Lindside Healthcare Center

Inspectors wroteBased on record review and staff interview, the facility failed to obtain informed consent for a psychotropic medication for Resident #4. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #4. Facility Census: 53. Findings Included: a) Resident #4 On 03/10/26 at 1:23 PM, a record review was completed for Resident #4. The review found a physician's order, dated 02/24/26, for Zoloft 25 mg one (1) tablet by mouth one (1) time a day for depression. Upon further review, a signed informed consent was not found for the medication in the medical record. On 03/10/2026 at 2:45 PM, the Director of Nursing (DON) confirmed the informed consent was not obtained for Zoloft.

Inspectors wroteBased on resident interviews, observation, and staff interview, the facility failed to ensure the full contact information for the Office of Health Facilities Licensure and Certification (OHFLAC) was posted for the residents. This was a random opportunity for discovery during the required resident council meeting during the Long-Term Care Survey Process. Census: 53.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure advance directives were correct and in accordance with Resident #44's wishes. This was true for one (1) of 19 residents reviewed for accurate advance directives throughout the Long-Term Care Survey Process. Resident Identifier: #44. Census: 53.

Inspectors wroteBased upon observation, resident interview, and staff interview, the facility failed to ensure a safe, clean, comfortable homelike environment. This was found to be true for one (1) of 24 residents reviewed during the Long-Term Care Survey Process. Resident identifier: #13. Facility census: 53.

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) in regard to immunizations. This was true for one (1) of one (1) residents reviewed for respiratory care throughout the Long-Term Care Survey Process. Resident identifier: #10. Census: 53.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure quality of care for residents. This failed practice was found true for one (1) of (4) four residents reviewed under the care area of accidents and one (1) of five (5) residents reviewed under the unnecessary medications pathway throughout the Long-Term Care Survey Process. Resident identifiers: #4 and Resident #7. Facility Census: 53.

Inspectors wroteBased upon resident interview, observation, and staff interview, the facility failed to ensure a safe environment to prevent a tripping hazard. This was found to be true for one (1) of 24 residents reviewed during the Long-Term Care Survey Process. Resident identifier: #13. Facility census: 53.

Inspectors wroteBased upon observation, record review, and staff interview, the facility failed to post nurse staffing information in a prominent location, readily available for review to the public. Additionally, the facility failed to maintain current information pertaining to actual hours worked by registered nurses, licensed practical nurses or nurse aides. Census: 53Findings included: a) Observation Upon initial entrance to the facility on [DATE] at approximately 10:00 AM, the Surveyor looked for the posted nurse staffing information in the lobby, front living room area, and main entrance area where many other signs were posted. The nurse staffing data was not found. The nurse staffing data was only located after asking the Nursing Home Administrator where it was located. The nurse staffing sheet was posted in the hallway near the nursing station. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop a care plan with measurable goals and interventions to address the care and treatment for a resident with dementia. This failed practice was found true for (1) one of (5) five residents reviewed for dementia care during the Long-Term Care Survey Process. Resident identifier #7. Facility census: 53.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure an accurate and complete medical record. This failed practice was found to be true for (2) two of (5) five residents reviewed under the care area of unnecessary medications during the Long-Term Care Survey Process. Resident identifiers: #43 and #3. Facility Census: 53.

Inspectors wroteBased on record review and staff interview, the facility failed to offer Pneumococcal vaccinations to aid in the prevention of Pneumonia. This failed practice was found true for (2) two of (5) five residents reviewed for vaccinations during the Long-Term Care Survey Process. Resident identifiers: Resident #15 and Resident #4. Facility Census 53.

Inspectors wroteBased on document review and staff interview, the facility failed to provide written documentation upon discharge on the right to appeal and provide contact information to the Ombudsman and local State Agency. This was true for 3 of 3 residents reviewed (Residents #61, #62, and #63). Facility census 58. Review of the discharge documentation on 02/10/26 during the hours of 10:15 a.m. through 11:15 a.m. for Residents #61, #62, and #63 revealed no readily available documentation that included any written information on the resident's right to appeal discharge with contact information to the local Ombudsman or State Agency. An interview on 02/10/26 at 11:40 a.m. with the facility's Director of Nursing (DON) verified these findings.

Inspectors wroteBased on record review and staff interview the facility failed to implement the facility Policy and Procedure entitled, West Virginia Abuse, Neglect and Misappropriation by failing to thoroughly investigate incidents of abuse between residents. The facility failed to obtain statements from staff who were working at the time of the incident. Furthermore, the facility failed to assess and interview like residents of the facility. This failed practice was true for three (three) of 5 (five) residents reviewed for abuse. Resident identifiers: #30, #54, and #1. Facility census: 54.

Inspectors wroteBased on record review and staff interview the facility failed to thoroughly investigate thoroughly investigate 2 (two) instances of resident-to-resident sexual abuse and one instance of resident-to-resident physical abuse by failing to obtain statements from staff who were working at the time of the incidents, furthermore the facility failed to assess and interview like residents of the facility. This failed practice was true for 3 (three) of 5 (five) residents reviewed for abuse. Resident identifiers: #30, #54, #1 and #39. Facility Census: 54.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a resident/resident's representative was provided a written Notice of Transfer for an acute hospital transfer. The facility also failed to provide evidence that a copy of the Notice of Transfer was sent to the Ombudsman. This was true for three (3) out of four (4) hospital transfers reviewed during the long-term care process. This had the potential to affect all residents being transferred or discharged . Resident identifiers: #20, #38, and #29. Facility census: 54.

Inspectors wroteBased on record review, resident, and staff interview. The facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for three (3) of five (5) residents reviewed for pain during the Long-Term Survey Process. Resident Identifier: #26, #29, and #157. Facility census: 54.

Inspectors wroteBased on resident interview, staff interview and record review, the facility failed to ensure the right to make choices about aspects of life that is important to one (1) of three (3) residents reviewed for choices. Specifically, Resident #35 was not given showers when requested or the choice. Resident identifiers: #19, and #35. Facility census: 54.

Inspectors wroteBased on record review and staff interview the facility failed to notify the representative/family of an acute hospitalization. This was true for two (2) out of three (3) residents reviewed for the care area of hospitalization during the Long-Term Care Survey process. Resident identifier: Resident #20. Facility census 54.

Inspectors wroteBased on record review and staff interview the facility failed to timely report allegations of suspected abuse between residents timely within the 2 (two) hour window to the appropriate State Agency. This failed practice was true for 2 (two) of 5 (five) residents reviewed for abuse. Resident Identifiers: Resident #39, Resident #01 and Resident #207. Facility Census: 54.

Inspectors wroteBased on medical review and staff interview, the facility failed to provide the resident/resident representative notice of the bed hold policy when Resident #29 was transferred to a local hospital. This was true for one (1) of three (3) residents reviewed for transfers. Resident identifier: #29. Facility census: 54.

Inspectors wroteBased on record review, resident, and staff interview. The facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the Residents assessed needs for care. This is true for one (1) of three (3) residents reviewed for ADL care. Resident identifiers: #108. Facility census: 54.

Inspectors wroteBased on record review and staff interview the facility failed to follow a physician's order to be notified of blood sugar greater than 400 for Resident #23. This was true for 1 (one) of 1 (one) residents reviewed for the Long Term Care Survey Process. Facility census: 54. Resident identifier: #23.

Inspectors wroteBased on observation, interviews with facility staff, and a review of facility policy and procedures, it was determined that the facility failed to follow acceptable infection control practices that controlled, or prevented, the spread of infection. This practice had the potential to affect all residents that reside in the facility. Facility Census: 54.

Inspectors wroteBased on staff interview, observation, and facility documents the facility failed to ensure the facility cleaning solution used to disinfect was used in accordance with manufacture directions. This failed practice had the potential to affect more than a limited number of residents. Facility census 60.

Inspectors wroteBased on observation, resident interview, staff interview, and Resident council meeting. The facility failed to meet the needs and Preferences of each resident, through an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This failed practice had the potential to affect more than a limited number of residents that currently reside in the facility. Resident identifiers: #41, #32, #17, #3, #40, #31, #8, #26, #11, #37, and #39. Facility census 60.

Inspectors wroteBased on employee record review, and staff interview the facility failed to ensure all dietary staff had a food handlers' card, to ensure the safe handling of the food for the Residents. This failed practice had to potential to affect more than a limited number of Residents that currently reside at the facility. Facility census 60.

Inspectors wroteBased on record review, resident council meeting, resident interview and staff interviews, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. The facility failed to implement evening activities of interest for the residents. This was a random opportunity for discovery. Facility census: 57. Findings Included: a) Resident Council During the Resident Council Meeting held on 10/18/22 at 2:43 PM the Residents as a group were asked the question, How are the activities? The following concerns were voiced. -Could be more activities, -We need evening activities, we do nothing but sit in our rooms after dinner. -It's so boring in the evenings, We need more to do in the evening. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to have two (2) licensed nurses to sign off at the beginning and ending of the shift to verify the control substances were accurate and accounted for as directed. This failed practice had the potential to affect more than a limited number of residents. This was discovered during the medication pass on 10/18/22. Facility census: 57.

Inspectors wroteBased on medical record review and staff interview, the consultant pharmacist failed to complete a medication regimen review every thirty (30) days. This was true for Residents #13, #29, #16 and #36. Additionally, the facility failed to timely complete a gradual dose reduction (GDR) as approved by the physician. Resident identifiers: #13, #29, #16 and #36. Facility census: 57.

Inspectors wroteBased on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 57 Findings Included: A facility policy titled labeling and dating with a date of 2017 stated the following. .Guidelines for Labeling and Dating .Food labels must include: -The food name -The date of preparation/receipt/removal from freezer -The use by date . [...]

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to provide an extra over-the-bed table for meals to prevent further injury due to spilled tray which cause a second (2nd) degree burn on right foot. Resident identifier: #2. Facility census: 57.

Inspectors wroteBased record review and staff interview, the facility failed to ensure a Physicians Orders for Scope of Treatment (POST) form was completed by the appropriate designee for one (1) of two (2) residents reviewed for advance directives. This failed practice had the potential to affect only a limited number of residents. Resident identifier: #35. Facility census: 57.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to follow the physician orders for Resident #109 with a order for Lidocaine patches without a dosage and Resident #2's orders for treatment of a second degree burn on the right foot. These failed practices had the potential to affect a limited number of residents. Resident identifiers: #109 and #2. Facility census: 57.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident's environment was as free of accident hazards as possible. Unit 3/4 medication cart was left unlocked and unattended. This was a random opportunity for discovery. Facility census: 57.

Inspectors wroteBased on medical record review, staff interview and resident interview, the facility failed to ensure a complete and accurate medical record. The facility failed to document Resident #6's bathing task and Resident #51's weights in the electronic medical record. This was a random opportunity of discovery. Resident identifiers: Resident #6 and Resident #51. Facility Census: 57 Findings Included: a) Resident #6 During an interview on 10/17/22 at 2:03 PM, Resident # 6 stated that I get a shower most of the time, they skip a few, don't get as many as I should, I think I am scheduled two (2) times a week. During a medical record review on 10/18/22 revealed Resident #6's bathing documentation as follows: Bed bath: -09/20/22 at 2:29 PM -09/22/22 at 11:58 AM -09/25/22 at 11:41 AM Showers: 09/24/22 at 12:48 AM No evidence of the bathing task was in the electronic medical record since 09/25/22. [...]