Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Belmont Manor during CMS and state inspections, most recent first.
Expired and moldy food was observed during a kitchen tour, affecting all 52 residents. Surveyors found an open box of Idaho potatoes in the pantry with a dusty fuzzy brownish blue film, including cut potatoes with the same film on the exposed sides, and a gallon of chocolate milk in the walk-in refrigerator that had expired. The DM confirmed the condition of the potatoes and the expired milk.
Residents were charged monthly bank service fees against their personal funds, but the facility had no evidence that residents or their representatives were told in advance about these charges. Record review showed multiple residents with diagnoses including CHF, DM, dementia, Alzheimer’s disease, depression, paraplegia, and disorientation had bank service charges on their statements, and business office staff confirmed the fees varied by account balance and that they were unaware whether residents had been notified.
Failure to monitor CHF status and weights: A resident with CHF, respiratory failure, CKD, diabetes, anemia, and continuous O2 use had 3+ edema on admission, only one documented weight after admission, and no documented ongoing assessment of Lasix effectiveness. Nursing notes showed persistent SOB, later orthopnea, and continued edema, but the provider was not notified of the new respiratory change. The resident was later hospitalized with acute CHF exacerbation with hypoxia, and staff confirmed the facility lacked a CHF monitoring protocol and did not routinely report missed weights.
Failure to use EBP for a resident with a pressure ulcer. A resident with diabetes, UTI, weakness, impaired mobility, and a sacral pressure ulcer received wound care, but the room had no EBP signage. RN confirmed the facility only used EBP for wounds present over a month or for residents with foley catheters or IV lines, despite the facility policy stating EBP applies to residents with wounds, including pressure ulcers, during high-contact care such as wound care.
The facility's kitchen practices were found to be unsanitary, with staff unaware of dishwasher types and using expired chlorine strips for testing. The deep fryer oil was not changed as per policy, and the refrigerator contained expired food. The ice maker's scoop was stored on a soiled surface, indicating a lack of adherence to food safety protocols.
The facility failed to maintain resident dignity by leaving urinary catheter bags uncovered and visible, affecting several residents with various medical conditions. Additionally, STNAs placed clothing protectors on residents without consent and engaged in personal conversations during meal service, compromising the dignity of residents during dining.
The facility failed to update care plans for four residents, leading to deficiencies in addressing their current health needs. A resident with significant weight loss did not have their care plan revised to reflect nutritional interventions. Another resident receiving hospice care had an outdated activity care plan, and a third resident's care plan did not reflect a change in antibiotic medication. The DON confirmed these care plans were not updated.
The facility failed to ensure proper pureed food consistency for four residents on a pureed diet. During food preparation, a dietary staff member did not taste the pureed foods to check for texture. The chicken was fibrous, and the vegetables were lumpy, while only the rice met the correct consistency. The facility's policy requires pureed food to be smooth and lump-free to reduce choking risks.
The facility failed to meet professional standards for catheter care and did not identify infection patterns, affecting a resident with an indwelling catheter. The infection control log showed multiple UTIs with E. coli, all on the same unit. An STNA did not follow proper infection control procedures during catheter care, and the facility's policy lacked specific instructions on glove removal.
The facility failed to ensure call lights were accessible for a visually impaired resident and did not provide appropriate table heights for a resident during meals. A resident with macular degeneration could not reach her call light, and another resident with Alzheimer's was seated at a table that reached her chin, hindering her ability to eat. Staff did not intervene to correct these issues.
Two residents were found to be restrained in a facility, contrary to their care plans and facility policy. One resident was unable to self-propel due to a reclined wheelchair and chair alarm, while another could not release a seat belt independently, despite it being intended as self-releasing. Staff confirmed these conditions acted as restraints, violating the residents' rights to freedom of movement.
A facility failed to ensure accurate comprehensive assessments for a resident with dementia and other conditions. The MDS assessments inaccurately documented the resident's use of alarms and falls, failing to reflect the actual use of a bed alarm and self-releasing seat belt, and the number of falls sustained. Additionally, the assessments inaccurately recorded the resident's use of antipsychotic medications, as confirmed by medical record reviews and an interview with the DON.
A facility failed to provide a resident with a written summary of her baseline care plan within 48 hours of admission. The resident, who had multiple health conditions, did not recall receiving the summary. The baseline care plan included a section for a signature to confirm receipt, but it was noted that the plan was reviewed verbally instead. An RN confirmed the facility's failure to provide written summaries.
A facility failed to develop comprehensive care plans for a resident with multiple health conditions, including dementia, diabetes, and hypertension. The resident was at moderate risk for falls, yet no fall prevention plan was created, resulting in a fall. Additionally, the resident's known allergy to Exelon was not documented in a care plan. An LPN confirmed the absence of care plans for these issues, and a constipation care plan was discontinued despite ongoing PRN orders.
The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
The facility failed to provide adequate nail and oral care for two residents, leading to deficiencies in their personal hygiene. One resident, with multiple diagnoses including dementia and a Stage IV pressure ulcer, was observed with long, dirty fingernails despite orders for weekly inspection and trimming. Another resident, with cognitive deficits, was found with dirty fingernails and poor oral hygiene, as the STNA admitted to not providing the necessary care during the morning routine.
A facility failed to implement physician orders for a resident with edema, hypertension, and diabetes, who was supposed to wear tubigrips for compression. Observations showed the resident's feet were swollen, and she was not wearing the prescribed tubigrips. An STNA could not find the tubigrips in the resident's room and noted they were sometimes not returned from laundry. Documentation of the resident refusing the tubigrips was questioned as the STNA was not on duty that day.
A resident with visual impairments, including cataracts and Alzheimer's, was observed without eyeglasses multiple times, affecting their ability to engage in activities. The facility failed to replace the resident's broken glasses, and staff were unaware of the need for prescription glasses, despite a care plan encouraging their use.
A facility failed to properly implement and monitor restorative services for residents with mobility and range of motion issues. One resident was observed without required palm guards and lacked proper monitoring of restorative programs. Another resident's range of motion programs were not reassessed or adjusted, and a third resident did not receive recommended ambulation programs, leading to a decline in mobility. Staff interviews revealed a lack of consistent follow-through and evaluation of restorative needs.
A facility failed to implement fall prevention interventions and conduct accurate investigations for a resident with severe cognitive impairment and a history of falls. Despite being at moderate risk for falls, the resident had no fall care plan prior to their first fall and subsequent falls were not properly addressed. Investigations lacked immediate interventions and complete documentation, including neurological checks and medication administration records. The facility's policy requirements were not met, as confirmed by the DON.
A resident with significant weight loss did not receive necessary medications, supplements, or routine meals. Despite recommendations for nutritional supplements and Remeron to increase appetite, the facility did not administer the medication as ordered. The care plan was not updated, and staff failed to provide meals or supplements when the resident slept through meal times. Observations and interviews confirmed these deficiencies, contributing to the resident's continued weight loss.
A resident with dementia and diabetes was prescribed Rexulti, but the facility failed to conduct necessary baseline AIMS assessments and blood glucose monitoring. Interviews with the DON and an LPN confirmed these oversights, which are required by the facility's psychoactive medication policy.
The facility failed to comply with regulations for psychotropic medications, affecting two residents. One resident received an antianxiety medication without a 14-day stop date, while another was given an antipsychotic without behavior documentation or an AIMS assessment. The facility's policy on psychoactive medications was not followed, as confirmed by the DON.
The facility failed to maintain accurate medical records for two residents. One resident's pressure ulcer was incorrectly documented, and another resident's allergy to Exelon was not accurately recorded in their hard chart, despite known adverse effects. These inaccuracies were confirmed by staff interviews.
A resident's electronic medical record was left open and visible on a computer screen at the nurses station, exposing personal health information such as their picture, date of birth, physician name, and medications. No staff were present to monitor the exposed information, and a registered nurse later confirmed the breach of privacy.
A facility failed to implement pressure relieving measures for a resident with a history of pressure ulcers. Despite a care plan intervention to float heels while in bed, the resident's heel was observed resting on a pillow, causing discomfort. The resident had multiple diagnoses, including pressure-induced deep tissue damage, and required pressure-reducing measures, which were not adhered to, leading to the deficiency.
A resident with a history of UTIs and an indwelling catheter did not receive appropriate care as ordered. Despite recommendations for topical estrogen and a urology follow-up, these were not implemented. Catheter care was not performed every shift, and urine samples were not collected from a clean catheter. Observations showed the catheter bag was uncovered with sediment present. These actions led to the deficiency.
The facility failed to ensure proper review and consultation for antibiotic use in two residents. One resident was prescribed Cefdinir for a UTI without confirming the urine sample method, and culture results were delayed. Another resident was on a daily antibiotic regimen without specialist consultation. The DON acknowledged these issues.
Expired and Moldy Food Found in Kitchen Storage
Penalty
Summary
Food was found to be expired and to have mold during an initial kitchen tour, affecting all 52 residents in the facility. In the pantry area, an open cardboard box on the bottom shelf contained large Idaho potatoes, several of which had a dusty fuzzy brownish blue film on them, and some were cut in half with the same film on the open side. In the walk-in refrigerator, surveyors also observed a gallon of chocolate milk that was about one quarter full and had an expiration date of 02/22/26. The dietary manager confirmed the potatoes had a brownish blue fuzzy layer and removed them, and also confirmed the milk was expired and discarded it. Review of the facility's Food Receiving and Storage policy stated refrigerated foods are to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.
Residents Not Informed of Banking Service Fees
Penalty
Summary
The facility failed to ensure residents or their resident representatives were informed in advance of charges that could be imposed against residents’ personal funds. Record review showed that Resident #8, who had diagnoses including congestive heart failure, insomnia, diabetes, and transient ischemic attack, had a quarterly banking statement with a $7.05 bank service charge. Resident #5, with diagnoses including cognitive communication deficit, major depressive disorder, and paraplegia, had a $5.47 bank service charge on the banking statement. Resident #22, who had diagnoses including dementia, anxiety, Alzheimer’s disease, and major depressive disorder, had a $1.23 bank service charge, and the Personal Funds Disposition Form for this resident stated the resident and/or representative authorized the facility to manage personal funds while residing in the facility. Resident #35, who had diagnoses including restlessness and agitation, wandering, diabetes, anxiety, Alzheimer’s disease, and disorientation, had a $0.12 bank service charge on the banking statement. Interview with business office personnel confirmed that a banking service fee was charged to each resident, that the fee came from the bank and varied by resident based on account balance, and that staff were unaware whether residents had been notified about the fee. Review of the admissions packet, admission agreement cheat sheet notes, and facility rules, regulations, policies, and procedure guides found no evidence that residents or their representatives were made aware in advance of the monthly banking service fee charged by PNC Bank for managing resident funds.
Failure to Monitor CHF Status and Weights
Penalty
Summary
The facility failed to timely assess and monitor the cardiopulmonary status, including weights, for a resident admitted with congestive heart failure, respiratory failure, heart disease, chronic kidney disease, diabetes, high blood pressure, anemia, and continuous oxygen use. On admission, the resident had 3+ pitting edema to both arms and lower legs, was on oxygen, and refused to be weighed on the first day. The physician ordered daily weights for three days, then weekly for four weeks, then monthly, and the care plan included weight monitoring and observation for signs and symptoms of CHF. The resident’s record showed only one documented weight after admission, and there was no evidence of ongoing weight monitoring after that. Nursing documentation repeatedly noted shortness of breath with exertion, 3+ pitting edema, oxygen use, and nebulizer treatments, but there was no evidence that the resident was monitored or assessed for the effectiveness of Lasix after it was started for fluid retention. The record also showed that the resident developed new orthopnea, with shortness of breath while lying flat and the head of bed elevated, but there was no documentation that the medical provider was notified of this change in respiratory status. Laboratory testing showed elevated BUN and creatinine, worsening hemoglobin, and an elevated WBC count, and the provider was notified of the results. Later, the resident developed blisters on the lower legs, continued shortness of breath, elevated respiratory rate, and persistent 3+ edema, after which the provider was notified and the resident was sent to the emergency room. Hospital records showed the resident was admitted with acute exacerbation of CHF with hypoxia, along with pneumonia, obstructive uropathy, and hydronephrosis. Staff interviews confirmed the facility did not have a CHF monitoring protocol, that weights were only obtained when ordered, and that refusal or inability to obtain weights was not reported unless persistent and affecting care.
Failure to Use EBP for Resident With Pressure Ulcer
Penalty
Summary
The facility failed to follow Enhanced Barrier Precautions (EBP) to reduce the transmission of multidrug-resistant organisms during high-contact resident care activities. Resident #20 was admitted with diagnoses including type 2 diabetes mellitus, urinary tract infection, muscle weakness, overactive bladder, hypertension, atherosclerotic heart disease, difficulty walking, lack of coordination, constipation, history of falling, and an unstageable pressure ulcer of the sacral region. The resident’s MDS indicated intact cognition, use of a walker, dependence for oral care and showering, substantial to maximal assistance with toileting, and substantial assistance with other ADLs. During wound care observation, the resident had a stage III sacral pressure ulcer and care was provided by RN #110 without infection control issues noted during the procedure. However, the resident’s room did not have EBP signage, and RN #110 confirmed this at the time of observation. RN #110 stated the facility only used EBP when wounds had been present for over a month or more, or for residents with foley catheters or IV lines, and did not use EBP when a pressure ulcer was new. The facility’s EBP policy stated that EBP signs should be placed on the resident’s door, PPE should be kept inside the room near the door, and EBP is indicated for residents with wounds, including chronic wounds such as pressure ulcers.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary kitchen practices, which could potentially affect all residents except one who did not receive nutrition from the kitchen. During an observation, a dietary staff member was found to be unaware of whether the facility had a high or low temperature dishwasher and was using expired chlorine strips to test sanitation levels. The dishwasher's temperature gauge was clouded, making it difficult to read, and there were missing records of water temperature and sanitation levels for certain meals. The facility's dishwashing policy did not address chemical sanitation levels, and the staff member confirmed that the dishwasher's temperature and sanitation levels were not checked before starting breakfast dishes. Additionally, the deep fryer oil was observed to be covered with debris and appeared black, indicating it had not been changed or filtered according to the facility's policy. The oil had not been changed for over a month, and maintenance staff admitted to not adhering to the cleaning schedule. The walk-in refrigerator contained macaroni salad that was not discarded per policy, and the ice maker's scoop was stored on a soiled surface with visible debris and hairs. These observations highlight a lack of adherence to food safety and sanitation protocols within the facility's kitchen operations.
Failure to Maintain Resident Dignity with Catheter Use and Dining Practices
Penalty
Summary
The facility failed to maintain resident dignity in several instances involving the use of indwelling urinary catheters and during dining. For residents with urinary catheters, such as Resident #12, #22, and #6, the urinary drainage bags were observed to be uncovered and visible to other residents and visitors, compromising their dignity. These residents had various medical conditions, including Parkinson's disease, end-stage renal disease, dementia, and neuromuscular dysfunction of the bladder, which necessitated the use of catheters. The visibility of the urine in the bags and tubing was confirmed by interviews with Registered Nurses #522 and #528, who acknowledged that the bags were not in protective covers. During dining, State tested Nurse Aides (STNAs) #105, #108, and #244 were observed placing cloth clothing protectors on residents without asking for their consent, affecting residents such as #3, #19, #21, #44, and #46. Additionally, STNAs engaged in personal conversations unrelated to the residents during meal service, and STNA #244 was noted to stand while assisting residents with their meals, which is not conducive to maintaining dignity. The Director of Nursing confirmed that residents should be offered a choice regarding the use of clothing protectors. The facility's policy on Quality of Life-Dignity, revised in January 2024, prohibits practices that compromise resident dignity, including ensuring urinary catheter bags are covered.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise comprehensive care plans for four residents, leading to deficiencies in addressing their current health needs. Resident #46, who was admitted with non-Alzheimer's type dementia, anxiety, breast cancer, and arthritis, experienced significant weight loss over several months. Despite the weight loss and the implementation of nutritional supplements, the care plan was not updated to reflect these changes. The Director of Nursing confirmed that the nutrition care plan had not been revised. Resident #21, with a history of Alzheimer's disease and other conditions, was receiving hospice services with a life expectancy of less than six months. The care plan, which had not been updated since 2020, did not reflect the resident's current status, including the loss of glasses and the admission to hospice care. The Director of Nursing verified that the activity care plan had not been revised to accommodate these changes. Resident #44, diagnosed with diabetes mellitus and other conditions, experienced a significant weight loss over several months. Despite the implementation of nutritional interventions, the care plan was not updated to reflect the resident's weight loss. Similarly, Resident #15, with a history of urinary tract infections and other health issues, had a care plan that inaccurately listed Macrobid as the long-term antibiotic, even though it had been changed to Trimethroprim in November 2023. The Director of Nursing confirmed that the care plan had not been updated to reflect this change.
Failure to Ensure Proper Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that food was pureed to the correct consistency for four residents who were on a pureed diet. During an observation of the pureed food preparation process, it was noted that the dietary staff member, identified as Dietary #570, pureed barbeque chicken, rice pilaf, and mixed vegetables according to the recipe and under sanitary conditions. However, the staff member did not taste the pureed foods to check for texture consistency. Upon testing, the chicken was found to be fibrous and not pureed to a creamy consistency, while the vegetables contained visible bits and were lumpy, indicating they were not fully blended. The rice was the only item that met the correct consistency. Dietary #570 confirmed that the chicken and vegetables were not pureed to a smooth consistency. The facility's Pureed Diet policy, reviewed in 2017, states that individuals with swallowing difficulties require modified textures to reduce the risk of aspiration or choking, and that pureed food should be smooth and lump-free, served at a pudding or mashed potato consistency. This deficiency affected four residents in a facility with a census of 51.
Infection Control and Catheter Care Deficiencies
Penalty
Summary
The facility failed to ensure catheter care met professional standards and to identify patterns of infection, affecting one resident with an indwelling catheter. The infection control log for June 2024 showed four urinary tract infections (UTIs) acquired after admission, with three of these infections caused by E. coli. All three residents with E. coli resided on the same unit, with the onset of infections recorded on the same date. During an interview, the Infection Control Preventionist initially did not recognize any patterns in the infection surveillance but later acknowledged the pattern after discussion. An observation of catheter care revealed that a State Tested Nurse Aide (STNA) did not follow proper infection control procedures. The STNA performed catheter care on a resident in enhanced barrier precautions but failed to remove gloves before touching the resident's bed covers, bed control, and handing the resident a book. The facility's catheter care policy, reviewed in January 2024, did not include instructions to remove gloves before touching these items. This oversight in the policy and the STNA's actions contributed to the deficiency.
Deficiencies in Resident Accommodation and Meal Positioning
Penalty
Summary
The facility failed to accommodate the needs of residents by not ensuring that call lights were readily accessible. This deficiency was observed in the case of a resident with macular degeneration, who was unable to see and required assistance with personal care. During an observation, the resident was found in her room in a wheelchair, unable to reach her call light, which was looped over a bedside table across the room. The resident expressed her inability to see and requested assistance from the surveyor to locate her call light. A State tested Nurse Aide confirmed that the call light was not within the resident's reach, which was contrary to the care plan that required the call light to be accessible to ensure a safe environment. Additionally, the facility did not provide appropriate table heights for residents during meals on the secured unit. A resident with non-traumatic brain dysfunction and Alzheimer's disease was observed seated in a specialty tilt wheelchair at a table that reached her chin, making it difficult for her to eat. Despite the presence of State tested Nurse Aides, the resident was not repositioned to a more suitable height or position during meal times. An interview with the Director of Nursing confirmed that residents should be properly positioned and at an appropriate table height during meals, which was not adhered to in this case.
Failure to Ensure Residents are Free from Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, affecting two residents. Resident #21, who was admitted with multiple diagnoses including Alzheimer's disease and unsteadiness on feet, was observed in a reclined specialty wheelchair with no leg rests, causing her legs to dangle without support. Despite the care plan indicating freedom of movement, the resident was unable to get out of the chair independently due to the reclined position and the use of a chair alarm. Interviews with staff confirmed that the wheelchair's configuration prevented the resident from self-propelling, effectively acting as a restraint. Resident #46, admitted with non-Alzheimer's dementia and other conditions, was also found to be restrained. The resident was observed in a specialized wheelchair with a seat belt and a chair pressure alarm. Despite being able to release the seat belt with cues, the resident was unable to do so upon command during the surveyor's observation, indicating that the seat belt acted as a restraint. The resident's care plan included a self-releasing seat belt, but the inability to release it independently was verified by staff, confirming the restraint. The facility's policy on restraints emphasized the right of residents to be free from restraints unless required for medical treatment. However, the observations and staff interviews revealed that the wheelchairs and alarms used for Residents #21 and #46 were not in compliance with this policy, as they restricted the residents' movement and ability to self-propel. The Director of Nursing confirmed that the wheelchairs and seat belt were considered restraints, highlighting a deficiency in the facility's adherence to its own policies and procedures.
Inaccurate Comprehensive Assessments for Resident
Penalty
Summary
The facility failed to ensure accurate comprehensive assessments for a resident with non-Alzheimer's dementia, anxiety, major depressive disorder, and diabetes mellitus type 2. The resident was ordered a self-releasing seat belt and a pressure-sensitive alarm, except while in a wheelchair, and received PRN Haldol for anxiety. However, the quarterly MDS assessments inaccurately documented the resident's use of alarms and falls. The assessments failed to reflect the resident's actual use of a bed alarm and self-releasing seat belt, and the number of falls sustained, which included five falls with two resulting in abrasions and a skin tear. Additionally, the MDS assessment inaccurately recorded the resident's use of antipsychotic medications. While the assessment indicated routine use only, the resident was administered PRN Haldol and began receiving Rexulti. These discrepancies were confirmed through medical record reviews, observations, and an interview with the Director of Nursing, highlighting errors in the MDS assessments related to alarms, falls, and psychotropic medications.
Failure to Provide Written Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to a resident within 48 hours of admission, as required. During an interview, the resident stated she did not recall receiving a summary of her baseline care plan. A review of the resident's medical record showed she was admitted with multiple diagnoses, including muscle wasting, hypokalemia, and depression, among others. The baseline care plan, dated shortly after admission, included a section for the resident or representative to sign, indicating receipt of the care plan and medication list. However, instead of a signature, there was a note stating the care plan was reviewed verbally with the resident. A registered nurse confirmed that the facility did not provide written summaries of the baseline care plans to residents or their responsible parties.
Failure to Develop Comprehensive Care Plans for Resident
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident, affecting their highest practicable well-being. Resident #46, who was admitted with diagnoses including non-Alzheimer's type dementia, anxiety, breast cancer, and arthritis, was identified as being at moderate risk for falls. However, no care plan was developed to prevent falls between March and June 2024, and the resident sustained a fall on June 5, 2024. Additionally, the resident had multiple health conditions such as diabetes mellitus, pain, constipation, and hypertension, yet no comprehensive care plans were created to address these issues. Furthermore, the resident had a known allergy to Exelon, which was not included in a care plan. Despite the resident's daughter informing the nurse about the negative effects of Rivastigmine, a medication related to Exelon, and the nurse practitioner discontinuing it, the allergy was not documented in a care plan. An interview with an LPN confirmed the absence of care plans for falls, medication allergies, pain, hypertension, or diabetes mellitus. The LPN also mentioned that a care plan for constipation was discontinued based on pharmacy recommendations, despite ongoing PRN orders for constipation treatment.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
Deficiency in Nail and Oral Care for Residents
Penalty
Summary
The facility failed to provide adequate nail and oral care for two residents, leading to deficiencies in their personal hygiene. Resident #22, who was admitted with multiple diagnoses including dementia and a Stage IV pressure ulcer, was observed with long fingernails and debris embedded under the nails, despite a physician's order to inspect and trim nails weekly. The facility's documentation indicated that aides were marking the task as completed, yet the resident's nails remained untrimmed and dirty. Additionally, the resident was under hospice care, receiving aide services five days a week, but the nail care was not adequately performed. Resident #49, admitted with diagnoses such as protein-calorie malnutrition and cognitive communication deficit, was also found with dirty fingernails and poor oral hygiene. Observations revealed debris under the nails and white buildup around the gums and between the teeth. Despite being moderately impaired for daily decision-making and requiring assistance with personal hygiene, the State Tested Nurse Aide (STNA) admitted to not providing nail or oral care during the morning routine. This lack of care was contrary to the physician's orders and the resident's care plan, which required regular inspection and maintenance of personal hygiene.
Failure to Implement Physician Orders for Compression Therapy
Penalty
Summary
The facility failed to implement physician orders for a resident diagnosed with edema, hypertension, and type two diabetes mellitus. The resident had a physician order to wear tubigrips on both legs at all times except during hygiene. However, observations and interviews revealed that the resident was not wearing tubigrips on multiple occasions, and her feet were swollen. The resident mentioned she used to wear compression stockings but was unaware of their current location. Documentation indicated that the resident wore tubigrips at one point but refused them later the same day. Further investigation showed that a State tested Nursing Assistant (STNA) was unable to locate the tubigrips in the resident's room and mentioned that sometimes they were not returned from laundry. The STNA also confirmed that she was not working on the resident's unit on the day the refusal was documented, raising questions about the accuracy of the documentation. The STNA stated she had a good relationship with the resident and could generally persuade her to comply with care requests.
Failure to Provide Necessary Visual Appliances
Penalty
Summary
The facility failed to ensure that a resident had access to necessary visual appliances, specifically eyeglasses, which affected their ability to engage in activities such as watching television and reading. The resident, who had diagnoses including cataracts, glaucoma, macular degeneration, and Alzheimer's disease, was observed multiple times without eyeglasses. Despite having a care plan that encouraged the use of glasses, the resident's eyeglasses were reportedly broken during a fall, and no replacement was provided. The facility's Missing Item Log showed no record of the glasses being broken or missing, and staff interviews revealed a lack of awareness regarding the resident's need for prescription glasses. The Director of Nursing confirmed that the resident had been seen by an eye doctor earlier in the year and was provided with a prescription, but was unaware of the missing glasses. The facility's policy on ancillary services indicated that ophthalmology visits were scheduled annually or as needed, but there was no evidence of follow-up to replace the broken glasses. The Activities Director and a Nurse Aide were both unaware of the resident's need for prescription glasses, and the resident was temporarily given non-prescription reader glasses found at the nursing station.
Failure to Implement and Monitor Restorative Services
Penalty
Summary
The facility failed to ensure that restorative services were properly initiated, assessed, reviewed, and revised for three residents with limited range of motion and mobility issues. Resident #12, who had multiple diagnoses including Parkinson's disease and rheumatoid arthritis, was observed without the required palm guards and had not been properly monitored for participation in restorative programs. The facility's documentation showed that restorative programs were signed off as completed, but there was no evidence of ongoing assessment or adjustment of these programs based on the resident's response or needs. Resident #21, with severe cognitive impairment and functional limitations, was enrolled in restorative programs for range of motion exercises. However, there was no documentation of cues provided, rest periods, or quarterly evaluations to assess the effectiveness of these programs. The care plan indicated a need for reassessment, but this was not carried out, leading to a lack of evidence that the programs were being effectively managed or adjusted. Resident #46, who had been discharged from physical therapy with recommendations for restorative programs, did not receive the recommended ambulation or transfer programs. Despite being initially independent, the resident experienced a decline in mobility, requiring further therapy. The facility failed to implement the recommended restorative programs, and there was no documentation explaining why these were not initiated. Interviews with staff revealed a lack of consistent follow-through and evaluation of the resident's restorative needs, contributing to the resident's decline in function.
Failure to Implement Fall Prevention Interventions and Accurate Investigations
Penalty
Summary
The facility failed to implement interventions and complete accurate investigations to prevent further falls for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including non-Alzheimer's type dementia, anxiety, and arthritis, was at moderate risk for falls according to the admission Fall Risk assessment. Despite this, there was no fall care plan in place prior to the resident's first fall on 06/05/24. Subsequent falls occurred on multiple occasions, with investigations revealing a lack of immediate interventions and incomplete documentation, such as missing neurological checks and failure to note medication administration prior to falls. The facility's policy required immediate intervention to prevent further falls and thorough documentation of assessments, including neurological checks for residents with head injuries or impaired cognition. However, the investigations into the resident's falls did not adhere to these requirements. For instance, after a fall on 07/06/24, no immediate intervention was implemented, and neurological checks were not completed. Similar deficiencies were noted in subsequent falls, where interventions were either not implemented or inaccurately documented, and neurological assessments were not conducted as per policy. The Director of Nursing confirmed these findings during an interview.
Failure to Provide Adequate Nutrition and Medication
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss received the necessary medications, supplements, and routine meals. The resident, who was admitted with diagnoses including non-Alzheimer's dementia, anxiety, major depressive disorder, breast cancer, and diabetes mellitus type 2, experienced a notable weight loss over several months. Despite recommendations for nutritional supplements and a new medication, Remeron, to increase appetite, the facility did not administer the medication as ordered. The resident's care plan was not updated to reflect the weight loss, and the staff failed to provide meals or supplements when the resident slept through scheduled meal times. Observations revealed that the resident was not offered alternative meals or supplements after missing breakfast due to sleeping. Interviews with staff confirmed that the resident's nutritional needs were not met, and the documentation regarding the administration of Remeron was unclear. The Director of Nursing acknowledged the oversight in not revising the care plan and the failure to provide meals or supplements when the resident was awake. The facility's inaction contributed to the resident's continued weight loss and inadequate nutritional intake.
Failure to Monitor Side Effects of Psychoactive Medication
Penalty
Summary
The facility failed to monitor side effects associated with the use of a psychoactive medication for a resident diagnosed with dementia, anxiety, major depressive disorder, and diabetes mellitus type 2. The resident was prescribed Rexulti, an antipsychotic medication, but the facility did not conduct a baseline Abnormal Involuntary Movement Scale (AIMS) assessment or monitor blood glucose levels as required. The medication guide for Rexulti indicates that it can cause serious side effects, including tardive dyskinesia and hyperglycemia, necessitating regular monitoring of blood sugar levels. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the necessary assessments and monitoring were not performed. The DON acknowledged that the resident, who has diabetes, was not receiving routine blood glucose monitoring as recommended. Additionally, the LPN admitted to not completing the required AIMS assessment before the resident began taking Rexulti. The facility's policy on psychoactive medications mandates that an AIMS assessment be conducted initially and every three months thereafter, which was not adhered to in this case.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications, specifically concerning the use of as-needed (PRN) antianxiety and antipsychotic medications. For Resident #22, the facility did not implement a 14-day stop date for an as-needed antianxiety medication, Ativan, which was ordered by hospice without a stop date. This oversight was confirmed by the Director of Nursing (DON), who acknowledged that more than 14 days had passed since the medication was ordered without a stop date being applied. For Resident #46, the facility did not document behaviors or provide an indication for the use of an antipsychotic medication, Haldol, which was administered as a one-time dose. The resident, who had diagnoses including dementia and anxiety, was given Haldol after being reported as extremely agitated. However, the Nurse Practitioner (NP) was not informed that a dose of Xanax, administered earlier in the day, had been effective. The NP stated that she would not have ordered the antipsychotic if she had known about the Xanax's effectiveness. Additionally, there was no behavior documentation for other PRN anxiolytics administered to the resident, and an AIMS assessment was not completed as required. The facility's policy on psychoactive medications, revised in January 2024, was not adhered to, as it requires documentation of specific behaviors and the use of a behavioral monitoring tool when PRN psychoactive medications are administered. The policy also mandates an AIMS assessment when such drugs are used, which was not completed for Resident #46. The DON confirmed the lack of behavior documentation and the absence of an AIMS assessment, indicating a failure to follow established protocols for the administration of psychoactive medications.
Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in their care documentation. For one resident, the medical record inaccurately documented a pressure ulcer as a Stage 1 ulcer with a depth of 0.1 cm, which is inconsistent with the characteristics of a Stage 1 ulcer. Additionally, a Suspected Deep Tissue Injury (SDTI) was incorrectly recorded with a depth measurement, which should not have been present. These errors were confirmed by a registered nurse during an interview, indicating a lack of accuracy in the resident's medical documentation. For another resident, the facility failed to accurately document an allergy to Exelon, a medication that had previously caused adverse effects. Despite the resident's daughter informing the staff of the allergy and the medication being discontinued, the resident's hard chart inaccurately displayed a label indicating no known allergies. This discrepancy was verified by the Director of Nursing, highlighting a failure to update and maintain accurate allergy information in the resident's medical records.
Resident Information Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident information, affecting one resident during a random observation. The resident, who was admitted with diagnoses including diabetes mellitus and depression, had their electronic medical record left open and visible on a computer screen at the main nurses station. This screen displayed personal health information, including the resident's picture, date of birth, physician name, and medications. At the time of the observation, no staff members were present at the nurses station to monitor the exposed information. A registered nurse later confirmed that the electronic medical record was indeed visible and open, exposing the resident's personal health information.
Failure to Implement Pressure Relieving Measures
Penalty
Summary
The facility failed to ensure pressure relieving measures were in place as ordered for a resident with a history of pressure ulcers. The resident, who was admitted with multiple diagnoses including pressure-induced deep tissue damage of the sacral region, had a care plan intervention to float heels while in bed. However, during an observation, it was noted that the resident's left heel was resting on a pillow instead of floating off it, as per the care plan. The resident expressed discomfort, and staff verified that the heel was not positioned correctly. The resident had a history of a fall resulting in a hip fracture and was readmitted with a suspected deep tissue injury to the sacrum. The resident's medical record indicated a risk of pressure ulcers and required pressure-reducing measures. Despite these documented needs, the facility did not adhere to the care plan, leading to the deficiency. This non-compliance was investigated under a specific complaint number.
Failure to Provide Adequate Catheter Care and Follow Medical Recommendations
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a history of urinary tract infections and an indwelling urinary catheter. The resident, who was admitted with multiple diagnoses including flaccid neuropathic bladder and urinary incontinence, experienced several urinary tract infections over a period of time. Despite recommendations from an infectious disease specialist for specific interventions such as the administration of topical estrogen and a follow-up with a urologist, there was no evidence that these were carried out. Additionally, the resident's catheter care was not performed every shift as ordered, with documentation showing it was only done once a day on several occasions. Further observations revealed that the resident's catheter bag was not covered, and there was white sediment in the tubing and bag, indicating potential issues with catheter maintenance. The facility's policy required catheter care every shift, but this was not adhered to, as confirmed by a registered nurse. Moreover, urine samples were not collected from a clean catheter as recommended, and there was no follow-up visit with a urologist to reassess the need for the indwelling catheter. These lapses in care and failure to follow medical recommendations contributed to the deficiency identified in the report.
Failure to Ensure Proper Antibiotic Review and Consultation
Penalty
Summary
The facility failed to ensure proper review and consultation regarding antibiotic use for two residents. Resident #9 was prescribed Cefdinir for a urinary tract infection (UTI) after returning from the emergency room, but the facility did not confirm whether the urine sample was obtained via catheterization, which is necessary to meet the McGeer criteria for a UTI. The culture results, which showed 50,000 cfu/ml of candida albicans, were not available until after the antibiotic course was completed, and there was no sensitivity panel to confirm the appropriateness of the antibiotic. The Director of Nursing (DON) acknowledged the lack of documentation and efforts to obtain timely lab results or consult with the physician. Resident #15 was admitted with a history of UTIs and was on a daily antibiotic regimen of Macrobid, which was later changed to Trimethoprim due to poor renal function. However, there was no evidence of consultation with a urologist or infectious disease specialist to assess the necessity of a daily preventative antibiotic. The DON confirmed that the resident was taking antibiotics daily without specialist consultation, and the facility physician had agreed to the long-term use of Macrobid for prevention.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 219 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near St Clairsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Health Center | 0.2 mi | ★★★★★ | 8 | 1 |
| Continuing Healthcare At Forest Hill | 0.9 mi | ★★★★★ | 9 | 0 |
| Cumberland Pointe Care Center | 3.1 mi | ★★★★★ | 16 | 0 |
| Sienna Hills Nursing & Rehabilitation | 6.1 mi | ★★★★★ | 0 | 0 |
| Rolling Hills Rehab And Care Ctr | 7.1 mi | ★★★★★ | 18 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.