How many inspection deficiencies does MAPLEWOOD HEALTHCARE CENTER have?

MAPLEWOOD HEALTHCARE CENTER has 40 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at MAPLEWOOD HEALTHCARE CENTER?

MAPLEWOOD HEALTHCARE CENTER has a two-star staffing rating from CMS with 0.55 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MAPLEWOOD HEALTHCARE CENTER located?

MAPLEWOOD HEALTHCARE CENTER is located in BRIDGEPORT, WV. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MAPLEWOOD HEALTHCARE CENTER have?

MAPLEWOOD HEALTHCARE CENTER has 77 certified beds.

Who owns MAPLEWOOD HEALTHCARE CENTER?

MAPLEWOOD HEALTHCARE CENTER is a for profit - corporation facility and is part of the COMMUNICARE HEALTH chain.

How does MAPLEWOOD HEALTHCARE CENTER compare to other nursing homes?

MAPLEWOOD HEALTHCARE CENTER has a 2-star overall rating, which is below average compared to other nursing homes in WV. Families should carefully review inspection findings and consider alternatives.

MAPLEWOOD HEALTHCARE CENTER

Name: MAPLEWOOD HEALTHCARE CENTER
Address: 1081 MAPLEWOOD DRIVE, BRIDGEPORT, WV, 26330, US
Telephone: (304) 842-4135
Rating: 2.0

1081 MAPLEWOOD DRIVE, BRIDGEPORT, WV 26330 · (304) 842-4135

For profit - Corporation 77 Beds COMMUNICARE HEALTH Data: November 2025

Trust Grade

38/100

#73 of 122 in WV

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MAPLEWOOD HEALTHCARE CENTER nursing home in BRIDGEPORT, WV - Photo 1 of 4

MAPLEWOOD HEALTHCARE CENTER nursing home in BRIDGEPORT, WV - Photo 2 of 4

Photo by Maplewood Healthcare Center

Last Inspection: March 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Maplewood Healthcare Center has received a Trust Grade of F, indicating significant concerns and a poor overall performance. It ranks #73 out of 122 facilities in West Virginia, placing it in the bottom half, and #4 out of 6 in Harrison County, meaning only two local options are better. Although the facility is improving, with issues decreasing from 13 in 2024 to 8 in 2025, it still has a high staffing turnover rate of 55%, which is above the state average of 44%. The center has faced some serious shortcomings, including failing to ensure medications were available for residents, leading to a seizure incident for one resident, and not having a qualified professional assess residents' activity needs. While it does have average RN coverage, the facility's overall rating is below average in most categories, raising concerns about the quality of care provided.

Trust Score: F
In West Virginia: #73/122
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $7,443 in fines. Higher than 91% of West Virginia facilities. Major compliance failures.
Skilled Nurses: Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for West Virginia. RNs are the most trained staff who monitor for health changes.
Violations: 40 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 13 issues

2025: 8 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below West Virginia average (2.7)

Below average - review inspection findings carefully

Staff Turnover: 55%

Near West Virginia avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $7,443

Below median ($33,413)

Minor penalties assessed

Chain: COMMUNICARE HEALTH

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (55%)

7 points above West Virginia average of 48%

The Ugly 40 deficiencies on record

1 actual harm

May 2025 8 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview the facility failed to ensure the resident and/or resident representative were afforded the right to participate in the care planning process with all required members of the interdisciplinary team. This was true for two (2) of two (2) sampled residents reviewed during a complaint survey. Resident Identifiers: #6 and #75. Facility Census: 74. Findings Include: a) State Agency Complaint The state agency received a complaint on 11/18/24 which indicated the following: The complainant was contacted by the facility's Social Worker about a care plan meeting for her mom. She said that the social worker normally only contacts her the day before or the day of the meeting but on this occasion, she did contact her a few days prior. This was helpful because she wanted to review her mom's care plan prior to the meeting. The complainant stated the social worker was the only staff member present on the care plan meeting that was held on the phone. She said she knew there was no interdisciplinary team there when this was going on. b) Facility's Process for Care Plan Meetings A review of the facility's process for Care Plan Meetings found the following: .5. The following team members will be present during the care plan meeting: A clinical representative, Dietary, Social Services, Activities, and therapy . 12. A care plan note must be created at the time of the meeting to include the brief discussion of the meeting, concerns, follow up etc. This note should include a list of all who attended the meeting, both from the resident/ representative and facility staff. The note can be found in PCC under progress notes. c) Resident #75 A review of Resident #75's medical record found she had the following care plan meetings with the following attendees: -- 07/25/24 Attendees: Social Services and Activities -- 10/24/24 Attendees: Social Services, Activities and Responsible Party. -- 01/23/25 Attendees: Social services and Responsible party. d) Resident #6 A review of Resident #6's medical record found the resident had the following care plan meetings with the following attendees: -- 05/16/24 Attendees Social Services and activities. -- 06/27/24 Attendees: Social Services and Activities -- 08/15/24 Attendees: Social Services and Activities. -- 11/14/24 Attendees Social Services and Responsible party. -- 02/13/25 Attendees: Social Services, Activities and Son -- 02/20/25 Attendees: Social Services and Activities e) Staff Interviews An interview with the Nursing Home Administrator on the afternoon of 05/08/25 confirmed the IDT team was not participating in the care plan meetings. She indicated the social worker was in charge of scheduling and coordinating the meetings and she did not realize they were not participating like they should. The Director of Nursing (DON) also present during the interview stated she would send a floor nurse to the meetings to represent nursing because they would know the resident the best and have the best input. Both agreed the only participating members were social services and activities who shared an office.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, record review and staff interview, the facility failed to maintain infection control standards Resident #53's urinary catheter. This was a random opportunity for discovery. Resident identifier: #53. Facility Census: 74. Findings include: a) Resident #53 On 05/07/25 at 3:24 PM, Resident #53's urinary catheter drainage bag was touching the floor. On 05/07/25 at 3:28 PM, Licensed Practical Nurse (LPN) #55 raised the resident's bed up to keep the urinary catheter drainage bag from touching the floor. On 05/07/25 at 3:35 PM, the Administrator was notified of the infection control breach. The Administrator stated, it should not be touching the floor. On 05/07/25 at 4:20 PM, the facility policy entitled, Catheter Care was reviewed. Section V under the heading of procedure states, Check that collection bag is not on the floor and is draining properly and secured allowing for no reflux of urine back to the bladder. (Typed as written.)

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement their abuse prohibition policy in regards to identifying and reporting all allegations of abuse and/or neglect. The facility failed report all allegations of abuse and or neglect to required agencies within the required time frames. This was a random opportunity for discovery and was true for 13 residents for a total of 15 allegations. Resident Identifiers; Resident #4, #50, #54, #16, #60, ##32, #33, #29, #73, #68, #76, #77, and #78. Facility Census: 74. Findings Include: a) Policy Review A review of the facility;s policy Titled: [NAME] Virginia Abuse, neglect, and Misappropriation Policy with an effective date of 10/17/24 found the following: .Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, visitors, and staff or others but has not yet been investigated and, if verified, could be noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source, and misappropriation of resident property VII. Reporting of incidents and Facility Response. 1. All alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported to the executive director immediately. 2. The executive director/designee will report appropriate incidents to OHFLAC< APS, The regional Ombudsman, and other local authorities including but not limited to local law enforcement iff appropriate, as required by state law. b) Grievance Forms review for the previous 12 months. A review of the facility's filed grievances for the previous 12 months on 05/07/25 found the following allegations of abuse and/or neglect contained on the grievance forms: -- 05/29/24 Resident # 4 grievance voiced during the resident council and read as follows:resident stated CNA (First Name of Nurse Aide (NA) #56) yelled at her for pushing her call bell resident states w/c is dirty. -- 06/24/24 Resident #76's family voiced this grievance to the DON , Hospice and Social Services and it read as follows: yesterday residents wife found him undressed from the waist down. His shirt had not been changed for several days. He had food from his tray and BM up his back. Also a staff member was going up the hall yesterday saying loudly quit ringing your bells. and residents and families could hear this. would like to have range of motion provided. -- 06/28/24 Resident #77's family reported this grievance to social services and it read as follows, Family came to see her Wednesday and she was dirty and in the dame hospital gown se had been in on Monday when she got here. Please be sure she has her cochlea implant in to talk with her. She is also known to lay it on bed and it could get lost, staff needs to make sure it is not in her bed if she isn't wearing it and it isn't in he charger. -- 07/06/24 Resident #54 grievance voiced by the residents family unsure who the grievance was reported too and read as follows: I would like to see if my mom's depend can be checked more often I have came everywhere day Thursday and Saturday and she was soaked through. -- 07/16/24 Resident #16 grievance voiced to the social worker and read as follows: timeliness of call bell response. they took her whistle away from her. She stated that she needed to go to the bathroom at 6:00 am a few days ago and staff came in and told her that they couldn't do it right now because they were passing breakfast trays. -- 08/06/24 Resident #54 grievance voiced by the residents family the concern was voiced to social services and read as follows, 'activities told social services followed up with the family who was visiting today. (First Name of Resident #54) daughter (First name of Resident #54's daughter) state (First Name of Resident #54) was so wet when she got here there was urine dripping down into her shoes. When Social service spoke with her she said she had already talked to the aide. -- 09/04/24 Resident #32 grievance voiced by family to social services which read as follows: Resident's daughter stated her mother told her that the CNA (First Name of NA #56) didn't change her sheet which was wet as the result of her using the bed pan. (First name of Nurse Aide #56) told her it wasn't wet and she didn't have time to change it. (First name of unidentified Staff) came in and said she would get someone to change her. She then stated (First name of two more staff members who no longer work at the facility) came in and put a thicker sheet over her wet sheet and that (First Name of Staff who no longer works at the facility) jerked her nightgown in the process. She said (First Name of Staff who no longer works at the facility) had told her mother a few das before she wasn't going to be caring for her anymore. She also said that (First Name of Staff) told her that [NAME] liked her. -- 09/28/24 Resident #60's family member voiced a concern to social services which read as follows: Expressed concern over mothers knee being bruised. They documented on the concern is was unknown how the injury occurred and the resolution was the NP (nurse practitioner) looked at her knee and confirmed it was healing. -- 10/08/24 Resident #78's family reported to nursing/social services the following grievance, daughter feels the stage 2 on (First Name of Resident #78)'S bottom is related to the staff leaving her up in her wheelchair last night to sleep because her bed had not been made. -- 10/28/24 Resident #33 voiced this grievance to social services and it read as follows: Resident came to social services and stated that another female resident was in her room and going through her belongings, when she told her to stop the other resident grabbed her neck and put her hand over (First Name of Resident #33) face. (First Name of Resident #33) said it did not cause her any pain or injury. -- 10/28/24 - Resident #29 reported the grievance to social services and it read as follows: Resident told the nurse, (First and Last Name of Registered Nurse #31) that there was a girl on night shift that came in and woke her up and startled her. She was tall with long blonde hair. She said she was husky not fat nor thin and tall like an amazon. She was rude and pulled her arm. -- 11/11/24 Resident #50 voiced to the social worker and read as follows: Resident does not like an evening CNA She would prefer not to have her care for her at night. Resident stated the CNA had previous lied about thing she said (First Name of Resident #50) had said to her. She stated the aide is loud and did not change her brief on several occasions. -- 01/21/25 Resident #73's family voiced this grievance to social services and it read as follows: Social Service was informed that the resident had a concern from over the weekend. When Social Service talked with her, (First name of Resident #73) expressed concern over how she felt an aide was rough with her when cleaning up a bowel movement midday on 01/19/25. She couldn't remember the staff members name. -- 04/01/25 Resident #68 reported the grievance to social services and it read as follows: 'They were outside my door at about 1:30 last night and they were being very ;loud. They were talking loudly and singing loudly. Yesterday (first Name of NA #56) got (first name of Resident #68's roommate) up to sit in the hall and go to the dining room. They didn't get her back to bed until 12:30 last night. (First Name of Nurse Aide no longer working at facility) put her back to bed and there was a girl with her in training. They also didn't change me till 5:00 am (Name of day shift aide #56) changed me before she left. -- 04/03/25 Resident #16 voiced by the residents family to to social services an read as follows: stated that the other night around shift change her mother was put on the toilet and the bathroom door was closed as well as the room door. No one came back for a half hour (First Name of Resident #16) was banging on the wall for assistance. A friends came to visit and found her in this situation and notified staff. A review of the facility's reportable log for the same time frame found none of the allegations noted above were on the log. An interview with the Nursing Home Administrator (NHA) on 05/07/25 at 6:02 PM confirmed if they were not on the log they were not reported. She stated she would double check and provide them had they been reported. The allegations were reviewed with the NHA and she agreed they needed to be reported. She assumed the social worker had done it.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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Based on record review and staff interview the facility failed to report all allegations and five (5) day follow up reports of abuse and or neglect to required agencies within the required time frames. This was a random opportunity for discovery and was true for 13 residents for a total of 16 allegations. Resident identifiers: #4, #50, #54, #16, #60, #32, #33, #29, #73, #68, #76, #77, and #78 Facility census: 74. Findings include: a) A review of the facility's filed grievances for the previous 12 months on 05/07/25 found the following allegations of abuse and/or neglect contained on the grievance forms: -- 05/29/24 Resident # 4 grievance voiced during the resident council and read as follows: resident stated CNA (First Name of Nurse Aide (NA) #56) yelled at her for pushing her call bell resident states w/c is dirty. -- 06/24/24 Resident #76's family voiced this grievance to the DON , Hospice and Social Services and it read as follows: yesterday residents wife found him undressed from the waist down. His shirt had not been changed for several days. He had food from his tray and BM up his back. Also a staff member was going up the hall yesterday saying loudly quit ringing your bells and residents and families could hear this. would like to have range of motion provided. -- 06/28/24 Resident #77's family reported this grievance to social services, and it read as follows, Family came to see her Wednesday and she was dirty and in the dame hospital gown se had been in on Monday when she got here. Please be sure she has her cochlea implant in to talk with her. She is also known to lay it on bed and it could get lost, staff needs to make sure it is not in her bed if she isn't wearing it and it isn't in he charger. -- 07/06/24 Resident #54 grievance voiced by the resident's family unsure who the grievance was reported too and read as follows: I would like to see if my mom's depend can be checked more often I have came everywhere day Thursday and Saturday and she was soaked through. -- 07/16/24 Resident #16 grievance voiced to the social worker and read as follows: timeliness of call bell response. they took her whistle away from her. She stated that she needed to go to the bathroom at 6:00 am a few days ago and staff came in and told her that they couldn't do it right now because they were passing breakfast trays. -- 08/06/24 Resident #54 grievance voiced by the resident's family the concern was voiced to social services and read as follows, 'activities told social services followed up with the family who was visiting today. (First Name of Resident #54) daughter (First name of Resident #54's daughter) state (First Name of Resident #54) was so wet when she got here there was urine dripping down into her shoes. When Social service spoke with her she said she had already talked to the aide. -- 09/04/24 Resident #32 grievance voiced by family to social services which read as follows: Resident's daughter stated her mother told her that the CNA (First Name of NA #56) didn't change her sheet which was wet as the result of her using the bed pan. (First name of Nurse Aide #56) told her it wasn't wet and she didn't have time to change it. (First name of unidentified Staff) came in and said she would get someone to change her. She then stated (First name of two more staff members who no longer work at the facility) came in and put a thicker sheet over her wet sheet and that (First Name of Staff who no longer works at the facility) jerked her nightgown in the process. She said (First Name of Staff who no longer works at the facility) had told her mother a few days before she wasn't going to be caring for her anymore. She also said that (First Name of Staff) told her that no one liked her. -- 09/28/24 Resident #60's family member voiced a concern to social services which read as follows: Expressed concern over mothers knee being bruised. They documented on the concern is was unknown how the injury occurred and the resolution was the NP (nurse practitioner) looked at her knee and confirmed it was healing. -- 10/08/24 Resident #78's family reported to nursing/social services the following grievance, daughter feels the stage 2 on (First Name of Resident #78)'S bottom is related to the staff leaving her up in her wheelchair last night to sleep because her bed had not been made. -- 10/28/24 Resident #33 voiced this grievance to social services, and it read as follows: Resident came to social services and stated that another female resident was in her room and going through her belongings, when she told her to stop the other resident grabbed her neck and put her hand over (First Name of Resident #33) face. (First Name of Resident #33) said it did not cause her any pain or injury. -- 10/28/24 - Resident #29 reported the grievance to social services and it read as follows: Resident told the nurse, (First and Last Name of Registered Nurse #31) that there was a girl on night shift that came in and woke her up and startled her. She was tall with long blonde hair. She said she was husky not fat nor thin and tall like an amazon. She was rude and pulled her arm. -- 11/11/24 Resident #50 voiced to the social worker and read as follows: Resident does not like an evening CNA She would prefer not to have her care for her at night. Resident stated the CNA had previous lied about thing she said (First Name of Resident #50) had said to her. She stated the aide is loud and did not change her brief on several occasions. -- 01/21/25 Resident #73's family voiced this grievance to social services and it read as follows: Social Service was informed that the resident had a concern from over the weekend. When Social Service talked with her, (First name of Resident #73) expressed concern over how she felt an aide was rough with her when cleaning up a bowel movement midday on 01/19/25. She couldn't remember the staff members name. -- 04/01/25 Resident #68 reported the grievance to social services, and it read as follows: 'They were outside my door at about 1:30 last night and they were being very ;loud. They were talking loudly and singing loudly. Yesterday (first Name of NA #56) got (first name of Resident #68's roommate) up to sit in the hall and go to the dining room. They didn't get her back to bed until 12:30 last night. (First Name of Nurse Aide no longer working at facility) put her back to bed and there was a girl with her in training. They also didn't change me till 5:00 am (Name of day shift aide #56) changed me before she left. -- 04/03/25 Resident #16 voiced by the resident's family to social services an read as follows: stated that the other night around shift change her mother was put on the toilet and the bathroom door was closed as well as the room door. No one came back for a half hour (First Name of Resident #16) was banging on the wall for assistance. A friends came to visit and found her in this situation and notified staff. A review of the facility's reportable log for the same time frame found none of the allegations noted above were on the log. An interview with the Nursing Home Administrator (NHA) on 05/07/25 at 6:02 PM confirmed if they were not on the log they were not reported. She stated she would double check and provide them had they been reported. The allegations were reviewed with the NHA, and she agreed they needed to be reported. She assumed the social worker had done it.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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Based on record review, resident interviews, and staff interviews, the facility failed to adequately deploy nursing staff across all shifts to properly care for residents and their safety. This was found to be true for 15 (fifteen) of 15 calendar days. Facility census: 74. Findings included: Nurse staffing postings review revealed the following: 11/02/24: Facility census: 74 LPN on night shift: 3 CNA on night shift: 2 CNA/resident ratio: 1:37 (one CNA for every 37 residents) 11/03/24: Facility census: 74 LPN on night shift: 4 CNA on night shift: 3 CNA/resident ratio: 1:25 11/07/24: Facility census: 73 LPN on night shift:3 CNA on night shift: 5 CNA/resident ratio: 1:11 11/09/24: Facility census: 74 LPN on night shift:3 CNA on night shift: 4 CNA/resident ratio: 1:18 11/10/24: Facility census: 74 LPN on night shift:2 CNA on night shift: 5 CNA/resident ratio: 1:15 12/25/24: Facility census: 74 LPN on night shift:2 CNA on night shift: 3 CNA/resident ratio: 1:25 12/31/24: Facility census: 75 LPN on night shift:2 CNA on night shift: 5 CNA/resident ratio: 1:15 2/26/25: Facility census: 76 LPN on night shift:3 CNA on night shift: 5 CNA/resident ratio: 1:15 03/08/25: Facility census: 76 LPN on night shift:3 CNA on night shift: 3 CNA/resident ratio: 1:25 03/09/25: Facility census: 76 LPN on night shift:3 CNA on night shift: 3 CNA/resident ratio: 1:25 03/25/25: Facility census: 77 LPN on night shift: 2 CNA on night shift: 3 CNA/resident ratio: 1:25 03/26/25: Facility census: 77 LPN on night shift:2 CNA on night shift: 5 CNA/resident ratio: 1:15 03/27/25: Facility census: 77 LPN on night shift: 4 CNA on night shift: 4 CNA/resident ratio: 1:19 04/02/25: Facility census: 76 LPN on night shift: 2 CNA on night shift: 3 CNA/resident ratio: 1:25 04/05/25 Facility census: 77 LPN on night shift: 2 CNA on night shift: 3 CNA/resident ratio: 1:25 A review of the current facility assessment, under the Section of staffing, states according to their acuity, 4-6 nurse aides are needed on night shift, along with 2-3 licensed nurses. During the morning of 05/07/25 during interviews with Resident #4, #50, and #38 these three residents complained of staffing shortages on night shifts and the long waits for responding to their call lights. During an interview NA #37 on 05/07/25 at approximately 9:50 PM, when asked after if she felt there was sufficient staffing on nights to properly care for residents, she responded, No, most nights we have 3 aides for all these residents, one in each wing. When asked if she was able to get all her tasks done before the end of shift, she stated no, unfortunately. When asked if she had any concerns that she wanted to share, she stated, I just feel this place is going downhill, several staff have left over the last few months. During an interview with LPN #38 on 05/07/25 at approximately 10:12 PM, she stated, I do not feel there is sufficient staff on nights. I frequently have to help the aides, and it is difficult for me to get all my documentation completed. Staffing information and time/attendance reports were reviewed with the NHA on 05/07/25 at 4:40 PM.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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Based on record review and staff interview, the facility failed to post nurse staffing with accurate information reflecting the actual hours worked, and total hours worked by category for nursing. This was true for 14 (fourteen) of 15 (fifteen) calendar days reviewed. The facility also failed to accurately reflect Facility census:75 Findings included: A) Record review 11/02/24: Nurse Staffing Report recorded a total of 191.50 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 221.88 hours worked for RNs, LPNs, and Certified Nurse Aides. 11/03/24: Nurse Staffing Report recorded a total of 337 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 227.5 hours worked for RNs, LPNs, and Certified Nurse Aides. 11/07/24: Nurse Staffing Report recorded a total of 240.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 260.5 hours worked for RNs, LPNs, and Certified Nurse Aides. 11/09/24: Nurse Staffing Report recorded a total of 307 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 244.75 hours worked for RNs, LPNs, and Certified Nurse Aides. 11/10/24: Nurse Staffing Report recorded a total of 283.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 240 hours worked for RNs, LPNs, and Certified Nurse Aides. 12/25/24: Nurse Staffing Report recorded a total of 249.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 222.5 hours worked for RNs, LPNs, and Certified Nurse Aides. 12/31/24: Nurse Staffing Report recorded a total of 298 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 220 hours worked for RNs, LPNs, and Certified Nurse Aides. 02/26/25: Nurse Staffing Report recorded a total of 191 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 220.75 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/08/25: Nurse Staffing Report recorded a total of 190.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 190.5 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/09/25: Nurse Staffing Report recorded a total of 187.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 209.25 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/25/25: Nurse Staffing Report recorded a total of 231 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 211.25 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/26/25: Nurse Staffing Report recorded a total of 218 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 255 hours worked for RNs, LPNs, and Certified Nurse Aides. 03/27/25: Nurse Staffing Report recorded a total of 242 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 249.25 hours worked for RNs, LPNs, and Certified Nurse Aides. 04/02/25: Nurse Staffing Report recorded a total of 177.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 192.75 hours worked for RNs, LPNs, and Certified Nurse Aides. 04/05/25: Nurse Staffing Report recorded a total of 199.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Time and attendance report records a total of 204.5 hours worked for RNs, LPNs, and Certified Nurse Aides. Additionally, an observation of the posted nursing staffing report on 05/07/25 reported 12 Certified Nurse Aides were supposed to be working evening shift (3:00 PM - 11:00 PM). An on-site visit at the facility on 05/07/25 at approximately 9:45 PM, revealed that were in actuality only 5 Certified Nursing Aides working that shift. B) Staff interview Staffing information and time/attendance reports were reviewed with the NHA on 05/07/25 at 4:40 PM. The NHA indicated a lack of awareness on how the data was accumulated and the lack o accuracy of the data.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure each resident received medically related social services. The facility failed to assist the residents in the assertion of their right related to being free from abuse and or neglect and comprehensive person-centered care planning. This was random opportunity for discovery and has the potential to affect more than a limited number of residents. Resident identifiers: #75, #6, #77, #4, #54, #16, #32, #60, #78, #33, #29, #50, #73, #68, and #16. Facility Census: 74. Findings include: a) A review of the SOM found medically related social services include Advocating for residents and assisting them in the assertion of their rights within the facility in accordance with §483.10, Resident Rights, §483.12, Freedom from Abuse, Neglect, and Exploitation, §483.15, Transitions of Care, §483.20, Resident Assessments (PASARR), and §483.21, Comprehensive Person-Centered Care Planning. b) Care Plan with Interdisciplinary Team 1) State Agency Complaint The state agency received a complaint on 11/18/24 which indicated the following: Complainant was contacted by the facility's Social Worker about a care plan meeting for her mom. She said that the social worker normally only contacts her the day before or the day of the meeting but on this occasion, she did contact her a few days prior. This was helpful because she wanted to review her mom's care plan prior to the meeting. The complainant stated the social worker was the only staff member present on the care plan meeting that was held on the phone. She said she knew there was no interdisciplinary team there when this was going on. 2) Facility's Process for Care Plan Meetings A review of the facility's process for Care Plan Meetings found the following: .5. The following team members will be present during the care plan meeting: A clinical representative, Dietary, Social Services, Activities, and therapy . 12. A care plan note must be created at the time of the meeting to include the brief discussion of the meeting, concerns, follow up etc. This note should include a list of all who attended the meeting, both from the resident/ representative and facility staff. The note can be found in PCC under progress notes. 3) Resident #75 A review of Resident #75's medical record found she had the following care plan meetings with the following attendees: -- 07/25/24 Attendees: Social Services and Activities -- 10/24/24 Attendees: Social Services, Activities and Responsible Party. -- 01/23/25 Attendees: Social services and Responsible party. 4) Resident #6 A review of Resident #6's medical record found the resident had the following care plan meetings with the following attendees: -- 05/16/24 Attendees Social Services and activities. -- 06/27/24 Attendees: Social Services and Activities -- 08/15/24 Attendees: Social Services and Activities. -- 11/14/24 Attendees Social Services and Responsible party. -- 02/13/25 Attendees: Social Services, Activities and Son -- 02/20/25 Attendees: Social Services and Activities 5) Staff Interviews An interview with the Nursing Home Administrator on the afternoon of 05/08/25 confirmed the IDT team was not participating in the care plan meetings. She indicated the social worker was in charge of scheduling and coordinating the meetings and she did not realize they were not participating like they should. The Director of Nursing (DON) also present during the interview stated she would send a floor nurse to the meetings to represent nursing because they would know the resident the best and have the best input. Both agreed the only participating members were social services and activities who shared an office. c) Abuse Reporting 1) Grievance Forms review for the previous 12 months. A review of the facility's filed grievances for the previous 12 months on 05/07/25 found the following allegations of abuse and/or neglect contained on the grievance forms: -- 05/29/24 Resident #4 grievance voiced during the resident council and read as follows: resident stated CNA (First Name of Nurse Aide (NA) #56) yelled at her for pushing her call bell resident states w/c is dirty. -- 06/24/24 Resident #76's family voiced this grievance to the DON , Hospice and Social Services and it read as follows: yesterday residents wife found him undressed from the waist down. His shirt had not been changed for several days. He had food from his tray and BM up his back. Also a staff member was going up the hall yesterday saying loudly quit ringing your bells. and residents and families could hear this. would like to have range of motion provided. -- 06/28/24 Resident #77's family reported this grievance to social services, and it read as follows, Family came to see her Wednesday and she was dirty and in the dame hospital gown se had been in on Monday when she got here. Please be sure she has her cochlea implant in to talk with her. She is also known to lay it on bed and it could get lost, staff needs to make sure it is not in her bed if she isn't wearing it, and it isn't in the charger. -- 07/06/24 Resident #54 grievance voiced by the resident's family unsure who the grievance was reported too and read as follows: I would like to see if my mom's depend can be checked more often I have came everywhere day Thursday and Saturday and she was soaked through. -- 07/16/24 Resident #16 grievance voiced to the social worker and read as follows: timeliness of call bell response. they took her whistle away from her. She stated that she needed to go to the bathroom at 6:00 am a few days ago and staff came in and told her that they couldn't do it right now because they were passing breakfast trays. -- 08/06/24 Resident #54 grievance voiced by the residents family the concern was voiced to social services and read as follows, 'activities told social services followed up with the family who was visiting today. (First Name of Resident #54) daughter (First name of Resident #54's daughter) state (First Name of Resident #54) was so wet when she got here there was urine dripping down into her shoes. When Social service spoke with her she said she had already talked to the aide. -- 09/04/24 Resident #32 grievance voiced by family to social services which read as follows: Resident's daughter stated her mother told her that the CNA (First Name of NA #56) didn't change her sheet which was wet as the result of her using the bed pan. (First name of Nurse Aide #56) told her it wasn't wet and she didn't have time to change it. (First name of unidentified Staff) came in and said she would get someone to change her. She then stated (First name of two more staff members who no longer work at the facility) came in and put a thicker sheet over her wet sheet and that (First Name of Staff who no longer works at the facility) jerked her nightgown in the process. She said (First Name of Staff who no longer works at the facility) had told her mother a few das before she wasn't going to be caring for her anymore. She also said that (First Name of Staff) told her that [NAME] liked her. -- 09/28/24 Resident #60's family member voiced a concern to social services which read as follows: Expressed concern over mothers knee being bruised. They documented on the concern is was unknown how the injury occurred and the resolution was the NP (nurse practitioner) looked at her knee and confirmed it was healing. -- 10/08/24 Resident #78's family reported to nursing/social services the following grievance, daughter feels the stage 2 on (First Name of Resident #78)'S bottom is related to the staff leaving her up in her wheelchair last night to sleep because her bed had not been made. -- 10/28/24 Resident #33 voiced this grievance to social services and it read as follows: Resident came to social services and stated that another female resident was in her room and going through her belongings, when she told her to stop the other resident grabbed her neck and put her hand over (First Name of Resident #33) face. (First Name of Resident #33) said it did not cause her any pain or injury. -- 10/28/24 - Resident #29 reported the grievance to social services and it read as follows: Resident told the nurse, (First and Last Name of Registered Nurse #31) that there was a girl on night shift that came in and woke her up and startled her. She was tall with long blonde hair. She said she was husky not fat nor thin and tall like an amazon. She was rude and pulled her arm. -- 11/11/24 Resident #50 voiced to the social worker and read as follows: Resident does not like an evening CNA She would prefer not to have her care for her at night. Resident stated the CNA had previous lied about thing she said (First Name of Resident #50) had said to her. She stated the aide is loud and did not change her brief on several occasions. -- 01/21/25 Resident #73's family voiced this grievance to social services and it read as follows: Social Service was informed that the resident had a concern from over the weekend. When Social Service talked with her, (First name of Resident #73) expressed concern over how she felt an aide was rough with her when cleaning up a bowel movement midday on 01/19/25. She couldn't remember the staff members name. -- 04/01/25 Resident #68 reported the grievance to social services and it read as follows: 'They were outside my door at about 1:30 last night and they were being very ;loud. They were talking loudly and singing loudly. Yesterday (first Name of NA #56) got (first name of Resident #68's roommate) up to sit in the hall and go to the dining room. They didn't get her back to bed until 12:30 last night. (First Name of Nurse Aide no longer working at facility) put her back to bed and there was a girl with her in training. They also didn't change me till 5:00 am (Name of day shift aide #56) changed me before she left. -- 04/03/25 Resident #16 voiced by the resident's family to social services an read as follows: stated that the other night around shift change her mother was put on the toilet and the bathroom door was closed as well as the room door. No one came back for a half hour (First Name of Resident #16) was banging on the wall for assistance. A friends came to visit and found her in this situation and notified staff. A review of the facility's reportable log for the same time frame found none of the allegations noted above were on the log. An interview with the Nursing Home Administrator (NHA) on 05/07/25 at 6:02 PM confirmed if they were not on the log they were not reported. She stated she would double check and provide them had they been reported. The allegations were reviewed with the NHA, and she agreed they needed to be reported. She assumed the social worker had done it.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on record review and staff interview, the facility failed to maintain an accurate and complete record for Resident #56. This was true for one (1) of five (5) residents reviewed under the care area of falls. Resident identifier: #56. Facility census: 74. Findings Include: a) Resident #56 On 05/07/25 at 12:30 PM, a record review was completed for Resident #56. The review found the resident had been transferred to an acute care facility. The transfer forms were noted with errors as follows: --Transfer date 11/01/24; incorrect date of 09/06/24 --Transfer date 11/25/24; incorrect date of 11/01/24 --Transfer date 03/04/25; incorrect date of 11/25/24 On 05/07/25 at 1:30 PM, the Administrator was notified and confirmed the dates on the transfer forms were incorrect.

Mar 2024 13 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the resident's representative/family member in a timely fashion of a significant change and the need to alter treatment. The facility transferred Resident #15 and Resident #35 to the hospital. However, their representatives/family members were not notified of the transfer. This was true for two (2) of six (6) residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident identifiers: #15 and #35. Facility census: 76. Findings included: a) Resident #15 A medical record review, completed on 03/05/24 at 9:22 PM, revealed the following details: -An electronic Medication Administration Note, dated 04/26/23 at 11:03 AM, documented Resident #15 was experiencing a decreased level of consciousness. It also noted, Resident unable to safely swallow medications at this time. NP [Nurse Practitioner] aware. -A second Nurses Note, dated 04/26/23 at 3:57 PM, documented the nurse practitioner had visited the resident to assess the resident's altered mental status. An order was given to transfer the resident to the hospital. -The transfer form did not indicate the resident's representative had been notified of the transfer to the hospital and made aware of the clinical situation. During an interview, on 03/06/24 at 2:02 PM, the Administrator stated the facility was unable to produce any evidence of Resident #15's representative/family member being notified of resident's change in condition and transfer to the hospital. b) Resident #35 A medical record review, completed on 03/05/24 at 9:39 PM, revealed Resident #35 had been transferred to the hospital on [DATE] and again on 02/07/24. The following details were found regarding the 01/31/24 hospital transfer: -A nurse's note, dated 01/31/24 at 6:43 PM, documented Resident #35 was experiencing shortness of breath and tachycardia (fast heart rate). The Resident's oxygen level would not rise above 85%. The physician ordered resident be sent to the hospital for further evaluation. -A nurses note, dated 02/01/23 at 5:57 AM, acknowledged a nurse called from hospital at approximately 3:00 AM inquiring if residents' legal representative/son was called regarding the hospital transfer. The nurse at the facility stated she was unable to confirm but did give the hospital nurse his number as resident was requesting, he be called. The hospital nurse reported resident was being admitted with the diagnosis of pneumonia. The following details were found regarding the 02/07/24 hospital transfer: -A PHP Telehealth Notification, dated 02/07/24 at 10:06 PM, documented Resident has a complaint of tachycardia (fast heart rate) onset tonight for the first time since her readmission. Additionally, her PO (by mouth) intake has been poor, and she has been drinking only little. She is very anxious. Her heart rate continues climbing and respirations increase during video visit. Resident's pulse was noted to be 180. An order was given to transfer the resident to the hospital for evaluation. -A Nurse's Note, dated 02/07/24 at 10:38 PM, indicated 911 had been called and a report had been given to the nurse at the hospital. During an interview, on 03/06/24 at 2:04 PM, the Administrator stated the facility was unable to produce any evidence of Resident #35's representative/family member being notified of resident's change in condition and transfer to the hospital on both the above-mentioned dates.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide evidence resident/resident's representative were provided a written Notice of Transfer for an acute hospital transfer. This was true for two (2) out six (6) hospital transfers reviewed during the long-term care process. Resident identifiers: #15, and #35. Facility census: 76. Findings included: a) Resident #15's Hospital Transfer on 04/26/23 A medical record review was completed on 03/05/24 at 9:22 PM. The record review revealed Resident #15 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer. During an interview, on 03/06/24 at 12:00 PM, the Administrator reported the facility had no evidence a Notice of Transfer was provided. b) Resident #35's Hospital Transfer on 01/31/24 A medical record review was completed on 03/05/24 at 9:39 PM. The record review revealed Resident #35 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer. During an interview, on 03/06/24 at 12:01 PM, the Administrator reported the facility had no evidence a Notice of Transfer was provided. c) Resident #35's Hospital Transfer on 02/07/24 A medical record review was completed on 03/05/24 at 9:39 PM. The record review revealed Resident #35 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer. During an interview, on 03/06/24 at 12:01 PM, the Administrator reported the facility had no evidence a Notice of Transfer was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to ensure that the resident's Pre-admission Screening (PAS) reflected pre-admission diagnoses for one (1) of two (2) residents reviewed for the category of PASARR (Pre-admission Screening and Record Review), during the Long-Term Care Survey process. Resident identifiers: #15. Facility census 76. Findings included: a) Resident #15 A record review, completed on 03/04/24 at 2:34 PM, revealed Resident #15 had an admitting diagnosis of bipolar. A PASARR, dated 10/03/22, did not identify Resident #29 had a bipolar diagnosis on Section III, Question 30 of the PAS. This PASARR indicated no Level II was required. A continued record review also revealed there was never a new PAS completed to reveal resident's bipolar diagnosis in order to address whether or not specialized services were needed. During an interview on 03/06/24 at 12:20 PM, the Social Worker acknowledged the 10/03/22 PAS failed to identify the resident's bipolar diagnosis. The Social Worker noted the facility had recently identified the need to review new resident admission PASARRs to be sure they were accurate and she had been working on monitoring those. The Social Worker then stated she would complete a new PASARR for Resident #15 to reflect her bipolar diagnosis.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to revise a resident's person-centered, comprehensive care plan for urinary catheter services. This was true for one (1) of two (2) residents reviewed for urinary catheter care during the Long-Term Care Survey Process. Resident identifier: #37. Facility census: 76. Findings included: a) Resident #37 A record review on 03/06/24 revealed there was an order for the removal of a urinary catheter on 01/05/24. The current care plan had not been revised to reflect the removal of the urinary catheter. In an interview with the Director of Nursing (DON) on 03/06/24 at 12:35 PM, the DON verified the urinary catheter for Resident #37 had been removed on 01/05/24 and the care plan had not been revised to reflect the catheter removal.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation and staff interviews the facility failed to provide an environment as free of accident hazards as possible. This was a random opportunity for discovery. Resident identifiers: #48 and #228 Facility census: #76 Findings include: a) Resident #48 On 03/04/24 at 12:15 PM an observation revealed a spray bottle of Clorox cleaner and a spray bottle of Bio-enzymatic odor eliminator left unattended on the window ledge in Resident #48's room. This was accessible to any resident that may happen to wander into the room. There were multiple residents that went throughout the facility either walking or in their wheelchair. During the long-term survey process Resident #55 was observed daily ambulating without supervision throughout A Hall, where the cleaner spray bottles were found. Resident #55 had an active diagnosis of dementia and wandering. The above was confirmed, on 03/04/24 at 12:33 PM, with Certified Nurse Aide #60 who agreed the bottles should not be left unattended. It was also confirmed with the Administrator on 03/05/24 at 11:10 AM. b) Resident #228 On 03/04/24 at 12:15 PM observation found a spray bottle of Clorox cleaner and a spray bottle of Bio-enzymatic odor eliminator left unattended on the window ledge in Resident #228's room. This was accessible to any resident that may happen to wander into the room. There were multiple residents that went throughout the facility either walking or in their wheelchair. During the long-term survey process Resident #55 was observed daily ambulating without supervision throughout A Hall where the cleaner spray bottles were found. Resident #55 had an active diagnosis of dementia and wandering. The above was confirmed on 03/04/24 at 12:33 PM with Certified Nurse Aide #60 who agreed the bottles should not be left unattended. It was also confirmed with the Administrator on 03/05/24 at 11:10 AM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of three (3) records reviewed for accurate POST (Physician Orders for Scope of Treatment) forms during the Long-Term Care Survey process. Resident identifier: #51. Facility census: 76. Findings included: a) Resident #51 A brief record review, completed on 03/04/24 at 1:28 PM, identified the resident had a Physician Orders for Treatment (POST) form on file. The facility had obtained verbal consent from the resident's legal representative on 05/19/22. The 2021 POST Form Guidance instructs, If the incapacitated patient's MPOA (Medical Power of Attorney) representative or Health Care Surrogate is unavailable at the time of form completion, this section can be signed by two witnesses for verbal confirmation of agreement from the patient's MPOA representative or health care surrogate. The form should be signed at the earliest available opportunity. During an interview on 03/06/24 at 12:40 PM, the Social Worker acknowledged verbal consent had been accepted almost two (2) years ago and the facility had failed to obtain a written signature from the resident's legal representative.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation and staff interview the facility failed to 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. This was a random opportunity of discovery. Resident Identifiers: #39, #48 and #228. Facility Census: 76 Findings Included: a) Resident #39 On 03/04/24 at 12:33 PM observation was made of Certified Nurse Aid (CNA) #60 passing lunch meal trays on A hall. The CNA passed Resident #39's meal tray without offering the resident any hand hygiene prior to eating her meal. When confirming with the CNA that no hand hygiene was performed and asking if they usually provide hand hygiene she stated, we usually do, you just caught me on an off day, they are up on the meal cart. On 03/04/24 at 12:36 PM CNA #60 confirmed that she should have given the residents their hand hygiene wipes prior to passing their meal tray. This was also confirmed with the Administrator on 03/05/24 at 11:50 AM. b) Resident #48 On 03/04/24 at 12:33 PM observation was made of Certified Nurse Aide (CNA) #60 passing lunch meal trays on A hall. The CNA passed Resident #48's meal tray without offering the resident any hand hygiene prior to eating her meal. When confirming with the CNA that no hand hygiene was performed and asking if they usually provide hand hygiene she stated, we usually do, you just caught me on an off day, they are up on the meal cart. On 03/04/24 at 12:36 PM CNA #60 confirmed that she should have given the residents their hand hygiene wipes prior to passing their meal tray. This was also confirmed with the Administrator on 03/05/24 at 11:50 AM. c) Resident #228 On 03/04/24 at 12:33 PM observation was made of Certified Nurse Aide (CNA) #60 passing lunch meal trays on A hall. The CNA passed Resident #228's meal tray without offering the resident any hand hygiene prior to eating her meal. When confirming with the CNA that no hand hygiene was performed and asking if they usually provide hand hygiene she stated, we usually do, you just caught me on an off day, they are up on the meal cart. On 03/04/24 at 12:36 PM CNA #60 confirmed that she should have given the residents their hand hygiene wipes prior to passing their meal tray. This was also confirmed with the Administrator on 03/05/24 at 11:50 AM.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected multiple residents

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Based on resident interview and staff interview, the facility failed to review resident rights during the residents stay. This was a random opportunity for discovery during the Long-Term Care Survey process and had the potential to affect more than a limited number of residents in the facility. Facility census: 76. Resident identifiers: #54, #3, #59, #22, #43, #25, #76. Findings included: a) During the Resident Council meeting on 03/05/24 at 1:20 PM, Residents #54, #3, #59, #22, #43, #25, #76 stated no one has gone over resident rights with them. On 03/05/24 at 2:54 PM, the Administrator confirmed resident rights had not been reviewed with residents regularly after admission to the facility.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0680 (Tag F0680)

Could have caused harm · This affected multiple residents

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Based on staff interview and record review, the facility failed to provide a qualified activity professional for recreational services. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Facility Census: 76 Findings included: During an interview, on 03/05/24 at 1:00 PM, with Activity Director (AD), she stated she was currently enrolled in the Modular Education Program for Activity Professionals (MEPAP) class and has been employed since May of 2023. On 03/05/24 at 01:30 PM, the Executive Director (ED) confirmed the Activity Director (AD) has been employed since May of 2023 without a Qualified Activity Professional overseeing the facility's AD.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observations and staff interviews, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered food was not stored properly and a treatment mask was found in the supply room. These deficient practices had the potential to affect any resident receiving nourishment from the kitchen. Facility census: 76. Findings included: a) Kitchen tour During the kitchen tour, on 03/04/24 at 11:42 AM, it was discovered a box of hamburger patties were opened and exposed in the walk-in freezer and in the storage room there was a treatment mask on a shelving unit. Observation with the Dietary Manager on 03/04/24 at 11:50 AM, verified the hamburger patties were open and exposed to the elements in the walk-in freezer and the treatment mask was lying on a shelf in the storage room.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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Based on observation and staff interviews the facility failed to maintain the garbage storage area in a sanitary condition. It was discovered the dumpster had a trash bag wedged under the dumpster. Facility census: 76. Findings included: a) Garbage refuse receptacle During an observation of the outside garbage receptacle on 03/07/24 at 11:40 AM, it was discovered a clear garbage bag was wedged under the dumpster. The garbage bag contained treatment masks and absorbent bed pads used for incontinence. An observation with the Nursing Home Administrator (NHA) on 03/07/24 at 1:45 PM, verified the garbage bag did not allow for sanitary conditions in the dumpster area.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected most or all residents

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Based on staff interview and record review, the facility failed to ensure a qualified staff person assessed each resident's activity pursuits by not providing a qualified activity professional. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents residing in the facility. Facility census: 76. Findings included: a) During an interview, on 03/05/24 at 01:00 PM, with Activity Director (AD), she stated she was currently enrolled in the Modular Education Program for Activity Professionals (MEPAP) class and had been employed since May of 2023. On 03/05/24 at 01:30 PM, the Executive Director (ED) confirmed the Activity Director (AD) had been employed since May of 2023 and had worked for eight (8) months without a qualified activity professional overseeing the facility's activity department. A record review, on 03/05/24 at 2:45 PM, revealed the resident's activity assessments are being completed by the AD who is not a Qualified Activity Professional, and the facility did not have a qualified activity professional in the facility overseeing the AD.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

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Based on observation and staff interview, the facility failed to ensure the correct alternative menus were posted to be available if the primary menu or immediate selections for a particular meal are not to a resident's liking. This was a random opportunity for discovery, and currently no residents are receiving enteral tube feedings in the facility, therefore; this failed practice had the potential to affect all residents residing in the facility. Facility Census: 76 Findings include: On 03/05/24 at 10:00 AM an Always available menu was observed posted by the daily menus near the dining room showing the following substitutes. -Hot or cold cereal- maple brown sugar oatmeal or variety of cold cereal -Gelatin, pudding, yogurt - variety -fruit cup- Mandarin oranges or peaches -sandwiches Deli meat, meat salad of the day, PB&J, ad grilled cheese -soup- Chicken noodle, tomato, or vegetable -cottage cheese and fruit plate -chef salad (mixed greens with assorted meats, cheese, tomato, and boiled egg) -Tossed salad ( lettuce, cheese, tomato) - Pickled Beets On 03/06/24 at 9:45AM the Culinary Director (CD) confirmed the always available menu posted was not correct and the current alternative menus was: -Burgers -Hotdogs -Deli Sandwiches During an interview with the Administrator on 03/06/24 at 10:59 AM, she confirmed the incorrect always available menu was posted.

Nov 2023 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pharmacy Services (Tag F0755)

A resident was harmed · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure medications were available for administration to residents. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for medications. This deficient practice caused harm to Resident #15. Resident #15 experienced seizures as a result of not receiving anticonvulsant medication as ordered and required an emergency room evaluation and medical testing. Resident identifiers: #15 and #24. Facility census: 76. Findings included: a) Resident #15 Resident #15 was admitted in August 2023. He had diagnoses of cerebral palsy, seizures, and moderate intellectual disabilities. His most recent Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 09/12/23 showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of Resident #15's physician's orders showed an order for brivaracetam (Briviact) 100 mg, two (2) times a day for seizures. The resident had been receiving this medication since 08/05/22. Review of Resident #15's Medication Administration Record (MAR) for July 2023 showed the resident did not receive brivaracetam on 7/30/23 at 9:00 PM and on 07/31/23 at 9:00 AM. The code 9 was recorded on these dates and times, which according to the MAR chart code meant, Other/see nurses notes. A nurses' note written on 07/30/23 at 8:18 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Medication on order. Unavailable in dispensary. A nurse's note written on 7/31/23 at 12:45 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Will receive on 7/31/2023 from pharmacy. Resident #15's MAR for August 2023 showed the resident did not receive brivaracetam on 08/03/23 at 9:00 PM, 08/04/23 at 9:00 AM, and 08/04/23 at 9:00 PM. The code 9 was recorded on these dates and times, which according to the MAR chart code meant, Other/see nurses notes. A nurse's note written on 08/03/23 at 9:24 PM stated, Brivaracetam Oral Tablet 100 MG Give 1 tablet by mouth two times a day for Seizures. Medication on order. A nurse's note written on 8/04/23 at 8:43 AM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Not received from pharmacy. A nurse's note written on 08/04/23 at 11:22 AM stated, Called pharmacy to order medication Brivaracetam 100mg for resident. It is to be delivered this evening. Pharmacist is going to possibly call in a dose to [pharmacy name] for today's dose. He will call later to confirm. A nurse's note written on 08/04/23 at 3:14 PM stated, NP [Nurse Practitioner] update on 2 missed doses of Brivaracetam no new orders at this time. Medication to arrive this day. A nurse's note written on 08/04/23 at 9:10 PM stated, During my evening med pass, this nurse heard screaming coming from dining area. When I arrived, pt [patient] was sitting in wheelchair, halfway slumped over shaking. Pt had dropped his water and snack on the floor. Pt involuntarily shook for approx [approximately] 2 mins. Was very disoriented with whole body weakness. Pt vitals 220/102, P [pulse] -112, O2 [oxygen saturation] -97%, R [respirations] -22, T [temperature] - 98.9. Provider notified. Received new orders to recheck BP [blood pressure] in 15 mins, if still elevated, send to ER [emergency room] for eval. Pt recheck was still 200/110. Pt sent to ER [emergency room], RN [registered nurse] supervisor on call notified. A nurse's note written on 08/04/23 at 9:54 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. not in cart, pharmacy on way with medication. A nurse's note written on 08/04/23 at 10:09 PM stated, Pt left with emergency transport via stretcher. Review of Resident #15's emergency department after visit summary showed the resident had been diagnosed with seizures. In the emergency department, the resident was subjected to having blood drawn for laboratory testing. He also had a chest x-ray, computerized tomography (CT scan) of the brain, and an electrocardiogram. The resident returned to the facility 08/05/23 at 3:27 AM. The admitting nurse's note stated, Pt arrived via stretcher with EMS [emergency medical services]. Pt very lethargic and sleepy, still experiencing weakness, and skin feels hot to touch. Pt did not have a fever upon exam. Pt was sent to [hospital name] and underwent labs, ECG [electrocardiogram], brain CT all unremarkable. Pt chest x-ray showing some vascular congestion per hospital RN staff. Frequent visual checks. Pt denies any complaints, call bell in reach. Further review of Resident #15's physician's orders showed at the time of his transfer to the emergency room, the resident was receiving two (2) anticonvulsant medications in addition to brivaracetam. The resident was receiving phenytoin sodium (Dilantin), 300 mg by mouth at bedtime and lacosamide (Vimpat) 200 mg, two times a day. Review of Resident #15's nurses notes since admission showed no evidence the resident had experienced seizures prior to 08/04/23. Resident #15 was not interviewable about the experience. However, the National Library of Health's article titled Postictal Seizure State, which was updated 07/10/23, and is available on-line, states, The postictal state is a period that begins when a seizure subsides and ends when the patient returns to baseline. It typically lasts between 5 and 30 minutes and is characterized by disorienting symptoms such as confusion, drowsiness, hypertension, headache, nausea, etc. This would be frightening to a reasonable person. During an interview on 11/07/23 at 10:05 AM, the Administrator and Director of Nursing confirmed Resident #15's brivaracetam was unavailable for administration on 07/30/23 at 9:00 PM, 07/31/23 at 9:00 AM, 08/03/23 at 9:00 PM, 08/04/23 at 9:00 AM, and 08/04/23 at 9:00 PM. The Administrator and Director of Nursing stated they did not know why the medication was unavailable. No further information was provided through the completion of the survey process. b) Resident #24 A record review, conducted on 11/06/23, for Resident #24, found a physician's order, written on 10/06/23, for Gabapentin oral tablet 600 mg, give one (1) tablet by mouth two (2) times a day for pain. Further review of the record showed staff had documented the medication, Gabapentin was not available on 10/06/2 starting at 8:33 pm, 10/07/23, 10/08/23, and 10/09/23 to be administered to the resident. An interview with the DON, on 11/07/23 at 11:06 AM, revealed the medication Gabapentin, had not been available to administer to Resident #24 from 10/06/23 through 10/09/23.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility failed to report alleged neglect within the required timeframe. This was a random opportunity for discovery. Resident identifier: #15. Facility census: 76. Findings included: a) Resident #15 The facility's policy titled Abuse, Neglect and Exploitation Policy with effective date 05/01/2017 and revision date 10/27/23 showed the following procedures: - All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the Executive Director/designee of the facility. - All alleged violations involving abuse, neglect, exploitation or mistreatment, are reported immediately, but not later than two (2) hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. - If the events that cause the allegations do not result in serious bodily injury, reporting to the administrator (Executive Director) and to other reporting regulatory bodies must occur within twenty-four (24) hours. In the facility's policy, neglect is defined as a failure to provide timely and consistent services, treatment or care to a resident or resident's [sic] which are necessary to obtain or maintain the resident's health, safety, or comfort; or a failure to provide timely and consistent goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident #15 was admitted in August 2022. He had diagnoses of cerebral palsy, seizures, and moderate intellectual disabilities. His most recent Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 09/12/23 showed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. Review of Resident #15's physician's orders showed an order for brivaracetam (Briviact) 100 mg, two (2) times a day for seizures. The resident had been receiving this medication since 08/05/22. Review of Resident #15's Medication Administration Record (MAR) for July 2023 showed the resident did not receive brivaracetam on 7/30/23 at 9:00 PM and on 07/31/23 at 9:00 AM. The code 9 was recorded on these dates and times, which according to the MAR chart code meant, Other/see nurses notes. A nurses' note written on 07/30/23 at 08:18 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Medication on order. Unavailable in dispensary. A nurse's note written on 7/31/23 at 12:45 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Will receive on 7/31/2023 from pharmacy. Resident #15's MAR for August 2023 showed the resident did not receive brivaracetam on 08/03/23 at 9:00 PM, 08/04/23 at 9:00 AM, and 08/04/23 at 9:00 PM. The code 9 was recorded on these dates and times, which according to the MAR chart code meant, Other/see nurses notes. A nurse's note written on 08/03/23 at 9:24 PM stated, Brivaracetam Oral Tablet 100 MG Give 1 tablet by mouth two times a day for Seizures. Medication on order. A nurse's note written on 8/04/23 at 8:43 AM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Not received from pharmacy. A nurse's note written on 08/04/23 at 11:22 AM stated, Called pharmacy to order medication Brivaracetam 100mg for resident. It is to be delivered this evening. Pharmacist is going to possibly call in a dose to [pharmacy name] for today's dose. He will call later to confirm. A nurse's note written on 08/04/23 at 3:14 PM stated, NP [Nurse Practitioner] update on 2 missed doses of Brivaracetam no new orders at this time. Medication to arrive this day. A nurse's note written on 08/04/23 at 9:10 PM stated, During my evening med pass, this nurse heard screaming coming from dining area. When I arrived, pt [patient] was sitting in wheelchair, halfway slumped over shaking. Pt had dropped his water and snack on the floor. Pt involuntarily shook for approx [approximately] 2 mins. Was very disoriented with whole body weakness. Pt vitals 220/102, P [pulse] -112, O2 [oxygen saturation] -97%, R [respirations] -22, T [temperature] - 98.9. Provider notified. Received new orders to recheck BP [blood pressure] in 15 mins, if still elevated, send to ER [emergency room] for eval. Pt recheck was still 200/110. Pt sent to ER [emergency room], RN [registered nurse] supervisor on call notified. A nurse's note written on 08/04/23 at 9:54 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. not in cart, pharmacy on way with medication. A nurse's note written on 08/04/23 at 10:09 PM stated, Pt left with emergency transport via stretcher. Review of Resident #15's emergency department after visit summary showed the resident had been diagnosed with seizures. The resident returned to the facility 08/05/23 at 3:27 AM. The admitting nurse's note stated, Pt arrived via stretcher with EMS [emergency medical services]. Pt very lethargic and sleepy, still experiencing weakness, and skin feels hot to touch. Pt did not have a fever upon exam. Pt was sent to [hospital name] and underwent labs, ECG [electrocardiogram], brain CT [computerized tomography}, all unremarkable. Pt chest x-ray showing some vascular congestion per hospital RN staff. Frequent visual checks. Pt denies any complaints, call bell in reach. On 08/16/23, the matter was reported to the Office of Health Facility Licensure and Certification (OHFLAC), the Ombudsman, and Adult Protective Services (APS). The reportable stated, [Resident's name] was noted to have not taken his seizure medication for three doses. His medication had not come from the pharmacy and was expected in that evening. Prior to his having any of the medication while the nurse was doing a med pass, a scream was heard from the dining room. [Resident's name] was noted to be having seizure like activity. His BP [blood pressure] and pulse were elevated, and he was weakened. He was not at his normal baseline of orientation. He was sent to the Emergency Department for evaluation. During an interview on 11/07/23 at 10:05 AM, the Administrator stated the reportable for the incident occurring on 08/04/23 was not done until 08/16/23 because administration was not aware of the situation until then. However, the Administrator confirmed facility nurses were aware the resident had not received his medication, had experienced a seizure, and required emergency room evaluation. No further information was provided through the completion of the complaint investigation.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure the timeliness of laboratory services to meet the needs of their residents. This was found true for two (2) of three (3) residents reviewed in which laboratory services were not obtained in a timely basis for Resident #55 and Resident #15. This deficient practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Resident #55 and Resident #15. Census: 76. Findings included: a) Resident #55 A record review on 11/06/23, showed Resident #55 to have a diagnosis of Hypomagnesmia (Low Magnesium) and was ordered to have a laboratory study of a magnesium level ordered to be conducted on 06/15/23. A review of the progress notes for Resident #55, showed a progress note, written on 06/16/23 at 1:39 pm, noting the lab was not drawn. Further record review, showed no evidence the laboratory study had been drawn for this order date. An interview, with the Director of Nursing (DON), on 11/07/23 at 9:15 AM, verified the order for the laboratory study for a magnesium level had been totally missed and was not drawn until August 2023, when the laboratory study had been ordered 6/16/23. No additional information was provided by facility staff at exit, conducted 11/07/23. b) Resident #15 Review of Resident #15's physician's orders showed an order written on 02/20/23 for Dilantin (phenytoin) level laboratory testing every six (6) months. The resident was receiving the medication Dilantin for seizure prevention. The resident had a Dilantin level obtained in February 2023. On 08/21/23, Resident #15's Medication Administration Record (MAR) showed the Dilantin level laboratory test should have been obtained on 08/21/23. However, the MAR showed a code of 9 which according to the MAR chart code means other/see nurses notes. A nurse's note written on 08/21/23 at 5:19 AM stated the lab was moved to lab day. A note written on 08/21/23 at 4:40 PM stated, blood was drawn for phenytoin and hemoglobin. A hemoglobin A1-C result was scanned in the resident's electronic health records, but a phenytoin level could not be located in the electronic health records. During an interview on 11/07/23 at 9:15 AM, the Director of Nursing (DON) stated the resident's phenytoin level had not been obtained in August 2023. She stated the laboratory testing would be performed today. .

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected multiple residents

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. Based on record review and staff interview, the facility failed to notify the resident's physician, or designee, when there was a need to alter treatment for three (3) of three (3) residents reviewed, when the facility failed to administer medications or failed to obtain laboratory services ordered by the physician. This deficient practice was found to be true for Resident #55 who failed to have laboratory values drawn per physician order , Resident #15 who failed to have laboratory services obtained and failed to receive medication ordered by the physician, and Resident #24 who failed to receive medications ordered by the physician. Resident identifiers: Resident #24, #55, and #15. Census: 76. Findings included: a) Resident #24 A record review, conducted on 11/06/23, for Resident #24, found a physician's order, written on 10/06/23, for Gabapentin oral tablet 600 mg, give one (1) tablet by mouth, two (2) times a day for pain. Further review of the record showed staff had documented the medication, Gabapentin was not available on 10/06/23 starting at 8:33 pm, 10/07/23, 10/08/23, and 10/09/23. There was no evidence in the electronic medical record that staff had notified the physician or designee, of the medicine being unavailable to administer to Resident #24. An interview with the Director of Nursing (DON) and Administrator, on 11/07/23 at 11:06 AM, revealed the physician was not notified in a timely manner for the missed dosages of medication. According to the progress notes, the facility did not notify the Nurse Practitioner until 10/08/23 at 7:43 am. b) Resident #55 A record review, on 11/06/23, showed Resident #55 to have a diagnosis of Hypomagnesmia (Low Magnesium) and was ordered to have a laboratory study of a magnesium level ordered to be conducted on 06/15/23. A review of the progress notes, for Resident #55, showed a progress note, written on 06/16/23 at 1:39 pm, noting the lab was not drawn. Further record review, showed no evidence the laboratory study had been drawn for this order date. An interview, with the Director of Nursing (DON), on 11/07/23 at 9:15 AM, verified the order for the laboratory study for a magnesium level had been totally missed and was not drawn until August 2023, when the laboratory study had been ordered 6/16/23. An additional interview, with the DON, on 11/07/23 at 11:07 AM, revealed the resident's physician had not been notified the laboratory study had not been obtained per physician's order. c) Resident #15 Review of Resident #15's physician's orders showed an order for brivaracetam (Briviact) 100 mg, two (2) times a day for seizures. The resident had been receiving this medication since 08/05/22. Review of Resident #15's Medication Administration Record (MAR) for July 2023 showed the resident did not receive brivaracetam on 7/30/23 at 9:00 PM and on 07/31/23 at 9:00 AM. The code 9 was recorded on these dates and times, which according to the MAR chart code meant, Other/see nurses notes. A nurses' note written on 07/30/23 at 08:18 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Medication on order. Unavailable in dispensary. A nurse's note written on 7/31/23 at 12:45 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Will receive on 7/31/2023 from pharmacy. Resident #15's MAR for August 2023 showed the resident did not receive brivaracetam on 08/03/23 at 9:00 PM, 08/04/23 at 9:00 AM, and 08/04/23 at 9:00 PM. The code 9 was recorded on these dates and times, which according to the MAR chart code meant, Other/see nurses notes. A nurse's note written on 08/03/23 at 9:24 PM stated, Brivaracetam Oral Tablet 100 mg, give 1 tablet by mouth two times a day for Seizures. Medication on order. A nurse's note written on 8/04/23 at 8:43 AM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. Not received from pharmacy. A nurse's note written on 08/04/23 at 11:22 AM stated, Called pharmacy to order medication Brivaracetam 100mg for resident. It is to be delivered this evening. Pharmacist is going to possibly call in a dose to [pharmacy name] for today's dose. He will call later to confirm. A nurse's note written on 08/04/23 at 3:14 PM stated, NP [Nurse Practitioner] update on 2 missed doses of Brivaracetam no new orders at this time. Medication to arrive this day. A nurse's note written on 08/04/23 at 9:54 PM stated, Brivaracetam oral tablet 100 mg, give 1 tablet by mouth two times a day for seizures. not in cart, pharmacy on way with medication. Resident #15 was transferred to the emergency room due to seizures on 08/04/23 at 10:09 PM. On 11/07/23 at 11:15 AM, the Administrator and Director of Nursing confirmed there was no documentation that the medical provider had been notified when the resident's medication was not available on 07/30/23 and 07/31/23. The Administrator and Director of Nursing also confirmed there was no documentation that the medical provider had been notified when the resident's medication was not available on 08/03/23. The Administrator stated the facility had no policy regarding notification to the medical provider when medication was not available.

Jul 2022 9 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interview, the facility failed to display the most recent State inspection survey results in a readily accessible area frequented by residents. It was discovered the State inspection was not posted in an area frequented by residents. This had the potential to affect a limited number of residents. Facility census: 75 Findings included: a) State inspection survey results posting During an observation on 07/20/22 at 1:30 PM, it was discovered the State inspection survey results were located under a shelf at the Nurse's desk, which was not accessible to residents. At 1:56 PM on 07/20/22 the Nursing Home Administrator (NHA) verified the State inspection survey results were not located in an area accessible to residents. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to maintain appropriate standards for completing the Advanced Directives. This was true for one (1) of 20 residents reviewed during the long-term survey process. Resident Identifiers: #52. Facility Census: 75. Findings included: a) Resident #52 On 07/19/22 at 1:38 PM, a record review of the Physician Orders for Scope of Treatment (POST) form was completed. The POST form was missing the date when the verbal consent was obtained from the Medical Power of Attorney (MPOA). The POST form also had only one (1) witness's signature verifying the verbal consent was obtained from the MPOA. The POST form requires two (2) witnesses for a verbal consent. The MPOA section was left blank and did not contain the MPOA's name, address and phone number. On 07/20/22 at 3:15 PM, the Administrator confirmed the POST form was missing the date the verbal consent was obtained and had only one witness's signature verifying verbal consent was obtained from the MPOA. The MPOA section was left blank with no name, address or telephone number listed. No further information was obtained during the survey process. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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. Based on staff interview and medical record review, the facility failed to develop comprehensive person-centered care plans to meet the psychosocial needs of the residents. Resident (R) #54 and R #6's care plans lack person centered non-pharmacological interventions to assist in dealing with anxiety and depression. This is true for two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: R#54 and #6. Facility census: 75. Findings included: a) Resident #54 Review of the medical record on 07/20/22, revealed R #54 is receiving Ativan (anti-anxiety medication) at bed time when needed for anxiety. R #54 is also taking Duloxetine hydrochloride (anti-depressant) twice a day for depression. The care plan identifies the Ativan for anxiety and states under the interventions Patient specific non-pharmacological intervention such as fluids, snacks, rest periods. The care plan is silent for non-pharmacological interventions related to the use of an antidepressant. Registered Nurse Assessment Coordinator (RNAC) #66 confirmed the care plan lacks resident specific non-pharmacological interventions to assist R #54 with her depression, during an interview on 07/20/22 at 11:30 AM. b) Resident #6 Review of the medical record on 07/20/22, revealed R #6 is currently receiving the following psychotropic medications: Abilify (antipsychotic) for bipolar related to major depression, Ativan (anti-anxiety) at bed time, Buspirone (anti-anxiety) every morning, Sertraline (antidepressant) daily, Trazadone (antidepressant) for insomnia, Vilazodone (antidepressant) daily, and Depakote (to treat anxiety related to bipolar) daily. The care plan identifies the psychotropic medications but lacks non-pharmacological interventions for staff to assist the resident in dealing with her feelings and behaviors. During an interview on 07/20/22 at 1:20 PM, Social Worker #37 confirmed R #6's care plan is silent for non-pharmacological interventions for staff to utilize to assist the resident with her psychological needs. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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. Based on observation, record review, and staff interview, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Splints had not been applied as ordered by the physician. This was true for one (1) of two (2) residents reviewed for the care area of position and mobility. Resident identifier: #22. Facility census: 75. Findings included: a) Resident #22 Review of Resident #22's physician's order found an order written on 11/26/19 for a left hand splint from breakfast to dinner time as tolerated and an order written on 01/17/20 for a left elbow splint from breakfast to dinner time as tolerated. During observation on 07/20/22 at 11:33 AM, Resident #22 was observed to not be wearing the left hand and left elbow splints. Licensed Practical Nurse (LPN) #82 confirmed Resident #22 was not wearing the splints. LPN #82 stated she would have the Nurse Aid (NA) apply the splint. During an interview on 07/20/22 at 12:03 PM, the Director of Nursing (DON) stated the NA had not applied the splints because she was not familiar with how to apply the devices. The DON stated the physical therapy department was asked to assist the NA, and Resident #22 is now wearing the splints. No further information was provided through the completion of the survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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. Based on medical record review, respiratory procedure policy, and staff interview the facility failed to provide respiratory services in accordance with professional standards of practice. This was discovered for one (1) of one (1) residents reviewed for respiratory care. Resident identifier: #59 Facility census: 75 Findings included: a) Resident #59 During a review of the Treatment Administration Record (TAR) for Resident #59, which verified the face mask for the continuous positive airway pressure (CPAP) was being cleaned daily, but the tubing was not being cleaned weekly as recommended. A review of the CPAP procedure policy recommended the face mask to be cleansed daily with soap and water and the tubing was to be cleansed weekly with soap and water. In an interview with the Director of Nursing (DON) on 07/20/22 at 12:30 PM, the DON reported their standard of practice was to clean the CPAP tubing once weekly and the face mask was to be cleaned daily. The DON verified the CPAP tubing was not be cleaned weekly. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . The facility failed to provide pharmaceutical services to meet residents' needs. Resident #71's medications were not received in a timely manner following her admission. This was true for one (1) of two (2) closed record reviews. Resident identifier: #71. Facility census: 75. Findings included: a) Resident #71 Review of Resident #71's medical records showed the resident was admitted on [DATE] at 4:52 PM. Review of Resident #71's Medication Administration Record showed the resident had not received the following medications after admission: --06/22/22: Insulin Glargine Solution Pen-injector, 35 units, subcutaneously at bedtime related to type 2 diabetes mellitus without complications, scheduled to be given at 9:00 PM --06/23/22: Isosorbide Mononitrate, 60 mg, one time a day related to essential hypertension, scheduled to be given at 9:00 AM --06/23/22: Januvia Tablet, 50 mg, one time a day related to type 2 diabetes mellitus without complications, scheduled to be given at 9:00 AM --06/23/22: Metoprolol Succinate, 100 mg, one time a day related to essential hypertension, scheduled to be given at 9:00 AM --06/23/22: Insulin Glargine Solution Pen-injector, 35 units, subcutaneously at bedtime related to type 2 diabetes mellitus without complications, scheduled to be given at 9:00 PM During an interview at 07/20/22 at 1:43 PM, the Director of Nursing (DON) confirmed Resident #22 had not received the above-listed medications. The DON stated medications are delivered to the facility from the pharmacy around 11:00 PM every night. The DON further stated if medication orders were written after 5:00 PM, the medications would not be delivered until approximately 11:00 PM the following night. Since Resident #71 was admitted at approximately 5:00 PM on 06/22/22, her medications would have been delivered at approximately 11:00 PM on 06/23/22. Some of the Resident's medications were available at the facility as floor stock or in a machine that stored medications frequently used in the facility. However, the medications listed above as not given were not available to be administered until delivered by the pharmacy. No further information was provided through the completion of the survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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. Based on record review and staff interview, the facility failed to ensure Resident #54's as needed anti-anxiety medication was limited to 14 days. This is true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier: #54. Facility census: 75. Findings include: a) Resident (R) #54 Review of the medical record on 07/20/22 found R #54 was prescribed Ativan as needed for anxiety at bed time. The order written on 07/15/22 states: Ativan Tablet 0.5 mg Give 0.5 mg by mouth as needed for anxiety at bedtime. The order lacks a stop date to identify the 14 day limit. During an interview on 07/20/22 at 11:00 AM, the administrator acknowledged R #54's Ativan order lacks a 14 day stop date. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. Expired medications were found in the medication preparation room floor stock. Facility census: 75. Findings included: a) Medication Storage and Labeling Facility Task On 07/20/22 at 2:03 PM, inspection of the medication preparation room was made under the observation of Licensed Practical Nurse (LPN) #31. Two (2) bottles of UTI-stat liquid were found to have expired in April 2022 and two (2) bottles of UTI-stat liquid were found to have expired in June 2022. LPN #31 confirmed the four (4) bottles of UTI-stat had expired. No further information was provided through the completion of the survey. .

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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. Based on observation and staff interview the facility failed to store food in accordance with professional standards for food service safety. During the kitchen tour, food was found not dated after opening. This had the potential to affect a limited number of residents receiving nourishment from the kitchen. Facility census: 75 Findings included: a) Kitchen tour During the kitchen tour on 07/19/22 at 11:07 AM, the freezer contained a package of chicken patties, which had not been dated after opening. An interview with the Dietary Manager (DM) on 07/19/22 at 11:09 AM, verified the package of chicken patties had not been dated when opened. .

Apr 2021 6 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure one (1) of 18 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifier: #62. Facility census: 72. Findings included: a) Resident #62 The WV Center for End-of-Life Care's 2016 Edition of Using the POST Form, for the Guidance for Healthcare Professionals provides the following guidance: According to the ethical principle of respect for patient autonomy and the legal principle of patient self-determination, individuals have the right to make their own healthcare decisions. The POST form should be completed after discussion with the patient or incapacitated patient's medical power of attorney representative or surrogate decision-maker regarding treatment preferences. The 2016 edition was in affect at the time the POST form was completed. The [NAME] Virginia Health Care Decisions Act (16-30-1) In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act, which was enacted to ensure that a patient's right to self-determination in healthcare decisions be communicated and protected (16-30-2). Additionally, the [NAME] Virginia Health Care Decisions Act addresses determination of incapacity: . a person may not be presumed to be incapacitated merely by reason of advanced age or disability . A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. (16-30-7). The Physician's Determination of Capacity was signed and dated on 10/02/20, noting Resident #62 demonstrates Capacity to make decisions. An electronic health record review revealed: -Resident #62 was admitted to the facility on [DATE]. -The facility's Social Worker prepared Resident #62's POST form in consultation with Resident #62's Medical Power of Attorney (not with Resident #62). Resident #62's MPOA signed the POST form. -Resident #62 was readmitted to the hospital on [DATE]. -Resident #62 returned to the facility on [DATE]. -The POST form was reviewed by the facility's Social Worker on 09/29/20, following Resident #62's readmission, and the box labeled no changes was marked. -The physician reviewed and signed POST form on 10/02/21, following Resident #62's readmission, also noting no changes. Resident #62's Care Plan was updated 04/06/21 and noted: Patient has expressed preferences for end-of-life care - Medical Power of Attorney. It further identified Resident #62's goal as Patient shall receive treatment in accordance with expressed wishes as documented on POST. On 04/20/21 at 2:05 PM, Resident #62 stated he has never been approached by his doctor, the Nurse Practitioner, the Social Worker, or any facility staff regarding his expressed wishes relating to end-of-life care. During an interview on 04/21/21 at 11:45 AM, the Social Worker confirmed Resident #62 had the legal right to be involved in end-of-life planning. The Social Worker stated it is protocol to assume every resident has capacity unless the doctor signs the Physician Determination of Capacity form stating otherwise. The Social Worker stated she will rectify the situation immediately by meeting with Resident #62 to discuss his expressed treatment preferences.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation and staff interview, the facility failed to provide two (2) of 18 sampled residents a safe, clean, comfortable and homelike environment. The facility failed to change Resident #42's soiled bed linens in a timely fashion. The facility also failed to provide non-skid strips in Resident #67's bathroom. Resident identifiers: #42 and #67. Facility census: 72. Findings included: a) Resident #42 On 04/19/21 at 11:00 AM, Resident #42 was found sleeping in bed. There were multiple orange/red stains on the resident's blanket. Additionally, there was a dry, pink stain measuring approximately 3 x 3 on Resident #42's sheet near the top of the bed, by Resident #42's pillow. At 4:00 PM on 04/19/21, Resident #42 was again found sleeping in bed. The stains on the blanket and the sheet were still present. Licensed Practical Nurse (LPN) #37 entered the room, observed the soiled linens, and stated she would be sure to change the bedding. At that time, Resident #42 woke up to the sound of conversation. LPN #37 apologized to the resident acknowledging the need to change soiled bed linens in a timely fashion. b) Resident #67 On 04/19/21 at 3:42 PM, an electronic health record review revealed an order for non-skid strips in front of toilet in Resident #67's bathroom. During a tour of Resident 67's bathroom, on 04/20/21 at 9:44 AM, the Director of Nursing (DON) observed there were no non-skid strips in front of the toilet. The DON acknowledged the need for non-skid strips in order to ensure the Resident #67 was able to use the bathroom safely, without risk of falling or injury, while maximizing the resident's independence.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, record review, and staff interview, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing. This was true for one (1) of two (2) residents reviewed for pressure ulcers during the annual long-term care survey process. Resident Identifier: #65. Facility Census: 72 Findings included: a) Resident #65 During an initial tour of the facility on 04/19/21 at 11:50 AM, heel protector/off-loading boots were found in a chair in Resident #65's room. Resident #65 was in bed. When asked if Resident #65 should be wearing the heel protector/off-loading boots, Licensed Practical Nurse (LPN) #37 replied, When he's resting in bed, they're uncomfortable for him. An electronic health record review on 04/19/21 at 7:50 PM, revealed the following physician order: Off-loading boots while in bed. The order was dated 04/07/21. On 04/21/21 at 9:00 AM, LPN #85 joined the surveyor in Resident #65's room to observe the resident, in bed, not wearing off-loading boots. LPN #85 commented, He is supposed to be wearing them. I wonder where they are? The off-loading boots were subsequently found in the resident's closet. LPN #85 then put them on Resident #65. The Director of Nursing (DON), during a meeting on 04/21/21 at 9:48 AM, was informed of the two occasions Resident #65 was not wearing off-loading boots while in bed. The DON acknowledged she would speak to nursing staff to ensure the physician order was consistently followed.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, record review and staff interview, the facility failed to maintain a resident's indwelling urinary (Foley) catheter bag in a manner to prevent the risk of contamination and urinary tract infection. This was a random opportunity for discovery. Resident Identifier: #62. Facility Census: 72. Findings included: a) Resident #62 Observation on 04/19/21 at 1:20 PM revealed Resident #62 asleep in his bed. Resident #62's Foley catheter bag was laying directly on the floor beside the resident's bed. Review of The Centers for Disease Control and Prevention's 2009 Guideline for Prevention of Catheter-Associated Urinary Tract Infections revealed the proper techniques for urinary catheter maintenance includes: Do not rest the bag on the floor. Interview on 04/19/21 at 1:25 PM with Licensed Practical Nurse (LPN) #37 confirmed Resident #62's Foley bag was laying on the floor and not attached to a non-movable part of the bed. LPN #37 stated she knew the Foley bag was to be kept off the floor to reduce the risk of contamination and said she would address the issue immediately. On 04/20/21 at 9:45 AM, the Director of Nursing (DON) was notified of Resident #62's Foley bag being found on the floor. The DON acknowledged the importance of keeping the Foley bag off the floor and added, Sometimes he will take it and shake it.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation and staff interview, the facility failed to provide respiratory care consistent with professional standards of practice. A nasal cannula was wrapped around the bed rail and a nebulizer mask was on the bedside table with no protective covering. These observations were random opportunities for discovery. Resident identifiers: #39 and #65. Facility Census: 72. Findings included: a) Resident #39 Observation on 04/19/21 at 11:35 AM, found Resident #39's nasal cannula and tubing wrapped around resident's bedrail. Licensed Practical Nurse (LPN) #37 stated it was not a sanitary, safe practice and the cannula should be placed in the sterile bag by resident's oxygen concentrator. During a meeting on 04/20/21 at 9:47 AM, the Director of Nursing (DON) acknowledged improper storage of the nasal cannula may lead to inadvertent contamination. b) Resident #65 Observation on 04/19/21 at 11:50 AM found Resident #65's nebulizer mask on the bedside table with no protective covering. LPN #37 immediately stated, That should be in the drawer and opened the top drawer of Resident #65's nightstand. She then stated, Well, there is no sterile bag in there. I will need to get another one. During a meeting 04/20/21 9:55 AM, the DON acknowledged improper storage of the nebulizer mask may lead to inadvertent contamination.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview the facility failed to ensure the medical record was complete and accurate for two (2) of 18 residents whose Physician Order for Scope of Treatment (POST) forms were reviewed. Resident identifiers: #13 and #67. Facility Census 72. Findings included: a) Resident #67 On [DATE] at 3:42 PM, an electronic health record review revealed the following regarding Resident #67's desire for intravenous (IV) fluids: The Physician Order for Scope of Treatment (POST) form, dated [DATE], stated: IV fluids for a trial period of no more than 2 weeks, then speak to physician. An active physician order, dated [DATE], stated: IV fluids for a trial period of no longer than: 2 weeks, then speak to MPOA (Medical Power of Attorney.) During an interview on [DATE] at 11:00 AM, the DON agreed the POST form directing then speak to physician and the physician's order stating then speak to MPOA contradicted one another and was an issue that needed to be addressed. b) Resident #13 On [DATE] at 2:22 PM, an electronic health record review revealed the following regarding Resident #13's code status: An active physician order, dated [DATE], stated: Resuscitate (CPR). The Physician Order for Scope of Treatment (POST) form, dated [DATE], stated: Do Not Attempt Resuscitation / DNR. Resident #13's care plan, dated [DATE], stated: CPR-Attempt to Resuscitate. Observation on [DATE] at 3:50 PM, found signage outside door, by Resident #13's name, which listed resident as FULL CODE. During an interview on [DATE] at 10:55 AM, the Director of Nursing (DON) acknowledged the discrepancy between the physician's order, the POST form, Resident #13's current care plan, and the signage outside Resident #13's door. The DON indicated the discrepancy would immediately be addressed.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• 40 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (38/100). Below average facility with significant concerns.
• 55% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Maplewood Healthcare Center's CMS Rating?

CMS assigns MAPLEWOOD HEALTHCARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within West Virginia, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Maplewood Healthcare Center Staffed?

CMS rates MAPLEWOOD HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, which is 9 percentage points above the West Virginia average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Maplewood Healthcare Center?

State health inspectors documented 40 deficiencies at MAPLEWOOD HEALTHCARE CENTER during 2021 to 2025. These included: 1 that caused actual resident harm and 39 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Maplewood Healthcare Center?

MAPLEWOOD HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by COMMUNICARE HEALTH, a chain that manages multiple nursing homes. With 77 certified beds and approximately 75 residents (about 97% occupancy), it is a smaller facility located in BRIDGEPORT, West Virginia.

How Does Maplewood Healthcare Center Compare to Other West Virginia Nursing Homes?

Compared to the 100 nursing homes in West Virginia, MAPLEWOOD HEALTHCARE CENTER's overall rating (2 stars) is below the state average of 2.7, staff turnover (55%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Maplewood Healthcare Center?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is Maplewood Healthcare Center Safe?

Based on CMS inspection data, MAPLEWOOD HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in West Virginia. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Maplewood Healthcare Center Stick Around?

Staff turnover at MAPLEWOOD HEALTHCARE CENTER is high. At 55%, the facility is 9 percentage points above the West Virginia average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Maplewood Healthcare Center Ever Fined?

MAPLEWOOD HEALTHCARE CENTER has been fined $7,443 across 1 penalty action. This is below the West Virginia average of $33,153. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Maplewood Healthcare Center on Any Federal Watch List?

MAPLEWOOD HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 77
Avg. Residents: 75
Occupancy: 98.3%
Ownership: For profit - Corporation
Chain: COMMUNICARE HEALTH
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
High Turnover: -5
1 Actual Harm citation: -5
40 Deficiencies: -10
Fines ($7,443): -2
Final Score: 38/100

Nearby Alternatives

UNITED TRANSITIONAL CARE CENTE... 5-star BRIDGEPORT HEALTHCARE CENTER 4-star CLARKSBURG HEALTHCARE CENTER 4-star

View all in BRIDGEPORT →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 515194