Inspection Reports for White Sulphur Springs Center

An unannounced onsite revisit survey was conducted at White Sulphur Springs Healthcare from August 20 to August 21, 2024.

The facility was found to be 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.

An unannounced annual recertification and relicensure survey was conducted including complaint investigations and review of residents' clinical records and facility documentation.

The facility was cited for multiple deficiencies including failure to provide necessary behavioral health care and psychiatric services, failure to employ qualified dietary staff, failure to revise care plans timely, improper disposal of garbage, inaccurate nurse staffing data, incomplete resident records, failure to provide person-centered care for dementia, failure to follow physician orders for nutrition and psychotropic medications, failure to maintain infection control during meal service, and environmental safety issues such as broken window panes and fire drill documentation.

Complaints 33009 and 31578 substantiated; 32434, 32599, and 30624 unsubstantiated.

Routine inspection to assess compliance with NFPA fire safety codes, kitchen safety, sprinkler system maintenance, electrical safety, emergency preparedness, and other regulatory requirements.

The facility had multiple deficiencies including improper egress door signage and locking, lack of kitchen suppression system inspections, sprinkler system maintenance issues, unsealed smoke barrier penetrations, electrical safety violations, incomplete emergency preparedness plan, and missing fire drills documentation. Corrective actions and education were provided with plans for audits and follow-up.

The document is a Statement of Deficiencies and Plan of Correction related to a facility survey.

The facility was found in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

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

The facility was found to be in substantial compliance with the applicable federal and state regulations, with credible evidence accepted in lieu of an onsite revisit. Previously cited deficient practices were corrected.

An unannounced annual recertification and relicensure survey was conducted to assess compliance with federal regulations for nursing home care.

The facility was found deficient in multiple areas including accuracy of resident assessments, pressure ulcer care, infection prevention and control, sufficient nursing staff, food quality and safety, environmental safety, pest control, PASARR coordination, meal/snack provision, and catheter care.

The inspection was conducted to assess compliance with NFPA 101 life safety code requirements and other regulatory standards related to emergency egress doors, emergency lighting, electrical systems maintenance, and generator testing.

The facility was found deficient in several areas including delayed-egress locking systems not installed according to NFPA 101, emergency lighting not functioning properly, failure to maintain and test electrical receptacles at patient bed locations, and missing documentation for generator load bank testing. Corrective actions and audits were planned or initiated for each deficiency.

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

The facility, White Sulphur Springs Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules, with previously cited deficient practices corrected.

The survey was a complaint investigation survey concluding on 05/24/2022, with plans of correction accepted in lieu of an onsite revisit.

An unannounced complaint investigation survey was conducted at White Sulphur Springs Center from May 23-24, 2022, based on multiple complaints received.

The facility was found deficient in maintaining a safe, clean, and homelike environment due to faulty faucets in several resident rooms, failure to thoroughly investigate an alleged elopement, and emergency exit doors that failed to open properly. Some complaints were substantiated with related deficiencies cited.

Complaint #25763 was unsubstantiated with no deficiencies cited. Complaint #25863 was unsubstantiated with no deficiencies cited. Complaint #26873 was substantiated with related deficiencies at F584 and F921. Complaint #26867 was unsubstantiated with no deficiencies cited. Complaint #26871 was substantiated with related deficiencies at F610 and F921.

An unannounced annual recertification and annual relicensure survey was conducted at White Sulphur Springs Center from November 29-December 1, 2021.

The survey identified multiple deficiencies including failure to treat residents with dignity during dining, failure to respect resident self-determination, unresolved wheelchair brake grievances, failure to post survey results accessibly, inadequate grievance process education, verbal and mental abuse of a resident, incorrect oxygen therapy settings, improper food storage, and lapses in infection control practices including improper PPE use and lack of resident hand hygiene before meals.

The inspection was conducted as an annual recertification survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.

The White Sulphur Springs Center 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 as an annual survey to assess compliance with federal and state regulations, including fire safety and resident rights.

The facility was found deficient in enclosing vertical openings between floors with appropriate fire resistance and in conducting required quarterly fire drills on all shifts. The facility was compliant with emergency preparedness requirements.

An unannounced revisit was conducted at White Sulphur Springs Center on January 6, 2021, for the annual recertification/licensure survey concluding on October 8, 2020.

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

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on 12/21/20.

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

An unannounced annual re-certification and annual re-licensure survey was conducted at White Sulphur Springs Center from 10/05/20 through 10/08/20.

The survey identified multiple deficiencies including failure to ensure residents were treated with dignity, failure to accommodate resident choices, failure to notify physicians of significant changes, failure to maintain a safe and homelike environment, inaccurate assessments, incomplete care plans, inadequate pain management, improper medication storage and labeling, unsanitary kitchen conditions, and failure to provide appropriate catheter care and enteral feeding.

The inspection was conducted to assess compliance with maintenance and testing requirements for the facility's Essential Electric System, specifically regarding the annual fuel quality test for the generator.

The facility failed to conduct the required annual fuel quality test for the generator as mandated by NFPA 110. This deficiency was verified through document review and staff interviews and acknowledged by the Administrator.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on July 29-30, 2020.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to emergency preparedness, and CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness Survey were conducted by the state survey agency on June 10, 2020.

The facility was found in compliance with infection control regulations (42 CFR 483.80) and emergency preparedness requirements (42 CFR 483.73 related to E-0024 (b)(6)).

The inspection was conducted as a complaint investigation survey based on complaints #23361 and #23246, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, White Sulphur Springs Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules, with previously cited deficient practices corrected.

Complaint investigation survey concluding on 01/24/20 for complaints #23361 and #23246. The facility was in substantial compliance with previously cited deficient practices.

An unannounced complaint survey was conducted at White Sulphur Springs Center from 01/20/20 to 01/22/20 based on complaints #23361 and #23246. Complaint #23361 was unsubstantiated with no deficiencies cited, while complaint #23246 was substantiated with related and unrelated deficiencies cited.

The facility was found deficient in multiple areas including failure to revise care plans when residents' advanced directive status changed, failure to ensure residents received therapeutic diets as ordered, inaccurate and incomplete medical record documentation of resident weights, and failure to maintain a safe, sanitary, and comfortable environment as evidenced by feces found on the floor of a resident's room during meal service.

Complaint #23361 was unsubstantiated with no deficiencies cited. Complaint #23246 was substantiated with related deficiencies cited at F692 and unrelated deficiencies cited at F657, F842, and F921.

The inspection was conducted as a complaint investigation survey related to complaint references #22661 and 22774, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, White Sulphur Springs Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules, with previously cited deficient practices addressed satisfactorily.

Complaint investigation survey concluding on 09/19/19 related to complaint references #22661 and 22774; facility found in substantial compliance with previously cited deficiencies.

An unannounced complaint survey was conducted at White Sulphur Springs Center from 09/16/19 to 09/19/19 based on substantiated complaints #22661 and #22774, and an unrelated deficiency.

The facility was found deficient in ensuring timely delivery of resident mail, notifying physicians of significant changes in residents' conditions including urinary voiding, monitoring therapeutic diets especially for residents at risk of choking, and following up on physician recommendations for physical therapy. Additionally, the facility failed to maintain accurate medical records, including misfiling death certificates in a resident's chart.

Complaint #22661 was substantiated with deficiencies cited at F576, F580, F658, F684, and F726. Complaint #22774 was substantiated with deficiencies cited at F600 and F684.

The inspection was conducted as a complaint investigation survey related to complaint reference #22264, concluding on 05/30/19.

The White Sulphur Springs Center was found to be 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 facility was in substantial compliance with previously cited deficient practices based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Complaint reference: #22264. The complaint investigation survey concluded on 05/30/19 with the facility found in substantial compliance.

An unannounced complaint survey was conducted at White Sulphur Springs Center from 05/28/19 to 05/30/19 based on complaint #22264 which was substantiated with related deficiencies cited.

The facility was found deficient in multiple areas including failure to notify a physician of a resident's pain after a fall, failure to ensure residents were free from abuse and neglect, inaccurate assessment coding related to a urinary tract infection, environmental hazards blocking an emergency exit, and inadequate pain management for a resident.

Complaint #22264 was substantiated with related deficiencies cited at F580, F600, and F697 and unrelated deficiencies cited at F689 and F641.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.

The facility was found to be in substantial compliance with the regulatory requirements, and the review of plans of correction and credible evidence was accepted in lieu of an onsite revisit. The facility was also in substantial compliance with previously cited deficient practices.

The inspection was conducted to assess the facility's compliance with the 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.

An unannounced annual re-certification and annual re-licensure survey was conducted at White Sulphur Springs Center from 02/11/19 through 02/14/19. The survey included observations, record reviews, resident, family and staff interviews, and review of facility documentation.

The facility was found deficient in multiple areas including reasonable accommodations, advance directives, grievance processes, care plan development and revision, quality of care, accident prevention, nutrition and hydration, respiratory care, pain management, medication labeling and storage, assistive devices for eating, confidentiality of resident records, and infection control practices.

Complaint Reference #21942 was substantiated with related deficiencies at F558 and F584.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.

The facility, White Sulphur Springs Center, was found to be in substantial compliance with the applicable federal and state regulations based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

An unannounced off hours annual recertification survey, relicensure survey and complaint investigation was conducted from 2018-02-19 through 2018-02-22. The complaint was unsubstantiated.

The facility was found deficient in multiple areas including accuracy of assessments, baseline and comprehensive care plans, quality of care, nutrition and hydration, dialysis services, restorative therapy, and medical record documentation. Deficiencies involved failure to accurately complete Minimum Data Set (MDS), develop timely care plans, implement physician orders, maintain nutritional status, provide restorative therapy as ordered, and document hospital transfers.

Complaint Reference #19587 was unsubstantiated with no related or unrelated deficiencies cited.

Routine inspection to assess compliance with fire safety, electrical systems, and other facility maintenance standards including NFPA codes.

The facility had multiple deficiencies related to fire safety systems including sprinkler piping loaded with wiring, fire extinguishers not maintained, smoke barriers with damaged drywall, missing fire drill times, electrical wiring issues, lack of GFCI receptacles near sinks, untested electrical patient-care equipment, and unsecured oxygen cylinder storage.

An unannounced revisit was conducted at White Sulphur Springs from 02/27/17 to 03/02/17 to complete a Quality Indicator Survey concluding on 12/15/16.

The facility was found to have corrected the previously cited deficient practices as reflected in the CMS-2567B. The revisit survey sample consisted of 18 residents.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted from December 5, 2016 through December 15, 2016, including an extended survey completed on December 15, 2016.

The facility was found deficient in multiple areas including failure to resolve grievances promptly, failure to protect a resident from potential abuse, failure to ensure dignity and respect, failure to maintain sanitary and homelike environment, failure to provide medically-related social services, failure to provide effective pain management, failure to revise care plans after incidents, failure to provide services per care plan, failure to maintain safe and comfortable environment, failure to maintain infection control, failure to post accurate nurse staffing data, and failure to provide adequate resident call systems.

The inspection was conducted to assess compliance with various NFPA (National Fire Protection Association) codes related to life safety, fire protection, electrical systems, and gas equipment in the facility.

The facility was found deficient in multiple areas including self-closing doors, sprinkler system maintenance, corridor door smoke resistance, electrical wiring and equipment safety, generator maintenance, oxygen cylinder storage, and staff training on medical gas handling. Deficiencies were discussed with facility leadership and plans of correction were submitted.

An unannounced revisit was conducted from December 15 to December 17, 2015, to follow up on the Quality Indicator Survey concluding on September 30, 2015.

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

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code Standard, specifically regarding exit access accessibility.

The facility failed to provide exit access that was readily accessible at all times, as the exit discharge path from the main dining hall led to a parking space occupied by a parked car, blocking safe evacuation for residents needing assistance. The egress pathway was also blocked by vehicles parking over the sidewalk.

An unannounced off hour annual Quality Indicator Survey was conducted at White Sulphur Springs Center from September 27, 2015 through September 30, 2015 to assess compliance with federal regulations.

The survey identified multiple deficiencies including inaccurate resident assessments, failure to provide individualized activity programs, failure to maintain accurate care plans, failure to ensure dignity during meal service, failure to provide adequate nutrition and hydration, failure to maintain infection control, and failure to post nurse staffing information timely.

This document is a plan of correction related to a prior Quality Indicator and Licensure Survey, accepted in lieu of an onsite revisit.

The facility, White Sulphur Springs Center, 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.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards and other regulatory requirements related to facility safety and resident rights.

The facility failed to maintain doors in exit passageways, smoke barrier walls, smoking areas, combustion air for mechanical equipment, and electrical wiring according to NFPA 101 Life Safety Code standards. Multiple deficiencies were identified including delaminating doors, penetrations in smoke barriers, improper disposal of cigarette butts, lack of outside combustion air for hot water heaters, and electrical receptacles not meeting code requirements.

An unannounced annual Quality Indicator Survey was conducted at White Sulphur Springs Center from July 21, 2014 through July 23, 2014 to assess compliance with regulatory requirements.

The survey identified multiple deficiencies including failure to implement a resident's care plan to maintain a clutter-free environment, unsafe bed rails with entrapment risks for two residents, an unlocked medical supply closet with hazardous chemicals accessible to residents, failure to act on a pharmacist's medication recommendation, and disorganized clinical records with documents for one resident found in another's chart.

The inspection was conducted as a complaint investigation based on complaint reference 13265/9075.

The complaint was found to be unsubstantiated and no citations were issued.

Complaint Reference: 13265/9075. Unsubstantiated complaint record with no citations.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for the White Sulphur Springs Center.

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).

Quality Indicator and Licensure Surveys conducted to assess compliance with regulatory requirements and quality indicators.

The facility was found deficient in multiple areas including failure to maintain residents' dignity, inaccurate resident assessments, incomplete care plans, failure to provide care according to care plans, failure to maintain accurate medical records, failure to monitor and manage medications properly, failure to prevent pressure ulcers, and failure to maintain infection control protocols.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including generator maintenance and the proper installation of Alcohol Based Hand Rub (ABHR) dispensers in corridors.

The facility failed to maintain battery-powered emergency lighting at the emergency generator transfer switch as required by NFPA 110. Additionally, two ABHR dispensers were found installed directly over electrical outlets (ignition sources) in corridors on the 200 and 400 wings, violating life safety code standards.

The inspection was conducted as a complaint investigation related to concerns about documentation and care practices at the facility from 07/25/12 to 07/26/12.

The investigation found that staff had not consistently completed ADL flow sheets documenting baths/showers for residents on two hallways (200 and 300). However, observations and interviews confirmed that baths were being given as required, indicating a documentation issue rather than a care provision problem.

Complaint Reference: 12119 / 7138. The complaint was unsubstantiated with an unrelated citation.

Complaint investigation based on substantiated complaints #11200 and #11248 regarding non-compliance with State nursing home licensure and Federal Medicare/Medicaid certification requirements.

The facility was found deficient in multiple areas including failure to investigate and report an unexplained bruise on a resident, failure to operationalize abuse and neglect policies, failure to promote dignity during mealtime, failure to respond to resident council concerns, failure to provide necessary care to maintain residents' well-being including neurological assessments after falls, failure to assist dependent residents with eating, insufficient nursing staff to meet care needs, and failure to ensure meal timing compliance.

Complaint references #11200 and #11248 were substantiated with deficiencies cited for non-compliance with State nursing home licensure and Federal Medicare/Medicaid certification requirements.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for the White Sulphur Springs Center.

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 substantiated complaint investigation (#11152) concurrently with a revisit to the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.

The facility failed to provide necessary care and services to assist two residents (#60 and #59) in attaining or maintaining their highest practicable physical well-being. Specifically, staff did not conduct a thorough physical assessment or notify the physician when Resident #60 had difficulty swallowing medications and vomiting, and staff failed to timely initiate the bowel protocol for Resident #59 who had no bowel movement for three consecutive days.

Complaint reference #11152 was substantiated with deficiencies cited. The complaint investigation was conducted concurrently with a revisit to the annual certification resurvey and state licensure inspection.

The inspection was conducted to assess compliance with federal regulations regarding resident care, medication administration, laboratory services, and facility policies.

The facility was found deficient in providing necessary care and services to maintain residents' well-being, timely administration of physician-ordered medications, proper labeling of medications, and obtaining ordered laboratory services. Specific issues included failure to assess and notify physicians about residents' swallowing difficulties, failure to implement bowel protocols, delayed antibiotic administration, and failure to obtain ordered lab tests.

Routine inspection of White Sulphur Springs Center to assess compliance with federal regulations related to resident rights, care planning, infection control, medication administration, and facility safety.

The facility was found deficient in multiple areas including failure to ensure resident rights and reasonable accommodations, incomplete assessments and care plans, inadequate supervision during meals leading to choking risk, improper medication administration, failure to follow bowel protocols, unsanitary food handling, delayed laboratory and diagnostic services, and poor infection control practices.

The inspection was conducted as an annual survey to assess compliance with health and safety regulations, including life safety code standards and facility policies.

The facility was found to have multiple deficiencies related to life safety code standards, including failure to mark doors that are not exits, failure to maintain hazardous area doors with self-closing devices, improper storage of oxygen cylinders, and non-compliance with electrical wiring standards.

This document is a plan of correction related to deficiencies identified during a prior inspection of the White Sulphur Springs Center nursing 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, as required by federal regulations.

The inspection was conducted as a complaint investigation related to complaint reference #10109, which was found to be unsubstantiated with unrelated deficiencies cited.

The facility failed to ensure the resident environment was free of accident hazards as two clear plastic medication cups containing ointments were left unattended on the overbed table of a visually impaired resident who could not self-administer medications. The director of nursing agreed the ointments should not have been left in the resident's room.

Complaint reference #10109 was unsubstantiated with unrelated deficiencies cited.

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

Based on review of facility documentation, staff interview, observations, and performance testing, the facility was found to be without waivers and in compliance with the Life Safety Code.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident rights, comprehensive assessments, drug regimen, food service, sanitary conditions, and medical record accuracy at the nursing facility.

The facility was found deficient in multiple areas including inaccurate resident assessments, use of unnecessary antipsychotic medication without proper indication or non-pharmacological interventions, failure to provide attractive meals with garnishes, unsanitary food handling contaminating the ice machine, and incomplete or inaccurate medical records for residents.

The inspection was conducted as a comprehensive annual survey of the White Sulphur Springs Center to assess compliance with federal regulations related to resident rights, care planning, medication administration, infection control, dietary services, and staff qualifications.

The facility was found deficient in multiple areas including failure to implement abuse/neglect policies properly, incomplete comprehensive assessments and care plans, unclear physician orders for medication administration, unnecessary use of antipsychotic drugs, failure to follow dietary menus and sanitary food handling practices, delays in medication administration, improper wound care, and failure to prohibit employment of a nursing assistant with a felony drug conviction.

The inspection was conducted to evaluate the facility's compliance with NFPA 101 Life Safety Code standards, specifically the maintenance and functionality of the fire alarm system.

The facility failed to maintain all components of the fire alarm system in accordance with NFPA 72. During testing, the automatic dialing system did not send a required trouble signal to the fire alarm annunciator panel when primary and secondary phone lines were disconnected.

This document is a plan of correction submitted in response to a prior inspection, specifically a paper revisit.

The document references a deficiency related to the facility's obligation to inform residents of their rights and services, but no detailed findings are provided in this excerpt.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, including smoke barrier integrity, fire drills, and emergency generator maintenance.

The facility failed to maintain smoke barrier walls with the required fire resistance rating due to unsealed openings around sprinkler pipes and electrical conduits. Additionally, fire drills were not conducted quarterly on each shift, and the emergency generator transfer switch lacked the required battery-powered emergency illumination light.

The inspection was conducted as an annual survey to assess compliance with state and federal regulations for nursing facilities, including resident rights, care planning, infection control, and staffing.

The facility was found deficient in multiple areas including failure to properly document determinations of resident incapacity, inaccurate transfer/discharge notices, incomplete and non-measurable care plans, improper medication administration practices, inadequate monitoring of dialysis patients, failure to post accurate nurse staffing data, failure to follow prescribed diets, lapses in infection control practices, and incomplete clinical records.

Paper revisit to review the facility's plan of correction following previous deficiencies.

The document contains a statement of deficiencies related to resident rights and notification requirements, with a focus on the facility's plan of correction.

The inspection was conducted as a standard annual survey of the White Sulphur Springs Center to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including documentation of resident transfers, notification of resident rights and bed-hold policies, sanitary conditions in food preparation and service, infection control practices related to medication administration and linens, and failure to maintain negative air pressure in soiled linen rooms.

The inspection was conducted as a standard regulatory survey to assess compliance with life safety code standards and other facility requirements.

The facility was found deficient in maintaining fire safety standards including unsealed smoke barrier penetrations, obstructed exit access, incomplete fire drills, corroded sprinkler heads, and inadequate inspection and maintenance of the range hood extinguishing system.

This document is a plan of correction related to a paper revisit survey of the White Sulphur Springs Center.

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

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

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

Annual inspection survey conducted to assess compliance with federal regulations regarding resident rights, quality of care, infection control, dietary services, and facility environment.

The facility was found deficient in multiple areas including failure to involve residents in medical decisions, failure to provide mail on Saturdays, inadequate smoking policy participation, uncomfortable room temperature, incomplete care plans, improper medication administration, failure to enforce fluid restrictions, unsecured utility room, improper handwashing technique, incorrect dietary servings, contamination during venipuncture, and inaccurate clinical records.

Complaint investigation related to substantiated complaint record #2-4112 regarding quality of care and nursing staff competency.

The facility failed to provide care in accordance with professional standards for one resident regarding medication administration, failed to prevent pressure sores and provide necessary treatment for four residents, and failed to ensure nurse aides demonstrated competency in the use of Plexus air therapy mattresses.

Complaint reference #2-4112 was substantiated with deficiencies cited.

Annual inspection of White Sulphur Springs Center to assess compliance with federal regulations related to resident rights, quality of life, resident assessments, care planning, medication administration, dietary services, infection control, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to ensure resident rights were exercised according to state law, inadequate promotion of resident dignity, incomplete resident assessments and care plans, failure to administer medications as ordered, inadequate supervision to prevent accidents, failure to provide therapeutic diets as ordered, poor dietary service practices including food preparation and sanitation, and ineffective infection control practices.

The inspection was conducted as a complaint investigation referenced as #2-3267, which was substantiated with deficiencies cited.

The facility failed to provide ordered medications in a timely manner for three of ten sampled residents (#64, #29, and #52). Medication administration delays were due to pharmacy supply issues and inability to administer medications as ordered.

Complaint reference #2-3267 was substantiated with deficiencies cited related to medication administration delays.

Complaint investigation referenced as #2-3194 to address concerns raised about the facility.

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

Complaint reference # 2-3194. Substantiated complaint report with No deficiencies.

The inspection was conducted to determine the facility's compliance with the Life Safety Code NFPA 101 - 2000 existing, based on observation, performance testing, and review of facility documentation from 09/15/03 to 09/18/03.

The facility was found to be in compliance with the Life Safety Code NFPA 101 - 2000 existing during the inspection period.

Annual survey of White Sulphur Springs Center to assess compliance with federal regulations related to resident rights, care, dietary services, infection control, and facility environment.

The facility was found deficient in multiple areas including resident rights and care planning, medication administration, dietary services, infection control, and environmental sanitation. Specific issues included improper surrogate appointment, failure to prevent self-administration of drugs, unreported abuse allegations, inadequate resident positioning, untimely lab work and assessments, poor food handling and preparation, and failure to maintain comprehensive care plans and discharge summaries.

The inspection was conducted based on complaints regarding resident care, including concerns about legally appointed representatives making health care decisions, resident hygiene and grooming prior to doctor's appointments, and oral care implementation.

The facility failed to ensure that the legally appointed representative made health care decisions for one resident, did not assure that three residents were bathed and groomed according to their preferences before transport to doctors' appointments, and did not implement the care plan for oral hygiene for one resident.

The investigation was complaint-driven, with substantiated findings that the facility failed in areas of resident rights, quality of life, and quality of care as related to specific residents (#44, #11, and #39).

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically focusing on staff familiarity with emergency fire plan procedures and the maintenance and testing of sprinkler systems.

The inspection found that not all facility staff were familiar with the emergency fire plan procedures related to fire alarm equipment, as evidenced by incorrect identification of fire alarm zones during a fire drill. Additionally, the facility sprinkler system was not inspected and tested according to NFPA 25 standards, with the last dry pipe full flow trip test exceeding the required three-year testing interval.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations regarding resident rights, quality of life, quality of care, dietary services, infection control, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to ensure residents' rights to vote, inadequate designation of legal surrogates, failure to maintain resident dignity, lack of resident choice in meals, improper treatment of pressure sores, failure to provide palatable pureed diets, inaccurate diet orders, and inadequate infection control practices.

The inspection was conducted in response to Complaint #2-2194 concerning the facility's failure to fully inform a resident's medical power of attorney (MPOA) about the resident's health status and behavioral issues, and failure to provide proper discharge notice.

The facility failed to fully inform the MPOA of the resident's total health status, including discontinuation and administration of antipsychotic medications related to behavioral problems. The MPOA was not properly notified of the seriousness of the resident's behaviors until late July 2002. Additionally, the facility failed to provide a timely 30-day discharge notice to the MPOA, sending it to an outdated address.

Complaint #2-2194 involved failure to inform the MPOA about the resident's health status and behavioral issues, and failure to provide a proper 30-day discharge notice. The complaint was substantiated based on medical record review, family and staff interviews.

The inspection was conducted to assess compliance with regulatory requirements, including verification of nurse aide registry status and resident rights notifications.

The facility failed to verify the nurse aide registry status for one nursing assistant before allowing employment. Interviews confirmed the nurse aide worked without registry verification and was removed from the schedule pending approval. Additional findings relate to resident rights notification requirements.

The visit was conducted as a complaint investigation (#2-2063) with entrance on 03/20/02 and exit on 03/21/02.

The complaint investigation was unsubstantiated with no deficiencies found during the visit.

Complaint Investigation #2-2063 was unsubstantiated with no deficiencies.

The inspection was conducted to determine the facility's compliance with the Life Safety Code NFPA 101 - 1981 New, based on observation, performance testing, and review of facility documentation from 02/26/02 to 02/27/02.

The facility was found to be in compliance with the Life Safety Code NFPA 101 - 1981 New during the inspection period.

Annual inspection survey conducted to assess compliance with federal regulations for nursing home care.

The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, lack of privacy during care, inadequate positioning and care planning, failure to implement physician orders, pressure ulcer prevention and treatment deficiencies, unsafe environment hazards, improper dietary services, unpleasant odors in resident rooms, infection control lapses, and failure to obtain ordered laboratory tests.

The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident rights, quality of care, and other facility obligations.

The facility was found deficient in ensuring proper exercise of resident rights, specifically regarding the timing of health care surrogate appointments and resuscitation decisions. Additionally, medication administration errors were identified for two residents, where medications were either not available or doses were omitted.

The inspection was conducted as a comprehensive annual survey of the White Sulphur Springs Center to assess compliance with federal regulations related to resident rights, quality of care, medication administration, infection control, and clinical record maintenance.

The facility was found deficient in multiple areas including improper exercise of resident rights, inadequate accommodation of resident needs, failure to develop comprehensive care plans, medication administration errors, lack of proper podiatric care, insufficient monitoring of antipsychotic drug use, infection control breaches, and incomplete or inaccurate clinical records, particularly regarding advance directives and code status.

The inspection was conducted in response to Complaint #21130 to investigate allegations related to quality of care.

The facility failed to provide proper incontinence care to three residents, as staff did not use soap or cleansing agents as required by facility policy when cleaning residents after incontinent episodes.

Complaint #21130 was investigated and substantiated based on observations, record review, and staff interviews indicating deficient incontinence care.

The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations related to resident rights, quality of care, abuse prevention, and infection control at the White Sulphur Springs Center.

The facility was found deficient in multiple areas including failure to ensure residents' rights to formulate advance directives, failure to protect residents from verbal abuse by other residents, inadequate provision of portable oxygen for residents requiring oxygen therapy, failure to provide CPR and medication as ordered, inadequate supervision to prevent accidents, and use of unnecessary medications without adequate clinical indications.

The inspection was conducted as a comprehensive annual survey of the White Sulphur Springs Center nursing facility to assess compliance with federal regulations and standards.

The facility was found to have multiple deficiencies including improper use of physical restraints, failure to report abuse allegations timely, inadequate quality of care in bladder training and range of motion maintenance, failure to provide psychiatric consultation, unsafe medication administration practices, poor infection control including hand hygiene and cohorting practices, unsafe physical environment conditions, and unsanitary dietary service practices.

The inspection was conducted to assess compliance with the NFPA 101 Life Safety Code standards related to building construction type, fire resistance, and ventilation systems.

The inspection found that the fire rated construction type of the building was not completely maintained due to unsealed recessed ceiling light fixtures in multiple locations. Additionally, ventilation equipment was not installed according to NFPA 90A standards, with exhaust fans discharging into attic space without ductwork and attic construction using combustible materials.

The document is a Statement of Deficiencies and Plan of Correction for a nursing facility inspection, addressing regulatory compliance related to resident rights and physical environment safety.

The facility was found deficient in informing residents of their rights and services, and had physical environment issues including a manual sliding dead bolt locking device that prevented emergency egress and an inoperable nurse call system on emergency power affecting 19 beds.

The document is a plan of correction related to deficiencies identified during a facility inspection, specifically addressing fire safety code violations.

The facility was found to have penetrations in smoke barrier walls by PVC piping without fire rated protective collars, reducing the one-hour fire rated construction requirement.

The inspection was conducted following complaints regarding residents' rights, privacy, quality of life, social services, environment, noise levels, dietary services, and infection control at the White Sulphur Springs Center.

The facility was found deficient in multiple areas including denial of resident rights to independent decision making, failure to ensure personal privacy, inadequate dining environment, failure to address resident grievances, lack of appropriate activities, insufficient social services support, improper use of resident lounge as storage, failure to maintain comfortable sound levels, inadequate range of motion treatment, failure to provide bedtime snacks consistently, and improper infection control practices.

The complaint investigation focused on Resident #48's rights to independent decision making and discharge planning, privacy concerns due to wanderers entering rooms, quality of life issues including dining environment and noise disturbances, lack of resident activities, social services failures, environmental concerns about use of resident lounge, dietary service issues with bedtime snacks, and infection control practices.