Moundsville Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with a newly evident or a possible serious mental health disorder. This was true for one (1) out of four (4) sampled residents reviewed under the PASARR pathway during the Long-Term Care Survey Process. Resident identifier: #3. Facility census: 124.Findings included: a) Resident #3 On 12/11/2025 at 8:45 AM, a record review was completed for Resident #3. The review found the Pre-admission Screening and Resident Review (PASSAR) dated 03/07/23. The following diagnoses were added after the resident was admitted to the facility on [DATE]. The following diagnoses were added to the medical record on the following dates: --Vascular dementia 03/04/25 --Anxiety disorder 04/10/24 --Psychotic disorder 04/10/24 --Auditory hallucinations 04/10/24 On 12/11/25 at 9:30 AM, the Administrator confirmed the diagnoses were added after admission and a new PASSAR should have been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASARR) reflected pre-admission diagnoses. This was true for one (1) out of four (4) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifier: #32. Facility census: 124.Findings included:a) Resident #32A medical record review, completed on 12/10/25 at 10:14 AM, revealed Resident #32 had been admitted to the facility on [DATE] with the following diagnosis:-Major Depression DisorderThe resident's admitting PASARR marked NONE under Section III Question 30 entitled, Current Diagnosis (Check all that apply). Additionally, Section V Question 40 entitled, Major Mental Illness (MI) or Suspected MI was also marked NONE. During an interview on 12/10/25 at 11:16 AM, Social Worker #47 reported that Resident #32's Major Depression Disorder diagnoses had not been captured on the admission PASARR and a new one had not been completed.

Based on record review, policy review, and staff interview, the facility failed to ensure a resident admitted with an existing pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing. This was true for one (1) out of three (3) residents reviewed under the pressure ulcer pathway throughout the Long-Term Care Survey Process. Resident identifier: #100. Facility census: 124. a) Resident #100 The CommuniCare Policies and Standard Procedures indicated that a Resident / patient admitted with skin integrity issues will receive treatment as indicated based on location, stage and drainage. A stage III or IV Pressure Ulcer has four options for treatment, and none of the options were started until 12/02/25. Resident #100 was admitted to Moundsville Healthcare on 11/26/25. Upon admission the Licensed Practical Nurse (LPN) employee #33 completed the Nursing admission Evaluation and noted there were only Non-Pressure Skin issues present. On 11/26/25 at 1:49 PM Employee #33 wrote a progress note that stated: Report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview, the facility failed to maintain and infection prevention and control program designed to prevent infections during medication administration to and failed to ensure proper storage of a urinal in Resident #7's bathroom. This was true for one (1) of three residents observed during medication administration and a random opportunity for discovery of the improper storage of a urinal. Resident identifier: #15. Facility Census: 124. Findings Include: a) Medication Administration Policy On 12/10/25 at 9:15 AM, a review of the facility Medication Administration Policy was completed. The review found under the heading of Procedure section s. states, Do not touch the medication, either when opening a liquid or dose pack. (Typed as written.) Also, under section u iii. states, Gloves must be worn for splitting tablets. (Typed as written.) b) Resident #15 On 12/10/25 at 8:55 AM, an observation of medication administration to Resident #15 was made. Licensed Practical Nurse (LPN) #127 dropped a white round pill while removing it from the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and staff interview, the facility failed to thoroughly investigate the elopement of Resident #101. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents in the facility. Resident identifier: #101. Facility census: 117. Findings included: a) Resident #101 A facility reported incident (FRI) dated 07/15/24 stated, Resident (#101) exited the center at 7:03 PM through the front door via emergency exit and at 7:35 PM staff was alerted that resident was seen by an off duty staff member RN who stayed until center showed up. Resident did not want to be at the center. At approximately 2:00 PM on 08/14/24 an interview was conducted with the Administrator (NHA). When asked why no one heard the alarm to address the resident elopement within 30 minutes. The NHA stated that they could not confirm if the doors were alarmed on that specific instance, nor could comment on why no one heard or responded to the alarm. The NHA could only comment that upon testing after the event the alarms were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, policy review, medical record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases, to help prevent cross-contamination and infections including Covid-19 in regard to, laundry services, water management, and meal services. This failed practice had the potential to affect every resident currently residing in the facility. Facility Census: 120. Findings included: a) Water Management During facility record review of the water management revealed, the documentation was not maintained to prevent growth of water borne pathogens including description of the building water system. The flow diagram did not Identify the building's water systems for which Legionella control measures are needed. No documentation was provided describing the building water systems using text or testing protocols or dead leg water flushes. On 03/05/24 at 2:20 PM the Maintenance Director verified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, resident interview, and staff interview, the facility failed to honor the choices of Resident #82 by failing to schedule showers during the resident's preferred time of the day. This was true for one (1) of two (2) residents reviewed for choices during the long-term care survey process. Resident identifier: 82. Facility census: 120. a) Resident #82 At approximately 02:26 PM on 04/01/24, an interview was conducted with Resident #82. During the interview, when asked if they felt if the facility honored their choices, Resident #82 stated No, I keep getting flipped back and forth between day showers and night showers, and I don't want night showers. I've told them every time they move me to night showers that I don't like them because I don't want to go to bed with my hair wet. They moved me back to day showers and a couple days later, moved me back to night, and that's where I am still. They won't tell me why I can't have a shower on day shift either. Upon record review the following progress notes were found, pertaining to Resident #82's showers, typed as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and resident interview the facility failed to develop and/or implement care plans related to communication, nutrition, pain management, and positioning devices. This failed practice was found true for (3) three of 30 residents reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers #55, #75, and # 90. Facility census 120. Findings Include: a) Resident # 55 communication During the initial observation on 04/01/24 at 2:00 PM, it was discovered that Resident # 55 was hard of hearing and needed visitors/staff to write on a wipe off board to communicate with her. During an interview on 04/01/24 at 2:00 PM, Resident # 55 stated, I can't hear so you have to use the board to talk to me. Everybody uses the board. A record review on 04/03/24 at 10:00 AM, of Resident # 55's communication care plan revised on 09/21/23 reads as follows: FOCUS: -[NAME] has a communication problem related to being hard of hearing. [NAME] has a right hearing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, resident interview, and staff interview the facility failed to provide a program of activities to meet the physical, mental, and psychosocial well being of each resident. This failed practice was found true for (2) two of (5) five residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #23 and #93. Facility census 120. Findings Include: a) Resident # 23 During an interview on 04/01/24 at 1:02 PM, Resident #23, stated, I can't go out to the activity programs, because they never get me up to my wheelchair. A record review on 04/02/24 at 1:00 PM, of Resident #23's care plan read as follows: Focus: Resident enjoys group activities such as, special events, Bingo, card games, likes working puzzles, likes visits with her husband, being outdoors and socializing. Goal: - Resident will participate in activities of choice through review date. Interventions: -Assist with transport to activities as needed -Encouraging attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to follow professional standards of practice for tube feeding. The tube feeding documentation for Resident #102 did not include whether she required tube feeding for oral intake less than 50% of the meal. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of tube feeding. Resident identifier: #102. Facility census: 120. Findings included: a) Resident #102 Review of Resident #102's physician orders showed an order written on 03/05/24 to give a tube feeding bolus of 240 milliliters (ml) of Jevity 1.5 with 100 ml of water three (3) times a day if the resident ate less than 50% of the meal. Review of Resident #102's Medication Administration Record (MAR) for March 2024: Breakfast The MAR showed the tube feeding bolus was marked with a check mark for breakfast on 03/06/24 through 03/08/24, 03/11/24 through 03/15/24, 03/18/24 through 03/22/24, 03/24/24 through 03/28/24, and 03/30/24 through 03/31/24. Review of Resident #102's MAR for March 2024 showed the tube feeding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and policy review the facility failed to store food in a safe, sanitary manner to prevent food borne illness. This failed practice had the potential to affect more than a limited number of residents. Facility census 120. Findings included: a) Dietary walk-in refrigerator and freezer During the initial tour of the facilities kitchen on 04/01/24 at 12:06 PM found that the following items were out of date in the walk-in refrigerator: - Chicken noodle soup in a clear plastic container with a use by date of 03/25/23. - Sliced cheese in a clear plastic container with a use by date of 03/23/24. - Parmesan cheese in a clear plastic container with a use by date of 03/30/23. Further observation found the following items out of date in the walk-in freezer: - Pepperoni that was brown in color in a clear plastic container with a use by date of 06/04/23. -Tomato sauce in a clear plastic container with a use by of 12/31/23. During an interview on 04/01/24 at 12:20 PM, with the Dietary Manager, he confirmed all of the items were out of date. A review on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: #69, #100 and #75. Facility census: 120. Findings included: a) Resident #69 An observation of meal services, on 04/01/24 at 12:55 PM, revealed Resident #69's Roommate received her tray. Resident #69 was yelling, I want my (explicit language) tray. During the observation at 1:08 PM, Resident #69 received her tray after multiple trays were passed. During an interview at 1:15 PM with Nurse Aide (NA) #63, NA #63 stated that they just serve the trays from the cart as they come out, in no specific order. She also stated that Resident #69 should have received her tray when the roommate received a tray. b) Resident #100 During an observation on 04/02/24 at 12:05 PM, of the noon time meal in the dining room, Resident #103 was served her lunch tray, along with 2 other residents seated at the same table. Further observation showed that Resident #100 was also seated at the same table. She was served…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, resident interview, and staff interview, the facility failed to provide accommodations for Resident #93, by failing to have a geriatric chair available for the resident for transportation to activities and other needs for the resident. This was true for one (1) of two (2) residents reviewed for accommodation of needs during the long-term care survey process. In addition, the facility failed to have the Ombudsman's contact information posted at a level easily accessible to residents in wheelchairs. This has the potential to affect more than a limited number of residents. Resident identifier: 93. Facility census: 120. Findings included: a) Resident #93 At approximately 1:30 PM on 04/01/24, an interview was conducted with Resident #93. Resident #93 stated they had not been up out of bed in a long time because the sling used for the mechanical lift hurt them when the staff used it. Resident #93 stated they would like to get out of bed more, attend activities, and move around the facility. At approximately 3:00 PM on 04/01/24, Resident #93 was observed in their bed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to protect the confidentiality of resident records by leaving a computer screen on, unattended in the hallway. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 120. a) Observation At approximately 04:01 PM on 04/02/24, while administering medication, Registered Nurse (RN) #80 left the screen on the computer on, while the computer was in the hallway, displaying resident information. Upon returning to the cart, RN #80 acknowledged leaving the computer screen on, stating I can't believe I did that, I have never done that before.

Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #110. Facility census: 120. Findings included: a) Resident #110 Review of Resident #110's medical records showed the resident had a fall on 02/04/24 and fractured her right hip. Review of Resident #110's Significant Change/Medicare Five (5) Day Minimum Data Set (MDS) Assessment with Assessment Reference Date (ARD) 02/16/24 showed No for the question if the resident had any falls since the prior assessment. On 04/04/24 at 8:46 AM, Minimum Data Set Registered Nurse #55 confirmed Resident #110's MDS with ARD 02/16/24 was incorrect and should have indicated the resident had a fall with major injury. She stated she submitted a corrected MDS after the surveyor identified the error.

Based on observation, staff interview, family interview, and record review, the facility failed to ensure the resident and/or resident representative is invited to the care plan conference. This was a random opportunity for discovery during the Long-Term Care Process. Resident identifier: 51. Facility census: 120. Findings included: a) Resident #51 On 04/02/24 at 1:20 PM, Resident #51's Representative states in the past year she has only been to one care plan conference and that was after Resident #51 was admitted to the facility a year ago. On 04/03/24 at 11:39 AM, the Director of Social Services #24 (DSS) states, the Assistant Director of Nursing (ADON) took care of the invitations sent out to representatives for the care plan conference; however, when she left that kind of fell off to the side. The DSS confirmed Resident #51's representative has not been getting invited to care plan conferences. On 04/03/24 at 12:07 PM , the Minimum Data Set Registered Nurse (MDS RN) provided six (6) Care Plan Conference signature sheets for Resident #51. A record review on 04/03/24 at 12:10 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, resident interview, and staff interview, the facility failed to provide care within acceptable standards of care, by administering medications without a physician's order. This was true for one (1) of 30 residents reviewed during the long-term care survey process. Resident identifier: 318. Facility census: 120. Findings include: a) Resident #318 At approximately 02:32 PM on 04/01/24, an interview was conducted with Resident #318. During the interview, Resident #318 stated they were in severe pain, and had been since they arrived at the facility on 03/11/24. The resident reported they suffered a broken shoulder that had not healed in two and a half months. Resident #318 stated the facility would not give them anything other than Tylenol to manage their pain. Record review was conducted for Resident #318's orders. Orders indicated there were no orders for non-pharmacological interventions, Tylenol, or any other pain medication to manage Resident #318's pain. At approximately 11:55 AM on 04/03/24, another interview was conducted with Resident #318 regarding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview the facility failed to ensure Resident #8 had a palm guard in place as ordered by the physician to prevent further decrease in range of motion. This failed practice was found true for (1) one of (1) residents reviewed for Range of Motion (ROM) during the Long-Term Care Survey Process. Resident identifier #8. Facility Census 120. Findings include: a) Resident #8 During an observation on 04/01/24 at 1:00 PM, it was discovered that Resident # 8 had a contracture of her left hand. A record review on 04/02/24 at 9:30 AM revealed that Resident # 8 is ordered a Palm guard to Left hand as tolerated. May remove for hygiene. Further record review of Resident #8's care plan revised on 02/26/24 reads as follows: Focus: (Resident #8 name) has muscle pain to her left hand and left shoulder areas. ( Resident #8 name) uses a palm guard on her left hand. Goal: - She will be without pain through her review. Interventions: -Observe for pain and report to MD if noted. - Treatment as ordered by MD - Remove Left hand Palm guard for hygiene QD and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, the facility failed to ensure meds were stored in accordance with professional standards of practice. Two (2) of three (3) medication carts observed had vials of insulin that had been opened more than 28 days ago. Resident identifiers: #65, #51. Facility census: 120. Findings included: a) Resident #65 On 04/02/24 at 8:52 AM, the 600 hallway medication cart was inspected with Registered Nurse (RN) #119 in attendance. An opened vial of Lantus (glargine) insulin for Resident #65 was in the cart. The insulin vial had an opening date of 02/28/24 written on the vial in marker. The vial also had an expiration date of 03/25 written on the insulin box in marker. RN #116 confirmed the insulin vial for Resident #65 had been opened more than 28 days ago. Review of Resident #65's physician's orders showed an order for insulin glargine (Lantus), 8 units every day for diabetes. b) Resident #51 On 04/02/24 at 9:08 AM, the 300 hallway medication cart was inspected with Licensed Practical Nurse (LPN) #89 in attendance. An opened vial of Lantus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, the facility failed to ensure medical records were complete and accurate for two (2) of 30 residents reviewed in the long-term care survey sample. Refusals of heel protectors were not documented for Resident #13. A diagnosis of Post-traumatic Stress Disorder (PTSD) was not documented in the diagnoses list for Resident #81. Resident identifiers: #13, #81. Facility census: 120. Findings included: a) Resident #13 Review of Resident #13's physician's orders showed an order written on 10/31/23 which stated, Prevention: Apply Heel Protectors WIB (while in bed) and at rest, QS (every shift) and PRN (as needed) for Pressure Relief. Observation of Resident #13's room on 04/01/24 at 2:59 PM, showed the resident's heel protectors were laying on the floor in the corner of the room. During an observation on 04/02/24 at 12:15 PM, Resident #13 was noted to be up in a Geri-chair, which was leaned back. She did not have heel protectors on, but she had on thick socks and her heels were resting on a pillow on the Geri-chair footrest. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview the facility failed to serve food at a palatable, safe, and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. Facility census: 121. Findings Included: a) Facility Food A record review during a complaint survey for cold food of Resident Council Minutes for 07/07/23 found Residents voiced their concerns about food not being hot enough. An Observation 09/13/23 at 11:40 AM of the lunch holding temperatures found the following: -Meatloaf - 111 -Puree meatloaf - 160 After Surveyor intervention the Meatloaf was placed back in oven, and a second pan was placed on the steam table. On 09/13/23 at 1:14 PM a tray temperature was obtained from the last tray on the 300 Hall found the following: -Meatloaf - 97 -Mashed Potatoes - 98 -Carrots - 90 On 09/13/23 at 1:33 PM, a tray temperature was obtained from the last tray on the 400 hall and revealed the following: -Meatloaf - 109 -Mashed Potatoes - 118 -Carrots - 109 An interview with the Dietary Manager immediately after the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observation, medical record review and staff interview, the facility failed to develop individualized and person centered care plans. A care plan was not developed for a resident with falls or a resident with palm protectors. In addition, the activities care plan for a resident with cognitive deficits was not developed to meet her individual needs. This is true for one (1) of three (3) residents reviewed for falls, one (1) of three (3) reviewed for activities, and a random opportunity for discovery of the hand palm protector not in place. Resident identifiers: #98, #41, and #63. Facility census: 101. Findings include: a) Resident (R) #98 Review of the medical record on 07/27/22, revealed R#98 experienced an unobserved fall on 07/22/22 and was found next to his bed. The fall risk assessment dated [DATE] identified him to be a high risk for falls. The care plan is silent for falls or any interventions in place to protect R#98 from falling. On 07/27/22 at 9:00 AM, Corporate consultant #140 reviewed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, staff and resident interview, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice of following physician's orders and in accordance with the person-centered care plan. This was found to be true for four (4) of 29 residents reviewed for care and treatment during the LTCSP. The facility failed to provide care in accordance with the physician's orders to withhold straws from Resident #89. The facility failed to follow-up on the current physician's order for treatment for Resident #44. The facility failed to provide care based on a documented and accurate assessment for Residents #50 regarding bowel elimination and Resident #30 regarding weight monitoring. Resident Identifiers: Residents #89, #44, #50 and #30. Census: 101. Findings included: a.) Resident #89 A review of the medical record for Resident #89 showed a current physician's order for the resident to have no straws. An observation, on 07/26/22 at 01:20 PM, revealed three (3) beverages with straws sitting on the over the bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview , the facility failed to ensure two (2) of six (6) medication carts were maintained in accordance with standards of practice. During a random opportunity for discovery, two (2) medication carts had medications being administered to residents that were not dated when opened. This had the potential to affect more than a limited number of residents. Census: 101. Findings included: a.) 500 wing Medication cart An observation of the 500 wing medication cart, on 07/26/22 at 08:01 AM, revealed a bottle of Melatonin, opened, with no date of when the bottle was opened and put into use. An interview, on 07/26/22 at 08:01 AM, with Registered Nurse (RN), RN #36, verified the Melatonin had been opened and was being administered to residents as stock medication. RN #36 confirmed there was no date when the medication was open and the bottle of Melatonin should have been dated when opened. RN #36 stated further it was policy that staff date bottles when opened. b.) 200 wing Medication cart An observation of the 200 wing medication cart, on 07/26/22 at 08:44…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, fall risk and elopement evaluations were inaccurate and bowel movement record was incomplete. This practice affected three (3) of 29, residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #53, #50 and #74. Facility census: 101. Findings included: a) Resident #53 An observation on 07/25/22 at 11:31 AM, found Resident #53 (R #53) sitting in a wheelchair (w/c) in the dining room with a wander guard alarm in place around his right wrist. A review of the Resident #53's medical record on 07/25/22 revealed a Physician order: -- Wander guard, to right wrist at all times to alert staff to elopement attempts. Check placement and functioning. With an order date 12/31/19. Review of Residents #53's care plan on 07/26/22, found: Focus/problem: Elopement --Resident #53 is at risk for elopement from the facility, Related to Dementia. The goal associated with this problem: --Resident will not elope from the facility through next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including the prevention and/or containment of COVID-19. Surveyors were not informed of the building's Covid-19 status on entry and hand sanitizer and N95 masks were not available at the door. Linen and trash cans in isolation rooms were not hands free. Bed pans were improperly stored and a resident's catheter bag rested on the floor. This practice has the potential to affect a more than a limited number of residents residing in the facility. Facility census: 101. Findings include: a) Facility entrance The survey team entered the facility on 07/25/22 at 11:00 AM and were greeted by Hospitality Aide (HA) #1. HA #1 failed to tell the survey team the facility was in Covid-19 outbreak and failed to tell the team to change the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #300 and #15. Facility census: 101. Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires skilled nursing facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is: - not medically reasonable and necessary; or - considered custodial Findings included: a) Resident #300 On 07/26/22 at 11:59 AM, a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review was completed regarding the beneficiary protection notification liability…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on medical record review and staff interview, the facility failed to provide evidence a Bed Hold Notice was given to residents/resident representatives when transferred to the hospital. This was true for one (1) out of one (1) hospital transfers reviewed during the long-term care process. This had the potential to affect all residents being transferred or discharged . Resident identifier: #82. Facility census: 101. Findings included: a) Resident #82's Hospital Transfer on 04/03/22 A medical record review was completed on 07/27/22 at 2:15 PM. The record revealed Resident #82 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Bed Hold Notice. During an interview with the Director of Nursing (DON), on 07/27/22 at 2:33 PM, the DON reported the Bed Hold Notice may not have been provided to resident/resident's representative upon transfer since the facility had only been at 78% of capacity and the resident would not have been charged for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY . Based on record review and staff interview, the facility failed to ensure the assessment accurately reflected a resident's current status. This was true for one (1) of 29 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #87. Census: 101 Findings included: a) Resident #87 A review of the Minimum Data Set (MDS), dated [DATE], indicated insulin was given to the resident seven (7) days a week. An interview with the Director of Nursing (DON), on 07/26/22 at 03:30 PM, revealed Resident #87 had received insulin but the insulin was discontinued on 04/22/22 . The DON stated further the resident no longer was receiving any insulin and the MDS, dated [DATE], had been coded incorrectly. .

Based on observation, record review and staff interview, the facility failed to ensure a care plan approach was revised when the approach was no longer appropriate for the resident This was true for one (1) of 29 residents reviewed during the Long Term Care Survey Process (LTCSP).Resident identifier : Resident #35. Census: 101 Findings included: a.) Resident #35 An observation of Resident #35's room, on 07/25/22 at 01:21 PM revealed a room, with no homelike decorations/pictures. A review of the care plan that had been revised on 07/07/22 noted an intervention to Personalize room with pictures/personalize doorway with picture/name in large print. An observation on 07/27/22 at 08:30 AM, in the presence of the Administrator revealed the room with no personalization except a TV and a paper calendar for July, but no pictures noted. Observation of the doorway, revealed no picture /name with large print. An interview with the Director of Nursing (DON) on 07/27/22 08:35 AM, confirmed the resident does not come out of the room. An additional interview, with the DON at 07/27/22 08:44 AM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview, the facility failed to provide and ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This is true for 1 of 3 reviewed for activities. Resident identifier: R#41. Facility census: 101. Findings include: a) Resident (R) #41 Review of the medical record on 07/27/22 found R #41 has moderately impaired cognition with a diagnosis of encephalopathy and altered mental status. She is wheelchair bound and requires assistance of one (1) to two (2) staff with all activities of daily living. The activity assessment completed on 12/06/21 states the following: (Resident Name) is a new admission to the center. She is alert with some confusion. Her interests include cards/games, crafts/art, helping others, sports, talking/conversing, trips/shopping, watching television, and movies. Staff is to visit with (Resident Name) at least twice weekly and encourage her to discuss and pursue her interests. Staff is to offer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview the facility failed to provide the services, care, and equipment to assure that a Resident's maintains, and/or improves to their highest level of range of motion (ROM) and mobility. This was a random opportunity for discovery. Resident Identifier #63. Facility census 101. a) Resident #63 An observation during initial tour on 07/25/22 at 2:07 PM, found Resident #63 lying in bed with both hands in fists without hand protection. Medical record review on 07/25/22, showed Physicians orders, dated 10/13/21: --Patient to wear left palm roll with finger separators daily. Skin checks prior to donning/after doffing. --Patient to wear right palm protector daily. Skin checks prior to donning/ after doffing. A second observation 07/27/22 at 9:40 AM revealed, #63 lying in bed with both hands in fists without the ordered left palm roll or the right palm protector. During an interview on 07/27/22 Registered Nurse (RN) #122 verified Resident # 63 did not have skin protection devices in place. RN #122 also stated that she was unaware of the palm protection…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to ensure the environment for one (1) of 29 residents reviewed during the long-term care survey process was free from accident hazards over which the facility had control. Resident identifier: #45. Facility census: 101. Findings included: a) Identified Accident Hazard On 07/25/22 at 12:25 PM, a random observation revealed a four (4) ounce tube of antifungal cream stored in Resident #45's bathroom. Directions on the tube of medication read, For external use only. Keep out of reach of children. At 12:30 PM, RN #36 confirmed the presence of the above-mentioned medication stored in the bathroom. RN #36 removed the medication, stated it never should have been stored there, and acknowledged the medicine was an accident hazard. .

Based on record review and staff interview, the facility failed to ensure a resident who did not maintain an acceptable parameter of nutritional status, received care in accordance with physician's orders to monitor the resident's condition by obtaining daily weights after the resident had been identified to have had a significant weight loss. This was true for one (1) of three (3) residents reviewed during the Long Term Care Survey Process (LTCSP) for nutrition. Resident Identifier: #89. Census: 101 Findings included: a.) Resident # 89 A review of the medical record for Resident #89 revealed a 10.80 percent weight loss from 04/28/22 through 07/24/22. Further review of the medical record showed an order to obtain daily weights starting today (06/29/22) for four (4) weeks until 07/27/22 and to monitor for significant weight gain or loss of plus or minus three (3) pounds (lbs.) A review of the weights from 06/29/22 through 07/27/22 revealed the daily weights were not obtained in accordance with the physician's orders, No weights were completed for 07/02/22, 07/03/22, 07/04/22,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and staff interview, the facility failed to ensure all medication irregularities were identified and reported to the resident's physician and facility's Director of Nursing (DON) in accordance with professional pharmacy standards of practice, This finding was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: Resident #52. Census: 101 Findings included: a.) Review of Literature 1.) FDA.gov, reference ID: 4032692 A review of FDA.gov literature under prescribing information for Zoloft, warnings and precautions included the following: Serotonin Syndrome: Increased risk when co-administered with other serotonergic agents (e.g., SSRI, SNRI, triptans), but also when taken alone. If it occurs, discontinue ZOLOFT and initiate supportive treatment. (5.2) Increased Risk of Bleeding: Concomitant use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), other antiplatelet drugs, warfarin, and other anticoagulants may increase this risk. (5.3) Activation of Mania/Hypomania: Screen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation of medication administration, staff interview, and record review, the facility failed to ensure the facility's medication error rate was less than five (5) percent. Facility staff failed to administer medications according to professional standards for one (1) resident, during medication administration, contributing to a 7.41 % medication error rate. This deficient practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifiers: # 52. Census: 101 Findings included: a.) Policy 5.3.14 Medication Administration: Crushing Of Medications A review of the facility's policy for Medication Administration, Policy 5.3.14 Crushing Of Medications, effective date 06/21/2017, showed under the procedure, crushing of medications required a physician's order and the facility was provided with a Do Not Crush list and labels were to be placed on medications with cautionary Do Not Crush as indicated. Medications which are enteric coated, extended release, sublingual or otherwise noted by manufacturer as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to maintain current food handler cards for one (1) of nine (9) employees reviewed in the Dietary Department. This practice had the potential to affect a limited number of residents who receive their nutrients from the kitchen. Facility census: 101. Findings included: a) Food Handlers Cards On 07/26/22 at 1:06 PM, a review of food handlers' cards for dietary staff were reviewed. Employee #57 had a Marshall County, WV Food Safety Manager Training certificate on file that expired on 06/21/22. During an interview on 07/26/22 at 2:15 PM, the Certified Dietary Manager (CDM) stated she would need to check with the Human Resources Department and would provide follow-up information regarding Employee #57's paperwork. On 07/27/22 at 11:40 AM, the CDM reported Employee #57 obtained a food handlers card on 07/26/22 but had gone without an approved certification from 06/22/22-07/25/22. The CDM added the lapse of certification had been an oversight and had been immediately corrected once identified. .

Based on observation and staff interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The kitchen had two (2) unlabeled and undated food items. This practice had the potential to affect a limited number of residents who receive nutrition from the kitchen. Facility Census 101. Findings Included: a) Initial Tour of the Kitchen During an initial tour of the kitchen beginning at 11:20 am on 07/25/22 with the Certified Dietary Manager (CDM) the following issues were identified: - One (1) clear package of what the CDM identified as cake mix had been opened but was unlabeled and undated. - One (1) package of sliced bread had been opened but was unlabeled and undated. The CDM verified the presence of unlabeled and undated food items, stated the kitchen staff had failed to follow the facility protocol for food items that had been opened, and promptly disposed of the remaining cake mix and sliced bread. .