dependent residents, and food safety issues related to freezer temperature monitoring and kitchen ceiling condition.

The inspection was conducted to assess compliance with fire safety and building codes, including hazardous area enclosures, fire alarm system maintenance, sprinkler system maintenance, and smoke barrier construction.

The facility was found deficient in multiple areas including failure to ensure hazardous areas were properly enclosed with fire-rated doors, incomplete documentation and maintenance of the fire alarm system, lack of inspection and maintenance records for the sprinkler system, and unsealed penetrations compromising smoke barriers. Corrective actions and audits were planned or implemented to address these deficiencies.

The inspection was conducted as a complaint survey, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint survey concluding on 10/26/21.

St. Barbara's Memorial Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with the facility in substantial compliance with previously cited deficient practices.

The complaint survey concluded on 10/26/21, and the facility was found to be in substantial compliance with previously cited deficient practices.

An unannounced complaint survey was conducted at St. Barbara's Nursing Home from 10/25/21 to 10/26/21, simultaneously with a Federal Infection Control Survey (FICS). The complaint investigation was triggered by Complaint #25881.

The facility failed to ensure six of eleven residents had Physician Orders for Scope of Treatment (POST) forms completed per the West Virginia Center for End-of-Life Care directions, specifically lacking dated physician signatures required for validity. The complaint was unsubstantiated but unrelated deficiencies were cited.

Complaint #25881 was unsubstantiated with unrelated deficiencies cited.

The document is a Plan of Correction related to a facility inspection, addressing compliance with resident rights and notification requirements.

The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements. A deficiency related to informing residents of their rights and services was noted.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the regulatory requirements, with credible evidence accepted in lieu of an onsite revisit. Previously cited deficient practices were corrected.

The inspection was a routine regulatory survey to assess compliance with health, safety, and fire protection standards at St. Barbara's Memorial Nursing Home.

The facility was found deficient in multiple areas including delayed-egress locking systems, cooking equipment protection, smoke barrier maintenance, sprinkler system maintenance, corridor door integrity, fire drills, electrical receptacle testing, and emergency generator maintenance. Corrective actions and plans of correction were submitted for each deficiency.

An unannounced annual re-certification and annual re-licensure survey was conducted at St. Barbara's Memorial Nursing Home from August 16-18, 2021.

The survey identified deficiencies including failure to display the most recent State inspection and Ombudsman contact information in an accessible area, inaccurate completion of Minimum Data Set (MDS) assessments for active diagnoses, failure to follow physician orders for antibiotic administration and laboratory testing, and unsanitary conditions in the kitchen drip pan.

The visit was a Focused Infection Control survey to assess compliance with infection control regulations and COVID-19 related practices.

St. Barbara's Memorial Hospital was found to be in substantial compliance with infection control regulations, CMS and CDC recommended practices for COVID-19, based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

A COVID-19 Focused Infection Control Survey was conducted by the state survey agency to assess compliance with infection control regulations and CMS/CDC recommended practices related to COVID-19.

The facility was found out of compliance with infection control regulations due to a staff member failing to perform hand hygiene after doffing personal protective equipment (PPE), which violated the facility's infection prevention and control program.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.

The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency.

The facility was found in compliance with infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.

An unannounced complaint investigation was conducted at St. Barbara's Memorial Nursing Home on 09/16/19 to 09/17/19 to investigate allegations.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable federal and state regulations.

Complaint #23058 was unsubstantiated with no related or unrelated deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility was found to be in substantial compliance with the applicable federal and state regulations. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit, confirming compliance with previously cited deficient practices.

The visit was conducted as a complaint investigation survey related to complaint reference #22819, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, St. Barbara's Memorial Nursing Home, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint reference number 22819 was investigated, and the facility was found in substantial compliance with no onsite revisit required.

An unannounced annual re-certification and annual re-licensure survey was conducted at St. Barbara's Memorial Nursing Home from 07/08/19 through 07/10/19.

The facility was found deficient in developing and implementing comprehensive person-centered care plans, ensuring quality of care including oxygen administration, maintaining accurate drug records, food safety, infection control, and maintaining resident records. Specific issues included incomplete care plans for residents' end-of-life wishes and use of assistive devices, oxygen delivery inconsistencies, incomplete controlled substance documentation, undated food items, lack of separation in laundry areas, and non-compliance with advance directives requirements.

The inspection was a routine survey to assess compliance with federal and state regulations including fire safety, sprinkler system installation, electrical equipment maintenance, and resident rights notifications.

The facility was found deficient in ensuring self-closing devices on hazardous area doors, proper installation and clearance of sprinkler heads, and maintaining testing and labeling of patient-care related electrical equipment. Corrective actions and audits were planned and implemented to address these issues.

An unannounced complaint survey was conducted at St. Barbara's Memorial Nursing Home from 06/25/19 to 06/26/19 based on complaint #22819 which was substantiated with related deficiencies cited.

The facility was found to have deficiencies including failure to maintain a safe, comfortable, and homelike environment due to torn or ill-fitting window screens in 10 resident rooms, and failure to develop a person-centered, individualized care plan with measurable goals and appropriate interventions for a resident with a venous stasis ulcer.

Complaint #22819 was substantiated with related deficiencies cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, St. Barbara's Memorial Nursing Home, was found to be in substantial compliance with the applicable federal and state regulations, with previously cited deficient practices corrected as evidenced by accepted plans of correction and credible evidence.

The document is a statement of deficiencies and plan of correction for St. Barbara's Memorial Nursing Home, related to regulatory compliance and emergency preparedness requirements.

The facility was found in compliance with all applicable Federal, State and local Emergency Preparedness requirements. One deficiency related to notice of rights was cited.

The inspection was a routine survey to assess compliance with fire safety, electrical systems, and other regulatory requirements at the nursing home facility.

The facility was found deficient in maintaining hazardous areas with automatic-closing doors, sprinkler system maintenance and testing, portable fire extinguisher installation height, smoke barrier door latching, electrical breaker box security, emergency generator maintenance, and annual fire door assembly testing. Corrective actions and plans of correction were submitted for each deficiency.

An unannounced annual re-certification and annual re-licensure survey was conducted at St. Barbara's Memorial Nursing Home from September 24, 2018 through September 27, 2018.

The survey identified multiple deficiencies including failure to maintain resident dignity and privacy, improper medication labeling and administration, inaccurate medical transcription, inadequate infection control practices, and failure to ensure pneumococcal immunization compliance. Corrective actions and staff re-education plans were implemented for each deficiency.

The document is a plan of correction submitted by St. Barbara's Memorial Nursing Home following a Quality Indicator and Licensure Survey concluding on 10/18/17, accepted in lieu of an onsite revisit.

The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

The inspection was conducted to evaluate compliance with NFPA 101 fire drill requirements, specifically to assess whether fire drills were held at unexpected times and under varying conditions as required.

The facility failed to hold fire drills at unexpected times and under varying conditions as required by NFPA 101. Fire drills were conducted at the same times on second and third shifts, and silent drills were performed without involving the fire alarm panel.

An unannounced Annual Quality Indicator Survey was conducted at Saint Barbara's Memorial Nursing Home from October 16, 2017 through October 18, 2017 to assess compliance with federal regulations.

The survey identified multiple deficiencies including unsecured hazardous chemicals and clean supplies accessible to residents, undated opened food items, unsecured controlled substance storage, breaches in infection control practices during medication administration, and an unlatched soiled laundry chute posing infection control risks.

The inspection was conducted as a complaint investigation, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit for complaint investigation(s) concluding on 06/20/17.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint References: #18036. The facility is in substantial compliance with the previously cited deficient practices based on review of plans of correction and credible evidence.

An unannounced complaint survey was conducted at Saint Barbara's Memorial Nursing Home on June 19-20, 2017, triggered by complaint #18036 which was substantiated with related deficiencies.

The facility failed to protect residents after an allegation of verbal abuse by a nurse aide towards Resident #1. The facility also failed to timely report and investigate the allegation of abuse. Corrective actions included termination of the involved nurse aide, staff in-service training, and ongoing monitoring.

Complaint #18036 was substantiated. The allegation involved Nurse Aide #22 verbally abusing Resident #1 by using foul language when the resident requested to be put back to bed. The facility failed to protect the resident, failed to timely report the abuse, and failed to properly investigate the allegation. The nurse aide was terminated and notifications were sent to the Nurse Aide Abuse Registry and Adult Protective Services.

The document is a plan of correction related to a prior Quality Indicator and Licensure Survey for St. Barbara's Memorial Nursing Home, addressing previously cited deficient practices.

The facility was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at St. Barbara's Memorial Nursing Home from November 14, 2016 through November 22, 2016.

The survey identified multiple deficiencies including failure to ensure legal surrogate rights were updated, failure to notify physician and family timely of changes in resident condition, failure to provide resident privacy during wound care, failure to ensure call bells were within reach, failure to notify residents of roommate changes, failure to conduct comprehensive assessments and care plans, failure to maintain infection control practices, failure to maintain safe medication storage, and failure to maintain safe environment with secure bed rails and grab bars.

The inspection was conducted as an annual survey to assess compliance with building construction and fire safety regulations, including sprinkler coverage and fire drill procedures.

The facility failed to provide complete sprinkler coverage for certain exterior areas and did not conduct fire drills at varied times as required by NFPA 101. Corrective actions were planned and completed to address these deficiencies.

The visit was a Quality Indicator Survey conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

St. Barbara's Memorial Nursing Home was found to be in substantial compliance with the previously cited deficient practices and 42 CFR Part 483 requirements.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, including fire drills, sprinkler system maintenance, and emergency generator testing.

The facility failed to conduct quarterly fire drills on each shift at unexpected times, maintain sprinkler pipes free from external loads, and properly maintain and document weekly testing of the emergency generator battery.

An unannounced annual Quality Indicator Survey was conducted at St. Barbara's Memorial Nursing Home from October 5, 2015 through October 8, 2015, including an extended survey from October 7 to 8, 2015.

The survey identified multiple deficiencies including failure to notify physicians of significant changes in residents' conditions, inaccurate comprehensive assessments, failure to follow medication orders especially related to hypoglycemia and antihypertensive medications, failure to maintain sanitary food storage, incomplete clinical records regarding dental status, and failure of the Quality Assurance and Assessment Committee to identify and address these quality deficiencies.

The document is a plan of correction related to a prior Quality Indicator and Licensure Survey concluding on 07/31/14, accepted in lieu of an onsite revisit.

The facility, St. Barbara's Memorial Nursing Home, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed through plans of correction and credible evidence.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at St. Barbara's Memorial Nursing Home from July 28, 2014 through July 31, 2014.

The facility was found deficient in pharmaceutical services, drug labeling and storage, and infection control. Issues included unlabeled and expired medications, failure of the pharmacist to identify medication problems, and an unsanitary ice machine used for resident care.

The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2000, based on review of documentation, staff interview, observations, and performance testing.

The facility was found to be without waivers and in compliance with the provisions of the NFPA 101, Life Safety Code, 2000.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for St. Barbara's Memorial Nursing Home.

The document includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by federal regulations.

The inspection was a routine Quality Indicator Survey conducted to assess compliance with federal regulations regarding resident rights, privacy, care planning, accident prevention, medication administration, and call system functionality.

The facility was found deficient in multiple areas including failure to provide full visual privacy with curtains in semi-private rooms, failure to deliver mail on Saturdays, failure to revise care plans after resident falls, failure to protect a resident from additional falls, a significant medication error attempt involving insulin administration to the wrong resident, and a non-functional call bell system in room #6.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically regarding the maintenance and testing of the facility's medical gas system.

The facility did not ensure that the oxygen system, a medical gas system, had a periodic testing procedure implemented as required by NFPA 99 - Chapter 5 Gas and Vacuum Systems. Documentation of the latest oxygen system check was outdated (dated 11/15/04) and lacked details on the number and locations of oxygen outlets tested.

The inspection was conducted to assess compliance with professional standards of care, medication management, food safety, and regulatory requirements in the nursing facility.

The facility was found deficient in several areas including failure to obtain clarification orders for narcotic administration, failure to assess and monitor pain medication effectiveness, improper holding temperatures of cold food items, and failure of the pharmacist to identify and report irregularities in residents' medication regimens. These deficiencies had the potential to affect resident safety and care quality.

The inspection was conducted to assess compliance with NFPA 99 and NFPA 110 life safety code standards related to medical gas storage and emergency power systems.

The facility failed to store oxygen cylinders in accordance with NFPA 99, including unsecured storage of cylinders and lack of required signage. Additionally, the facility failed to maintain emergency battery-powered lighting at the generator site and switch room as required by NFPA 110.

The inspection was conducted to determine the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was found to be in compliance with the Life Safety Code provisions.

The inspection was conducted as a comprehensive annual survey of St. Barbara's Memorial Nursing Home to assess compliance with federal regulations and standards for nursing facilities.

The facility was found deficient in multiple areas including failure to conduct thorough criminal background checks for out-of-state employees, failure to develop comprehensive and interdisciplinary care plans for residents, failure to provide care ensuring highest practicable well-being, failure to serve food under sanitary conditions, failure to maintain an effective infection control program, and failure to appoint an acting administrator during the licensed administrator's absence.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of St. Barbara's Memorial Nursing Home.

Based on medical record review, facility policies, observations, and interviews, the facility was found to be in compliance with State licensure and Federal Medicare/Medicaid certification requirements.

The inspection was conducted in response to a complaint referenced as #2-7195.

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

Complaint reference #2-7195 was investigated and found to be unsubstantiated with no deficiencies cited.

Paper revisit to review previously identified deficiencies and the facility's plan of correction.

The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on informing residents of their rights and services. No new deficiencies or severity levels are explicitly stated.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident rights, care planning, medication use, infection control, and quality assurance.

The facility was found deficient in multiple areas including failure to update care plans based on assessments, lack of gradual dose reduction for psychoactive medications, inadequate infection control policies and practices, and insufficient follow-up and documentation of resident falls and quality assurance activities.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of St. Barbara's Memorial Nursing Home.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

Paper revisit to review previously identified deficiencies and the facility's plan of correction.

The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. No new inspection findings or severity levels are detailed.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the Life Safety Code requirements.

The inspection was conducted as an annual survey to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including resident assessments, care planning, medication administration, clinical record accuracy, accident hazards, and pharmacy services. Specific issues included inaccurate resident assessments, failure to address medication monitoring in care plans, improper labeling of enteral feedings, unsafe storage of cleaning supplies, and administration of incorrect medication.

Paper revisit to review previously identified deficiencies and the facility's plan of correction.

The document contains a statement of deficiencies and a plan of correction related to resident rights and notification requirements. No new deficiencies or severity levels are explicitly stated.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, and observations, the facility was determined to be in compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

Annual inspection of St. Barbara's Memorial Nursing Home to assess compliance with federal regulations including resident rights, privacy, staff screening, resident assessments, medication storage, infection control, and administrative requirements.

The facility was found deficient in multiple areas including failure to ensure visual privacy of clinical records, inadequate staff background checks, lack of dignity in feeding practices, incomplete resident assessments, failure to timely and accurately submit MDS data, improper medication security, inadequate TB screening for staff, and failure to provide required abuse registry notices to employees.

The inspection was conducted as a complaint investigation referenced as #2-4236, substantiated with deficiencies cited related to resident rights and communication.

The facility failed to fully inform the legal representative (medical power of attorney) of one resident (Resident #58) about the outcome of an investigation into bruising injuries. The investigation was completed, but no evidence showed that the outcome was communicated to the resident's representative.

Complaint reference #2-4236 was substantiated with deficiencies cited regarding failure to inform the legal representative of Resident #58 about the outcome of an injury investigation.

The inspection was conducted to determine the facility's compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be in compliance with the Life Safety Code.

The inspection was conducted based on a review of facility documentation, staff interview, and observations to determine compliance with regulatory requirements.

The facility was found to be in compliance with no deficiencies cited during the inspection.

The inspection was conducted in response to complaint reference #2-4008 to investigate allegations related to nursing staff coverage and other concerns.

The complaint was found unsubstantiated, but unrelated deficiencies were cited, including failure to ensure a registered nurse was on duty for eight consecutive hours seven days a week as required.

Complaint reference #2-4008 was unsubstantiated with unrelated deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-3189, substantiated with deficiencies found related to nursing services.

The facility failed to provide sufficient nursing staff to meet the care needs of 57 residents, particularly on the night shift of 09/15/03 when only one CNA and one licensed nurse were on duty. This staffing shortage affected timely assistance for residents requiring turning, repositioning, mouth care, and incontinence care.

Complaint reference #2-3189 was substantiated with deficiencies related to nursing staffing shortages impacting resident care.

The inspection was conducted to review facility documentation, staff interviews, observations, and performance testing to determine compliance with NFPA 101, Life Safety Code, 1967.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 1967.

The inspection was conducted as an annual survey to assess compliance with federal regulations regarding resident rights, staff treatment of residents, quality of care, dietary services, pharmacy services, and clinical record maintenance.

The facility was found deficient in multiple areas including inadequate monitoring and intervention to prevent psychological abuse by a resident, improper use and documentation of antipsychotic medications, failure to maintain sanitary dietary conditions, incomplete pharmacist drug regimen reviews, failure to report drug irregularities, and incomplete clinical records with missing signatures and documentation.

The inspection was conducted to assess the facility's compliance with the provisions of NFPA 101, Life Safety Code; 1967 Existing Edition.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was determined to be in compliance with the Life Safety Code.

The inspection was conducted to investigate complaints regarding the facility's failure to immediately report injuries of unknown origin for two residents (#31 and #55).

The facility failed to report injuries of unknown origin for two residents as required. Incident reports showed bruises with unknown causes, and staff did not proceed with further investigations or identify probable causes. The director of nursing and social worker confirmed that no evidence of probable causes was found and that the facility was instructed not to report incidents if a probable cause was identified, which was not the case here.

The complaint investigation found that the facility did not report injuries of unknown origin for residents #31 and #55. The facility staff failed to identify probable causes and did not proceed with further investigations as required. The social worker confirmed no probable cause was identified for these injuries.

The inspection was conducted to determine the facility's compliance with NFPA 101:10; Life Safety Code, 1967 Existing Edition.

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be in compliance with the Life Safety Code.

The inspection was conducted to assess compliance with federal regulations regarding resident rights, comprehensive care planning, and pharmacy services in the nursing home.

The facility failed to develop a comprehensive care plan for one resident's stage II pressure ulcer and the pharmacist failed to report drug irregularities for four residents using psychoactive medications. No dosage reductions or monitoring recommendations were made for these medications.

The inspection was conducted as a survey of St. Barbara's Memorial Nursing Home to assess compliance with federal long term care regulations.

Based on the survey conducted from August 14-16, 2000, St. Barbara's Memorial Nursing Home was found to be in compliance with federal long term care regulations.

The inspection was conducted based on a review of facility documentation, staff interviews, and observations to determine compliance with the provisions of 483.70 Physical Environment.

The facility was found to be in compliance with the provisions of 483.70 Physical Environment.

The inspection was conducted to review compliance with NFPA 101 Life Safety Code standards, specifically focusing on the maintenance, inspection, and testing of the facility's sprinkler system.

The facility's sprinkler system was found not to be completely tested as required. The weekly test procedure did not meet NFPA 25:5 standards, and documentation supporting the annual flow test of the fire pump was not available.