CLARKSBURG HEALTHCARE CENTER
For profit - Limited Liability company
110 Beds
COMMUNICARE HEALTH
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
56/100
#21 of 122 in WV
Photo by Randall Greynolds
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Clarksburg Healthcare Center has a Trust Grade of C, which means it is average compared to other facilities, falling in the middle of the pack. It ranks #21 out of 122 nursing homes in West Virginia, placing it in the top half, and #3 out of 6 in Harrison County, indicating only one local option is better. However, the facility is worsening, with the number of issues increasing from 10 in 2023 to 11 in 2024. Staffing is a concern, rated at 2 out of 5 stars, with a turnover rate of 51%, which is around the state average. Additionally, there are some serious incidents to note: a resident was able to leave the facility unsupervised, raising safety concerns, and care plans were not updated following significant falls for multiple residents, which could lead to further complications. On a positive note, the facility maintains average RN coverage, which can help catch issues that may be overlooked by other staff. Overall, while there are strengths, families should be aware of the facility's weaknesses and recent incidents.
- Trust Score
- C
- In West Virginia
- #21/122
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $10,036 in fines. Higher than 70% of West Virginia facilities. Some compliance issues.
- Skilled Nurses ○ Average
- 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 ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
56/100
Top 17%
Review needed
10 → 11 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 10 issues
2024: 11 issues
The Good
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Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
Staff Turnover: 51%
Near West Virginia avg (46%)
Higher turnover may affect care consistency
Federal Fines: $10,036
Below median ($33,413)
Minor penalties assessed
Chain: COMMUNICARE HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
1 life-threatening
Oct 2024
11 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on record review, observations and staff interview, the facility failed to ensure residents were provided with a safe environment to prevent elopement, resulting in Resident #41 leaving the faci...
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Based on record review, observations and staff interview, the facility failed to ensure residents were provided with a safe environment to prevent elopement, resulting in Resident #41 leaving the facility. This failure to ensure residents did not exit the facility unattended on 07/11/2024 placed all at risk residents who could have exited the facility in an Immediate Jeopardy (IJ) situation. This will be cited at past noncompliance because the facility corrected the failure as of 07/09/24, prior to this survey. Resident Identifier: #41. Facility Census:96.
The State Agency (SA) determined this Past Non_Compliance had the potential to cause serious injury, harm, impairment or death to occur. Past non compliance Immediate Jeopardy was issued on 10/16/24 at 3:32 PM. The past non compliance occurred on 07/11/24 and was corrected on 07/13/24.
Findings included:
a) Resident #41
On 07/11/24 Resident # 41 left the facility through an unsecured door and walked to the front returning to the facility.
1) Progress Notes
7/11/2024 01:12
Pt went out a side door and then walked to the front door. Pt was gone for no more than 30 minutes. No complaints, no apparent injuries. Pt is at baseline. Pt now wearing a wanderguard.
7/11/2024 19:44
Note Text: Resident walked down the end of hall then looked around to see if anyone was watching and went to open the door. This UCN redirected residents from opening the door so that the alarm would go off and that leads to steps. Resident stated she works here and that she needed to go that way. After explaining that the alarm would go off, she stated it does that at my house too! Easily redirected.
6/30/2024 18:04
Note Text: Resident frequently out in hall wandering and carrying her blanket without shoes and is unsteady on feet. redirected to the room to put shoes on and to get her walker. then assisted the dining room to socialize with other residents. Has indicated several times she has to leave here because it is not safe because the building is going to catch on fire. Resident speaking of her family and how her Dad was cutting hay yesterday and it started pouring the rain down. Resident also thinks she is here to help other residents and states I am not not working anymore. I have worked for the past two weeks, and I am exhausted. staff continues to provide 1 on 1 with reassurance and activities of distraction when a resident is exhibiting episodes of anxiousness, worry, and confusion. interventions only successful for short periods. has had recent change in Cymbalta
6/28/2024 18:43
Note Text: Resident wandering the halls several times today, often without shoes or shoes halfway on, once came walking down the hall with a tablet in bra and purse on shoulder. Requesting to go home. Redirection last for short periods
2) Interviews
On 10/16/24 at 1:50 PM- Administrator was interviewed concerning resident's elopement. The administrator reported the resident went out the D hall door, walked down the stairs and around the outside walkway to the front door. The administrator reported another resident had attempted to go out the door earlier. He stated, The nurse reset the alarm, but did not get it set. The alarm had not been turned all the way so it did not alarm when the resident went out. The administrator stated the patient had not previously attempted to leave the facility.
On 10/16/24 at approximately 2:00 PM The Director of Nursing (DON) stated Staff education was started immediately and all staff education were completed on 07/13/24
3) Observation
On 10/16/24 at 1:20 PM- Survey team investigated door alarms on all wings. Inside door alarms were triggered with a scream alarm. Outside doors, past the unit's armed doors at the bottom of the stairwells, are not armed and are labeled, This door leads to OUTSIDE. Coded doors are labeled with: Push until the alarm sounds. Door can be opened in 15 seconds.
Unit LPN #51 reported a code white is called twice daily with all door alarms checked. If the door alarms are not armed, a code yellow is called and a resident count is initiated and all administration comes to the first floor nurses station
4) Record Review
During record review on 10/16/24 revealed the following:
Staff were alerted on 07/11/24 at approximately 12:00 AM that Resident #41 was outside knocking in the front door of the facility. Resident was let back inside and immediately evaluated head to toe and a wonder guard was ordered for Resident #41. The facility initiated an investigation to determine how Resident #41 eloped the facility. Through a thorough investigation the facility found the door alarm on the D-Hall was not reset correctly after another resident had set off the door alarm earlier.
The facility educated all staff on the following:
~Inspecting all door alarms to ensure they are alarmed and properly functioning
~Review elopement prevention and management policy
~Proper Procedure for door alarms.
~Education on the OHFLAC reporting criteria.
All staff were educated prior to starting their next scheduled shift, and all staff educations were completed 07/13/24. The facility also conducted elopement drills on 07/17/24, 08/14/24, 09/17/24, and 10/9/24 with no issues noted.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review and staff interview the facility failed to notify the Medical Power of Attorney of abnormal testing results. Resident Identifier: #145 Facility Census: #96
Findings included:
a)...
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Based on record review and staff interview the facility failed to notify the Medical Power of Attorney of abnormal testing results. Resident Identifier: #145 Facility Census: #96
Findings included:
a) Resident #145
On 10/16/24 at 2:10 PM record review shows that Resident #145 had abnormal laboratory and urinalysis results that were not relayed to the Medical Power of Attorney (MPOA).
According to the Mayo Clinic:
A complete blood count (CBC) is a blood test. It's used to look at overall health and find a wide range of conditions, including anemia, infection and leukemia. The normal white blood cell count range is typically between 4 and 11 depending on age and medical conditions.
Review of a Complete Blood Count (CBC) laboratory results collected on 12/29/23 and printed on 12/30/23 shows an abnormal white blood count (WBC) of 27.6. There are additional test results on the laboratory report that are flagged as abnormal.
The urinalysis is also marked as abnormal and containing white blood cells and bacteria.
There is no documentation that the MPOA was informed of the testing results.
When discussed with the Director of Nursing on 10/16/24 at 3:25 PM, she confirmed that the results were not reported to the MPOA due to the declining condition of the resident.
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
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Based on observation, resident and staff interview, facility record review, and medical record review, the allegation that the facility failed to ensure that residents were free from abuse and negle...
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Based on observation, resident and staff interview, facility record review, and medical record review, the allegation that the facility failed to ensure that residents were free from abuse and neglect is found to be substantiated. This was true for Residents #16, #34, and #11. Facility census: 96.
Findings included:
a) Resident #16
On 10/16/2024 a review of the Facility Reported Incident (FRI) which occurred on 09/05/24 and found Resident #16 saturated with a ring of urine staining the bed linens, street clothes and shoes. The report specified that initially the resident was angered about the incident, but afterward placed the incident behind him and was doing better.
The witness statement submitted by CNA #119 and undated read as follows:
When I arrived on shift [Resident #16] was one of my first residents I checked on. I got him ready for bed, toileted him, offered to change his clothes. He didn't want to be layed down. I later returned with snacks and ice water and I got him a tea. I did regular rounds also, then around 3:30-4:00 AM, he rang was hungry so I got him and his room mate an ice cream. He also had leg pain (nurse alerted) also toileted. I then regularly checked on his pain every little bit making sure he was okay he also complained about urine burning (nurse also alerted) I pushed fluids and offered regular toileting.
Certified Nursing Assistant (CNA) #119 was suspended pending investigation with a signed statement saying that discipline could include termination. In an interview at 2:15 PM 10/16/24 with the Director of Nursing (DON), stated that CNA #119 was suspended pending the investigation which was deemed unsubstantiated with unverified details. The facility did take immediate corrective action by changing the schedule of the CNA #119. She was terminated at a later date due to another incident with another resident, not as a result of the incident involving Resident #16.
Review of the report provided to Adult Protective Services (APS) indicated that additional notifications were sent to the Ombudsman, facility administration, Office of Health Facilities and Certification (OHFLAC) by the Social Services Director. It indicates that while the resident retains capacity with a Brief Interview for Mental Status (BIMS) of 15, that they are unable to care for or protect themselves due to physical disability and chronic illness (needing advanced assistance with activities of daily living) but was not at immediate risk of serious injury or death or is in an emergency situation as defined by W.Va. Code Subsection 9-6-1.
An additional statement from the morning shift CNA #79 on 09/06/24 which read as follows:
Went to get resident up and dressed for the day. When I pulled back the blankets he was still dressed in his clothes from the day before, shoes still on and completely saturated in urine. Resident stated last night was awful and he hadn't been touched all night long.
The written, signed witness statement from Resident #19 taken on 09/06/24 read as follows concerning the event of 09/05/24:
Last night was bad. Staff would not answer call light or would stand and not assist me. Told me ' you don't need help'. Left in clothes and dirty briefs and would not change me. This was night shift and it was a girl with ponytails; brown hair; skinny; around 5 ' 1. I asked for help getting up. I hated last night . I was so upset.
Review of the resident's orders confirmed that Resident #16 required advanced assistance with their Activities of Daily Living (ADL)s. The care plan specifically stated:
Toileting hygiene: Totally dependent of 1. 1 Helper does all the effort. Resident does none of the effort Date Initiated: 05/04/24.
b) Resident #34
On 10/17/24 review of a FRI dated 04/22/24 and reported to Administration on 04/23/24 involved CNA #121 witnessing CNA #120 behaving inappropriately toward Resident #34 to bed. CNA #120 called Resident #34 a child molester, and as he was grinding his teeth told him she'd smack him in the mouth if he didn't stop. Neither CNA works at the facility any longer.
Resident #34 lacks capacity and is mostly nonverbal. Surveyor attempted to contact the resident representative but received no return call on 10/17/2024 at 10:00 AM. Per resident Minimum Data Set (MDS) he is dependent on facility staff for maximal assistance with all ADL's and all other activities. The resident care plan indicates that he had a hearing impairment, communication deficit, impaired cognitive functioning, and depression for which he receives antidepressant medication and is monitored for side-effects.
The surveyor observed the resident in the hallway ambulating and people-watching on 05/17/24. The surveyor complimented the resident's choice in outfit for the day, at which time the resident smiled warmly and continued actively watching other residents and staff in the corridor. The surveyor observed that there were no behaviors indicating distress as a result of this incident as the resident was nonverbal, but friendly and responsive to interaction.
Immediate action taken by facility administration was to suspend CNA #120 pending investigation. They reported the incident to OHFLAC, the facility Ombudsman, and the CNA Registry. The facility Employee Corrective Action form states that there would be disciplinary action up to and including termination. This form was signed by facility administration and the alleged perpetrating party on 04/23/24.
All staff were interviewed and none reported having heard or participated in inappropriate conduct toward residents except for CNA #121. The written witness statement (signed/dated 04/23/24) from CNA #121 read as follows:
We were putting [Resident #34] to sleep and the aid [CNA #120] called him a child molester and as he was grinding his teeth she said if he didn't stop she was going to smack him in his mouth . Resident #11 told me that [CNA #120] put a pillow over her face and said 'pillow therapy' but [Resident #11] doesn't know if she was joking or not.
The surveyor interviewed the DON at approximately 10:30 AM on 10/17/24, who expressed that immediately upon discovery of the second allegation of the abusive treatment of Resident #11, the facility administration opened a second investigation. She stated that CNA #120 had not returned onsite between the time of the initial suspension for the events surrounding Resident #34 and the discovery of the events surrounding Resident #11. She provided the employee dismissal paperwork which confirmed that both events were corroborated serving as basis for CNA #120's employment termination (at the conclusion of the concurrent investigations) as of 04/24/24.
c) Resident #11
Upon reviewing the witness statement of CNA #121 alleging abuse of Resident #34 the surveyor took note of and initiated investigation into the allegation of abusive rhetoric by CNA #120 against Resident #11.
The written witness statement (signed/dated 04/23/24) from CNA #121 read as follows:
We were putting [Resident #34] to sleep and the aid [CNA #120] called him a child molester and as he was grinding his teeth she said if he didn't stop she was going to smack him in his mouth . Resident #11 told me that [CNA #120] put a pillow over her face and said 'pillow therapy' but [Resident #11] doesn't know if she was joking or not.
A second witness testimony from CNA #75 on 04/23/24 read as follows:
(name redacted) told me that [CNA #120] put a pillow on her head and said 'pillow therapy'! She said she thought [CNA #120] was joking.
Resident #11 has capacity as of 06/14/24, with a BIMS of 15. She is bedridden, and upon review of her care plan, 10/07/24 she began receiving hospice services. Per the resident's MDS, she is completely dependent on facility staff for maximal assistance with all ADL's and/or any other activities as a result of the resident's decline in health.
Review of the facility investigation record revealed that they had reported the allegation of misconduct upon discovery to OHFLAC, Ombudsman, APS (414443), and the CNA registry on 04/23/24 after the interview with CNA #121 revealed additional inappropriate behavior toward Resident #11. The form included the added detail under the section pertaining to interview with the perpetrator that [CNA #120] says she's not the only one who jokes about pillow therapy.
Two (2) surveyors went to interview Resident #11 who stated that she had a close rapport with CNA #120 during her employment at the facility. She stated that the CNA was being jovial when stating that they should try pillow therapy as a result of the resident having been complaining about the uncomfortable state of her declining condition. She stated that the pillow did not make contact with her head, but that Resident #11 had been complaining about the state of her condition and that was the direct response in jest from CNA #120. The resident tried to reassure the surveyors that she still had her voice and more importantly her head and that she would make it known if she felt threatened or disturbed in any way by staff.
The surveyor interviewed the DON, who expressed that immediately upon discovery of the second allegation of the abusive treatment of resident #11, the facility administration opened a second investigation. She stated that CNA #120 had not returned onsite between the time of the initial suspension for the events surrounding resident #34 and the discovery of the events surrounding resident #11. She provided the employee dismissal paperwork which confirmed that both events were corroborated serving as basis for CNA #120's employment termination (at the conclusion of the concurrent investigations) as of 04/24/24.
Review of the facility's Employee Separation Report (completed within 24 hours of termination) provides a secondary confirmation that CNA #120 did not return to the facility between the initiation of her suspension, pending investigation into resident #16 ' s allegation of abuse, and the conclusion of the investigations into resident #34 and resident #11 abuse allegations. These were both found to be substantiated, and the repercussion entailed the immediate termination of employment of CNA #120.
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
Based on record review, resident interview and staff interview, the facility failed to develop a person-centered comprehensive care plan for Resident #80 regarding the use of hearing aids, and not hav...
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Based on record review, resident interview and staff interview, the facility failed to develop a person-centered comprehensive care plan for Resident #80 regarding the use of hearing aids, and not having careplaned Resident #294 having fistula in left arm. This is true for one (1) of 24 residents reviewed during the survey process. Resident identifier: #294. Facility Census: 96
Findings included:
a) Resident #294
On 10/14/24 at 12:00 PM surveyor observed a sign posted being Resident #294's bed stating no blood pressure(B/P) or labs in left arm)
During record review on 10/15/24 at approximately 10:00 AM of Resident #294's orders showed an order to check fistula in left arm for bruit and thrill every shift.
Further record review on 10/15/24 revealed the following:
- Facility staff documented on 10/04/24, 10/05/24, and 10/12/24 B/P was obtained in Resident #294's left arm.
- The care plan did not address or contain anything about not taking the blood pressure or labs in the left arm, and did not identify residents having a fistula in the left arm.
An interview on 10/15/24 at approximately 1:00 PM with the Director of Nursing (DON) confirmed the care plan did not address residents having an fistula in the left arm and there was nothing in the medical record stating not to take B/P or obtain labs from the left arm. DON also states the B/P's obtained were not taken in Resident#294's left arm, the staff had incorrectly documented the B/P being taken in the left arm.
On 10/15/24 at 2:05 PM Resident #294 states they have had the fistula in their arm for approximately 7 years, and does not recall ever having a B/P taken in that arm while in the facility.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
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Based on record review and staff interview, the facility failed complete a change of condition for a declining resident and caused a delay in treatment for a resident. Resident Identifiers: #50 and ...
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Based on record review and staff interview, the facility failed complete a change of condition for a declining resident and caused a delay in treatment for a resident. Resident Identifiers: #50 and #145. Facility Census: #96.
Findings included:
a) Resident # 50
On 10/14/24 at 2:16 PM record review shows Resident #50 had several orders and progress notes dated 10/05/24 concerning her condition.
The following details were reviewed in the nurses progress notes:
10/5/2024 18:24
Nurses Note
Note Text: Resident decline in ability to consume Po intake. Resident is gagging with the touch of food in her mouth. This nurse contacted (in house physician). He gave recommendations for care and resident Medical Power of Attorney (MPOA) declined further testing. MPOA stated I do not feel like anything is wrong, I think she is just tired. This nurse talked to MPOA about the use of morphine and educated MPOA on comfort focused treatment. MPOA changed resident post form to DNR-CC. MPOA in agreement with new order and is sitting at resident bedside.
10/5/2024 17:58
Nurses Note
Note Text: New order per (in house physician) to discontinue PO medications. Start resident on Morphine sulfate 0.25 ml q1h PRN for pain, distress and/or air hunger. MPOA in agreement with new orders.
Record review shows there was no change in condition completed in regards to the changes referred to in the above nurses progress notes.
On 10/16/24 at 12:08 PM the Director of Nursing (DON) confirmed that a change of condition should have been completed for the following items in the nurses progress notes
1. Changed POST to DNR comfort care
2. Started morphine
3. Physician order to discontinue all PO medications
4. Resident decline in ability to consume PO intake.
b) Resident #145
On 10/17/24 at 10:56 AM record review shows that the family of Resident #145 voice concern on 12/12/23 about the resident not responding to their questions.
Time line of documentation;
12/12/23 at 10:50 AM Family voiced concern about resident not responding to there questions.
12/14/23 at 111:17 AM there was a wound care note documented.
There were no additional in house progress notes documented until 12/17/23 at 5:39 PM COVID Binaz Negative
12/24/23 at 8:50 PM Spoke with Hospice triage nurse they will send someone out to evaluate resident
12/24/23 at 8:54 PM documentation reads that resident was COVID negative.
12/24/23 8:41 PM reduced mental alertness and not speaking. PT vital signs taken, temp found. Lungs clear and diminished. Urine does not smell offensive. Pt unable to tell me what is wrong. Call placed to family and hospice.
Temperature documented in vital signs on 12/24/23 at 8:55 PM as 101.5 Fahrenheit (F). Additional temperatures documented in vital signs were:
12/24/23 at 10:58 PM 102 F
12/26/23 at 10:29 PM 100.5 F
12/27/23 at 9:39 PM 101. F
12/28/23 at 6:11 AM 102.4 F
12/27/23 at 5:48 PM received an order for a two (2) view chest X-ray. Results on 12/27/23 at 11:38 PM shows No acute cardiopulmonary disease:.
12/28/23 at 4:38 AM Nurse called Hospice nurse to relay request from family for laboratory work.
12/28/23 at 10:08 AM Elevated temps noted. New order for Tylenol via mouth/suppository if unable to swallow. Note: Documentation shows resident has had a temperature for four (4) days, this is the first order for Tylenol.
12/28/23 at 3:51 PM New order from Hospice for U/A and C&S (urinalysis and culture and sensitivity) via straight catheterization and CBC (complete blood count) with differential to be drawn on 12/28/23 night shift.
12/29/23 at 3:02 AM blood sample obtained from residents left anti-cubical with one attempt.
12/29/23 at 3:37 AM urine sample obtained via straight catheter with one attempt.
12/30/23 at 6:48 PM Resident bed rested this shift family at beside with her all shift. Resident displays signs of pain and anxiousness several times this shift. Grimacing and whimpering. Scheduled Ativan and Morphine given with positive results. Resident did void X 2. Oral care also completed this shift. Family with resident at this time. Oxygen on re-breather, oxygen saturation above 92%, head of bed elevated with no signs or symptoms of shortness of breath voiced no notes.
12/31/23 3:32 AM Absence of vital signs verified by 2 nurses (names inserted). No respiration or heartbeat noted. Pupils fixed ad dilated. Family at bedside is aware. Director of Nursing notified. Physician called. Also Hospice has been notified.
Further documentation shows Resident #145 has a history of urinary tract infections (UTI) while she was a resident at the facility.
1/17/19 Amoxicillin tablet 500 milligrams (mg) Give 500 mg by mouth two times a day for UTI for 7 days.
12/02/20 Macrobid Capsule 100 mg Give 100 mg by mouth two times a day for UTI for 7 days.
11/05/21 Ciproflaxacin HCL tablet 250 mg Give 1 tablet by mouth every 12 hours for infection for 3 days
3/15/23 Cephalexin Suspension Reconstituted 250 mg/5 milliliters Give 10 ml by mouth four times a day for UTI for 7 days
03/17/23 Ceftriaxone Sodium Injection Solution Reconstituted 1 GM (Ceftriaxone Sodium) Inject 1 gram intramuscularly one time a day for UTI for 3 Days
There was evidence of the complete blood count (CBC) and UA and C&S laboratory work that was obtained on 12/29/23 and printed on 12/30/23 at 12:39 PM with abnormal results as follows:
Urinalysis showed elevated WBC's as well as bacteria in the urine sample
WBC (white blood count) elevated at 27.600.
Resident #145 had been a Hospice resident in November 2023 but was discontinued and re-consulted on 12/24/23. Hospice notes were reviewed for 12/12/23 through 12/28/23 as provided by the facility.
On 10/17/24 at 12:01 PM the above was confirmed with the DON. When presented and ask why the Tylenol was never addressed with the Resident's first temperature on 12/24/23 at 102 F and why a urinalysis with a culture and sensitivity was never obtained until 12/29/23 she stated she did not know. A delay in treatment was discussed and there was no further information provided prior to exiting the survey.
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, medical record review, and staff interview, the allegation that the facility failed to ensure n...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, medical record review, and staff interview, the allegation that the facility failed to ensure nutrition and hydration status maintenance for Resident #295 was substantiated. Facility census: 96.
Findings included:
On 10/16/24 the surveyor reviewed an initial reporting form submitted as a Facility Reported Incident (FRI) which occurred and was reported on 04/17/24. This FRI indicates that LPN #85 stopped Resident #295's ordered tube feeding on night shift 04/17/24 stating that the tube feed was stopped because it didn't flush well. At this time the Nurse Practitioner (NP) was notified and the tube feeding was restarted during the day shift of 04/17/24 with additional supplements.
According to the five-day followup, the facility administration notified Resident #295's health care surrogate at 11:20 AM on 04/17/24. Additionally, administration reported the event to the LPN Board and the Ombudsman at 10:29 AM. The report indicates that the resident was not interviewable.
The followup form indicates that the allegation could not be verified, and that the allegation was refuted by evidence collected during the investigation. Per LPN #85 the tube feeding was disconnected for a short period of time.
In an addendum, facility administration conducted interviews with the alleged victim's responsible parties, emphasizing that the victim was not capable of interview. Witnessing LPN #71 reported that he initiated the tube feeding at 04/16/24 during day shift and it was still running when he left the facility at 7:30 PM. When LPN #71 came back for dayshift on 04/17/24, LPN #85 reported to LPN #71 that the resident's tube did not flush well, and that LPN #85 did not realize there was that much left. CNA #28 reported that on the morning of 04/17/24 the resident's bottle of Glucerna still had a lot left in the bottle.
In an administration-initiated interview with the alleged perpetrator, LPN #85 stated that on 04/17/24 the machine started beeping and he noticed that the resident's tubing was separated and the end-cap was removed. LPN #85 cleaned the tube and restarted the feeding. LPN #85 stated that around 6:12 AM the tube feeding was disconnected and at that point the tube flushed easily.
In an interview with with LPN #71 and CNA #28, separately at 12:30 PM on 10/16/24. The two corroborated that the Glucerna 1.5 kcal/ml 1 liter had been initiated 04/16/24, and was still administrating upon their departure at 7:30 PM. LPN #71 stated that he found it unusual that everything had been cleaned and set up upon return to day-shift, and at this point CNA #28 reported that 800 ml of the Glucerna remained because the resident had not been tolerating it well. When asked why LPN #85 did not seek to attain orders to discontinue feeding, both LPN #71 and CNA #28 found themselves at a loss, stating I really don't know.
At approximately 3:30 PM on 10/16/24 the surveyor requested LPN #85's contact information to conduct an interview. The DON confirmed that because they had determined their investigation to be inconclusive, no further disciplinary action had been taken against LPN #85. The surveyor attempted to contact LPN #85 (who had returned from their subsequent suspension) on three occasions, beginning at 12:45 PM 10/16/24, again at 2:00 PM the same day, and on 10/17/24 at 10:30 AM. Each time the recipient's voicemail box was not set up, and the phone was disconnected from service.
Review of orders indicate that the resident was to receive 85 ml Glucerna per hour and H2O at 65 ml per hour. At 7:30 AM LPN #71 stated there was 800 ml of the Glucerna 1.5 kcal/ml remaining. At the time LPN #85 discontinued the feeding, they failed to obtain an order for discontinuation at any point throughout the night. The resident was discharged [DATE] from the facility after this incident to the emergency room did not return to the facility. A Physician's note from 05/23/24 states that they likely transferred to another long term care facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, the facility failed to store the residents' personal food in a way that was separate or easily distinguishable from facility food. This failed practice has th...
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Based on observation and staff interview, the facility failed to store the residents' personal food in a way that was separate or easily distinguishable from facility food. This failed practice has the potential to affect more than a limited number of resident's. FACILITY:FACILITY Facility Census: #96.
Findings included:
Finding confirmed by the Dietary Manager(DM) on 10/15/24 during the kitchen investigation initiated at 11:45 AM included: a resident's food item found in the facilities main freezer in the kitchen. An opened box of popcorn shrimp in the facility freezer was not dated or labeled. The DM stated the item was a resident's personal item and there was no room in the resident's freezer for the frozen food.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan regarding a fall with major injury for Res...
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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 revise a care plan regarding a fall with major injury for Resident #47, behaviors and the discontinuation of medications for Resident #51, and the code status of Resident #50. This is true for three (3) of 24 residents reviewed during the survey process. Resident Identifier: #47, #51 and #50. Facility Census: 96.
Findings Included:
a) Resident #47
On [DATE] at 12:15 AM, the care plan was reviewed for Resident #47. The review found the care plan had not been revised to indicate a fall with major injury had occurred on [DATE].
A progress note dated [DATE] at 0000 by the facility nurse practitioner states the following:
Post fall with head injury
History Of Present Illness:
[DATE]
This is an (Age and sex redacted) being seen after sustaining a fall. Provider was in the building when the fall occurred. I arrived to the bedside Staff had assisted resident back to her bed. She had hit her head on the floor. There was already bruising forming and edema on frontal region of her head. She stated she felt like she was passing out. She is pale and drowsy. Vital signs were taken which were stable. She is mildly anxious at the time of the fall. Due to the head injury. Recommendations were made to call 911 and have her evaluated at the hospital. Neurochecks are within normal limits during focused exam. She is at her cognitive baseline. Staff remained with resident until ambulance arrived for transport. Ice was placed on her head due to swelling. She denies any other injury or complaints from the fall. (Typed as written.)
An additional progress note [DATE] at 8:28 PM states, Resident fell at the facility therefore sent to hospital. Resident has returned from ER diagnosed with two broken ribs on her right side. Resident received new order from Norco 5/325mg PRN(as needed) Q (every) 6 (six) hours. Encourage deep breathing exercise. (Typed as written.)
On [DATE] at 3:00 PM, the Director of Nursing (DON) was notified and confirmed the care plan did not indicate the resident had an actual fall with major injury.
b) Resident #51
On [DATE] at 1:00 PM, the care plan was reviewed for Resident #51. The review found the care plan did not indicate specific behaviors under the focus area of behavior problem related to vascular dementia. The review, also, found under the focus areas of mood problem related to dementia and diabetes had an intervention to administer medications per medical provider's care. The resident is currently not taking any prescribed medications.
On [DATE] at 3:00 PM, the DON was notified and confirmed the care plan did not indicate any specific behaviors and the resident was not currently taking any prescribed medications.
c) Resident #50
On [DATE] at 12:56 PM record review for Resident #50 shows her Medical Power of Attorney made a change in her advanced directives were initiated on [DATE]. According to the Physicians Determination of Capacity dated [DATE] Resident #50 lacks capacity to make medical decisions.
On [DATE] Resident #50's Physician Orders for Scope of Treatment (POST) form was updated to be No Cardiopulmonary Resuscitation (CPR) with comfort focused treatments, no artificial means of nutrition desired.
A review of the comprehensive person-centered care plan does not indicate the changes made to the POST form in regards to comfort care.
There are no goals or interventions in place for comfort care in regards to respect and dignity and to be comfortable during the end of life process
On [DATE] at 1:43 PM the above findings regarding the care plan were reviewed with the DON who agreed the care plan should have been updated to reflect comfort care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affec...
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Based on observation and staff interview, the facility failed to store and label food in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. FACILITY: FACILITY Facility Census: #96.
Findings included:
Findings confirmed by the Dietary Manager(DM) on 10/14/24 during kitchen investigation initiated at 11:45 AM included:
a) Large container of tea with no date/smeared date (not legible). Kitchen staff (#27), stated, That was yesterday's. SS reviewed with DM. The DM stated, That's made every day. Measuring cup with tea on the bottom was sitting on top of the container. Tea was relabeled with current date prior to end of the kitchen tour.
b) Pitchers were stored on a shelf with water inside x 2. DM stated there was a limited amount of space to properly store items in the kitchen.
c) [NAME] cake mix was opened on 08/17/24- not sealed and spilling out of bag- no use by date was marked.
d) Dented can x 1 - Campbell's chicken noodle soup.
e) Devil's Food Cake mix opened on 09/29/24- sealed-no use by date.
f) [NAME] cake mix was opened on 08/17/24- not sealed and spilling out of bag;-no use by date.
g) Burrito shells opened 10/05/24-no use by date.
h) Bag of ravioli was found in the freezer with no dates.
i) Chicken patties opened in the freezer with no date. Two additional bags were unopened, but not dated (out of the box). DM reported he had an employee that is pulling food out of the boxes and not
dating them.
j) Opened bag of frozen carrots were not dated.
k)10/15/24 10:36 AM - Two pantries were investigated. No dates on ice cream products or boxes in either pantry. The DM stated the ice cream is replaced weekly and it is a scheduled weekly replacement order.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on record review and staff interviews, the facility failed to have an accurate medical record for three (3) of 24 residents reviewed during the Long Term Care Survey. Resident identifier: #294, ...
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Based on record review and staff interviews, the facility failed to have an accurate medical record for three (3) of 24 residents reviewed during the Long Term Care Survey. Resident identifier: #294, #9, #76. Facility Census: 96.
Findings Included:
a) Resident #294
On 10/14/24 at 12:00 PM surveyor observed a sign posted being Resident #294's bed stating no blood pressure (B/P) or labs in left arm).
During record review on 10/15/24 at approximately 10:00 AM of Resident #294's orders showed an order to check fistula in left arm for bruit and thrill every shift.
Further record review on 10/15/24 revealed the following:
- Facility staff documented on 10/04/24, 10/05/24, and 10/12/24 B/P was obtained in Resident #294's left arm.
- The care plan did not address or contain anything about not taking the blood pressure or labs in the left arm, and did not identify Resident #294 as having a fistula in the left arm.
An interview on 10/15/24 at approximately 1:00 PM with the Director of Nursing (DON) confirmed the care plan did not address Resident #294 as having an fistula in the left arm and there was nothing in the medical record stating not to take B/P or obtain labs from the left arm. The DON also stated that B/P's obtained were not taken in Resident#294's left arm, the staff had incorrectly documented the B/P being taken in the left arm.
On 10/15/24 at 2:05 PM Resident #294 states they have had the fistula in their arm for approximately 7 years, and does not recall ever having a B/P taken in that arm while in the facility.
b) Resident #9
On 10/15/24 at 3:34 PM record review shows Resident #9 had the following Physicians orders:
Topiramate Oral Tablet 50 MG (Topiramate) Give 100 mg orally two times a day for health maintenance
Gabapentin Oral Capsule 300 MG (Gabapentin) Give 300 mg orally at bedtime for health maintenance
Medical diagnosis for Resident #9 reflects the following:
Migraine, unspecified, no intractable, without status migrainosus
Diabetes Mellitus due to underlying condition with hyperglycemia
The above two medication orders indicate they are for health maintenance which is not an approved diagnosis.
Topiramate is used for migraines and Gabapentin is use for diabetic nephropathy
On 10/16/24 at 9:13 AM it was confirmed with the DON that Resident #9 was indeed receiving Topiramate for migraines and Gabapentin for diabetic nephropathy.
c) Resident #76
On 10/15/24 at 4:00 PM, a record review was completed for Resident #76. The review found an assessment entitled Pain Observation Tool dated 10/03/24. The assessment indicated the resident received Norco 5 mg (five milligram) three times daily for pain which was effective for the resident's pain.
On 10/15/24 at 4:30 PM, the Director of Nursing (DON) was interviewed regarding Resident #76's pain medication. The DON was notified and confirmed the resident was prescribed this pain medication. The DON stated, the resident has never been on prescribed Norco while at the facility.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review and staff interview, the facility failed to maintain an infection control program during medication administration. This had the potential to affect more than a lim...
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Based on observation, record review and staff interview, the facility failed to maintain an infection control program during medication administration. This had the potential to affect more than a limited number of residents. This is a random opportunity for discovery. Facility Census: 96.
Findings Included:
a) Medication Administration
On 10/16/24 at 8:45 AM, an observation of Licensed Practical Nurse (LPN) #51 during medication administration on B hall was completed. There are 22 residents who reside on the B hall. LPN #51 was assigned the entire B hall for medication administration.
On 10/16/24 at 8:57 AM, LPN #51 failed to complete hand hygiene between Resident #32 and Resident #2.
On 10/16/24 at 9:35 AM, LPN #51 left the B Hall to go the medication room. Upon return, LPN #51 did not complete hand hygiene prior to administering medication to Resident #37.
On 10/16/24 at 9:55 AM, an interview was held with LPN #51. LPN #51 stated, I thought I did hand hygiene at these times.
On 10/16/24 at 10:00 AM, the Director of Nursing (DON) was notified of the failure to complete hand hygiene prior to medication administration. The DON stated, thank you for letting me know.
b) Facility Policy
On 10/16/24 at 10:15 AM, the DON provided a copy of the facility policy entitled, Medication Administration. In Section II entitled, Preparation, h. states, Perform hand hygiene before and after each resident's medication is administered.
Jul 2023
2 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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to revise a care plan for adaptive equipment during meals. This was a random opportunity for discovery. Resident #56. Facility Census: 9...
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Based on record review and staff interview, the facility failed to revise a care plan for adaptive equipment during meals. This was a random opportunity for discovery. Resident #56. Facility Census: 91.
Findings included:
a) Resident #56
On 07/25/23 at 11:00 AM, a review of the current physician's orders found Kennedy cup on all trays dated 07/20/23. The care plan was reviewed and did not list the Kennedy cup on all trays as an intervention under the focus care area of a potential for nutritional problem.
On 07/25/23 at 12:45 PM, during the noon meal, Resident #56's meal ticket was reviewed. A Kennedy cup was listed on the meal ticket. However, the resident did not have a Kennedy cup on their tray.
On 07/25/23 at 12:20 PM, Licensed Practical Nurse (LPN) #9 confirmed the Kennedy cup should be on the lunch tray and should be listed on the care plan.
On 07/25/23 at 1:45 PM, the Administrator was notified and stated, okay.
No further information was obtained during the survey process.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review and staff interview, the facility failed to follow a physician's order for adaptive equipment during meals. This was a random opportunity for discovery. Resident #5...
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Based on observation, record review and staff interview, the facility failed to follow a physician's order for adaptive equipment during meals. This was a random opportunity for discovery. Resident #56. Facility Census: 91.
Findings Included:
a) Resident #56
On 07/25/23 at 12:18 PM, during the noon meal, Resident #56's meal ticket was reviewed. A Kennedy cup was listed on the meal ticket. However, the resident did not have a Kennedy cup on the lunch tray. A review of the current physician's order was found for a Kennedy cup on all trays dated 07/20/23.
On 07/25/23 at 12:20 PM, Licensed Practical Nurse (LPN) #9 confirmed the Kennedy cup should be used during all meals. LPN #9 stated, let me get one .dietary must have not put it on the tray.
On 07/25/23 at approximately 1:30 PM, Culinary Director #48 was notified and stated, it must have gotten missed .I had to change their assignments today.
On 07/25/23 at 1:45 PM, the Administrator was notified and stated, okay.
No further information was obtained during the survey process.
Jan 2023
8 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, policy review, resident interview, and staff interview, the facility failed to ensure a residents' rig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, policy review, resident interview, and staff interview, the facility failed to ensure a residents' right to formulate an advance directive. This was true for one (1) of 24 resident's reviewed in the Long-Term Care Survey Process. Resident identifier: #7. Facility census: 82.
Findings included:
a) Resident #7
On 01/09/23 at 1:28 PM, a brief record review revealed the following details:
--Resident #7 was admitted to the facility on [DATE].
--Resident #7 had capacity to make her own decisions.
--There was a Physician Orders for Scope of Treatment (POST) form on file, completed on 12/13/22, which indicated no advance directive in existence.
During an interview on 01/10/23 at 11:30 AM, Social Worker #70 reported she specifically remembered going over paperwork with Resident #7 and discussing resident's right to formulate a medical power of attorney if she desired. Social Worker #70 stated she would check with the medical records department to locate the paperwork that would have been signed during the meeting. Social Worker #70 acknowledged there was no documentation in the electronic medical record to reflect the discussion had occurred.
On 01/10/23 at 3:39 PM, Social Worker #70 provided a copy of the signed paperwork that was reviewed with Resident #7 following her admission to the facility. The Social Worker reported the document had been scanned following her meeting with Resident #7 but had not been uploaded to the electronic medical record. A review of the paperwork revealed the following details were reviewed with the resident:
--You have the right to complete written advance directives for your family and your doctor to follow when making decisions about your health care in the event that you become unable to decide for yourself.
--West Virginia law recognizes two types of written advance directives for health care decision-making: A Living Will and the Medial Power of Attorney.
--A Living Will is a legal document that tells your doctor how you want to be treated if you are terminally ill or permanently unconscious and cannot make decisions for yourself.
--A Medical Power of Attorney is a legal document that allows you to name a person to make health care decisions for you if you are too sick to make them for yourself.
Resident #7 had answered Yes to the question which stated, I have not completed an advance directive and I would like additional information and help to create one. This form was signed by Resident #7 and dated for 12/15/22.
On 01/11/23 at 9:25 AM, review of the facility policy titled, Advance Directives was completed. The policy directs: The facility will, in a timely manner, inform the resident directly of the rights related to the formulation of an advance directive and assist the resident as needed in this process.
During an interview, on 01/11/23 at 9:50 AM, the Social Work Supervisor #25 stated the department failed to follow-up with Resident #7 to formulate Advance Directives.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
.
Based on medical record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed under closed records dur...
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Based on medical record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed under closed records during the Long-Term Care Survey Process (LTCSP). The MDS assessment for Resident #85 did not accurately reflect the resident's discharge status. Resident identifier: #85. Facility census: 82.
Findings included:
a) Resident #85
On 01/10/23 at 12:41 PM, a review of the electronic medical record was completed. A review of the Discharge MDS, with an Assessment Reference Date (ARD) of 11/03/22, revealed Section A was marked as Resident #85 being discharged to an acute hospital. However, the discharge plan documentation, dated 11/02/22, noted resident was scheduled for a discharge to home.
During an interview on 01/10/22 at 2:12 PM, the MDS Coordinator confirmed Resident #85 was discharged to home. The MDS Coordinator noted the MDS coding reflecting a discharge to an acute hospital was in error.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
.
Based on resident interview, record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was tr...
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Based on resident interview, record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. This was true for two (2) of 24 sample residents reviewed during the Long Term Care Survey Process. Resident #9 had no order for a pressure reducing device and Resident # 26 had no repeat laboratory (lab) work obtained. Resident identifiers: #9 and #26. Facility census: 82.
Findings included:
a) Resident #9
During the resident interview with Resident #9 on 01/09/23 at 11:47, stated the air mattress worked well to keep her repositioned, since she was unable to move due to her multiple sclerosis (MS).
A medical record review on 01/10/23 revealed the current care plan had an intervention developed on 05/17/22 for a pressure reducing device on bed at all times for pressure ulcer risk. Further record review indicated there was no physician's order obtained for the pressure reducing air mattress.
In an interview with the Director of Nursing (DON) on 01/10/23 at 2:05 PM, verified there was no physician's order for the pressure reducing air mattress for Resident #9's bed.
b) Resident #26
During a medical record review on 01/10/23, the Lab Results Report received on 05/18/22 were reviewed by the physician which requested a complete blood count (CBC) to be repeated in two (2) weeks. There was no evidence the repeat CBC lab work was completed.
In an interview with the DON on 01/11/23 at 8:48 AM, verified there was no documentation the repeat CBC lab work had been completed.
.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
.
Based on resident interview, record review and staff interviews the facility failed to provide the proper hemodialysis diet. This was true for one (1) of one (1) resident reviewed for dialysis durin...
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Based on resident interview, record review and staff interviews the facility failed to provide the proper hemodialysis diet. This was true for one (1) of one (1) resident reviewed for dialysis during the Long Term are Survey Process. The physician's orders for dietary restrictions were not being followed for Resident #61. Resident identifier: #61. Facility census: 84.
Findings included:
a) Resident #61
During the resident interview on 01/09/23 at 11:56 AM, Resident #61 reported she is often served soups, which she was not to have due to fluid restrictions.
A record review completed on 01/10/23, revealed a physician's order for no soups to limit fluid intake with a start date of 11/21/2022. A review of resident's meal ticket did not indicate no soups to limit fluid intake.
In an interview with the Dietary Manager on 01/10/23 at 2:50 PM, reported the order for no soups due to fluid intake was not under the proper dietary category, which explained why the order was not included in the dialysis diet.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
.
Based on observation, record review and staff interview, the facility failed to follow physician's orders in accordance with professional standards of practice. This was true for two (2) of two (2) ...
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Based on observation, record review and staff interview, the facility failed to follow physician's orders in accordance with professional standards of practice. This was true for two (2) of two (2) residents reviewed for the care area of respiratory care. Resident identifiers: #27 and #31. Facility census: 82.
Findings Included:
a) Resident #27
On 01/09/23 at 11:20 AM, the oxygen setting on the concentrator was 1.5 liters per minute (LPM). A physician's order dated 11/16/22 was for the oxygen setting of 2 LPM. Licensed Practical Nurse (LPN) #2 confirmed the setting of the oxygen was incorrect for Resident #27. LPN #2 corrected the setting.
b) Resident #31
On 01/09/23 at 11:22 AM, the oxygen setting on the concentrator was 2.5 LPM. A physician's order dated 08/26/22 was for the oxygen setting of 2 LPM. LPN #2 confirmed the setting of the oxygen was incorrect for Resident #31. LPN #2 corrected the setting.
No further information was obtained during the survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
.
Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, a post form was not completed accurately. This was true for on...
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Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, a post form was not completed accurately. This was true for one (1) of 24 Residents reviewed during the Long-Term Care Survey Process (LTCSP).
Findings included:
a) Resident #19
Record review on 01/10/23, revealed: Section E (Patient/Resident, Guardian/ MPOA Representative) was not completed with a Signature on Resident #19's active Physician Order for Scope of Treatment Form (POST Form). Verbal Consent with the Medical Power of Attorney' name was written in this section with the date 04/11/2022.
During an interview on 01/10/22 at 1:11 PM the Social Worker Director, confirmed Resident #19's POST form was inaccurate with section E incomplete without a Resident representative's signature.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
.
Based on observation and staff interview, the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident specifically prem...
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Based on observation and staff interview, the facility failed to implement an ongoing activity program designed to meet the interests of and support the well-being of each resident specifically premeal activities not being provided. This was a random opportunity for discovery. Facility census: 82.
Findings included:
a) Dining observations
An observation of meal service on 01/09/23 from 11:30 AM to 11:50 AM, found 19 residents sitting with eight (8) Residents sleeping in the C and D hall dining room, waiting for their noon meal. No activities provided.
A second observation of the C and D hall dining room on 01/10/23 at 11:00 AM found 10 Resident's sitting around the room with no staff or activities be provided.
A third observation of meal service on 01/10/23 from 11:25 AM to 11:43 AM, found 16 residents sitting with six (6) Residents sleeping in the C and D hall dining room, waiting for their noon meal. No activities being provided.
During an Interview on 01/10/23 at 11:45 AM with the Activities Director confirmed, staff should be present in the dining room providing premeal activities, such as soft music, trivia, or socialization.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
.
Based on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This was a random opportunity for discovery that had the potential to affect more...
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Based on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This was a random opportunity for discovery that had the potential to affect more than a limited number of residents residing in the facility. Facility census: 82.
Findings included:
a) Garbage and refuse disposal
On 01/10/23 at 12:45 PM, observation was made of the garbage dumpster located on the facility grounds. The lid to the dumpster was not closed. Additionally, a white trash bag containing garbage was lying on the ground beside the dumpster. These deficient practices were confirmed by the Administrator on 01/10/23 at 12:50 PM.
No further information was provided through the completion of the survey.
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Sept 2021
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
.
Based on observation and staff interview, the facility failed to provide the Resident #84 the right to a dignified existence. This failed practice was true for 1 (one) of 1 (one) resident reviewed f...
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Based on observation and staff interview, the facility failed to provide the Resident #84 the right to a dignified existence. This failed practice was true for 1 (one) of 1 (one) resident reviewed for the care area of catheter care during the Long-Term Care Survey process. Resident identifier: #84. Facility census 85.
Findings include:
a) Resident #84
On 09/20/21 at 3:16 PM, upon entering the residents' room the urinary catheter bag was found to be uncovered. This allowed anyone passing the room to have view of the collected urine in the urinary catheter bag. It was brought to the attention of Licensed Practical Nurse (LPN) #37.
The Director of Nursing (DON) was notified on 9/20/21 at 3:40 PM. No further information was provided through the completion of the survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview, and facility policy, the facility failed to formulate a discharge plan when the Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review, staff interview, and facility policy, the facility failed to formulate a discharge plan when the Resident expressed a desire to return home. In addition, when the the resident left the facility against medical advise (AMA) the facility failed to contact Adult Protective Services (APS) in a timely manner. This was true for one (1) of one (1) residents reviewed for discharge during the Long-Term Care Survey Process. Resident identifier: #438. Facility census: 85.
Findings included:
a) Resident #438
Record review found Resident #438 was admitted to the facility on [DATE]. The resident was admitted from a local hospital after surgery for a fracture of the left femur. Addition diagnoses included: chronic obstructive pulmonary disease, cerebral palsy, history of falls, contractures of the left and right ankle, right and left hip, and right and left knees.
Review of the residents admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/22/21 found the resident participated in the MDS assessment and expected to be discharged to the community after placement.
Record review found the resident has capacity to make medical decisions.
Review of the Resident's care plan found no care planning related to discharge to the community.
No interventions were developed to ensure a smooth and safe transition from the facility.
On 06/04/21 the resident informed the facility he had called transportation and was leaving the facility.
The following notes in the medical record were written on the day of the discharge:
06/04/21 Discharge Plan of Care and Instructions Reason for discharge: (Name of resident) has been discharged for the following reason: The transfer or discharge is for the welfare of the resident or other residents.
discharged to: Home/Private Residence
Additional information about this event can be found in the Discharge Plan of Care and Instructions Form.
Under the heading of medications listed to be taken after discharge, the facility form was blank. No equipment or support care was listed as being needed.
In an interview with the Administrator (NHA) on 9/21/21 at 8:43 AM, the NHA said he tried to talk the Resident out of leaving the facility but the resident called a taxi to transport him from the facility. The NHA said the facility did not make any referrals and did not send any medications with the resident because the facility had no knowledge the resident was leaving until a taxi showed up to transport him. The NHA confirmed the medical record contained no information to support the NHA spoke with the Resident prior to discharge. The NHA said the facility made a referral to APS after the Resident left the facility.
At 9:30 AM on 09/21/21, the Registered Nurse Assessment Coordinator (RNAC) provided a copy of the referral made to APS. The referral form was made on 06/11/21, seven (7) days after the Resident left the facility.
At 10:00 AM on 09/21/21, the NHA acknowledged the referral was made on 06/11/21.
He stated that the Social Worker was out with COVID so the referral was not made timely when the Resident left the facility. The NHA reviewed the facility policy entitled, Discharge of a Resident, revised on 03/01/18 and acknowledged the following direction provided in the policy:
.The facility will immediately notify Adult Protective Services (APS) of the resident's discharge against medical advice (AMA) . The NHA confirmed the facility did not follow the facility policy when the Resident left AMA.
On 09/22/21 at 11:05 AM, the Social Worker (SW) #44 reviewed the care plan and confirmed the care plan did not reference the Resident's desire to return to the community, even though he resided at the facility from 03/15/21 until 06/04/21. SW #44 said, I have been off work with COVID.
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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 medical record review and staff interview, the facility failed to ensure pressure ulcers were correctly staged for one (1) of nine (9) residents reviewed for the care area of pressure ulcer...
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Based on medical record review and staff interview, the facility failed to ensure pressure ulcers were correctly staged for one (1) of nine (9) residents reviewed for the care area of pressure ulcers. Resident identifier: #5. Facility census: 85.
Findings included:
a) Resident #5
Review of Resident #5's medical record showed the resident developed a stage 2 pressure ulcer of the coccyx on 08/18/21. Weekly wound assessments were performed. The pressure ulcer continued to be documented as a Stage II until 09/10/21. On 09/17/21, Resident #5's pressure ulcer of the coccyx was documented as Stage I.
The National Pressure Ulcer Advisory Panel (NPUAP) released a position statement in 2000 advising that pressure ulcers should not be reverse staged or down staged The statement, which is available on-line, stated, Pressure ulcers heal to progressively more shallow depth, they do not replace lost muscle, subcutaneous fat, or dermis before they re-epithelialize . A Stage IV pressure ulcer cannot become a Stage III, Stage II, and/or subsequently Stage I.
During an interview on 09/21/21 at 12:30 PM, the Director of Nursing (DON) agreed that Resident #5's pressure ulcer should not have been down staged from a stage 2 to stage 1. No further information was provided through the completion of the survey process.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
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Based on observation and staff interview, the facility failed to ensure the nurse staffing was posted in a prominent place and readily accessible to residents on the second floor. This was a random ...
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Based on observation and staff interview, the facility failed to ensure the nurse staffing was posted in a prominent place and readily accessible to residents on the second floor. This was a random opportunity for discovery. Facility Census: 85.
Findings included:
a) Posting of Nurse Staffing
On 09/21/21 at 8:00 AM, a tour of the facility's first floor revealed nurse staffing was posted beside a billboard to the left of the elevator. In addition, nurse staffing was posted behind the first floor's nurses' station. On 09/21/21 at 8:10 AM, a tour of the facility's second floor revealed nurse staffing was posted behind the second floor's nurses' station. An interview with Medical Records Assistant #79, at that time, revealed nurse staffing was always posted behind the nurses' station on 2nd floor and was not displayed anywhere else.
The Director of Nursing (DON), on 09/21/21 at 9:20 AM, acknowledged that nurse staffing was not posted in a prominent place that would be readily accessible to residents on the second floor of the facility.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure three (3) of 25 residents reviewed during the long-t...
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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 three (3) of 25 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 identifiers: #2, #62, #88. Facility Census: 85.
Findings included:
a) Resident #2
A medical record review, completed on [DATE] at 2:17 PM, found Resident #2 lacked capacity to make medical decisions. There was a signed Medical Power of Attorney (MPOA) form, dated [DATE], on file designating Resident #2's daughter as MPOA. Section E of Resident #2's POST form, dated [DATE], did not list the name, address, and telephone number of the MPOA. Additionally, the POST form was signed by Resident #2's spouse not the legal MPOA.
In 2002, the POST form was incorporated into the [NAME] Virginia Health Care Decisions Act, which was enacted to ensure a patient's right to communicate healthcare decisions. (16-30-2).
The directions for completing the POST form, compiled by the [NAME] Virginia Center for End-of-Life, state the patient or representative/surrogate must sign the form in this section. The guidance further clarifies the signature is mandatory and a form lacking the signature is NOT valid. The directions also state in situations when the person loses or has lost decision-making capacity, the name, address, and phone number of the person legally authorized to make healthcare decisions for the incapacitated person are to be listed on the lines marked Name/Address/Phone.
During an interview on [DATE] at 9:00 AM, the Director of Nursing (DON) acknowledged the MPOA had not signed the POST form and that Section E of the POST form did not list the name, address, and telephone number of the MPOA. The DON stated the facility was in the process of completing audits on resident POST forms and this would be addressed.
b) Resident #62
A medical record review, completed on [DATE] at 1:36 PM, found Resident #62 lacked capacity to make medical decisions. A health care surrogate (HCS) was appointed by the physician on [DATE]. There was a POST form signed by the HCS on [DATE]. Section E of Resident #2's POST Form did not list the name, address, and telephone number of the HCS.
The directions for completing the POST form, compiled by the [NAME] Virginia Center for End-of-Life, state in situations when the person loses or has lost decision-making capacity, the name, address, and phone number of the person legally authorized to make healthcare decisions for the incapacitated person are to be listed on the lines marked Name/Address/Phone.
During an interview on [DATE] at 8:52 AM, the DON acknowledged Section E of the POST form did not list the name, address, and telephone number of the HCS. The DON stated the facility was in the process of completing audits on resident POST forms and this would be addressed.
c) Resident #88
Record review found the Resident was admitted to the facility on [DATE]. The resident expired on [DATE].
The Resident completed a new Physician's Orders for Scope of Treatment (POST) form, changing her wishes from a full code, attempt Cardiopulmonary Resuscitation (CPR) to no CPR.
The resident, who had capacity, signed the POST form but did not date the form to indicate when her wishes were changed.
On [DATE] at 9:45 AM, the Administrator confirmed the POST form was not dated by the Resident to indicate when her wishes for end of life care changed.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on record review and staff interview, the facility failed to ensure four (4) of four (4) residents reviewed for the care...
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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 four (4) of four (4) residents reviewed for the care area of beneficiary protection notification received the notices required by the Centers for Medicare/Medicaid Services (CMS) when Medicare benefits were terminated by the facility and the residents remained at the facility with benefit days remaining. Resident identifiers: #438, #238, #32 and #7. Facility census: 85.
Findings included:
a) CMS notices required:
If the Skilled Nursing Facility (SNF) provides the beneficiary with SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage), form CMS-10055, the facility has met its obligation to inform the beneficiary of his or her potential liability for payment and related standard claim appeal rights. Issuing the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123, to a beneficiary only conveys notice to the beneficiary of his or her right to an expedited review of a service termination and does not fulfill the facility's obligation to advise the beneficiary of potential liability for payment. A facility must still issue the SNFABN to address liability for payment.
b) Resident #438
Record review found the resident was admitted to the facility on [DATE]. On 05/28/21 the resident was terminated from Medicare services by the facility.
Record review found the resident had capacity to make medical decisions.
On 09/21/21 at 8:43 AM, the Administrator and Registered Nurse Assessment Coordinator (RNAC) #140 confirmed the resident did not receive any beneficiary notices (CMS #10123 or CMS #10055) when benefits were terminated by the facility. The Resident had benefit days remaining and remained at the facility. (Beneficiary notices are required to be provided to the resident or legal representative in writing as to why specific services may not be covered and of the resident's/beneficiary's potential liability for payment for the non-covered services.)
The resident remained at the facility without a payer source from 05/28/21 until his self initiated discharge on [DATE].
Continued record review found 2 letters, dated 06/11/21 and 06/25/21, mailed to the residents home by the facility. Both letters notified the resident he owed the facility $3,184.00 for his stay. The second letter, dated 06/25/21 notified the resident if the account was not paid within 10 days from the date of the letter, the facility would, Initiate collection remedies and notify the appropriate governmental authorities of your failure to honor the terms of the admission Agreement between you and (Name of the nursing home.)
During an interview that began at 9:30 AM on 09/21/21 Registered Nurse Assessment Coordinator (RNAC) #139 confirmed she was in charge of providing the beneficiary notices to the resident and she had missed providing the Resident with CMS forms #10123 and #10050. When she was asked why the facility would demand payment from the resident when the Resdient was unaware Medicare services were not longer paying for his stay, she stated, I will have to call the corporate billing person who provides the collection letters.
RNAC #139 contacted the corporate billing person, Employee #143 by telephone. E #143 was asked why she had initiated a collection letter to the resident. She stated the resident was private pay after his Medicare benefits were cut by the facility. When asked if she was aware the Resident had not received notice his benefits were being cut, she stated, no. E #143 said she would have to contact her boss about the problem.
c) Resident #238
Record review found the resident received a Notice of Medicare Non-Coverage, (CMS form #10123) on 05/10/21. The last day of covered services was 05/13/21.
During an interview that began at 9:30 AM on 09/21/21 Registered Nurse Assessment Coordinator (RNAC) #139 confirmed the facility did not provide a copy of CMS #10055 to Resident #238. RNAC #139 said she did not know both forms were required.
d) Resident #32
Record review found the resident received a Notice of Medicare Non-Coverage (CMS form #10123) on 05/03/21. The last day of covered services was 05/04/21. The facility is required to provide CMS #10123 at least 2 days prior to termination of services.
During an interview that began at 9:30 AM on 09/21/21 Registered Nurse Assessment Coordinator (RNAC) #139 confirmed the facility did not provide a copy of the CMS #10055 to Resident #32 and the facility did not provide the notice 2 days prior to termination of services. RN #139 said she did not know both forms were required.
e) Resident #7
Record review found the resident received a Notice of Medicare Non-Coverage (CMS) form #10123) on 06/21/21. The last day of covered services was 06/24/21.
During an interview that began at 9:30 AM on 09/21/21 Registered Nurse Assessment Coordinator (RNAC) #139 confirmed the facility did not provide a copy of the CMS #10055 to Resident #7.
f) Interview with the administrator
On 09/22/21 at 8:48 AM, the Administrator confirmed Residents #238, #32 and #7 only received 1 of the required letters (CMS 10123) when these 3 resident were cut from Medicare by the facility.
The administrator said Resident #438 knew he was being cut from Medicare services and the Resident knew he was going to be responsible to pay a bill at the facility; however, the administrator could not provide evidence to support his statement.
The administrator said the facility had scanned some hand written notes from the Social Worker in the residents chart yesterday-09/21/21. (The resident has been discharged from the facility since 06/05/21; therefore, notes were entered 81 days after the Resident left the facility.) The administrator was asked if the notes were scanned after surveyor intervention and he replied, yes, but these notes were written over a period of time.
When asked if the Social Worker had privileges to type her notes into the electronic medical system, he stated, yes. The administrator confirmed it was not facility practice to have staff write hand written notes on an unlined piece of paper and scan them into the medical record under a miscellaneous tab.
In addition, the administrator said staff should type notes in the medical record on the day when the events occur.
The administrator was unable to provide evidence Resident #438 received CMS #10123 informing the resident he was being terminated from Medicare skilled services and the reason for the termination. In addition the administrator was unable to provide a copy of CMS form #10055 notifying the resident of his responsible to pay for services if he continued to remain at the facility.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #78
An electronic medical record review was completed on 09/21/21 at 10:00 AM. Resident #78 was transferred to the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
b) Resident #78
An electronic medical record review was completed on 09/21/21 at 10:00 AM. Resident #78 was transferred to the hospital on [DATE]. Evidence the Notice of Transfer was given to Resident #78 was scanned in the electronic medical record. There was no evidence found in the electronic medical record that the long-term care Ombudsman had been notified of the transfer.
During an interview on 09/21/21 at 1:00 PM, the Clinical Care Specialist (CCS) reported nursing staff prepares all necessary paperwork when a resident is transferred to the hospital. The CCS further explained nursing staff fax the Notice of Transfer to the long-term care Ombudsman. The fax confirmation is then given to social services.
The Social Services Director, on 09/21/21 at 1:10 PM, disclosed she was unable to locate any evidence the ombudsman had been notified.
c) Resident #64
A review of the medical record on 09/21/21 at 2:28 PM revealed the resident had been sent out to the hospital on [DATE] due to increased temperature and low oxygen saturation. There was no indication staff had provided notice of the transfer according to regulation.
An interview with the social worker #44 on 09/22/21 at 11:50 AM, verified that the facility had not provided the necessary information regarding the transfer to the ombudsman. This notice was not found by employee #44 to verify the information was sent as required.
Based on medical record reviews and staff interviews, the facility failed to provide Notices of Transfer to the State Ombudsman. This was discovered for three (3) of three (3) residents reviewed for hospitalizations during the Long Term Care Survey Process (LTCSP). Resident #28, #78 and #64 were transferred to an acute care hospital, and no Notices of Transfer were provided to the State Ombudsman. Resident identifiers: #28, #78 and #64 Facility census: 85.
Findings included:
a) Resident #28
A record review completed on 09/21/21, revealed Resident #28 had been transferred to an acute care hospital on [DATE], 07/19/21 and 08/24/21. There was no evidence the Notices of Transfer had been sent to the State Ombudsman.
An interview with the Director of Nursing Services (DNS) on 09/21/21 at 3:10 PM, confirmed there was no verification the Notices of Transfer had been sent to the State Ombudsman for hospitalizations on 06/05/21, 07/19/21 and 08/24/21 for Resident #28.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
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Based on observations, medical record reviews and staff interviews the facility failed to complete accurate Minimum Data Set (MDS) assessments for three (3) of 25 resident MDS assessments reviewed d...
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Based on observations, medical record reviews and staff interviews the facility failed to complete accurate Minimum Data Set (MDS) assessments for three (3) of 25 resident MDS assessments reviewed during the Long Term Care Survey Process (LTCSP). The MDS assessments for Resident #48 was inaccurate for the use of alarms, Resident #62 was inaccurate in the area of pressure ulcers, Resident #58 was inaccurate for a contracture. Resident identifiers: #48, #62, and #58. Facility census: 85.
Findings included:
a) Resident #48
A medical record review on 09/22/21, revealed Resident #48 had an order, as written; Bed and chair alarm to alert staff of unassisted transfers, with a start date of 07/19/21. Further review indicated the MDS assessment with an assessment reference date (ARD) of 08/02/21 was not coded for daily use of a chair and bed alarm.
An interview with the MDS Coordinator on 09/22/21 at 8:40 AM, verified the chair and bed alarm had not been properly coded as being used daily by Resident #48.
b) Resident #62
A review of the facility matrix, on 09/20/21 at 12:51 PM, identified a facility acquired stage IV pressure ulcer for Resident #62.
On 09/21/21 at 10:45 AM, an electronic health record review was completed which revealed:
- A quarterly MDS with an ARD of 07/28/21 indicated Resident #62 had one (1) unhealed stage 4 pressure ulcer.
- A Wound Assessment / Pressure Ulcer Reassessment, dated 07/15/21, indicating a right heel deep tissue injury measuring 1cm x 1 cm.
- A Wound Assessment / Pressure Ulcer Reassessment, dated 07/22/21, indicating a right heel stage IV pressure ulcer measuring .5 cm x .5 cm.
-A Wound Assessment / Pressure Ulcer Reassessment, dated 07/29/21, indicating a right heel deep tissue injury measuring 0 cm x 0 cm and noting the right heel is closed and resolving.
In an interview, on 09/21/21 at 12:06 PM, Registered Nurse Assessment Coordinator (RNAC) #140 reported she reviewed the 07/22/21 Wound Assessment when completing the quarterly MDS on 07/28/21. RNAC #140 recognized the discrepancy between the wound assessments completed the week prior and the week after the 07/22/21 wound assessment.
In an interview, on 09/21/21 at 12:15 PM, the Director of Nursing (DON) acknowledged the 07/22/21 wound assessment completed by RN #57 was inaccurate. The DON reported when RN #57 completed the 07/22/21 wound assessment, she accidentally clicked on Stage IV pressure ulcer instead of a deep tissue injury which is the choice right below.
c) Resident #58
Medical record review of the resident's current diagnoses found the Resident has a contracture of the right wrist. This diagnosis was added to the medical record on 10/20/17.
Review of the current care plan found the following focus problems:
(Name of resident) has potential for pressure ulcer development r/t (related to) right hemiplegia, DM (diabetes mellitus), immobility, right wrist/hand contracture and incontinence.
Date Initiated: 06/15/2011
Revision on: 08/06/2021
(Name of resident) has an ADL (activities of daily living) Self Care Performance Deficit r/t CVA (cerebral vascular accident) with right upper extremity, paralysis, right hand contracture. Has hx (history) of refusing right hand splint that therapy recommends.
Date Initiated: 01/31/2011
Revision on: 01/05/2021
Review of the most recent Minimum Data Set (MDS), an annual, with an Assessment Reference Date (ARD) of 08/06/21 found the MDS coded the Resident as having no contractures.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
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b) Resident #84
On 09/20/21 3:16 PM, upon entering the Residents' room, observation found the ordered fall mats were not in place by the bed.
The Medical Record review indicates a physician's order...
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b) Resident #84
On 09/20/21 3:16 PM, upon entering the Residents' room, observation found the ordered fall mats were not in place by the bed.
The Medical Record review indicates a physician's order for fall mats to the left and right side of the bed.
It was brought to the attention of Licensed Practical Nurse (LPN) #37. The Director of Nursing (DON) was notified on 9/20/21 at 3:40 PM. No further information was provided through the completion of the survey process.
c) Resident #48
A medical record review completed on 09/22/21, revealed Resident #24 had an order as written on 04/23/21 for fall mats on each side of the bed.
During an observation on 09/22/21 at 12:30 PM, it was discovered there was only one (1) floor mat applied to the right side of Resident #48's bed.
In and interview with the Employee #141, Registered Nurse (RN), verified the staff had not followed the order to place floor mats on each side of the bed.
Based on observation, record review, and staff interview, the facility failed to follow physician's orders for three (3) of 25 residents reviewed during the long-term care survey process. Physician's orders for laboratory testing were not followed for Resident #65. Physician's orders for fall mats were not followed for Resident #84 and Resident #48. Resident identifiers: #65, #84, #48. Facility census: 85.
Findings included:
a) Resident #65
Review of Resident #65's medical records showed the resident was receiving the medication Depakote (divalproex) 10 capsules to equal 1250 milligrams (mg) by mouth at bedtime for generalized anxiety disorder. Monitoring Depakote (divalproex) levels in the blood is important to identify toxicity, which can lead to liver failure.
On 02/03/20, Resident #65 was seen by a psychiatrist, who gave a recommendation to draw a Depakote (divalproex) level.
On 06/23/20, the facility's physician ordered a Depakote (divalproex) level to be drawn for Resident #65.
Further review of the medical records showed Resident #65 had a divalproex blood level drawn on 07/15/19. The result showed a non-toxic level. No more recent Depakote (divalproex) levels were located in the medical record. Resident #65's most recent liver function testing was performed on 12/06/20.
During an interview on 09/22/21 at 8:45 AM, the Director of Nursing (DON) confirmed Resident #65 had no Depakote (divalproex) levels drawn after the recommendation made by the psychiatrist on 02/03/20 and the physician's order written on 06/23/20. The DON confirmed Resident #65's most recent Depakote (divalproex) level was obtained on 7/15/19. She stated she had called the physician to obtain an order for a Depakote level.
No further information was provided through the completion of the survey.
b) Resident #84
On 09/20/21 3:16 PM, upon entering the Residents' room, observation found the ordered fall mats were not in place by the bed.
The Medical Record review indicates a physician's order for fall mats to the left and right side of the bed.
It was brought to the attention of Licensed Practical Nurse (LPN) #37. The Director of Nursing (DON) was notified on 9/20/21 at 3:40 PM. No further information was provided through the completion of the survey process.
c) Resident #48
A medical record review completed on 09/22/21, revealed Resident #24 had an order as written on 04/23/21 for fall mats on each side of the bed.
During an observation on 09/22/21 at 12:30 PM, it was discovered there was only one (1) floor mat applied to the right side of Resident #48's bed.
In and interview with the Employee #141, Registered Nurse (RN), verified the staff had not followed the order to place floor mats on each side of the bed.
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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 observation and staff interview, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Food items not stored properly and...
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Based on observation and staff interview, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Food items not stored properly and equipment had a buildup of food debris. This practice has the potential to affect more than a limited number of residents who are served food from the kitchen. Census: 85.
Findings included:
a) Observation of the kitchen
Observations of the kitchen area on 09/20/21 at 11:20 AM, with the dietary manager (DM) #75 found the following issues:
Eggs in the walk-in refrigerator were not stored on lower shelf. Storage on the lower shelf is required to prevent any contamination should an egg become cracked and spill onto items stored in a lower shelf.
A container of mayonnaise was stored in the walk-in refrigerator with a piece of saran wrap on top of the container. The mayonnaise was not dated to indicate when opened. The saran wrap did not create a tight seal that would prevent the product from possible contamination and spoilage.
The drip pan, on the stove, was found to have accumulated food debris and was in need of cleaning.
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CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected multiple residents
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Based on observation, record review, and staff interview, the facility failed to ensure safe storage of food in Resident #67's room. The facility failed to monitor daily the temperatures for the per...
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Based on observation, record review, and staff interview, the facility failed to ensure safe storage of food in Resident #67's room. The facility failed to monitor daily the temperatures for the personal refrigerator kept in the resident's room. This was a random opportunity for discovery. Resident identifier: #67. Facility census: 85.
Findings included:
a) Resident #67
On 09/21/21 at 2:00 PM, a small refrigerator was noted in Resident #67's room. Taped to the refrigerator was a piece of paper labeled Refrigerator Temperature Chart. This paper was a form with spaces to record the refrigerator temperature every morning and evening, as well as the initials of the person performing the temperature reading. The month September was written on the form. The form stated, Temperature Requirements: Refrigerator = 41 or below .Notify Food Service Supervisor of temperature problems IMMEDIATELY.
The only temperatures recorded on the form were on the mornings of 09/01/21, 09/02/21, 09/13/21, 09/14/21, 09/17/21, 09/18/21, 09/19/21, and 09/20/21. No evening temperatures had been recorded on any days.
During an interview on 09/21/21 at 2:15 PM, the Administrator agreed the refrigerator temperature had not been recorded twice daily. The administrator stated it was the responsibility of Environmental Services Workers to check and record the temperatures of refrigerators located in residents' rooms.
The facility's policy titled Sanitation/Food Handling with issue date 12/01/02 stated that all refrigerators must have a thermometer and refrigerator thermometers must be checked twice daily with temperatures recorded on the Refrigerator/Freezer Temperature Log.
No further information was provided through the completion of the survey process.
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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
- "What changes have you made since the serious inspection findings?"
- "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
- • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
- • 32 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $10,036 in fines. Above average for West Virginia. Some compliance problems on record.
- • Grade C (56/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 56/100. Visit in person and ask pointed questions.
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About This Facility
What is Clarksburg Healthcare Center's CMS Rating?
CMS assigns CLARKSBURG HEALTHCARE CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within West Virginia, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Clarksburg Healthcare Center Staffed?
CMS rates CLARKSBURG HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 51%, compared to the West Virginia average of 46%.
What Have Inspectors Found at Clarksburg Healthcare Center?
State health inspectors documented 32 deficiencies at CLARKSBURG HEALTHCARE CENTER during 2021 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 31 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Clarksburg Healthcare Center?
CLARKSBURG 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 110 certified beds and approximately 94 residents (about 85% occupancy), it is a mid-sized facility located in CLARKSBURG, West Virginia.
How Does Clarksburg Healthcare Center Compare to Other West Virginia Nursing Homes?
Compared to the 100 nursing homes in West Virginia, CLARKSBURG HEALTHCARE CENTER's overall rating (4 stars) is above the state average of 2.7, staff turnover (51%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Clarksburg Healthcare Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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 Immediate Jeopardy citations and the below-average staffing rating.
Is Clarksburg Healthcare Center Safe?
Based on CMS inspection data, CLARKSBURG HEALTHCARE CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in West Virginia. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Clarksburg Healthcare Center Stick Around?
CLARKSBURG HEALTHCARE CENTER has a staff turnover rate of 51%, which is 5 percentage points above the West Virginia average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Clarksburg Healthcare Center Ever Fined?
CLARKSBURG HEALTHCARE CENTER has been fined $10,036 across 1 penalty action. This is below the West Virginia average of $33,179. 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 Clarksburg Healthcare Center on Any Federal Watch List?
CLARKSBURG 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.