Every finding on record at Clarksburg Healthcare Center

Based on observation, record review and staff interview, the facility failed to ensure staff hand hygiene was completed during the dining process. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 88.Findings included: a) The facility's policy and procedure for Standard Precautions stated that hand hygiene should be performed: A. Before eating/feeding or assisting in the dining room and tray pass. On 04/28/26 at 11:55 AM, during the dining room observation, Registered Nurse #75 did not use hand hygiene between residents while serving. Nurse Aide #72 and Registered Nurse #75 passed drinks to each other and then served the residents their drinks without performing hand hygiene. At 12:05 PM, Licensed Practical Nurse #33 confirmed the hand hygiene issues in the dining room.

Based on record review, observation, resident interview and staff interview, the facility failed to follow menus as posted, This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #31, #47 and #71. Facility Census: 88.Findings included: a) On 04/29/2026 at 11:52 AM, the menu posted at the entrance of the first-floor dining room stated: Cranberry Orange ChickenGarlic and [NAME] roasted Red Skin PotatoesDinner RollMandarin Oranges On 04/29/2026 at 11:52 AM, Nurse Aide #88 confirmed cabbage was not listed on the posted menu and cabbage was served to residents for lunch in the dining room. b) Resident #31 On 04/28/26 at 10:50 AM, during the initial interview, Resident #31 reported receiving chicken wings which were not on the menu for a couple of meals. c) Resident #47 On 04/29/26, Resident #47 received ravioli and cabbage which were not listed on the posted menu. Licensed Practical Nurse #77 confirmed that residents received ravioli and cabbage for the lunch meal. d) Resident #71 On 04/29/26, Resident #71 received ravioli and cabbage which were not listed on the posted menu. Licensed Practical Nurse #77 confirmed that residents received ravioli and cabbage for the lunch meal.

Based on observation, record review and staff interview, the facility failed to develop and implement care plans for fall interventions, means of communication and multiple diagnoses. The failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #5, #61 and #44. Facility Census: 88. a) Resident #5 - On 05/04/26, Resident #5's care plan was reviewed for fall precautions/interventions. The resident's care plan stated, Device: Non-skid strips to floor on the left side of bed. and Device: Nonslip material to wheelchair for safety. The resident's orders stated, DEVICE: DYCEM to wheelchair for safety every shift, and Device: Non-skid strips to floor on the left side of bed. On 05/04/26, the state surveyor observed Resident #5's room and wheelchair. There were no non-skid strips of tape on the resident's left side of the bed and Dycem was placed on top of the resident's wheelchair cushion. On 05/04/26 3:40 PM, Corporate Registered Nurse #101 confirmed there was no non-skid tape on the resident's left side of the bed and Dycem was on top of the resident's cushion instead of underneath the cushion to help prevent the cushion from sliding/slipping out of the wheelchair. Corporate Registered Nurse #101 confirmed the Dycem should have been placed under the resident's wheelchair cushion. b) Resident #61 - On 04/28/26 at 11:20 AM, Resident #61 was interviewed during the initial survey process. The resident was non-verbal and was able to utilize gestures to communicate. The resident's care plan stated, Resident is rarely or never understood but can communicate through gestures. The care plan stated two (2) times on page three (3) to discuss feelings, stated on page five (5) to encourage resident to voice feelings, and discuss coping skills, stated on on page thirteen (13) to discuss feelings, and stated on page fourteen to verbalize feelings, perceptions and fears. On 05/04/26 at 11:56 AM, the Director of Nursing confirmed the care plan stated in multiple places to verbalize and that the resident communicated via gestures. c) Resident #44 On 04/29/2026 at 1:44 PM, a record review was completed for Resident #44. The review found the care plan was not developed for the diagnosis of lupus anticoagulant syndrome. The care plan did list lupus as a focus area. However, the resident did not have the diagnosis of lupus. On 04/29/26 at 4:00 PM, the Director of Nursing (DON) was notified and confirmed the care plan had not been developed for the correct diagnosis of lupus anticoagulant syndrome.

Based on observation, resident/family interviews, and record review, the facility failed to ensure patient care equipment, specifically mechanical lifts with frayed, taped wires, was maintained in safe operating condition. Resident identifiers: #21, #31, #9, #17, #75, #44, #45, #47, #13, #79, #29, #66, #105, #73, #82, #83, #16, #33, #63, #64, #68, and #84. Facility Census: 88. Findings included:a) On 04/29/26 at approximately 4:30 PM, a resident's family member spoke with the state survey team concerning an issue with the mechanical lifts. The Joerns' Hoyer Lifts, model [NAME]-PRESENCE-S) were an issue per the discussion. The family member stated the resident lifts were dirty and had electrical tape on them. They reported sometimes only one lift was in operating condition and was used between both floors.On 04/29/26 at 5:15 PM, the Survey Team inspected the lifts in the shower rooms on both floors. Both lifts had electrical tape on the wires attached to the cradle on both sides. The lift on the first floor had frayed wires at the base of the electrical tape on the left side.At 5:30 PM, the state surveyor interviewed Nurse Aide #59, who confirmed there was black electrical tape on the wires attached to the cradle bar of the lift on the first floor and reported they had been asking for new lifts.At 5:33 PM, the Administrator confirmed the black electrical tape and stated, They (wires) are not exposed. He stated that he would just have maintenance put more tape on it. The administrator then verified the frayed wire and confirmed maintenance was still in the building. The State Surveyor asked the Administrator for a copy of the purchase orders for the lifts and the administrator reported he was in the process of obtaining bids.Direct Supply quotes, dated 02/04/26, were provided for the following items: Hand Switch/Assembly, APC Cradle, Wire Harness Kit, APC, and Lift Part, Boom Actuator for HOY_PRESENCE_S w/Smart Monitor.Twenty-two residents required lift utilization for safe transfers in the facility. Ten (10) residents on the first floor require the lifts for transfers and twelve (12) residents on the second floor require a lift for transfers.On 04/29/26 at 6:28 PM, the Administrator stated that the piece of the lift with the taped wires is called the cradle. The Administrator stated that even if the cradle were to short out it still would not drop the resident. The Administrator declined to remove the black electrical tape because the wires were either frayed or he was tearing them apart.On 04/29/26 at 6:28 PM, Director of Plant Maintenance #24 stated that an exposed wire underneath was the reason it was taped. He reported that the lift had been malfunctioning for the last year. Director of Plant Maintenance #24 reported he does not have electrical certification.According to the manufacturer's manual, provided by the facility, on page 13: 6. emergency stop: The red emergency stop button is located on the control box and is activated by pressing in. This will cut all power to the lift and can only be reset by twisting the button clockwise and releasing. The manufacturer's manual further stated, DO NOT use or store a lift in a wet or corrosive environment such as shower, bath or pool locations. Both lifts were stored in the shower rooms. The Administrator confirmed the lifts were stored in the shower rooms on both floors of the facility.The facility's policy and procedure for Mechanical Lifts and Transfers stated, 1.a. Lifts are utilized to provide a safe and ergonomic method to assist residents to transfer, stand, or toilet without physically/manually lifting them., II.c. Inspect and position equipment for smooth, safe transfer., and X. Post Lift b. Report any mechanical concerns and remove lift from operation, if found.

The Facility failed to ensure residents were served meals timely on A Hall.During the annual survey process, the facility failed to ensure timely provision of meals in accordance with posted meal service times of 7:00 AM to 8:15 AM for Breakfast, 12:00 PM to 1:15 PM for Lunch, and 5:00 PM to 6:15 PM for Dinner.Observation revealed that at 9:40 AM on 5/5/26, residents on A Hall were still being served breakfast, significantly beyond the scheduled meal service window. Resident #74, identified as requiring feeding assistance, was still waiting for their meal at that time. During an interview, CNA #72 stated, This happens often, regarding delayed meal tray delivery from the kitchen. It was further reported that A Hall received meal trays around 9:00 AM. During an interview, the facility administrator stated, One hallway has to be last, when addressing the delayed meal service.Additionally, surveyor observation noted meal pass occurring on A Hall at approximately 9:40 AM. On 4/28/26 at 10:50 AM, Resident #31 expressed concern regarding consistently late meal service, stating, I fall asleep waiting for dinner. They reported that dinner is often not served until 7:00 PM-7:30 PM, indicating ongoing delays beyond expected service times.

Based on record review, observation and staff interview, the facility failed to ensure physician's orders for fall preventions were followed. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #5. Facility Census: 88.Findings included:Resident #5 a) On 05/04/26, Resident #5's orders were reviewed for fall precautions/interventions. The resident's orders stated, DEVICE: DYCEM to wheelchair for safety every shift, and Device: Non-skid strips to floor on the left side of bed. On 05/04/26, the state surveyor observed Resident #5's room and wheelchair. There were no non-skid strips of tape on the resident's left side of the bed and Dycem was placed on top of the resident's wheelchair cushion instead of underneath it. On 05/04/26 at 3:40 PM, Corporate Registered Nurse #101 confirmed there was no non-skid tape on the resident's left side of the bed and Dycem was on top of the resident's cushion instead of underneath it to help prevent the cushion from sliding/slipping out of the wheelchair. Corporate Registered Nurse #101 confirmed the Dycem should have been placed under the resident's wheelchair cushion.

Based on observation, record review and staff interview, the facility failed to ensure residents received therapeutic diets as ordered by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #5 and #35. Facility Census: 88.Findings included: Resident #5 On 04/28/26, Resident #5's tray card was reviewed. The residents' tray card stated, Dys Mech - Regular and Pureed Buttered Dinner Roll - #16 Scp. The resident received a whole, unbuttered roll with the lunch meal. Resident #5's diet order stated, Regular Diet Dys Mech texture, Nectar Thickened Liquids consistency. Resident #35 On 04/28/26, Resident #35's tray card was reviewed. the residents tray card stated, Dys Mech - Regular and Pureed Bettered Dinner Roll - #16 Scp. Resident #35's diet order stated, Regular diet Dys Mech texture, thin liquids consistency, for diet. At 12:10 PM, Registered Dietician #20 confirmed Resident #5's and Resident #35's tray cards stated Dysphagia Mechanical Soft Diet with pureed buttered dinner roll - #16 scoop and that the residents did not receive a pureed consistency roll but received a regular roll. The residents did not consume their whole, regular rolls secondary to surveyor intervention, and staff checked additional dysphagia mechanical soft trays in the dining room for regular consistency bread. The diet extension for Dysphagia Mechanical Soft stated, Buttered Dinner Roll .Pureed #16 Sc

Based on observation, resident interview and staff interview, the facility failed to ensure drinks including water and other liquids were served consistent with residents' needs and preferences. This failed practice had the potential to affect a limited number of residents, Resident Identifier: #12. Facility Census: 88.Findings included: a) Resident #12 On 04/28/26 at 12:15 PM, during the dining room observation on the first floor of the facility, Resident #12's tray card stated, Hot Coffee - 6 Oz. Resident #12 did not receive hot coffee as printed on the tray card. When the state surveyor asked the resident if she wanted coffee, the resident stated, Yes, I wanted coffee. The resident received coffee following surveyor intervention. On 04/28/26, Licensed Practical Nurse #33. confirmed the resident did not receive coffee as printed on the tray card. The facility's policy and procedure for Dining and Food Preference stated, Individual dining, food and beverage preferences are identified for all residents and patients.

Based on observation, record review and staff interview, the facility failed to dispose of an expired vial of insulin for Resident #11 on the B medication cart. This was a random opportunity for discovery. Resident Identifier: #11. Facility Census: 88.Findings Include: a) Resident #11 On [DATE] at 9:10 AM, the medication cart on B hall was checked for the care area of medication storage. An expired vial of Lispro insulin for Resident #11 was found. Licensed Practical Nurse (LPN) #77 verified the insulin vial expired on [DATE]. The vial's opening date was noted as [DATE]. On [DATE] at 9:14 AM, the Director of Nursing (DON) was notified and confirmed that insulin expired 28 days after the vial is opened.

Based on record review, staff interview and observation, the facility failed to ensure the residents' environment in the shower room was free from accident hazards on A Hall. This failed practice had the potential to affect a limited number of residents. Resident Identifier #39. Facility Census: 88.Findings included: a) Resident #39 On 04/29/26 at 6:09 PM, the state surveyor investigated the shower room on C Hall. Resident #39, a resident from D Hall, was in the bathroom adjacent to the shower room. The resident could open the door from the bathroom into the shower room. The shower door was locked with a keypad entrance. The bathroom door is not locked from the hallway. A gallon jug of Medco Prewash MP2017 was open and sitting on top of the wheelchair washer machine. According to the Safety Data Sheet (SDS), the product is labeled: H315 Causes skin irritation and H319 Causes serious eye irritation. This was a random opportunity for discovery. Licensed Practical Nurse #42 confirmed the bottle of cleaner was open and in the shower room. The gallon jug of Medco Prewash MP2017 was removed from the shower room.

Based on record review, staff interview, and observation the facility failed to provide meals at a scheduled time. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 96. Findings included:a) Meal times During a complaint investigation for Residents not being served meals on time meals found Resident Council Minutes: May 13, 2025-Meals are late. The kitchen already gets rid of left overs or are running out of main selection. Residents are unable to get an alternate. June 10, 2025- Meals continue to coming out late especially at dinner. Staff are rushing residents to eat and it is running into evening activities. July 8,2025-Meals continue to coming out late and it is running into activities.August 12, 2025 - Meals continue to coming out late especially at dinner. Staff are rushing residents to eat and it is running into evening activities.September 9, 2025-Residents wants consistency with quality of meals and times that meals are served. October 14, 2025- Meals are late especially at dinner. Sometimes trays are missing.During an Interview on 11/10/25 at 1150 AM with Resident #33 stated that meals are never on time especially dinner. During an Interview with Resident #12 on 11/10/25 at 12:00 PM stated that food times is the biggest problem. They are always late. The facility said they are working on it but it has not changed. An Interview with Resident #88's Daughter on 11/10/25 at 12:20 PM revealed that the facility takes very good care of her mom. She stated that she don't have any complaints but the meals are always late.Observation of meal times 7-8 AM Breakfast, 12 -115 PM Lunch, 5-615 PM Dinner.During an interview on 11/11/25 at about 2:30 PM the Administrator verified that mealtimes have had some issues with consistency in meal time. He also stated that they just recently changed Dietary Manager.

Based on record review, observations and staff interview, the facility failed to ensure residents were provided with a safe environment to prevent elopement, resulting in Resident #41 leaving the facility. This failure to ensure residents did not exit the facility unattended on 07/11/2024 placed all at risk residents who could have exited the facility in an Immediate Jeopardy (IJ) situation. This will be cited at past noncompliance because the facility corrected the failure as of 07/09/24, prior to this survey. Resident Identifier: #41. Facility Census:96. The State Agency (SA) determined this Past Non_Compliance had the potential to cause serious injury, harm, impairment or death to occur. Past non compliance Immediate Jeopardy was issued on 10/16/24 at 3:32 PM. The past non compliance occurred on 07/11/24 and was corrected on 07/13/24. Findings included: a) Resident #41 On 07/11/24 Resident # 41 left the facility through an unsecured door and walked to the front returning to the facility. 1) Progress Notes 7/11/2024 01:12 Pt went out a side door and then walked to the front door. Pt was gone for no more than 30 minutes. No complaints, no apparent injuries. Pt is at baseline. Pt now wearing a wanderguard. 7/11/2024 19:44 Note Text: Resident walked down the end of hall then looked around to see if anyone was watching and went to open the door. This UCN redirected residents from opening the door so that the alarm would go off and that leads to steps. Resident stated she works here and that she needed to go that way. After explaining that the alarm would go off, she stated it does that at my house too! Easily redirected. 6/30/2024 18:04 Note Text: Resident frequently out in hall wandering and carrying her blanket without shoes and is unsteady on feet. redirected to the room to put shoes on and to get her walker. then assisted the dining room to socialize with other residents. Has indicated several times she has to leave here because it is not safe because the building is going to catch on fire. Resident speaking of her family and how her Dad was cutting hay yesterday and it started pouring the rain down. Resident also thinks she is here to help other residents and states I am not not working anymore. I have worked for the past two weeks, and I am exhausted. staff continues to provide 1 on 1 with reassurance and activities of distraction when a resident is exhibiting episodes of anxiousness, worry, and confusion. interventions only successful for short periods. has had recent change in Cymbalta 6/28/2024 18:43 Note Text: Resident wandering the halls several times today, often without shoes or shoes halfway on, once came walking down the hall with a tablet in bra and purse on shoulder. Requesting to go home. Redirection last for short periods 2) Interviews On 10/16/24 at 1:50 PM- Administrator was interviewed concerning resident's elopement. The administrator reported the resident went out the D hall door, walked down the stairs and around the outside walkway to the front door. The administrator reported another resident had attempted to go out the door earlier. He stated, The nurse reset the alarm, but did not get it set. The alarm had not been turned all the way so it did not alarm when the resident went out. The administrator stated the patient had not previously attempted to leave the facility. On 10/16/24 at approximately 2:00 PM The Director of Nursing (DON) stated Staff education was started immediately and all staff education were completed on 07/13/24 3) Observation On 10/16/24 at 1:20 PM- Survey team investigated door alarms on all wings. Inside door alarms were triggered with a scream alarm. Outside doors, past the unit's armed doors at the bottom of the stairwells, are not armed and are labeled, This door leads to OUTSIDE. Coded doors are labeled with: Push until the alarm sounds. Door can be opened in 15 seconds. Unit LPN #51 reported a code white is called twice daily with all door alarms checked. If the door alarms are not armed, a code yellow is called and a resident count is initiated and all administration comes to the first floor nurses station 4) Record Review During record review on 10/16/24 revealed the following: Staff were alerted on 07/11/24 at approximately 12:00 AM that Resident #41 was outside knocking in the front door of the facility. Resident was let back inside and immediately evaluated head to toe and a wonder guard was ordered for Resident #41. The facility initiated an investigation to determine how Resident #41 eloped the facility. Through a thorough investigation the facility found the door alarm on the D-Hall was not reset correctly after another resident had set off the door alarm earlier. The facility educated all staff on the following: ~Inspecting all door alarms to ensure they are alarmed and properly functioning ~Review elopement prevention and management policy ~Proper Procedure for door alarms. ~Education on the OHFLAC reporting criteria. All staff were educated prior to starting their next scheduled shift, and all staff educations were completed 07/13/24. The facility also conducted elopement drills on 07/17/24, 08/14/24, 09/17/24, and 10/9/24 with no issues noted.

Based on observation, record review and staff interview, the facility failed to maintain an infection control program during medication administration. This had the potential to affect more than a limited number of residents. This is a random opportunity for discovery. Facility Census: 96. Findings Included: a) Medication Administration On 10/16/24 at 8:45 AM, an observation of Licensed Practical Nurse (LPN) #51 during medication administration on B hall was completed. There are 22 residents who reside on the B hall. LPN #51 was assigned the entire B hall for medication administration. On 10/16/24 at 8:57 AM, LPN #51 failed to complete hand hygiene between Resident #32 and Resident #2. On 10/16/24 at 9:35 AM, LPN #51 left the B Hall to go the medication room. Upon return, LPN #51 did not complete hand hygiene prior to administering medication to Resident #37. On 10/16/24 at 9:55 AM, an interview was held with LPN #51. LPN #51 stated, I thought I did hand hygiene at these times. On 10/16/24 at 10:00 AM, the Director of Nursing (DON) was notified of the failure to complete hand hygiene prior to medication administration. The DON stated, thank you for letting me know. b) Facility Policy On 10/16/24 at 10:15 AM, the DON provided a copy of the facility policy entitled, Medication Administration. In Section II entitled, Preparation, h. states, Perform hand hygiene before and after each resident's medication is administered.

Based on observation and staff interview, the facility failed to store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. FACILITY: FACILITY Facility Census: #96. Findings included: Findings confirmed by the Dietary Manager(DM) on 10/14/24 during kitchen investigation initiated at 11:45 AM included: a) Large container of tea with no date/smeared date (not legible). Kitchen staff (#27), stated, That was yesterday's. SS reviewed with DM. The DM stated, That's made every day. Measuring cup with tea on the bottom was sitting on top of the container. Tea was relabeled with current date prior to end of the kitchen tour. b) Pitchers were stored on a shelf with water inside x 2. DM stated there was a limited amount of space to properly store items in the kitchen. c) [NAME] cake mix was opened on 08/17/24- not sealed and spilling out of bag- no use by date was marked. d) Dented can x 1 - Campbell's chicken noodle soup. e) Devil's Food Cake mix opened on 09/29/24- sealed-no use by date. f) [NAME] cake mix was opened on 08/17/24- not sealed and spilling out of bag;-no use by date. g) Burrito shells opened 10/05/24-no use by date. h) Bag of ravioli was found in the freezer with no dates. i) Chicken patties opened in the freezer with no date. Two additional bags were unopened, but not dated (out of the box). DM reported he had an employee that is pulling food out of the boxes and not dating them. j) Opened bag of frozen carrots were not dated. k)10/15/24 10:36 AM - Two pantries were investigated. No dates on ice cream products or boxes in either pantry. The DM stated the ice cream is replaced weekly and it is a scheduled weekly replacement order.

Based on record review and staff interviews, the facility failed to have an accurate medical record for three (3) of 24 residents reviewed during the Long Term Care Survey. Resident identifier: #294, #9, #76. Facility Census: 96. Findings Included: a) Resident #294 On 10/14/24 at 12:00 PM surveyor observed a sign posted being Resident #294's bed stating no blood pressure (B/P) or labs in left arm). During record review on 10/15/24 at approximately 10:00 AM of Resident #294's orders showed an order to check fistula in left arm for bruit and thrill every shift. Further record review on 10/15/24 revealed the following: - Facility staff documented on 10/04/24, 10/05/24, and 10/12/24 B/P was obtained in Resident #294's left arm. - The care plan did not address or contain anything about not taking the blood pressure or labs in the left arm, and did not identify Resident #294 as having a fistula in the left arm. An interview on 10/15/24 at approximately 1:00 PM with the Director of Nursing (DON) confirmed the care plan did not address Resident #294 as having an fistula in the left arm and there was nothing in the medical record stating not to take B/P or obtain labs from the left arm. The DON also stated that B/P's obtained were not taken in Resident#294's left arm, the staff had incorrectly documented the B/P being taken in the left arm. On 10/15/24 at 2:05 PM Resident #294 states they have had the fistula in their arm for approximately 7 years, and does not recall ever having a B/P taken in that arm while in the facility. b) Resident #9 On 10/15/24 at 3:34 PM record review shows Resident #9 had the following Physicians orders: Topiramate Oral Tablet 50 MG (Topiramate) Give 100 mg orally two times a day for health maintenance Gabapentin Oral Capsule 300 MG (Gabapentin) Give 300 mg orally at bedtime for health maintenance Medical diagnosis for Resident #9 reflects the following: Migraine, unspecified, no intractable, without status migrainosus Diabetes Mellitus due to underlying condition with hyperglycemia The above two medication orders indicate they are for health maintenance which is not an approved diagnosis. Topiramate is used for migraines and Gabapentin is use for diabetic nephropathy On 10/16/24 at 9:13 AM it was confirmed with the DON that Resident #9 was indeed receiving Topiramate for migraines and Gabapentin for diabetic nephropathy. c) Resident #76 On 10/15/24 at 4:00 PM, a record review was completed for Resident #76. The review found an assessment entitled Pain Observation Tool dated 10/03/24. The assessment indicated the resident received Norco 5 mg (five milligram) three times daily for pain which was effective for the resident's pain. On 10/15/24 at 4:30 PM, the Director of Nursing (DON) was interviewed regarding Resident #76's pain medication. The DON was notified and confirmed the resident was prescribed this pain medication. The DON stated, the resident has never been on prescribed Norco while at the facility. 45171 45173

Based on record review and staff interview, the facility failed to revise a care plan regarding a fall with major injury for Resident #47, behaviors and the discontinuation of medications for Resident #51, and the code status of Resident #50. This is true for three (3) of 24 residents reviewed during the survey process. Resident Identifier: #47, #51 and #50. Facility Census: 96. Findings Included: a) Resident #47 On [DATE] at 12:15 AM, the care plan was reviewed for Resident #47. The review found the care plan had not been revised to indicate a fall with major injury had occurred on [DATE]. A progress note dated [DATE] at 0000 by the facility nurse practitioner states the following: Post fall with head injury History Of Present Illness: [DATE] This is an (Age and sex redacted) being seen after sustaining a fall. Provider was in the building when the fall occurred. I arrived to the bedside Staff had assisted resident back to her bed. She had hit her head on the floor. There was already bruising forming and edema on frontal region of her head. She stated she felt like she was passing out. She is pale and drowsy. Vital signs were taken which were stable. She is mildly anxious at the time of the fall. Due to the head injury. Recommendations were made to call 911 and have her evaluated at the hospital. Neurochecks are within normal limits during focused exam. She is at her cognitive baseline. Staff remained with resident until ambulance arrived for transport. Ice was placed on her head due to swelling. She denies any other injury or complaints from the fall. (Typed as written.) An additional progress note [DATE] at 8:28 PM states, Resident fell at the facility therefore sent to hospital. Resident has returned from ER diagnosed with two broken ribs on her right side. Resident received new order from Norco ,d+[DATE]mg PRN(as needed) Q (every) 6 (six) hours. Encourage deep breathing exercise. (Typed as written.) On [DATE] at 3:00 PM, the Director of Nursing (DON) was notified and confirmed the care plan did not indicate the resident had an actual fall with major injury. b) Resident #51 On [DATE] at 1:00 PM, the care plan was reviewed for Resident #51. The review found the care plan did not indicate specific behaviors under the focus area of behavior problem related to vascular dementia. The review, also, found under the focus areas of mood problem related to dementia and diabetes had an intervention to administer medications per medical provider's care. The resident is currently not taking any prescribed medications. On [DATE] at 3:00 PM, the DON was notified and confirmed the care plan did not indicate any specific behaviors and the resident was not currently taking any prescribed medications. c) Resident #50 On [DATE] at 12:56 PM record review for Resident #50 shows her Medical Power of Attorney made a change in her advanced directives were initiated on [DATE]. According to the Physicians Determination of Capacity dated [DATE] Resident #50 lacks capacity to make medical decisions. On [DATE] Resident #50's Physician Orders for Scope of Treatment (POST) form was updated to be No Cardiopulmonary Resuscitation (CPR) with comfort focused treatments, no artificial means of nutrition desired. A review of the comprehensive person-centered care plan does not indicate the changes made to the POST form in regards to comfort care. There are no goals or interventions in place for comfort care in regards to respect and dignity and to be comfortable during the end of life process On [DATE] at 1:43 PM the above findings regarding the care plan were reviewed with the DON who agreed the care plan should have been updated to reflect comfort care. 45171

Based on record review and staff interview the facility failed to notify the Medical Power of Attorney of abnormal testing results. Resident Identifier: #145 Facility Census: #96 Findings included: a) Resident #145 On 10/16/24 at 2:10 PM record review shows that Resident #145 had abnormal laboratory and urinalysis results that were not relayed to the Medical Power of Attorney (MPOA). According to the Mayo Clinic: A complete blood count (CBC) is a blood test. It's used to look at overall health and find a wide range of conditions, including anemia, infection and leukemia. The normal white blood cell count range is typically between 4 and 11 depending on age and medical conditions. Review of a Complete Blood Count (CBC) laboratory results collected on 12/29/23 and printed on 12/30/23 shows an abnormal white blood count (WBC) of 27.6. There are additional test results on the laboratory report that are flagged as abnormal. The urinalysis is also marked as abnormal and containing white blood cells and bacteria. There is no documentation that the MPOA was informed of the testing results. When discussed with the Director of Nursing on 10/16/24 at 3:25 PM, she confirmed that the results were not reported to the MPOA due to the declining condition of the resident.

Based on observation, resident and staff interview, facility record review, and medical record review, the allegation that the facility failed to ensure that residents were free from abuse and neglect is found to be substantiated. This was true for Residents #16, #34, and #11. Facility census: 96. Findings included: a) Resident #16 On 10/16/2024 a review of the Facility Reported Incident (FRI) which occurred on 09/05/24 and found Resident #16 saturated with a ring of urine staining the bed linens, street clothes and shoes. The report specified that initially the resident was angered about the incident, but afterward placed the incident behind him and was doing better. The witness statement submitted by CNA #119 and undated read as follows: When I arrived on shift [Resident #16] was one of my first residents I checked on. I got him ready for bed, toileted him, offered to change his clothes. He didn't want to be layed down. I later returned with snacks and ice water and I got him a tea. I did regular rounds also, then around 3:30-4:00 AM, he rang was hungry so I got him and his room mate an ice cream. He also had leg pain (nurse alerted) also toileted. I then regularly checked on his pain every little bit making sure he was okay he also complained about urine burning (nurse also alerted) I pushed fluids and offered regular toileting. Certified Nursing Assistant (CNA) #119 was suspended pending investigation with a signed statement saying that discipline could include termination. In an interview at 2:15 PM 10/16/24 with the Director of Nursing (DON), stated that CNA #119 was suspended pending the investigation which was deemed unsubstantiated with unverified details. The facility did take immediate corrective action by changing the schedule of the CNA #119. She was terminated at a later date due to another incident with another resident, not as a result of the incident involving Resident #16. Review of the report provided to Adult Protective Services (APS) indicated that additional notifications were sent to the Ombudsman, facility administration, Office of Health Facilities and Certification (OHFLAC) by the Social Services Director. It indicates that while the resident retains capacity with a Brief Interview for Mental Status (BIMS) of 15, that they are unable to care for or protect themselves due to physical disability and chronic illness (needing advanced assistance with activities of daily living) but was not at immediate risk of serious injury or death or is in an emergency situation as defined by W.Va. Code Subsection 9-6-1. An additional statement from the morning shift CNA #79 on 09/06/24 which read as follows: Went to get resident up and dressed for the day. When I pulled back the blankets he was still dressed in his clothes from the day before, shoes still on and completely saturated in urine. Resident stated last night was awful and he hadn't been touched all night long. The written, signed witness statement from Resident #19 taken on 09/06/24 read as follows concerning the event of 09/05/24: Last night was bad. Staff would not answer call light or would stand and not assist me. Told me ' you don't need help'. Left in clothes and dirty briefs and would not change me. This was night shift and it was a girl with ponytails; brown hair; skinny; around 5 ' 1. I asked for help getting up. I hated last night . I was so upset. Review of the resident's orders confirmed that Resident #16 required advanced assistance with their Activities of Daily Living (ADL)s. The care plan specifically stated: Toileting hygiene: Totally dependent of 1. 1 Helper does all the effort. Resident does none of the effort Date Initiated: 05/04/24. b) Resident #34 On 10/17/24 review of a FRI dated 04/22/24 and reported to Administration on 04/23/24 involved CNA #121 witnessing CNA #120 behaving inappropriately toward Resident #34 to bed. CNA #120 called Resident #34 a child molester, and as he was grinding his teeth told him she'd smack him in the mouth if he didn't stop. Neither CNA works at the facility any longer. Resident #34 lacks capacity and is mostly nonverbal. Surveyor attempted to contact the resident representative but received no return call on 10/17/2024 at 10:00 AM. Per resident Minimum Data Set (MDS) he is dependent on facility staff for maximal assistance with all ADL's and all other activities. The resident care plan indicates that he had a hearing impairment, communication deficit, impaired cognitive functioning, and depression for which he receives antidepressant medication and is monitored for side-effects. The surveyor observed the resident in the hallway ambulating and people-watching on 05/17/24. The surveyor complimented the resident's choice in outfit for the day, at which time the resident smiled warmly and continued actively watching other residents and staff in the corridor. The surveyor observed that there were no behaviors indicating distress as a result of this incident as the resident was nonverbal, but friendly and responsive to interaction. Immediate action taken by facility administration was to suspend CNA #120 pending investigation. They reported the incident to OHFLAC, the facility Ombudsman, and the CNA Registry. The facility Employee Corrective Action form states that there would be disciplinary action up to and including termination. This form was signed by facility administration and the alleged perpetrating party on 04/23/24. All staff were interviewed and none reported having heard or participated in inappropriate conduct toward residents except for CNA #121. The written witness statement (signed/dated 04/23/24) from CNA #121 read as follows: We were putting [Resident #34] to sleep and the aid [CNA #120] called him a child molester and as he was grinding his teeth she said if he didn't stop she was going to smack him in his mouth . Resident #11 told me that [CNA #120] put a pillow over her face and said 'pillow therapy' but [Resident #11] doesn't know if she was joking or not. The surveyor interviewed the DON at approximately 10:30 AM on 10/17/24, who expressed that immediately upon discovery of the second allegation of the abusive treatment of Resident #11, the facility administration opened a second investigation. She stated that CNA #120 had not returned onsite between the time of the initial suspension for the events surrounding Resident #34 and the discovery of the events surrounding Resident #11. She provided the employee dismissal paperwork which confirmed that both events were corroborated serving as basis for CNA #120's employment termination (at the conclusion of the concurrent investigations) as of 04/24/24. c) Resident #11 Upon reviewing the witness statement of CNA #121 alleging abuse of Resident #34 the surveyor took note of and initiated investigation into the allegation of abusive rhetoric by CNA #120 against Resident #11. The written witness statement (signed/dated 04/23/24) from CNA #121 read as follows: We were putting [Resident #34] to sleep and the aid [CNA #120] called him a child molester and as he was grinding his teeth she said if he didn't stop she was going to smack him in his mouth . Resident #11 told me that [CNA #120] put a pillow over her face and said 'pillow therapy' but [Resident #11] doesn't know if she was joking or not. A second witness testimony from CNA #75 on 04/23/24 read as follows: (name redacted) told me that [CNA #120] put a pillow on her head and said 'pillow therapy'! She said she thought [CNA #120] was joking. Resident #11 has capacity as of 06/14/24, with a BIMS of 15. She is bedridden, and upon review of her care plan, 10/07/24 she began receiving hospice services. Per the resident's MDS, she is completely dependent on facility staff for maximal assistance with all ADL's and/or any other activities as a result of the resident's decline in health. Review of the facility investigation record revealed that they had reported the allegation of misconduct upon discovery to OHFLAC, Ombudsman, APS (414443), and the CNA registry on 04/23/24 after the interview with CNA #121 revealed additional inappropriate behavior toward Resident #11. The form included the added detail under the section pertaining to interview with the perpetrator that [CNA #120] says she's not the only one who jokes about pillow therapy. Two (2) surveyors went to interview Resident #11 who stated that she had a close rapport with CNA #120 during her employment at the facility. She stated that the CNA was being jovial when stating that they should try pillow therapy as a result of the resident having been complaining about the uncomfortable state of her declining condition. She stated that the pillow did not make contact with her head, but that Resident #11 had been complaining about the state of her condition and that was the direct response in jest from CNA #120. The resident tried to reassure the surveyors that she still had her voice and more importantly her head and that she would make it known if she felt threatened or disturbed in any way by staff. The surveyor interviewed the DON, who expressed that immediately upon discovery of the second allegation of the abusive treatment of resident #11, the facility administration opened a second investigation. She stated that CNA #120 had not returned onsite between the time of the initial suspension for the events surrounding resident #34 and the discovery of the events surrounding resident #11. She provided the employee dismissal paperwork which confirmed that both events were corroborated serving as basis for CNA #120's employment termination (at the conclusion of the concurrent investigations) as of 04/24/24. Review of the facility's Employee Separation Report (completed within 24 hours of termination) provides a secondary confirmation that CNA #120 did not return to the facility between the initiation of her suspension, pending investigation into resident #16 ' s allegation of abuse, and the conclusion of the investigations into resident #34 and resident #11 abuse allegations. These were both found to be substantiated, and the repercussion entailed the immediate termination of employment of CNA #120.

Based on record review, resident interview and staff interview, the facility failed to develop a person-centered comprehensive care plan for Resident #80 regarding the use of hearing aids, and not having careplaned Resident #294 having fistula in left arm. This is true for one (1) of 24 residents reviewed during the survey process. Resident identifier: #294. Facility Census: 96 Findings included: a) Resident #294 On 10/14/24 at 12:00 PM surveyor observed a sign posted being Resident #294's bed stating no blood pressure(B/P) or labs in left arm) During record review on 10/15/24 at approximately 10:00 AM of Resident #294's orders showed an order to check fistula in left arm for bruit and thrill every shift. Further record review on 10/15/24 revealed the following: - Facility staff documented on 10/04/24, 10/05/24, and 10/12/24 B/P was obtained in Resident #294's left arm. - The care plan did not address or contain anything about not taking the blood pressure or labs in the left arm, and did not identify residents having a fistula in the left arm. An interview on 10/15/24 at approximately 1:00 PM with the Director of Nursing (DON) confirmed the care plan did not address residents having an fistula in the left arm and there was nothing in the medical record stating not to take B/P or obtain labs from the left arm. DON also states the B/P's obtained were not taken in Resident#294's left arm, the staff had incorrectly documented the B/P being taken in the left arm. On 10/15/24 at 2:05 PM Resident #294 states they have had the fistula in their arm for approximately 7 years, and does not recall ever having a B/P taken in that arm while in the facility. 45173

Based on record review and staff interview, the facility failed complete a change of condition for a declining resident and caused a delay in treatment for a resident. Resident Identifiers: #50 and #145. Facility Census: #96. Findings included: a) Resident # 50 On 10/14/24 at 2:16 PM record review shows Resident #50 had several orders and progress notes dated 10/05/24 concerning her condition. The following details were reviewed in the nurses progress notes: 10/5/2024 18:24 Nurses Note Note Text: Resident decline in ability to consume Po intake. Resident is gagging with the touch of food in her mouth. This nurse contacted (in house physician). He gave recommendations for care and resident Medical Power of Attorney (MPOA) declined further testing. MPOA stated I do not feel like anything is wrong, I think she is just tired. This nurse talked to MPOA about the use of morphine and educated MPOA on comfort focused treatment. MPOA changed resident post form to DNR-CC. MPOA in agreement with new order and is sitting at resident bedside. 10/5/2024 17:58 Nurses Note Note Text: New order per (in house physician) to discontinue PO medications. Start resident on Morphine sulfate 0.25 ml q1h PRN for pain, distress and/or air hunger. MPOA in agreement with new orders. Record review shows there was no change in condition completed in regards to the changes referred to in the above nurses progress notes. On 10/16/24 at 12:08 PM the Director of Nursing (DON) confirmed that a change of condition should have been completed for the following items in the nurses progress notes 1. Changed POST to DNR comfort care 2. Started morphine 3. Physician order to discontinue all PO medications 4. Resident decline in ability to consume PO intake. b) Resident #145 On 10/17/24 at 10:56 AM record review shows that the family of Resident #145 voice concern on 12/12/23 about the resident not responding to their questions. Time line of documentation; 12/12/23 at 10:50 AM Family voiced concern about resident not responding to there questions. 12/14/23 at 111:17 AM there was a wound care note documented. There were no additional in house progress notes documented until 12/17/23 at 5:39 PM COVID Binaz Negative 12/24/23 at 8:50 PM Spoke with Hospice triage nurse they will send someone out to evaluate resident 12/24/23 at 8:54 PM documentation reads that resident was COVID negative. 12/24/23 8:41 PM reduced mental alertness and not speaking. PT vital signs taken, temp found. Lungs clear and diminished. Urine does not smell offensive. Pt unable to tell me what is wrong. Call placed to family and hospice. Temperature documented in vital signs on 12/24/23 at 8:55 PM as 101.5 Fahrenheit (F). Additional temperatures documented in vital signs were: 12/24/23 at 10:58 PM 102 F 12/26/23 at 10:29 PM 100.5 F 12/27/23 at 9:39 PM 101. F 12/28/23 at 6:11 AM 102.4 F 12/27/23 at 5:48 PM received an order for a two (2) view chest X-ray. Results on 12/27/23 at 11:38 PM shows No acute cardiopulmonary disease:. 12/28/23 at 4:38 AM Nurse called Hospice nurse to relay request from family for laboratory work. 12/28/23 at 10:08 AM Elevated temps noted. New order for Tylenol via mouth/suppository if unable to swallow. Note: Documentation shows resident has had a temperature for four (4) days, this is the first order for Tylenol. 12/28/23 at 3:51 PM New order from Hospice for U/A and C&S (urinalysis and culture and sensitivity) via straight catheterization and CBC (complete blood count) with differential to be drawn on 12/28/23 night shift. 12/29/23 at 3:02 AM blood sample obtained from residents left anti-cubical with one attempt. 12/29/23 at 3:37 AM urine sample obtained via straight catheter with one attempt. 12/30/23 at 6:48 PM Resident bed rested this shift family at beside with her all shift. Resident displays signs of pain and anxiousness several times this shift. Grimacing and whimpering. Scheduled Ativan and Morphine given with positive results. Resident did void X 2. Oral care also completed this shift. Family with resident at this time. Oxygen on re-breather, oxygen saturation above 92%, head of bed elevated with no signs or symptoms of shortness of breath voiced no notes. 12/31/23 3:32 AM Absence of vital signs verified by 2 nurses (names inserted). No respiration or heartbeat noted. Pupils fixed ad dilated. Family at bedside is aware. Director of Nursing notified. Physician called. Also Hospice has been notified. Further documentation shows Resident #145 has a history of urinary tract infections (UTI) while she was a resident at the facility. 1/17/19 Amoxicillin tablet 500 milligrams (mg) Give 500 mg by mouth two times a day for UTI for 7 days. 12/02/20 Macrobid Capsule 100 mg Give 100 mg by mouth two times a day for UTI for 7 days. 11/05/21 Ciproflaxacin HCL tablet 250 mg Give 1 tablet by mouth every 12 hours for infection for 3 days 3/15/23 Cephalexin Suspension Reconstituted 250 mg/5 milliliters Give 10 ml by mouth four times a day for UTI for 7 days 03/17/23 Ceftriaxone Sodium Injection Solution Reconstituted 1 GM (Ceftriaxone Sodium) Inject 1 gram intramuscularly one time a day for UTI for 3 Days There was evidence of the complete blood count (CBC) and UA and C&S laboratory work that was obtained on 12/29/23 and printed on 12/30/23 at 12:39 PM with abnormal results as follows: Urinalysis showed elevated WBC's as well as bacteria in the urine sample WBC (white blood count) elevated at 27.600. Resident #145 had been a Hospice resident in November 2023 but was discontinued and re-consulted on 12/24/23. Hospice notes were reviewed for 12/12/23 through 12/28/23 as provided by the facility. On 10/17/24 at 12:01 PM the above was confirmed with the DON. When presented and ask why the Tylenol was never addressed with the Resident's first temperature on 12/24/23 at 102 F and why a urinalysis with a culture and sensitivity was never obtained until 12/29/23 she stated she did not know. A delay in treatment was discussed and there was no further information provided prior to exiting the survey.