Based on record review and staff interviews, it was determined that the facility failed to ensure that staff were offered and educated about the COVID-19 vaccine. This was evident for four of five employee health files reviewed during the Infection Control task.Findings include:On 8/01/2025 at 1:59 PM, the surveyor reviewed staff immunization records and found that Staff #1, #5, #6, and the Director of Nursing (DON) were not offered or educated about the COVID-19 vaccine or most recent booster for 2024-2025.On 8/01/2025 at 2:31 PM, the surveyor interviewed the Nursing Home Administrator (NHA), who also serves as the facility DON. When asked whether staff were offered and educated about the COVID-19 vaccine or informed that it is an annual requirement, the NHA stated she was unaware of the requirement and confirmed that staff were neither educated nor offered the vaccine or booster. She advised the surveyor to confirm the process with the facility's Infection Preventionist Nurse (IPN #3).On 8/04/2025 at 1:20 PM, the surveyor interviewed IPN #3, who stated she was not aware that offering or educating staff about the COVID-19 vaccine and booster was a requirement. She further confirmed that the facility had not been offering or educating staff on the vaccine.On 8/04/2025 at 1:57 PM, the surveyor interviewed Staff #7, who is responsible for employee health. Staff #7 stated she was also unaware of the requirement to offer and educate staff regarding the COVID-19 vaccine and booster. She stated that the facility would adopt this process moving forward.On 8/05/2025 at 8:52 AM, the surveyor reviewed the facility's policy and procedure titled Employee Health Immunization Program (Policy V.032S, effective/reviewed on 6/20/2025), which stated in part: In accordance with WVUHS's (West Virginia University Health System) duty to provide and maintain a workplace that is free of known hazards, and consistent with guidance from CDC (Centers for Disease Control and Prevention) and other organizations, WVUHS adopts this policy to help safeguard the health of its Healthcare Workers (HCWs), their families, patients, clients, visitors, and the community at large from infectious diseases that may be reduced by vaccinations.Under General Guidelines:6.) COVID-19a) Vaccinate with 1 dose of an updated COVID-19 vaccine if HCW not up to date, and in accordance with current guidelines.

Based on observations and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: An initial tour of the facility's kitchen was conducted on 7/30/2025 at 9:53 AM with staff #9, the Director of Nutrition.Observation of the facility's walk-in coolers revealed the following:-An opened and almost finished buttermilk ranch dressing with a label dated 12/10/24. Staff stated that they received it on 12/10/24, but it should have been dated with an open and expiration date.-A Dusseldorf Mustard with a date on the container, 6/5/25. Staff #9 stated that the date on the container indicated when they received it, but it should have been labelled with an open and use-by date.-Banana pudding mix dated 7/28/25. Staff #9 stated that it was the preparation date and noted that it should have been labelled with a use-by date.-Chocolate pudding mix with a preparation date of 7/28/25, but had no use-by date.-Sour cream in a bowl lacked a use-by date.-Bagged provolone cheese, dated 7/29/25. Staff #9 stated that the date indicated was the preparation date; however, it lacked a use-by date.Further observation of the facility's walk-in freezer revealed an open bag of sausage links and an open bag of chicken tenders, both of which were missing their use-by dates.An interview later that day with staff #9 revealed that the facility's food labeling system had run out of labels. So, they had called the company, and it was on backorder. However, they had to use improvised labels, and their staff were inconsistent with their interim labeling process.

Based on record reviews and interviews, it was determined that the facility failed to 1). document the route of oxygen delivery each time a patient's oxygen saturation was documented. This was evident for 3 out of 3 residents (Resident #163, Resident #159, Resident #162) reviewed for Respiratory care and 2). failed to have hospice documentation in the medical recored. This was evident for 1 resident (Resident # 209) reviewed during an annual survey.The findings include: 1). On 3/16/23 at 8:37 AM, a review of medical records revealed that Resident #159 was admitted to the subacute unit on 3/6/23 for rehabilitation. Further review revealed a physician's order, dated 3/6/23, for the resident to receive oxygen 2 liters via nasal cannula when sleeping, and during the day when needed, to maintain an oxygen saturation level of 89%. A nasal cannula is a device designed to deliver oxygen directly to a patient's nose via a plastic tube that is tucked behind the ears and has two small soft flanges that aim for oxygen into the nostrils. Pulse oximetry is a technique of measuring the amount of oxygen in a patient's bloodstream (specifically peripheral capillary oxygen saturation, or 'SpO2') via a small device that is placed on the person's fingernail. The SpO2 measurement is given as a percentage. On 03/16/23 at 07:56 AM, a review of the vital signs that were recorded for Resident # 159 from 3/6/23 through 3/16/23 revealed that the pulse oximetry oxygen saturation was documented on the following dates and times: 3/6/23 at 21:30, 3/7/23 at 4:41 PM, 3/8/23 at 4:04, 3/9/23 at 4:11/23, 3/10/23 at 6:22 AM, 3/11/23 at 5:30 AM, 3/11/23 at 3:00 PM, Further review of the vital sign documentation for the above dates failed to reveal the route of oxygen delivery. On 03/16/23 at 08:27 AM, a review of medical records revealed that Resident # 169 was admitted to the subacute unit for rehabilitation on 3/8/23. Further review revealed a physician's order, dated 3/8/23, for the resident to be administered oxygen at 2/L via nasal cannula in order to maintain oxygen saturation rates above 89%. On 3/16/23 at 9:30 AM, a review of vital signs for Resident #169 from 3/11/23 through 3/15/23 revealed that the oxygen saturation was documented on the following dates and times: 3/11/23 at 3:00 PM, 3/12/23 at 7:08 PM., 3/13/23 at 3:59 PM, 3/14/23 at 3:45 PM, and 3/15/23 at 4:51 PM. Further review of the vital sign documentation for the above dates failed to reveal the route of oxygen delivery. On 03/16/23 at 09:12 AM, review of medical records revealed Resident # 162, was admitted to the subacute unit for rehabilitation on 3/10/23. Further review revealed a physician's orders for the resident to receive oxygen at a rate of 2/L nasal cannula to maintain oxygen saturation levels above 89 %. On 03/16/23 at 10:37 AM, a review of Resident #162's vital signs from 3/10/23 through 3/15/23 revealed that oxygen saturation was documented on the following dates and times: 3/10/23 at 4:00 PM. 3/11/23 at 3:00 PM, 3/13/23 at 3:59 PM, 3/14/23 at 5:30 AM, 3/15/23 at 5:30 AM. Further review of the vital sign documentation for the above dates failed to reveal the route of oxygen delivered. The Director of Nursing (DON) was interviewed on 03/16/23 at 08:07 AM. During the interview, she reported that the nurses are expected to document the route of oxygen administration, if the resident was receiving additional oxygen, and how much additional oxygen the resident was receiving every time the oxygen saturation level is documented. In addition, the DON reported that the subacute unit followed the Lippincott procedures guide for the administration of oxygen. On 3/16/23, a review of the Lippincott procedures Guide for the administration of oxygen revealed that documentation associated with oxygen administration should includes the type of delivery device( route). 2) On 3/14/23 at 1:00 PM, Resident #209's medical record was reviewed. A 3/7/23 documented history and physical from Resident #209's attending physician revealed that Resident #209 was transferred from acute care to the subacute unit for hospice care on 03/06/23. Further review of Resident #209's medical record failed to reveal documentation of the care provided from the contracted company that was providing hospice services. On 3/14/23 at 1:30 PM, an interview was conducted with RN #4 and the Director of Nursing (DON) about what communication was in place between the subacute unit's staff and the hospice staff. RN #4 stated that hospice staff wouild meet with the subacute's unit staff after their encounter with the resident and verbally shared what they did, and would give any updates related to the resident's care. RN #4 stated that hospice had been in to care for the resident since the resident's admission. The surveyor informed RN #4 and the DON that the hospice notes were not found in the medical record. The DON stated that hospice staff documented the information in their own medical record system and that they shared a care plan, however, the hospice notes were not kept in Resident #209's medical record. On 3/16/23 at 9:28 AM, a second interview was conducted with the DON regarding the hospice notes. The DON confirmed the hospice notes should have been filed in the resident's medical record.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 2 (#2, #4) of 5 residents reviewed for unnecessary medications. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. The findings include: 1) Review of the medical record for Resident #2 on 12/13/18 revealed a physician's history and physical, dated 11/5/18, which documented the assessment diagnoses of subarachnoid bleed, subdural hematoma, NSTEMI (non-ST elevated myocardial infarction), multiple myeloma (in relapse), renal disease, bladder cancer and pulmonary hypertension. Review of the MDS assessment with an assessment reference date (ARD) of 11/14/18 and 11/21/18, Section I, diagnosis, failed to capture the diagnoses. Discussed with the Director of Nursing (DON) on 12/13/18 at 12:04 PM. 2) Review of the medical record for Resident #4 on 12/13/18 revealed a physician's history and physical, dated 11/22/18, which documented the assessment diagnoses of depression in which the resident took the antidepressant Citalopram, anemia in which the resident took Ferrous Gluconate twice per day, chronic kidney disease, protein-calorie malnutrition and cellulitis of the scrotum. Review of the MDS with an ARD of 12/4/18, Section I, diagnosis, failed to capture the diagnoses. Discussed with the DON on 12/13/18 at 12:44 PM.

Based on medical record review, staff interview, and observation, it was determined the facility failed to develop comprehensive person-centered care plans with measurable goals. This was evident for 2 (#4, #5) of 5 residents reviewed for unnecessary medications. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) Review of the medical record for Resident #5 on 12/13/18 revealed the resident was admitted to the unit 11/20/18 with an order for the anticoagulant Eliquis. On 11/25/18, the resident was started on another anticoagulant medication, Coumadin. The resident took the Coumadin from 11/25/18 to 12/12/18. Review of care plans for Resident #5 failed to produce a care plan for the anticoagulant with specific interventions and measurable goals. Further review of the medical record revealed that Resident #5 took the pain medications Hydrocodone bitart/acetaminophen (lortab 5/325) 3 times per day when needed for pain and Tylenol 650 mg. every 4 hours when needed for pain. Observation was made on 12/13/18 during medication administration of Resident #5 receiving medication. The nurse asked the resident if he/she had any pain and the resident replied he/she had pain on a scale of 6-8. The nurse gave the resident Lortab for the pain. Review of care plans for Resident #5 revealed a care plan for pain, however, the goal was not measurable. Reviewed with the Director of Nursing on 12/13/18 at 9:57 AM. 2) Review of the medical record for Resident #4 on 12/13/18 revealed a physician's history and physical note, dated 11/22/18, which documented that the resident had uncontrolled Type 2 diabetes with complications. Review of Resident #4's December 2018 physician orders revealed diabetic medication orders for 17 units of Levemir Insulin every evening, 7 units of Novolog insulin 3 times per day with food and Metformin 1,000 mg every day. Review of care plans created for Resident #4 failed to produce a specific, resident centered care plan for diabetes that had resident centered, measurable goals. This was discussed with the Director of Nursing on 12/13/18 at 12:44 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined the facility failed to develop an individualized discharge plan/care plan for a resident admitted to the facility for short term rehabilitation. This was evident for 1 (#7) of 1 resident reviewed for discharge. The findings include: Review of the medical record for Resident #7 on 12/12/18 revealed documentation that the resident was admitted on [DATE] and discharged on 9/14/18. Review of Resident #7's care plans failed to produce a care plan for discharge planning which would have identified the resident's person-centered discharge goals. Discussed with the Director of Nursing on 12/12/18 at 4:20 PM who confirmed the finding.

Based on observation and interview with staff,, it was determined that the facility staff failed to date and label food items. The findings include: Observation was made, on 12/13/18 8:05 AM, during a tour of kitchen with the Dietary Manager of the first walk-in refrigerator. Observation was made of a storage rack with 2 trays of pie/cheesecake. The tray on the top shelf had 10 slices of pie/cheesecake and the second shelf had a tray with 12 slices of pie/cheesecake. The slices were wrapped in saran wrap, however, the items were not labeled or dated. The Dietary Manager confirmed the findings.

Based on observation and staff interview it was determined the facility failed to keep the walk-in freezer in the kitchen in safe operating condition. This was evident during the initial tour of the kitchen. The findings include: On 12/13/18 at 8:05 AM, during a tour of the kitchen with the Dietary Manager, observation was made of the walk-in freezer. There were ice formations on the ceiling in the freezer and under the 2 compressor fans. There was ice build-up on a bag of green beans and a box of cheese tortellini. There was a 2-inch-tall ice mound on top of a box of food which was located on the top shelf under the compressor fans. The Dietary Manager stated, we had that problem back in the summer and it is occurring again. I will have to call maintenance.