Moundsville Healthcare Center

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure medication carts were locked when nurses were not in attendance. These were random opportunities of discovery. Facility Census: 124. Findings Include: a) Medication Administration Policy On 12/10/25 at approximately 9:15 AM, the facility Medication Administration policy was reviewed. The review found under the heading of Procedure letter k. stated the following: Do not leave medication cart unlocked. (Typed as written.) b) Resident #15 On 12/10/2025 at 8:50 AM, an observation was made on the 200 hall which found the medication cart unlocked. The medication cart was left unattended for approximately three (3) minutes. On 12/10/25 at 8:53 AM, Licensed Practical Nurse (LPN) #127 exited Resident #15's room into the hallway. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure documentation of residents' pain and treatment was performed in accordance with professional standards of practice. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of pressure ulcers. Resident identifier: 90. Facility census: 124.

Inspectors wroteBased on resident representative interview, record review and staff interview, the facility failed to accommodate a resident's dietary needs related to religious beliefs. This was a random opportunity for discovery. Resident identifier: #110. Facility census: 124.

Inspectors wroteBased on food tray temperatures and resident interviews, the facility failed to serve food to residents that was palatable and at an appetizing temperature. Based on resident interview and staff interview, the facility failed to ensure hot foods were served hot. This failed practice was true for one (1) of one (1) hallways tested for food tray temperatures throughout the complaint survey process Facility census: 124.

Inspectors wroteBased on resident interviews, interviews during resident council, observation and staff interview, the facility failed to ensure a substantial/nourishing snack was provided between the evening meal and breakfast. This is true for Resident #115, Resident #39 and Resident Council. Facility Census 124.

Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to maintain the equipment in safe operating condition. This practice had the potential to affect more than an isolated number of residents. Facility census: 124.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate medical record for documentation of Resident #12's incontinence status and Resident #110's care plan. This was true for two (2) of 25 residents reviewed during the survey process. Resident Identifiers: #12 and #110. Facility Census: 124. a) Resident #110 -Activity staff had documented in resident's care plan, She does not eat meat, fish, eggs or caffeine due to her religious beliefs. - A dietary order stated Lacto-Ovo Vegetarian diet. A lacto-ovo vegetarian diet excludes meat, poultry, and fish but includes dairy products (lacto) and eggs (ovo). This type of vegetarianism is plant-based, with a foundation of fruits, vegetables, grains, nuts, and seeds, and it also incorporates milk, cheese, yogurt, and eggs for nutrients like protein, calcium, and vitamin B12. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to consult a resident's physician when the resident experienced a change in condition related to oxygen saturation levels. This was true for one (1) of three (3) residents reviewed in the closed record review process during the Long-Term Care Survey Process. Additionally, based on record review and staff interview, the facility failed to notify the resident's representative / family member / emergency contact of a significant change and the need to alter treatment. The facility transferred Resident #25 to the hospital. However, the resident's representative / family member / emergency contact was not notified of the transfer. This was true for one (1) of two residents reviewed for hospitalizations during the Long-Term Care Survey Process. Resident Identifiers: #125. Facility Census: 124.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure privacy and confidentiality of medical records for Resident #15 during medication administration. This was a random opportunity for discovery. Resident Identifier: #15. Facility Census: 124. Findings Include: a) Resident #15 On 12/10/2025 at 8:50 AM, an observation of the computer screen was made on the 200 hall which was left unlocked as well as written shift report sheets visible to anyone passing by the medication cart. On 12/10/25 at 8:53 AM, Licensed Practical Nurse (LPN) #127 exited Resident #15's room into the hallway. LPN #127 stated, I went into the room when the resident was calling out .I know I shouldn't have left the computer screen unlocked and the shift report sheets visible. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide the residents / resident representatives with a written notice of the Notice of Transfer /Discharge (including the residents' right to appeal the discharge and the process and how to contact the long-term care Ombudsman) when being transferred to the hospital. This was true for one (1) of two (2) residents reviewed for hospital transfers throughout the Long-Term Care Survey Process. Resident identifiers: #25 and #123. Facility census: 124.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with a newly evident or a possible serious mental health disorder. This was true for one (1) out of four (4) sampled residents reviewed under the PASARR pathway during the Long-Term Care Survey Process. Resident identifier: #3. Facility census: 124.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident's Pre-admission Screening and Resident Review (PASARR) reflected pre-admission diagnoses. This was true for one (1) out of four (4) residents reviewed under the category of PASARR, during the Long-Term Care Survey Process. Resident identifier: #32. Facility census: 124.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure a resident admitted with an existing pressure ulcer received the necessary treatment and services, consistent with professional standards of practice, to promote healing. This was true for one (1) out of three (3) residents reviewed under the pressure ulcer pathway throughout the Long-Term Care Survey Process. Resident identifier: #100. Facility census: 124. a) Resident #100 The CommuniCare Policies and Standard Procedures indicated that a Resident / patient admitted with skin integrity issues will receive treatment as indicated based on location, stage and drainage. A stage III or IV Pressure Ulcer has four options for treatment, and none of the options were started until 12/02/25. Resident #100 was admitted to Moundsville Healthcare on 11/26/25. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain and infection prevention and control program designed to prevent infections during medication administration to and failed to ensure proper storage of a urinal in Resident #7's bathroom. This was true for one (1) of three residents observed during medication administration and a random opportunity for discovery of the improper storage of a urinal. Resident identifier: #15. Facility Census: 124. Findings Include: a) Medication Administration Policy On 12/10/25 at 9:15 AM, a review of the facility Medication Administration Policy was completed. The review found under the heading of Procedure section s. states, Do not touch the medication, either when opening a liquid or dose pack. (Typed as written.) Also, under section u iii. states, Gloves must be worn for splitting tablets. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to meet the nutritional needs of the residents in accordance with established national guidelines due to not following the menu or recipes. The facility failed to follow the approved menus making random substitutions of food items. This had the potential to affect more than a limited amount of residents who received their meals from the kitchen. Facility census: 124. Findings Included: a) 12/08/25 Lunch MealOn 12/08/25, carrot cake with cream cheese frosting was on the lunch menu. Resident tray tickets and menu postings in the facility listed carrot cake with cream cheese frosting as the dessert. Instead, angel food cake was given to residents as a substitute. This was acknowledged by the District Manager for Healthcare Service's Group (HCSG) at approximately 12:35 PM. [...]

Inspectors wroteBased on record review, observations and staff interview, the facility failed to ensure one (1) resident was provided with a safe environment to prevent elopement. This resulted in Resident #101 leaving the facility and being found outside the facility, two (2) blocks away. The facility's failure to ensure the resident did not exit the facility unattended on 07/09/24 placed him at risk and in an Immediate Jeopardy (IJ) situation. This will be cited as past noncompliance because the facility corrected the failure as of 07/29/24, prior to this survey. Resident identifier: #101. Facility census: 117.

Inspectors wroteBased on record review, and staff interview, the facility failed to thoroughly investigate the elopement of Resident #101. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents in the facility. Resident identifier: #101. Facility census: 117.

Inspectors wroteBased on resident interview, record review and staff interview, the facility failed to provide pain management to Resident #318. Harm occurred when the facility failed to address the resident's complaints of continued pain resulting from a right humerus fracture. There were no orders for non-pharmacological interventions, or any pain medications prescribed for 21 days. In addition, Resident #75's pain management was not addressed. Resident identifiers: #318 and #75. Facility census: 120.

Inspectors wroteBased on observation, policy review, medical record review, and staff interview the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases, to help prevent cross-contamination and infections including Covid-19 in regard to, laundry services, water management, and meal services. This failed practice had the potential to affect every resident currently residing in the facility. Facility Census: 120.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to honor the choices of Resident #82 by failing to schedule showers during the resident's preferred time of the day. This was true for one (1) of two (2) residents reviewed for choices during the long-term care survey process. Resident identifier: 82. Facility census: 120. a) Resident #82 At approximately 02:26 PM on 04/01/24, an interview was conducted with Resident #82. During the interview, when asked if they felt if the facility honored their choices, Resident #82 stated No, I keep getting flipped back and forth between day showers and night showers, and I don't want night showers. I've told them every time they move me to night showers that I don't like them because I don't want to go to bed with my hair wet. [...]

Inspectors wroteBased on observation, record review, staff interview, and resident interview the facility failed to develop and/or implement care plans related to communication, nutrition, pain management, and positioning devices. This failed practice was found true for (3) three of 30 residents reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers #55, #75, and # 90. Facility census 120. Findings Include: a) Resident # 55 communication During the initial observation on 04/01/24 at 2:00 PM, it was discovered that Resident # 55 was hard of hearing and needed visitors/staff to write on a wipe off board to communicate with her. During an interview on 04/01/24 at 2:00 PM, Resident # 55 stated, I can't hear so you have to use the board to talk to me. Everybody uses the board. [...]

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to provide a program of activities to meet the physical, mental, and psychosocial well being of each resident. This failed practice was found true for (2) two of (5) five residents reviewed for activities during the Long-Term Care Survey Process. Resident identifiers #23 and #93. Facility census 120. Findings Include: a) Resident # 23 During an interview on 04/01/24 at 1:02 PM, Resident #23, stated, I can't go out to the activity programs, because they never get me up to my wheelchair. A record review on 04/02/24 at 1:00 PM, of Resident #23's care plan read as follows: Focus: Resident enjoys group activities such as, special events, Bingo, card games, likes working puzzles, likes visits with her husband, being outdoors and socializing. Goal: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to follow professional standards of practice for tube feeding. The tube feeding documentation for Resident #102 did not include whether she required tube feeding for oral intake less than 50% of the meal. This deficient practice had the potential to affect one (1) of one (1) resident reviewed for the care area of tube feeding. Resident identifier: #102. Facility census: 120.

Inspectors wroteBased on observation, staff interview and policy review the facility failed to store food in a safe, sanitary manner to prevent food borne illness. This failed practice had the potential to affect more than a limited number of residents. Facility census 120.

Inspectors wroteBased on observation and staff interview the facility failed to treat each resident with respect and dignity regarding meal service. This was a random opportunity for discovery. Resident identifier: #69, #100 and #75. Facility census: 120.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to provide accommodations for Resident #93, by failing to have a geriatric chair available for the resident for transportation to activities and other needs for the resident. This was true for one (1) of two (2) residents reviewed for accommodation of needs during the long-term care survey process. In addition, the facility failed to have the Ombudsman's contact information posted at a level easily accessible to residents in wheelchairs. This has the potential to affect more than a limited number of residents. Resident identifier: 93. Facility census: 120.

Inspectors wroteBased on observation and staff interview, the facility failed to protect the confidentiality of resident records by leaving a computer screen on, unattended in the hallway. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 120. a) Observation At approximately 04:01 PM on 04/02/24, while administering medication, Registered Nurse (RN) #80 left the screen on the computer on, while the computer was in the hallway, displaying resident information. Upon returning to the cart, RN #80 acknowledged leaving the computer screen on, stating I can't believe I did that, I have never done that before.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed for the care area of falls. Resident identifier: #110. Facility census: 120.

Inspectors wroteBased on observation, staff interview, family interview, and record review, the facility failed to ensure the resident and/or resident representative is invited to the care plan conference. This was a random opportunity for discovery during the Long-Term Care Process. Resident identifier: 51. Facility census: 120.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to provide care within acceptable standards of care, by administering medications without a physician's order. This was true for one (1) of 30 residents reviewed during the long-term care survey process. Resident identifier: 318. Facility census: 120.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure Resident #8 had a palm guard in place as ordered by the physician to prevent further decrease in range of motion. This failed practice was found true for (1) one of (1) residents reviewed for Range of Motion (ROM) during the Long-Term Care Survey Process. Resident identifier #8. Facility Census 120.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure meds were stored in accordance with professional standards of practice. Two (2) of three (3) medication carts observed had vials of insulin that had been opened more than 28 days ago. Resident identifiers: #65, #51. Facility census: 120.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure medical records were complete and accurate for two (2) of 30 residents reviewed in the long-term care survey sample. Refusals of heel protectors were not documented for Resident #13. A diagnosis of Post-traumatic Stress Disorder (PTSD) was not documented in the diagnoses list for Resident #81. Resident identifiers: #13, #81. Facility census: 120.

Inspectors wroteBased on observation, record review and staff interview the facility failed to serve food at a palatable, safe, and appetizing temperature. This failed practice had the potential to affect more than a limited number of residents. Facility census: 121. Findings Included: a) Facility Food A record review during a complaint survey for cold food of Resident Council Minutes for 07/07/23 found Residents voiced their concerns about food not being hot enough. An Observation 09/13/23 at 11:40 AM of the lunch holding temperatures found the following: -Meatloaf - 111 -Puree meatloaf - 160 After Surveyor intervention the Meatloaf was placed back in oven, and a second pan was placed on the steam table. On 09/13/23 at 1:14 PM a tray temperature was obtained from the last tray on the 300 Hall found the following: [...]

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to develop individualized and person centered care plans. A care plan was not developed for a resident with falls or a resident with palm protectors. In addition, the activities care plan for a resident with cognitive deficits was not developed to meet her individual needs. This is true for one (1) of three (3) residents reviewed for falls, one (1) of three (3) reviewed for activities, and a random opportunity for discovery of the hand palm protector not in place. Resident identifiers: #98, #41, and #63. Facility census: 101.

Inspectors wroteBased on observation, record review, staff and resident interview, the facility failed to ensure care and treatment was provided in accordance with professional standards of practice of following physician's orders and in accordance with the person-centered care plan. This was found to be true for four (4) of 29 residents reviewed for care and treatment during the LTCSP. The facility failed to provide care in accordance with the physician's orders to withhold straws from Resident #89. The facility failed to follow-up on the current physician's order for treatment for Resident #44. The facility failed to provide care based on a documented and accurate assessment for Residents #50 regarding bowel elimination and Resident #30 regarding weight monitoring. Resident Identifiers: Residents #89, #44, #50 and #30. Census: 101.

Inspectors wroteBased on observation and staff interview , the facility failed to ensure two (2) of six (6) medication carts were maintained in accordance with standards of practice. During a random opportunity for discovery, two (2) medication carts had medications being administered to residents that were not dated when opened. This had the potential to affect more than a limited number of residents. Census: 101.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Specifically, fall risk and elopement evaluations were inaccurate and bowel movement record was incomplete. This practice affected three (3) of 29, residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #53, #50 and #74. Facility census: 101.

Inspectors wroteBased on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including the prevention and/or containment of COVID-19. Surveyors were not informed of the building's Covid-19 status on entry and hand sanitizer and N95 masks were not available at the door. Linen and trash cans in isolation rooms were not hands free. Bed pans were improperly stored and a resident's catheter bag rested on the floor. This practice has the potential to affect a more than a limited number of residents residing in the facility. Facility census: 101.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #300 and #15. Facility census: 101. Review of Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice on Non-coverage (SNF ABN) Form CMS-10055 (2018) denoted Medicare requires skilled nursing facilities to issue the SNF ABN to Medicare beneficiaries prior to providing care that Medicare usually covers, but may not pay for because the care is: - not medically reasonable and necessary

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence a Bed Hold Notice was given to residents/resident representatives when transferred to the hospital. This was true for one (1) out of one (1) hospital transfers reviewed during the long-term care process. This had the potential to affect all residents being transferred or discharged . Resident identifier: #82. Facility census: 101.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the assessment accurately reflected a resident's current status. This was true for one (1) of 29 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #87. Census:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure a care plan approach was revised when the approach was no longer appropriate for the resident This was true for one (1) of 29 residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier : Resident #35. Census:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide and ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. This is true for 1 of 3 reviewed for activities. Resident identifier: R#41. Facility census: 101.

Inspectors wroteBased on observation and staff interview the facility failed to provide the services, care, and equipment to assure that a Resident's maintains, and/or improves to their highest level of range of motion (ROM) and mobility. This was a random opportunity for discovery. Resident Identifier #63. Facility census 101. a) Resident #63 An observation during initial tour on 07/25/22 at 2:07 PM, found Resident #63 lying in bed with both hands in fists without hand protection. Medical record review on 07/25/22, showed Physicians orders, dated 10/13/21: --Patient to wear left palm roll with finger separators daily. Skin checks prior to donning/after doffing. --Patient to wear right palm protector daily. Skin checks prior to donning/ after doffing. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the environment for one (1) of 29 residents reviewed during the long-term care survey process was free from accident hazards over which the facility had control. Resident identifier: #45. Facility census: 101.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident who did not maintain an acceptable parameter of nutritional status, received care in accordance with physician's orders to monitor the resident's condition by obtaining daily weights after the resident had been identified to have had a significant weight loss. This was true for one (1) of three (3) residents reviewed during the Long Term Care Survey Process (LTCSP) for nutrition. Resident Identifier: #89. Census:

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure all medication irregularities were identified and reported to the resident's physician and facility's Director of Nursing (DON) in accordance with professional pharmacy standards of practice, This finding was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident Identifier: Resident #52. Census:

Inspectors wroteBased on observation of medication administration, staff interview, and record review, the facility failed to ensure the facility's medication error rate was less than five (5) percent. Facility staff failed to administer medications according to professional standards for one (1) resident, during medication administration, contributing to a 7.41 % medication error rate. This deficient practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifiers: # 52. Census:

Inspectors wroteBased on observation and staff interview, the facility failed to maintain current food handler cards for one (1) of nine (9) employees reviewed in the Dietary Department. This practice had the potential to affect a limited number of residents who receive their nutrients from the kitchen. Facility census: 101.

Inspectors wroteBased on observation and staff interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The kitchen had two (2) unlabeled and undated food items. This practice had the potential to affect a limited number of residents who receive nutrition from the kitchen. Facility Census 101. Findings Included: a) Initial Tour of the Kitchen During an initial tour of the kitchen beginning at 11:20 am on 07/25/22 with the Certified Dietary Manager (CDM) the following issues were identified: - One (1) clear package of what the CDM identified as cake mix had been opened but was unlabeled and undated. - One (1) package of sliced bread had been opened but was unlabeled and undated. [...]