Deficiencies per Year
20
15
10
5
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Follow-Up
Census: 63
Deficiencies: 0
Aug 19, 2025
Visit Reason
Follow-up to 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 visit.
Report Facts
Census: 63
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 0
Jun 2, 2025
Visit Reason
Investigation of Complaint #39140 at Woodlands Retirement Community.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #39140 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Complaint Number: 39140
Census: 60
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 4
May 1, 2025
Visit Reason
Annual survey conducted from 2025-04-28 to 2025-05-01 to assess compliance with health and safety regulations and employee training requirements.
Findings
Deficiencies were cited related to incomplete tuberculosis screening for employees, inadequate employee training within required timeframes, and housekeeping and maintenance issues including damaged carpets, missing bathroom fixtures, and cleanliness concerns.
Severity Breakdown
Class II: 2
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure each employee's personnel record contained a health record with results of pre-employment tuberculosis screening. | Class III |
| Failed to provide and maintain a record of training to new employees on all required topics within the first 15 days of employment, including specialty care and infection control. | Class II |
| Failed to provide and maintain a record of training to new employees on Alzheimer's disease and related dementias within the first 15 days of employment. | Class II |
| Failed to ensure adequate housekeeping and maintenance required to carry out services, including damaged carpet, missing towel bars and toilet paper holders, and unclean sink. | — |
Report Facts
Census: 65
Employees with deficient TB screening: 5
Employees reviewed for training: 5
Employees with deficient training: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #17 | Identified for failure to complete required training on specialty care, infection control, and Alzheimer's disease within 15 days of employment | |
| Employee #28 | Personnel file lacked evidence of second step of TB test | |
| Employee #33 | Personnel file showed first step of TB test read after hire date | |
| Employee #50 | Personnel file showed first step of TB test read after hire date | |
| Employee #56 | Personnel file lacked documented results of TB test | |
| Employee #83 | Interviewed regarding issues with TB screening and employee training delays |
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 0
Apr 29, 2025
Visit Reason
Annual environmental inspection of the Woodlands Retirement Community to assess compliance with health and safety regulations.
Findings
No deficiencies were cited during this annual environmental inspection. The facility was found to have no critical or noncritical deficiencies.
Report Facts
Sprinkler Type: 13
Census: 77
Deficiencies cited: 0
Health Department Noncritical Deficiencies: 0
Health Department Critical Deficiencies: 0
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Sep 18, 2024
Visit Reason
Investigation of Complaint #34087 conducted from 09/17/24 to 09/18/24.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation.
Complaint Details
Complaint #34087 was investigated and substantiated; however, no deficiencies were cited.
Report Facts
Complaint Number: 34087
Census: 74
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 0
May 1, 2024
Visit Reason
Annual survey conducted from 04/29/24 to 05/01/24 to assess compliance with regulatory standards at Woodlands Retirement Community.
Findings
No deficiencies were cited during the annual survey, indicating compliance with applicable regulations.
Report Facts
Census: 73
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 0
May 1, 2024
Visit Reason
Annual environmental inspection conducted to assess compliance with health and safety regulations.
Findings
No deficiencies were cited during the inspection, indicating compliance with applicable standards.
Report Facts
Census: 73
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Oct 26, 2023
Visit Reason
Investigation of Complaint #29613 conducted on 10/26/23 from 9:15 AM to 11:30 AM.
Findings
The complaint was substantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #29613 was substantiated with no deficiencies cited.
Report Facts
Census: 62
Inspection Report
Follow-Up
Census: 72
Deficiencies: 0
Aug 2, 2023
Visit Reason
This was a first follow-up visit to the annual survey to verify correction of previously cited deficiencies.
Findings
The deficiencies identified in the prior annual survey were corrected as of this follow-up visit.
Report Facts
Census: 72
Inspection Report
Environmental
Census: 68
Deficiencies: 1
May 31, 2023
Visit Reason
The inspection was conducted as an environmental survey of the Woodlands Retirement Community to assess compliance with health and safety regulations.
Findings
The facility had deficiencies identified during the May 1, 2023 survey, specifically deficiencies numbered 0446 and 0450. By the May 31, 2023 follow-up survey, all deficiencies were corrected.
Deficiencies (1)
| Description |
|---|
| Deficiencies numbered 0446 and 0450 were cited during the initial May 1, 2023 survey. |
Report Facts
Facility census: 65
Facility census: 68
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 5
May 18, 2023
Visit Reason
The inspection was an annual survey conducted from 05/09/23 to 05/18/23 to assess compliance with regulatory requirements for Woodlands Retirement Community.
Findings
The facility was found deficient in multiple areas including incomplete tuberculosis screening records for employees, failure to submit surety bond for resident funds approval, missing assurance statements in admission agreements, inadequate housekeeping and maintenance, and failure to document and report unplanned resident weight changes to physicians.
Severity Breakdown
Class III: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure all employees have health records containing results of pre-employment tuberculosis screening, including missing or invalid second step PPD tests. | Class III |
| Failure to submit surety bond for resident funds to OHFLAC for approval. | Class III |
| Admission agreements lacked assurance statement that residents shall not be liable for undisclosed costs. | — |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
| Failure to document resident weights and notify physicians of unplanned weight loss or gain of five pounds or more for multiple residents. | Class III |
Report Facts
Census: 66
Employees missing second step PPD: 4
Residents affected by surety bond issue: 12
Residents affected by missing assurance statement: 66
Residents with unreported weight changes: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #56 | Missing documentation of second step PPD screening | |
| Employee #59 | Missing documentation of second step PPD screening | |
| Employee #65 | Invalid second step PPD screening timing | |
| Employee #98 | Missing required documentation on PPD screening | |
| Employee #86 | Medical Records Specialist | Interviewed regarding PPD screening vendor issues and surety bond submission |
Inspection Report
Routine
Census: 65
Deficiencies: 2
May 1, 2023
Visit Reason
The inspection was conducted to assess compliance with fire safety, disaster preparedness, and physical facility maintenance standards at the Woodlands Retirement Community.
Findings
The facility failed to document that all new residents were shown how to evacuate in an emergency within 24 hours of admission, and multiple ceiling heating/cooling registers were found loaded with dust and debris. Additionally, missing base trim was observed in a resident bathroom. These deficiencies were acknowledged by the Director of Health Services.
Severity Breakdown
Class I: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure and document that all new residents were shown how to evacuate the residence in an emergency within 24 hours of admission. | Class I |
| Failure to maintain a safe, sanitary, and accident-free living environment due to dust/debris accumulation on ceiling heating/cooling registers and missing base trim in a resident bathroom. | Class I |
Report Facts
Facility census: 65
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health Services | Verified findings related to emergency evacuation documentation and acknowledged deficiencies at exit interview | |
| Director of Maintenance | Verified findings related to physical facility maintenance issues |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 0
Oct 5, 2022
Visit Reason
The visit was a revisit to the annual inspection of the Woodlands Retirement Community to assess compliance and verify correction of previous deficiencies.
Findings
The inspection found that deficiencies previously cited were cleared. The report notes no current deficiencies at the time of the revisit.
Report Facts
Census: 62
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 12
Apr 28, 2022
Visit Reason
Annual survey conducted to assess compliance with regulatory requirements for Woodlands Retirement Community.
Findings
The facility was found deficient in multiple areas including failure to provide an activity calendar, incomplete functional needs assessments, medication administration documentation issues, inadequate housekeeping and maintenance, lack of required employee training, incomplete policies and procedures availability, failure to maintain resident privacy, incomplete nursing documentation, and incomplete disclosure of costs in admission agreements.
Severity Breakdown
Class I: 1
Class II: 4
Class III: 3
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to provide a monthly activity calendar listing social and recreational activities for residents on 1 East Wing. | Class III |
| Failed to ensure functional needs assessments and service plans were updated to reflect residents' current needs, specifically Resident #45. | Class II |
| Medications were not administered on multiple days without documented reasons for residents #16, #36, #45, #2, and #44. | Class I |
| Failed to provide required training to new employees and agency nurses within 15 days of employment, including emergency procedures and dementia training. | Class II |
| Failed to have paper copies of policies and procedures available for review by residents and the public; policies only available online and not easily accessible. | Class III |
| Failed to develop and adopt written policies and procedures consistent with assisted living requirements, including signing and dating policies at adoption and changes. | Class III |
| Failed to maintain an activity program meeting residents' interests and promoting well-being; activity room locked and no group activities due to COVID restrictions. | — |
| Failed to ensure full disclosure of all costs and changes in care needs resulting in cost modifications in admission agreements. | — |
| Failed to provide two-hour Alzheimer's and dementia training to agency staff within 15 days of hire. | Class II |
| Failed to maintain resident privacy and confidentiality; clipboard with residents' ADL and vital signs was left uncovered in public view. | Class II |
| Failed to ensure weekly registered nurse visits and documentation for residents with nursing care needs, specifically Resident #41 with diabetes and insulin order. | Class II |
| Inadequate housekeeping and maintenance observed including personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Census: 61
Deficiencies cited: 12
Residents with medication issues: 5
Agency nurses reviewed: 18
Agency nurses without dementia training: 3
Completion dates: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #139 | Interviewed about activity calendar absence | |
| Employee #150 | Interviewed about activity calendar absence | |
| Director of Nursing | Director of Nursing | Interviewed about service plan updates and medication documentation |
| Employee #185 | Agency nurse lacking dementia training | |
| Employee #198 | Agency nurse lacking dementia training | |
| Employee #201 | Agency nurse lacking dementia training | |
| Administrative Assistant #149 | Discussed policy availability and training for agency nurses | |
| Licensed Practical Nurse #138 | LPN | Interviewed about clipboard privacy issue |
| HR #97 | Interviewed about agency nurse personnel files and training | |
| Chief Financial Officer | CFO | Interviewed about disclosure of costs in contracts |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 0
Apr 5, 2022
Visit Reason
Annual environmental inspection of the Woodlands Retirement Community conducted on April 5, 2022.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 60
Inspection Report
Follow-Up
Census: 70
Deficiencies: 0
Aug 30, 2021
Visit Reason
Follow-up to annual survey to verify correction of previously cited deficiencies.
Findings
All three deficiencies identified in the prior annual survey have been corrected as of the follow-up visit.
Report Facts
Census: 70
Deficiencies corrected: 3
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 4
May 25, 2021
Visit Reason
Annual survey conducted from 05/17/21 to 05/25/21 to assess compliance with health and safety regulations, employee health screenings, training, and certification requirements.
Findings
The facility failed to ensure five employees had pre-employment tuberculosis screenings, four employees received timely training on service plans and specialty care, one licensed practical nurse maintained expired CPR certification, and housekeeping and maintenance deficiencies were observed in the adolescent consumers' residence.
Severity Breakdown
Class III: 2
Class II: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure five employees had pre-employment tuberculosis screening documentation. | Class III |
| Failed to ensure four employees received training within 15 days of employment on service plans and specialty care. | Class II |
| Failed to ensure one licensed practical nurse maintained current CPR certification as required by facility policy. | Class III |
| Failed to ensure adequate housekeeping and maintenance in the adolescent consumers' residence, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Facility census: 73
Employees without TB screening: 5
Employees without timely service plan training: 4
Employees with expired CPR certification: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #35 | Lacked documentation of pre-employment tuberculosis screening | |
| Employee #55 | Lacked documentation of pre-employment tuberculosis screening and service plan training | |
| Employee #59 | Lacked documentation of pre-employment tuberculosis screening and service plan training | |
| Employee #74 | Lacked documentation of pre-employment tuberculosis screening and service plan training | |
| Employee #87 | Lacked documentation of pre-employment tuberculosis screening and service plan or specialty care training | |
| Employee #89 | Licensed Practical Nurse (LPN) | Had expired CPR certification as of 12/2020 |
| Employee #76 | Medical Staff | Interviewed regarding CPR and training deficiencies |
| Employee #27 | Human Resources Director | Provided information on new hire training processes |
| Employee #19 | Laundry Manager | Provided information on specialty care training documentation |
| Employee #90 | Food Service Director | Provided information on dietary specialty training |
| Employee #47 | Temporary Housekeeping Lead | Provided information on housekeeping training |
| Employee #66 | Temporary Maintenance Lead | Provided information on maintenance training |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Feb 22, 2021
Visit Reason
The inspection was conducted as a substantiated complaint investigation related to Complaint #25097 at Woodlands Retirement Community.
Findings
The complaint investigation found no deficiencies at the facility during the inspection conducted on February 18 and February 22, 2021.
Complaint Details
Complaint #25097 was substantiated but no deficiencies were found during the investigation.
Report Facts
Census: 72
Inspection Report
Follow-Up
Census: 71
Deficiencies: 0
Feb 4, 2021
Visit Reason
Follow-up to complaint #WV00023408 to verify correction of previously identified deficiency.
Findings
Only one deficiency was identified during the complaint investigation and it was corrected at the time of this follow-up visit.
Complaint Details
Follow-up to complaint #WV00023408; only deficiency was corrected.
Report Facts
Census: 71
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 2, 2021
Visit Reason
The inspection was conducted as a complaint survey (#WV00025017) to investigate 15 allegations made against the facility.
Findings
All 15 allegations investigated during the complaint survey were found to be unsubstantiated.
Complaint Details
Complaint survey #WV00025017 with 15 allegations, all unsubstantiated.
Report Facts
Allegations investigated: 15
Inspection Report
Routine
Deficiencies: 0
Jan 20, 2021
Visit Reason
Infection Control survey conducted at Woodlands Retirement Community on January 20, 2021.
Findings
No deficiencies were identified during the infection control survey.
Inspection Report
Follow-Up
Census: 71
Deficiencies: 0
Dec 2, 2020
Visit Reason
Follow-up survey conducted to verify correction of previously cited deficiencies from the September 30, 2020 inspection.
Findings
All deficiencies cited in the prior survey (0441, 0445, 0450, and 0452) were corrected by the December 2, 2020 follow-up inspection.
Report Facts
Deficiencies cited: 4
Facility census: 72
Facility census: 71
Inspection Report
Routine
Census: 72
Deficiencies: 4
Sep 30, 2020
Visit Reason
The inspection was conducted to assess the facility's compliance with physical facilities maintenance, housekeeping, fire safety, disaster and emergency preparedness, and overall environmental safety standards.
Findings
The facility failed to maintain a safe, sanitary, and accident-free living environment, with issues including dust and debris in kitchen areas, broken and missing floor tiles, missing light fixture covers, rusty air registers, and inadequate documentation and rehearsal of disaster preparedness plans. Multiple deficiencies were cited related to physical facilities and fire safety.
Deficiencies (4)
| Description |
|---|
| Failed to maintain a safe, sanitary, and accident-free living environment; dust and debris observed in kitchen areas. |
| Failed to keep the interior and exterior of the residence clean and in good repair; broken and missing floor tiles, missing light fixture cover, rusty air conditioning/heating register. |
| Failed to document and rehearse the disaster and emergency preparedness plan annually, including verification of staff participation and critique of rehearsal. |
| Disaster and emergency preparedness plan lacked an emergency transportation policy. |
Report Facts
Facility census: 72
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kitchen Manager | Verified findings related to kitchen cleanliness and disaster preparedness documentation | |
| Food Services Director | Acknowledged findings at exit interview | |
| CEO | Responsible for review of Evacuation and Disaster Procedures Manual | |
| Director of Health Services | Responsible for review of Evacuation and Disaster Procedures Manual |
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 1
May 21, 2020
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration errors and resident care concerns at Woodlands Retirement Community.
Findings
The licensee failed to ensure medications were administered according to physician orders, specifically one resident (#59) received blood pressure medication outside prescribed parameters. The investigation found issues with agency nurses not following medication administration protocols and inadequate alert settings in the electronic medication record system.
Complaint Details
Complaint #23408 was substantiated. The complaint involved medication administration errors and concerns about staff knowledge and staffing levels. The complaint was entered on 2020-05-18 and exited on 2020-05-21.
Severity Breakdown
Class I: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident #59 was given blood pressure medication outside of physician-designated parameters. | Class I |
Report Facts
Resident count: 75
Medication errors: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #55 | Registered Nurse | Reviewed medication administration records and acknowledged lack of alert settings in electronic MAR |
Inspection Report
Routine
Census: 75
Deficiencies: 3
Oct 31, 2019
Visit Reason
The inspection was conducted to assess compliance with health and safety standards, personnel records, and health care standards at Woodlands Retirement Community.
Findings
The facility failed to ensure timely tuberculosis screenings for employees, adequate housekeeping and maintenance, and proper documentation accompanying residents transferred to hospitals.
Severity Breakdown
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a health record containing the results of a pre-employment and annual tuberculosis screening were available for two of nine residents. | Class III |
| Failed to ensure adequate housekeeping and maintenance required to carry out its services, including issues such as carpet damage, missing bathroom fixtures, and unclean sinks. | — |
| Failed to ensure a summary was prepared to accompany residents transferred to the hospital including medical history, functional needs assessment, service plan, physician's orders, advance directives, and allergies for two of three applicable residents. | — |
Report Facts
Facility census: 75
Late TB screening days: 47
Number of residents lacking TB screening records: 2
Number of residents lacking hospital transfer documentation: 2
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 0
Oct 28, 2019
Visit Reason
The inspection was conducted as an annual survey of the Woodlands Retirement Community to assess compliance with health and safety regulations.
Findings
The report includes initial comments from the inspection conducted from October 28-31, 2019, noting a census of 75 residents. Specific deficiencies or findings are not detailed in the provided page.
Report Facts
Census: 75
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 0
Sep 25, 2019
Visit Reason
Annual environmental inspection of Woodlands Retirement Community conducted on September 25, 2019.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 71
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Jun 3, 2019
Visit Reason
The inspection was conducted as a complaint investigation from May 29, 2019 to June 3, 2019.
Findings
The report documents a complaint investigation at Woodlands Retirement Community with a census of 70 residents. Specific findings or deficiencies are not detailed in the provided text.
Complaint Details
Complaint ID: WV00022602
Report Facts
Census: 70
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 0
May 15, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID# WV00022456.
Findings
No deficiencies were cited during the complaint investigation conducted on May 15-16, 2019.
Complaint Details
Complaint ID# WV00022456 was investigated and found to have no deficiencies cited.
Report Facts
Census: 71
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Mar 18, 2019
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID WV00022128.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint ID WV00022128 was investigated and found to have no deficiencies cited.
Report Facts
Census: 74
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Jan 24, 2019
Visit Reason
The inspection was conducted as a complaint investigation related to the Woodlands Retirement Community.
Findings
No deficiencies were cited during the complaint investigation conducted from January 21-24, 2019.
Complaint Details
Complaint ID WV00021806 was investigated and found to have no deficiencies cited.
Report Facts
Census: 77
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Jan 21, 2019
Visit Reason
The inspection was conducted as a complaint investigation from January 21-24, 2019, related to the Woodlands Retirement Community.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint ID: WV00021733. No deficiencies cited.
Report Facts
Census: 77
Inspection Report
Follow-Up
Census: 75
Deficiencies: 0
Dec 6, 2018
Visit Reason
The visit was a follow-up survey conducted to verify correction of previously cited deficiencies from the annual licensure survey conducted in September 2018.
Findings
The follow-up survey found that all previously cited deficiencies were corrected.
Report Facts
Census: 70
Census: 75
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 0
Sep 26, 2018
Visit Reason
The visit was conducted as an annual licensure survey and environmental inspection of the facility.
Findings
No deficiencies were cited during the inspection. The Fire Marshal report dated 2018-09-10 included recommendations, but no critical or noncritical deficiencies were noted by the Health Department.
Report Facts
Sprinkler Type: 13
Deficiencies cited: 0
Health Department Noncritical Deficiencies: 0
Health Department Critical Deficiencies: 0
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 4
Sep 19, 2018
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with employee orientation and training requirements, housekeeping and maintenance standards, and resident assessment and service plan updates.
Findings
The facility failed to maintain proper records of new employee training and annual in-service training for multiple employees. Housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean areas. Additionally, resident service plans were not updated to reflect current needs or significant changes for six of twelve residents reviewed.
Severity Breakdown
Class II: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide and maintain a record of training to new employees prior to scheduling them to work unsupervised and within the first fifteen days of employment. | Class II |
| Failed to provide and maintain a record of annual in-service training on resident rights, confidentiality, abuse prevention, resident activities, infection control, and fire safety for seven employees. | Class II |
| Failed to ensure assessment and service plans reflect residents' current needs and are updated annually or as indicated by significant changes for six residents. | Class II |
| Failed to ensure adequate housekeeping and maintenance; observed personal belongings behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bars and toilet paper holders, and dirty sink. | — |
Report Facts
Census: 70
Days late for annual training: 128
Days late for annual training: 495
Days late for annual training: 493
Days late for annual training: 138
Days late for annual training: 484
Days late for annual training: 89
Days late for annual training: 493
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Mentioned in relation to deficient employee training and late annual activity training | |
| Employee #6 | Mentioned in relation to deficient employee training and late annual activity training | |
| Employee #12 | Mentioned in relation to missing new employee training documentation | |
| Employee #18 | Mentioned in relation to deficient employee training and late annual activity training | |
| Employee #32 | Mentioned in relation to incomplete new employee training documentation | |
| Employee #39 | Mentioned in relation to deficient employee training and late annual activity training | |
| Employee #44 | Mentioned in relation to deficient employee training and late annual activity training | |
| Employee #70 | Mentioned in relation to incomplete new employee training documentation | |
| Employee #88 | Mentioned in relation to deficient employee training and late annual activity training | |
| Employee #109 | Mentioned as responsible for scheduling annual training in Relias system |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 0
Sep 13, 2018
Visit Reason
The inspection was conducted as a complaint investigation for Complaint ID WV00021105 from September 11-13, 2018.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint ID WV00021105 was investigated with no deficiencies cited.
Report Facts
Census: 68
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Dec 4, 2017
Visit Reason
The inspection was conducted in response to a complaint identified by Complaint ID WV00019284.
Findings
No deficiencies were cited during this complaint investigation inspection.
Complaint Details
Complaint ID WV00019284 was investigated and found to have no deficiencies.
Report Facts
Census: 65
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 0
Oct 13, 2017
Visit Reason
The inspection was conducted as an annual licensure survey of the Woodlands Retirement Community.
Findings
No deficiencies were cited during the annual licensure survey conducted from October 10-13, 2017.
Report Facts
Census: 67
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 0
Sep 12, 2017
Visit Reason
The visit was conducted as an annual licensure survey to assess environmental conditions and compliance at Woodlands Retirement Community.
Findings
The inspection found no deficiencies cited during the annual licensure survey conducted on 09/12/2017.
Report Facts
Census: 65
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
May 4, 2017
Visit Reason
The inspection was conducted as a complaint investigation from May 1-4, 2017, related to the Woodlands Retirement Community.
Findings
No deficiencies were found during the complaint investigation conducted at the facility.
Complaint Details
Complaint ID WV00017743 was investigated with no deficiencies found.
Report Facts
Census: 62
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Jan 12, 2017
Visit Reason
The inspection was conducted as a complaint investigation from January 10-12, 2017, related to Complaint ID WV00017096.
Findings
No deficiencies were found during the complaint investigation.
Complaint Details
Complaint ID WV00017096 was investigated and found to have no deficiencies.
Report Facts
Census: 67
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Oct 26, 2016
Visit Reason
The inspection was conducted as a complaint investigation at Woodlands Retirement Community from October 24-26, 2016.
Findings
No deficiencies were found during the complaint investigation.
Complaint Details
Complaint investigation conducted with no deficiencies found; substantiation status not explicitly stated.
Report Facts
Deficiencies cited: 0
Census: 74
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 0
Sep 29, 2016
Visit Reason
The visit was conducted as an annual licensure survey including an annual environmental inspection.
Findings
No deficiencies were cited during the annual licensure and environmental survey conducted on September 29, 2016.
Report Facts
Census: 63
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 0
Sep 22, 2016
Visit Reason
The document is an annual licensure survey conducted from September 19-22, 2016, to assess compliance with regulatory requirements for the Woodlands Retirement Community.
Findings
The survey found no deficiencies during the inspection period, indicating compliance with applicable standards.
Report Facts
Deficiencies cited: 0
Census: 69
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Feb 23, 2016
Visit Reason
The inspection was conducted as a complaint investigation for complaint number WV00015143.
Findings
No deficiencies were cited during this complaint investigation.
Complaint Details
Complaint #: WV00015143; No deficiencies cited.
Report Facts
Census: 76
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 0
Oct 27, 2015
Visit Reason
The visit was conducted as an annual licensure survey focusing on environmental conditions at the facility.
Findings
No deficiencies were cited during this annual licensure survey. The facility was found to be in compliance with the applicable regulations.
Report Facts
Census: 70
Deficiencies cited: 0
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 0
Sep 10, 2015
Visit Reason
The inspection was conducted as an annual licensure survey of the Woodlands Retirement Community.
Findings
The report summarizes the annual licensure survey conducted from September 7-10, 2015, with a census of 79 residents. No specific deficiencies or severity levels are detailed in the provided document.
Report Facts
Census: 79
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Jan 16, 2015
Visit Reason
The inspection was conducted as a complaint investigation for complaint number WV00012845 from January 14-16, 2015.
Findings
No deficiencies were cited during the complaint investigation.
Complaint Details
Complaint #: WV00012845. No deficiencies cited.
Report Facts
Census: 78
Inspection Report
Annual Inspection
Census: 18
Deficiencies: 0
Oct 21, 2014
Visit Reason
The visit was conducted as an annual licensure survey to assess the environment of the facility.
Findings
The inspection found no deficiencies related to the environment during the annual licensure survey.
Report Facts
Census: 18
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Sep 25, 2014
Visit Reason
The inspection was conducted as a complaint investigation from September 22-25, 2014.
Findings
The report does not provide detailed findings or deficiencies within the text, only indicating it was a complaint investigation with a census of 77 residents.
Complaint Details
Complaint investigation conducted from September 22-25, 2014. No substantiation status or detailed complaint findings are provided.
Report Facts
Census: 77
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 0
Sep 25, 2014
Visit Reason
The document is an annual licensure survey conducted to assess compliance with regulatory requirements for the Woodlands Retirement Community.
Findings
The report provides a summary statement of deficiencies identified during the annual licensure survey conducted from September 22-25, 2014, with a census of 77 residents. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 77
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Jan 16, 2014
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #WV00009526 from January 13-16, 2014, concerning issues raised by residents and family members about staff behavior and medication administration.
Findings
The investigation found failure to provide prompt written responses to complaints, inadequate medication administration in accordance with physician orders for three residents, and deficiencies in housekeeping and maintenance. Specific issues included lack of documentation of complaints, medication not available or administered as ordered, and physical environment concerns.
Complaint Details
Complaint #WV00009526 involved allegations that a nurse yelled at Resident #71 and that staff spoke harshly to residents. The complaint was not formally documented or investigated internally. Follow-up showed the employee in question was no longer employed and the resident and family were satisfied with care after interventions.
Severity Breakdown
Class I: 1
Class III: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure prompt action and written response to complaints within four days as required by regulation. | Class III |
| Failure to administer medications in accordance with physician orders for three residents, including missed doses and unavailable medications. | Class I |
Report Facts
Census: 73
Medication missed doses: 10
Medication missed days: 3
Medication missed days: 3
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 0
Jan 13, 2014
Visit Reason
The inspection was conducted as a complaint investigation for complaint #WV00009526 from January 13-16, 2014.
Findings
The report documents a complaint investigation and a follow-up visit related to complaint #WV00009526. The census was 73 during the initial complaint investigation and 66 during the follow-up.
Complaint Details
Complaint #WV00009526 was investigated from January 13-16, 2014, with a follow-up on February 25, 2014. Census was 73 during the initial investigation and 66 during the follow-up.
Report Facts
Census: 73
Census: 66
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 2
Sep 20, 2013
Visit Reason
The document is an annual survey inspection of Woodlands Retirement Community conducted to assess compliance with health and safety regulations.
Findings
The inspection found deficiencies related to safety and environmental conditions, including inadequate supervision during weekend nights and maintenance issues such as damaged carpet, missing bathroom fixtures, and cleanliness concerns.
Deficiencies (2)
| 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 no awake staff on weekend nights. |
| The Center failed to ensure adequate housekeeping and maintenance, including personal belongings left behind furniture, carpet damage, torn furniture, missing towel bars and toilet paper holders, and dirty sinks. |
Report Facts
Census: 68
Sample Size: 3
Completion Date for Repairs: 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Named in follow-up survey section | |
| Operations Supervisor | Participated in tour and observations | |
| Treatment Coordinator | Participated in tour and observations |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 0
Sep 11, 2013
Visit Reason
The inspection was conducted as an annual licensure survey of the Woodlands Retirement Community.
Findings
The report provides a summary of deficiencies identified during the annual licensure survey conducted from September 9-11, 2013, with a census of 72 residents. Specific deficiencies are not detailed in the provided text.
Report Facts
Census: 72
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 3
Aug 22, 2013
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations and other facility requirements.
Findings
The facility failed to rehearse the disaster and emergency preparedness plan with all staff annually as required, with the last documented review over fourteen months prior. Additionally, deficiencies in housekeeping and maintenance were noted, including damaged carpets, missing bathroom fixtures, and unclean areas.
Severity Breakdown
Class I: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to rehearse the disaster and emergency preparedness plan with all staff annually. | Class I |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bar and toilet paper holder, and unclean sink. | — |
| Unsafe environment due to lack of alarms on outside doors and insufficient awake staff on weekend nights. | — |
Report Facts
Census: 68
Completion date for carpet replacement: Sep 30, 2004
Completion date for disaster/emergency in-service training: Sep 19, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged the delay in disaster and emergency preparedness plan review. | |
| Administrative Assistant | Acknowledged the delay in disaster and emergency preparedness plan review. | |
| President | Participated in exit conference discussing the lack of annual disaster preparedness review. | |
| Director of Human Resources | Responsible for monitoring OHFLAC requirements and in-service training. | |
| Medical Director | Responsible for monitoring OHFLAC requirements and in-service training. | |
| Director of Nursing | Responsible for monitoring OHFLAC requirements and in-service training. |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Jul 22, 2013
Visit Reason
The inspection was conducted as a complaint investigation identified by complaint number WV00008433.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint investigation #WV00008433 was unsubstantiated.
Report Facts
Census: 70
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Apr 25, 2013
Visit Reason
The inspection was conducted as a complaint investigation for the Woodlands Retirement Community.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint investigation #WV00008020 was unsubstantiated.
Report Facts
Census: 76
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 3
Apr 1, 2013
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to protect the physical and mental well-being of residents in the secured unit, including issues with staffing levels and resident behavior.
Findings
The facility failed to maintain adequate staffing levels on the secured dementia unit, resulting in insufficient supervision and care for fourteen residents. Multiple incidents of resident-to-resident and resident-to-staff physical aggression were documented. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpets, missing bathroom fixtures, and unclean conditions.
Complaint Details
Complaint investigation WV00007828 conducted March 26-April 1, 2013, regarding failure to protect residents' well-being and inadequate staffing on the secured dementia unit.
Severity Breakdown
Class II: 1
Class I: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect the physical and mental well-being of residents in the secured dementia unit, including inadequate staffing and failure to report violent behaviors immediately. | Class II |
| Failure to maintain adequate staffing levels on the secured unit to meet resident needs. | Class I |
| Inadequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks. | — |
Report Facts
Resident count: 14
Census: 78
Staffing levels: 2
Staffing levels: 1
Dates of staffing schedule issues: 26
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Mar 26, 2013
Visit Reason
The inspection was conducted as a complaint investigation at Woodlands Retirement Community from March 26 to April 1, 2013.
Findings
The report documents a complaint investigation and a subsequent complaint follow-up visit on May 6, 2013, with deficiencies corrected by the follow-up. Specific deficiencies are not detailed in the provided text.
Complaint Details
Complaint investigation conducted from March 26 to April 1, 2013, with a follow-up visit on May 6, 2013 confirming deficiencies were corrected.
Report Facts
Census: 78
Census: 12
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Dec 27, 2012
Visit Reason
The inspection was conducted as a complaint investigation and subsequent complaint follow-up for Woodlands Retirement Community between November 26 and December 5, 2012, with a follow-up visit on December 27, 2012.
Findings
The complaint investigation and follow-up found deficiencies which were subsequently corrected by the facility as noted in the report.
Complaint Details
Complaint investigation #WV00007417 was conducted from November 26 to December 5, 2012, with a follow-up visit on December 27, 2012. Deficiencies identified during the complaint investigation were corrected by the follow-up date.
Report Facts
Census: 81
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFS II | Surveyor during complaint investigation |
| Elizabeth Smith | HFNS I | Surveyor during complaint investigation and follow-up |
| Sharon Kirk | PM II | Surveyor during complaint investigation and follow-up |
| Cyndy Siders | HFNS I | Surveyor during complaint follow-up |
| Bev Randolph | HFNS I | Surveyor during complaint follow-up |
Inspection Report
Follow-Up
Census: 74
Deficiencies: 0
Dec 27, 2012
Visit Reason
The visit was a second follow-up survey to verify correction of deficiencies identified during the annual licensure survey conducted on September 18, 2012.
Findings
The follow-up survey found that deficiencies identified in the prior survey were corrected as of December 5, 2012. The census at the time of follow-up was 74 residents.
Report Facts
Census: 85
Census: 74
Census: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | HFS II | Surveyor during annual licensure survey and follow-up |
| Sharon Kirk | RN, MSN, PM II | Surveyor during follow-up survey |
| Cyndy Siders | RN, HFNS I | Surveyor during follow-up survey |
| Elizabeth Smith | RN, HFNS I | Surveyor during follow-up survey |
| Bev Randolph | RN, HFNS I | Surveyor during follow-up survey |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Dec 27, 2012
Visit Reason
The inspection was conducted as a complaint investigation and subsequent complaint follow-up related to facility compliance.
Findings
The report documents a complaint investigation conducted July 9-20, 2012, followed by two complaint follow-up visits on September 24-27, 2012, and December 27, 2012. Deficiencies identified during the complaint investigation were corrected by the final follow-up.
Complaint Details
Complaint Investigation #WV00007181 conducted July 9-20, 2012 with census 87. Follow-up visits occurred September 24-27, 2012 (census 85) and December 27, 2012 (census 74). Deficiencies were corrected by the final follow-up.
Report Facts
Census: 87
Census: 85
Census: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFS II | Surveyor during complaint investigation and first complaint follow-up |
| Donna Williamson | RN, HFNS II | Surveyor during first complaint follow-up |
| Sharon Kirk | RN, MSN, PM | Surveyor during second complaint follow-up |
| Cyndi Siders | RN, HFNS I | Surveyor during second complaint follow-up |
| Elizabeth Smith | RN, HFNS I | Surveyor during second complaint follow-up |
| Bev Randolph | RN, HFNS I | Surveyor during second complaint follow-up |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 10
Dec 5, 2012
Visit Reason
Annual licensure survey and follow-up inspection to assess environmental and physical facility compliance at Woodlands Retirement Community.
Findings
The facility was found deficient in maintaining safe egress with incomplete concrete sidewalks, inadequate housekeeping and maintenance including unsanitary kitchen conditions, improper storage of oxygen cylinders, and an insufficient nurse call system audible only at the nurse's station. Corrective actions and follow-ups were planned or completed by December 2012.
Deficiencies (10)
| Description |
|---|
| The designated emergency exit on the first floor, Wing 4, lacked a hard, slip-resistant concrete walkway leading to the main walkway or parking area. |
| Excessive accumulation of old grease, food particles, and debris in kitchen areas including dishwashing area, walk-in cooler, and freezer. |
| Mice droppings observed in the kitchen baker's area and evidence of mice in dining room and unit one East. |
| Battery powered resident scooter was left unattended in corridor outside resident room #333, violating charging and ventilation protocols. |
| Several soiled and clean utility rooms were found locked with keys left in the locks by staff. |
| Bar soap found lying on tub rim in spa room without resident identification. |
| Resident room #317 contained three oxygen cylinders; only two permitted. No oxygen use warning sign posted. |
| Resident room #311 had an electric extension cord in use. |
| Oxygen storage room contained cylinders not secured in brackets to prevent tipping. |
| Nurse call system alarm audible only inside nurse's station, not to all staff on duty. |
Report Facts
Census: 85
Completion Date: Dec 19, 2012
Completion Date: Oct 10, 2012
Completion Date: Dec 24, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey and follow-up inspection. |
| Keith Carpenter | HFS II Surveyor | Conducted the follow-up survey on December 5, 2012. |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 8
Nov 26, 2012
Visit Reason
The inspection was conducted as a complaint investigation based on allegations related to medication administration, resident care, housekeeping, maintenance, complaint handling, dietary services, pest control, and call system functionality.
Findings
The facility was found deficient in multiple areas including inaccurate and late documentation, failure to implement physician orders timely, inadequate supervision and resident care, poor housekeeping and maintenance, failure to address complaints promptly, improper dietary management, presence of rodents, and a malfunctioning call system.
Complaint Details
The complaint investigation was substantiated with findings of multiple deficiencies including medication errors, delayed physician order implementation, inadequate supervision, poor complaint handling, pest infestation, and call system failures. Several resident complaints were not addressed timely or adequately.
Severity Breakdown
Class I: 3
Class II: 2
Class III: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to maintain accurate records and reports, including late entries without proper documentation. | Class II |
| Inadequate housekeeping and maintenance, including damaged carpets, torn furniture, missing bathroom fixtures, and unclean sinks. | — |
| Failure to provide appropriate supervision and resident care, resulting in poor wound treatment and delayed implementation of physician orders. | Class I |
| Failure to respond to resident complaints promptly and provide written responses within required timeframes. | Class III |
| Failure to implement physician's orders and administer medications correctly, including missed doses and delayed equipment delivery. | Class I |
| Failure to provide therapeutic diets according to physician orders and communicate diet changes to dietary staff. | Class I |
| Presence of rodents in the facility, including sightings in dining and kitchen areas and mouse droppings on dishes. | Class III |
| Call system was frequently non-operational, especially during storms, and was not audible in resident rooms, compromising resident safety. | Class II |
Report Facts
Census: 81
Missed medication doses: 23
Days delay: 10
Weeks delay: 7
Complaints related to residents: 5
Days for complaint response: 4
Carpet replacement deadline: Sep 30, 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RC | Director of Nursing | Named in findings related to inaccurate documentation, complaint handling, and medication administration. |
| LM | Administrator | Named in complaint handling and response to resident grievances. |
| EW | Chief Financial Officer | Named in complaint response and call system issues. |
| TH | Registered Dietitian | Named in dietary services deficiencies and diet order clarifications. |
| KR | Employee of Best Home Medical | Interviewed regarding delays in delivery of medical equipment. |
| AA | Technician from Electronic Specialty Company | Interviewed regarding call system damage and repairs. |
Inspection Report
Annual Inspection
Census: 85
Capacity: 88
Deficiencies: 17
Sep 27, 2012
Visit Reason
Annual licensure survey conducted to assess compliance with state regulations including staffing, resident care, facility maintenance, and administrative requirements.
Findings
The facility was found deficient in multiple areas including failure to complete abuse registry checks prior to hiring, inadequate housekeeping and maintenance, insufficient staff training, improper management of resident funds, incomplete resident registers, inadequate complaint investigations, admission of residents exceeding licensed care level, improper medication storage, infection control violations, insufficient scheduled activities, and failure to provide therapeutic diets as ordered.
Complaint Details
Complaint investigations were inadequate with missing documentation, failure to interview relevant staff, and lack of timely written responses to complainants. Resident council complaints were not addressed or reported back to residents. Training on complaint handling was not provided as required.
Severity Breakdown
Class I: 4
Class II: 5
Class III: 6
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to complete nurse aide abuse registry and central abuse registry checks prior to hire for multiple employees. | Class II |
| Inadequate housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and unclean sinks. | — |
| Failure to ensure at least one employee on duty has current first aid and CPR certification. | Class I |
| Failure to provide specialty care and complaint handling training to new employees. | Class II |
| Failure to provide annual in-service training on resident rights, confidentiality, abuse prevention, infection control, and fire safety to all employees. | Class II |
| Failure to provide annual Alzheimer's disease and related dementias training to employees. | Class II |
| Failure to maintain complete personnel records including abuse registry checks, TB screening, and current licenses. | — |
| Failure to maintain a complete resident register with admission and discharge dates for multiple residents. | Class III |
| Failure to manage resident funds only at written request and using generally accepted accounting principles; incomplete documentation and lack of surety bond approval. | Class III |
| Failure to provide quarterly accounting of resident funds to residents or representatives. | Class III |
| Failure to respond to resident complaints promptly and provide written responses within four days; inadequate complaint investigations and follow-up. | Class III |
| Admission of resident with care needs exceeding licensed level of care, specifically continuous pacemaker monitoring. | Class III |
| Medications stored in unlocked cabinets accessible to residents in multiple nursing stations. | Class I |
| Failure to provide resident care using appropriate infection control techniques; staff administered eye drops without gloves and while ill. | Class I |
| Failure to provide at least one hour of scheduled activities daily; no activities provided on Labor Day; resident complaints about activities not addressed. | Class III |
| Failure to provide therapeutic diets according to physician orders and written instructions; staff unaware of fluid restriction requirements. | — |
| Toxic substances found in unlocked cabinets accessible to residents throughout the facility. | Class I |
Report Facts
Census: 85
Total Capacity: 88
New Employees without abuse registry check: 4
New Employees without central abuse registry check: 5
Deficiencies cited: 15
Resident beds reserved for nursing care: 3
Residents on fluid restriction: 2
Resident funds managed: 8
Resident funds balance > $200: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AC | Certified Nursing Assistant | Named in abuse registry check deficiency and training deficiencies |
| KH | Certified Nursing Assistant | Named in abuse registry check deficiency and training deficiencies |
| TJ | Licensed Practical Nurse | Named in abuse registry check deficiency and training deficiencies |
| CK | Licensed Practical Nurse | Named in abuse registry check deficiency and license expiration |
| TC | Licensed Practical Nurse | Named in abuse registry check deficiency and training deficiencies |
| LM | Administrator | Named in license expiration and resident fund management deficiencies |
| RC | Director of Nursing | Named in multiple deficiencies including training, complaint investigations, and admission of residents exceeding level of care |
| EW | Chief Financial Officer | Named in resident fund management deficiencies |
| RD | Licensed Practical Nurse | Named in admission of resident exceeding level of care and infection control deficiencies |
| SH | Licensed Practical Nurse | Named in fluid restriction and infection control deficiencies |
| DA | Dietary Manager | Named in dietary and fluid restriction deficiencies |
| DM | Dietary Staff | Named in dietary and fluid restriction deficiencies |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 3
Sep 27, 2012
Visit Reason
The inspection was conducted as a complaint investigation following allegations related to resident complaints not being addressed promptly and issues with medication administration and treatment compliance.
Findings
The facility failed to ensure resident complaints were documented, investigated, and responded to in writing within four days. There were multiple unresolved complaints documented in resident council minutes and complaint files. Additionally, the facility failed to ensure medications and treatments were administered according to physician orders, including inadequate monitoring of residents on fluid restrictions. Housekeeping and maintenance deficiencies were also noted from a prior survey.
Complaint Details
The complaint investigation was triggered by multiple resident complaints about staffing, food quality, medication errors, and safety concerns. The administrator failed to ensure complaints were addressed promptly and documented. Several complaints were not documented or investigated properly, including missing resident property and rough care by staff. Resident council minutes revealed ongoing unresolved issues.
Severity Breakdown
Class I: 1
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to document, investigate, and respond to resident complaints promptly. | Class III |
| Failure to ensure medications and treatments were provided in accordance with physician's orders for multiple residents. | Class I |
| Inadequate housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and unclean conditions. | — |
Report Facts
Census: 87
Census: 85
Number of complaints documented: 2
Residents with fluid restrictions: 2
Residents reviewed for medication/treatment compliance: 14
Residents with medication/treatment noncompliance: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFS II Surveyor | Surveyor conducting complaint investigation July 9-20, 2012 and follow-up September 24-27, 2012 |
| Donna Williamson | RN, HFNS II Surveyor | Surveyor conducting complaint follow-up September 24-27, 2012 |
| Norma | Licensed Practical Nurse | Named in complaint investigation related to resident #82's complaint of rough care |
| LM | Administrator | Administrator who failed to ensure complaints were addressed promptly |
| RC | Registered Nurse | Provided documentation and interview regarding complaint investigations and fluid restriction monitoring |
| TB | Resident Assistant | Interviewed regarding fluid restriction documentation |
| JB | Resident Aide | Interviewed regarding fluid restriction documentation |
| SH | Licensed Practical Nurse | Interviewed regarding fluid restriction monitoring |
| DA | Dietary Manager | Interviewed regarding resident complaints and fluid restriction knowledge |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 0
Sep 24, 2012
Visit Reason
The inspection was conducted as an annual licensure survey of the Woodlands Retirement Community to assess compliance with regulatory requirements.
Findings
The report indicates that deficiencies were identified during the annual licensure survey conducted from September 24-27, 2012, but these deficiencies were corrected by the follow-up survey on December 27, 2012. Technical assistance was also provided.
Report Facts
Census at annual survey: 85
Census at follow-up survey: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | LSW, HFS II | Surveyor during the annual licensure survey |
| Donna Williamson | RN, HFNS II | Surveyor during the annual licensure survey |
| Sharon Kirk | RN, MSN, PM II | Surveyor during the follow-up survey |
| Cyndy Siders | RN, HFNS I | Surveyor during the follow-up survey |
| Elizabeth Smith | RN, HFNS I | Surveyor during the follow-up survey |
| Bev Randolph | RN, HFNS I | Surveyor during the follow-up survey |
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 7
Sep 18, 2012
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with health care standards, physical facilities, and safety regulations at Woodlands Retirement Community.
Findings
The survey identified multiple deficiencies including failure to keep medications securely locked, inadequate housekeeping and maintenance, unsafe storage of oxygen cylinders, unsafe hot water temperatures exceeding 120°F, and unsafe physical conditions such as lack of slip-resistant surfaces at emergency exits and unsafe electrical extension cord use.
Severity Breakdown
Class I: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to keep medications in a locked room or cabinet accessible only to staff; medication cart left unattended and unlocked. | Class I |
| Failure to maintain safe egress with a hard, slip-resistant concrete walkway at emergency exit. | Class I |
| Failure to maintain sanitary and safe food preparation and kitchen environment including grease buildup, mice droppings, excessive ice buildup in freezer, and improper trash container lids. | Class I |
| Unsafe storage of oxygen cylinders not secured in brackets and exceeding allowed quantity in resident rooms. | Class I |
| Hot water temperatures exceeding 120°F in public and assisted living restrooms, posing immediate and serious threat. | Class I |
| Unsafe electrical extension cord use in resident room. | Class I |
| Unsafe housekeeping conditions including damaged carpet, missing towel bars, dirty sinks, and personal belongings improperly stored. | Class I |
Report Facts
Census: 85
Medication containers observed: 30
Medication containers observed: 4
Oxygen cylinders in resident room #317: 3
Hot water temperature: 136
Hot water temperature: 126
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 5
Jul 20, 2012
Visit Reason
The inspection was conducted based on complaints and concerns regarding medication administration, staffing levels, housekeeping, maintenance, resident rights, and complaint handling at the assisted living residence.
Findings
The facility was found deficient in multiple areas including inadequate medication administration and documentation for 12 of 14 residents, insufficient staffing levels not meeting resident care needs, failure to provide specialty care training for new employees, inadequate housekeeping and maintenance, and failure to properly document and respond to resident complaints in a timely manner.
Complaint Details
The complaint investigation revealed multiple concerns from residents, family members, and staff including medication errors, inadequate staffing, unmet care needs, poor housekeeping, maintenance issues, and lack of timely response to complaints. The administrator acknowledged some misunderstandings about staffing counts and failed to provide evidence of complaint resolution.
Severity Breakdown
Class I: 1
Class II: 2
Class III: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure compliance with medication administration and documentation requirements for multiple residents. | Class II |
| Inadequate staffing levels based on resident care needs, with documented shortages on multiple days. | Class I |
| Failure to provide specialty care training on ileostomy care to all new employees based on resident needs. | Class II |
| Failure to address resident complaints promptly and provide written responses within four days. | Class III |
| Inadequate housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and unclean areas. | — |
Report Facts
Residents with two or more care needs: 72
Minimum direct care staffing required: 8.25
Minimum direct care staffing required: 6
Minimum direct care staffing required: 5
Days with staffing shortages: 12
Residents reviewed for medication issues: 14
Residents with medication deficiencies: 12
Residents census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LM | Administrator | Interviewed regarding staffing levels, complaint handling, and facility compliance. |
| SH | Licensed Practical Nurse (LPN) | Provided information about ileostomy training and resident care. |
| Deborah Dodrill | Surveyor | Conducted the inspection July 9-20, 2012. |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 0
Nov 2, 2011
Visit Reason
The visit was conducted as an annual licensure survey of the Woodlands Retirement Community from October 31 to November 2, 2011.
Findings
No deficiencies were cited during the survey, and technical assistance was provided.
Report Facts
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beverly Randolph | RN, HFNS I | Surveyor |
| Sharon Kirk | RN, MSN, Program Manager | Surveyor |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 0
Oct 19, 2011
Visit Reason
The visit was conducted as an annual licensure survey of the Woodlands Retirement Community.
Findings
The survey found no deficiencies at the facility during the inspection.
Report Facts
Census: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Named as the surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 9
Oct 13, 2010
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with health, safety, and physical facility regulations at Woodlands Retirement Community.
Findings
The facility was found deficient in maintaining a safe environment, including electrical wiring issues, unsealed penetrations through smoke barriers, improper charging of power chairs in resident rooms, and inadequate housekeeping and maintenance in various areas such as the kitchen and resident rooms.
Severity Breakdown
Class I: 3
Class II: 6
Deficiencies (9)
| Description | Severity |
|---|---|
| Electrical wiring in the housekeeping room was not routed through conduit. | Class I |
| Unsealed penetrations through smoke barriers and fire separations were not sealed with fire rated material. | Class I |
| Power operated chairs were being charged in resident rooms instead of a well ventilated, non-resident use area with fire separation. | Class I |
| Kitchen had uncleaned grease splatter behind stove and oven. | Class II |
| Blackish mildew accumulated on the rim/wall area of the three compartment sink. | Class II |
| Debris and dust behind the ice machine. | Class II |
| Grease splatter on the wall behind the three compartment sink. | Class II |
| Debris, dust, and old food particles underneath food storage racks in the walk-in cooler. | Class II |
| Blackish mold/mildew on the door gasket to the walk-in cooler. | Class II |
Report Facts
Census: 79
Deficiencies cited: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Named as the surveyor conducting the inspection |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 0
Oct 13, 2010
Visit Reason
Annual licensure survey conducted to assess compliance with state regulations for the Woodlands Retirement Community.
Findings
The survey identified deficiencies which were subsequently corrected as noted in the follow-up survey conducted on November 30, 2010.
Report Facts
Census: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted both the annual licensure survey and the follow-up survey |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 0
Sep 14, 2010
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for the Woodlands Retirement Community.
Findings
No deficiencies were found during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ernie Chafin | HFNS II | Surveyor |
| Pamela Martin | HFNS II | Surveyor |
| Deborah Dodrill | LSW, HFS II | Surveyor |
Inspection Report
Annual Inspection
Census: 68
Deficiencies: 0
Sep 24, 2009
Visit Reason
The visit was conducted as an annual licensure survey to assess the environment and compliance of the Woodlands Retirement Community.
Findings
No deficiencies were found during the survey. Only technical assistance was provided.
Report Facts
Census: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Named as the surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 71
Deficiencies: 0
Sep 16, 2009
Visit Reason
The visit was conducted as an annual licensure survey of the Woodlands Retirement Community.
Findings
No deficiencies were found during the survey, and technical assistance was provided.
Report Facts
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Marine | LSW HFSII | Surveyor |
| Kathy Beauchamp | HFNSII | Surveyor |
Inspection Report
Annual Inspection
Census: 75
Deficiencies: 0
Oct 1, 2008
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 or technical assistance were identified during the annual licensure survey.
Report Facts
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 0
Sep 25, 2008
Visit Reason
The inspection was conducted as an annual licensure survey from September 22-30, 2008, including a complaint investigation.
Findings
The annual licensure survey was completed with no deficiencies noted in the summary. The complaint investigation (#WV00004322) was unsubstantiated.
Complaint Details
Complaint investigation #WV00004322 was conducted and found to be unsubstantiated.
Report Facts
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFSII Surveyor | Named as a surveyor for the annual licensure survey |
| Kathy Beauchamp | HFNSII Surveyor | Named as a surveyor for the annual licensure survey |
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Jun 30, 2008
Visit Reason
The inspection was conducted as a complaint investigation for WV#00004200 at Woodlands Retirement Community.
Findings
The complaint investigation was unsubstantiated and no deficiencies were found during the survey.
Complaint Details
Complaint investigation WV#00004200 was unsubstantiated with no deficiencies identified.
Report Facts
Census: 70
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deb Dodrill | HFS II | Surveyor involved in complaint investigation |
| Donna Williamson | HFNS I | Surveyor involved in complaint investigation |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 0
Nov 7, 2007
Visit Reason
Annual licensure survey conducted from November 5-7, 2007 to assess compliance with regulatory requirements.
Findings
No deficiencies were identified during the survey; only technical assistance was provided.
Report Facts
Census: 76
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah Dodrill | HFSII Surveyor | Named as a surveyor during the annual licensure survey |
| Martha Tarley | HFNSI Surveyor | Named as a surveyor during the annual licensure survey |
| Kathy Beauchamp | HFNSII Surveyor | Named as a surveyor during the annual licensure survey |
Inspection Report
Annual Inspection
Census: 73
Deficiencies: 0
Sep 19, 2007
Visit Reason
The inspection was conducted as an annual licensure survey to assess the facility's compliance with regulatory requirements.
Findings
No deficiencies or technical assistance were identified during the annual licensure survey.
Report Facts
Census: 73
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 0
Sep 28, 2006
Visit Reason
The inspection was conducted as an annual licensure survey of the Woodlands Retirement Community.
Findings
No deficiencies were cited during the survey. Technical assistance was provided to the facility.
Report Facts
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Dunn | HFNSII | Surveyor during the annual licensure survey |
| Ernie Chafin | HFNSII | Surveyor during the annual licensure survey |
| Deborah Dodrill | HFSII | Surveyor during the annual licensure survey |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 0
Sep 13, 2006
Visit Reason
Annual licensure survey conducted to assess environmental and regulatory compliance of the facility.
Findings
The survey found no deficiencies during the inspection.
Report Facts
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 0
Aug 2, 2006
Visit Reason
The inspection was conducted as a complaint investigation for complaint #WV00002859.
Findings
The complaint investigation was unsubstantiated and no deficiencies were cited during the survey.
Complaint Details
Complaint #WV00002859 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Dunn | HFNSII | Surveyor involved in complaint investigation |
| Deborah Dodrill | HFSII | Surveyor involved in complaint investigation |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 0
Nov 9, 2005
Visit Reason
The visit was conducted as an annual licensure survey of the Woodlands Retirement Community.
Findings
The report documents the annual licensure survey conducted on November 8-9, 2005, with a census of 60 residents. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Becky Dunn | HFNSII | Surveyor for the annual licensure survey |
| Betty Marine | HFSII | Surveyor for the annual licensure survey |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 3
Sep 22, 2005
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with health, safety, and environmental regulations at the Woodlands Retirement Community.
Findings
The survey identified multiple deficiencies including inadequate housekeeping and maintenance, unsanitary food preparation areas, and unsafe hot water temperatures exceeding 120°F in resident rooms. Corrective actions and plans of correction were documented for each deficiency.
Severity Breakdown
Class I: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Inadequate housekeeping and maintenance including personal belongings left behind furniture, carpet damage, missing bathroom fixtures, and dirty sinks. | — |
| Unsanitary conditions in kitchen #1 including grease buildup, mold and mildew on tiles and equipment, dust and debris on appliances, uncovered and undated food items, and poor organization in walk-in freezer. | Class I |
| Hot water temperatures in resident rooms exceeding 120°F, with readings up to 144°F, posing an immediate and serious threat to residents. | Class I |
Report Facts
Census: 64
Hot water temperature: 131
Hot water temperature: 144
Hot water temperature: 113
Completion date: 2004
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 0
Sep 22, 2005
Visit Reason
The inspection was conducted as an annual licensure survey to assess environmental and other compliance aspects of the Woodlands Retirement Community.
Findings
The report documents deficiencies found during the annual survey and notes that a follow-up survey was conducted to verify correction of these deficiencies. The follow-up survey confirmed that the deficiencies were corrected.
Report Facts
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Named as surveyor for both the annual licensure survey and the follow-up survey |
Inspection Report
Follow-Up
Census: 46
Deficiencies: 0
Dec 7, 2004
Visit Reason
This visit was the first follow-up to the re-licensure inspection conducted on October 19-20, 2004, to verify correction of previously identified deficiencies.
Findings
The follow-up inspection found that deficiencies identified during the re-licensure survey were corrected, and technical assistance was provided.
Report Facts
Census at re-licensure: 37
New employees reviewed: 6
Tenured employees: 7
Resident records reviewed: 8
Inspection Report
Renewal
Census: 37
Deficiencies: 7
Oct 20, 2004
Visit Reason
The inspection was conducted as a re-licensure survey of the Woodlands Retirement Community on October 19-20, 2004, to review personnel files, resident records, and compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to screen new employees through the nurse aide abuse registry prior to hiring, inadequate employee orientation and training documentation, failure to revise and provide updated resident contracts, inadequate housekeeping and maintenance, failure to document weekly nursing notes for residents requiring nursing care, and failure to document emergency evacuation training for new residents within 24 hours of admission.
Severity Breakdown
Class I: 1
Class II: 3
Class III: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to determine if potential employees were listed on the nurse aide abuse registry prior to hiring. | Class II |
| Failure to provide and maintain records of training to new employees on required topics within the first 15 days of employment. | Class II |
| Failure to revise the written resident contract to specify all required information including CPR, costs, complaints, and liability insurance. | Class III |
| Failure to provide current residents with updated contracts including required provisions within 90 days of the effective date of the rule. | Class III |
| Failure to assure weekly progress notes by a Registered Nurse for residents requiring nursing care services. | Class II |
| Failure to show all new residents how to evacuate the residence in an emergency within 24 hours of admission and document this in the residents' records. | Class I |
| Inadequate housekeeping and maintenance including presence of personal belongings behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Personnel file review: 6
Tenured employees: 7
Resident records reviewed: 8
Employees lacking abuse registry screening: 6
New employees lacking training documentation: 6
Residents lacking emergency evacuation documentation: 3
Residents lacking weekly RN notes: 5
Inspection Report
Census: 36
Deficiencies: 0
Sep 23, 2004
Visit Reason
Environment Survey conducted to assess the facility's environment and safety conditions.
Findings
No deficiencies were issued during this environment survey.
Report Facts
Census: 36
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Aug 19, 2004
Visit Reason
Complaint Investigation #1592 was conducted in conjunction with the Long Term Care program surveyor to investigate a complaint at the facility.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited during the visit.
Complaint Details
Complaint Investigation #1592 was unsubstantiated with no deficiencies cited.
Report Facts
Census: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Wickline | Long Term Care program surveyor | Conducted the complaint investigation |
Inspection Report
Plan of Correction
Census: 6
Deficiencies: 15
Nov 19, 2003
Visit Reason
The inspection was conducted as an environmental survey to assess compliance with health and safety regulations, specifically focusing on dietary services and the physical environment of the facility.
Findings
The survey found multiple deficiencies including unsanitary conditions in the kitchen such as blood on the floor, old food residues on equipment, mislabeled food containers, and inadequate housekeeping and maintenance in the residential areas, including damaged carpets, missing bathroom fixtures, and unsafe door alarms.
Deficiencies (15)
| Description |
|---|
| Red liquid substance (blood) on kitchen floor not cleaned promptly after staff injury. |
| Old food particles and greasy sticky surfaces under and behind kitchen appliances. |
| Food processors with old dried food substance on surfaces and seams. |
| Large plastic bin labeled 'SUGAR' filled with flour. |
| Large plastic bins storing various food items with old food crumbs and greasy lids. |
| Floor underneath baking preparation table with food debris and greasy sticky surface. |
| Large rubber trash can in food preparation area found without lid. |
| Kitchen Aid beater with old dried food substance and dried liquid on surface. |
| Adolescent girls' bedrooms have outside doors without alarms; staff not awake on weekend nights to monitor safety. |
| Outside door in TV room does not lock. |
| Miscellaneous personal belongings behind dresser in girls' bedroom. |
| Iron burn and bleach spots on carpet. |
| Chair in living room with multiple tears exposing stuffing. |
| Upstairs bathroom missing towel bar and toilet paper holder/bar. |
| Bathroom sink dirty and in need of cleaning. |
Report Facts
Center census: 6
Sample size: 3
Plan of correction completion date: 2004
Carpet replacement deadline: 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operations Supervisor | Accompanied tour and provided information about staffing and environment | |
| Treatment Coordinator | Accompanied tour of residence and rooms | |
| Kitchen Supervisor | Observed blood on floor and involved in cleaning response | |
| Maintenance Person | Responded to surveyor's concerns and replaced trash can lid | |
| Dietary Manager | Provided in-service training on Safety and Sanitation | |
| Food Service Director | Monitors cleaning schedule compliance | |
| Administrator | Monitors quarterly compliance with safety and sanitation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 30, 2003
Visit Reason
Complaint investigation #922 was conducted at Woodlands Retirement Community from October 25-30, 2003 to investigate allegations related to resident abuse and failure to protect the mental well-being of residents.
Findings
The investigation found that the administrator failed to protect residents' mental well-being, with documented incidents of staff yelling at residents and improper handling of a resident who was found on the floor in distress. The facility also failed to conduct proper investigations and notify Adult Protective Services. Additionally, inadequate housekeeping and maintenance issues were observed in the residence.
Complaint Details
Complaint investigation #922 was conducted at Woodlands Retirement Community from October 25-30, 2003. The investigation was substantiated with findings of failure to protect residents' mental well-being, failure to report and investigate abuse allegations properly, and inadequate staff training on abuse prevention and reporting.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to protect the mental well-being of residents, including an incident where a resident was found on the floor crying and shaking and was yelled at by staff. | Class II |
| Failure to report neglect, abuse, or emergency situations immediately and to conduct thorough investigations within required timeframes. | Class I |
| Inadequate housekeeping and maintenance, including personal belongings left behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and dirty sink. | — |
Report Facts
Dates of complaint investigation: October 25-30, 2003
Date of incident: March 10, 2003
Date resident expired: March 11, 2003
Deadline for carpet replacement: September 30, 2004
Timeframe for abuse investigation: 24
Timeframe for complaint response: 4
Timeframe for adult protective services reporting: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| C D | Licensed Practical Nurse | Named in abuse incident on March 10, 2003 involving improper treatment of a resident |
Inspection Report
Deficiencies: 3
Oct 3, 2002
Visit Reason
The inspection was conducted as an environmental survey to assess compliance with disaster training, water supply safety, and general housekeeping and maintenance standards at Woodlands Retirement Community.
Findings
The survey found that the administrator had not conducted the required annual disaster rehearsal with all personnel from all shifts, hot water temperatures in resident rooms exceeded safe levels (above 120 degrees Fahrenheit), and housekeeping and maintenance deficiencies were observed including damaged carpets, missing bathroom fixtures, and unclean sinks.
Severity Breakdown
Class II: 1
Class I: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Administrator failed to conduct required annual disaster rehearsal with all personnel from all shifts. | Class II |
| Hot water temperatures in resident rooms exceeded safe levels, reaching up to 136 degrees Fahrenheit. | Class I |
| Inadequate housekeeping and maintenance including damaged carpet, missing towel bars and toilet paper holders, and dirty sinks. | — |
Report Facts
Hot water temperature: 129
Hot water temperature: 127
Hot water temperature: 129
Hot water temperature: 136
Center census: 6
Sample size: 3
Carpet replacement completion date: Sep 30, 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operations Supervisor | Participated in tour and observations of adolescent consumers' residence | |
| Treatment Coordinator | Participated in tour and observations of adolescent consumers' residence | |
| Maintenance Supervisor | Responsible for adjusting hot water temperatures and scheduling disaster rehearsals |
Inspection Report
Complaint Investigation
Deficiencies: 4
Nov 7, 2001
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report major incidents as required by regulation.
Findings
The facility failed to report a major incident involving a resident leaving the facility without notifying staff. Additionally, deficiencies were noted in maintaining a safe environment and adequate housekeeping.
Complaint Details
The complaint investigation #2001-4-107 involved a resident (#32) leaving the facility without notifying staff. The incident was not reported to the Office of Health Facility Licensure and Certification until the survey date. The complaint was substantiated with corrective actions initiated.
Severity Breakdown
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to report major incidents to the Office of Health Facility Licensure and Certification as required. | Class III |
| The adolescent girls' bedrooms had outside doors without alarms or alert devices, and staff were not awake on weekend nights to monitor safety. | — |
| An outside door in the TV room did not lock. | — |
| Inadequate housekeeping and maintenance including personal belongings behind dresser, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Center Census: 6
Sample Size: 3
Completion Date: Nov 6, 2001
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Spoke with resident #32 and person who aided resident in leaving facility; responsible for reporting major incidents |
| Charge Nurse | Charge Nurse | Responsible for filing reports on major incidents and reviewing incident reports with Administrator and Director of Nursing |
| Employee #6 | Licensed Practical Nurse | Discovered resident #32 missing during evening medication pass |
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