Clarksburg Healthcare Center

Inspectors wroteBased on observation, record review and staff interview, the facility failed to develop and implement care plans for fall interventions, means of communication and multiple diagnoses. The failed practice had the potential to affect more than a limited number of residents. Resident Identifiers: #5, #61 and #44. Facility Census: 88. a) Resident #5 - On 05/04/26, Resident #5's care plan was reviewed for fall precautions/interventions. The resident's care plan stated, Device: Non-skid strips to floor on the left side of bed. and Device: Nonslip material to wheelchair for safety. The resident's orders stated, DEVICE: DYCEM to wheelchair for safety every shift, and Device: Non-skid strips to floor on the left side of bed. On 05/04/26, the state surveyor observed Resident #5's room and wheelchair. [...]

Inspectors wroteBased on record review, observation, resident interview and staff interview, the facility failed to follow menus as posted, This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #31, #47 and #71. Facility Census: 88.

Inspectors wroteThe Facility failed to ensure residents were served meals timely on A Hall. During the annual survey process, the facility failed to ensure timely provision of meals in accordance with posted meal service times of 7:00 AM to 8:15 AM for Breakfast, 12:00 PM to 1:15 PM for Lunch, and 5:00 PM to 6:15 PM for Dinner. Observation revealed that at 9:40 AM on 5/5/26, residents on A Hall were still being served breakfast, significantly beyond the scheduled meal service window. Resident #74, identified as requiring feeding assistance, was still waiting for their meal at that time. During an interview, CNA #72 stated, This happens often, regarding delayed meal tray delivery from the kitchen. It was further reported that A Hall received meal trays around 9:00 AM. During an interview, the facility administrator stated, One hallway has to be last, when addressing the delayed meal service. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure staff hand hygiene was completed during the dining process. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 88.

Inspectors wroteBased on observation, resident/family interviews, and record review, the facility failed to ensure patient care equipment, specifically mechanical lifts with frayed, taped wires, was maintained in safe operating condition. Resident identifiers: #21, #31, #9, #17, #75, #44, #45, #47, #13, #79, #29, #66, #105, #73, #82, #83, #16, #33, #63, #64, #68, and #84. Facility Census: 88.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure physician's orders for fall preventions were followed. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #5. Facility Census: 88.

Inspectors wroteBased on record review, staff interview and observation, the facility failed to ensure the residents' environment in the shower room was free from accident hazards on A Hall. This failed practice had the potential to affect a limited number of residents. Resident Identifier #39. Facility Census: 88.

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

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure drinks including water and other liquids were served consistent with residents' needs and preferences. This failed practice had the potential to affect a limited number of residents, Resident Identifier: #12. Facility Census: 88.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure residents received therapeutic diets as ordered by the physician. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #5 and #35. Facility Census: 88.

Inspectors wroteBased on record review, staff interview, and observation the facility failed to provide meals at a scheduled time. This has the potential to affect all residents that get their nutrition from the kitchen. Facility census: 96.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased 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:

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).