Inspection Reports for Wishing Well Assisted Living Community at Fairmont

1543 COUNTRY CLUB ROAD, WV, 26554

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Deficiencies (last 17 years)

Deficiencies (over 17 years) 3.9 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

57% better than West Virginia average
West Virginia average: 9 deficiencies/year

Deficiencies per year

16 12 8 4 0
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025

Census

Latest occupancy rate 24 residents

Based on a June 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Census over time

0 20 40 60 Mar 2009 Jan 2011 Nov 2013 Dec 2017 Jan 2021 Jun 2024 Jun 2025
Inspection Report Annual Inspection Census: 24 Deficiencies: 0 Jun 11, 2025
Visit Reason
The document is an annual survey inspection conducted from 06/09/25 to 06/11/25 at Wishing Well Assisted Living Community A.
Findings
No deficiencies were cited during this annual survey inspection.
Report Facts
Census: 24
Inspection Report Plan of Correction Census: 6 Deficiencies: 2 May 14, 2025
Visit Reason
The document is a plan of correction review following a behavioral health survey conducted from February 9-11, 2004, to address deficiencies related to safety and supervision in the facility.
Findings
The initial survey found that the facility did not provide a safe environment for adolescent consumers, including lack of alarms on outside doors and insufficient awake staff on weekend nights. The plan of correction was reviewed and deficiencies were corrected as of May 14, 2025.
Deficiencies (2)
Description
The adolescent girls' bedrooms have outside doors without alarms or alert devices, and staff are not awake on weekend nights to monitor consumers.
An outside door in the TV room does not lock.
Report Facts
Center census: 6 Sample size: 3
Inspection Report Complaint Investigation Census: 22 Deficiencies: 3 Mar 24, 2025
Visit Reason
The inspection was conducted as an investigation of Complaint #37917 regarding regulatory compliance and licensing issues at the assisted living facility.
Findings
The complaint was substantiated with deficiencies cited including failure to notify the Secretary of a permanent change in the administrator within 10 days, failure to submit a license renewal application at least 90 days prior to expiration, and inadequate housekeeping and maintenance.
Complaint Details
Investigation of Complaint #37917 dated 03/24/25. The complaint was substantiated and deficiencies were cited.
Severity Breakdown
Class III: 1 Class II: 1
Deficiencies (3)
DescriptionSeverity
Failure to notify the Secretary in writing within 10 days of any permanent change in the administrator of the residence.Class III
Failure to submit an application to renew the license at least 90 days prior to expiration.Class II
Failure to ensure adequate housekeeping and maintenance required to carry out services, including damaged carpet, missing towel bars, and dirty sink.
Report Facts
Census: 22 License expiration date: Mar 22, 2025 License renewal check date: Mar 17, 2025
Employees Mentioned
NameTitleContext
Unit ManagerInterviewed regarding notification of Secretary about administrator change and license renewal
Nursing Home AdministratorNamed in plan of correction for failure to notify Secretary and license renewal
Inspection Report Annual Inspection Census: 29 Deficiencies: 0 Jul 3, 2024
Visit Reason
The inspection was conducted as the facility's annual survey from July 1, 2024 to July 3, 2024.
Findings
The annual survey found no deficiencies cited at the facility during the inspection period.
Report Facts
Census: 29
Inspection Report Annual Inspection Census: 27 Deficiencies: 0 Jun 27, 2024
Visit Reason
The inspection was an Environmental-Annual survey conducted to assess compliance with health and safety regulations at the assisted living facility.
Findings
The survey found no deficiencies, with no violations reported by the Fire Marshall or Health Department. The facility was compliant with all inspected environmental and safety standards.
Report Facts
Sample size: 100 Fire Marshall violations: 0 Health Department violations: 0 Sprinkler count: 13
Inspection Report Annual Inspection Census: 25 Deficiencies: 0 Aug 21, 2023
Visit Reason
The inspection was conducted as an annual survey of the assisted living facility.
Findings
The annual survey found no deficiencies cited during the inspection period from August 14 to August 21, 2023.
Report Facts
Census: 25
Inspection Report Annual Inspection Census: 24 Deficiencies: 0 Aug 15, 2023
Visit Reason
The inspection was conducted as an annual environmental survey to assess compliance with state requirements for the assisted living facility.
Findings
The facility was found to be in substantial compliance with the applicable state rules based on review of documentation, staff interviews, observations, and performance testing. No deficiencies or tags were cited during this inspection.
Report Facts
Census: 24
Inspection Report Annual Inspection Census: 29 Deficiencies: 0 Aug 25, 2022
Visit Reason
The inspection was conducted as an annual survey of the assisted living facility.
Findings
The annual survey found no deficiencies cited during the inspection conducted from August 23 to August 25, 2022.
Report Facts
Census: 29
Inspection Report Annual Inspection Census: 31 Deficiencies: 0 Jun 21, 2022
Visit Reason
Annual environmental inspection of Wishing Well Assisted Living Community A conducted on June 21, 2022.
Findings
No deficiencies were cited during this annual environmental inspection. The Fire Marshal report dated June 22, 2022, included no recommendations.
Report Facts
Census: 31
Inspection Report Complaint Investigation Census: 31 Deficiencies: 0 Nov 17, 2021
Visit Reason
The inspection was conducted as a complaint investigation following a substantiated complaint received on 09/21/2021 regarding the facility.
Findings
The inspection found deficiencies related to the complaint; however, all citations were corrected by the time of the follow-up survey on 11/17/2021.
Complaint Details
Complaint #26034 was substantiated. The complaint investigation entrance was on 09/21/2021 with a census of 29, and a follow-up survey on 11/17/2021 showed all citations corrected.
Report Facts
Census at complaint investigation: 29 Census at follow-up survey: 31
Inspection Report Complaint Investigation Census: 29 Deficiencies: 2 Sep 22, 2021
Visit Reason
The inspection was conducted as a complaint investigation (Complaint #26034) regarding residents' rights to make choices about daily activities during a COVID-19 outbreak and the adequacy of housekeeping and maintenance services.
Findings
The facility failed to ensure residents' rights to make choices regarding daily activities, as group dining and activities were paused despite no positive COVID-19 cases. Additionally, inadequate housekeeping and maintenance were observed, including damaged carpets, missing bathroom fixtures, and unclean sinks.
Complaint Details
Complaint #26034 was substantiated. The complaint involved residents not being allowed to participate in group dining and activities during a COVID-19 outbreak despite negative test results and full vaccination status of residents and staff.
Severity Breakdown
Class III: 1
Deficiencies (2)
DescriptionSeverity
Failure to ensure residents were given the right to make choices regarding activities of daily life, including attending group dining and activities during COVID-19 outbreak.Class III
Inadequate housekeeping and maintenance including personal belongings left behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Facility census: 29 COVID testing rounds: 6 Sample size: 3
Inspection Report Annual Inspection Census: 28 Deficiencies: 0 May 6, 2021
Visit Reason
The inspection was conducted as the annual survey of Wishing Well Assisted Living Community A to assess compliance with regulatory requirements.
Findings
The annual survey found no deficiencies at the facility during the inspection period from May 3 to May 6, 2021.
Report Facts
Census: 28
Inspection Report Plan of Correction Deficiencies: 1 Mar 22, 2021
Visit Reason
The document is a plan of correction following a previous behavioral health survey conducted February 9-11, 2004, addressing deficiencies related to safety and supervision in the facility.
Findings
The deficiency involved inadequate safety measures such as lack of alarms on outside doors and insufficient awake staff supervision on weekend nights. The plan of correction states that staff deployment changes will be implemented by July 1, 2004, to provide awake-night supervision during weekend shifts.
Deficiencies (1)
Description
The Center did not implement programs in an environment that is safe and appropriate for the needs of the consumers, including lack of alarms on outside doors and insufficient awake staff on weekend nights.
Report Facts
Center Census: 6 Sample Size: 3 Plan of Correction Completion Date: Jul 1, 2004
Inspection Report Complaint Investigation Census: 26 Deficiencies: 1 Jan 27, 2021
Visit Reason
The inspection was conducted in response to a complaint (#25002) regarding a potential breach of resident confidentiality in electronic communications.
Findings
The administration failed to maintain Resident X's confidentiality in a mass email sent to families, which included visible email addresses of all residents. The complaint was substantiated, but Resident X did not experience any negative outcome. The facility reviewed electronic communications and implemented corrective actions to prevent future breaches.
Complaint Details
Complaint #25002 was substantiated. The breach involved a mass email sent on 09/30/20 to 98 families with visible email addresses. The facility reviewed communications for the past 60 days and found no further breaches. Resident X experienced no negative outcome.
Severity Breakdown
Class II: 1
Deficiencies (1)
DescriptionSeverity
Administration failed to maintain Resident X's confidentiality in electronic communication by sending a mass email that contained visible email addresses of all residents.Class II
Report Facts
Facility census: 26 Number of residents potentially affected: 26 Number of families emailed in breach: 98
Employees Mentioned
NameTitleContext
Administrator #43AdministratorSent mass emails using blind copy to protect privacy; responsible for corrective actions and education.
Administrator #45AdministratorFormer administrator who sent the mass email with visible email addresses; no longer works at the center.
Licensed Practical Nurse #32Licensed Practical NurseSpoke about mass emails and contacted Administrator #43.
Inspection Report Routine Census: 26 Deficiencies: 0 Jan 26, 2021
Visit Reason
The visit was conducted as an Infection Control Survey at the assisted living community.
Findings
The survey found no citations or deficiencies related to infection control during the inspection period.
Report Facts
Census: 26
Inspection Report Routine Census: 27 Deficiencies: 0 Dec 7, 2020
Visit Reason
The inspection was conducted as an environmental survey of the assisted living facility to assess compliance with health and safety regulations.
Findings
The facility was found to have no deficiencies during the environmental survey conducted on December 7, 2020.
Report Facts
Facility census: 27
Inspection Report Annual Inspection Deficiencies: 0 Feb 24, 2020
Visit Reason
Desk review completed for revisit to annual survey to verify correction of previous deficiencies.
Findings
Credible evidence was accepted and all previously cited deficiencies were corrected.
Inspection Report Annual Inspection Census: 24 Deficiencies: 3 Jan 22, 2020
Visit Reason
The inspection was conducted as an annual survey of Wishing Well Assisted Living Community to assess compliance with health care standards, personnel records maintenance, and housekeeping and maintenance requirements.
Findings
The facility failed to maintain confidential personnel records for the administrator and registered nurse on site, and failed to send pertinent medical information with residents upon transfer to hospital. Additionally, housekeeping and maintenance deficiencies were observed, including damaged carpet, missing bathroom fixtures, and unclean areas.
Deficiencies (3)
Description
Failed to maintain confidential personnel records for the administrator and registered nurse.
Failed to send pertinent medical information with two residents upon transfer to hospital.
Inadequate housekeeping and maintenance including damaged carpet, missing towel bar and toilet paper holder, and dirty sink.
Report Facts
Census: 24 Sample Size: 3
Employees Mentioned
NameTitleContext
Administrator #18AdministratorNamed in personnel record deficiency and interview regarding personnel files
Employee #17Director of NursingNamed in personnel record deficiency
LPN Supervisor #8LPN SupervisorInterviewed regarding transfer discharge documentation
Inspection Report Annual Inspection Census: 24 Deficiencies: 0 Jan 14, 2020
Visit Reason
The inspection was an annual environmental follow-up survey conducted to assess compliance with environmental standards at the assisted living community.
Findings
The survey found no deficiencies or concerns; no tags were cited, and no complaints were substantiated during the visit.
Report Facts
Sample size: 100 Census: 24
Inspection Report Routine Census: 24 Deficiencies: 7 Dec 11, 2019
Visit Reason
The inspection was conducted to assess the facility's compliance with maintenance, housekeeping, and physical environment standards to ensure a safe, sanitary, and accident-free living environment.
Findings
The facility failed to maintain the kitchen ceiling drywall patch and air supply vents, which were rusty and unsealed. Additional housekeeping deficiencies included personal belongings left behind furniture, carpet damage, missing bathroom fixtures, and a dirty sink. Corrective actions and plans of correction were documented.
Deficiencies (7)
Description
Three foot by two foot drywall patch on kitchen ceiling was not painted or sealed.
Ceiling air supply vents throughout the kitchen appeared rusty.
Miscellaneous small personal belongings behind dresser in girls bedroom.
Iron burn and bleach spots on carpet.
Chair in living room with more than one tear exposing stuffing.
Upstairs bathroom missing towel bar and toilet paper holder/bar.
Sink was dirty and in need of cleaning.
Report Facts
Facility census: 24 Drywall patch size: 6
Employees Mentioned
NameTitleContext
Maintenance SupervisorVerified findings and completed corrective actions such as painting and sealing drywall patch and sanding/painting vents
Nursing SupervisorVerified findings during facility tour
Administrator (NHA)Inspected kitchen and ensured no other drywall or rusty vents; responsible for re-education and audits
Inspection Report Annual Inspection Census: 26 Deficiencies: 0 Jan 28, 2019
Visit Reason
The visit was conducted as an annual licensure survey of the facility.
Findings
The annual licensure survey conducted from January 28-30, 2019, found no deficiencies at the facility.
Report Facts
Census: 26
Inspection Report Annual Inspection Census: 23 Deficiencies: 0 Dec 10, 2018
Visit Reason
The visit was conducted as an annual licensure survey for Wishing Well Assisted Living Community A.
Findings
The inspection found no deficiencies at the facility during the annual licensure survey.
Report Facts
Census: 23
Inspection Report Complaint Investigation Census: 28 Deficiencies: 0 Apr 23, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number WV00020165.
Findings
No deficiencies were cited during the complaint investigation conducted on April 23, 2018.
Complaint Details
Complaint Number: WV00020165. No deficiencies cited.
Report Facts
Census: 28
Inspection Report Annual Inspection Census: 30 Deficiencies: 0 Jan 17, 2018
Visit Reason
The visit was conducted as an annual licensure survey of the Wishing Well Assisted Living Community A facility.
Findings
No deficiencies were cited during this annual licensure survey conducted on January 16-17, 2018.
Report Facts
Census: 30
Inspection Report Annual Inspection Census: 29 Deficiencies: 0 Dec 4, 2017
Visit Reason
The visit was conducted as an annual licensure survey for Wishing Well Assisted Living Community A to assess environmental compliance.
Findings
No deficiencies were cited during this annual licensure survey, indicating compliance with applicable standards.
Report Facts
Census: 29
Employees Mentioned
NameTitleContext
Kenny SartinHealth Facility Surveyor IISurveyor conducting the annual licensure survey
Inspection Report Annual Inspection Census: 29 Deficiencies: 3 Jan 3, 2017
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with employee orientation, training requirements, and facility housekeeping and maintenance standards.
Findings
The facility was found deficient in ensuring all new employees received required orientation and training within 15 days of hire, including emergency procedures, resident rights, confidentiality, abuse prevention, and dementia-related training. Additionally, the facility failed to maintain adequate housekeeping and maintenance, with issues such as damaged carpet, missing bathroom fixtures, and unclean areas observed.
Deficiencies (3)
Description
Failure to ensure all new employees received training on emergency procedures, disaster plans, policies and procedures, resident rights, confidentiality, abuse prevention, and reporting within 15 days of hire.
Failure to provide training to all new employees within 15 days of employment and annually thereafter on Alzheimer's disease and related dementias, including communication approaches, prevention and management of problem behaviors, and appropriate activities and programming.
Failure to maintain adequate housekeeping and maintenance, including presence of personal belongings behind furniture, iron burns and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder in bathroom, and dirty sink.
Report Facts
Number of Deficiencies: 2 Census: 29 Training delay days: 309 Training delay days: 226 Training delay days: 95 Training delay days: 22 Training delay days: 21 Training delay days: 25 Training delay days: 32 Training delay days: 34 Training delay days: 126 Training delay days: 95
Employees Mentioned
NameTitleContext
Employee #6Licensed Practical NurseNamed in findings for delayed and incomplete orientation and specialty care training
Employee #8Personal Care AssistantNamed in findings for delayed and incomplete orientation training
Employee #16Registered NurseNamed in findings for delayed and incomplete orientation and dementia training
Employee #3Named in findings for outdated dementia training
Employee #11Named in findings for outdated dementia training
Employee #15Named in findings for outdated dementia training
Inspection Report Annual Inspection Census: 29 Deficiencies: 1 Jan 3, 2017
Visit Reason
The visit was conducted as an annual licensure survey of the assisted living facility.
Findings
Two deficiencies were identified during the annual licensure survey. A follow-up survey conducted on February 13, 2017, with a census of 30, confirmed that all deficiencies were corrected.
Deficiencies (1)
Description
Two deficiencies were cited during the annual licensure survey.
Report Facts
Deficiencies cited: 2 Census: 29 Census: 30
Inspection Report Annual Inspection Census: 29 Deficiencies: 2 Dec 12, 2016
Visit Reason
The inspection was conducted as an annual licensure survey to assess environmental conditions and compliance with disaster preparedness and physical facility maintenance regulations.
Findings
The facility was found deficient in completing the annual review of the disaster and emergency preparedness plan and maintaining the interior of the residence in clean and good repair, including a missing ceiling light cover in a resident bathroom.
Severity Breakdown
Class III: 1 Class II: 1
Deficiencies (2)
DescriptionSeverity
Failure to complete the disaster and emergency preparedness plan review on an annual basis.Class III
Failure to maintain the interior of the residence clean and in good repair, including a missing ceiling light cover in resident room 605 bathroom.Class II
Report Facts
Census: 29 Deficiencies cited: 2
Employees Mentioned
NameTitleContext
Maintenance SupervisorAgreed the disaster preparedness plan review had not been completed and the ceiling light cover needed replacement
Safety Committee ChairmanSigned and dated the updated disaster and emergency preparedness plan
AdministratorSigned and dated the updated disaster and emergency preparedness plan
Inspection Report Follow-Up Census: 32 Deficiencies: 0 Feb 1, 2016
Visit Reason
The visit was a follow-up survey conducted to verify compliance after the annual licensure survey conducted on December 14, 2015.
Findings
The follow-up survey was conducted to assess the status of previously cited deficiencies. The prior annual licensure survey cited deficiencies numbered 247 and 254.
Report Facts
Deficiencies cited: 2 Census: 33 Census: 32
Inspection Report Annual Inspection Census: 33 Deficiencies: 0 Jan 6, 2016
Visit Reason
The visit was conducted as an annual licensure survey of the assisted living facility.
Findings
The annual licensure survey conducted from January 4-6, 2016 found no deficiencies cited at the facility.
Report Facts
Census: 33
Inspection Report Annual Inspection Census: 33 Deficiencies: 2 Dec 14, 2015
Visit Reason
The visit was conducted as an annual licensure survey focusing on environmental conditions, including disaster and emergency preparedness, housekeeping, and physical facilities.
Findings
The facility was found deficient in updating emergency contracts annually and maintaining the interior and exterior of the residence in clean and good repair, including issues with light fixtures, sprinkler escutcheons, ceiling tiles, and general housekeeping.
Severity Breakdown
CLASS III: 1 CLASS II: 1
Deficiencies (2)
DescriptionSeverity
Failure to review and update the disaster and emergency preparedness plan annually, including signing and dating the plan to verify review.CLASS III
Failure to keep the interior and exterior of the residence clean and in good repair, including uncovered light fixtures, missing sprinkler escutcheons, damaged ceiling tiles, holes in walls, and missing dumpster lid.CLASS II
Report Facts
Deficiencies cited: 2 Census: 33
Inspection Report Annual Inspection Census: 34 Deficiencies: 0 Dec 22, 2014
Visit Reason
The visit was conducted as an Annual Licensure Survey and Environmental Survey to assess compliance with regulatory requirements.
Findings
There were no deficiencies cited during the environmental survey completed on 12/22/2014.
Report Facts
Census: 34
Inspection Report Annual Inspection Census: 36 Deficiencies: 0 Nov 19, 2014
Visit Reason
The inspection was conducted as an annual licensure survey of the Wishing Well Assisted Living Community A.
Findings
The report documents the annual licensure survey conducted from November 17-19, 2014, with a census of 36 residents. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 36
Inspection Report Annual Inspection Census: 29 Deficiencies: 0 Dec 11, 2013
Visit Reason
The visit was conducted as an annual licensure survey of the assisted living facility.
Findings
The report documents the annual licensure survey conducted from December 9 to 11, 2013, with a census of 29 residents. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 29
Inspection Report Annual Inspection Census: 30 Deficiencies: 0 Nov 19, 2013
Visit Reason
The inspection was conducted as an annual licensure survey of the Wishing Well Assisted Living Community A facility.
Findings
The annual inspection found no deficiencies or technical assistance needs. A light cover in the walk-in cooler was noted as cracked.
Report Facts
Census: 30
Inspection Report Annual Inspection Census: 30 Deficiencies: 13 Dec 19, 2012
Visit Reason
Annual licensure survey conducted to assess compliance with assisted living facility regulations including staffing, health care standards, employee training, and facility maintenance.
Findings
The facility was found deficient in multiple areas including inadequate housekeeping and maintenance, incomplete employee orientation and training, failure to maintain complete personnel records, incomplete resident health assessments and tuberculosis screenings, lack of physician orders for medications, and insufficient post-incident monitoring documentation. Corrective actions and plans of correction were provided for each deficiency.
Severity Breakdown
Class I: 3 Class II: 4 Class III: 4
Deficiencies (13)
DescriptionSeverity
Failure to maintain a safe and appropriate environment; unsecured doors and lack of awake weekend night staff.
Inadequate housekeeping and maintenance including damaged carpet, missing bathroom fixtures, and dirty sinks.
Failure to maintain written policies and procedures consistent with assisted living rules.Class III
Failure to submit required information for central abuse registry screening prior to hiring employees.Class II
Failure to notify licensing agency of permanent changes in administrator and supervising nurse within required timeframe.Class III
Inadequate staffing levels based on resident care needs.Class I
Failure to ensure all employees have current CPR certification.Class I
Failure to provide and maintain records of employee orientation and annual in-service training on required topics.Class II
Failure to maintain complete confidential personnel records including hire dates, registry checks, and TB screenings.Class III
Resident contract did not contain all required information and contained unclear or inconsistent wording.Class III
Failure to complete resident health assessments and tuberculosis screenings within required timeframes.Class II
Failure to obtain physician orders for medications administered to residents.Class I
Failure to monitor and document resident condition at least every eight hours for 24 hours following an accident.Class II
Report Facts
Resident census: 30 Residents with two or more care needs: 13 Minimum direct care staffing required: 2.25 Minimum direct care staffing required: 2 Minimum direct care staffing required: 1.75 Number of new employees without abuse registry screening: 3 Number of residents without timely health assessments or TB screenings: 6 Number of residents without physician medication orders: 2 Number of residents without proper post-incident monitoring: 4
Employees Mentioned
NameTitleContext
CWDirector of NursingNamed in findings related to failure to submit abuse registry screening and incomplete personnel records
CFAdministratorNamed in findings related to failure to submit abuse registry screening, incomplete personnel records, and failure to notify licensing agency of staff changes
CSLicensed Practical NurseNamed in findings related to incomplete personnel records and lack of required screenings; no longer employed
AHLicensed Practical NurseNamed in findings related to lack of CPR certification and incomplete personnel records
ABLicensed Practical NurseNamed in findings related to lack of annual training and incomplete personnel records
Inspection Report Annual Inspection Census: 30 Deficiencies: 0 Dec 17, 2012
Visit Reason
The inspection was conducted as an annual licensure survey of the assisted living community to assess compliance with regulatory requirements.
Findings
The report documents the annual licensure survey conducted from December 17-19, 2012, with a census of 30 residents. A follow-up survey was conducted on March 5, 2012, where deficiencies were corrected and technical assistance was provided.
Report Facts
Census: 30 Census: 29
Employees Mentioned
NameTitleContext
Deb DodrillLSW, HFS IISurveyor during the annual licensure survey
Donna WilliamsonRN, HFNS IISurveyor during the annual licensure survey and follow-up survey
Michelle ReddRN, HFNS ISurveyor during the annual licensure survey and follow-up survey
Elizabeth SmithRN, HFNS ISurveyor during the annual licensure survey
Inspection Report Complaint Investigation Census: 29 Deficiencies: 0 Dec 11, 2012
Visit Reason
The inspection was conducted as a complaint investigation from December 10 to 12, 2012, related to Wishing Well Assisted Living Community A.
Findings
The complaint investigation was partially substantiated, but no deficiencies were cited. Technical assistance was provided during the visit.
Complaint Details
Complaint investigation #WV00007433 was partially substantiated with no deficiencies cited.
Report Facts
Census: 29
Employees Mentioned
NameTitleContext
Donna WilliamsonRN, HFNS IISurveyor conducting the complaint investigation
Inspection Report Annual Inspection Census: 29 Deficiencies: 0 Nov 29, 2012
Visit Reason
The visit was conducted as an annual licensure survey to assess compliance with environmental and other regulatory standards.
Findings
No deficiencies were cited during the annual licensure survey, indicating the facility met the required standards at the time of inspection.
Report Facts
Census: 29
Employees Mentioned
NameTitleContext
Sharron BallHFS IISurveyor conducting the annual licensure survey
Inspection Report Annual Inspection Census: 34 Deficiencies: 0 Jan 25, 2012
Visit Reason
Annual licensure survey conducted from January 23-25, 2012 to assess compliance with regulatory requirements.
Findings
No deficiencies were cited during the survey. Technical assistance was provided to the facility.
Employees Mentioned
NameTitleContext
Louise HallRN HFNS IISurveyor during the annual licensure survey
Jane CostRN HFNS IISurveyor during the annual licensure survey
Inspection Report Annual Inspection Census: 36 Deficiencies: 0 Nov 29, 2011
Visit Reason
The visit was conducted as an annual licensure survey of the assisted living facility.
Findings
No deficiencies or technical assistance were identified during the survey.
Report Facts
Census: 36
Employees Mentioned
NameTitleContext
Keith CarpenterSurveyorConducted the annual licensure survey
Inspection Report Annual Inspection Census: 31 Deficiencies: 2 Jan 19, 2011
Visit Reason
The inspection was conducted as an annual licensure survey of the Wishing Well Assisted Living Community A to assess compliance with state regulations and licensing requirements.
Findings
The survey identified deficiencies including failure to maintain confidential personnel records with required tuberculosis screenings for two employees, and failure to update resident service plans to reflect current care needs for eight residents. Additionally, housekeeping and maintenance issues were noted in the facility environment.
Severity Breakdown
Class III: 1 Class II: 1
Deficiencies (2)
DescriptionSeverity
Failure to maintain confidential personnel records including annual tuberculosis screening for two employees.Class III
Failure to ensure resident service plans are updated to reflect current needs for eight residents.Class II
Report Facts
Census: 31 Employees missing annual tuberculosis screening: 2 Residents with outdated service plans: 8
Employees Mentioned
NameTitleContext
LEEmployee missing annual tuberculosis screening
TMEmployee missing annual tuberculosis screening
Jane CostRN, HFNS IISurveyor
Louise HallRN, HFNS IISurveyor
Donna WilliamsonRN, HFNS IISurveyor
Inspection Report Annual Inspection Census: 31 Deficiencies: 0 Jan 18, 2011
Visit Reason
The inspection was conducted as an annual licensure survey of the assisted living facility to assess compliance with regulatory requirements.
Findings
The report documents the annual licensure survey conducted on January 18-19, 2011, with a census of 31 residents. A follow-up survey on March 9, 2011, with a census of 37 residents, confirmed that deficiencies identified previously were corrected.
Report Facts
Census: 31 Census: 37
Employees Mentioned
NameTitleContext
Jane CostRN, HFNS IISurveyor during the annual licensure and follow-up surveys
Louise HallRN, HFNS IISurveyor during the annual licensure and follow-up surveys
Donna WilliamsonRN, HFNS IISurveyor during the annual licensure survey
Inspection Report Annual Inspection Census: 29 Deficiencies: 0 Jan 4, 2011
Visit Reason
Annual licensure survey conducted to assess compliance with regulatory requirements for the assisted living facility.
Findings
No deficiencies were found during the inspection. Only technical assistance was provided.
Report Facts
Census: 29
Employees Mentioned
NameTitleContext
Keith CarpenterNamed in the report as associated with the annual licensure survey
Inspection Report Annual Inspection Census: 34 Deficiencies: 1 Mar 10, 2010
Visit Reason
The inspection was conducted as an annual licensure survey with a follow-up visit to verify correction of previous deficiencies.
Findings
The facility failed to ensure that residents with nursing care needs received comprehensive weekly assessments by a registered nurse. Documentation was inconsistent and incomplete, particularly regarding insulin management, skin integrity, neuropathy, and dietary compliance for residents #11, #12, and #26. The plan of correction was not fully implemented and deficiencies were repeated.
Severity Breakdown
Class II: 1
Deficiencies (1)
DescriptionSeverity
Failure to ensure residents with nursing care needs are assessed weekly with comprehensive documentation addressing insulin or dosage, skin integrity, neuropathy, and dietary compliance.Class II
Report Facts
Census: 34 Sample Size: 3 Deficiency entries: 6 Deficiency entries: 11 Deficiency entries: 11
Employees Mentioned
NameTitleContext
Jane CostRN, HFNS IISurveyor during annual licensure survey
Louise HallRN, HFNS IISurveyor during annual licensure survey and follow-up
Inspection Report Annual Inspection Census: 52 Deficiencies: 0 Jan 20, 2010
Visit Reason
The inspection was conducted as an annual licensure survey to assess the environment and compliance of the assisted living community.
Findings
No deficiencies were cited during the annual licensure survey. Technical assistance was provided to the facility.
Report Facts
Census: 52
Employees Mentioned
NameTitleContext
Jason T. LintnerSurveyorConducted the annual licensure survey
Inspection Report Annual Inspection Census: 34 Deficiencies: 8 Jan 12, 2010
Visit Reason
Annual licensure survey conducted on January 11-12, 2010 to assess compliance with state regulations for assisted living facilities.
Findings
The facility was found deficient in multiple areas including employee orientation and training, nursing assessments, service plan updates, transfer documentation, dietary services, and housekeeping/maintenance. Several employees lacked required training documentation, nursing assessments were incomplete or missing, service plans did not reflect current resident needs, and dietary restrictions were not properly implemented or monitored.
Severity Breakdown
Class I: 2 Class II: 5 Class III: 1
Deficiencies (8)
DescriptionSeverity
Failure to provide and document required employee orientation and annual training including emergency procedures, resident rights, abuse prevention, infection control, and Alzheimer's disease training.Class II
Failure to ensure nursing assessments are performed and documented by registered nurses within 24 hours of resident return from hospital or significant change in condition.Class I
Failure to ensure weekly nursing assessments are consistently completed and comprehensive for residents with nursing care needs.Class II
Failure to ensure transfer forms accompany residents transferred to hospital with required medical information.Class II
Failure to maintain and update service plans to reflect current resident needs and physician orders.Class II
Failure to follow physician orders for therapeutic diets, including fluid restrictions, and failure to monitor and document resident compliance.Class I
Failure to notify physician of unplanned weight loss or gain of five pounds or more.Class III
Failure to maintain a safe, clean, and appropriate physical environment including housekeeping and maintenance issues such as damaged carpet, missing bathroom fixtures, and unclean sinks.
Report Facts
Census: 34 Deficiencies cited: 8 Weight changes: 5 Training completion timeframe: 15 Plan of correction completion date: Mar 5, 2010
Employees Mentioned
NameTitleContext
Jane CostRN, HFNS IISurveyor
Louise HallRN, HFNS IISurveyor
KWAideNamed in training deficiency for missing documentation
SMcAideNamed in training deficiency for missing documentation
JPRNNamed in training deficiency and transfer documentation deficiency
BHAdministratorNamed in training deficiencies
LKRN/DONNamed in training deficiencies
MKRNNamed in training deficiencies
DGLPNNamed in training deficiencies
JHLPNNamed in training deficiencies
HRLPNNamed in training deficiencies
CWTraining CoordinatorUnable to provide requested training documentation
Inspection Report Complaint Investigation Census: 35 Deficiencies: 0 Nov 3, 2009
Visit Reason
The inspection was conducted as a complaint investigation for Wishing Well Assisted Living Community A.
Findings
The complaint investigation was unsubstantiated and no deficiencies were found during the survey.
Complaint Details
Complaint investigation #WV00005285 was unsubstantiated with no deficiencies identified.
Report Facts
Census: 35
Employees Mentioned
NameTitleContext
Jane CostRN HFNS IISurveyor involved in complaint investigation
Louise HallRN HFNS IISurveyor involved in complaint investigation
Inspection Report Complaint Investigation Census: 38 Deficiencies: 3 Oct 7, 2009
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to maintain accurate records and reports, adherence to nurse license restrictions, admission of residents with extensive nursing care needs, and medication administration according to physician orders.
Findings
The facility failed to ensure accurate medication administration records, employed a nurse with license restrictions who administered narcotics and psychotropic medications contrary to those restrictions, admitted a resident requiring extensive nursing care without appropriate waiver, and failed to administer medications according to physician orders. Additionally, housekeeping and maintenance deficiencies were noted from a prior 2004 behavioral health survey.
Complaint Details
Complaint Investigation #5218 conducted on October 7, 2009, involving allegations of improper medication administration by a nurse with license restrictions, admission of a resident with extensive nursing care needs, and failure to administer medications as ordered.
Severity Breakdown
Class I: 2 Class II: 1
Deficiencies (3)
DescriptionSeverity
Failure to maintain accurate records and reports as required by regulation, including falsification of medication administration records by a registered nurse with license restrictions.Class II
Admission of a resident requiring extensive nursing care (IV therapy) without appropriate waiver or transfer.Class I
Failure to administer medications according to physician orders.Class I
Report Facts
Residents administered narcotics and/or psychotropic medications in September 2009: 18 Residents administered narcotics and/or psychotropic medications in October 2009: 21 Census: 38
Employees Mentioned
NameTitleContext
Jane CostRN HFNS IISurveyor
Louise HallRN HFNS IISurveyor
LKDirector of NursesInterviewed regarding waiver for resident admission
Inspection Report Complaint Investigation Census: 38 Deficiencies: 0 Oct 7, 2009
Visit Reason
The inspection was conducted as a complaint investigation (Complaint Investigation #5218) on October 7, 2009, followed by a complaint follow-up visit on November 3, 2009.
Findings
The complaint investigation identified deficiencies which were subsequently corrected by the time of the follow-up visit on November 3, 2009.
Complaint Details
Complaint Investigation #5218 was conducted with a census of 38 residents. A follow-up visit on November 3, 2009, with a census of 35 residents confirmed that deficiencies were corrected.
Report Facts
Census: 38 Census: 35
Employees Mentioned
NameTitleContext
Jane CostRN HFNS IISurveyor during complaint investigation and follow-up
Louise HallRN HFNS IISurveyor during complaint investigation and follow-up
Inspection Report Follow-Up Census: 34 Deficiencies: 0 Apr 30, 2009
Visit Reason
This was a 1st follow-up survey visit to verify correction of deficiencies related to the environment following a Change of Ownership (CHOW) survey conducted on March 16, 2009.
Findings
The follow-up survey found that the previously cited deficiency related to the environment was corrected.
Report Facts
Census: 34
Employees Mentioned
NameTitleContext
Jason T. LintnerSurveyor during the follow-up survey
Inspection Report Follow-Up Census: 35 Deficiencies: 0 Apr 28, 2009
Visit Reason
This was a follow-up survey conducted to verify correction of deficiencies identified during the Change of Ownership (CHOW) survey conducted March 9-12, 2009.
Findings
The follow-up survey found that the previously cited deficiencies were corrected.
Report Facts
Census: 36 Census: 35
Employees Mentioned
NameTitleContext
Jane CostRN, HFNS IISurveyor during the Change of Ownership (CHOW) survey
Louise HallRN, HFNS IISurveyor during both the Change of Ownership (CHOW) survey and the follow-up survey
Inspection Report Change Of Ownership Census: 35 Deficiencies: 10 Mar 16, 2009
Visit Reason
The inspection was conducted as a Change of Ownership (CHOW) survey to assess compliance with health and safety regulations, specifically focusing on the environment and dietary services.
Findings
The inspection found multiple deficiencies in the kitchen related to food safety and sanitation, including improper storage of wet rags, employee drinks near food, inadequate cooling of food, lack of sanitizing solutions, improper glove use, and mold accumulation. The environment also showed issues with housekeeping and maintenance.
Deficiencies (10)
Description
Wet rags were being stored dirty and without sanitizing solution.
Employee drinks and other belongings were stored on or near ready-to-eat foods and food contact surfaces.
Cabbage soup/broth drained from cooked meat was stored improperly cooling in the walk-in refrigerator.
No buckets of properly concentrated sanitizing solution were located at food preparation and/or service areas for clean-ups.
Not all food handlers were wearing gloves when handling ready-to-eat, potentially hazardous foods.
Ready-to-eat, potentially hazardous foods on the hot hold service unit were not properly stirred and had a surface temperature of 117°F while the internal temperature was 151°F.
Extensive accumulation of mold or residue located on the floor cove behind the dishwasher and in the ventilation duct above the dishwasher.
The internal chute of the ice bin was moldy.
Employees were observed using bare hands to handle ready-to-eat, potentially hazardous foods.
Employees were observed handling dirty dishware and then handling clean dishware without changing gloves and/or washing their hands.
Report Facts
Census: 35
Employees Mentioned
NameTitleContext
Jason T. LintnerSurveyorNamed as surveyor conducting the inspection
Keith CarpenterSurveyorNamed as surveyor conducting the inspection
Inspection Report Routine Census: 36 Deficiencies: 3 Mar 12, 2009
Visit Reason
The inspection was conducted as a Change of Ownership (CHOW) survey from March 9-12, 2009, to assess compliance with health care standards and facility regulations.
Findings
The facility was found deficient in ensuring complete transfer/discharge summaries for residents, proper medication self-administration assessments, and management of physician-ordered therapeutic diets. Additionally, housekeeping and maintenance issues were noted in a behavioral health survey from 2004 referenced in the document.
Severity Breakdown
Class I: 1 Class II: 2
Deficiencies (3)
DescriptionSeverity
Failure to ensure a complete summary of information accompanies a resident at the time of transfer or discharge, including missing allergies and incomplete forms.Class II
Failure to assure a licensed health care professional determines a resident's ability to safely self-administer medications and obtain a signed physician's order.Class II
Failure to assure physician ordered therapeutic diets are provided and managed as required, including lack of documentation and fluid intake monitoring.Class I
Report Facts
Census: 36 Residents transferred without complete summary: 4 Medications self-administered without physician order: 1 Fluid restriction amount: 1200
Employees Mentioned
NameTitleContext
Jane CostRN, HFNS IISurveyor involved in the inspection
Louise HallRN, HFNS IISurveyor involved in the inspection
BVDietary ManagerProvided information on dietary services and fluid restriction
JDGenesis Corporation resource nurseProvided corporate policy/procedure regarding fluid restrictions

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