Inspection Reports for Tygart Valley Health & Rehabilitation

This document is a plan of correction related to a previous investigation survey concluding on 2024-01-10, accepted in lieu of an onsite revisit.

The facility, Tygart Valley Health & Rehabilitation, 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.

An unannounced annual recertification survey was conducted at Tygart Valley Health and Rehabilitation from 01/08/24 to 01/10/24 to assess compliance with healthcare regulations and standards.

The facility was found deficient in multiple areas including accuracy of assessments, resident rights, dignified dining, respiratory care, food safety, abuse investigation reporting, PASARR coordination, advance directives, medication administration, discharge planning, communication aids, dental services, infection control, food temperature, tube feeding management, and staff posting accuracy.

The inspection was a recertification survey conducted to assess compliance with regulatory requirements, including fire safety systems and electrical equipment maintenance.

The facility failed to maintain the fire alarm system, sprinkler system, and electrical patient-care related equipment in accordance with NFPA standards. Deficiencies were identified in documentation and testing of fire alarm sensitivity, sprinkler system inspection, and electrical testing of a whirlpool tub.

The inspection was a recertification survey conducted to assess compliance with federal and state regulations at Tygart Valley Health & Rehabilitation.

The facility was found to be in compliance with all applicable provisions, including the Facility Emergency Preparedness Plan, which met all federal and state requirements. Several tags were cited during the initial survey but were corrected by the first revisit.

This document is a plan of correction related to a prior survey for Tygart Valley Health & Rehabilitation, addressing previously cited deficient practices and confirming substantial compliance.

The facility is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit for the survey concluding on 09/27/2022.

An unannounced annual recertification and annual relicensure survey was conducted at Good Samaritan Society of Barbour County from September 19-27, 2022.

The facility was found deficient in multiple areas including resident rights and dignity, self-administration of medications, resident and family group grievance handling, notification of changes in condition, personal privacy during treatments, reporting of alleged violations, transfer/discharge notifications, comprehensive care plan implementation, CPR certification, quality of care including weight monitoring and neurological checks, pressure ulcer care, accident hazard prevention, respiratory care, drug regimen review, medication storage, menu portion control, food safety, and advanced directives documentation.

The inspection was conducted to assess the facility's compliance with the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

The document is a Statement of Deficiencies and Plan of Correction for Tygart Valley Health & Rehabilitation, summarizing compliance with federal, state, and local 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.

An unannounced annual re-certification and annual re-licensure survey was conducted at Good Samaritan Society of Barbour County from May 24-26, 2021.

The facility was found deficient in multiple areas including accident hazards due to improper storage of laryngectomy care products, failure to prevent urinary tract infections related to catheter care, failure to provide adequate nutrition and hydration, improper medication storage without dating, and failure to follow proper hand hygiene practices in the kitchen dish room.

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, Good Samaritan Society of Barbour County, was found to be in substantial compliance with the applicable federal and state regulations. The review included plans of correction and credible evidence accepted in lieu of an onsite revisit.

The inspection was conducted to assess compliance with NFPA 101 fire safety standards, specifically regarding hazardous areas and smoke barriers in the facility.

The facility failed to ensure that hazardous areas such as the soiled utility room, laundry room, and mechanical room doors were one-hour fire rated as required by NFPA 101. Additionally, a 4x6 inch penetration in the rated smoke barrier wall above the kitchen ceiling was found, compromising the smoke barrier integrity.

An unannounced focused infection control survey was conducted at Good Samaritan from February 1, 2021 to February 2, 2021.

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.

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.

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, Good Samaritan Society of Barbour County, was found to be in substantial compliance with the applicable federal and state regulations based on a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced annual re-certification and annual re-licensure survey was conducted from 08/12/19 through 08/14/19 at Good Samaritan Society of Barbour County.

The facility was found deficient in multiple areas including failure to review resident rights during Resident Council meetings, improper posting of State inspection results, unresolved resident grievances, failure to notify Ombudsman of resident transfers, inaccurate Minimum Data Set (MDS) assessments, incomplete and inaccurate care plans, inadequate infection control practices during medication administration, and failure to provide varied secondary alternative meals.

The inspection was conducted to assess the facility's compliance with the NFPA 101, Life Safety Code, 2012, and applicable Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of NFPA 101, Life Safety Code, 2012, and all applicable Emergency Preparedness requirements.

An unannounced complaint investigation was conducted at Good Samaritan Society of Barbour County from 03/26/19 to 03/27/19.

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

Complaint #21683 was unsubstantiated with no related or unrelated deficiencies cited.

This document is a Plan of Correction related to deficiencies identified in a prior inspection of Tygart Valley Health & Rehabilitation.

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

An unannounced annual re-certification and annual re-licensure survey was conducted at Good Samaritan Society of Barbour County from 08/13/18 through 08/16/18.

The facility was found deficient in multiple areas including failure to ensure catheter bag covers were used, failure to notify physicians of changes in bowel movements, failure to issue Medicaid liability notices, environmental concerns with bathroom doors and vents, inaccurate dental assessments, incomplete and non-person-centered care plans, failure to obtain hospice orders, failure to act on pharmacist medication irregularities, medication administration errors, and failure to maintain proper refrigerator/freezer temperatures.

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 previously cited deficient practices corrected as evidenced by accepted plans of correction and credible evidence in lieu of an onsite revisit.

The inspection was a routine survey to assess compliance with fire safety codes and other regulatory requirements at the facility.

The facility was found deficient in ensuring self-closing devices on storage room doors, maintaining an approved automatic sprinkler system, conducting required fire drills on all shifts, and maintaining documentation for sprinkler system inspections. These deficiencies could potentially impact all residents, staff, and visitors.

The inspection was conducted to assess compliance with NFPA 13 and NFPA 25 standards for the installation, maintenance, and testing of the facility's automatic sprinkler system.

The facility failed to ensure that the automatic sprinkler system was properly installed and maintained according to NFPA 13 and NFPA 25 standards, with sprinkler heads obstructed by exit lights and ceiling lights, and lack of documentation for a required five-year internal inspection of sprinkler system piping. These deficiencies could affect all residents, staff, and visitors.

A review of the plans of correction and credible evidence was accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 07/19/17.

The facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule, and with the previously cited deficient practices.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted from July 18, 2017 through July 19, 2017 at Good Samaritan Society of Barbour County.

The facility was found to have deficiencies related to food storage practices, specifically unlabeled and outdated foods in the Residents' snack refrigerator in the activity room, which posed a potential risk to residents. The facility implemented corrective actions including education of staff and family members, signage, and policy revisions.

The inspection was conducted as a routine survey to assess compliance with fire safety, electrical systems, medical equipment maintenance, and staff training requirements.

The facility failed to maintain proper documentation and testing for the fire alarm system, emergency generator maintenance, electrical equipment testing, and medical gas equipment training. These deficiencies could potentially affect all residents, staff, and visitors.

An unannounced complaint investigation was conducted December 20, 2016 to December 21, 2016 at Good Samaritan of Barbour County for Complaint Reference 16911.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

An unannounced revisit was conducted at Barbour County Good Samaritan Society on August 2-3, 2016 for the Quality Indicator Survey concluding June 9, 2016.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted from May 31, 2016 through June 9, 2016 to assess compliance with regulatory requirements.

The facility was found deficient in maintaining comfortable temperature levels, conducting accurate comprehensive assessments, preventing abuse, respecting resident dignity, completing accurate assessments, developing comprehensive care plans, preventing pressure ulcers, addressing weight loss, timely physician visits, infection control, medication management, immunizations, food safety, and medical record documentation.

The inspection was a routine life safety code survey conducted to assess compliance with NFPA standards related to fire safety, electrical wiring, medical gas storage, and emergency generator maintenance.

The facility was found deficient in multiple areas including failure to maintain smoke barrier walls with proper fire resistance, improper labeling and storage of medical gas cylinders, inadequate maintenance of portable fire extinguishers, failure to maintain emergency generator testing and battery monitoring, and electrical wiring issues with exposed wiring and missing junction box covers.

The inspection was conducted as a complaint investigation, concluding on 09/16/15, to review previously cited deficient practices and verify compliance.

The facility, Barbour County Good Samaritan Society, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Complaint Reference: 14028. The complaint investigation concluded on 09/16/15 with the facility found in substantial compliance with previously cited deficient practices.

An unannounced complaint survey was conducted at Barbour County Good Samaritan Society from September 14, 2015 through September 16, 2015, related to complaint #14028 which was substantiated with related and unrelated deficiencies cited.

The facility failed to develop comprehensive care plans addressing central venous catheter care for residents with PICC lines, failed to ensure qualified personnel administered IV medications via PICC lines, and failed to provide care ensuring the highest practicable well-being for a resident by placing an IV without a physician's order and administering medication via the wrong route.

Complaint #14028 was substantiated with related and unrelated deficiencies cited based on observations, clinical record reviews, interviews with residents, family, and staff, and review of facility documentation.

The document is a plan of correction submitted in response to previously cited deficient practices during Quality Indicator and Licensure Surveys.

The facility, Barbour County Good Samaritan Society, is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. The plan of correction and credible evidence were accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 06/11/15.

Routine inspection of Tygart Valley Health & Rehabilitation to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements.

The facility failed to properly fireproof smoke barrier penetrations, conduct fire drills at varied times, maintain sprinkler systems free of external loads and debris, maintain generator documentation and timely repairs, and ensure electrical safety including restricted access to electrical panels and proper GFI protection near water sources.

Unannounced annual Quality Indicator and Licensure Surveys were conducted at Barbour County Good Samaritan Society from June 8, 2015 through June 11, 2015 to assess compliance with regulatory requirements.

The survey identified deficiencies including inaccurate comprehensive Minimum Data Set (MDS) assessments related to urinary continence and falls, failure to check nurse aide abuse registry for some employees, failure to revise care plans to reflect changes in resident needs, and inadequate infection control practices related to uncovered bedpans.

The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint investigation(s) concluding on 02/05/15.

The facility, Barbour County Good Samaritan Society, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint Reference: 12938. The facility is in substantial compliance with the previously cited deficient practices based on the review of plans of correction and credible evidence.

An unannounced complaint survey was conducted at Barbour County Good Samaritan Society from February 3, 2015 through February 5, 2015, triggered by complaint #12938 which was substantiated with a related deficiency cited.

The facility failed to ensure adequate supervision of residents with aggressive behaviors, resulting in multiple resident-to-resident altercations involving residents #4, #14, #35, and others. Staff were unable to provide one-to-one supervision for Resident #35, who exhibited severe cognitive impairment and behavioral issues, leading to repeated incidents of hitting and pushing other residents.

Complaint #12938 was substantiated with a related deficiency cited. The complaint involved multiple allegations of resident-to-resident abuse, with seven of ten allegations substantiated. The facility census at the time was 49 residents.

The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint investigation(s) concluding on 2014-11-19.

The facility, Barbour County Good Samaritan Society, 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.

Complaint Reference: 12328. The complaint investigation concluded with the facility in substantial compliance and no onsite revisit was required.

The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint investigation(s) concluding on 2014-10-22.

The facility, Barbour County Good Samaritan Society, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. The previously cited deficient practices were corrected as evidenced by the accepted plans of correction.

Complaint Reference: 12143. The facility was found in substantial compliance with previously cited deficient practices following the complaint investigation concluding on 2014-10-22.

Complaint Survey #12328 was conducted due to allegations that the facility did not ensure medications were administered according to physician's orders, residents were not assessed for medication effects, residents did not receive necessary services for activities of daily living, and staff awareness of resident care needs was inadequate.

The facility failed to provide necessary care and services to maintain the highest practicable well-being for one resident (#45) by not administering Fentanyl patches as ordered, resulting in medication errors and an excessive dose. Additionally, the clinical record was inaccurate as the physician's order was not transcribed correctly to the medication administration record.

The complaint was substantiated for failure to ensure medications were administered according to physician's orders. Other allegations regarding assessment and monitoring of medication effects, provision of necessary services for activities of daily living, and staff awareness of resident care needs were unsubstantiated.

An unannounced complaint survey was conducted at Barbour County Good Samaritan on October 21-22, 2014, triggered by complaint #12143 which was substantiated with related and unrelated deficiencies cited.

The survey found multiple deficiencies including failure to correctly communicate transfer/discharge appeal rights, failure to thoroughly investigate an allegation of neglect for Resident #43, failure to provide dignified ostomy care for Resident #40, failure to develop a comprehensive care plan for Resident #40 addressing urinary incontinence, and failure to provide appropriate treatment to restore bladder function for Resident #40.

Complaint #12143 was substantiated with related and unrelated deficiencies cited. The complaint sample consisted of 7 residents. The facility census on the first day of the complaint investigation survey was 59 residents.

The document is a plan of correction related to a Quality Indicator and Licensure Survey for Tygart Valley Health & Rehabilitation, addressing previously cited deficient practices.

The facility, Barbour County Good Samaritan, is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. The plan of correction and credible evidence were accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 02/07/14.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted based on observations, clinical record reviews, interviews, and facility documentation review.

The facility had multiple deficiencies including incomplete comprehensive assessments for six residents, failure to develop comprehensive care plans addressing identified needs for two residents, failure to provide care to maintain nutritional status for one resident, failure to ensure drug regimen was free from unnecessary drugs for one resident, failure to maintain accurate and complete medical records for one resident, failure to comply with county health department food handler requirements, and failure to maintain an effective quality assurance committee.

The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements including life safety code standards and facility policies.

The facility was found deficient in several areas including inadequate signage on delayed-egress doors, failure to conduct required fire drills quarterly on each shift, and failure to exercise the diesel generator under load monthly as required.

The inspection was conducted as a complaint investigation based on complaint reference 13228 / 8827 from 09/29/13 to 10/01/13.

The complaint was unsubstantiated and no citations were issued during the investigation.

Complaint reference 13228 / 8827 was investigated and found to be unsubstantiated with no citations.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory oversight of Tygart Valley Health & Rehabilitation.

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, including Medicaid-related information.

The inspection was conducted in response to a complaint (Reference: 13172 / 8491) regarding housekeeping and maintenance services, specifically the cleanliness of the shower room on the 200 hall.

The facility failed to maintain a clean shower room on the 200 hall, with dried white debris leaking from the shower panel and a black moist mold-like substance on the wall molding and floor. The condition was observed over several days and confirmed by staff interviews. The shower panel was not functioning properly and was leaking. The facility took corrective actions including cleaning the shower room and replacing the shower panel.

Complaint Reference: 13172 / 8491. The complaint was unsubstantiated but resulted in an unrelated citation for housekeeping deficiencies.

The document is a statement of deficiencies and plan of correction related to regulatory compliance for Tygart Valley Health & Rehabilitation.

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. The facility must also provide written descriptions of legal rights and Medicaid-related information.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Tygart Valley Health & Rehabilitation.

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).

The inspection was conducted to assess compliance with regulatory requirements, specifically focusing on the development of comprehensive care plans for residents.

The facility failed to develop a comprehensive care plan with measurable goals and interventions for a resident (#48) who had an exposed tendon posterior to the left knee. Despite physician orders and staff interviews confirming the condition, no care plan was found in the resident's record.

Second re-visit to QIS conducted from 12/11/12 to 12/13/12 to evaluate correction of previously cited deficiencies.

The facility failed to develop a comprehensive care plan for a resident with an exposed tendon, failed to properly date and dispose of refrigerated medications, and did not maintain proper refrigerator temperatures. Additionally, the facility's quality assurance committee failed to ensure correction of previously cited deficiencies, resulting in ongoing noncompliance affecting all residents.

The inspection was conducted as a complaint investigation referenced as 12265 / 7435.

The complaint was unsubstantiated and no citations were issued.

Complaint Reference: 12265 / 7435. The complaint was unsubstantiated with no citations.

Complaint investigation and revisit with repeat citations conducted from 10/02/12 to 10/05/12.

The facility failed to develop comprehensive care plans addressing essential healthcare needs for residents #42 and #74, failed to update care plans for residents #10 and #42 when health status deteriorated, and failed to provide necessary dialysis care for resident #42 as per care plan and facility policy.

Complaint Reference: 7285 / 12196. Revisit with repeat citations.

Revisit for the Quality Indicator and Licensure Surveys ending 07/24/12 from 10/02/12 to 10/05/12.

The facility failed to correct multiple deficiencies identified in the previous survey related to care planning, provision of care, food safety, medication storage, emergency planning, and quality assurance. Specific failures included incomplete care plans, lack of updated medical orders, inadequate dialysis care, unsanitary food storage, improper medication refrigeration, and absence of a written plan for missing residents.

The inspection was conducted as a complaint investigation based on complaint references 7285 and 12197.

The complaint was unsubstantiated and no citations were issued as a result of the investigation.

Complaint Reference: 7285 / 12197. Unsubstantiated complaint record with no citations.

The inspection was conducted in response to complaints regarding failure to notify responsible parties of changes in residents' health status and other care concerns.

The facility failed to notify responsible parties and physicians of changes in health status for two residents, failed to maintain resident dignity due to inadequate privacy curtains, failed to develop and revise comprehensive care plans appropriately, failed to provide adequate supervision to prevent falls, failed to maintain safe water temperatures, and failed to maintain a functioning call system on the 100 Hall.

Complaint Reference: 7209 / 12158. The investigation was conducted from 07/11/12 to 07/24/12 based on complaints regarding failure to notify responsible parties of changes in residents' health status and other care concerns.

Routine Quality Indicator and Licensure Surveys conducted from 07/15/12 to 07/24/12, including off-hours review.

The facility had multiple deficiencies including failure to notify responsible parties of health status changes, inadequate care planning, failure to provide adequate supervision to prevent accidents, improper medication management, infection control lapses, unsafe water temperatures, and incomplete emergency preparedness plans.

Routine inspection of Tygart Valley Health & Rehabilitation to assess compliance with NFPA Life Safety Code standards and other regulatory requirements.

The facility failed to maintain smoke barrier walls with proper fire resistance, did not conduct required quarterly fire drills on all shifts, failed to maintain fire alarm system sensitivity testing every two years, lacked smoke detector coverage in the nursing station, failed to secure oxygen cylinders properly, and did not exercise the diesel generator under load for three months in 2012. Additionally, there was no battery-powered emergency lighting at the generator transfer switch location.

The inspection was conducted in response to a complaint referenced as State 12077 / ACTS 7053.

The complaint was unsubstantiated and no citations were issued as a result of the investigation.

Complaint Reference: State 12077 / ACTS 7053. The complaint was unsubstantiated with no citations.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Tygart Valley Health & Rehabilitation.

The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges as required by regulation.

The inspection was conducted as a complaint investigation based on substantiated complaints regarding mistreatment, neglect, abuse, and misappropriation of resident property at the facility.

The facility failed to report allegations of neglect, verbal abuse, stolen property, and failure to provide care as required by state law. Additionally, a nursing assistant failed to immediately report witnessed abuse incidents involving two residents. The facility did not ensure proper implementation of abuse identification and reporting policies.

Complaint Reference: State #12031, ACTS #6954. Substantiated complaint record with citation. Allegations included failure to provide mouth care and wound care, verbal abuse, stolen personal property, and failure to provide care for dentures. Specific residents involved: #37, #70, #53, #54. Facility census at time of complaint: 52.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the facility.

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, including Medicaid-related information.

The inspection was conducted as a complaint investigation from 02/21/12 to 02/23/12 following a substantiated complaint record with related citation.

The facility failed to ensure that four of nine sampled residents received treatment and services to increase range of motion or prevent further decrease. Specifically, three residents were not ambulated as ordered and one resident did not have knee braces applied as ordered.

Complaint Reference #12018 was substantiated with related citation.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of Tygart Valley Health & Rehabilitation.

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

Complaint investigation due to substantiated complaint record with deficiencies related to resident care and services.

The facility failed to provide necessary care and services to maintain residents' well-being, including failure to follow physician orders for bowel movements for 5 residents, failure to provide showers/baths per protocol for 13 residents, and serving food at improper temperatures affecting resident satisfaction.

Substantiated complaint record with deficiencies related to resident care and services including bowel care, hygiene, and food temperature.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Tygart Valley Health & Rehabilitation.

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).

The inspection was conducted as a complaint investigation based on complaint references #11054 and #11082. The investigation focused on substantiated and unsubstantiated complaints regarding resident care and reporting.

The facility failed to immediately report alleged violations involving mistreatment, neglect, or abuse to the administrator and other officials as required by state law. Specifically, the facility delayed reporting an incident involving Resident #52's rib fractures and a medication omission incident. Both incidents were eventually reported after corporate office intervention.

Complaint reference #11054 was substantiated with deficiencies cited. Complaint reference #11082 was unsubstantiated with no related deficiencies cited.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with NFPA 101, Life Safety Code; 2000 Existing Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review.

The inspection was conducted concurrently with complaint investigations #9294 and #9335, which were unsubstantiated, and the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.

The facility was cited for multiple deficiencies including failure to ensure rights exercised by a legal representative, failure to provide written notification of Medicare service discontinuation, improper management of personal funds, failure to convey personal funds upon death timely, failure to screen employees through the nurse aide registry, inaccurate resident assessments, unsanitary kitchen conditions, and failure to ensure timely physician visits.

Complaint references #9294 and #9335 were unsubstantiated with no related deficiencies cited.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Tygart Valley Health & Rehabilitation.

The report includes a deficiency related to the facility's failure to properly inform residents of their rights, rules, services, and charges in accordance with regulatory requirements.

The facility was entered on 09/14/09 for a complaint investigation referencing complaints #9260, #9266, #9268, and #9272.

The facility failed to deploy sufficient direct care nursing staff across all shifts to meet the mandated 2.25 hours per resident per day, with staffing postings found inaccurate and misleading. Residents reported delays in care and dissatisfaction with staff responsiveness. The facility also failed to post accurate nurse staffing data as required.

Complaint references #9260, #9266, #9268, and #9272 were substantiated with deficiencies cited.

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 part of an annual survey to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including failure to provide individualized activities for isolated residents, unsanitary housekeeping conditions, incomplete comprehensive assessments and care plans, inadequate pressure sore treatment, lack of full-time RN coverage, improper food handling, and incomplete clinical records.

The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident care, medication management, laboratory services, and resident rights at Tygart Valley Health & Rehabilitation.

The facility was found deficient in multiple areas including failure to revise care plans after significant lab abnormalities, use of unnecessary antipsychotic drugs without proper monitoring or gradual dose reduction, and failure to provide ordered laboratory services in a timely manner.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Tygart Valley Health & Rehabilitation.

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, including Medicaid-related information.

Routine inspection of Tygart Valley Health & Rehabilitation nursing facility to assess compliance with federal regulations including resident rights, grievances, infection control, staffing, and care planning.

The facility had multiple deficiencies including failure to post accurate ombudsman information, failure to properly investigate and respond to resident grievances and complaints, inadequate notification of bed-hold policies, failure to report and investigate abuse/neglect allegations, inadequate nurse aide registry verification, failure to maintain resident dignity during meals, failure to act on resident council complaints, incomplete social assessments, failure to address psychosocial needs of a quadriplegic resident, unsafe environment due to unsecured mechanical room, improper food temperature and sanitation, failure to provide influenza and pneumococcal immunizations, failure to post nurse staffing data accessibly, failure to maintain infection control measures, failure to obtain ordered lab tests, and failure of the quality assurance committee to effectively address these issues.

The inspection was conducted to review 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.

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 no new findings detailed beyond the initial comments.

The inspection was conducted to review facility documentation, staff interviews, and observations to determine compliance with the NFPA 101, Life Safety Code; 2000 Existing Edition.

The facility was found to be in compliance with the provisions of NFPA 101, Life Safety Code; 2000 Existing Edition based on the review.

The inspection was conducted as the facility's annual Medicare/Medicaid certification survey, concurrently with a complaint investigation.

The facility was found deficient in multiple areas including failure to ensure medical decisions were made by the appointed representative for an incapacitated resident, inadequate discharge procedures, failure to provide written bed-hold policy, incomplete and outdated care plans, inconsistent documentation of PRN medication effectiveness, unsafe storage of chemicals and medications, failure to provide required RN coverage, failure to post accurate nurse staffing data, failure to follow menus for dietary restrictions, and presence of expired medications.

Complaint reference #2-6292 was unsubstantiated with no related deficiencies cited.

This document is a plan of correction submitted as a paper revisit following a prior inspection.

The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand, but no detailed findings or severity levels are provided.

The inspection was conducted in response to a complaint referenced as #2-6076.

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

Complaint reference #2-6076 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-6040, which was found to be unsubstantiated but resulted in unrelated deficiencies being cited.

The facility failed to ensure the accuracy of minimum data set (MDS) assessments for two residents (#3 and #33). Resident #3's MDS incorrectly documented an external catheter and an ostomy, which were not present. Resident #33's MDS inaccurately reported application of dressings, which was not supported by treatment records.

Complaint reference #2-6040 was unsubstantiated but unrelated deficiencies were cited.

This document is a plan of correction submitted in response to deficiencies identified in a prior survey of the facility.

The document references 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, including Medicaid-related information.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards related to fire safety, means of egress, sprinkler systems, fire extinguishers, and medical gas storage at the facility.

The facility failed to maintain fire safety standards including incomplete fire-rated smoke barriers, inadequate corridor exit width due to obstructions, corroded sprinkler heads, lack of required Class K fire extinguisher in the kitchen, improper storage of soiled linen and trash receptacles exceeding allowed capacity, and improper storage of oxygen cylinders with combustible materials without required signage.

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 exercise of rights, staff treatment of residents, resident assessment accuracy, comprehensive care plans, range of motion services, drug regimen review, infection control, and clinical record maintenance. Specific issues included incomplete legal documentation for residents, failure to investigate abuse allegations thoroughly, inaccurate resident assessments, incomplete nursing care and treatment, failure to provide ordered therapy services, lack of pharmacist communication to physicians, improper infection control practices during ice pass, and incomplete clinical documentation.

The inspection was conducted as a complaint investigation following a substantiated complaint record with a deficiency cited.

The facility failed to provide a safe, clean, comfortable, and homelike environment. Observations during the complaint investigation revealed dirty and poorly maintained resident living and dining areas, including soiled heat registers, cobwebs, dust, mold, and feces-like splatters in various locations.

Complaint reference: 2-5147. Substantiated complaint record with a deficiency cited.

The inspection was conducted as a substantiated complaint investigation related to failure to monitor the effectiveness of 'as needed' pain medications and failure to monitor labs for residents on Coumadin therapy.

The facility failed to ensure that five residents receiving 'as needed' pain medication were monitored for medication effectiveness. Additionally, the facility failed to monitor labs for one resident on Coumadin therapy, resulting in Coumadin toxicity and hospitalization. The resident subsequently died due to complications related to the toxicity and other conditions.

Complaint reference #2-4354 was substantiated with deficiencies cited related to medication monitoring and lab monitoring failures.

This document is a plan of correction related to a paper revisit of a prior inspection.

The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally, but no detailed findings or severity levels are provided.

The inspection was conducted to assess compliance with regulatory standards related to resident rights, medication administration, and quality of care.

The facility was found deficient in failing to clarify a physician's medication order for Phenobarbital, which lacked the strength specification, and failing to apply a physician-ordered medical device (heel protectors) to a resident to prevent skin breakdown.

The inspection was conducted in response to complaint reference #2-4293.

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

Complaint reference #2-4293 was investigated and found to be unsubstantiated with no deficiencies cited.

Complaint investigations were conducted related to substantiated and unsubstantiated complaints, focusing on resident care, medication administration, and facility environment.

The facility had multiple deficiencies including incomplete resident assessments, inadequate care plans for residents on dialysis and hospice, failure to check gastrostomy tube placement, failure to apply physician-ordered devices, unsafe physical environment, dietary staff not wearing hair nets, delayed medication procurement, incorrect medication labeling, failure to obtain ordered lab tests timely, incorrect medication administration records, and lack of physician attendance at quality assurance meetings.

Complaint reference #2-4250 was substantiated with no related deficiencies cited. Complaint reference #2-4253 was unsubstantiated with no related deficiencies cited.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically regarding the maintenance and spacing of the facility's automatic sprinkler system.

The facility failed to maintain all components of the sprinkler system in accordance with NFPA 13 standards. Two of three sprinkler heads in the kitchenette were spaced approximately 54 inches apart without baffles, violating the minimum spacing requirement of six feet on center due to removal of a wall.

The inspection was conducted as a complaint investigation referenced as #2-4217.

The complaint was substantiated; however, no deficiencies were cited during the investigation.

Complaint reference #2-4217 was substantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-4198, substantiated with deficiencies cited.

The facility failed to ensure that one resident (Resident #27) who was found wedged between the mattress and side rails had been thoroughly assessed and care planned for side rails and bed. The resident suffered injury due to improper bed setup and lack of assessment or care plan for the bed and side rails.

Complaint reference #2-4198 was substantiated with deficiencies cited related to quality of care and accident hazards involving Resident #27.

The inspection was conducted as a complaint investigation related to allegations of abuse and other regulatory compliance issues at the facility.

The facility was found to have substantiated deficiencies including failure to immediately report and thoroughly investigate allegations of abuse, failure to ensure scheduled activities such as Bingo occurred consistently, lack of a care plan for a resident's need for a doll baby, and failure to complete annual performance reviews for nursing assistants.

Complaint reference #2-4111 was substantiated with deficiencies cited related to abuse allegations and other regulatory violations.

The inspection was conducted as a complaint investigation referenced as #2-4073.

The complaint was substantiated, but no deficiencies were cited during the investigation.

Complaint reference #2-4073 was substantiated with no deficiencies cited.

The inspection was conducted as an annual survey of the nursing facility to assess compliance with federal regulations including resident rights, staff treatment of residents, and resident assessments.

The facility was found deficient in timely reporting of an abuse allegation involving one resident, and failure to complete a comprehensive resident assessment for another resident, specifically missing required resident assessment protocols for dehydration and tube feeding.

The inspection was conducted as a comprehensive annual survey of Tygart Valley Health & Rehabilitation to assess compliance with federal regulations related to resident care, safety, and facility operations.

The facility was found deficient in multiple areas including failure to thoroughly investigate bruising of unknown origin, lack of privacy during medication administration, incomplete resident assessments, failure to follow physician orders, inadequate monitoring of bowel movements leading to fecal impaction, poor personal hygiene maintenance, improperly seasoned food, unsafe physical environment, incomplete nurse aide registry checks, and infection control issues.

The inspection was conducted to review the facility's compliance with NFPA 101 Life Safety Code standards, specifically regarding the testing and exercising of the emergency electrical generator.

The inspection found that testing of the facility's emergency electrical generator was incomplete. Key information such as the total electrical load placed on the generator and the minimum exhaust gas temperatures recommended by the manufacturer were unknown, necessitating a load bank test of the emergency generator.

The inspection was conducted based on complaint investigation #2-3045 regarding infection control practices at the facility.

The facility failed to ensure that resident equipment such as shower chairs and bedside commodes were sanitized after use, with multiple observations confirming soiled equipment. This posed a risk of infection to all residents using such equipment.

Complaint investigation #2-3045; substantiation status not explicitly stated.

The inspection was conducted to assess the facility's compliance with regulatory requirements related to quality of care, clinical record maintenance, and medication management, including the use of antipsychotic drugs and weight monitoring.

The facility failed to ensure that residents' drug regimens were free from unnecessary drugs, specifically antipsychotic medications without adequate monitoring or indications for continued use for three residents. Additionally, clinical records were not accurately documented, particularly regarding weight monitoring and care plan information for thirteen residents.

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

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

The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents (e.g., fecal impaction), inadequate quality of care related to pressure sore management and resident positioning during meals, medication administration errors, and unsafe physical environment conditions such as improper battery recharging locations and faulty electrical outlets.

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

Based on review of facility documentation, staff interview, performance testing, and observations, the facility was determined to be in compliance with the NFPA 101 Life Safety Code; 1967 Existing Edition.

The inspection was conducted due to multiple allegations of physical, verbal, and sexual abuse, neglect, and misappropriation of resident property reported by residents and visitors, which were not properly reported or investigated by the facility.

The facility failed to report or prevent further potential abuse during investigations of multiple allegations, including physical, verbal, sexual abuse, neglect, and misappropriation of property. Additionally, the facility failed to provide necessary treatment and preventive care for a resident with a pressure sore, which progressed to a Stage III pressure sore due to lack of assessment and intervention.

The complaint investigation revealed that the facility did not report or prevent further abuse during investigations of multiple allegations including physical, verbal, sexual abuse, neglect, and misappropriation of property. The sexual abuse allegation was reported to Adult Protective Services by a source other than the facility.