Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Clarksburg Healthcare Center during CMS and state inspections, most recent first.
Care plans were not accurately developed or implemented for a resident's fall interventions, a non-verbal resident's communication needs, and another resident's correct diagnosis. Staff observed missing or incorrectly placed fall-prevention devices, the care plan for the non-verbal resident repeatedly directed verbal communication despite gestures being the resident's method of communication, and a care plan listed lupus instead of the correct diagnosis of lupus anticoagulant syndrome; the DON confirmed these issues.
Posted menus were not followed as served to residents. A resident reported receiving chicken wings that were not on the menu for a couple of meals, and two residents received ravioli and cabbage even though those items were not listed on the posted lunch menu. An NA and an LPN confirmed cabbage was served despite not being on the menu.
Delayed meal service on A Hall. Surveyors observed residents still being served breakfast well past the posted breakfast window, with a resident needing feeding assistance still waiting for a meal. Staff reported that late tray delivery from the kitchen happens often, and the DON/administrator acknowledged that one hallway has to be last. A resident also reported that dinner is often served late, sometimes not until 7:00 PM-7:30 PM.
Hand hygiene was not completed during the dining process. During a dining room observation, an RN served residents without cleaning hands between residents, and a NA and RN passed drinks to each other and then served residents without performing hand hygiene. An LPN confirmed the hand hygiene issues.
Mechanical lifts were not maintained in safe operating condition. A family member reported the lifts were dirty and had electrical tape on them, and surveyors observed taped wires and frayed wiring on the cradle of the lifts in shower rooms on both floors. An aide confirmed staff had been asking for new lifts, while the Administrator acknowledged the taped and frayed wires and the plant maintenance director said the lift had been malfunctioning for the last year. The lifts were also stored in shower rooms despite the manufacturer’s warning against use or storage in wet or corrosive areas.
Failure to follow fall prevention orders for a resident. The resident had orders for DYCEM on the wheelchair and non-skid strips on the left side of the bed, but the surveyor observed the strips were missing and the Dycem was placed on top of the wheelchair cushion instead of underneath it. An RN confirmed the placement was incorrect.
Open Cleaner Left in Shower Room: A resident was observed in the bathroom adjacent to the shower room, where the bathroom door could be opened into the shower area. An open gallon jug of Medco Prewash MP2017 was sitting on top of the wheelchair washer machine, and an LPN confirmed the cleaner was open in the shower room. The SDS listed the product as causing skin and eye irritation.
An expired vial of Lispro insulin for a resident was found on the B hall med cart during a random check of medication storage. An LPN verified the expiration, and the DON confirmed that opened insulin expires 28 days after opening.
A resident did not receive hot coffee as listed on the tray card during a dining room observation. When the surveyor asked if she wanted coffee, the resident said yes and received it after surveyor intervention. An LPN confirmed the coffee had not been served as printed, despite the facility policy stating that individual food and beverage preferences are identified for all residents.
A facility failed to provide therapeutic diets as ordered for two residents. Both residents had dysphagia mechanical soft diet orders, but their tray cards indicated a pureed buttered dinner roll and they were served a regular roll instead of the ordered pureed consistency roll. The RD confirmed the mismatch, and staff checked additional dysphagia mechanical soft trays in the dining room for regular bread.
The facility did not consistently serve meals at scheduled times, with repeated resident complaints and observations confirming that meals, especially dinner, were often late. Residents and a family member reported ongoing issues with meal timing, missing trays, and lack of alternatives, leading to rushed meals and interference with activities. The administrator acknowledged the inconsistency in meal service.
The facility failed to update care plans for three residents after significant changes in their conditions. A resident's care plan was not revised after a fall with major injury, another's did not reflect current behaviors or medication status, and a third's did not include changes in advanced directives for comfort care. The DON confirmed these deficiencies.
The facility failed to adhere to professional standards for food storage and labeling, as observed during a kitchen investigation. Issues included improperly dated or undated food items, such as tea, cake mixes, burrito shells, ravioli, chicken patties, and frozen carrots. A dented can of soup and undated ice cream products were also noted. The Dietary Manager acknowledged these issues, citing limited storage space and improper employee practices.
The facility failed to maintain accurate medical records for three residents. One resident's records did not reflect a restriction on taking blood pressure from an arm with a fistula, and staff documented readings from that arm. Another resident's medication orders were inaccurately documented for 'health maintenance' instead of specific conditions. A third resident's records incorrectly indicated the use of Norco for pain management, which was not prescribed. The DON confirmed these discrepancies.
An LPN failed to perform hand hygiene between administering medications to residents and after returning from the medication room, contrary to facility policy. The DON was informed of these lapses, which occurred during medication administration to 22 residents on a specific hall.
A facility failed to inform a resident's MPOA of abnormal lab and urinalysis results, including a high white blood cell count and presence of bacteria. The DON confirmed the oversight was due to the resident's declining condition.
A facility failed to protect residents from abuse and neglect, with incidents involving neglect of a resident left in urine-soaked clothing, verbal abuse towards a nonverbal resident, and inappropriate joking about 'pillow therapy' with a bedridden resident. These incidents highlight a lack of proper care and respect for residents' dignity and safety.
A facility failed to include a resident's fistula in their care plan, despite a sign indicating no blood pressure or labs should be taken from the left arm. Records showed blood pressure was documented as taken from the left arm, but the DON confirmed this was a documentation error. The resident, with a fistula for seven years, did not recall blood pressure being taken from that arm.
The facility failed to document a change of condition for a resident who experienced a decline in oral intake and began morphine treatment, as confirmed by the DON. Additionally, there was a delay in addressing a family concern for another resident who showed reduced alertness and elevated temperatures, with a history of UTIs. The delay in treatment and lack of timely documentation were confirmed through record reviews and staff interviews.
A resident's tube feeding was improperly managed when an LPN stopped the feeding due to flushing issues without obtaining a discontinuation order. The feeding was not restarted until the day shift, and a significant amount of the feeding remained unadministered. The resident was later discharged to the emergency room and did not return.
The facility failed to store a resident's personal food separately from facility food, as observed during a kitchen investigation. A resident's opened box of popcorn shrimp was found in the main freezer without a date or label. The Dietary Manager confirmed the item belonged to a resident and noted a lack of space in the resident's freezer. This practice could affect more than a limited number of residents.
Care plans were not accurately developed or implemented for falls, communication, and diagnosis needs
Penalty
Summary
Failure to develop and implement complete care plans was identified for fall interventions, means of communication, and multiple diagnoses for Residents #5, #61, and #44. For Resident #5, the care plan included non-skid strips to the left side of the bed and nonslip material to the wheelchair for safety, and the orders stated Dycem to the wheelchair every shift and non-skid strips to the left side of the bed. However, on observation of the room and wheelchair, there were no non-skid strips on the left side of the bed, and the Dycem was placed on top of the wheelchair cushion instead of under it. A Corporate RN confirmed the missing tape and that the Dycem should have been placed under the cushion. For Resident #61, the resident was non-verbal and able to communicate through gestures, but the care plan repeatedly directed staff to verbalize with the resident, discuss feelings, encourage the resident to voice feelings, and discuss coping skills. The DON confirmed the care plan used verbal communication language despite the resident communicating via gestures. For Resident #44, record review found the care plan was not developed for the diagnosis of lupus anticoagulant syndrome; instead, it listed lupus as a focus area even though the resident did not have a diagnosis of lupus. The DON confirmed the care plan had not been developed for the correct diagnosis.
Posted Menus Were Not Followed
Penalty
Summary
The facility failed to follow the posted menus as served to residents. On 04/29/2026, the menu posted at the entrance of the first-floor dining room listed cranberry orange chicken, garlic and roasted red skin potatoes, dinner roll, and mandarin oranges, but cabbage was served to residents for lunch even though it was not on the posted menu. Nurse Aide #88 confirmed that cabbage was not listed on the menu and was served in the dining room. Resident #31 reported on 04/28/26 that chicken wings were served for a couple of meals even though they were not on the menu. Resident #47 and Resident #71 both received ravioli and cabbage on 04/29/26, and Licensed Practical Nurse #77 confirmed that residents received ravioli and cabbage for the lunch meal.
Delayed Meal Service on A Hall
Penalty
Summary
The facility failed to ensure meals were served timely on A Hall in accordance with the 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. During survey observation on 5/5/26 at 9:40 AM, residents on A Hall were still being served breakfast well beyond the scheduled window, and Resident #74, who required feeding assistance, was still waiting for a meal at that time. A CNA stated that delayed meal tray delivery from the kitchen happens often, and it was reported that A Hall received meal trays around 9:00 AM. The facility administrator stated, "One hallway has to be last," in response to the delayed meal service. Surveyor observation also noted meal pass occurring on A Hall at approximately 9:40 AM, and on 4/28/26 at 10:50 AM, Resident #31 stated concern about consistently late meal service, saying, "I fall asleep waiting for dinner," and reported that dinner is often not served until 7:00 PM-7:30 PM.
Hand Hygiene Not Performed During Dining Service
Penalty
Summary
Provide and implement an infection prevention and control program. Based on observation, record review, and staff interview, the facility failed to ensure staff completed hand hygiene during the dining process. The facility’s Standard Precautions policy stated that hand hygiene should be performed before eating, feeding, or assisting in the dining room and tray pass. During a dining room observation on 04/28/26 at 11:55 AM, RN #75 did not perform hand hygiene between residents while serving. Nurse Aide #72 and RN #75 passed drinks to each other and then served residents their drinks without performing hand hygiene. At 12:05 PM, LPN #33 confirmed the hand hygiene issues observed in the dining room.
Mechanical Lifts Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure mechanical lifts were maintained in safe operating condition. During a family member’s discussion with the survey team, concerns were raised that the Joerns Hoyer lifts were dirty and had electrical tape on them, and that sometimes only one lift was working and had to be used between both floors. Surveyors then observed the lifts in the shower rooms on both floors and found electrical tape on the wires attached to the cradle on both sides of each lift, with frayed wires visible at the base of the tape on the first-floor lift. A nurse aide confirmed the black electrical tape on the first-floor lift and reported staff had been asking for new lifts. The Administrator acknowledged the taped and frayed wires and stated maintenance was still in the building, while also saying he would have maintenance put more tape on it and declining to remove the tape. The Director of Plant Maintenance stated the lift had been malfunctioning for the last year and that he did not have electrical certification. The facility also kept both lifts stored in shower rooms, despite the manufacturer’s manual stating not to use or store a lift in a wet or corrosive environment such as shower, bath, or pool locations.
Failure to Follow Fall Prevention Orders
Penalty
Summary
The facility failed to follow physician orders for fall prevention for Resident #5. The resident’s orders included DYCEM to the wheelchair for safety every shift and non-skid strips on the left side of the bed. During observation of the resident’s room and wheelchair, the surveyor found no non-skid strips on the left side of the bed, and the Dycem was placed on top of the wheelchair cushion instead of underneath it. A Corporate RN confirmed that the non-skid tape was missing and that the Dycem should have been placed under the wheelchair cushion to help prevent it from sliding.
Open Cleaner Left in Shower Room
Penalty
Summary
The facility failed to ensure the shower room environment was free from accident hazards on A Hall. During record review, staff interview, and observation, the state surveyor found that Resident #39, a resident from D Hall, was in the bathroom adjacent to the shower room and could open the door from the bathroom into the shower room. The shower room door was locked with a keypad entrance, while the bathroom door was not locked from the hallway. An open gallon jug of Medco Prewash MP2017 was sitting on top of the wheelchair washer machine in the shower room. The product’s Safety Data Sheet identified it as causing skin irritation and serious eye irritation. Licensed Practical Nurse #42 confirmed that the bottle of cleaner was open in the shower room.
Expired Insulin Found on Medication Cart
Penalty
Summary
A deficiency was identified in medication storage and labeling when an expired vial of Lispro insulin for Resident #11 was found on the B hall medication cart during a random observation of the medication storage area. The vial was discovered at 9:10 AM, and LPN #77 verified that the insulin had expired on the date noted in the record. The vial’s opening date was also documented, and at 9:14 AM the DON confirmed that insulin expires 28 days after a vial is opened.
Failure to Serve Beverage Per Tray Card
Penalty
Summary
The facility failed to ensure drinks, including water and other liquids, were served consistent with residents' needs and preferences. During a dining room observation on the first floor, Resident #12's tray card listed hot coffee, 6 oz, but the resident did not receive the coffee as printed on the tray card. When asked by the state surveyor if she wanted coffee, the resident stated, "Yes, I wanted coffee," and received coffee after surveyor intervention. An LPN later confirmed that the resident did not receive coffee as printed on the tray card. The facility policy and procedure for Dining and Food Preference stated that individual dining, food, and beverage preferences are identified for all residents and patients.
Therapeutic Diet Orders Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure therapeutic diets were provided as ordered by the attending physician for Resident #5 and Resident #35. Resident #5 had an order for a regular diet with dysphagia mechanical soft texture and nectar-thickened liquids, but the tray card stated Dys Mech - Regular and Pureed Buttered Dinner Roll - #16 Scp, and the resident was served a whole, unbuttered roll with the lunch meal. Resident #35 had an order for a regular diet with dysphagia mechanical soft texture and thin liquids, and the tray card also stated Dys Mech - Regular and Pureed Bettered Dinner Roll - #16 Scp. At 12:10 PM, the Registered Dietician confirmed that both residents' tray cards indicated a dysphagia mechanical soft diet with a pureed buttered dinner roll, but the residents did not receive a pureed consistency roll and instead received a regular roll. The residents did not consume their whole rolls secondary to surveyor intervention, and staff checked additional dysphagia mechanical soft trays in the dining room for regular consistency bread.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to provide meals at scheduled times, as evidenced by multiple months of Resident Council Minutes documenting repeated complaints about late meal service, particularly at dinner. Residents reported that meals were consistently late, with some instances of missing trays and a lack of available alternatives when main selections ran out. The delays in meal service also caused staff to rush residents during meals, which interfered with evening activities. These issues were corroborated by direct interviews with several residents and a family member, all of whom confirmed the ongoing problem of late meal delivery. Observation of scheduled meal times indicated that breakfast, lunch, and dinner were set within specific time frames, but staff and administrative interviews acknowledged ongoing inconsistency in adhering to these times. The administrator confirmed that meal timing had been problematic and noted a recent change in the Dietary Manager, but did not indicate that the issue had been resolved. The deficiency affected all residents who received nutrition from the kitchen, with a facility census of 96.
Failure to Update Care Plans Following Significant Changes
Penalty
Summary
The facility failed to revise care plans for three residents following significant changes in their conditions. Resident #47 experienced a fall resulting in a head injury and two broken ribs, yet the care plan was not updated to reflect this major injury. Despite the incident being documented by a nurse practitioner and the resident being sent to the hospital, the care plan remained unchanged, which was confirmed by the Director of Nursing (DON). Resident #51's care plan did not specify behaviors related to vascular dementia and incorrectly included interventions for administering medications, although the resident was not taking any prescribed medications. Additionally, Resident #50's care plan was not updated to reflect changes in her advanced directives and POST form, which indicated a shift to comfort-focused treatments and no CPR. The lack of updates to the care plan was acknowledged by the DON, highlighting a failure to ensure the care plans accurately reflected the residents' current medical needs and directives.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store and label food in accordance with professional standards for food service safety, as observed during a kitchen investigation. A large container of tea was found with an illegible date, and a measuring cup with tea residue was placed on top of it. Pitchers containing water were improperly stored on a shelf due to limited space. Various food items, including cake mixes, burrito shells, ravioli, chicken patties, and frozen carrots, were found opened without use-by dates or proper sealing. Additionally, a dented can of Campbell's chicken noodle soup was noted. Ice cream products and boxes in two pantries were also found without dates, although the Dietary Manager stated that ice cream is replaced weekly as part of a scheduled order.
Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for three residents during a Long Term Care Survey. For one resident, a sign was posted indicating no blood pressure or labs should be taken from the left arm due to a fistula, yet the medical record did not reflect this restriction, and staff had documented blood pressure readings from the left arm on multiple occasions. The care plan also failed to address the presence of the fistula. The Director of Nursing (DON) confirmed the oversight and stated that the blood pressure readings were incorrectly documented. Another resident's medical records showed medication orders for Topiramate and Gabapentin for 'health maintenance,' which is not an approved diagnosis. The DON confirmed that the medications were actually prescribed for migraines and diabetic nephropathy, respectively. Additionally, a third resident's records included an assessment indicating the use of Norco for pain management, but the DON confirmed that the resident had never been prescribed Norco while at the facility.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to maintain an infection control program during medication administration, as observed on 10/16/24. An LPN was responsible for administering medication to 22 residents on B hall. During the medication administration process, the LPN did not perform hand hygiene between administering medication to two residents, and again failed to perform hand hygiene after leaving and returning to the medication room before administering medication to another resident. The LPN believed they had completed hand hygiene at the necessary times. The Director of Nursing was informed of these lapses in hand hygiene, which were contrary to the facility's policy that requires hand hygiene before and after each resident's medication administration.
Failure to Notify MPOA of Abnormal Test Results
Penalty
Summary
The facility failed to notify the Medical Power of Attorney (MPOA) of a resident's abnormal laboratory and urinalysis results. On October 16, 2024, a record review revealed that a resident had an abnormal white blood cell count of 27.6, as well as additional flagged abnormal test results from a Complete Blood Count (CBC) conducted on December 29, 2023. The urinalysis also showed abnormalities, including the presence of white blood cells and bacteria. Despite these findings, there was no documentation indicating that the MPOA was informed of these results. The Director of Nursing confirmed that the results were not reported to the MPOA due to the resident's declining condition.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving three residents. Resident #16 was found in a state of neglect, with urine-soaked clothing and bedding, indicating a lack of proper care and attention from the staff. The resident, who required advanced assistance with activities of daily living, was left unattended and not properly toileted throughout the night, leading to distress and discomfort. Resident #34 was subjected to verbal abuse by a CNA, who threatened physical harm and used derogatory language. This resident, who is mostly nonverbal and dependent on staff for maximal assistance, was unable to communicate the distress caused by the incident. The inappropriate behavior was witnessed by another CNA, highlighting a failure in maintaining a safe and respectful environment for residents. Resident #11 was involved in an incident where a CNA made a threatening joke about 'pillow therapy,' which was perceived as abusive by another staff member. Although the resident later described the interaction as jovial and not threatening, the comment was inappropriate and unprofessional. This resident, who is bedridden and receiving hospice care, relies entirely on staff for assistance, making the incident particularly concerning.
Failure to Address Fistula in Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with a fistula in the left arm. During the survey, it was observed that there was a sign posted by the resident's bed indicating no blood pressure or labs should be taken from the left arm. However, the care plan did not address this restriction or the presence of the fistula. Record reviews showed that blood pressure was documented as being taken from the left arm on several occasions, although the Director of Nursing confirmed this was a documentation error. The resident, who had the fistula for approximately seven years, stated they did not recall having blood pressure taken from that arm while in the facility.
Failure to Document Change of Condition and Delay in Treatment
Penalty
Summary
The facility failed to complete a change of condition for Resident #50, who experienced a decline in her ability to consume oral intake and began gagging with the touch of food. The in-house physician recommended discontinuing oral medications and starting morphine sulfate for pain, distress, and air hunger, with the Medical Power of Attorney (MPOA) in agreement. Despite these significant changes, no change of condition was documented, which was confirmed by the Director of Nursing (DON) as a requirement that was not met. For Resident #145, the facility did not promptly address a family concern about the resident's lack of response to questions. The resident exhibited reduced mental alertness and elevated temperatures over several days, yet there was a delay in ordering Tylenol and conducting a urinalysis with culture and sensitivity. The resident had a history of urinary tract infections, and the delay in treatment was confirmed by the DON, who could not provide an explanation for the oversight. The deficiencies in both cases involved a lack of timely documentation and response to changes in the residents' conditions, leading to delays in appropriate treatment. These failures were confirmed through record reviews and staff interviews, highlighting significant lapses in the facility's care processes.
Failure to Maintain Resident's Nutrition and Hydration
Penalty
Summary
The facility failed to ensure the proper nutrition and hydration status for a resident, as evidenced by the mishandling of the resident's tube feeding. On the night shift, an LPN stopped the resident's ordered tube feeding, citing that the tube did not flush well. The tube feeding was not restarted until the day shift, and additional supplements were provided. The resident's health care surrogate was notified, and the incident was reported to the LPN Board and the Ombudsman. The resident was not interviewable, and the facility's follow-up investigation could not verify the allegation, although it was noted that the tube feeding was disconnected for a short period. Interviews with staff revealed discrepancies in the handling of the tube feeding. A witnessing LPN reported that the tube feeding was still running when he left the facility, but upon his return, it was found that a significant amount of the feeding remained, indicating it had not been administered as ordered. The LPN responsible for the night shift stated that the machine had beeped, and he noticed the tubing was separated, which led to the feeding being stopped. Despite these issues, no order was obtained to discontinue the feeding, and the resident was eventually discharged to the emergency room and did not return to the facility.
Improper Storage of Resident's Personal Food
Penalty
Summary
The facility failed to properly store residents' personal food items separately from the facility's food, as observed during a kitchen investigation. A resident's personal food item, specifically an opened box of popcorn shrimp, was found in the facility's main freezer without any date or label. The Dietary Manager confirmed that the item belonged to a resident and explained that there was no available space in the resident's designated freezer for the frozen food. This practice has the potential to affect more than a limited number of residents, as it was not in compliance with the facility's policy regarding the use and storage of foods brought in by family and other visitors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clarksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Oaks Healthcare Center | 2.9 mi | ★★★★★ | 3 | 0 |
| Bridgeport Healthcare Center | 6.3 mi | ★★★★★ | 10 | 0 |
| United Transitional Care Center | 8.6 mi | ★★★★★ | 0 | 0 |
| Maplewood Healthcare Center | 8.9 mi | ★★★★★ | 8 | 0 |
| Salem Center | 9.6 mi | ★★★★★ | 0 | 0 |
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