Celebration Villa of Martinsburg

    200 Gloucester Dr, Martinsburg, WV 25401
    • Assisted Living

    Clean homey community with activities

    I toured the community and was very pleased - it's clean, homey, and well kept with comfortable private studios. The staff are caring, knowledgeable, and responsive; residents seemed happy and active with plenty of activities, outings, on-site amenities (salon, medical transport) and good dining options. My mom is content there and I would recommend it for someone seeking compassionate, resident-focused care.

    Loved one of resident
    Jul 2026

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Coordination with health care providers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (medical)
    • Transportation arrangement (non-medical)
    • Transportation to doctors appointments

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    4.25·(71)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      4.2
    • Staff

      4.3
    • Meals

      3.2
    • Amenities

      4.1
    • Value

      2.4

    Pros

    • Warm, home-like atmosphere
    • Compassionate and visible nursing and caregiving staff
    • Engaging activities program (music, outings, bingo, themed events)
    • Restaurant-style dining with varied menu and breakfast options
    • On-site amenities: hair salon, physical therapy room, library, enclosed courtyards
    • Private studio apartments with en-suite bathrooms and walk-in showers
    • Transportation services for shopping and medical appointments
    • Family-style events and opportunities for socialization
    • Clean and well-maintained common areas
    • Personalized meal preparation and special-event dining
    • Responsive hospice and end-of-life support
    • Competitive pricing and perceived value
    • Thorough admissions tours and helpful admissions staff

    Cons

    • Inconsistent management and billing practices
    • Staffing shortages and high staff turnover
    • Clinical leadership instability and delayed hiring
    • Variable food quality and meal preparation consistency
    • Cleanliness and sanitation concerns in resident rooms and bathrooms
    • Pest-control concerns in resident areas
    • Privacy and security control gaps and unauthorized-access risk
    • Limited on-site clinical services and lab availability
    • Transportation coordination gaps for medical appointments
    • Limited housing options (predominantly studios), not ideal for couples

    Summary of reviews

    Celebration Villa of Martinsburg is described overall as a smaller, homelike assisted-living community with strengths in visible caregiving, social programming, and on-site amenities. Many families praised the warm atmosphere, personalized touches in meals and events, and staff who are present and engaged with residents. The community offers a range of conveniences that appeal to independent and assisted residents: a restaurant-style dining area, music and themed activities, transportation for shopping and appointments, an on-site hair salon, a physical therapy room, and enclosed outdoor courtyards. Several accounts highlight compassionate nursing interactions and positive hospice support during end-of-life care.

    Care quality and staffing present a mixed picture. Positive reports emphasize attentive aides, responsive nursing when available, and continuity of long-term staff in some cases. At the same time, reviews point to operational challenges: staffing shortages, turnover, and periods without stable clinical leadership have affected perceptions of reliability. Families noted delays in hiring a Director of Nursing and concerns about experience levels in charge nurses. Prospective residents should ask about current staffing ratios, leadership stability, and response times during a tour.

    Dining and activities are frequent points of contrast. The facility is praised for a family-style dining environment, varied menus, breakfast options, and special-event meals. Activity programming—music sessions, resident piano playing, outings, bingo, crafts, and family dinners—receives consistent positive feedback for social engagement. However, reviewers also describe inconsistent meal preparation quality, occasional complaints about seasoning, temperature, and portioning, and periodic dissatisfaction with food service. Asking for a sample menu and arranging a meal visit is advisable.

    The physical plant and amenities reflect an older, cozy building with single-level layouts, fireplace-equipped common areas, and private studio units with walk-in showers. Some reviewers appreciated the smaller scale and homier feel; others described smaller or darker rooms and noted the facility's age. Cleanliness and sanitation concerns in certain rooms and bathrooms were reported alongside mentions of pest-control issues and isolated maintenance problems. In addition, the community appears to offer limited housing types—primarily studios—which may be less suitable for couples seeking private two-room apartments.

    Management and operational practices are a recurring area of concern. Reviews indicate inconsistent billing and administrative follow-through, occasional transportation coordination problems for medical appointments, and limited on-site clinical services such as lab draws. Privacy and security control gaps were raised, and a subset of families raised allegations of theft and unauthorized access; these items point to the importance of asking specific questions about room access controls, laundry procedures, and inventory practices. There were also references to regulatory complaints in some accounts, suggesting families should request documentation on state inspections and corrective actions.

    In summary, Celebration Villa of Martinsburg appears to offer a strong, small-community experience for residents who prioritize social programming, a homelike setting, and visible caregiving staff. At the same time, operational weaknesses—particularly around management consistency, clinical leadership, cleanliness in some areas, and security controls—warrant careful due diligence. Visitors should conduct an in-person tour, sample a meal, review staffing and leadership credentials, inspect resident rooms and common-area sanitation, and obtain clarification on billing, transport coordination, and clinical services before deciding.

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    Location

    Map showing location of Celebration Villa of Martinsburg

    Celebration Villa of Martinsburg is located at 200 Gloucester Dr, Martinsburg, WV, 25401.

    About Celebration Villa of Martinsburg

    Celebration Villa of Martinsburg is a one-story senior living community that offers assisted living, memory care, and independent living spaces, and they've got some nice choices when it comes to apartments, whether someone wants a studio or a spacious two-bedroom, and they even have a few semi-private rooms for folks who prefer to share. Residents can keep their pets with them since it's a pet-friendly place and they'll find places to walk outside, like gardens, patios, and a central courtyard that give some peace and let everyone enjoy a bit of fresh air. People who want to live on their own can do that here, but there's help available too, like support with dressing, bathing, and taking medicine from staff who are there 24 hours a day. The apartments come with simple features seniors might need, such as safety supports, telephone hookups for family chats, and utilities all covered, and there's free Wi-Fi and cable TV for those who like to watch something or connect online.

    There's a dining room where folks can gather for meals, and when someone doesn't feel like going out, room service is an option. Community areas around the building let neighbors meet up for card games or just to visit, and there are recreational rooms for things like crafts, music, and group activities. The life enrichment programming keeps residents busy throughout the week, whether it's karaoke, trivia, arts and crafts, family nights, or outings like shopping, trips to restaurants, or getting outside on a pleasant day, and the transportation service gets folks out to medical appointments or other places in town if they need it.

    Residents can get help with linens and laundry as there is both in-house service and dry cleaning, plus housekeepers stop by weekly. If anyone needs a haircut, hair and barber services come right to the building, so there's no need to go out. Staff provide medication help, and there are scheduled visits from occupational or physical therapists if that's needed. The memory care neighborhood includes a program called "Along the Journey," which was created to support those dealing with Alzheimer's or other dementias, so residents get the right care in a calm and safe part of the building with outdoor areas and staff who know how to help people with memory challenges.

    Parking's available both for residents and guests, so anyone stopping by won't need to search for a place to leave the car, and the grounds crew keeps the place tidy and pleasant all year round. For those times someone needs short-term care, maybe after a hospital stay or just while their family takes a break, respite care is available. Celebration Villa of Martinsburg focuses on comfort, sensible routines, and offering choices, whether someone wants full independence or needs daily help, and they aim to keep things affordable for seniors who count on benefits, veterans' aid, or assistance programs, plus there are resources to help caregivers plan and support their family members. More information about the community and what they offer can be found on their website at https://www.prioritylc.com/communities/celebration-villa-of-martinsburg/.

    About Priority Life Care

    Celebration Villa of Martinsburg is managed by Priority Life Care.

    Priority Life Care stands as a prominent family-owned senior living provider that was founded in 2009 by the Petras family during a Thanksgiving dinner business presentation. The company opened its first community in Maple Heights, Ohio in 2010 and has since grown to operate 66 senior living communities spanning from New York to Texas. Headquartered in Fort Wayne, Indiana, Priority Life Care has established itself as a significant player in the senior housing industry under the leadership of Co-Founder and CEO Sevy Petras. The company received Great Place to Work certification for both 2022-2023 and 2023-2024 cycles, reflecting its commitment to workplace excellence.

    People often ask...

    Celebration Villa of Martinsburg offers competitive pricing, with rates starting at a cost of $3,050 per month.

    Celebration Villa of Martinsburg offers assisted living.

    There are 60 photos of Celebration Villa of Martinsburg on Mirador.

    The full address for this community is 200 Gloucester Dr, Martinsburg, WV 25401.

    No, Celebration Villa of Martinsburg does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In West Virginia, the Office of Health Facility Licensure & Certification licenses care facilities, conducting health and life-safety surveys, complaint investigations, and revisits.

    License number1670
    StatusActive
    Facility typeAssisted Living Residence
    Capacity97 residents
    LicenseeEC OPCO MARTINSBURG, LLC TRADENAME CELEBRATION VILLA OF MARTINSBURG
    EffectiveApril 10th, 2024
    ExpiresApril 9th, 2025
    View the official license record

    Inspection Reports

    177

    Reports

    23

    Type A Citations

    3

    Type B Citations

    81

    Complaints

    25

    Years

    20 Apr 2026Complaint
    Investigated the complaint; determined the allegation was substantiated and found no deficiencies.
    26 Feb 2026Complaint
    Investigated the complaint and found no deficiencies.
    01 Dec 2025Complaint
    Investigated the abuse allegation and found that OHFLAC notification within 72 hours and related documentation were not properly forwarded.
    • 5.2.6Resident Rights
    08 Jul 2025Revisit
    Verified the deficiency cited in the complaint was corrected.
    30 Apr 2025Complaint
    Identified staffing deficiencies and delayed call light responses that could affect residents' care.
    • Staffing requirements and call-light response times
    30 Apr 2025Revisit
    Investigated a complaint; the deficiencies were corrected.
    13 Mar 2025Complaint
    Found multiple deficiencies, including insufficient day shift staffing for residents with high care needs, failure to notify authorities about a supervising RN hire, inadequate monitoring after a major incident, and insufficient staffing during meals leading to care tasks overlapping with dietary duties.
    • Staffing requirements
    • Notification of permanent change in administrator and supervising RN
    • Accident, illness, and major incident procedure
    • Staffing requirements (24-hour direct care staff and adequate staffing)
    24 Feb 2025Revisit
    Verified the deficiency identified in the complaint was corrected during the revisit.
    10 Feb 2025Complaint
    Investigated the complaint and found no deficiencies.
    19 Dec 2024Complaint
    Found no deficiencies after investigating the complaint.
    17 Dec 2024Revisit
    Verified deficiencies were corrected following the follow-up to the annual review.
    31 Oct 2024Licensure
    Found multiple deficiencies involving TB health records, staff training, food handler certification, medication security, and leadership delegation.
    • TB screening health records; two-step testing
    • Employee Orientation and Training; new hire training records
    • Employee Orientation and Training; annual in-service training
    • Alzheimer's disease and related dementias training
    • Administrator in charge designation; coverage when not present
    • Food handler certification
    • Medications secured and destruction records
    30 Oct 2024Life Safety
    Found no deficiencies. Census documented as 63.
    29 Oct 2024Revisit
    Investigated the complaint and corrected the citations.
    26 Jun 2024Complaint
    Identified deficiencies in service plans, medication administration, and call system reliability to reflect residents' current needs and safety concerns.
    • Assessment and Service Plans
    • W. Va. Code §§16-5O-1, et seq. and W. Va. Code R. §§64-60-1, et seq.Medications and Treatments
    • Physical Facilities
    05 Mar 2024Complaint
    Investigated the complaint and found the allegation unsubstantiated with no deficiencies cited.
    20 Dec 2023Licensure
    Identified multiple deficiencies related to health screening records, employee training, and nursing care documentation for residents.
    • 64-14-4.6(1d)Health records; pre-employment TB screening
    • 64-14-4.5.1Employee orientation and training
    • 64-14-4.5.3Staffing requirements; first aid/CPR training
    • 64-14-4.5.3Alzheimer's disease and related dementias training
    • 64-14-6.3.1Assessment and service plans; health assessments
    • 64-14-6.6.7Limited and intermittent nursing care; service plans
    • 64-14-6.6.8Progress notes; nursing visits
    20 Dec 2023Complaint
    Concluded that major incident reporting to OHFLAC was not completed, closed resident records were incomplete, and transfer documentation was not consistently provided with residents leaving care.
    • Subsection 2.23 of this ruleReporting major incidents to OHFLAC
    • Maintain accurate records and reports
    • Documentation accompanying transfer of a resident
    11 Dec 2023Life Safety
    Found no deficiencies during the annual environmental review.
    18 Jul 2023Complaint
    Found no deficiencies. Allegations unsubstantiated.
    22 May 2023Revisit
    Cleared a deficiency from a prior finding during a revisit to the annual survey; census was 47.
    21 Apr 2023Complaint
    Investigated the complaint and found no deficiencies.
    20 Mar 2023Revisit
    Observed improper food storage and open beverage items in the kitchen, indicating infection control lapses; identified deficiencies in package integrity and infection control standards.
    • Type AFDA 2013 Food Code 3-202.15Package Integrity
    • Type AInfection control standard under Medications and Treatments (Class I)Infection control
    03 Feb 2023Licensure
    Identified multiple deficiencies across admission/discharge processes, resident contracts, medication management, and food safety, including unlabeled resident food and incomplete policy access.
    • Type AW. Va. Code R. 64-17-1 et seq.; FDA Food Code 2013 3-302.12Food storage and labeling in resident refrigerator
    • Type AW. Va. Code R. 64-17-1 et seq.Policies and procedures accessibility in admission contracts
    • Type AW. Va. Code R. 64-17-1 et seq.; FDA Food Code 2013 3-302.12Food safety and infection control in meal/service areas
    • Type AW. Va. Code R. 64-17-1 et seq.Medication storage and handling in admission contracts
    • Type AW. Va. Code R. 64-17-1 et seq.Management of residents' funds in admission contracts
    • Type AW. Va. Code R. 64-17-1 et seq.Full disclosure of costs in admission contracts
    • Type AW. Va. Code R. 64-17-1 et seq.Liability and property insurance information in admission contracts
    • Type AW. Va. Code R. 64-17-1 et seq.Health and nursing services and CPR in admission contracts
    • Type AW. Va. Code R. 64-17-1 et seq.Assessment and Service Plans; medical assessments
    02 Feb 2023Revisit
    Cleared the citations after reviewing credible evidence; no deficiencies cited.
    01 Feb 2023Life Safety
    Determined substantial compliance with state requirements.
    26 Jan 2023Revisit
    Investigated the complaint follow-up and cleared prior citations.
    24 Oct 2022Revisit
    Corrected deficiencies identified during the follow-up; no new deficiencies cited.
    16 Aug 2022Complaint
    Investigated a complaint alleging failure to report a major incident promptly and deficiencies in RN notification and transfer documentation related to a resident injury.
    • Subsection 2.23 of this ruleReporting Major Incidents
    • Immediate RN notification requirementLimited and Intermittent Nursing Care
    • Accident, Illness, and Major Incident ProcedureAccident, Illness, and Major Incident Procedure
    • Health Care StandardsHealth Care Summary/Transfer Documentation
    14 Jul 2022Complaint
    Found deficiencies in medication administration that left residents without prescribed medications due to supply problems and delays. The issues affected multiple residents and spanned multiple medications.
    • Failure to administer prescribed medications as ordered
    02 Feb 2022Revisit
    Investigated the reported issue and cleared the cited deficiency. Census counted 42 residents during the visit.
    31 Jan 2022Revisit
    Found no deficiencies.
    13 Jan 2022Complaint
    Found deficiencies in nurse notification, 24-hour accessibility planning, and pain management/restraint practices that could affect residents.
    • E 403Limited and Intermittent Nursing Care
    • E 406Plan for 24-hour accessibility between residence and RN
    • E 331Treatment; no abuse, neglect, or restraints
    02 Jun 2021Revisit
    Cleared deficiencies were verified during a follow-up to the annual survey.
    04 Mar 2021Licensure
    Found deficiencies in death documentation designating estate administrators, hand hygiene lapses during medication passes, and deteriorated common-area furniture upholstery.
    • E417Release of resident belongings to estate administrator or executor
    • E394Medications and Treatments – infection control and hand hygiene
    • E450Physical facilities – seating upholstery in common areas
    01 Mar 2021Life Safety
    Found no deficiencies.
    03 Feb 2021Complaint
    Investigated the complaint and concluded it was substantiated, but no deficiencies were cited.
    23 Dec 2020Inspection
    Found no deficiencies during the infection control survey.
    13 May 2020Complaint
    Investigated the complaint and found no deficiencies.
    07 Apr 2020Revisit
    Concluded that all deficiencies were corrected after the follow-up review.
    27 Feb 2020Inspection
    Investigated and found multiple deficiencies related to resident death handling, transfer documentation, annual health assessments, and medication security.
    • Resident belongings and funds release after death
    • Notification of physician/hospice staff and next of kin
    • Health care standards for assessments and summaries
    • Assessment and Service Plans; transfer/discharge documentation
    • Medications and Treatments; locked storage
    25 Feb 2020Life Safety
    Verified all deficiencies were corrected.
    13 Jan 2020Life Safety
    Identified failure to review and update the disaster and emergency preparedness plan within the past year and to sign and date the plan to verify review.
    • Type A9.2.5 regulationDisaster and Emergency Preparedness Plan Review
    27 Mar 2019Complaint
    Found no deficiencies. The complaint was investigated.
    11 Feb 2019Life Safety
    Identified environmental deficiencies during a licensure survey. A follow-up visit occurred.
    • Environmental
    • Environmental
    10 Jan 2019Complaint
    Identified multiple deficiencies across staffing, training, health assessments, dietary services, and resident care processes. Cited for noncompliance with state requirements.
    • 64CSR14-5.4.c.Staffing Requirements
    • 64CSR14-5.5.a.Employee Orientation and Training
    • 64CSR14-5.5.c.Employee Orientation and Training (Alzheimer's)
    • 64CSR14-7.3.a.Health Care Standards
    • 64CSR14-7.6.i.Health Care Standards
    • 64CSR14-9.1.c.Dietary Services
    10 Jan 2019Complaint
    Found no deficiencies.
    07 Jan 2019Life Safety
    Found deficiencies in disaster and emergency preparedness documentation and in interior/exterior cleanliness.
    • 64CSR14-10.2.g.Disaster & Emergency Preparedness
    • 64CSR14-11.1.d.Physical Facilities
    18 Jul 2018Revisit
    Cited a repeat deficiency during the change of ownership review, which was corrected on follow-up.
    12 Jun 2018Life Safety
    Identified deficiencies in maintaining clean and well-repaired interiors and exteriors, with extensive cracks and peeling paint observed in multiple areas.
    • 64CSR14-11.1.d.Physical Facilities
    04 Jun 2018Revisit
    Identified deficiencies in weekly RN visits and progress notes for multiple residents, including insulin-dependent cases and residents with a colostomy or catheter.
    • 64 CSR 14-7.6.hHealth Care Standards
    11 Apr 2018Licensure
    Found the RN failed to document weekly progress notes and to see four residents weekly, including one with a colostomy, one with a suprapubic catheter, and three insulin-dependent diabetics.
    • 64CSR14-7.6.hHealth Care Standards
    10 Apr 2018Life Safety
    Identified deficiencies in interior and exterior maintenance; observed extensive ceiling cracks, wall damage, and peeling paint.
    • 64CSR14-11.1.d.Physical Facilities
    21 Mar 2018Complaint
    Investigated a complaint and found no deficiencies.
    26 Dec 2017Complaint
    Found insufficient day-shift direct care staffing, inadequate housekeeping, and privacy violations affecting a resident.
    • 64CSR14-5.4.b.Staffing Requirements
    • 64CSR14-5.4.f.Staffing Requirements
    • 64CSR14-6.2.j.Resident Rights
    20 Dec 2017Revisit
    Investigated a complaint and found deficiencies.
    20 Dec 2017Revisit
    Found that residents’ fingernail care was not consistently provided, resulting in neglect for two residents, with multiple deficiencies cited.
    • 64CSR14-6.2.b.Resident Rights
    20 Dec 2017Complaint
    Investigated a complaint and found no deficiencies.
    15 Nov 2017Licensure
    Found deficiencies in staffing on the night shift and in training of new employees, indicating insufficient direct care coverage for residents with two or more care needs and missing required training Records for several new hires.
    • 64CSR14-5.4.b.Staffing Requirements
    • 64CSR14-5.5.a.Employee Orientation and Training
    15 Nov 2017Complaint
    Found violations of the four-day written response requirement for resident complaints, with delays documented for four residents.
    • 64CSR14-6.2.nResident Rights
    • 64CSR14-6.2.nComplaint response timeliness
    10 Oct 2017Complaint
    Identified neglect related to fingernail care and outdated service plans for a resident.
    • 64CSR14-6.2.b.Resident Rights
    • 64CSR14-7.3.d.Health Care Standards
    02 Oct 2017Life Safety
    Found no deficiencies cited during the annual licensure survey.
    14 Jun 2017Complaint
    Investigated the complaint and found no deficiencies.
    23 Jan 2017Revisit
    Identified two deficiencies; a repeat deficiency was cited and later corrected.
    23 Jan 2017Revisit
    Concluded that deficiencies were corrected following the investigation and subsequent follow-up.
    10 Jan 2017Revisit
    Identified two deficiencies during the licensure review; follow-up occurred in January 2018.
    01 Dec 2016Complaint
    Investigated a complaint and found no deficiencies.
    01 Dec 2016Licensure
    Found no deficiencies.
    25 Oct 2016Life Safety
    Found deficiencies in disaster and emergency drill documentation, interior maintenance, and hot water mixing valve compliance.
    • 64CSR14-10.2.g.Disaster & Emergency Preparedness
    • 64CSR14-11.1.d.Physical Facilities
    • 64CSR14-11.5.d.Physical Facilities
    29 Sept 2016Complaint
    Investigated the complaint and found no deficiencies.
    08 Aug 2016Complaint
    Found no deficiencies.
    19 May 2016Revisit
    Investigated the complaint and its follow-up.
    31 Mar 2016Complaint
    Found that residents' complaints were not addressed promptly and responses were not provided in writing within four days as required.
    • 64CSR14-6.2.n.Resident Rights - prompt action and written response to complaints
    15 Dec 2015Life Safety
    Identified deficiencies during the annual licensure survey. Follow-up occurred to address these deficiencies.
    18 Nov 2015Life Safety
    Identified deficiencies in disaster preparedness and physical facilities. These included missing emergency shelter agreements, no emergency transportation policy, and a lack of a three-day food and drinking water supply, plus maintenance issues affecting safety.
    • 64CSR14-10.2.c.Disaster & Emergency Preparedness
    • 64CSR14-11.1.b.Physical Facilities
    17 Sept 2015Licensure
    Conducted a licensure survey and found no deficiencies.
    10 Jun 2015Complaint
    Investigated a complaint and found no deficiencies.
    16 Dec 2014Licensure
    Found multiple deficient practices across training, resident rights, care planning, medication administration, and admission/discharge processes, indicating broad regulatory noncompliance.
    • 64CSR14-5.5.aEmployee Orientation and Training
    • 64CSR14-5.7.b.1-8Admission and Discharge
    • 64CSR14-6.1.fResident Rights
    • 64CSR14-6.2.nResident Rights
    • 64CSR14-7.3.cHealth Care Standards
    • 64CSR14-7.4.aHealth Care Standards
    • 64CSR14-7.6.iHealth Care Standards
    • 64CSR14-7.7.cHealth Care Standards
    07 Oct 2014Life Safety
    Found no deficiencies.
    05 Dec 2013Licensure
    Found no deficiencies.
    03 Dec 2013Life Safety
    Found no deficiencies.
    24 Oct 2013Life Safety
    Investigated deficiencies involving unsafe storage and temperature control; found unprotected prepared food and cleaning supplies stored openly, and hot water temperatures outside the required range.
    • Type A64CSR14-11.1.b.Physical Facilities
    • Type A64CSR14-11.5.b.Physical Facilities
    19 Jun 2013Revisit
    Investigated a complaint and identified a deficiency which was corrected; technical assistance was provided.
    19 Jun 2013Complaint
    Investigated a complaint and found no deficiencies.
    13 May 2013Complaint
    Found deficient practices in staffing, complaint handling, and facility call systems, with inadequate complaint investigations.
    • 64CSR14-5.4.fStaffing Requirements
    • 64CSR14-6.2.nResident Rights – Complaint Handling
    • 64CSR14-11.1.iPhysical Facilities – Call System
    • Complaint Investigation
    10 Apr 2013Complaint
    Found deficiencies in care coordination and sanitation: a resident with care needs exceeding the licensed level was not informed about a needed transfer, and rodents were found in a resident room.
    • 64 CSR 14-7.1.eHealth Care Standards
    • 64 CSR 14-11.1.ePhysical Facilities
    04 Dec 2012Life Safety
    Concluded that deficiencies were corrected during follow-up.
    28 Nov 2012Revisit
    Investigated the complaint and found that deficiencies were corrected during follow-up.
    28 Nov 2012Licensure
    Identified deficiencies in involving residents in menu planning and in maintaining daily records of foods served. Residents reported limited meal choices and concerns with food quality.
    • 64CSR14-9.1.e.Dietary Services - Resident participation in menu planning
    • 64CSR14-9.1.g.Dietary Services - Daily record of actual foods served
    03 Oct 2012Complaint
    Investigated found insufficient staffing and poor handling of resident complaints, leading to delays in meals, laundry, showers, and towel supplies, with lack of timely written responses to complaints.
    • 64CSR14-5.4.f.Staffing Requirements
    • 64CSR14-6.2.n.Resident Rights
    01 Oct 2012Life Safety
    Identified dirty and greasy conditions in the kitchen, including a dirty floor, sticky countertops, and sticky cooler doors.
    • 64CSR14-11.1.b.Physical Facilities
    05 Sept 2012Life Safety
    Investigated the complaint and found no deficiencies.
    04 Jun 2012Complaint
    Investigated the complaint and found no deficiencies.
    10 May 2012Complaint
    Investigated a complaint and found the allegation unsubstantiated.
    28 Jan 2012Revisit
    Identified deficiencies in food service/documentation; ombudsman reported residents were happy with meals.
    • Food service/menu documentation
    13 Dec 2011Complaint
    Identified deficient infection control practices involving MRSA and C. difficile cases. Inadequate handwashing facilities and limited access to properly fitting gloves were reported.
    • 64CSR14-7.4.m.Infection control standards
    13 Dec 2011Revisit
    Investigated a complaint and noted deficiencies that were corrected.
    02 Nov 2011Licensure
    Investigated multiple deficiencies across staff training, abuse reporting, health assessments, care planning, and record-keeping following resident events and admissions.
    • 64CSR14-5.5.a.Employee Orientation and Training
    • c64CSR14-5.7.c.Admission and Discharge
    • c64CSR14-6.2.c.Resident Rights
    • d64CSR14-6.2.d.Resident Rights
    • f64CSR14-6.2.f.Resident Rights
    • g64CSR14-7.1.g.Health Care Standards (Transfers/Discharges)
    • Type A64CSR14-7.3.a.Health Care Standards
    • d64CSR14-7.3.d.Health Care Standards
    • Type A64CSR14-7.4.a.Health Care Standards
    • c64CSR14-7.5.c.Health Care Standards
    • f64CSR14-7.6.f.Health Care Standards
    • h64CSR14-7.6.h.Health Care Standards
    • c64CSR14-7.7.c.Health Care Standards
    • d64CSR14-9.1.d.Dietary Services
    01 Nov 2011Life Safety
    Found no deficiencies. The survey indicated ongoing compliance with applicable requirements.
    31 Oct 2011Revisit
    Investigated found failures to initiate timely service plans and to secure signed physician orders before administering medications, with multiple documentation gaps identified.
    • 64CSR14-7.3.c.Health Care Standards 7.3.c
    • 64CSR14-7.4.b.Health Care Standards 7.4.b
    08 Aug 2011Revisit
    Identified failures to start resident service plans within seven days of admission and to administer medications with proper orders, documentation, and staff identification.
    • 64CSR14-7.3.c.7.3.c. Service plans
    • 64CSR14-7.4.a.7.4.a. Medication administration
    • 64CSR14-7.4.b.7.4.b. Medication administration identification
    08 Aug 2011Complaint
    Investigated a complaint and found it unsubstantiated.
    14 Jun 2011Complaint
    Found deficiencies related to protection of residents' property, medication administration and documentation, and secure storage of medications.
    • Type B64CSR14-6.2.b.Resident Rights
    • Type B64CSR14-7.1.b.Health Care Standards
    • Type A64CSR14-7.4.a.Health Care Standards
    • Type B64CSR14-7.4.b.Health Care Standards
    • g64CSR14-7.4.g.Health Care Standards
    02 Apr 2011Revisit
    Corrected deficiencies identified during the survey.
    01 Feb 2011Revisit
    Investigated a complaint and found deficiencies corrected on follow-up.
    01 Feb 2011Revisit
    Found that service plans did not reflect residents' current needs or changes. Documentation was missing for pacemakers, diabetes management, wounds, and behavioral health, and updates were not consistently performed.
    • 64CSR14-7.3.d.Health Care Standards
    10 Nov 2010Licensure
    Investigated found multiple deficiencies related to background screening, staff training, resident safety, health assessments, care plans, medication documentation, and weekly nursing reviews.
    • 64CSR14-5.1.gGeneral Administrative Requirements
    • 64CSR14-5.5.aEmployee Orientation and Training
    • 64CSR14-5.5.bEmployee Orientation and Training
    • 64CSR14-6.2.bResident Rights
    • 64CSR14-7.3.aHealth Care Standards
    • 64CSR14-7.3.dHealth Care Standards
    • 64CSR14-7.4.bHealth Care Standards
    • 64CSR14-7.6.hHealth Care Standards
    25 Oct 2010Life Safety
    Found deficiencies in maintaining a safe, sanitary, and accident-free environment, including trip hazards and multiple unsanitary conditions in various areas and rooms.
    • 64CSR14-11.1.b.Physical Facilities - maintenance to keep interior and exterior safe, sanitary, and accident-free
    • 64CSR14-11.1.d.Physical Facilities - interior cleanliness and repair
    28 Sept 2010Revisit
    Investigated the complaint and identified deficiencies during the initial and follow-up visits.
    21 Jul 2010Revisit
    Identified multiple medication administration discrepancies and missing physician orders, including documentation gaps and a repeat deficiency.
    • 64CSR14-7.4.b.Health Care Standards
    02 Jun 2010Complaint
    Found deficiencies in documenting residents' health status, in administering medications per orders, and in notifying physicians of weight changes.
    • Type A64CSR14-7.2.c.Health Care Standards - Documentation in resident records
    • Type A64CSR14-7.4.b.Health Care Standards - Medication administration per physician's orders
    • Type A64CSR14-9.1.d.Dietary Services - Weight monitoring and physician notification
    29 Mar 2010Life Safety
    Corrected deficiencies identified during the survey.
    02 Feb 2010Life Safety
    Identified unsafe and unsanitary conditions, including a trip hazard from piled paper in a resident's room and widespread cleanliness issues in the kitchen and laundry areas along with odors in several rooms.
    • 64CSR14-11.1.b.Physical Facilities
    • 64CSR14-11.1.d.Physical Facilities
    03 Jan 2010Revisit
    Found no deficiencies cited during the 2010 annual licensure survey and follow-up.
    02 Dec 2009Licensure
    Found deficiencies in pre-employment fingerprint screening, service plan updates, and medication administration practices.
    • 64CSR14-5.1.gGeneral Administrative Requirements Prior to Hiring
    • 64CSR14-7.3.dHealth Care Standards - Service Plans
    • 64CSR14-7.4.aHealth Care Standards - Identification for Medication Administration
    • 64CSR14-7.4.bHealth Care Standards - Medication Administration by Unlicensed Personnel
    27 Oct 2009Life Safety
    Identified 64 deficiencies during the annual licensure survey.
    23 Mar 2009Revisit
    Investigated a complaint and found the problem was addressed with new policies and staff involvement; no follow-up was conducted.
    24 Feb 2009Complaint
    Investigated a report of alleged neglect; found that staff failed to immediately report to adult protective services, failed to file the APS reporting form within 48 hours, and failed to notify the licensing agency within the required time frame.
    • 64CSR14-6.2.c.Resident Rights
    13 Jan 2009Revisit
    Found no deficiencies.
    02 Dec 2008Revisit
    Identified deficiencies during the licensure survey and its follow-up.
    14 Oct 2008Life Safety
    Found no deficiencies during the annual licensure survey.
    07 Oct 2008Licensure
    Investigated multiple deficiencies across staff training, transfer documentation, service plans, medication administration, post-accident monitoring, nursing assessments, and weight monitoring.
    • 64CSR14-5.5.a.Employee Orientation and Training
    • 64CSR14-5.5.b.Annual In-Service Training
    • 64CSR14-7.1.g.Health Care Standards - Transfer/Discharge Summary
    • 64CSR14-7.3.d.Health Care Standards - Service Plans Updated
    • 64CSR14-7.4.a.Health Care Standards - Medication Administration
    • 64CSR14-7.5.c.Health Care Standards - Post-Accident Monitoring
    • 64CSR14-7.6.f.Health Care Standards - Nursing Assessments after ER/Hospital Return
    • 64CSR14-9.1.d.Dietary Services - Weight Monitoring and Reporting
    29 Apr 2008Complaint
    Investigated a complaint and found no deficiencies.
    15 Jan 2008Complaint
    Investigated a complaint and found no deficiencies.
    15 Nov 2007Licensure
    Found multiple deficiencies across staff training, resident care planning, transfers, and medication management.
    • 64CSR14-5.5.aEmployee Orientation and Training
    • 64CSR14-5.5.bEmployee Orientation and Training
    • 64CSR14-5.5.cEmployee Orientation and Training
    • 64CSR14-5.7.b.1-8Admission and Discharge
    • 64CSR14-7.1.gHealth Care Standards
    • 64CSR14-7.3.dHealth Care Standards
    • 64CSR14-7.4.aHealth Care Standards
    • 64CSR14-7.4.bHealth Care Standards
    • 64CSR14-7.4.gHealth Care Standards
    30 Oct 2007Life Safety
    Found deficiencies in resident rights, disaster preparedness, and facility maintenance. Observed improper restraint use, no annual disaster drill, unsecured oxygen storage, and inadequate cleaning.
    • 64CSR14-6.2.b.Resident Rights
    • 64CSR14-10.2.g.Disaster & Emergency Preparedness
    • 64CSR14-11.1.b.Physical Facilities
    • 64CSR14-11.1.c.Physical Facilities
    • 64CSR14-11.1.d.Physical Facilities
    22 Aug 2007Complaint
    Determined the complaint to be unsubstantiated and noted that technical assistance was provided.
    12 Feb 2007Revisit
    Found no deficiencies.
    04 Feb 2007Life Safety
    Determined that previously cited deficiencies were corrected.
    18 Dec 2006Complaint
    Investigated found deficiencies across governance and operations, including failure to hold multidisciplinary care conferences, understaffing and slow response to alarms, failure to report and investigate alleged abuse, poor handling of complaints, and inadequate housekeeping.
    • 64CSR14-5.2.a.Multidisciplinary Care Conferences
    • 64CSR14-5.4.a.Staffing Requirements
    • 64CSR14-6.2.c.Resident Rights - Reporting of abuse
    • 64CSR14-6.2.d.Resident Rights - Investigation of abuse
    • 64CSR14-6.2.n.Resident Rights - Complaint resolution
    • 64CSR14-11.1.d.Physical Facilities - Interior cleanliness and housekeeping
    14 Dec 2006Life Safety
    Identified deficiencies in the call system and in securing hazardous substances, including pendants not audible and toxic products not locked.
    • Type A64CSR14-11.1.i.Physical Facilities
    • 64CSR14-11.6.c.Physical Facilities
    28 Nov 2006Inspection
    Identified multiple deficiencies in staffing, licensure verification, resident care planning, training, and emergency procedures.
    • 64CSR14-5.2.a.Change of Ownership (CHOW)
    • 64CSR14-5.4.g.Staffing Schedule Accuracy
    • 64CSR14-5.5.a.Employee Orientation and Training
    • 64CSR14-5.5.b.Employee Orientation and Training (Annual In-Service)
    • 64CSR14-5.5.c.Alzheimer's Disease and Dementia Training
    • 64CSR14-7.3.c.Health Care Standards
    • 64CSR14-7.3.d.Health Care Standards
    • 64CSR14-7.4.a.Health Care Standards
    • 64CSR14-7.6.e.Health Care Standards
    • 64CSR14-7.6.h.Health Care Standards
    • 64CSR14-7.6.i.Health Care Standards
    • 64CSR14-9.1.d.Dietary Services
    • 64CSR14-10.2.h.Disaster & Emergency Preparedness
    20 Sept 2006Life Safety
    Found no deficiencies.
    20 Sept 2006Revisit
    Found no deficiencies.
    08 Aug 2006Revisit
    Identified widespread deficiencies in staffing, medication administration, recordkeeping, resident funds handling, and abuse reporting.
    • 64CSR14-5.2.aThe Licensee shall comply with this rule
    • 64CSR14-5.2.cThe licensee shall protect the physical and mental well-being of residents
    • 64CSR14-5.4.aStaffing Requirements
    • 64CSR14-5.4.bStaffing Requirements
    • 64CSR14-5.4.cStaffing Requirements
    • 64CSR14-5.5.aEmployee Orientation and Training
    • 64CSR14-5.5.bEmployee Orientation and Training
    • 64CSR14-5.8.gManagement of Resident Funds
    • 64CSR14-6.2.cResident Rights
    • 64CSR14-6.2.dResident Rights
    • 64CSR14-6.2.fResident Rights
    • 64CSR14-7.1.gHealth Care Standards
    • 64CSR14-7.4.bHealth Care Standards
    08 Aug 2006Complaint
    Investigated a complaint; deficiencies related to the complaint were moved to follow up at the annual survey.
    20 Jul 2006Life Safety
    Found that an annual disaster drill was not conducted as required.
    • 64CSR14-10.2.g.Disaster & Emergency
    13 Jun 2006Licensure
    Identified multiple deficiencies in staffing, health care, dietary, admission/discharge, and safety practices, resulting in citations for noncompliance.
    • 64CSR14-5.2.f.Major incidents reporting
    • 64CSR14-5.4.a.Direct care staffing minimum
    • 64CSR14-5.4.b.Additional direct care staffing per needs assessment
    • 64CSR14-5.4.c.On-duty first aid/CPR training
    • 64CSR14-5.4.g.Staffing records accuracy
    • 64CSR14-5.5.a.Employee orientation and training (new hires)
    • 64CSR14-5.5.b.In-service training for all staff
    • 64CSR14-5.7.h.Admission and discharge records
    • 64CSR14-5.8.g.Management of resident funds
    • 64CSR14-7.1.a.Health care standards - admissions
    • 64CSR14-7.1.g.Health care standards - discharge/transfer summaries
    • 64CSR14-7.3.a.Health assessments and tuberculosis screening
    • 64CSR14-7.3.c.Service plans after admission
    • 64CSR14-7.3.d.Service plan updates and changes
    • 64CSR14-7.4.b.Prescriptions and orders documented
    • 64CSR14-7.6.d.Registered nurse visit records
    • 64CSR14-7.6.h.RN weekly visits and progress notes
    • 64CSR14-9.1.c.Dietary services and therapeutic diets
    • 64CSR14-11.6.c.Locked storage for hazardous materials
    06 Jun 2006Life Safety
    Identified multiple deficiencies in disaster planning, safety, and facility maintenance, including missing flood procedures, lack of annual drills, and hazardous conditions in resident areas.
    • 64CSR14-10.2.b.Disaster & Emergency – Flood procedures
    • 64CSR14-10.2.g.Disaster & Emergency – Annual drills
    • 64CSR14-10.2.h.Disaster & Emergency – Evacuation verification within 24 hours of admission
    • 64CSR14-11.1.b.Physical Facilities – Safe environment; hazardous materials
    • 64CSR14-11.1.c.Physical Facilities – Preventive maintenance program
    • 64CSR14-11.1.d.Physical Facilities – Cleanliness and repair
    17 Jan 2006Life Safety
    Deficiencies were corrected after the follow-up environmental review.
    • Environmental deficiency
    17 Jan 2006Revisit
    Verified that the cited deficiency was corrected after follow-up following a complaint investigation.
    17 Jan 2006Revisit
    Corrected a deficiency identified during follow-up.
    25 Oct 2005Life Safety
    Investigated findings showed door alarms were often off or not audible and staff did not respond promptly to alarms, compromising resident safety.
    • 64CSR14-11.1.b.PHYSICAL FACILITIES
    07 Sept 2005Revisit
    Identified deficiencies during the annual licensure survey.
    23 Aug 2005Life Safety
    Identified deficiencies and corrected them during the annual licensure survey.
    14 Jul 2005Life Safety
    Found multiple safety and maintenance deficiencies, including nonfunctional nurse call and door alarm systems, inaudible alarms, and improper storage of toxic substances.
    • 64CSR14-11.1.c.Preventive maintenance program for nurse call system
    • 64CSR14-11.1.i.Nurse call system audible to staff
    • 64CSR14-11.1.j.Exit door alarm systems function properly
    • 64CSR14-11.6.c.Locked storage for toxic/hazardous materials
    15 Jun 2005Revisit
    Identified deficiencies in staff training, medication administration and storage, and weekly nursing assessments.
    • Type A64 CSR 14-5.5.aEMPLOYEE ORIENTATION AND TRAINING
    • Type A64 CSR 14-7.4.aHEALTH CARE STANDARDS
    • g64 CSR 14-7.4.gHEALTH CARE STANDARDS
    • h64 CSR 14-7.6.hHEALTH CARE STANDARDS
    07 Jun 2005Life Safety
    Investigated the complaint and follow-up activities; a deficiency labeled E 006 was corrected.
    • E 006
    19 May 2005Life Safety
    Found deficiencies in disaster preparedness, nurse call maintenance, call audibility, exit door alarm functionality, and locked storage of hazardous materials.
    • 64CSR14-10.2.g.Disaster & Emergency
    • 64CSR14-11.1.c.Physical Facilities - Preventive maintenance of nurse call system
    • 64CSR14-11.1.i.Physical Facilities - Call system audible to staff
    • 64CSR14-11.1.j.Physical Facilities - Alarm systems for exit doors
    • 64CSR14-11.6.c.Physical Facilities - Locked storage for toxic/hazardous materials
    11 May 2005Licensure
    Identified multiple deficiencies across background checks, CLIA compliance, staff training, resident records, medication administration, weekly nurse oversight, and dietary management.
    • 64CSR14-5.1.g.Background checks before hiring
    • 64CSR14-5.2.aCLIA waiver requirement
    • 64CSR14-5.4.c.CLIA waiver documentation for finger-stick testing
    • 64CSR14-5.5.aNew employee orientation training
    • 64CSR14-5.5.bAnnual in-service training for staff
    • 64CSR14-5.6.aPersonnel records and pre-employment screening
    • 64CSR14-7.4.aMedication administration by unlicensed personnel
    • 64CSR14-7.6.hWeekly RN visits and resident identification
    • 64CSR14-7.6.iRN oversight and staff training on condition changes
    • 64CSR14-9.1.c.Dietary services – physician-ordered diets followed
    15 Feb 2005Life Safety
    Investigated a complaint about resident safety due to malfunctioning door alarms and nurse call systems, revealing multiple deficiencies in alarm functionality and maintenance. Found insufficient responses to alarms and wandering risks.
    • 64CSR14-11.1.b.Physical Facilities - Maintenance and operation of door alarms and audible alarms on entrances
    • 64CSR14-11.1.c.Physical Facilities - Preventive maintenance program for equipment
    • 64CSR14-11.1.i.Physical Facilities - Call system audible to staff
    • 64CSR14-11.1.j.Physical Facilities - Alarm systems for wandering residents
    01 Sept 2004Revisit
    Concluded that all deficiencies were corrected.
    28 Jul 2004Complaint
    Found deficiencies in medication management, including medications unavailable at times and incomplete MAR signatures.
    • 64CSR14-7.4.b.Prescription orders and copies maintained in resident records
    • 64CSR14-7.4.f.Complete and signed MARs with administering staff's identifying signatures
    28 Jul 2004Revisit
    Investigated a complaint and found that all deficiencies were corrected.
    23 Jun 2004Life Safety
    Investigated environmental re-licensure activities and documented an initial survey followed by a follow-up.
    08 Jun 2004Revisit
    Found deficiencies in reporting major incidents, nursing assessments after changes in condition, service plans for limited/intermittent care, medication management, and staff training.
    • 64CSR14-5.2.f.Major incidents reporting to OHFLAC
    • 64CSR14-5.5.a.Employee orientation and training
    • 64CSR14-7.3.d.Health care standards - nursing assessments after significant change
    • 64CSR14-7.4.b.Health care standards - prescription orders
    • 64CSR14-7.5.d.Health care standards - notification of physician for major incidents
    • 64CSR14-7.6.g.Health care standards - service plans for admission and change
    • 64CSR14-7.6.h.Health care standards - weekly progress notes for limited/intermittent care
    • 64CSR14-7.6.i.Health care standards - staff training for limited/intermittent care
    29 Apr 2004Life Safety
    Identified extensive cleaning and maintenance deficiencies affecting interior spaces and hazard areas; corrective actions were implemented.
    • 64CSR14-11.1.d.PHYSICAL FACILITIES
    21 Apr 2004Revisit
    Investigated complaints identified widespread deficiencies in staffing, supervision, training, medication management, care planning, and dietary/snack provisions, with ongoing safety concerns for residents.
    • 64CSR14-5.4.a.STAFFING REQUIREMENTS
    • 64CSR14-5.4.c.STAFFING REQUIREMENTS
    • 64CSR14-5.4.h.ALARM SYSTEM AND SUPERVISION
    • 64CSR14-5.5.a.EMPLOYEE ORIENTATION AND TRAINING
    • 64CSR14-5.7.b.1-8ADMISSION AND DISCHARGE
    • 64CSR14-5.7.c.ADMISSION AND DISCHARGE
    • 64CSR14-7.3.d.HEALTH CARE STANDARDS
    • 64CSR14-7.4.b.HEALTH CARE STANDARDS
    • 64CSR14-7.5.b.HEALTH CARE STANDARDS
    • 64CSR14-7.5.c.HEALTH CARE STANDARDS
    • 64CSR14-7.6.g.HEALTH CARE STANDARDS
    • 64CSR14-7.6.h.HEALTH CARE STANDARDS
    • 64CSR14-7.6.i.HEALTH CARE STANDARDS
    • 64CSR14-9.1.b.DIETARY SERVICES
    18 Feb 2004Complaint
    Investigated numerous deficiencies, including failure to report a major incident, inadequate staffing and supervision, unsafe medication handling, missing resident service plans and nursing assessments after hospital events, elopement risk due to disengaged alarms, and ongoing odor/maintenance concerns.
    • 64CSR14-5.2.f.Major incident reporting
    • 64CSR14-5.4.a.Staffing requirements - direct care
    • 64CSR14-5.4.h.Staffing requirements - supervision and alarms
    • 64CSR14-7.3.c.Health care standards - service plans within seven days
    • 64CSR14-7.3.d.Health care standards - nursing assessment after significant change
    • 64CSR14-7.4.g.Medication storage - locked/accessible only to staff
    • 64CSR14-7.4.h.Medication storage - original containers
    • 64CSR14-7.6.h.Nursing oversight - weekly progress notes
    • 64CSR14-11.1.b.Physical facilities - odor control and housekeeping
    11 Dec 2003Life Safety
    Identified that toxic materials were not securely stored, with multiple rooms containing toxic substances accessible to residents.
    • 64CSR14-11.6.c.PHYSICAL FACILITIES - locked storage for toxic materials
    11 Nov 2003Revisit
    Identified that medication orders on multi-page documentation lacked signed and dated pages for all items.
    • Medication orders must be signed and dated
    23 Oct 2003Life Safety
    Investigated sanitation and storage issues, finding unclean conditions and strong odors in at least one resident room, and unsecured toxic substances in multiple rooms.
    • 64CSR14-11.1.b.PHYSICAL FACILITIES
    • 64CSR14-11.6.c.LOCKED STORAGE FOR TOXIC MATERIALS
    • 64CSR65-11.2.g.SANITATION
    • 64CSR65-11.3.e.GENERAL LIVING ENVIRONMENT
    10 Sept 2003Revisit
    Found multiple deficiencies in medication management and self-administration processes, including failure to follow physician orders, incomplete evaluations of residents who self-medicate, and missing documentation of self-administration ability.
    • 64CSR14-7.4.b.Medications administered according to physician orders; prescriptions kept in resident records
    • 64CSR14-7.4.cDocumentation of ability to self-administer medications
    • 64CSR65-8.5.b.Medications; prescription drugs shall be obtained, administered or self-administered only on written order; OTC meds require professional determination
    • 64CSR65-8.5.b.3Self-administration documentation in resident records
    16 Jul 2003Life Safety
    Found deficiencies in disaster preparedness, sanitation, and locked storage for toxic materials.
    • 64CSR65-10.2.g.Disaster & Emergency Preparedness
    • 64CSR65-11.2.g.Sanitation
    • 64CSR65-11.3.e.General Living Environment
    15 Jul 2003Revisit
    Identified multiple deficiencies in medication administration, self-medication evaluation, and disaster preparedness information, including meds not given per orders and lack of documentation. Also found failures to verify self-medication capability and to provide required emergency information within 24 hours of admission.
    • 64CSR65-8.5.b.MEDICATIONS
    • 64CSR65-8.5.b.MEDICATIONS
    • 64CSR65-8.5.b.MEDICATIONS
    • 64CSR65-8.5.b.MEDICATIONS
    • 64CSR65-8.5.b.MEDICATIONS
    • 64CSR65-8.5.b.3MEDICATIONS
    • 64CSR65-10.2.f.DISASTER & EMERGENCY PREPAREDNESS
    15 May 2003Life Safety
    Found deficiencies in disaster preparedness, sanitation, and storage practices.
    • 64CSR65-10.2.d.DISASTER & EMERGENCY PREPAREDNESS
    • 64CSR65-10.2.g.DISASTER & EMERGENCY PREPAREDNESS
    • 64CSR65-11.2.g.SANITATION
    • 64CSR65-11.3.e.GENERAL LIVING ENVIRONMENT
    08 May 2003Inspection
    Identified multiple deficiencies related to restricted admissions waivers, resident death documentation, staffing, service planning, medication management, and disaster preparedness.
    • 64CSR65-5.5.bRESTRICTED ADMISSIONS
    • 64CSR65-5.10.b.1-3RESIDENT DEATH
    • 64CSR65-6.2.aSTAFFING REQUIREMENTS
    • 64CSR65-8.3.aPLANNING
    • 64CSR65-8.5.bMEDICATIONS
    • 64CSR65-8.5.b.1MEDICATIONS
    • 64CSR65-8.5.b.3MEDICATIONS
    • 64CSR65-10.2.fDISASTER & EMERGENCY PREPAREDNESS
    04 Mar 2003Life Safety
    Found repeated failures to provide locked storage for toxic materials, with toxins found in several resident rooms over multiple follow-ups.
    • 64CSR14-11.6.c.PHYSICAL FACILITIES
    03 Oct 2002Life Safety
    Observed sanitation deficiencies in the food service area, with a dirty and sticky kitchen floor and soiled walls; follow-up noted ongoing cleanliness problems.
    • 64CSR65-11.2.h.6Sanitation - maintaining the food service environment in a clean, safe and sanitary manner
    01 Oct 2002Revisit
    Found deficiencies in employee orientation training within 24 hours and in locked storage for toxic materials. Also observed unsecured toxic materials and related safety concerns.
    • 64CSR65-6.3.aEmployee Orientation & Training
    • 64CSR65-11.3.e.General Living Environment: Locked storage for toxic materials
    23 Jul 2002Revisit
    Identified deficiencies in staff orientation training within 24 hours and in maintaining locked storage for toxic materials.
    • 64CSR65-6.3.aEmployee Orientation & Training
    • 64CSR65-11.3.e.General Living Environment
    23 Jul 2002Life Safety
    Identified sanitation deficiencies in the food service area, including a heavily soiled kitchen floor and walls near cooking areas.
    • 64CSR65-11.2.h.6SANITATION
    15 May 2002Licensure
    Identified deficiencies in staff orientation and training as well as sanitation practices, including missing written orientation plans and lack of documented annual training, and unsafe meal service for a resident.
    • 64CSR65-6.3.a6.3.a Employee orientation & training
    • 64CSR65-6.3.b.1-96.3.b Written plan of orientation and training; initial training
    • 64CSR65-6.3.d.1-56.3.d In-service training (annual)
    • 64CSR65-11.2.h.611.2.h.6 Sanitation - food service environment
    03 Oct 2001Complaint
    Identified deficiencies in resident records management and incident reporting, including missing closed records, incomplete registry data, and inadequate documentation and notification of injuries and incidents.
    • 64CSR65-5.8.aRESIDENT RECORDS
    • 64CSR65-5.8.eRESIDENT RECORDS
    • 64CSR65-8.6.a.1-3ACCIDENT ILLNESS & INCIDENT
    • 64CSR65-8.6.cACCIDENT ILLNESS & INCIDENT
    • 64CSR65-8.6.dACCIDENT ILLNESS & INCIDENT
    05 Jun 2001Life Safety
    Identified deficiencies in disaster and emergency preparedness planning and annual drills, along with sanitation and safety issues in living and kitchen areas.
    • 64CSR65-10.2.d.DISASTER & EMERGENCY PREPAREDNESS
    • 64CSR65-10.2.g.DISASTER & EMERGENCY PREPAREDNESS
    • 64CSR65-11.2.g.SANITATION
    • 64CSR65-11.2.h.6SANITATION
    05 Jun 2001Revisit
    Found deficiencies in emergency training for new staff and in communicating disaster and emergency procedures to residents within 24 hours of admission.
    • 64CSR65-6.3.aEMPLOYEE ORIENTATION & TRAINING
    • 64CSR65-10.2.fDISASTER & EMERGENCY PREPAREDNESS
    18 Apr 2001Licensure
    Identified multiple deficiencies in staff training, medication management, and incident notification and documentation.
    • 64CSR65-6.3.aEMPLOYEE ORIENTATION & TRAINING
    • 64CSR65-8.5.bMEDICATIONS
    • 64CSR65-8.5.dMEDICATIONS
    • 64CSR65-8.6.dACCIDENT ILLNESS & INCIDENT

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