Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ansted Center during CMS and state inspections, most recent first.
Menu items were not consistently followed as posted or reflected on tray cards. Several residents received peas instead of the listed California blend vegetables, one resident received sauerkraut that was not on the menu, and a resident’s tray card did not match the vegetables served. A state surveyor also observed the garnish for a fish sandwich being prepared incorrectly until the item was changed to match the menu after intervention.
Improper Food Storage and Dating: Surveyors found multiple food items in dry storage, the freezer, and a nourishment center that were leaking, opened, undated, unlabeled, or past their use-by dates. Items included cake mix, buns, dented cans, noodles in an unlabeled zipper bag, opened biscuits, angel food cakes, sterile water with yellowish liquid, and resident food items such as apples, bread, and crackers that were expired or improperly dated. The AM confirmed the findings and the facility policies required food to be labeled, dated, wrapped or covered, and stored to prevent cross contamination.
Improper Disposal of Garbage and Refuse: During an exterior tour of the dumpster area, loose trash was observed scattered around the dumpster, including gloves, plastic spoons, plastic lids, plastic bags, Styrofoam bowls, a Pringles container, soda bottles, and tissue. The observation was confirmed with the DON.
The facility failed to send required written notices when three residents’ account balances were within $200 of the $2,000 Medicaid asset limit. Record review showed balances above or near the limit, and the BOA stated the notices had not been sent; the Admissions Director confirmed this.
Homelike Environment Deficiencies in Resident Rooms and Hallways: The facility was cited after the surveyor observed missing and disrepaired caulking around a toilet in one resident room, torn floor molding near a sink in another room, and bug lights in the 100 and 200 hallways with multiple dead insects visible on sticky paper. The findings were reviewed and confirmed with the Administrator.
Failure to Provide Transfer, Ombudsman, and Bed-Hold Notices: The facility failed to provide required written transfer/discharge notices and bed-hold documentation for two residents transferred to acute care. One resident had capacity and was transferred after a fall with a subsequent femur fracture surgery; the other lacked capacity and was also transferred to acute care. In both cases, the facility sent medical information to the hospital, but did not issue the required transfer/discharge notice to the resident or representative, did not notify the State LTC Ombudsman, and had incomplete bed-hold authorization documentation.
Incorrect PASARR Screenings: The facility failed to ensure PASARR accuracy for three residents reviewed by surveyors. One resident’s PAS omitted schizophrenia despite that diagnosis on admission, another resident’s PASSR listed no current diagnosis despite records showing bipolar disorder and anxiety with related psychotropic medication orders, and a third resident’s PASARR omitted depression and mental disorder, unspecified despite the resident’s documented diagnoses and MDS.
Failure to provide nail care was identified when several residents were observed with long, jagged, unkept fingernails and stated they wanted them trimmed or shorter. The facility's nail care policy required nails to be kept short and smooth and to be routinely cleaned and inspected during ADL care, but the DON offered no further comment when the findings were reported. In a separate finding, an offensive odor was noted coming from one resident's room, which the DON associated with a yeast infection; the resident later received a shower and had orders for Diflucan and topical Nystatin/Nystop.
Incomplete and inaccurate resident records were identified for three residents. One resident’s vaccine consents lacked staff witness signatures, another resident’s chart contained conflicting POST forms showing full code and DNR status, and a third resident’s diagnosis list did not match the resident’s active psychotropic medication orders and documented diagnoses.
Infection control and EBP failures were observed when staff carried linens against their clothing, a NA provided incontinence care to a resident with CRE and exited without a gown, and wound care was performed for a resident with a chronic wound without PPE or EBP signage at the door. An EBP sign outside another room also failed to identify the specific bed on precautions, and the DON confirmed the wound resident should have been on EBP.
A resident reported that his reclining chair used for sleeping did not function properly, and surveyor observation confirmed the leg/foot rest would not deploy. The resident said he elevated his legs in a wheelchair at night because of the malfunctioning chair, and the concern was brought to the DON's attention.
Quarterly resident trust account statements were not verified for two residents. Both residents stated they had not received statements showing their account balances, and the BOA could not provide verification after the former BOM left the position. Only a letter showing the quarter ending balance for one quarter was later produced for each resident, with no additional statement proof available.
Incorrect or incomplete PASARRs were found for three residents after new mental health diagnoses were identified or current diagnoses were not reflected on the PASARR. One resident had dementia listed as the primary diagnosis but also had bipolar disorder, hallucinations, and a provider attestation indicating schizoaffective symptoms; another resident’s PASARR listed bipolar disorder while later records showed depression and related psychotropic orders; a third resident’s PASARR omitted PTSD despite an active PTSD diagnosis.
Incorrect Oxygen Delivery Setting: A resident on continuous O2 via NC was observed with the concentrator set below the ordered rate. The resident reported SOB and staff confirmed the concentrator was malfunctioning and not delivering the prescribed setting, with the resident's O2 order and care plan both directing oxygen at the ordered rate.
A resident was observed with bilateral bed rails in use even though the facility’s bed safety evaluation indicated rails should not be used. The assessment recorded No for all mobility questions, and the follow-up documented that alternatives such as elevating the HOB and a PT/OT screen were successful, concluding that bed rails should not be used. The DON later confirmed the resident should not have bed rails.
A resident was not allowed to return to the facility after a hospital stay for behavioral evaluation, with the facility refusing readmission based on prior behaviors. The facility did not issue a discharge notice, involve the resident or representative in discharge planning, document inability to meet the resident's needs, or seek reasonable accommodations, despite having an available bed.
A resident was denied readmission following hospitalization without receiving the required written discharge notice, which should have included the reason for discharge, effective date, and appeal rights. The resident, their representative, and the LTC ombudsman were not notified, and there was no evidence of coordinated discharge planning with the hospital or community services. The Administrator and DON confirmed that the necessary notice was not issued.
The facility did not consistently monitor or document food temperatures before meal service, resulting in multiple instances where meals were served cold or not at a safe temperature. Several residents reported that their food was often cold or only barely warm, and staff confirmed gaps in temperature logging due to staffing issues.
A resident with a history of aggressive behavior and cognitive impairments physically abused another resident by slapping them, resulting in redness to the face. The aggressive resident had previously exhibited threatening behavior, but the facility failed to implement adequate measures to prevent further incidents, such as consistent supervision or effective interventions. Staff interviews revealed that verbal threats were not reported or investigated, contributing to the environment where the abuse occurred.
A facility failed to assess fall risks and administer medications as ordered, leading to multiple falls and missed medication doses for two residents. One resident, with a history of falls, experienced several falls resulting in a subdural hematoma and subsequent death. The facility did not complete required fall risk evaluations or document circumstances of falls, hindering effective intervention. Another resident missed doses of Parkinson's medication, as confirmed by the DON.
A resident's dental status was inaccurately documented in the MDS assessments, failing to note two missing teeth. Despite the social worker's acknowledgment of the missing teeth upon admission, the issue was not reflected in assessments on multiple occasions. A nurse admitted to missing this entry. The resident had not been seen by a dentist for over a year, with missed and refused appointments noted.
A resident in constant pain missed doses of a controlled pain medication because the MD failed to sign the orders in a timely manner. Despite the facility having the medication in emergency stock, the pharmacy required a valid prescription, which was delayed due to the MD's practice of signing orders only once a week. Staff reported the MD was unresponsive to calls or messages related to resident care.
The facility failed to provide two residents with accessible and functional call lights. One resident's call light was not working, and the facility was unaware of the issue until identified by a surveyor. Another resident's call light was inaccessible due to the cord being trapped between the bed and the wall. A NA had to adjust the bed and reposition the cord to make it reachable.
A resident with cognitive impairments and a history of aggression physically abused another resident, but the facility failed to implement its abuse prevention policies. Despite multiple incidents of aggression and threats, staff did not report or investigate these as required, leading to a deficiency in protecting residents from abuse.
A resident in a long-term care facility was verbally and physically abused by another resident, with staff witnessing the incidents but failing to report or investigate them as required by the facility's abuse prohibition policy. The policy mandates immediate reporting and investigation of abuse, which was not followed in this case.
A resident with a history of aggressive behavior physically and verbally abused another resident, but the facility failed to identify or investigate these incidents as abuse. Despite multiple threats and aggressive actions, staff did not report or investigate the incidents, leading to a deficiency citation.
A facility failed to update the PASRR for a resident who was later diagnosed with anxiety disorder and unspecified dementia with behavioral disturbance. The resident was initially admitted with multiple diagnoses, including encephalopathy and altered mental status. The DON acknowledged the oversight, indicating a lapse in updating resident assessments with new diagnoses.
A resident with a BIMS score of six exhibited escalating aggressive behaviors, including physical aggression and medication refusal, over several months. Despite these significant changes, the facility failed to update the PASRR, as acknowledged by the DON. The deficiency was identified during a survey, with the potential to affect other residents.
A resident with a history of falls and multiple medical conditions was admitted to a facility without a proper fall risk evaluation. Despite experiencing multiple falls, the facility failed to document necessary details or perform root cause analyses, leading to inadequate fall prevention strategies. The DON acknowledged these deficiencies, including the lack of awareness and use of a built-in fall risk evaluation tool in their system.
A resident in a long-term care facility exhibited aggressive behavior, including slapping another resident and making threats, due to a lack of individualized activities. Despite having an activity assessment that identified preferences such as watching TV and woodworking, these activities were not implemented. The facility's failure to engage the resident in meaningful activities may have contributed to the aggressive incidents.
The facility failed to implement fall interventions for a resident identified as a fall risk, as the bed was not in the lowest position and a fall mat was missing. Additionally, another resident, assessed as needing a total lift, was manually assisted after a fall, contrary to facility policy. The DON confirmed the need for mechanical lift assistance.
Menu Not Followed as Posted and on Tray Cards
Penalty
Summary
The facility failed to ensure the posted lunch menu and resident tray cards were followed as written. On 03/23/2026, the posted menu listed Salisbury steak with gravy or kielbasa, scalloped potatoes, California blend vegetables, a dinner roll, and brown sugar glazed angel food cake, but multiple residents received items that did not match the menu. Resident #37 received California blend vegetables, while the tray card stated peas, and the resident stated, "They're never right." Resident #54, #21, #30, and #25 all received peas instead of California blend vegetables. Resident #15 received sauerkraut, which was not on the menu and was removed from the tray because the smell made her sick. On 03/24/2026, the state surveyor observed that the garnish for the fish sandwich was being prepared with parsley instead of the lettuce and tomato listed on the menu, and the Account Manager stated she would fix it to match the menu; lettuce and tomato were then served after surveyor intervention.
Improper Food Storage and Dating
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety and in a manner that prevents foodborne illness to residents. During a kitchen investigation, surveyors found yellow cake mix leaking out of a bag onto a shelf in dry storage, hotdog and hamburger buns with no use-by date, an undated dented can of Imperial pumpkin, a dented can of Gehls Mild Cheddar Cheese, and lasagna noodles stored in a plastic zipper bag without a label. In the freezer, Bakers' Source Southern Style Biscuits were found opened in the delivery brown box, not sealed, and without a use-by date, and two angel food cakes were also found without a use-by date. At the nourishment center in the main dining room, surveyors found opened sterile water dated 1/22 with yellowish water in the bottle, apples for a resident with a use-by date of 03/04/2026, open bread with a use-by date of 03/23/2026, and crackers in a zipper bag with a use-by date of 03/20/26. The Account Manager confirmed the items and stated the policy for food brought in by family was to discard after seven days. The facility's policies stated food brought in for residents would be held in the refrigerator for three days following the date on the label and discarded by staff upon notification to the resident, and that dry goods and cold foods would be stored labeled, dated, wrapped or in covered containers, and arranged to prevent cross contamination.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to dispose of garbage and refuse properly and failed to maintain a clean and sanitary environment. During an exterior tour of the garbage dumpster area, loose trash was observed scattered around the dumpster, including multiple gloves, plastic spoons, plastic lids, plastic bags, Styrofoam bowls, a Pringles container, soda bottles, and loose tissue. The observation was confirmed with the DON.
Failure to Notify Residents of Medicaid Asset Limit Balances
Penalty
Summary
The facility failed to ensure that three residents received written notification when their account balances reached within $200 of the $2,000 Medicaid asset limit. A record review on 03/25/26 showed resident account balances of $2,795.17 for Resident #55, $2,835.00 for Resident #27, and $1,990.00 for Resident #10. During interview on 03/25/26 at 1:00 PM, the Business Office Advisor stated that the required notices regarding assets being over or within $200 of the Medicaid limit had not been sent. The Admissions Director confirmed this information on 03/26/26 at 1:30 PM.
Homelike Environment Deficiencies in Resident Rooms and Hallways
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment based on observations and staff interview. In room 212, the surveyor observed missing and disrepaired caulking around the base of the toilet. In room 215, the floor molding near the sink was torn and in disrepair. During a facility walkthrough, the surveyor also observed insect control devices in the 100 and 200 hallways with multiple dead insects adhered to visible sticky paper, and this condition was confirmed with the Administrator. The surveyor reviewed and confirmed the room and hallway findings with the Administrator during the survey.
Failure to Provide Transfer, Ombudsman, and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written transfer or discharge notices and related bed-hold documentation for two residents who were transferred to acute care facilities. For Resident #64, who had the capacity to make their own medical decisions, the resident had an emergency transfer to an acute care facility after a fall at the facility and later returned following surgery for a left femur fracture. The facility provided an electronic eInteract Communication Form with resident medical information to the hospital, but did not issue a transfer/discharge notice to the resident or to the Office of the State Long Term Care Ombudsman. A Bed Hold Notice was present in the electronic medical record, but the facility obtained verbal consent from the resident's next of kin without a written signature or a second person witness to the verbal consent. For Resident #10, who did not have the capacity to make their own medical decisions, the resident was transferred to an acute care facility and later returned to the facility. The facility again provided an electronic eInteract Communication Form with resident medical information to the hospital, but did not issue a transfer/discharge notice to the resident's representative or to the Office of the State Long Term Care Ombudsman. A Bed Hold Notice of Policy and Authorization was located in the electronic medical record, but it was not signed by the facility or by the resident's representative. When reviewed with the DON, she acknowledged the errors and the lack of a transfer notice.
Incorrect PASARR Screenings
Penalty
Summary
The facility failed to ensure the accuracy of PASARR screenings for three of seven residents reviewed during the survey. For Resident #8, the record showed admission with a diagnosis of schizophrenia, but the PAS dated 02/20/26 did not include schizophrenia. The DON later confirmed the PAS was incorrect and stated the facility was aware of issues with PASARRs. For Resident #18, the latest PASSR dated 2/1/24 listed no current diagnosis in Section 30, even though the resident’s medical record showed bipolar disorder mild or moderate severity and anxiety disorder, along with physician orders for medications used for bipolar disorder, depression, anxiety, and targeted behaviors. For Resident #64, the PASARR completed at another facility listed only mood disorder, stable, managed with medications, and did not include depression or mental disorder, unspecified, even though the resident’s diagnoses and MDS reflected mental disorder, not otherwise specified. The DON stated she identified PASARRs as an issue and had put a plan in place to get them corrected.
Failure to Provide Nail Care and Address Resident Odor
Penalty
Summary
Failure to provide nail care to dependent residents was identified after observation, interview, and policy review showed that multiple residents had long, jagged, unkept fingernails. Resident #2 was observed with long, jagged fingernails and stated she wanted them shorter; the concern was later relayed to RN #4. Resident #39 was observed with long, jagged, unkept fingernails and said he wanted them trimmed but was not sure who would do it. Resident #42 was observed during lunch with long, jagged, unkept fingernails and stated he wanted them shorter. Resident #57 was observed with long, jagged, unkept fingernails and said he wanted them trimmed, adding that he had clippers in his drawer but would need help trimming his nails. The facility policy titled NSG222 Nail Care, dated 05/01/25, stated that patient nails would be kept short and smooth to avoid skin injury and that routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis. During interview on 03/26/26, the DON was informed of the findings and provided no further comments regarding the lack of nail care for these residents. In a separate finding, Resident #53 was noted during survey to have an offensive odor permeating the hallway from the resident's room, and the DON stated the odor was most likely associated with the resident and challenges related to a yeast infection. Record review showed the resident received a shower after the issue was brought to nursing staff, and physician orders included Diflucan and topical Nystatin/Nystop for yeast-related treatment.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
Medical records were not kept accurate and complete for three residents reviewed in the area of unnecessary medications. For one resident, informed consents for the COVID-19 vaccine and multiple other immunizations were signed by the resident, but there were no staff witness signatures on either consent form. The DON was notified and confirmed the missing witness signatures. For another resident, the record contained a WV POST form dated 01/23/26 marked full code, while the electronic health record and care plan identified the resident as DNR. A later review found an additional POST form dated 03/20/26 showing the resident elected DNR, but the earlier POST form remained in the record. Social Services staff stated the newer POST form was uploaded and staff were expected to follow the most recent date, and there was no facility policy addressing voiding POST forms. For a third resident, the diagnosis list reflected bipolar disorder and anxiety disorder, but the resident’s active physician medication orders also referenced depression, and the Unit Manager and Administrator agreed the diagnosis report should include bipolar disorder, depression, and anxiety.
Infection Control and Enhanced Barrier Precautions Failures
Penalty
Summary
The facility failed to follow established infection prevention and control protocols during multiple observed events involving linen handling and enhanced barrier precautions. A staff member was observed carrying clean linens and a blanket against their clothing while moving them through the hallway, and another staff member was observed carrying bagged linens and incontinence products while exiting a resident care area without wearing a gown. The report also noted that an enhanced barrier precautions sign outside one resident room did not identify which bed was associated with the precautions, and corporate nursing confirmed the bed was not identified on the signage. Resident #4 had a history of carbapenem-resistant Enterobacteriaceae (CRE) and required enhanced barrier precautions, with the door sign stating that a gown must be worn for high-contact care. On 03/24/26, Nurse Aide #46 was observed providing incontinence care to Resident #4 behind a closed divider curtain and then leaving the area without a gown. Resident #30 had an unstageable coccyx wound and moisture-associated skin damage to both buttocks, and during observed wound care by two RNs, there was no enhanced-barrier-precautions sign at the door and neither nurse donned PPE before entering and providing care. The DON confirmed Resident #30 had a chronic wound and should have been on enhanced barrier precautions, and the facility policy defined chronic wounds as wounds not healing as expected or present for more than 30 days.
Failure to Provide a Functioning Reclining Chair
Penalty
Summary
Reasonably accommodating the needs and preferences of each resident was not provided for Resident #39. During an interview on 03/27/26 at 10:45 AM, the resident stated that the reclining chair used for sleeping did not function properly. Observation and interview showed that the leg/foot rest of the recliner would not deploy, and the resident reported that he elevated his legs in a wheelchair at night because of the malfunctioning chair. The concern was brought to the attention of the DON, and documentation provided by the facility indicated that a new reclining chair was ordered after surveyor intervention.
Quarterly resident trust account statements not verified
Penalty
Summary
Properly hold, secure, and manage each resident's personal money deposited with the nursing home was not ensured for two residents because quarterly statements were not provided or could not be verified. Resident #41 and the resident's daughter stated they had not received a quarterly statement showing the amount in the resident's account. The Business Office Advisor said the former Business Office Manager had left and she did not think she could verify that quarterly statements had been provided. A letter dated 07/23/25 was later provided showing a quarterly statement for the quarter ending June 2025, but no additional statements could be produced. Resident #24 also stated she had not received a quarterly statement showing the amount of money in her account. The Business Office Advisor again stated she could not provide any quarterly statement verifications because the former Business Office Manager had recently left the position. A letter dated 07/23/25 was later provided showing that Resident #24 had received a letter indicating the account balance for the quarter ending June 2025, but no additional statement verifications were available before the end of the survey.
Incorrect or Incomplete PASARRs for Residents with New Mental Disorders
Penalty
Summary
The facility failed to ensure a new PASARR was completed when three residents developed new mental disorders or had PASARR information that did not match their current diagnoses. For Resident #53, the most recent PASARR completed at an acute care facility listed dementia as the primary diagnosis, but also typed in bipolar disorder and other related conditions including altered mental status, visual hallucinations, bipolar illness, and dementia with behavioral problem. The resident did not have capacity to make their own medical decisions and had diagnoses including depression, bipolar disorder, anxiety disorder, and adjustment disorder with mixed anxiety and depressed mood, along with physician orders for Seroquel XR, buspirone, and Depakote for agitation, hallucinations, delusions, and targeted behaviors. The record also included a provider attestation for schizophrenia, schizoaffective or schizophreniform diagnosis stating the resident exhibited signs and symptoms of schizoaffective disorder. For Resident #22, the PASARR completed by the facility checked only "other related conditions" and inserted bipolar disorder, while the resident later developed depression during the stay and the most recent MDS listed bipolar disorder and depression. The resident did not have capacity to make their own medical decisions and had orders for Lamictal, Cymbalta, and buspirone for depression, bipolar disorder, and behaviors such as yelling out and restlessness. For Resident #7, the PASARR dated 06/27/25 did not include PTSD, even though the record showed PTSD as an active diagnosis dated 07/09/25, and the DON confirmed the PASARR was incorrect.
Incorrect Oxygen Delivery Setting
Penalty
Summary
The facility failed to ensure oxygen therapy was provided at the correct setting per the physician's order and the resident's care plan for Resident #37. On 03/23/2026, during the initial interview, the resident's oxygen concentrator was observed set at 2 liters, while the resident stated she was supposed to be on 4 liters and reported difficulty breathing. At 11:27 AM, Corporate RN #81 reported the concentrator was set between 2 and 3 liters, confirmed the order was for 3 liters, and stated the unit was being given to maintenance to fix. At the same time, Unit Manager #10 reported the concentrator would not go above 2.5 liters and that it was being replaced and sent to maintenance. The resident's order specified oxygen at 3 L/min via nasal cannula continuously, and the care plan directed oxygen administration via nasal cannula as ordered/indicated. A progress note later documented that the resident reported feeling short of breath, the oxygen concentrator was found to be malfunctioning, the concentrator was replaced, and the resident stated she was no longer short of breath with a pulse oximetry reading of 93% via nasal cannula.
Improper Use of Bed Rails Despite Evaluation Showing They Should Not Be Used
Penalty
Summary
Resident #44 was observed on 03/23/26 with bilateral bed rails in use even though the facility’s Bed Safety Evaluation dated 01/25/26 indicated that bed rails should not be used for this resident. The evaluation’s Step 2 guidance stated that if a No was recorded for any of the eight mobility questions, staff were to attempt alternatives, and the assessment recorded No for all seven mobility questions. The Bed Safety Evaluation Follow-up dated 01/26/26 documented that alternatives, including elevating the head of the bed and a PT/OT screen, were attempted and were successful, with the conclusion that bed rails should not be used for this resident. During interview on 03/24/26, the DON reviewed the evaluations and confirmed that Resident #44 should not have bed rails.
Failure to Permit Resident Return and Complete Required Discharge Process
Penalty
Summary
The facility failed to ensure that a resident was permitted to return following a hospitalization for behavioral evaluation. The resident had been transferred to the emergency room due to increased agitation and verbal aggression, as documented in progress notes and per physician order. After the hospital stay, the hospital care manager reported that the facility refused to readmit the resident, citing prior behavioral issues, and extended this refusal to all facilities owned or operated by the same company. There was no evidence that the facility completed a discharge notice, involved the resident or their representative in the discharge planning process, documented that the resident's needs could not be met, or made efforts to determine reasonable accommodations or interventions to support the resident's return. Additionally, the facility had an available bed at the time the resident's hospital bed-hold expired. The administrator confirmed that the decision to decline readmission was made by the clinical administrative team and acknowledged that no discharge notice was issued.
Failure to Provide Required Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide the required written notice to a resident, their representative, and the state long-term care ombudsman prior to discharging the resident and refusing readmission after hospitalization. Record review showed that the resident was transferred to the hospital and remained there beyond the bed-hold period, but hospital documentation indicated the resident was ready to return. Despite this, the facility declined readmission and did not issue a written discharge notice. There was no evidence that the notice included the reason for discharge, the effective date, or information about appeal rights, nor was there documentation that the ombudsman received a copy or that discharge planning was coordinated with the hospital and community services. Interviews with the Administrator and DON confirmed that the required written notice was not provided.
Failure to Serve Food at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures, as evidenced by missing food temperature records on multiple dates between January and May. A review of the temperature logs revealed numerous instances where required food temperatures were not recorded for various meals, including breakfast, lunch, and supper. The Certified Dietary Manager acknowledged the gaps in documentation, attributing them to staff turnover and workload issues. The Administrator confirmed that food temperatures were not taken on the identified dates. Resident interviews further substantiated the deficiency, with several residents reporting that their meals were frequently served cold or only barely warm. One resident specifically mentioned that biscuits and gravy were not hot, while another stated that the food was cold all the time except for a cheeseburger. These findings indicate that the failure to consistently monitor and document food temperatures resulted in residents receiving meals that were not at an appetizing or safe temperature.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in a physical altercation where one resident slapped another. The incident involved a resident with a history of aggressive behavior and cognitive impairments, including dementia and anxiety disorder. This resident had previously exhibited physical aggression, such as breaking windows and threatening staff and other residents. Despite these behaviors, the facility did not effectively manage or monitor the resident, leading to the incident where the resident slapped another resident, causing redness to the face. The aggressive resident had a documented history of behavioral disturbances and was known to be a danger to themselves and others. Multiple incidents were recorded where the resident displayed aggression, including using objects as weapons and verbally threatening other residents. Despite these documented behaviors, the facility did not implement adequate measures to prevent further incidents, such as consistent one-on-one supervision or effective behavioral interventions. Interviews with staff revealed that the aggressive resident had verbally threatened other residents on multiple occasions, but these incidents were not reported or investigated as abuse allegations. The facility's failure to identify, report, and investigate these incidents contributed to the environment where the physical abuse occurred. The lack of effective person-centered interventions and inadequate staff training in managing such behaviors were also identified as contributing factors to the deficiency.
Deficiencies in Fall Risk Assessment and Medication Administration
Penalty
Summary
The facility failed to ensure that residents were assessed to identify risk factors and provide care and services that are resident-centered to prevent falls with injury. This was evident in the case of a resident who was admitted following a fall at home and had a history of repeated falls. The facility did not complete a Fall Risk Evaluation upon admission or after subsequent falls, as required by their policy. The resident experienced multiple falls within the facility, resulting in injuries, including a subdural hematoma, which ultimately led to the resident's transfer to a hospital and subsequent death. The facility's Director of Nursing (DON) acknowledged the lack of documentation and assessment, which hindered the development of effective, individualized fall prevention interventions. Additionally, the facility failed to ensure that medications were administered as ordered for another resident. The Medication Administration Record (MAR) showed missing doses of a prescribed medication for Parkinson's disease on multiple occasions. The DON confirmed that these doses were not documented as administered, indicating a lapse in medication management and adherence to physician orders. The deficiencies highlight a lack of adherence to established policies and procedures for fall risk assessment and medication administration. The facility's failure to document and assess fall risks and medication administration compromised the safety and well-being of the residents involved. The DON's acknowledgment of these deficiencies underscores the need for improved oversight and adherence to care protocols to prevent such incidents in the future.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of assessments for a resident's dental status. A record review and observation revealed that a resident had two missing teeth, which were not documented in the Minimum Data Set (MDS) assessments completed on multiple occasions, including post-admission. The resident's last dental assessment by a dentist was over a year ago. Despite the resident's missing teeth being noted by the social worker upon admission, the MDS assessments on several dates did not reflect this dental issue. A registered nurse acknowledged missing the entry of the missing natural teeth in the assessment. The resident had refused a dental appointment on one occasion and was not seen on another due to illness, with a future appointment scheduled.
MD's Delay in Signing Orders Leads to Missed Pain Medication
Penalty
Summary
The facility's Medical Director (MD) failed to sign medication orders in a timely manner, resulting in a resident missing doses of a controlled pain medication. Resident #37, who was in constant pain, reported missing her pain medication because the doctor had not signed the orders, preventing the nurses from administering it. The facility had the medication in their emergency stock, but the pharmacy required a valid, active prescription to allow the facility to pull from the emergency stock. The order for Norco was entered into the system by a registered nurse, but it was not signed by the MD until later in the evening, causing the resident to miss doses throughout the day. Interviews with the Director of Nursing (DON) and staff revealed that the MD only signed orders once a week, on Mondays, and refused to sign any additional orders during the week, even though he had the capability to do so remotely. This practice led to delays in medication administration when new orders were obtained after Monday. Staff also reported that the MD was unresponsive to calls or messages related to resident care or needed orders. The DON acknowledged that the resident did not receive her pain medication due to the MD's delay in signing the order.
Deficiency in Call Light Accessibility and Functionality
Penalty
Summary
The facility failed to ensure that two residents had access to a working call light system, which is essential for their safety and communication needs. On September 29, 2024, it was observed that Resident #2's call light was not functioning. The Director of Nursing (DON) stated that the facility was unaware of the malfunction until it was identified by the surveyor. The resident did not recall informing anyone about the issue, indicating a lack of communication or awareness regarding the non-functional call light. Additionally, Resident #55's call light was found to be inaccessible as the cord was trapped between the bed and the wall, and draped over the overhead lights, making it immovable. A Nurse Aide (NA) had to be called to adjust the bed and reposition the call light cord so that the resident could reach it. This situation highlights the facility's failure to ensure that call lights are both functional and accessible to residents.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures prohibiting physical abuse and did not adequately investigate allegations of abuse. Resident #159, who had a history of aggressive behavior and cognitive impairments, physically abused Resident #9 by slapping them in the face. Prior to this incident, Resident #159 exhibited multiple aggressive behaviors, including physical aggression towards staff and other residents, and damaging property. Despite these behaviors, the facility did not effectively manage or report these incidents as required by their policies. Resident #159 had been admitted with diagnoses including encephalopathy, altered mental status, cognitive communication deficit, unspecified dementia with behavioral disturbances, and anxiety disorder. The resident had a low Brief Interview for Mental Status (BIMS) score, indicating significant cognitive impairment. Over several months, Resident #159 displayed aggressive behaviors, such as hitting windows with a bar and threatening other residents, which were documented in medical records but not adequately addressed or reported as abuse. Interviews with staff revealed that incidents of verbal abuse by Resident #159 towards Resident #9 were not reported or investigated. Staff members witnessed Resident #159 making threatening statements to Resident #9, but these were not identified as abuse incidents. The facility's policy required immediate reporting and investigation of such incidents, but this was not followed, leading to a failure in protecting residents from abuse.
Failure to Report and Investigate Resident Abuse
Penalty
Summary
The facility failed to report and investigate incidents of abuse involving two residents. On one occasion, a resident slapped another resident in the face, resulting in redness on the victim's face. Prior to this physical abuse, there were multiple instances of verbal abuse where the aggressor threatened the victim. These incidents were witnessed by staff members, including two nurse aides, who reported hearing the aggressor make threatening statements. Despite these observations, the incidents were not reported or investigated as required by the facility's abuse prohibition policy. The facility's policy mandates that any suspected abuse, including patient-to-patient abuse, must be reported immediately to supervisors and relevant authorities. However, the staff failed to adhere to this policy, as evidenced by the lack of reporting and investigation of the verbal and physical abuse incidents. The facility's policy also requires that the aggressor be removed from the situation and that adequate supervision be provided to prevent further altercations, but these measures were not implemented. The failure to follow these procedures resulted in a deficiency in the facility's handling of abuse allegations.
Failure to Investigate Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse were thoroughly investigated, specifically involving two residents. Resident #159, who had a history of aggressive behavior and cognitive impairments, physically and verbally abused Resident #9. Despite multiple incidents of aggression and threats by Resident #159, the facility did not identify or investigate these as allegations of abuse. This oversight was determined to be past non-compliance. Resident #159 had been admitted with diagnoses including encephalopathy, altered mental status, and unspecified dementia with behavioral disturbances. The resident exhibited aggressive behaviors, such as hitting emergency exit doors and windows, and was combative with staff. On several occasions, Resident #159 verbally threatened Resident #9 and other residents, yet these incidents were not reported or investigated as abuse. The facility's failure to recognize and act on these threats and aggressive behaviors contributed to the deficiency. Interviews with staff revealed that they witnessed Resident #159's aggressive and threatening behavior towards Resident #9, including verbal threats and physical aggression. However, these incidents were not reported or investigated as required by the facility's abuse prohibition policy. The facility's lack of action in identifying and investigating these incidents of verbal and physical abuse led to the deficiency being cited.
Failure to Update PASRR with New Diagnoses
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident with new qualifying diagnoses. During a medical record review, it was discovered that a resident, who was admitted with multiple diagnoses including encephalopathy and altered mental status, was later diagnosed with anxiety disorder and unspecified dementia with behavioral disturbance. Despite these new diagnoses, the PASRR was not updated to reflect these changes. The Director of Nursing acknowledged that the PASRR requirements were not met, indicating a lapse in the facility's process for updating resident assessments with new diagnoses.
Failure to Update PASRR for Resident with Intensified Behaviors
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident whose behaviors had intensified significantly. The resident, identified as Resident #159, was admitted with a Brief Interview for Mental Status (BIMS) score of six, indicating limited capacity. Initially, the PASRR was completed accurately and did not require a Level II evaluation. However, over several months, the resident exhibited escalating aggressive behaviors, including physical aggression towards staff and other residents, refusal of medications, and attempts to elope from the facility. The resident's behavior included incidents such as hitting a window with a mechanical lift lever, refusing medications while using foul language, and physically assaulting staff and other residents. Despite these behaviors, the PASRR was not updated to reflect the resident's significant change in condition. The resident was sent to a local hospital for psychiatric evaluation on multiple occasions, but returned without new orders or medication changes. The facility's failure to update the PASRR was acknowledged by the Director of Nursing during an interview. The deficiency was identified during a long-term care survey process, highlighting the facility's oversight in not notifying the appropriate authorities about the resident's significant change in condition. This oversight had the potential to affect a minimum number of residents, as the facility census was 60 at the time of the survey. The Director of Nursing agreed that the PASRR requirements were not met, indicating a lapse in the facility's compliance with regulatory standards.
Failure to Implement Resident-Centered Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered fall risk care plan for a resident who was admitted following an unwitnessed fall at home. The resident, an elderly female with a history of Alzheimer's Disease, Parkinson's Disease, and repeated falls, was admitted with several medical conditions and medications that increased her risk of falls. Despite these known risk factors, the facility did not complete a Fall Risk Evaluation upon admission or after subsequent falls, as required by their policy. The resident experienced multiple falls during her stay, including one that resulted in a subdural hematoma and her eventual transfer to a larger hospital. The facility's documentation was incomplete, lacking necessary details about the circumstances of the falls and the resident's condition, such as orthostatic blood pressure readings and the use of non-skid footwear. The Director of Nursing (DON) acknowledged these deficiencies, admitting that the facility did not perform root cause analyses for the falls or document the necessary information to develop effective, individualized interventions. The facility's failure to utilize available tools and assessments to identify and mitigate the resident's fall risk factors contributed to the deficiency. The DON admitted that the staff was unaware of a built-in fall risk evaluation tool in their electronic system, which was not utilized to inform the resident's care plan. This oversight, along with the lack of documentation and analysis, resulted in inadequate fall prevention strategies for the resident, ultimately leading to her injury and hospitalization.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities, which led to a deficiency in care for Resident #159. The resident was involved in multiple incidents of aggressive behavior, including slapping another resident, pushing a wheelchair to aggravate another resident, and making threatening statements. These behaviors were observed by staff members, but there was no evidence of individualized activities being provided to address the resident's needs and preferences, as identified in the resident's activity assessment. The resident's activity assessment indicated preferences for being alone, watching TV, listening to rock music, family visits, going for rides, woodworking, tinkering, fishing, and sitting outdoors. Despite these preferences being documented, there was no record of these activities being implemented as interventions during the incidents. The lack of individualized activities may have contributed to the resident's aggressive behavior, as there was no engagement in meaningful activities that aligned with the resident's interests. Additionally, the facility's failure to provide individualized activities was compounded by the inability to reach the resident's Medical Power of Attorney during episodes of aggressive behavior. This lack of communication and engagement in preferred activities may have exacerbated the resident's behavioral issues, leading to repeated incidents of aggression and ultimately the resident's transfer to a hospital and subsequent passing at a hospice house.
Failure to Implement Fall Interventions and Use Mechanical Lift
Penalty
Summary
The facility failed to implement fall interventions for Resident #27, who was identified as a fall risk due to cognitive loss, lack of safety awareness, impaired mobility, and a history of falls with fractures. Despite the care plan specifying that the bed should be in the lowest position with fall mats on both sides, an observation revealed that the bed was not in the lowest position, and the fall mat was missing on one side. This oversight was acknowledged by the facility administrator. Additionally, the facility did not adhere to its policy regarding the use of mechanical lifts for Resident #159 after a fall. The resident, who was assessed as requiring a total lift with a divided leg sling, was instead assisted manually by an LPN and a nurse aide. The Director of Nursing confirmed that the resident should have been assisted with the mechanical lift as per the assessment and facility policy.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ansted
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fayetteville Healthcare Center | 5.2 mi | ★★★★★ | 4 | 0 |
| Hidden Valley Center | 10.4 mi | ★★★★★ | 9 | 0 |
| Montgomery General Hospital | 12.9 mi | ★★★★★ | 0 | 0 |
| Montgomery General Elderly Care | 12.9 mi | ★★★★★ | 14 | 0 |
| Hilltop Center | 14.4 mi | ★★★★★ | 15 | 0 |
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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.