Inspection Reports for Wyngate of Weirton
100 WYNGATE DRIVE, Weirton, WV, 26062
Back to Facility ProfileDeficiencies (last 24 years)
Deficiencies (over 24 years)
6.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than West Virginia average
West Virginia average: 9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
56 residents
Based on a September 2024 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 56
Deficiencies: 0
Sep 3, 2024
Visit Reason
Revisit to Annual Survey conducted from 09/02/24 to 09/03/24 to verify correction of previously cited deficiencies.
Findings
The deficiencies identified in the prior annual survey were corrected as of the revisit conducted on 09/03/24.
Report Facts
Census: 56
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 4
Jul 25, 2024
Visit Reason
The annual survey was conducted from 07/22/24 to 07/25/24 to assess compliance with regulatory requirements for the assisted living residence.
Findings
Deficiencies were cited related to failure to report a major incident timely, inadequate employee screening compliance, incomplete medication administration records, and inadequate housekeeping and maintenance.
Severity Breakdown
Class I: 1
Class II: 1
Class III: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Licensee failed to notify the Office of Health Facility Licensure and Certification of a major incident within the required timeframe for one resident. | Class III |
| Licensee failed to ensure all employees were subject to the West Virginia Clearance for Access: Registry and Employment Screening Act; one employee worked unsupervised before clearance. | Class II |
| Licensee failed to ensure all residents' medication administration records contained all required signatures for three residents. | Class I |
| Center failed to ensure adequate housekeeping and maintenance; observations included personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Resident count: 56
Employees reviewed: 8
Residents reviewed: 8
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #2 | Employee allowed to work unsupervised before WV CARES clearance | |
| Employee #19 | Employee interviewed regarding failure to report major incident | |
| Residence Manager #27 | Residence Manager | Interviewed about employee scheduling and WV CARES clearance |
| Wellness Manager | Reeducated staff on reporting major incidents and medication documentation | |
| Lead Nurse | Reeducated staff on reporting major incidents and medication documentation |
Inspection Report
Renewal
Census: 56
Deficiencies: 0
Jul 23, 2024
Visit Reason
The inspection was conducted as a license renewal to determine if the residence complies with state requirements.
Findings
The residence was found to be in substantial compliance with the state rule based on review of facility documentation, staff interview, observations, and performance testing. No deficiencies were cited during this inspection.
Report Facts
Census: 56
Inspection Report
Follow-Up
Census: 61
Deficiencies: 0
Jan 24, 2024
Visit Reason
Second follow-up to annual survey to verify correction of previously cited deficiencies.
Findings
The deficiencies identified in the prior annual survey were corrected, and no new deficiencies were cited during this follow-up visit.
Report Facts
Census: 61
Inspection Report
Follow-Up
Census: 65
Deficiencies: 2
Nov 14, 2023
Visit Reason
First follow-up to annual survey conducted from 11/13/23 to 11/14/23 to verify correction of previous deficiencies and assess compliance.
Findings
The facility was found deficient in ensuring employee pre-employment tuberculosis screenings were completed prior to hire dates and in timely completion and documentation of resident admission and annual health assessments. Four citations were cleared, one was re-cited, and one additional related deficiency was cited.
Severity Breakdown
Class III: 1
Class II: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure each employee's record contained results of pre-employment tuberculosis screening prior to hire date for five of six employees reviewed. | Class III |
| Failed to ensure admission and annual health assessments were completed timely and included signature and date of completion for seven of 41 residents reviewed. | Class II |
Report Facts
Census: 65
Employees with deficient TB screening: 5
Residents with deficient assessments: 7
Residents reviewed for assessments: 41
Employees reviewed for TB screening: 6
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 0
Nov 14, 2023
Visit Reason
Investigation of Complaint #29554 conducted on 11/14/23 from 2:15 PM to 3:15 PM.
Findings
The complaint was unsubstantiated, and no deficiencies were cited during the investigation.
Complaint Details
Complaint #29554 was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Census: 65
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 0
Sep 25, 2023
Visit Reason
Annual environmental inspection of Wyngate Of Weirton conducted on September 25, 2023.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 61
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 6
Sep 21, 2023
Visit Reason
Annual survey conducted from 09/18/23 to 09/21/23 to assess compliance with assisted living facility regulations.
Findings
The facility was found deficient in multiple areas including employee background checks, resident death documentation, transfer documentation, timely annual health assessments, tuberculosis testing documentation, and housekeeping and maintenance issues.
Severity Breakdown
Class II: 2
Class III: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure all employees were subject to West Virginia Clearance for Access: Registry and Employment Screening Act requirements. | — |
| Failed to document the name of the person who picked up the body for two residents who passed away at the facility. | Class III |
| Failed to prepare and retain a summary of resident medical history and other required documentation prior to resident transfers for two residents. | — |
| Failed to ensure each resident had an annual health assessment completed timely for one resident. | Class II |
| Failed to follow all applicable federal, state, or local laws for tuberculosis screening and documentation for four employees, including incomplete documentation of TB skin tests. | Class II |
| Failed to ensure adequate housekeeping and maintenance required to carry out services, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
Report Facts
Census: 63
Employees with deficient background checks: 2
Residents with missing death documentation: 2
Residents with missing transfer documentation: 2
Residents with late annual health assessment: 1
Employees with deficient TB testing documentation: 4
Inspection Report
Follow-Up
Census: 59
Deficiencies: 0
May 8, 2023
Visit Reason
The visit was a follow-up to the annual survey conducted to assess compliance and corrective actions at the facility.
Findings
The report documents the initial comments of the follow-up survey with a census of 59 residents. No specific deficiencies or findings are detailed in the provided page.
Report Facts
Census: 59
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Mar 22, 2023
Visit Reason
The inspection was conducted as a complaint investigation from 03/20/23 to 03/22/23 regarding failure to maintain a resident register and medication administration issues.
Findings
The facility failed to maintain a complete resident register for two discharged residents and failed to ensure medications were properly administered, discontinued, and dosage changes recorded for one resident during multiple hospital admissions. Documentation and interviews confirmed these deficiencies.
Complaint Details
Complaint ID: 28006. The complaint investigation was conducted from 03/20/23 12:00 PM to 03/22/23.
Deficiencies (2)
| Description |
|---|
| Failed to maintain a register with the name and place to which two discharged residents were transferred. |
| Failed to ensure medications were administered, discontinued, and dosage changed as ordered for one resident during hospital admissions. |
Report Facts
Residents discharged without transfer information: 2
Residents reviewed for medication issues: 3
Hospital admissions: 3
Census: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Manager #26 | Conceded that disposition of discharged residents was not recorded in the register. | |
| Registered Nurse #4 | Consulted regarding residents' transfer information and medication orders. | |
| Employee #4 | Interviewed about medication administration issues during resident hospital admissions. |
Inspection Report
Follow-Up
Census: 65
Deficiencies: 0
Jan 5, 2023
Visit Reason
This was a 1st follow-up/revisit to the annual survey to verify correction of previously cited deficiencies.
Findings
The deficiencies identified in the prior annual survey were corrected and cleared. No new deficiencies were found during this follow-up visit.
Report Facts
Census: 65
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 6
Oct 5, 2022
Visit Reason
Annual survey conducted to assess compliance with staffing requirements, housekeeping and maintenance, resident assessments, nursing care, and activity documentation.
Findings
The facility was found deficient in staffing levels on day and night shifts, inadequate housekeeping and maintenance, incomplete resident health assessments, insufficient nursing care documentation, and lack of documentation for activities. Several residents required assistance with bathing, dressing, and other care needs. The facility had insufficient direct care staff on multiple shifts and failed to maintain proper documentation for nursing and activities.
Deficiencies (6)
| Description |
|---|
| Failed to ensure adequate direct care staff on day shift for residents with two or more care needs. |
| Failed to ensure adequate housekeeping and maintenance; observed personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bars and toilet paper holders, and dirty sink. |
| Failed to ensure documentation of activities indicating whether activities took place. |
| Failed to ensure each resident had a written, signed, and dated health assessment by a licensed healthcare professional within required timeframes. |
| Failed to ensure adequate direct care staff on night shift for residents with two or more care needs. |
| Failed to ensure registered nurse saw residents weekly and documented progress notes for residents with nursing care needs. |
Report Facts
Census: 59
Residents with two or more care needs: 42
Direct care staff required on day shift: 4
Direct care staff scheduled on some day shifts: 3
Direct care staff required on night shift: 3
Direct care staff scheduled on night shift: 2
Residents' weekly nursing notes missing: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Mentioned in relation to minimal direct care provision and incomplete nursing notes |
| Licensed Practical Nurse #50 | Licensed Practical Nurse | Mentioned regarding duties including medication pass and limited direct care time |
| Assistant Residence Manager | Mentioned regarding review of employee punch cards and awareness of staffing levels | |
| Regional Executive Director | Mentioned during exit interview acknowledging staffing counts |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 0
Sep 14, 2022
Visit Reason
Annual environmental inspection of Wyngate Of Weirton conducted on September 14, 2022.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 62
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Jul 14, 2022
Visit Reason
The inspection was conducted in response to Complaint 27000 to investigate an allegation at the facility.
Findings
The complaint investigation found 1 allegation which was not substantiated, and no citations were written.
Complaint Details
1 allegation was investigated and found to be unsubstantiated; no citations were issued.
Report Facts
Census: 54
Complaint number: 27000
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 0
Oct 28, 2021
Visit Reason
The inspection was conducted as an annual survey of the facility.
Findings
The report contains initial comments about the annual survey conducted from October 25 to October 28, 2021, with a census of 46 residents. No specific deficiencies or findings are detailed in the provided page.
Report Facts
Census: 46
Inspection Report
Routine
Census: 46
Deficiencies: 5
Oct 18, 2021
Visit Reason
The inspection was conducted as a routine survey to assess compliance with health, safety, housekeeping, maintenance, and emergency preparedness regulations at Wyngate of Weirton.
Findings
The facility was found deficient in proper laundry storage practices, housekeeping and maintenance issues including mold/mildew stains and damaged furnishings, failure to annually review and document the disaster and emergency preparedness plan, and inadequate documentation of disaster preparedness rehearsals.
Deficiencies (5)
| Description |
|---|
| Laundry was not stored appropriately; soiled laundry was found uncovered or not in covered containers. |
| Housekeeping and maintenance deficiencies including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sinks. |
| Failure to review and update the disaster and emergency preparedness plan annually with proper signatures. |
| Failure to document and rehearse the disaster and emergency preparedness plan with all staff annually. |
| Physical facilities maintenance issues including mold/mildew stains around toilet and shower bases. |
Report Facts
Facility census: 46
Deficiency codes: 4
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 1
Oct 18, 2021
Visit Reason
The inspection was an annual recertification survey conducted to assess the facility's compliance with regulatory standards.
Findings
The survey identified deficiencies with tags 0443, 0445, 0450, and 0496. A follow-up survey was conducted on 11/30/2021 to review the correction of these deficiencies.
Deficiencies (1)
| Description |
|---|
| Deficiencies identified with tags 0443, 0445, 0450, and 0496 |
Report Facts
Deficiencies cited: 4
Sample Size: 80
Census: 46
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 8, 2021
Visit Reason
The inspection was conducted as a follow-up to Complaint #25085 to verify correction of previously identified deficiencies.
Findings
Credible evidence was accepted in place of an onsite revisit, and the deficiency related to the complaint was found to be corrected.
Complaint Details
Complaint #25085 was investigated and found to be corrected based on credible evidence accepted on 04/08/21.
Deficiencies (1)
| Description |
|---|
| Deficiency related to Complaint #25085 was corrected as of 04/08/21. |
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 0
Mar 9, 2021
Visit Reason
Revisit to Annual Survey to verify correction of previous deficiencies.
Findings
All citations from the prior survey were corrected as of the revisit conducted on March 8-9, 2021.
Report Facts
Census: 35
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Mar 8, 2021
Visit Reason
Complaint investigation conducted due to concerns about the facility's failure to maintain current documentation of a resident's health status and proper care, specifically regarding Resident #62 who developed decubitus ulcers.
Findings
The facility failed to keep current documentation regarding Resident #62's health status and care, including repositioning and wound care. Numerous documentation gaps were found in Resident Assistant Service Checklist forms, and the resident developed multiple pressure ulcers and infections. Staffing shortages during a COVID-19 outbreak contributed to incomplete documentation and care. The complaint was unsubstantiated but cited.
Complaint Details
Complaint #: WV00025085. Unsubstantiated complaint with a citation.
Severity Breakdown
Class II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to keep current documentation regarding resident's health status and staff responses to changes, specifically for Resident #62 with decubitus ulcers. | Class II |
Report Facts
Resident census: 35
Days lacking documented repositioning: 23
Days lacking documented repositioning: 6
Days lacking documented repositioning: 3
Wound size: 2
Wound size: 2.5
Wound size: 0.1
Medication duration: 7
Work order completion timeframe: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN/Wellness Manager #41 | RN/Wellness Manager | Verified Resident #62's transfer, health decline, and documentation issues during interview. |
| Resident Assistant #29 | Resident Assistant | Provided care for Resident #62 and confirmed repositioning and documentation practices. |
| Resident Assistant #22 | Resident Assistant | Verified skin breakdown and repositioning frequency for Resident #62. |
| Residence Manager #07 | Residence Manager | Verified staffing shortages and documentation issues during COVID-19 outbreak. |
| Resident Assistant #37 | Resident Assistant | Verified repositioning frequency before and after skin breakdown for Resident #62. |
Inspection Report
Annual Inspection
Census: 56
Deficiencies: 5
Nov 18, 2020
Visit Reason
Annual survey conducted from 11/16/20 to 11/18/20 to assess compliance with assisted living residence regulations and health care standards.
Findings
The facility was found deficient in several areas including failure to ensure all employees had eligibility fitness determinations, incomplete personnel records regarding proof of education, inadequate housekeeping and maintenance, failure to prepare proper transfer summaries for residents, and incomplete Physician Orders for Scope of Treatment (POST) forms.
Deficiencies (5)
| Description |
|---|
| Failure to ensure each assisted living residence employee had received an eligibility fitness determination or variance from the West Virginia Clearance for Access: Registry and Employment Screening unit. |
| Failure to maintain confidential personnel records including proof of required education or license for employees. |
| Inadequate housekeeping and maintenance including personal belongings left behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. |
| Failure to prepare a summary to accompany residents during transfer that includes medical history, functional needs, physician's orders, advanced directives, allergies, and progress notes. |
| West Virginia Physician Orders for Scope of Treatment (POST) form was not properly filled out, lacking signature and date by the preparer. |
Report Facts
Employee records reviewed: 6
Facility census: 56
Residents reviewed for transfer documentation: 10
Residents reviewed for POST form: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Manager #19 | Assistant Manager | Verified employee records and eligibility fitness determination status during interview. |
| Lead Nurse #2 | Lead Nurse | Confirmed missing documentation on transfer forms and POST form signature during interview. |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 0
Aug 24, 2020
Visit Reason
Annual environmental inspection of Wyngate Of Weirton conducted on August 24, 2020.
Findings
No deficiencies were cited during this annual environmental inspection.
Report Facts
Census: 58
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 11, 2020
Visit Reason
The document is a statement of deficiencies and plan of correction related to a behavioral health survey conducted at Wyngate of Weirton.
Findings
The report indicates that credible evidence review in place of onsite revisit revealed the citation was corrected. Previously, deficiencies included lack of awake-night supervision on weekends and unsecured outside doors in adolescent girls' bedrooms.
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 awake-night supervision on weekends and unsecured outside doors. |
Report Facts
Center census: 6
Sample size: 3
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Nov 21, 2019
Visit Reason
The annual survey was conducted to assess compliance with regulatory requirements for assisted living facilities, including personnel records and facility maintenance.
Findings
The facility failed to ensure that one employee had a documented eligibility fitness determination from the West Virginia Clearance for Access Registry and Employment Screening. Additionally, the facility did not maintain adequate housekeeping and maintenance, with issues such as damaged carpet, missing bathroom fixtures, and unclean sinks observed.
Deficiencies (2)
| Description |
|---|
| Failed to ensure one assisted living residence employee had a letter of notification of eligibility fitness determination from WVCARES. |
| Failed to ensure adequate housekeeping and maintenance, including damaged carpet, missing towel bars and toilet paper holders, and unclean sinks. |
Report Facts
Facility census: 59
Employee files reviewed: 7
Employee identifier: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #32 | Residence Manager | Employee missing documented eligibility fitness determination |
| Resident Coordinator #24 | Verified fingerprint collection and lack of eligibility letter for Employee #32 |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 0
Aug 21, 2019
Visit Reason
The inspection was an annual environmental survey conducted at Wyngate Of Weirton to assess compliance with health and safety regulations.
Findings
The facility had a census of 62 residents at the time of the inspection and no deficiencies were cited during this annual environmental survey.
Report Facts
Census: 62
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 0
Sep 26, 2018
Visit Reason
The inspection was conducted as an annual licensure survey of the facility.
Findings
The annual licensure survey conducted from September 24-26, 2018 found no deficiencies cited at the facility.
Report Facts
Census: 64
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 0
Aug 14, 2018
Visit Reason
The visit was conducted as an Annual Licensure Survey focusing on the annual environmental inspection of the facility.
Findings
The inspection found no deficiencies during the annual environmental survey conducted on August 14, 2018.
Report Facts
Census: 67
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Jul 17, 2018
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint ID WV00020703.
Findings
No deficiencies were cited during this complaint investigation.
Complaint Details
Complaint ID WV00020703 was investigated and found to have no deficiencies cited.
Report Facts
Census: 61
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Feb 22, 2018
Visit Reason
The inspection was conducted as a complaint investigation from February 20-22, 2018, related to the facility Wyngate of Weirton.
Findings
The report documents a complaint investigation with no detailed findings or deficiencies explicitly stated in the provided page. The census was 63 at the time of the visit.
Complaint Details
Complaint ID WV00019672 investigated during the visit from February 20-22, 2018. No substantiation status or detailed complaint outcomes are provided in the document.
Report Facts
Census: 63
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Dec 11, 2017
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of sexual abuse and failure to report and notify appropriate agencies.
Findings
The facility failed to ensure timely reporting of suspected abuse to the West Virginia Department of Health and Human Resources Adult Protective Services and the licensing agency. The administrator and registered nurse were unaware of the required reporting procedures, and documentation of required reports was missing.
Complaint Details
The complaint involved an allegation by Resident #52 that a male aide (Employee #19) sexually abused her. The allegation was reported verbally to APS immediately but the required written reports and notifications to APS, the licensing agency (OHFLAC), and the ombudsman were not completed within the required timeframes.
Severity Breakdown
Class I: 1
Class III: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report suspected abuse or neglect immediately and complete the required Adult Protective Services reporting form within 48 hours. | Class I |
| Failure to notify the licensing agency within 72 hours of an allegation of abuse, exploitation, or neglect and failure to forward documentation of the investigation and response. | Class III |
Report Facts
Census: 65
Related deficiencies: 2
Timeframe for APS reporting: 48
Timeframe for licensing agency notification: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee #10 | Licensed Practical Nurse | Reported the allegation to APS by telephone immediately |
| Employee #19 | Male Aide | Alleged perpetrator of sexual abuse |
| Employee #53 | Aide | Went to Resident #52's room to assist her on the morning of the incident |
| Administrator | Failed to send required reports to APS, OHFLAC, and ombudsman; unaware of reporting requirements | |
| Registered Nurse (RN) | Registered Nurse | Failed to notify OHFLAC about the incident; unaware of reporting requirements |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 2
Dec 11, 2017
Visit Reason
The inspection was conducted as a complaint investigation from December 11-13, 2017, related to two deficiencies identified by complaint ID WV00019336.
Findings
Two related deficiencies (6.2.c and 6.2.f) were identified during the complaint investigation. A follow-up visit on January 29, 2018, confirmed that the deficiencies were corrected.
Complaint Details
Complaint ID WV00019336 triggered the investigation. Two related deficiencies were found and subsequently corrected as confirmed in the follow-up visit.
Deficiencies (2)
| Description |
|---|
| Deficiency 6.2.c (0163) |
| Deficiency 6.2.f (0166) |
Report Facts
Deficiencies cited: 2
Census: 65
Census: 63
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 0
Sep 20, 2017
Visit Reason
The visit was conducted as an Annual Licensure Survey to assess compliance with regulatory requirements.
Findings
No deficiencies were cited during the annual licensure survey conducted from September 18-20, 2017.
Report Facts
Census: 66
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 0
Aug 8, 2017
Visit Reason
Annual environmental inspection of Wyngate Of Weirton facility conducted on August 8, 2017.
Findings
No deficiencies were cited during the annual environmental inspection.
Report Facts
Census: 66
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 0
Aug 18, 2016
Visit Reason
The inspection was conducted as an annual licensure survey of the facility.
Findings
The annual licensure survey conducted from August 15-17, 2016 found no deficiencies cited at the facility.
Report Facts
Census: 63
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 0
Aug 8, 2016
Visit Reason
The document is an annual licensure survey conducted to assess the facility's compliance with environmental and health safety standards.
Findings
The annual environmental inspection found no deficiencies cited at the facility during the visit.
Report Facts
Census: 63
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 0
Mar 30, 2016
Visit Reason
The inspection was conducted as a complaint investigation from March 28-30, 2016.
Findings
The report documents a complaint investigation at Wyngate of Weirton with a census of 63 residents. No specific deficiencies or findings are detailed in the provided text.
Complaint Details
Complaint investigation conducted from March 28-30, 2016. No substantiation status or detailed complaint findings are provided.
Report Facts
Census: 63
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 0
Jul 29, 2015
Visit Reason
The visit was conducted as an Annual Licensure Survey for the facility Wyngate of Weirton.
Findings
The report documents the annual licensure survey conducted from July 27-29, 2015, with a census of 65 residents. No specific deficiencies or severity levels are detailed in the provided page.
Report Facts
Census: 65
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 0
Jul 22, 2015
Visit Reason
Annual Licensure Survey conducted to assess environmental compliance at the facility.
Findings
No deficiencies were cited during this annual licensure survey.
Report Facts
Census: 64
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Oct 14, 2014
Visit Reason
The inspection was conducted as a complaint investigation (CI# WV 00012135) from October 14-16, 2014, to assess compliance with health and safety regulations, specifically related to dietary services and infection control.
Findings
The facility was found deficient in dietary services as an employee was observed handling food without gloves, violating infection control procedures. The administrator acknowledged the issue and staff were re-educated on proper glove use during food handling.
Complaint Details
Complaint Investigation CI# WV 00012135 conducted October 14-16, 2014. The complaint was substantiated based on observation and record review of dietary service violations.
Severity Breakdown
CLASS II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Employee #42/resident assistant was observed scraping a resident's tuna fish off the plate onto a slice of bread, then folding the bread and giving it to the resident while wearing no gloves. | CLASS II |
Report Facts
Census: 62
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Oct 14, 2014
Visit Reason
The inspection was conducted as a complaint investigation from October 14-16, 2014, followed by a complaint follow-up visit on November 24, 2014.
Findings
The report documents findings related to a complaint investigation and subsequent follow-up at the facility. Specific deficiencies or detailed findings are not explicitly stated in the provided text.
Complaint Details
Complaint Investigation CI# WV 00012135 was conducted October 14-16, 2014 with a census of 62, followed by a Complaint Follow-Up on November 24, 2014 with a census of 63.
Report Facts
Census: 62
Census: 63
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 0
Oct 14, 2014
Visit Reason
The document reports on an annual licensure survey conducted from July 14-16, 2014, with a follow-up survey on October 14, 2014.
Findings
The report summarizes the annual licensure survey and a follow-up survey for the facility, noting census counts during these inspections. Specific deficiencies or findings are not detailed in the provided text.
Report Facts
Census: 64
Census: 62
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 0
Aug 26, 2014
Visit Reason
The inspection was conducted as an Annual Licensure Survey and Environmental Survey of the facility.
Findings
No deficiencies were cited during this annual licensure and environmental survey.
Report Facts
Census: 69
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Lubic | HFSII Surveyor | Surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 1
Jul 16, 2014
Visit Reason
The inspection was conducted as an Annual Licensure Survey from July 14-16, 2014 to assess compliance with health care standards.
Findings
The facility was found deficient in ensuring that upon a resident's death, belongings were properly released to the estate administrator or executor for four residents. Documentation was incomplete or incorrect regarding the disposition of residents' belongings.
Severity Breakdown
CLASS III: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that upon a resident's death, belongings were released to the estate administrator or executor for four residents. | CLASS III |
Report Facts
Census: 64
Number of residents with deficient documentation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in relation to failure to ensure proper release of belongings | |
| Registered Nurse (RN) | Named in relation to failure to ensure proper release of belongings |
Inspection Report
Follow-Up
Census: 68
Deficiencies: 0
Sep 25, 2013
Visit Reason
The visit was a follow-up survey to verify correction of previously cited deficiencies.
Findings
The deficiencies identified in the prior inspection were corrected as of the follow-up survey date.
Report Facts
Census: 68
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 0
Sep 6, 2013
Visit Reason
The document reports on the Annual Licensure Survey conducted from August 5-8, 2013, and a follow-up survey on September 16, 2013, to assess compliance with licensure requirements.
Findings
The report summarizes the findings from the annual licensure survey and a follow-up survey, including census counts and compliance status. Specific deficiencies or corrective actions are not detailed in the provided text.
Report Facts
Census: 69
Census: 67
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 1
Aug 8, 2013
Visit Reason
The facility underwent an annual licensure survey conducted from August 5-8, 2013, to assess compliance with health care standards and regulations.
Findings
The survey found deficiencies related to the failure of the administrator and registered nurse to determine whether residents were capable of self-administering medications, with discrepancies noted in medication administration records and expired medications present. Additionally, housekeeping and maintenance issues were noted in a behavioral health survey from 2004, but the main 2013 survey focused on medication administration compliance.
Severity Breakdown
CLASS II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to determine whether residents were capable of self-administering medications as required by health care standards. | CLASS II |
Report Facts
Census: 69
Sample Size: 3
Completion Date: Oct 8, 2013
Inspection Report
Annual Inspection
Census: 69
Deficiencies: 4
Jul 24, 2013
Visit Reason
The inspection was conducted as an Annual Licensure Survey focusing on environmental and physical facility compliance, including disaster and emergency preparedness.
Findings
The facility failed to provide documented evidence of annual disaster and emergency preparedness training for all staff. Additionally, unsafe storage practices were observed in mechanical rooms and unsecured oxygen cylinders were found in a nursing closet. Housekeeping and maintenance deficiencies were also noted, including damaged carpets, missing bathroom fixtures, and cluttered storage areas.
Severity Breakdown
CLASS I: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide documented evidence of annual disaster and emergency preparedness training for all staff from each shift. | CLASS I |
| Mechanical rooms cluttered with items obstructing access to furnaces, electrical units, and sprinkler system components. | CLASS I |
| Oxygen cylinders stored unsecured in a nursing closet without proper signage. | CLASS I |
| Housekeeping and maintenance deficiencies including damaged carpet, missing towel bars and toilet paper holders, and dirty sink. | CLASS I |
Report Facts
Census: 69
Deficiency completion date: Sep 25, 2013
Training dates: Aug 22, 2013
Training dates: Aug 23, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding disaster and emergency preparedness training documentation. | |
| Maintenance Director | Interviewed and observed mechanical rooms and oxygen storage. | |
| Assistant Manager | Located sign-in sheets from prior training and responsible for maintaining training records. |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Jan 2, 2013
Visit Reason
The inspection was conducted as a complaint investigation for facility WV00007454 during January 2-3, 2013.
Findings
The report documents a complaint investigation conducted by surveyor Michelle Redd, RN, HFNS1, but does not provide specific findings or deficiencies within the text.
Complaint Details
Complaint investigation for facility WV00007454 conducted January 2-3, 2013. No substantiation status or detailed complaint findings are provided.
Report Facts
Census: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Redd | RN, HFNS1 | Surveyor conducting the complaint investigation |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 0
Oct 9, 2012
Visit Reason
The inspection was conducted as an annual licensure survey followed by a survey follow-up to verify correction of deficiencies.
Findings
The annual licensure survey was conducted from July 30 to August 2, 2012, with a census of 65. A follow-up survey on October 9, 2012, with a census of 64, confirmed that deficiencies identified in the initial survey were corrected.
Report Facts
Census: 65
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deb Dodrill | LSW, HFS | Surveyor during the annual licensure survey |
| Donna Williamson | RN, HFNS II | Surveyor during the annual licensure survey |
| Bev Randolph | RN, HFNS I | Surveyor during the follow-up survey |
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 0
Oct 1, 2012
Visit Reason
The inspection was conducted as an annual licensure survey to assess the environment of the facility.
Findings
No deficiencies or technical assistance were identified during the annual licensure survey.
Report Facts
Census: 77
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 3
Aug 2, 2012
Visit Reason
Annual Licensure Survey conducted from July 30 to August 2, 2012, to assess compliance with resident rights, medication administration, infection control, and housekeeping standards.
Findings
The facility failed to promptly address resident complaints with timely written responses, had multiple medication administration errors involving insulin dosing for several residents, and did not consistently follow appropriate infection control practices. Additionally, housekeeping and maintenance deficiencies were noted from prior observations.
Severity Breakdown
Class I: 2
Class III: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Administrator failed to ensure resident complaints were promptly addressed with written responses within four days in six of seven instances. | Class III |
| Administrator and registered nurse failed to ensure medications, specifically insulin, were administered as ordered for four residents, with multiple dosing errors and missed doses. | Class I |
| Administrator and registered nurse failed to provide care utilizing appropriate infection control techniques, including improper dressing change and medication handling. | Class I |
Report Facts
Census: 65
Complaint instances with delayed response: 6
Medication errors for Resident #37: 55
Missed insulin doses for Resident #37: 6
Medication errors for Resident #47: 11
Missed insulin doses for Resident #47: 17
Medication errors for Resident #49: 34
Missed insulin doses for Resident #49: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| KR | Licensed Practical Nurse | Observed failing to follow infection control practices during dressing change and medication pass |
| MC | Registered Nurse | Completed training with licensed practical nurses on medication administration and infection control |
| Deb Dodrill | LSW, HFS I Surveyor | Surveyor for the annual licensure survey |
| Donna Williamson | RN, HFNS II Surveyor | Surveyor for the annual licensure survey |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Apr 10, 2012
Visit Reason
The inspection was conducted as a complaint investigation for facility WYNGATE OF WEIRTON on April 10-11, 2012.
Findings
The investigation found that some allegations were substantiated while others were unsubstantiated. No deficiencies were cited, and technical assistance was provided.
Complaint Details
Allegations substantiated and unsubstantiated as noted; no deficiencies cited.
Report Facts
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Donna Williamson | RN, HFNS II | Surveyor conducting the complaint investigation |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 0
Sep 13, 2011
Visit Reason
The visit was conducted as an annual licensure survey of the facility Wyngate of Weirton.
Findings
No deficiencies were cited during this annual licensure survey. Technical assistance was provided to the facility.
Report Facts
Census: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor during the annual licensure survey |
| Louise Hall | RN, HFNS II | Surveyor during the annual licensure survey |
| Beverly Randolph | RN, HFNS I | Surveyor during the annual licensure survey |
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 0
Aug 15, 2011
Visit Reason
The visit was conducted as an Annual Licensure Survey focusing on environmental conditions at the facility.
Findings
No deficiencies were cited during the survey and no technical assistance was given.
Report Facts
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Akers | HFSI | Surveyor conducting the annual licensure survey |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Apr 18, 2011
Visit Reason
The inspection was conducted as a complaint investigation for the facility Wyngate of Weirton on April 18, 2011.
Findings
The complaint investigation was unsubstantiated as determined by surveyors Jane Cost, RN, HFNS II and Louise Hall, RN, HFNS II.
Complaint Details
Complaint investigation was unsubstantiated.
Report Facts
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor involved in complaint investigation |
| Louise Hall | RN, HFNS II | Surveyor involved in complaint investigation |
Inspection Report
Follow-Up
Census: 64
Deficiencies: 0
Nov 29, 2010
Visit Reason
The visit was a follow-up survey to verify corrections after the annual licensure survey conducted in September 2010.
Findings
The report documents the follow-up survey conducted on November 29, 2010, at Wyngate of Weirton with a census of 64 residents. The surveyors were Jane Cost, RN, HFNS II and Louise Hall, RN, HFNS II.
Report Facts
Census: 62
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor for both Annual Licensure Survey and Follow-Up Survey |
| Louise Hall | RN, HFNS II | Surveyor for both Annual Licensure Survey and Follow-Up Survey |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 1
Sep 22, 2010
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with state regulations and fire safety codes.
Findings
The facility failed to show compliance with applicable state fire commission rules, resulting in a provisional license due to non-compliance with the Fire Code. A plan of correction was submitted addressing fire safety deficiencies including inspection and repair of fire safety equipment and systems.
Severity Breakdown
CLASS I: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to show compliance with applicable rules of the state fire commission, resulting in a provisional license due to non-compliance with the Fire Code. | CLASS I |
Report Facts
Census: 61
Deficiencies cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason T. Lintner | Surveyor | Named as surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 61
Deficiencies: 0
Sep 22, 2010
Visit Reason
The visit was conducted as an annual licensure survey to assess the facility's compliance with regulatory requirements.
Findings
The survey found that deficiencies previously identified were corrected. No new deficiencies are detailed in the report.
Report Facts
Census: 61
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason T. Lintner | Surveyor | Named as surveyor conducting the annual licensure survey |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 8
Sep 22, 2010
Visit Reason
Annual licensure survey conducted to assess compliance with health and safety regulations, staffing requirements, health care standards, medication administration, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to maintain current CPR training for staff, incomplete or untimely resident health assessments, inadequate housekeeping and maintenance, incomplete or inaccurate resident service plans, lack of resident identification on medication records, missing or unsigned physician medication orders, unavailability of medications, improper storage of Schedule II drugs, and lack of specialized training for staff conducting blood glucose monitoring.
Severity Breakdown
Class I: 3
Class II: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to assure at least one employee with current CPR training is on duty at all times. | Class I |
| Failure to ensure adequate housekeeping and maintenance required to carry out services. | — |
| Failure to complete written, signed, and dated health assessments within required timeframes. | Class II |
| Resident service plans did not reflect current needs of residents. | — |
| Failure to ensure resident identification on medication administration records. | Class I |
| Failure to ensure medications have corresponding signed and dated physician orders and are administered according to orders. | — |
| Failure to secure Schedule II drugs with two locks as required. | Class I |
| Failure to provide specialized training and competency for staff conducting blood glucose monitoring/testing. | Class II |
Report Facts
Census: 62
Staff without current CPR training: 13
Residents without timely health assessments: 3
Residents with inaccurate service plans: 6
Residents without photo ID on MAR: 11
Residents with medication order issues: 5
Residents requiring blood glucose monitoring: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SH | Supervising Registered Nurse | Interviewed regarding CPR training lapses, health assessment documentation, medication administration, and blood glucose monitoring training. |
| RB | Licensed Practical Nurse | Observed administering incorrect dosage of medication to Resident #3. |
| Jane Cost | RN, HFNS II | Surveyor during the annual licensure survey. |
| Louise Hall | RN, HFNS II | Surveyor during the annual licensure survey. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 6
Dec 14, 2009
Visit Reason
The inspection was conducted as a complaint investigation (#WV00005383) to assess the safety and maintenance conditions of the facility.
Findings
The facility failed to maintain a safe and accident-free living environment, with heating units in residents' rooms reaching dangerously high temperatures posing risks of bodily injury and fire. Combustible materials were found too close to heating units, and physical damages such as carpet burns and missing bathroom fixtures were observed.
Complaint Details
Complaint investigation #WV00005383 conducted on December 14, 2009. Deficiency was moved to shell #09UG12.
Deficiencies (6)
| Description |
|---|
| Surface temperature of baseboard heating unit in Resident #51's room ranged from 135 F to 233 F, creating risk of bodily injury and fire. |
| Surface temperature on the wall above Resident #51's heating unit measured approximately 164 F, creating potential fire hazard. |
| Surface of window sill above Resident #51's heating unit was bubbling or peeling due to heat. |
| Residents' beds located close to heating units posed extreme risk of burning if residents fell against the units. |
| Combustible materials such as furniture, curtains, and bedding were situated within close proximity to heating units, increasing fire risk. |
| Facility failed to ensure adequate housekeeping and maintenance, including presence of personal belongings behind dresser, carpet damage, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Temperature range: 135
Temperature range: 233
Temperature: 164
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jason T. Lintner | Surveyor | Named as surveyor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 3
Dec 7, 2009
Visit Reason
The inspection was conducted as a complaint investigation regarding the physical well-being and safety of residents, specifically following an incident where Resident #51 sustained burns from contact with a baseboard heater.
Findings
The administrator failed to ensure the physical well-being of Resident #51 who suffered extensive burns from contact with a hot baseboard heater. The facility also failed to maintain a safe and accident-free living environment due to dangerously hot heating units, combustible materials placed too close to heaters, and inadequate housekeeping and maintenance.
Complaint Details
Complaint Investigation #WV00005383 initiated due to Resident #51's burns from a baseboard heater. The investigation confirmed the resident was in contact with the heater for approximately 35 minutes. Surveyors included Jane Cost, RN HFNS II; Louise Hall, RN HFNS II; and Jason T. Lintner.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident #51 received burns from contact with a baseboard heater that was hot enough to cause injury. | Class II |
| The surface temperatures of baseboard heating units posed an immediate and serious threat of bodily injury and fire. | Class I |
| Inadequate housekeeping and maintenance including damaged furniture, stained carpet, missing bathroom fixtures, and dirty sinks. | — |
Report Facts
Resident burns duration: 35
Resident census: 54
Surface temperature range: 135
Surface temperature range: 233
Surface temperature on wall: 164
Completion date for corrective actions: Jan 30, 2010
Completion date for policy implementation: Feb 11, 2010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor involved in complaint investigation. |
| Louise Hall | RN HFNS II | Surveyor involved in complaint investigation. |
| Jason T. Lintner | Surveyor involved in complaint investigation. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Dec 7, 2009
Visit Reason
The inspection was conducted as a complaint investigation (#WV00005383) at Wyngate of Weirton.
Findings
The complaint investigation was conducted by surveyors on December 7 and 14, 2009, with a follow-up on February 23, 2010. The follow-up found no deficiencies and provided technical assistance.
Complaint Details
Complaint investigation #WV00005383 was substantiated with no deficiencies found upon follow-up. Technical assistance was provided.
Report Facts
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor during complaint investigation |
| Louise Hall | RN HFNS II | Surveyor during complaint investigation |
| Jason T. Lintner | Surveyor during complaint investigation and follow-up |
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 9
Sep 2, 2009
Visit Reason
Annual Licensure Survey conducted from August 31, 2009 to September 2, 2009 to assess compliance with health facility regulations.
Findings
The facility was found deficient in multiple areas including employee training, medication administration, documentation of resident health status, housekeeping and maintenance, therapeutic diet provision, monitoring of resident incidents, nursing assessments, and secure storage of hazardous materials.
Severity Breakdown
Class I: 5
Class II: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure new employees receive training within the first fifteen days of employment on specialty care. | Class II |
| Failure to maintain current documentation regarding resident's health status, changes, and staff responses. | Class II |
| Failure to assure resident medications are administered as required by state rules, including lack of supervising RN signatures on MARs. | Class I |
| Failure to assure resident medications and treatments are administered according to current, signed physician orders. | Class I |
| Failure to keep a complete record of all medications given to each resident, including initials/signatures verifying administration. | Class I |
| Failure to ensure monitoring and documentation of resident condition every 8 hours following an incident or illness, with assessments specific to injuries. | Class II |
| Failure to ensure weekly nursing assessments are comprehensive to the identified diagnosis for residents with limited and intermittent care needs. | Class II |
| Failure to ensure physician ordered therapeutic diets are provided and fluid restrictions are followed. | Class I |
| Failure to maintain toxic and hazardous materials in locked storage accessible only to responsible employees. | Class I |
Report Facts
Census: 48
Employee training sample size: 3
Resident sample size for training needs: 5
Medication Administration Records reviewed: 49
Incident reports reviewed: 5
Residents with missed medication doses: 13
Residents with weekly nursing assessment issues: 4
Residents with fluid restriction: 1
Residents confused and wandering: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor conducting the annual licensure survey |
| Louise Hall | RN HFNS II | Surveyor conducting the annual licensure survey |
| JH | Approved Medication Assistive Personnel (AMAP) | Stated medication had not been available from pharmacy |
| CM | LPN | Provided information about fluid restriction and dietary compliance |
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 0
Sep 2, 2009
Visit Reason
The inspection was conducted as an Annual Licensure Survey from August 31, 2009 to September 2, 2009 to assess compliance with licensure requirements.
Findings
The report indicates that deficiencies identified during the annual survey were subsequently corrected as confirmed by a follow-up survey conducted on October 21, 2009.
Report Facts
Census during annual survey: 48
Census during follow-up survey: 56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor during annual and follow-up surveys |
| Louise Hall | RN HFNS II | Surveyor during annual survey |
Inspection Report
Annual Inspection
Census: 46
Deficiencies: 0
Aug 24, 2009
Visit Reason
The visit was conducted as an Annual Licensure Survey to assess the environment of the facility.
Findings
No deficiencies were cited during this annual inspection, though technical assistance was provided.
Report Facts
Census: 46
Inspection Report
Follow-Up
Census: 53
Deficiencies: 0
Feb 2, 2009
Visit Reason
The document reports on a follow-up survey conducted to verify correction of deficiencies identified in the annual licensure survey and prior follow-up visits.
Findings
The follow-up survey found that previously cited deficiencies were corrected as of the February 2, 2009 visit.
Report Facts
Census: 58
Census: 52
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Louise Hall | RN, HFNS II | Surveyor for annual licensure survey and follow-up visits |
| Donna Williamson | RN, HFNS I | Surveyor for annual licensure survey |
| Jane Cost | RN, HFNS II | Surveyor for follow-up visits |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Nov 12, 2008
Visit Reason
The inspection was conducted as a complaint investigation related to a complaint #WV000004486, done in conjunction with the first follow-up to the annual inspection.
Findings
The facility failed to establish written policies and procedures specific to resident intimacy and governing the care and safety of residents. Additionally, inadequate housekeeping and maintenance issues were observed, including personal belongings left out, carpet damage, and missing bathroom fixtures.
Complaint Details
Complaint #WV000004486 was investigated during November 10-12, 2008, in conjunction with the first follow-up to the annual inspection. The census at the time was 52. Surveyors were Louise Hall, RN HFNS II and Jane Cost, RN HFNS II.
Deficiencies (2)
| Description |
|---|
| Failure to establish policies and procedures specific to governing the care and safety of residents, including no documented policy regarding intimacy between residents. |
| Inadequate housekeeping and maintenance including personal belongings behind dresser, iron burn and bleach spots on carpet, torn chair, missing towel bar and toilet paper holder, and dirty sink. |
Report Facts
Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Louise Hall | RN HFNS II | Surveyor during complaint investigation |
| Jane Cost | RN HFNS II | Surveyor during complaint investigation |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 4
Nov 12, 2008
Visit Reason
Annual licensure survey conducted on September 9-10, 2008 with a follow-up survey in November 10-12, 2008 in conjunction with a complaint investigation.
Findings
The facility failed to provide adequate employee orientation and annual training, maintain accurate medication administration records consistent with physician orders, and ensure adequate housekeeping and maintenance. Multiple deficiencies were repeated from prior surveys.
Complaint Details
Complaint investigation #4486 was conducted in conjunction with the follow-up survey on November 10-12, 2008.
Severity Breakdown
Class I: 1
Class II: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to provide and maintain records of training to new employees within the first 15 days of employment including emergency procedures, abuse prevention, complaint procedures, infection control, and specialty care training. | Class II |
| Failure to provide and maintain records of annual in-service training to all staff on resident rights, confidentiality, abuse prevention, infection control, fire safety, evacuation plans, and specialty care. | Class II |
| Failure to ensure medications are administered according to physician orders, including discrepancies in medication administration records and missing physician orders. | Class I |
| Failure to ensure adequate housekeeping and maintenance, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sinks. | — |
Report Facts
Census: 58
Census: 52
Number of tenured employees lacking documented annual training: 9
Number of resident records with medication discrepancies: 4
Number of resident records with medication discrepancies: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Louise Hall | RN, HFNS II | Surveyor during annual licensure survey and follow-up. |
| Donna Williamson | RN, HFNS I | Surveyor during annual licensure survey. |
| Jane Cost | RN, HFNS II | Surveyor during follow-up survey. |
| TP | Nurse | New employee lacking documented orientation and training. |
| PK | Aide | Newly hired employee lacking documented training. |
| BD | Aide | Newly hired employee lacking documented training. |
| AS | Aide | Newly hired employee lacking documented training. |
| JB | Supervising Registered Nurse | Acknowledged training deficiencies and incomplete training materials. |
| AW | Acting Wellness Manager | Interviewed regarding medication order discrepancies and training. |
| KS | Interviewed regarding employee training records. | |
| RB | Administrator | Providing in-services on resident rights, confidentiality, activities, and other topics. |
| NC | Administrator | Providing in-services on fire safety, evacuation procedures, and coumadin therapy precautions. |
| LE | Administrator | Providing in-services on fire safety, evacuation procedures, and coumadin therapy precautions. |
| KE | Registered Nurse | Lacking documented training in multiple areas; scheduled for training. |
| JF | Administrator | Providing in-services on resident rights, confidentiality, activities, and other topics. |
| SH | Administrator | Providing in-services on confidentiality, abuse prevention, and other topics. |
| EM | Administrator | Providing in-services on resident rights, confidentiality, infection control, and other topics. |
| MS | Administrator | Providing in-services on abuse prevention, resident rights, fire safety, and other topics. |
| CM | LPN | Unable to rectify medication order discrepancies during review. |
| RB | Dietary Manager | Unaware of fluid restriction order for resident. |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Nov 10, 2008
Visit Reason
The inspection was conducted as a complaint investigation (#WV000004486) from November 10-12, 2008, to address concerns raised about the facility.
Findings
The report documents a complaint investigation and a subsequent follow-up visit on February 2, 2009, noting that deficiencies identified during the complaint investigation were corrected by the follow-up.
Complaint Details
Complaint investigation #WV000004486 was conducted from November 10-12, 2008, with a follow-up visit on February 2, 2009. Deficiencies identified were corrected by the follow-up.
Report Facts
Census: 52
Census: 53
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Louise Hall | RN HFNS II | Surveyor during complaint investigation and follow-up |
| Jane Cost | RN HFNS II | Surveyor during complaint investigation and follow-up |
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 10
Sep 10, 2008
Visit Reason
Annual licensure survey conducted on September 9-10, 2008 to assess compliance with health and safety, administrative, employee training, service plan, medication administration, and dietary regulations.
Findings
The facility was found deficient in multiple areas including failure to provide criminal background checks for employees, inadequate employee orientation and annual training, incomplete and outdated resident service plans, failure to administer medications according to physician orders, and failure to report significant weight changes to physicians. Housekeeping and maintenance issues were also noted from prior surveys.
Severity Breakdown
Class I: 2
Class II: 7
Class III: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Administrator failed to provide documentation of criminal background check for one of nine employee files reviewed. | Class II |
| Administrator and supervising RN failed to provide adequate training for new employees within the first 15 days of employment. | Class II |
| Administrator and supervising RN failed to provide documentation of required annual training for nine of nine tenured employee files reviewed. | Class II |
| Administrator and supervising RN failed to provide documentation that initial and annual training on Alzheimer's disease and related dementias for a required period of two hours has occurred. | Class II |
| Administrator failed to ensure a service plan is developed for each resident within seven days of admission. | Class II |
| Administrator failed to ensure resident service plans reflect the current needs of the resident. | Class II |
| Administrator failed to ensure medications are administered according to physician orders. | Class I |
| Administrator failed to ensure an unplanned five pound or more weight gain or loss is reported to the resident's physician. | Class III |
| Administrator and supervising RN failed to ensure each resident with nursing needs have a service plan developed which reflects those needs. | Class I |
| Administrator and supervising RN failed to ensure each resident with nursing needs is assessed by the registered nurse at least weekly. | Class II |
Report Facts
Census: 58
Employee files reviewed: 9
New employee files reviewed: 1
Tenured employee files reviewed: 9
Resident files reviewed: 11
Residents without service plans within 7 days: 4
Residents with incomplete service plans: 8
Residents with medication record discrepancies: 4
Weight gain: 10
Weight gain: 11
Weight loss: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| TP | Employee | Named in findings for missing criminal background check and inadequate orientation and training |
| AW | Acting Wellness Manager and Corporate Nurse Representative | Interviewed regarding missing documentation and training failures |
| KS | Acting Director of Nursing | Interviewed regarding missing documentation and training failures |
| RB | Employee | Named in findings for missing annual training |
| NC | Employee | Named in findings for missing annual training |
| LE | Employee | Named in findings for missing annual training |
| KE | Employee | Named in findings for missing annual training |
| JF | Employee | Named in findings for missing annual training |
| JH | Employee | Named in findings for missing annual training |
| SH | Employee | Named in findings for missing annual training |
| EM | Employee | Named in findings for missing annual training |
| MS | Employee | Named in findings for missing annual training |
| Jody Bowden | Registered Nurse | Named as responsible for reviewing and updating service plans and monitoring nursing needs |
| Louise Hall | RN, HFNS II | Surveyor |
| Donna Williamson | RN, HFNS I | Surveyor |
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 0
Aug 26, 2008
Visit Reason
The visit was conducted as an annual licensure survey focusing on the environment of the facility.
Findings
No deficiencies were found during the survey; only technical assistance was provided.
Report Facts
Census: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 0
Mar 11, 2008
Visit Reason
The document reports on the annual licensure survey conducted at Wyngate of Weirton from August 27-29, 2007, with follow-up surveys conducted to verify correction of deficiencies.
Findings
The annual licensure survey and subsequent follow-up visits identified deficiencies which were later corrected by the time of the last follow-up on March 11, 2008.
Report Facts
Census: 60
Census: 59
Census: 50
Census: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor for annual licensure and follow-up surveys |
| Louise Hall | RN HFNS II | Surveyor for annual licensure and follow-up surveys |
| Deborah Dodrill | LSW, HFS II | Surveyor for annual licensure survey |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 5
Jan 16, 2008
Visit Reason
Annual Licensure Survey conducted August 27-29, 2007 with follow-up surveys on October 31, 2007 and January 16, 2008 to assess compliance with health care standards and licensing requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure transfer summaries accompany residents at transfer, inadequate housekeeping and maintenance, and medication administration issues such as incomplete medication administration records (MARs), lack of required credentials for medication assistive personnel (AMAP), and failure to properly review MARs monthly. Several deficiencies were repeated from prior surveys.
Severity Breakdown
Class I: 3
Class II: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure a summary accompanies the resident at the time of transfer including medical history, physician orders, allergies, and advanced directives. | Class II |
| Failure to ensure adequate housekeeping and maintenance including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sinks. | — |
| Failure to maintain required credentials for all AMAPs and failure to ensure medication administration records are reviewed monthly by RN with signature and date. | Class I |
| Failure to ensure all new medication entries on MAR are reviewed and verified by RN with signature/initials and date. | Class I |
| Failure to ensure PRN medications have specific parameters for administration including dosage, frequency, and purpose. | Class I |
Report Facts
Census: 60
Census: 59
Census: 50
Number of MARs reviewed: 55
Number of residents transferred without proper documentation: 8
Number of AMAPs without required credentials: 4
Number of MARs with incomplete PRN documentation: 26
Number of MARs with unsigned new entries: 30
Number of MARs lacking RN review date: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN HFNS II | Surveyor during annual and follow-up surveys |
| Louise Hall | RN HFNS II | Surveyor during annual and follow-up surveys |
| Deborah Dodrill | LSW, HFS II | Surveyor during annual licensure survey |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 6
Oct 31, 2007
Visit Reason
Annual Licensure Survey conducted August 27-29, 2007 with a follow-up survey on October 31, 2007 to verify correction of deficiencies.
Findings
The facility was found deficient in multiple areas including employee training and documentation, personnel records, medication administration, transfer summaries, nursing documentation, and housekeeping/maintenance issues. Several deficiencies were repeat findings from prior surveys.
Severity Breakdown
Class I: 1
Class II: 3
Class III: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to ensure all employees receive training on all required topics and maintain written records of annual in-services. | Class II |
| Failed to maintain confidential personnel files with required information and ensure tuberculosis screening is completed prior to hire and annually thereafter. | Class III |
| Failed to ensure transfer summaries accompany residents at time of transfer with required medical and care information. | Class II |
| Failed to maintain required credentials for all Approved Medication Assistive Personnel (AMAP), ensure monthly review of medication administration records (MAR) by RN with signature and date, and verify new medication entries on MAR by RN. | Class I |
| Failed to ensure weekly nursing documentation for residents with nursing care needs reflecting status and changes in condition. | Class II |
| Failed to ensure adequate housekeeping and maintenance including physical environment safety and appropriateness. | — |
Report Facts
Census: 60
Census: 59
Number of employees lacking training documentation: 5
Number of AMAP employees lacking education verification: 4
Number of MARs lacking RN review date: 55
Number of residents lacking weekly nursing documentation: 5
Inspection Report
Annual Inspection
Census: 58
Deficiencies: 0
Sep 11, 2007
Visit Reason
The visit was conducted as an Annual Licensure Survey to assess the environment of the facility.
Findings
The survey found no deficiencies in the environment of the facility during the inspection.
Report Facts
Census: 58
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor | Conducted the annual licensure survey |
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 11
Aug 29, 2007
Visit Reason
Annual licensure survey conducted from August 27-29, 2007 to assess compliance with state regulations for Wyngate of Weirton.
Findings
The facility was found deficient in multiple areas including failure to complete abuse registry checks prior to hire, inadequate employee training documentation, incomplete tuberculosis screenings, failure to obtain waivers for residents requiring nursing care, lack of transfer summaries, medication administration discrepancies, inadequate weekly nursing assessments, failure to provide physician ordered therapeutic diets, unsecured oxygen cylinders, and improper storage of toxic materials.
Severity Breakdown
Class I: 6
Class II: 4
Class III: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure nurse aide abuse registry and central abuse registry checks were completed prior to hire for new employees. | Class II |
| Failure to provide and maintain documentation of annual in-service training on required topics for all employees. | Class II |
| Failure to complete tuberculosis screening prior to hire and annually thereafter for employees. | Class III |
| Failure to obtain waivers for residents requiring ongoing or extensive nursing care. | Class I |
| Failure to ensure transfer summaries accompany residents transferred to other facilities. | Class II |
| Failure to ensure quarterly reviews and credential documentation for approved medication assistive personnel (AMAP), and failure to ensure medication administration records are reviewed and signed monthly by RN. | Class I |
| Failure to ensure all resident medications are administered according to current physician orders, including discrepancies in medication orders and self-administered medications without orders. | Class I |
| Failure to ensure weekly nursing assessments and documentation for residents with nursing care needs. | Class II |
| Failure to provide and monitor physician ordered therapeutic diets for residents. | Class I |
| Failure to secure free-standing oxygen cylinders at all times. | Class I |
| Failure to store toxic materials in locked storage accessible only to responsible persons and failure to secure resident apartments to prevent access to toxic materials. | Class I |
Report Facts
New employees without prior abuse registry check: 4
New employees without complete central abuse registry documentation: 2
Tenured employees lacking required training: 5
New employees without TB screening prior to hire: 5
Residents without nursing care waivers: 2
Residents transferred without transfer summaries: 8
Medication administration records lacking RN review date: 30
Residents with medication discrepancies: 6
Residents lacking weekly nursing assessments: 5
Unsecured oxygen tanks observed: 6
Residents who are confused and wander: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| VD | New employee hired 6/25/07 with delayed nurse aide abuse registry check and TB screening. | |
| CA | New employee hired 6/4/07 with delayed nurse aide abuse registry check and incomplete fingerprint card date. | |
| NK | New employee hired 7/16/07 with delayed nurse aide abuse registry check and TB screening. | |
| TE | New employee hired 7/20/07 with delayed nurse aide abuse registry check and TB screening. | |
| HH | Tenured employee lacking annual TB screening. | |
| CM | Tenured employee lacking evidence of training on confidentiality, activities, Alzheimer/dementia care, and fire safety. | |
| EM | Tenured employee lacking evidence of training on activities and Alzheimer/dementia care. | |
| JF | Tenured employee lacking evidence of training on activities and Alzheimer/dementia care. | |
| NC | Tenured employee lacking evidence of training on confidentiality and activities. | |
| CS | Approved medication assistive personnel lacking written verification of education. | |
| JH | Approved medication assistive personnel lacking written verification of education and incomplete quarterly reviews. |
Inspection Report
Follow-Up
Census: 62
Deficiencies: 0
Sep 18, 2006
Visit Reason
The visit was a follow-up survey conducted to verify correction of deficiencies identified during the annual licensure survey.
Findings
The follow-up survey found that the previously cited deficiencies were corrected.
Report Facts
Census: 64
Census: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor for both the annual licensure survey and the follow-up survey |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 7
Aug 22, 2006
Visit Reason
Annual licensure survey conducted on August 21-22, 2006 to assess compliance with health and safety, staffing, employee training, medication administration, health care standards, dietary services, and physical facilities regulations.
Findings
The facility was found deficient in multiple areas including failure to ensure at least one employee with current CPR training on each shift, inadequate employee in-service training especially on abuse prevention, insufficient documentation and parameters for PRN medications, lack of specific training on resident health care issues, failure to notify physicians of significant resident weight changes, and improper storage of toxic materials accessible to residents.
Severity Breakdown
Class I: 3
Class II: 2
Class III: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to assure at least one employee with current CPR training is scheduled during each shift. | Class I |
| Failure to provide and maintain annual in-service training on abuse prevention and reporting to all staff. | Class II |
| Failure to ensure PRN medications have documented specific parameters for administration. | Class I |
| Failure to provide needed training for staff on specific resident health care issues including Foley catheters, insulin injections, wound care, colostomy, and dialysis. | Class II |
| Failure to notify physician of any unplanned weight loss or gain of five pounds or more. | Class III |
| Failure to maintain toxic materials in locked storage accessible only to authorized personnel. | Class I |
| Failure to ensure adequate housekeeping and maintenance required to carry out services, including presence of personal belongings behind furniture, carpet damage, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Census: 62
Number of shifts without CPR trained staff: 32
Number of tenured employees without abuse prevention training: 8
Number of residents: 62
Weight fluctuations: 6
Weight fluctuations: 9
Weight fluctuations: 10
Weight fluctuations: 17
Number of confused and wandering residents: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Cook | LPN | Named in CPR training deficiency |
| Cecilia McClory | LPN | Named in CPR training deficiency |
| Jane Cost | RN, HFNS II | Named in annual licensure survey |
| Louise Hall | RN, HFNS II | Named in annual licensure survey |
| Myra McClead | RN, HFNS II | Named in annual licensure survey |
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 0
Aug 21, 2006
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with regulatory requirements for the facility.
Findings
The report documents the annual licensure survey conducted on August 21-22, 2006, with a census of 62 residents. A follow-up survey on October 23, 2006, with a census of 64 residents, confirmed that deficiencies identified previously were corrected.
Report Facts
Census: 62
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | RN, HFNS II | Surveyor during Annual Licensure Survey and Survey Follow-Up |
| Louise Hall | RN, HFNS II | Surveyor during Annual Licensure Survey and Survey Follow-Up |
| Myra McClead | RN, HFNS II | Surveyor during Annual Licensure Survey |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 6
Aug 3, 2006
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess the facility's compliance with health, safety, and environmental regulations.
Findings
The facility was found deficient in maintaining a safe, clean, and sanitary environment, including unsecured fire alarm panel keys, food debris in kitchen and resident areas, and tripping hazards from electrical cords. Several housekeeping and maintenance issues were noted, such as damaged furniture, carpet stains, and missing bathroom fixtures.
Severity Breakdown
Class I: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Fire alarm control panel keys left in the lock, allowing unauthorized access. | Class I |
| Dust, food, plastic wraps, and debris present under and around refrigerators in resident rooms. | Class I |
| Kitchen equipment including blender, broiler, microwave, and can opener had old dried food splatter and stains. | Class I |
| Hand held scoops for sugar and flour bins stored inside containers with handles touching material. | Class I |
| Floor area around ice machine drain contained food particles and debris. | Class I |
| Electrical cords routed in a manner creating tripping hazards in resident rooms. | Class I |
Report Facts
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Named in relation to the Annual Licensure Survey. |
Inspection Report
Annual Inspection
Census: 64
Deficiencies: 0
Oct 19, 2005
Visit Reason
The inspection was conducted as an annual licensure survey of the facility Wyngate of Weirton.
Findings
The report documents the annual licensure survey conducted on October 17 and 19, 2005, with a census of 64 residents. No specific deficiencies or severity levels are detailed in the provided text.
Report Facts
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jane Cost | HFNSII | Surveyor for the annual licensure survey |
| Myra McClead | HFNSI | Surveyor for the annual licensure survey |
| Louise Hall | HFNSII | Surveyor for the annual licensure survey |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 2
Sep 13, 2005
Visit Reason
The facility underwent an annual licensure survey to assess compliance with health, safety, housekeeping, maintenance, and disaster preparedness regulations.
Findings
The inspection found deficiencies in disaster preparedness training, cleanliness and maintenance of the physical environment, and housekeeping practices. Several areas in the kitchen and residence were noted to be unclean or in disrepair, and not all staff participated in the required disaster rehearsal.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Administrator failed to include all employees in a disaster rehearsal. | Class I |
| Licensee failed to maintain a clean living environment, including storage on top of hot water tank, dirty microwave, debris behind aquarium, dirty ice machine area, and unclean kitchen equipment. | Class II |
Report Facts
Census: 66
Deficiency Class I: 1
Deficiency Class II: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Named as part of the annual licensure survey report | |
| Administrator | Responsible for disaster rehearsal and follow-up | |
| Director of Nursing | Involved in conducting disaster preparedness plan in inservice | |
| Kitchen Manager | Responsible for cleaning and implementing new kitchen cleaning schedule | |
| Maintenance Director | Moved ice machine and freezers/coolers for cleaning |
Inspection Report
Annual Inspection
Census: 66
Deficiencies: 0
Sep 13, 2005
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with regulatory requirements for the facility.
Findings
The report documents the annual licensure survey conducted on September 13, 2005, with a census of 66 residents. A follow-up survey on November 2, 2005, indicated that previously identified deficiencies were corrected.
Report Facts
Census: 66
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keith Carpenter | Surveyor conducting the annual licensure and follow-up surveys |
Inspection Report
Follow-Up
Census: 63
Deficiencies: 0
Nov 18, 2004
Visit Reason
First follow-up to Annual Survey conducted to verify correction of previously identified deficiencies.
Findings
The report summarizes the follow-up to the annual survey where deficiencies identified earlier were reviewed and corrected. Six medical records and nine employee files were reviewed during the annual survey and follow-up.
Report Facts
Census: 62
Census: 63
Medical records reviewed: 6
Employee files reviewed: 9
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 8
Sep 21, 2004
Visit Reason
Annual survey conducted to review medical records, employee files, and compliance with health and safety regulations at Wyngate of Weirton.
Findings
The inspection identified multiple deficiencies including failure to maintain a safe environment, inadequate housekeeping and maintenance, incomplete resident service plans, lack of current physician orders for medications, improper medication storage, and unsecured toxic materials. Corrective actions and plans of correction were provided for each deficiency.
Severity Breakdown
Class I: 4
Class II: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to implement programs in a safe environment; doors without alarms and inadequate weekend supervision. | — |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, missing bathroom fixtures, and dirty sink. | — |
| Failure to verify employee screening through the West Virginia state police central abuse registry for new hires. | Class II |
| Resident service plans did not reflect current needs or significant changes in condition for multiple residents. | Class II |
| Failure to maintain current physician orders for medications and failure to follow physician orders for residents. | Class I |
| Medications were not kept in locked storage accessible only to responsible staff; unsecured basket with multiple residents' medications found. | Class I |
| Failure to provide maintenance and housekeeping to maintain a safe, sanitary, and accident-free environment; unlocked closet with syringes accessible to residents. | Class I |
| Failure to keep toxic materials in locked storage accessible only to responsible staff; unlocked cabinet with alcohol, hydrogen peroxide, and iodine. | Class I |
Report Facts
Resident records reviewed: 6
Employee files reviewed: 9
Residents without current physician orders: 3
New employee files without abuse registry screening: 3
Resident census: 62
Inspection Report
Environmental Survey
Census: 60
Deficiencies: 0
Aug 31, 2004
Visit Reason
Environmental survey conducted to assess the facility's compliance with health and safety regulations.
Findings
No deficiencies were issued during the environmental survey conducted on August 31, 2004, with a census of 60 residents.
Report Facts
Census: 60
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 5
Feb 18, 2004
Visit Reason
The inspection was conducted as a complaint investigation related to the elopement and injury of resident #66 on January 2, 2004.
Findings
The facility failed to protect the physical well-being of residents, specifically resident #66 who eloped and suffered injuries leading to death. The administrator failed to report the major incident timely, and the facility lacked adequate alarm systems and proper documentation of preventative measures. Additionally, housekeeping and maintenance deficiencies were noted.
Complaint Details
Complaint Investigation #WV00001079 regarding resident #66 who eloped from the home on January 2, 2004, was found injured outside and later expired. The investigation found failures in resident protection, incident reporting, alarm system adequacy, and documentation of preventative measures.
Severity Breakdown
Class I: 2
Class II: 1
Class III: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to protect the physical well-being of residents, evidenced by resident #66 eloping and sustaining injuries. | Class II |
| Failure to report a major incident to the Office of Health Facility Licensure and Certification no later than the next business day. | Class III |
| Failure of RN/LPN to document possible preventative actions to avoid similar occurrences in the future. | Class I |
| Failure to provide an adequate alarm system to protect residents exhibiting potentially harmful behaviors such as wandering. | Class I |
| Inadequate housekeeping and maintenance, including damaged carpet, missing bathroom fixtures, and unclean sink. | — |
Report Facts
Center Census: 6
Sample Size: 3
Residents Confused: 39
Wanderers: 3
Incident Date: Jan 2, 2004
Incident Time: 1830
Hospital Admission Date: Jan 2, 2004
Hospital Admission Time: 1905
Resident Expiration Date: Jan 3, 2004
Resident Expiration Time: 1600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| C.P. | LPN | Nurse on duty during resident #66 elopement, interviewed regarding incident and alarm system. |
Inspection Report
Complaint Investigation
Census: 6
Deficiencies: 2
Feb 18, 2004
Visit Reason
The inspection was conducted as a complaint investigation (#WV00001079) on February 18, 2004, with a follow-up visit on April 8, 2004 to verify correction of deficiencies.
Findings
The investigation found that the facility did not provide a safe environment for adolescent consumers, including lack of alarms on outside doors and insufficient awake staff supervision on weekend nights. Deficiencies were corrected by the follow-up visit.
Complaint Details
Complaint Investigation #WV00001079 conducted on February 18, 2004. Deficiencies were corrected by the first follow-up on April 8, 2004.
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
Plan of Correction
Census: 6
Deficiencies: 2
Feb 11, 2004
Visit Reason
The inspection was conducted as a behavioral health survey to assess the safety and appropriateness of the environment for adolescent consumers.
Findings
The survey found that the center did not implement programs in a safe environment appropriate for the consumers, specifically noting unsecured outside doors and lack of awake staff supervision on weekend nights. A plan of correction was proposed to provide awake-night supervision during weekend shifts by July 1, 2004.
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 safety. |
| An outside door in the TV room does not lock. |
Report Facts
Center census: 6
Sample size: 3
Plan of correction completion date: Jul 1, 2004
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 4, 2003
Visit Reason
Annual Survey conducted at Wyngate at Weirton on September 2-4, 2003.
Findings
The survey found no plan of correction necessary for technical assistance. The report includes multiple observations regarding housekeeping, medication administration, resident care plans, and facility maintenance. Specific deficiencies were noted in housekeeping and maintenance, medication documentation, and resident care documentation.
Deficiencies (4)
| Description |
|---|
| The facility failed to ensure adequate housekeeping and maintenance required to carry out its services, including miscellaneous personal belongings behind furniture, carpet damage, torn furniture, missing bathroom fixtures, and unclean sink. |
| Medication administration deficiencies including incomplete documentation on PRN medications, lack of signed physician orders for self-administered medications, and incomplete medication administration records (MAR). |
| Resident care documentation deficiencies including lack of timely progress notes for residents receiving outside services and limited/intermittent nursing care, and inadequate monitoring following accidents. |
| Facility must assure all residents are offered meals and snacks that meet resident needs and choices, including dietary requirements for residents receiving hemodialysis. |
Report Facts
Sample Size: 3
Center Census: 6
Dates: 2003-09-02 to 2003-09-04
Carpet replacement deadline: 2004
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 3
Sep 12, 2002
Visit Reason
Annual Survey conducted at Wyngate of Weirton to assess compliance with state and federal regulations regarding medication administration, privacy and confidentiality, and housekeeping and maintenance.
Findings
The facility failed to ensure safe medication administration practices, maintain confidentiality of resident records, and provide adequate housekeeping and maintenance. Specific issues included pre-filling medication minders by a resident's daughter, unlocked and accessible resident records, and physical environment deficiencies such as damaged carpet and missing bathroom fixtures.
Severity Breakdown
Class I: 1
Class II: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Medications were administered using a pre-filled medication minder by the resident's daughter, which is not permitted by state regulations. | Class I |
| Resident records were stored in unlocked cabinets and were accessible to unauthorized persons, compromising confidentiality. | Class II |
| Inadequate housekeeping and maintenance including personal belongings behind furniture, carpet damage, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
Report Facts
Center Census: 6
Sample Size: 3
Resident Records: 37
Medications Dispensed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| K.H. | R.N. | Interviewed regarding open door policy at nurse's station |
| P.M. | L.P.N. | Observed administering medications and acknowledged pre-filling practice |
Inspection Report
Annual Inspection
Deficiencies: 6
Sep 11, 2002
Visit Reason
The inspection was conducted to evaluate compliance with health, safety, environmental, and operational regulations at Wyngate of Weirton, including disaster preparedness, food service sanitation, housekeeping, laundry, electrical safety, and storage of hazardous materials.
Findings
The facility was found deficient in several areas including failure to conduct an annual disaster rehearsal, inadequate food service sanitation, unsafe storage and use of helium tanks, inadequate housekeeping and maintenance, unsecured hazardous materials, and improper use of electrical extension cords. Corrective actions and plans of correction were provided for each deficiency.
Severity Breakdown
Class I: 4
Class II: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to conduct an annual disaster rehearsal as required by regulation. | Class II |
| Food storage and preparation areas were not kept free from contamination, including unlined wire mesh container, soiled ice machine, grease and food splatter on walls and floors, uncovered trash containers, and dirty kitchen equipment. | Class I |
| Failure to assure that all potential internal disasters are identified and appropriate procedures incorporated into the disaster plan, including unsafe storage and use of helium tanks. | Class I |
| Inadequate housekeeping and maintenance including personal belongings behind dresser, carpet damage, torn chair, missing towel bars and toilet paper holders, and dirty sink. | — |
| Failure to provide locked storage for hazardous materials; unsecured beauty shop door and cabinet containing hazardous cleaning supplies. | Class I |
| Use of electrical extension cords in common areas contrary to regulation; power strip recommended instead. | Class I |
Report Facts
Sample Size: 3
Center Census: 6
Completion Date: Oct 21, 2002
Replacement Date: Sep 30, 2004
Inspection Report
Original Licensing
Census: 6
Deficiencies: 6
Oct 11, 2001
Visit Reason
The inspection was conducted as an original licensing survey to assess compliance with physical facilities, safety, housekeeping, and emergency preparedness regulations prior to admitting residents.
Findings
The facility was found to have multiple deficiencies including lack of a substantial completion form for construction, inadequate drainage causing potential hazards, missing components in the disaster plan, poor housekeeping and maintenance issues, missing sprinkler head cover plates, and an uninstalled nurse call system.
Severity Breakdown
Class I: 2
Class II: 2
Class III: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Facility did not provide a substantial completion form from the architect for construction compliance. | Class I |
| Inadequate drainage causing accumulation of water and potential ice hazards on walkways. | Class II |
| Disaster and emergency preparedness plan lacked emergency transportation agreement, shelter agreement, and 72-hour emergency menu. | Class II |
| Facility failed to ensure adequate housekeeping and maintenance; observed personal belongings behind dresser, carpet damage, torn chair, missing towel bar and toilet paper holder, and dirty sink. | — |
| Cover plates for sprinkler heads missing and grab bars with missing end cover plates. | Class III |
| Nurse call system was not installed though equipment was on premises but not plugged in. | Class I |
Report Facts
Center census: 6
Sample size: 3
Work order completion timeframe: 30
Carpet replacement deadline: 2004
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operations Supervisor | Participated in tour and interview regarding safety and housekeeping | |
| Treatment Coordinator | Participated in tour regarding housekeeping observations | |
| Keith | Conducted inspection and discussed nurse call system status |
Loading inspection reports...



