Weirton Geriatric Center

Inspectors wroteBased on observation, staff interview and review of facility policy, the facility failed to ensure waste was properly contained in dumpsters/compactors and were covered with lids. Facility Census 121.

Inspectors wroteBased on observation, staff interview and review of documentation the facility failed to ensure the right to personal privacy and confidentiality of personal and medical records by leaving Resident #34's electronic chart open and unattended on medication cart in hallway. This was a random opportunity for discovery. Facility Census 121.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's Pre-admission Screening (PAS) reflected a pre-admission diagnosis for Resident #101 during the annual long-term care survey. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #101. Facility Census: 121. Findings Included: a) On 04/23/2025, a record review was completed for Resident #101's PAS submitted 11/21/23. Sections III (MI/MR Assessment) and V (Supplemental Questions for Major Mental Illness or suspected MI) of the PAS indicated no diagnoses. Resident #101 had an admission diagnosis of Bipolar Disorder, Unspecified. b) On 04/23/2025 at 3:31, the Director of Nursing confirmed there was no bipolar diagnosis on the initital PAS and stated, it was an oversight on our part.

Inspectors wroteBased on staff interview and review of documentation the facility failed to develop and implement a comprehensive person-centered care plan to include trauma informed care for resident who had diagnosis of Post Traumatic Stress Disorder (PTSD). This is true for resident #59. Facility Census 121.

Inspectors wroteBased on observation, inspection, and record review, the facility failed to follow a physician's order for the administration of oxygen. This was a random opportunity for discovery. Resident Identifier: #108. Facility Census: 121. Findings Include: a) Resident #108 During an interview with Resident #108 on 04/21/25 at approximately 2:37 PM, it was noted that the resident was receiving oxygen therapy. An inspection of the oxygen concentrator showed that it was set to deliver 3.0 liters per minute. The resident mentioned that she had just finished her breakfast and expressed that she was comfortable. Record review on 04/22/25 at 9:12 AM revealed a physician's order that stated: OXYGEN AT 2 LPM CONTINUOUS VIA NC D/T COPD Ongoing observation during the course of the survey revealed the following readings: [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide Trauma informed care for resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). This is true for resident #59. Facility Census #121. Findings Included: a) On 04/22/25 at 10:23 AM a reviewed resident's diagnosis list included: F43.10 Post-Traumatic Stress Disorder, Unspecified with an onset date of 08/26/24. b) On 04/22/25 at 10:30 AM review of resident's care plan and there was no evidence that Post Traumatic Stress Disorder was addressed on Resident #59's care plan. c) On 04/23/24 at 3:12 PM during an interview with social worker #97 who reported that she was not aware that resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). She acknowledged that resident had a behavior management program and was not receiving trauma-informed care. [...]

Inspectors wroteb) Resident #57 On 04/07/24 at approximately 7:30 PM, Resident #89 was near the nurse's station, at the table where books were laid out for the resident's use. She was selecting some books from the table when Resident #57 took exception to it. Resident #57 beckoned her over, grabbed her fingers and twisted hard, yelling Give me the books. Put them back! Resident #89 was a [AGE] year-old female diagnosed with dementia, short term memory loss, inability to process information, and a lack of capacity to make medical decisions. Resident has resided at the facility since March 2024. Her Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 07/12/24 showed the resident had a Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that all alleged violations involving abuse and the administration of physician ordered medication in excessive doses were reported in a timely fashion to all appropriate state agencies. This was true for two (2) out of seven (7) facility reported incidents (FRIs) reviewed. Resident identifier: #89. Facility census: 121.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure resident falls resulting in serious bodily injury were reported in a timely manner to the appropriate state agencies. The failure to make a timely report and to report to the appropriate state agencies was true for three (3) of three (3) sampled residents for falls resulting in serious bodily injury during the Long Term Care Survey Process. Resident identifiers: #57, #108, and #67. Facility census: 119.

Inspectors wroteBased on record review and staff interview, the pharmacist failed to identify incomplete medication orders during their Medical Record Review (MRR). Resident identifiers: #42, #91 and #104. Facility Census: 119 Findings Included: a) Resident #42 Resident #42 has a diagnosis of anxiety and major depressive disorder. She has an order for Buspirone (anti anxiety medication) tablet 5 milligrams, oral, twice a day at 6:00 AM and 6:00 PM start date 11/09/22 with no end date. There was no diagnosis listed for this medication order. The pharmacist failed to identify this incomplete medication order during their MRR. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. b) Resident #91 Resident #91 has an order for Cipro (antibiotic) (Ciprofloxacin HCL) tablet; 250 milligrams; oral twice a day at 6:00 AM and 8:00 PM. Start date of 3/21/2023, ending on 3/28/2023. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure resident rooms were designed or equipped to assure full visual privacy for each resident. This was true for five (5) out of five (5) resident rooms during the long-term care survey process. Resident identifiers: #108, #57, #55, #12, and #103. Facility census: 119.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a resident's room in a clean and homelike manner. Feeding tube supplies were in an open box on the floor and filling up the visitor chair in the room. This is true for one (1) of two (2) residents reviewed for feeding tubes. Resident identifier: #18. Facility census: 119.

Inspectors wroteBased on Resident Council Meeting, observations and staff interview, the facility failed to post grievance forms in prominent locations throughout the facility. A resident or resident representative should have access to grievance forms, and freedom to file grievances anonymously. This had the potential to affect a limited number of residents. Facility census: 119.

Inspectors wroteBased on record review and staff interview the facility failed to develop a person-centered care plan to address the resident's medical, physical, mental and psychosocial needs. This was discovered for one (1) of five (5) residents reviewed for the area of unnecessary medications. The care plan for Resident #11 was not developed for the use of psychotropic medication. Resident identifier: #11. Facility census: 119.

Inspectors wroteBased on record review, staff interview and policy review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. The facility failed to complete neurological checks for an unwitnessed fall. This was true for one (1) of three (3) residents reviewed for falls during the Long Term Care Survey Process. Resident identifier: #72 Facility Census: 119 Findings Included: a) Resident #72 Record review on 3/29/23 at 11:31 AM shows Resident #72 had an unwitnessed fall on 11/26/22 at 7:00 PM. She obtained a left leg skin tear which was treated at the center with first aid. Upon review of the neurological policy and medical record documentation the facility did not complete any neurological checks until 11/26/22 at 11 PM, four (4) hours after the fall. The facility policy (not dated) for Events of a Fall states: . [...]

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not properly stored. This was a random opportunity for discovery, during the Long-Term Care Survey Process. Resident identifiers: #64, and #42. Facility census: 119. Findings Included: a) Resident #64 An observation on 03/27/23 at 11:23 AM found Resident #64's face mask for his bilevel positive airway pressure (BIPAP) laying on a shelf without being placed in a protective bag. An interview on 03/27/23 at 11:35 AM with License Practical Nurse (LPN) #145 confirmed that Resident #64's's BIPAP Mask should be placed and stored in a protective bag when not in use. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each medication order included an adequate indication for use. This is true for two (2) of nine (9) residents reviewed for medications during the long term care survey process. Resident identifiers: #111, #91. Facility census: 119.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each medication order included an adequate indication for use for psychotropic medications. Resident identifiers: #42 and #104. Facility Census: 119 Findings Included: a) Resident #42 Resident #42 has a diagnosis of anxiety and major depressive disorder. She has an order for Buspirone (anti anxiety) tablet 5 milligrams, oral, twice a day at 6:00 AM and 6:00 PM start date 11/09/22, and was current order at the time of this review. There was no diagnosis for this medication. This was confirmed with the Director of Nursing on 3/28/23 at 1:30 PM. b) Resident #104 Resident #104 has a diagnosis of major depressive disorder. [...]

Inspectors wroteBased on Interview and record review the facility failed to ensure all qualified staff had their food handler's card. This has the ability to affect all Residents that get their nutrition from the kitchen. Facility census: 119.

Inspectors wroteBased on observation and staff interview the facility failed to monitor temperatures on a resident's refrigerator. This was a random opportunity for discovery. Resident identifier: #18. Facility census: 119.

Inspectors wroteBased on observation and staff interview the facility failed to store garbage and refuse in a proper manner. The compactor areas were polluted with garbage, debris and medical supplies with the potential to attract pests and vermin. This has the potential to affect a limited number of residents that reside in the facility. Facility census: 119.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a complete and accurate medical record for two (2) of 29 sampled residents during the Long-Term Care Survey Process. Specifically, the facility failed accurately record a written physician order in the electronic medical record for Resident #57 and Resident #108. The facility also failed to maintain a complete and accurate medical record for one (1) of two (2) residents reviewed for the area of dialysis during the Long-Term Care Survey Process. Resident identifiers: #57, #108, and #73. Facility census: 119.

Inspectors wroteBased on observation and staff interview the facility failed to maintain resident's equipment in safe operating condition. During a random opportunity for discovery during the Long Term Care Survey Process, Resident #17's wheelchair was identified to be unsafe. Resident identifier #17. Facility census: 119.

Inspectors wroteBased on Resident Council interviews, observations and staff interview, the facility failed to display the most recent State inspection in a readily accessible area frequented by residents. It was discovered the State inspections were placed in an area too high for residents to reach. This had the potential to affect more than a limited number of residents. Facility census:

Inspectors wroteBased on record review, staff interview and observation, the facility failed to ensure Resident #71 who had a 12.11% weight loss in 6 months, received assistance with meals as required by the physician's orders. In addition, the resident had a 19.72% weight loss in the preceding 3 months prior to the most recent weight loss for a total of 29.44% weight loss in 9 months. This resulted in actual harm to the resident. The facility failed to provide supplements, the necessary level of assistance with eating, clear intervention directives, and to update care plan to include the physician orders for weight loss. The order to provide staff assistance with meals was not communicated to staff. This was found for one (1) of six (6) residents reviewed for the care area of nutrition during the long-term care survey process. Resident identifier: #71. Facility census: 115.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Drug Regimen Review Policy addressed the time frame in which the physician must respond to the pharmacist's recommendations. This failed practice had the potential to affect all residents residing in the facility. Facility census: 115.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence residents and/or resident representatives were provided a written Notice of Transfer for three (3) of three (3) records reviewed for an acute hospital transfer. The facility also failed to provide evidence the long-term care Ombudsman had been notified of the transfers. This had the potential to affect more than a limited number of residents transferred or discharged . Resident identifiers: #27, #102, and #107. Facility census: 115. a) Resident #27 A medical record review was completed on 11/16/21 at 11:15 AM. The record review revealed Resident #27 was transferred to the hospital on [DATE]. The record did not reflect the resident/resident's representative was provided a Notice of Transfer, nor did the record reflect the Notice of Transfer was sent to the Ombudsman. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and/or implement person-centered comprehensive care plans for six of 30 residents reviewed during the long term care survey process. Nutritional needs were not addressed for Resident's #46, #71, and #69. Catheter care was not addressed for Resident #64. Behavioral/emotional needs were not addressed for Resident #43. Resident identifiers: #46, #64, #71, #69, and #43. Facility census: 115.

Inspectors wroteBased on observation, resident review, and staff interview, the facility failed to follow physician's orders for six (6) of 30 residents reviewed during the long-term care survey process. Resident identifiers: #107, #69, #85, #83, #46, #71. Facility census: 115.

Inspectors wroteb.) Resident #105 An observation on 11/15/21 at 01:42 PM, revealed no operable call system was available in the bathroom for Resident #105. An interview, with Employee #325, on 11/15/21 at 01:51 PM, confirmed there was no functioning call system in Resident #105's bathroom and verified Resident #105 did go in the bathroom and could access a call system if available. An interview with RN # 67, on 11/15/21 at 01:56 PM, verified there should be a functioning call system in the residents bathroom and there was no functioning call light for Resident #105 to activate in case assistance was needed while in the bathroom. A review of the resident centered care plan, dated 11/10/21, for Resident #105, showed the resident was at risk for falls and noted the resident was to use the call light as a fall prevention measure. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to have food items labeled and dated correctly, unclean equipment in the kitchen, one pantry on enchanted garden refrigerator with spillage and temperature logs in the kitchen were incomplete. This failed practice had the potential to affect a limited amount of residents who receive nutrients from the kitchen and pantry. Facility Census 115.

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 and infections including Covid-19 in regard to, precaution signage and laundry services. This failed practice had the potential to affect more than a limited number of residents in the facility. Resident identifier: #263. Facility census: 115. Findings Included: a) Resident #263 On 11/15/21 at 12:37 AM, found no precaution signs on Resident #263's door. Medical record review on 11/16/21 at 10:38 AM, revealed, Resident #263 was in Covid isolation, Respiratory Droplet Precautions related to being new admission. During an interview on 11/16/21 at 10:41 AM, with the Nurse Aide (NA) revealed, Resident #263, was in modified droplet Precautions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to self-determination, and the reassessment of mental capacity as evidenced by the resident's improved cognition. This failed practice was true for one (1) of 30 residents reviewed during the long-term care process. Resident identifier: #94. Facility census: 115.

Inspectors wroteBased on observation and interview, the facility failed to provide reasonable accommodation in regards to a call light being accessible to the resident. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #39. Facility census: 115.

Inspectors wroteBased on record review and interview, the facility failed to ensure two (2) of (30) 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: #45 and #104. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Minimum Data Set (MDS) was accurately completed. This is true for one (1) of 30 residents reviewed. Facility census 115. Resident identifier #52.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to revise the comprehensive care plan when a change in condition occurred. This failed practice had the potential to affect two (2) of 30 residents reviewed during the long-term care survey process. Resident identifiers: #85 and #8. Facility census: 115.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one of two residents reviewed for the care area of position/mobility received the equipment necessary to maintain proper positioning while using a geri-chair. Resident identifier: #83. Facility census: 115.

Inspectors wroteBased on staff interview, observation, and record review, the facility failed to ensure tubing and drainage bags were not resting on the floor of the facility for two of four residents reviewed for catheter care. Resident identifiers: #64 and #104. Facility census: 115.

Inspectors wroteBased on observation, medical record review and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's order for oxygen was not followed. This is true for one of two reviewed during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #93. Facility Census: 115.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident reviewed for dental services received assistance with obtaining repairs to broken dentures. Resident identifier: #57. Facility census: 115.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide food in a form to meet the needs of residents. This failed practice had the potential to affect two of six residents reviewed for the care area of nutrition. Resident identifiers: #69, #46. Facility census: 115.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure adaptive eating equipment ordered by the physician was provided to the resident. This was a random opportunity for discovery. Resident identifier: #46. Facility census: 115.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident's medical record was complete and accurately documented for two (2) of 30 residents records reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: Resident # 72 and #14. Census:

Inspectors wroteBased on observation and interview, the facility failed to ensure all rooms in the facility were adequately equipped to allow residents to call for staff assistance. This was a random opportunity for discovery during the initial tour of the Long Term Care Survey Process (LTCSP) and affected resident #105. Resident identifier: #105. Facility census: 115.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure staff posting information contained the actual hours worked by nursing staff. This was a random opportunity for discovery and had the potential to affect all residents and visitors wishing to view the information. Facility census: 115.

Inspectors wroteBased on review of facility documents and staff interview, the facility failed to ensure the facility's assessment included an evaluation of the overall number of facility staff needed to ensure sufficient numbers of qualified staff are available to meet each resident's needs. In addition, the assessment did not include a competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. This was a random opportunity for discovery. Facility census: 115.