Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Cumberland Pointe Care Center during CMS and state inspections, most recent first.
The facility failed to manage generator maintenance in a timely manner after a delinquent account and billing miscommunication delayed receipt of the diesel generator testing report. The MD stated the contractor had not provided the report because the bill had not been paid, and the Administrator said larger invoices were handled through a corporate account without his direct review. Review showed the emergency generator fuel analysis had failed, the testing results were not obtained until requested by the facility, and an invoice for the contractor remained unpaid despite a check being issued.
Dignity was not maintained for two residents. One resident with an indwelling urinary catheter had a drainage bag hanging on the bed frame without a privacy cover, with urine visible and the bag visible from the doorway. Another resident with severe cognitive impairment was fed by a CNA who stood over her while attempting to assist with lunch, and the CNA verified staff should be seated when helping residents eat.
Failure to implement ordered restorative therapy for a resident with Parkinsonism, dementia, weakness, impaired gait, and limited ROM. The resident’s neurology note ordered restorative PT for the UEs after the resident had maxed out PT, but the task record showed no evidence the service was provided. The DON confirmed the resident was not receiving restorative services, and the Therapy Mgr/PTA said she was unaware of the order. The resident’s brother also reported the resident was often left in bed and needed help with meals.
A resident with repeated falls and impaired cognition had fall interventions listed in the care plan, including a motion sensor and a visual reminder to wear non-skid footwear, but observations showed the sensor was not functioning and the reminder was not present. Another resident who used a wheelchair with supervision was observed in a manual wheelchair with cracked, torn vinyl and exposed inner padding on the seat back, and an LPN verified the damage.
Failure to Maintain Hydration and Address Nutritional Decline: Two residents were found without fluids within reach, with staff unsure of current fluid orders and dietary records not matching the resident's actual status. One resident with dementia, Parkinson disease, CHF, and hemiplegia had repeated observations of no accessible fluids and a significant weight loss that was not promptly re-weighed or reported. Another resident with hospice status had an outdated fluid restriction still appearing on meal tickets despite the order being discontinued. A third resident at moderate malnutrition risk had a dietary recommendation for Prosource that was delayed for 10 days, during which the resident lost 5% of body weight in one month.
An LPN failed to provide post-inhaler mouth rinse instructions after a resident self-administered QVAR Redihaler. The resident, who had multiple chronic conditions including lung disease, was given oral meds and then used the inhaler, but was not observed rinsing his mouth and was not told to rinse as directed by the MAR and manufacturer insert.
Unsanitary medication administration was observed for a resident with chronic lung disease, vascular dementia, bipolar disorder, DM, depression, difficulty walking, HTN, weakness, and low back pain. An RN dropped a Farxiga tablet onto the med cart, picked it up with a bare hand, placed it in the med cup, and administered it, despite policy stating tablets and capsules are to be poured into the cup and never touched with fingers.
The facility did not consistently provide food that accommodated resident allergies, intolerances, and preferences, and failed to offer appealing meal options, resulting in residents not always receiving meals that met their individual dietary requirements.
The facility failed to maintain adequate staffing levels, affecting resident care. A resident with quadriplegia missed a shower due to staff shortages, while another with dementia had unkempt nails and hair, indicating insufficient personal care. A third resident did not receive a scheduled shower due to staffing constraints. Interviews revealed consistent concerns about inadequate staffing and delayed response to call lights, particularly on weekends.
The facility did not ensure an adequate emergency water supply, potentially affecting all 65 residents. The Administrator provided a document from the food service supplier indicating that in an emergency, the supplier might not be able to provide the necessary water. The facility had not arranged for an alternate water vendor.
The facility failed to complete criminal background checks for a nurse, an admission director, and a nursing assistant, potentially affecting all 65 residents. Despite fingerprint rejections, the employees continued working without completed checks, contrary to facility policy. The admission director had direct resident contact, highlighting the deficiency investigated under a specific complaint number.
The facility failed to maintain adequate staffing levels, particularly on weekends and night shifts, leading to delays in resident care and an increase in falls. Residents reported long wait times for assistance, and staff confirmed working with fewer aides than required. Despite management's awareness and attempts to hire more staff, the facility struggled to address the staffing deficiency.
The facility failed to follow infection control protocols during incontinence care and medication administration, and did not adhere to tuberculosis testing policies for staff. An STNA did not perform proper incontinence care and touched surfaces with contaminated gloves, while a nurse did not perform hand hygiene between residents. Additionally, two STNAs were not properly tested for tuberculosis before resident contact.
The facility failed to secure medications and manage insulin properly, affecting several residents. Keys to the medication room and narcotic cabinet were left accessible, and a medication cart was found unlocked. Insulin pens were not dated upon opening, leading to expired medications being used. These actions violated the facility's policies on medication storage and administration.
A facility failed to ensure resident dignity and respect when an STNA made an inappropriate comment to a resident with vascular dementia. The resident, who was moderately cognitively impaired, confirmed the comment but was not upset. The STNA had a history of unprofessional behavior, including cursing in front of residents. Despite the resident's lack of distress, the incident highlights a failure in maintaining a professional environment.
The facility failed to maintain a safe and clean environment for residents, with issues including a poorly fitted electric outlet cover, unclean conditions with smeared feces in a bathroom, and damaged furniture. These deficiencies were confirmed by staff and affected multiple residents.
A resident's missing dentures were not addressed by the facility, despite being reported by her representative. The facility lacked documentation and awareness of the issue, failing to follow their grievance policy. Staff interviews revealed confusion and a lack of coordination in addressing the resident's needs.
A facility failed to complete a new PASRR for a resident after a new diagnosis of delusional disorder was added. The resident, admitted from another facility, had previous diagnoses of unspecified psychosis, anxiety disorder, and vascular dementia. The Social Service Director confirmed the oversight, acknowledging that a new PASRR should have been completed.
Two residents with known constipation issues were not properly monitored for bowel movements, leading to significant gaps in documentation and lack of intervention. Despite care plans requiring regular monitoring and medication administration, one resident went 15 days without a recorded bowel movement, and another had a seven-day gap. The facility lacked a formal protocol for bowel movement tracking and intervention, contributing to these deficiencies.
A resident with a history of cerebral infarction and hemiplegia was not provided with necessary orthotic devices or restorative exercises to maintain or improve range of motion in the right lower extremity. The facility discontinued orders for a knee brace and ankle/foot orthotic (AFO) without implementing a comprehensive plan of care. Interviews revealed the resident's knee brace was ineffective, and therapy did not address the need for an AFO. The deficiency was identified when the resident's care plan was not updated upon re-admission.
A resident with Alzheimer's and a history of falls was observed multiple times without proper footwear, contrary to her care plan. Despite a physician's order to encourage wearing shoes, staff did not intervene until prompted by the DON. The facility's Fall Management policy was not followed, leading to a deficiency.
A resident with stage three kidney disease was incorrectly treated with antibiotics for a UTI despite not meeting treatment criteria. The facility continued administering Keflex, which was ineffective against the bacteria, and delayed notifying the physician about the resistance. This oversight occurred despite the facility's policy on antibiotic stewardship.
A facility failed to ensure a resident received the pneumococcal vaccine as recommended due to unclear documentation and verification issues. The resident's vaccination history was not properly recorded, leading to confusion about eligibility for the pneumococcal 13 or 20 vaccine. The Infection Preventionist had to contact the family and previous care facility to verify the resident's vaccination status, revealing a deficiency in the facility's record-keeping process.
The facility failed to provide written notification to residents, their representatives, and the Ombudsman regarding hospital transfers. Two residents were affected; one was transferred twice without proper notification to her guardian or the Ombudsman, and another was transferred without written notice to his wife. The Social Service Director admitted to not having evidence of the required notifications, indicating a failure to comply with regulations.
The facility failed to provide bed hold notices to residents or their representatives when residents were transferred to the hospital, affecting two residents. One resident with multiple diagnoses was hospitalized twice without a bed hold notice being issued to her guardian. Another resident was transferred to the hospital, and although his wife was notified, no bed hold notice was provided at the time of transfer.
Delayed Generator Maintenance Due to Billing and Communication Failures
Penalty
Summary
The facility failed to be administered in a manner that prevented a potential interruption in service or delay in receipt of inspection reports after it did not follow up timely on failed diesel generator testing. During the concurrent life safety code survey, the Maintenance Director stated the contracted company, Western Branch Diesel, had identified a concern with the diesel generator system not being properly maintained because he had not received the report from the company. He said someone at corporate had not paid the bill, which he believed was required before the report could be completed, and he thought a $500 payment was needed. Review showed the last fuel analysis report for the emergency generator was dated 08/14/24 and the fuel sample failed testing requirements. The Maintenance Director confirmed the testing results had not been received until they were requested from the generator contractor on 09/08/25. A Western Branch Diesel account representative stated the facility had been delinquent with its account, which delayed service of the diesel generator, and that the facility accounting department and Western Branch accounting department had recently brought the account current with an open line of credit. The Administrator stated he did not directly pay all facility bills and that larger service invoices were paid through a global corporate account without his review; he believed a miscommunication with Western Branch Diesel led to non-payment because invoices were being sent to an incorrect email after a biller change. Review of an invoice showed a balance due of $1,522.95, and a check dated 07/30/25 for that amount had not been cashed. The contract identified Western Branch Diesel as responsible for routine and annual generator preventive maintenance, and the Administrator job description stated the administrator was responsible for all financial transactions for the facility.
Dignity Not Maintained During Catheter Care and Mealtime Assistance
Penalty
Summary
The facility failed to maintain dignity for Resident #2 related to an indwelling urinary catheter drainage bag. Resident #2 was admitted with diagnoses including obstructive uropathy, diabetes mellitus, congestive heart failure, and severe malnutrition. The admission MDS showed moderate cognitive impairment and that the resident required maximum assistance for hygiene and was totally dependent on staff for dressing, bed mobility, transfers, and nutrition. During observation, Resident #2 was lying in bed with the catheter drainage bag hanging on the bed frame without a privacy cover, with urine visible in the bag and the bag visible from the doorway. An LPN later verified that the drainage bag did not have a privacy cover at the time of the observation. The facility also failed to maintain dignity during mealtime for Resident #70. Resident #70 had diagnoses including Alzheimer's disease and needed assistance with personal care. The quarterly MDS showed severe cognitive impairment and that the resident required moderate to maximum assistance for eating and was dependent on staff for all other ADLs. During observation, a CNA approached the resident and attempted to feed her pears while standing next to her and standing over her. The resident ate one bite and then refused to open her mouth for more food. The CNA later verified that staff attempted to feed the resident while standing and stated awareness that staff should be seated while assisting residents with eating.
Failure to Implement Ordered Restorative Therapy
Penalty
Summary
The facility failed to ensure orders for restorative therapy were implemented timely for one resident reviewed for positioning. The resident was admitted with diagnoses including myocardial infarction, Parkinsonism, diabetes, muscle weakness, lack of coordination, muscle wasting and atrophy, tremors, difficulty walking, peripheral vascular disease, dementia, and other abnormalities of gait and mobility. The resident’s MDS showed moderate cognitive impairment, dependence for mobility, limited ROM of both lower extremities, and no restorative therapy received. The care plan noted the resident may require assistance with ADLs and had poor participation in restorative programming added to the plan of care. A neurology note documented the resident was seen for follow-up and, for deconditioning and impaired walking with abnormal sensory exam, restorative physical therapy for the upper extremities three times per week was ordered because the resident had maxed out PT. Review of the resident’s task record showed no evidence that restorative therapy was provided from the time of that order through the survey date. The resident’s brother reported concerns that staff were not getting the resident out of bed and assisting with meals, stating that each time he visited the resident had been in bed and he had to assist with meals. The DON confirmed the resident was not receiving restorative services per the neurologist’s order, and the Therapy Manager/PTA stated she was not aware of the order and that the resident was not picked up for therapy or restorative services.
Fall Interventions Not in Place and Wheelchair Damaged
Penalty
Summary
The facility failed to ensure fall interventions were in place per the plan of care for a resident with a history of repeated falls and impaired cognition. Resident #5 was admitted with diagnoses including fracture of the left pubis and acetabulum, repeated falls, cognitive communication deficit, hallucinations, disorientation, weakness, and end stage renal disease. The resident’s fall history showed fifteen falls in one year, and the plan of care identified multiple fall risks, including debilitation, weakness, dementia, impaired cognition, poor decision making, psychotropic medication use, difficulty walking, abnormal gait, and repeated falls. Interventions added to the plan included a visual reminder to wear non-skid footwear and a motion sensor in the room. Observations of Resident #5’s room showed the motion detector was not alarming and there was no evidence of the visual reminder to wear non-skid footwear. This was confirmed during multiple observations with the MD, RN, CNA, Restorative Aide, and DON, and the CNA reported the motion detector was not functioning properly. The DON stated the resident had recently moved rooms and the visual reminder may have been left in the prior room, but no visual reminder was observed there. The facility also failed to ensure a wheelchair used by another resident was maintained without cracks, tears, and exposed padding. Resident #8, who had impaired cognition and used a wheelchair for mobility with supervision, was observed seated in a manual wheelchair with cracked and torn vinyl on the top left side of the seat back and visible inner padding exposed near the metal frame on two separate observations, and an LPN verified the condition of the wheelchair.
Failure to Maintain Hydration and Address Nutritional Decline
Penalty
Summary
The facility failed to ensure adequate hydration and timely response to changes in nutritional status for multiple residents. Resident #12 had diagnoses including Ogilvie's syndrome, COPD, type 2 diabetes, Parkinson disease, heart failure, dementia, anemia, and hemiplegia. The resident required supervision or touching assistance with eating and was ordered a mechanically altered diet with thin liquids and handled cups for meals. Survey observations found the resident in bed without fluids within reach on multiple occasions, including a cup across the room, a cup with no straw, and a cup containing only a small amount of ice and no water. Staff confirmed the resident was non-ambulatory and could not reach the fluids, and dietary staff stated the facility did not monitor fluid intakes and had no documented evidence that the resident was receiving adequate hydration. Resident #12 also had a significant weight loss that was not addressed in a timely manner. The resident weighed 207.2 pounds and later 192.2 pounds, a 12.2-pound loss or 7.2%. The record showed no evidence the resident was re-weighed to confirm accuracy, and no evidence that the resident, family, or provider was notified of the significant weight loss when it was identified. The dietary staff member responsible for weights stated she was not aware of the loss until several days later, reported she had seven days to address significant weight loss based on training, and confirmed she did not notify the physician or implement new interventions until later. The resident's brother reported staff did not encourage the resident to get up for meals or assist her with meals, and he often had to help her eat when he visited. Resident #09, who had moderate protein-calorie malnutrition, severe cognitive impairment, and hospice involvement, was also found without fluids within reach. The resident had a regular diet with thin liquids, and the fluid restriction that had previously been ordered had been discontinued months earlier. Despite this, the meal ticket still listed a 1500 mL fluid restriction, and survey observations found no fluids available at the bedside or a cup and unopened beverage placed across the room and out of reach. Staff were unsure whether the resident was on fluid restriction, and the dietary technician confirmed the meal ticket was inaccurate and had not been updated to reflect the discontinued restriction. Resident council minutes also documented complaints that day shift was not passing ice and fresh water. Resident #38 was admitted with multiple diagnoses including osteomyelitis, diabetic foot ulcer, CHF, neuropathy, and gait abnormalities, and was identified as moderate risk for malnutrition. The dietary assessment recommended Prosource twice daily, but the recommendation was not relayed to nursing until 10 days after the assessment, and the order was not entered until the following day. During that period, the resident lost 10 pounds, from 197 pounds to 187 pounds, which represented a 5.08% loss in one month. The dietician stated significant weight loss should be addressed within two days, and the dietary technician confirmed the delay between completing the assessment and sending the recommendation to nursing.
Failure to Provide Post-Inhaler Mouth Rinse
Penalty
Summary
The facility failed to provide post-inhaler care per manufacturer guidelines for Resident #22 after administration of QVAR Redihaler. Resident #22 was admitted on 06/29/18 with diagnoses including tumor of kidney, lung disease, heart failure, stroke, difficulty swallowing, weakness, moderate intellectual disability, epilepsy, high blood pressure, and depression. The physician order summary for September 2025 included QVAR Redihaler 80 mcg, inhale one puff twice a day. On 09/09/25 at 7:55 A.M., an LPN prepared medications including the QVAR Redihaler for Resident #22. At 8:04 A.M., the LPN administered the oral medications, and the resident drank four ounces of water. The LPN then handed the QVAR inhaler to the resident to self-administer. The resident shook the inhaler and inhaled one puff as ordered, then returned the inhaler to the LPN. The resident was not observed rinsing his mouth after use, and the LPN did not advise him to rinse his mouth. The MAR instructed the resident to rinse his mouth with water and not swallow the water after using QVAR Redihaler. During interview, the LPN confirmed she did not instruct the resident to rinse his mouth and stated, "he will do it later." The manufacturer insert for QVAR Redihaler stated that oropharyngeal candidiasis may occur and advised patients to rinse their mouth with water without swallowing after inhalation.
Unsanitary Medication Administration
Penalty
Summary
The facility failed to prepare and administer medications in a sanitary manner for Resident #55. Resident #55 was admitted with chronic lung disease, vascular dementia, bipolar disorder, diabetes mellitus, major depression, difficulty walking, high blood pressure, weakness, and low back pain, and had a physician order for Farxiga 10 mg by mouth daily along with other morning medications. During observation, RN #541 prepared the resident’s medications and dropped the Farxiga tablet directly onto the medication cart, then picked it up with a bare hand and placed it into the medication cup before administering the medications to the resident. RN #541 confirmed she picked up the tablet after it fell on the cart, used her bare hand, and administered it anyway, and stated she should have gotten a new Farxiga pill but did not. The facility’s Medication Administration Policy stated that all tablets and capsules are to be poured into the medication cup and never touched with fingers.
Failure to Accommodate Resident Dietary Needs and Preferences
Penalty
Summary
The facility failed to ensure that each resident received food that accommodated their allergies, intolerances, and preferences, and did not consistently provide appealing food options. This deficiency was identified through observations and review of facility practices, which showed that residents were not always provided with meals that met their individual dietary needs and preferences.
Staffing Deficiencies Impact Resident Care
Penalty
Summary
The facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents, affecting five specific residents and potentially impacting all 62 residents in the facility. Resident #27, who has multiple complex medical conditions including quadriplegia and congestive heart failure, did not receive a scheduled shower on a specific date, with the resident reporting that it was due to a staff shortage. The Director of Nursing confirmed the absence of documentation for the shower but attributed it to a communication issue rather than staffing shortages. Resident #31, diagnosed with conditions such as heart failure and dementia, was found to have long, unkempt nails and uncombed hair, indicating a lack of personal care. The resident reported insufficient staff to meet her needs, including assistance with activities of daily living (ADLs) and timely response to call lights. Observations confirmed the resident's nails were long and dirty, and her hair was unkempt, with staff acknowledging the need for immediate attention. Resident #16, with Alzheimer's disease and other health issues, did not receive a scheduled shower due to staffing constraints, as confirmed by a State Tested Nurse Aide (STNA) who was the only aide on the floor that day. Interviews with other residents and staff revealed consistent concerns about inadequate staffing, delayed response to call lights, and insufficient care, particularly on weekends. The facility's practice of sending staff home due to low census, without considering resident acuity, further exacerbated the staffing issues.
Failure to Ensure Emergency Water Supply
Penalty
Summary
The facility failed to ensure provisions were made to have water available in the event of an emergency, potentially affecting all 65 residents. During the entrance conference, the Administrator was asked about the facility's emergency water provisions. A document from the facility's food service supplier, dated 11/01/23, was provided, indicating that in an emergency, the supplier might not be able to provide the recommended amount of water. The document recommended that the facility ensure they had an alternate vendor set up. On 06/18/24, the Administrator confirmed that the facility had not made alternate arrangements for water provision in emergencies.
Failure to Complete Criminal Background Checks for Staff
Penalty
Summary
The facility failed to ensure that all staff had completed criminal background checks, which had the potential to affect all 65 residents. The criminal background check log revealed that fingerprint submissions for a Registered Nurse, an Admission Director, and a State Tested Nursing Assistant were rejected, and there was no evidence that the facility attempted to re-submit the fingerprints. The Human Resources Director confirmed that there were no completed criminal background checks for these employees and acknowledged that employees were not supposed to continue working if results were not received within 30 days. Despite the lack of completed background checks, the employees continued to work, with the Admission Director having direct contact with residents by greeting them on admission, taking them to their rooms, completing paperwork, and occasionally passing ice. The facility's policy required criminal background checks to be conducted before hiring new employees, in accordance with state law. This deficiency was investigated under Complaint Number OH00153674.
Inadequate Staffing Levels Lead to Resident Care Delays and Increased Falls
Penalty
Summary
The facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents, as evidenced by the review of the facility's Payroll Based Journal (PBJ) submission data and interviews with residents and staff. The PBJ data indicated low weekend staffing during the first quarter of 2024, and the facility assessment showed staffing levels were based on resident acuity levels. However, interviews with residents revealed significant concerns about inadequate staffing, particularly on weekends and night shifts. Residents reported having to wait extended periods for assistance, with some having to remain in bed longer than preferred due to insufficient staff to assist with transfers. Staff interviews corroborated the residents' concerns, highlighting the challenges faced due to inadequate staffing. State tested Nursing Assistants (STNAs) reported working with fewer aides than required, leading to delays in providing care and supervision. The lack of sufficient staff was linked to an increase in resident falls, as there were not enough aides to monitor and assist residents adequately. The STNAs also noted that the facility's mandating system for call-offs was not being followed, exacerbating the staffing issues. The facility's management was aware of the staffing concerns, as confirmed by interviews with the Administrator and a Registered Nurse (RN). Despite attempts to hire additional staff through online ads and offering sign-on bonuses, the facility struggled to maintain adequate staffing levels. The Administrator acknowledged the difficulty in consistently scheduling an additional nurse on night shifts, which further contributed to the staffing deficiency. This deficiency was investigated under Complaint Number OH00153674.
Infection Control and Tuberculosis Testing Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, affecting the care of residents. An STNA was observed providing incontinence care to a resident without following proper procedures, such as cleaning from the top of the buttocks toward the vaginal area and touching multiple surfaces with the same gloves used during care. The facility's incontinence care protocol lacked specific instructions on the correct cleaning method and when to remove gloves and perform hand hygiene. Additionally, a nurse failed to perform hand hygiene between administering medications to different residents, despite the facility's hand hygiene policy requiring it. The facility also did not adhere to its tuberculosis testing policy for healthcare workers. An STNA was rehired without evidence of a mantoux skin test upon rehire, and another STNA began working with resident contact before completing the required tuberculosis testing. The facility's policy required a two-step baseline TST if a previous negative result was obtained more than 12 months before new employment, and a single TST if a documented negative result was obtained within 12 months. These deficiencies were identified during a complaint investigation.
Medication Security and Insulin Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications, specifically insulin, were properly secured and managed according to professional standards. Observations revealed that keys to the medication room, which also provided access to the emergency narcotic cabinet, were left hanging on the wall at the nurse's station, accessible to unauthorized individuals. This was confirmed by two registered nurses who demonstrated the ease of access to the medication room and narcotic cabinet. Additionally, a medication cart was found unlocked and unattended, further compromising the security of medications. The facility also failed to properly date insulin upon opening and discard it after expiration, affecting five residents. Insulin pens for several residents were either not dated or had conflicting dates, making it impossible to determine their expiration. Interviews with registered nurses confirmed that the insulins should have been discarded due to the lack of proper dating, as insulin typically expires 28 days after being opened. The facility's policies on medication storage and administration were not adhered to, as evidenced by the improper handling and storage of insulin.
Failure to Maintain Resident Dignity and Professional Conduct
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, specifically affecting one resident diagnosed with vascular dementia, depression, and impulse disorder. The resident was moderately cognitively impaired but able to communicate and understand others. An incident involving a State tested Nursing Assistant (STNA) was reported, where the STNA made an inappropriate comment to the resident about his private parts. The comment was overheard by another STNA, who reported it to the nurses, but there was no documentation of any follow-up action regarding the inappropriate comment. The STNA involved had a history of unprofessional behavior, including cursing in a resident's room and being unprofessional with co-workers. During an interview, the STNA admitted to possibly using foul language in front of residents and visitors but denied making the specific inappropriate comment to the resident. The resident confirmed hearing the comment but stated it did not bother him, as he used to date the STNA. Despite the resident's lack of distress, the incident highlights a failure in maintaining a professional and respectful environment for residents.
Facility Fails to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents in the secure unit, affecting three residents. In one instance, an electric outlet cover in a resident's room was missing and later replaced with a cover that did not fit properly, as confirmed by the Housekeeping/Laundry Supervisor and the Administrator. This issue was initially identified by the Life Safety Surveyor, indicating a lapse in addressing safety concerns promptly. Another resident's room was found to be unclean, with food crumbs, a roll of toilet paper on the floor, and feces smeared on the bathroom floor and toilet. The resident reportedly placed food on the floor to feed nonexistent animals and used the sink to wash dirty linens. Additionally, a third resident's room had a gouged wall and a nightstand with peeling veneer, which were confirmed by the Administrator as needing repair. These observations highlight the facility's failure to ensure a clean and safe environment for its residents.
Failure to Address Missing Dentures Grievance
Penalty
Summary
The facility failed to address the concerns of a resident and her representative regarding missing dentures. The resident, who had a history of Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, intermittent explosive disorder, and major depressive disorder, was admitted to the facility with full upper and lower dentures. Despite the resident's representative reporting the dentures missing several months prior, the facility did not document this in their missing item reports, nor did they maintain a log for such incidents. Interviews with various staff members, including the Director of Nursing, State Tested Nursing Assistants, and the Housekeeping/Laundry Supervisor, revealed a lack of awareness and documentation regarding the missing dentures. The Director of Nursing admitted that the facility did not use a personal inventory sheet to track residents' belongings, which contributed to the confusion about whether the resident had dentures. The Housekeeping/Laundry Supervisor confirmed that the resident had reported the dentures missing, but no follow-up actions were documented. The facility's grievance policy, which outlines the process for addressing resident grievances, was not followed in this case. The policy requires a thorough investigation and documentation of grievances, but the facility failed to complete a missing item report or conduct an investigation into the missing dentures. The Administrator and Medical Records Employee were unaware of the missing dentures, and no steps were taken to coordinate a dental appointment to address the issue, despite the resident's representative's request for assistance.
Failure to Update PASRR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure a new resident review was completed for a resident after a newly diagnosed mental illness was added to their diagnoses. The resident, who was admitted from another nursing facility, had a history of unspecified psychosis, delusional disorder, anxiety disorder, and vascular dementia with behavioral disturbance. The initial PASRR identification screen completed at the prior facility did not indicate any serious mental illness, only a mood disorder. A subsequent PASRR screen before admission to the current facility also did not include the new diagnosis of delusional disorder. Upon review, it was found that no new PASRR Identification Screens were completed after the resident's admission to the facility, despite the new diagnosis of delusional disorder. The Social Service Director confirmed that a new PASRR should have been completed following the diagnosis but was not. This oversight affected the resident's care plan and the facility's compliance with PASRR requirements.
Failure to Monitor and Intervene for Constipation in Residents
Penalty
Summary
The facility failed to properly monitor and intervene for residents experiencing constipation, affecting two residents. Resident #5, diagnosed with vascular dementia and other conditions, was admitted with a known issue of constipation. Despite having a care plan that included monitoring bowel movements every shift and administering medications as ordered, there was a significant gap in documentation. The resident did not have a recorded bowel movement for 15 days, and there was no order for a prn laxative. Interviews with staff revealed inconsistencies in documentation and a lack of a clear protocol for bowel movement tracking and intervention. Resident #20, with diagnoses including Alzheimer's disease and constipation, also experienced a lapse in bowel movement monitoring. The resident's care plan required monitoring and recording bowel movements every shift, yet there was a seven-day period without a documented bowel movement. Although the resident had an order for a stool softener to be administered as needed, there was no evidence it was given during this time. Staff interviews suggested the possibility of undocumented bowel movements, but no additional evidence was provided to support this. The facility lacked a formal policy or protocol for bowel movement monitoring and intervention, relying instead on staff judgment and alerts from the electronic medical record system. This absence of a structured approach contributed to the failure to ensure timely and appropriate interventions for residents experiencing constipation, as evidenced by the prolonged periods without documented bowel movements for both residents.
Failure to Provide Orthotic Devices and Restorative Exercises
Penalty
Summary
The facility failed to provide appropriate care for a resident to maintain or improve range of motion (ROM) in the right lower extremity. The resident, who had a history of falling, heart failure, cerebral infarction, hemiplegia, muscle weakness, and other conditions, was not provided with orthotic devices or restorative exercises as needed. The resident's medical records showed that orders for a knee brace and an ankle/foot orthotic (AFO) were discontinued, and there was no evidence of a comprehensive plan of care addressing the resident's limited ROM. Interviews and observations revealed that the resident had lost his right leg brace and reported that therapy had taken his other brace. The therapy director was unaware of the resident's previous use of an AFO and confirmed that the resident had an over-the-counter knee brace that was not providing support. The therapy department had bought a new knee brace, but the resident did not like it, and it was returned. The resident was receiving active ROM through the restorative program, but there was no individualized plan of care for restorative services. Further investigation showed that the resident's AFO and knee brace plan of care had been discontinued in 2023, and upon the resident's return to the facility, these were not re-ordered or addressed. The therapy department screened the resident and referred him to orthotics for a new AFO and knee braces. The facility's failure to ensure the resident received necessary orthotic devices and restorative exercises led to the deficiency identified in the report.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident at risk for falls, as outlined in her care plan. The resident, who had Alzheimer's disease, dementia, and a history of falls, was observed multiple times without proper footwear, such as non-skid socks or shoes, which were part of her fall prevention plan. Despite having a physician's order to encourage the resident to wear shoes when out of bed, staff did not intervene to ensure compliance with this order. Observations revealed that the resident was seen walking in the hallway and sitting in the dining room without any footwear, and staff did not attempt to provide her with non-skid socks or shoes. It was only after the Director of Nursing inquired about the resident's slippers that a State Tested Nursing Assistant (STNA) approached the resident to offer socks, which the resident accepted. The STNA admitted that the resident had been ambulating without proper footwear for several days without staff intervention. The facility's Fall Management policy emphasizes the importance of assessing and implementing fall prevention strategies through an interdisciplinary approach. However, the staff failed to adhere to this policy by not ensuring the resident wore appropriate footwear, as outlined in her care plan. This lack of adherence to the care plan and policy contributed to the deficiency identified during the survey.
Failure in Antibiotic Stewardship for a Resident
Penalty
Summary
The facility failed to ensure that a resident met the criteria for antibiotic treatment, which was identified during a review of records, interviews, and policy evaluations. The resident, who was admitted with stage three kidney disease, was sent to the hospital for chest and flank pain. Despite being asymptomatic for a urinary tract infection (UTI), the resident was prescribed Keflex, an antibiotic, upon return to the facility. The hospital later informed the facility that the bacteria in the resident's urine was resistant to Keflex and recommended switching to Cipro. However, the resident's physician was not notified of the resistance until several days later, and the resident continued to receive Keflex, which was ineffective against the bacteria. The facility's infection control log and McGeer and Loeb's worksheets indicated that the resident did not meet the criteria for UTI treatment. Despite this, the resident was administered antibiotics, and the facility's infection preventionist confirmed that the provider was not informed of the resistance until days after the initial prescription. The facility's policy on antibiotic stewardship, which aims to optimize infection treatment and reduce antibiotic-related events, was not adhered to, as the antibiotics were not reviewed for appropriateness upon the resident's readmission from the hospital.
Deficiency in Pneumococcal Vaccination Documentation
Penalty
Summary
The facility failed to ensure that a resident received the pneumococcal vaccine as recommended. The resident, who was admitted with multiple diagnoses including encephalopathy, dementia, and hypertension, had a pneumococcal consent form indicating prior vaccination, but it was unclear which vaccine was administered or when. The electronic medical record inaccurately showed the resident as ineligible for the pneumococcal 13 or 20 vaccine. The Infection Preventionist/Co-Director of Nursing was uncertain about the resident's vaccination history and had to contact the family and previous care facility for verification. The previous facility only documented a refusal, while the family believed the resident had been vaccinated. After further investigation, it was discovered that the resident had received the PPSV23 vaccine and previously the PCV13. This confusion and lack of clear documentation led to a delay in administering the appropriate pneumococcal vaccine, highlighting a deficiency in the facility's vaccination record-keeping and verification process.
Failure to Notify Residents and Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents, their representatives, and the Ombudsman regarding hospital transfers, as required by regulations. This deficiency affected two residents who were hospitalized. Resident #5, who had multiple complex medical conditions including a urinary tract infection and cognitive impairments, was transferred to the hospital twice. The facility did not provide written notice to her guardian for the first transfer and failed to notify the Ombudsman for both transfers. Resident #68, who had several chronic health issues, was transferred to the hospital due to a medical emergency. Although his wife was notified by phone, the facility did not provide written notice of the transfer. The facility's policy requires that transfer notices include specific information and be provided in a language and manner understandable to the resident and their representative. Interviews with facility staff revealed that the Social Service Director was responsible for completing transfer notices and notifying the Ombudsman. However, the director admitted to not having evidence of providing the required notices for Resident #5's transfers and confirmed that no written notice was given for Resident #68's transfer. This lack of documentation and notification represents a failure to comply with regulatory requirements for resident transfers.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives when residents were transferred to the hospital, as required by policy. This deficiency affected two residents. Resident #5, who had multiple diagnoses including urinary tract infection, psychosis, and dementia, was hospitalized twice. The facility did not provide a bed hold notice to her guardian for either hospitalization. The Social Service Director confirmed that she did not issue the required notices for Resident #5's hospital admissions. Similarly, Resident #68, who had several medical conditions including cellulitis, diabetes, and leukemia, was transferred to the hospital. Although his wife was notified of the transfer, there was no documentation of a bed hold notice being provided at the time of transfer. The Social Services Designee confirmed that neither Resident #68 nor his wife received a bed hold policy at the time of transfer, despite being informed of the policy at admission.
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 255 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.
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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.
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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 | 3 mi | ★★★★★ | 8 | 1 |
| Belmont Manor | 3.1 mi | ★★★★★ | 5 | 0 |
| Continuing Healthcare At Forest Hill | 3.1 mi | ★★★★★ | 9 | 0 |
| Sienna Hills Nursing & Rehabilitation | 8.2 mi | ★★★★★ | 0 | 0 |
| Rolling Hills Rehab And Care Ctr | 10.1 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 July 2026) and official state health department websites.