White Sulphur Springs Center

Based on record review, resident representative interview, and staff interview, the facility failed to implement their grievance policy procedure to locate lost clothing and follow-up with resident/resident representative in a timely fashion.

Resident identifier: #31.

Facility census: 65.

Findings included: a) Resident #31 On 11/18/25 at 7:30 PM, an electronic medical record review was completed.

The record review revealed RN #68 had documented resident's sister had reported she had brought in twelve (12) pairs of socks but resident no longer had any in his room. RN #68 checked with laundry and the laundry staff member stated he had not seen them.

This was documented on 09/27/25 at 10:32 AM.

There was no further documentation in the electronic medical record related to the allegation of missing socks.

Review of the facility grievance log, which was completed on 11/18/25 at 7:50 PM, found there had not been a written grievance completed for the allegation of missing socks for Resident #31.

During a telephone interview on 11/19/25 at 12:15 PM, Resident #31's representative stated she had not been contacted since reporting resident's socks had gone missing.

During an interview on 11/19/25 at 1:00 PM, Unit Manager #9 reported if a resident reported missing clothing she would check with laundry and if it was not found that she would report the allegation of missing laundry to the social worker who would handle everything from there.

During an interview on 11/19/25 at 1:10 PM, LPN #10 stated if a resident reported missing clothing she would first check with laundry to see if it could be located. If that did not work, LPN reported she would report the allegation of missing clothing to upper management.

When questioned who upper management would be, LPN #10 stated she would report directly to the Administrator who would handle the paperwork and follow-up.

During an interview on 11/19/25 at 1:16 PM, LPN #68 reported she remembered documenting the allegation of Resident #31 missing twelve (12) pairs of socks.

She also stated she recalled checking with laundry and then reporting to her Unit Manager for further follow-up when laundry did not have socks.

During an interview on 11/19/25 at 1:21 PM, the Social Worker stated she did not recall ever being told that Resident #31 had socks that were missing and had not returned to his room.

Review of the facility's Grievance/Concern policy revealed the following expectations:-Concerns may be registered by telephone, mail, office visit, or direct outreach to staff-Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concern-Upon receipt of the Grivance/Concern Form, the Administrator or designee will document the grievance/concern on the grievance/concern log-When the grievance/concern is logged, the Administrator and appropriate department manager will be notified-The department manager will contact the person filing the grievance to acknowledge receipt and notify the person filing the grievance of resolution in a timely manner The Administrator, during an interview on 11/19/25 at approximately 2:00 PM, acknowledged the facility was unable to produce evidence that the allegation of Resident #31 missing twelve (12) pairs of socks had been investigated as per the facility's grievance/concern policy process.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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