Below average — CMS composite of the measures below.
The next survey window likely opens 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 Beckley Healthcare Center during CMS and state inspections, most recent first.
A facility failed to develop and/or implement comprehensive care plans for four residents. One resident’s care plan omitted a documented MDD diagnosis, another had conflicting hygiene preferences in the care plan, a resident who was totally dependent for eating was often left without feeding assistance despite care plan directions, and another resident’s bed was observed not in the lowest position even though that intervention was in the care plan.
A resident who was totally dependent for feeding was repeatedly left with meals in front of him without staff assistance, and he had to ask for help while struggling to eat lunch and a nutritional supplement. Another resident who was totally dependent for bathing and preferred showers twice weekly did not have documentation showing the required shower frequency, and the record did not show refusals for the missed showers.
A resident who was documented as totally dependent for eating was repeatedly left with meals largely untouched while staff placed the tray on the over-bed table and exited without providing feeding help. The resident also reported that staff did not bring drinks between meals, and surveyors observed no fluids accessible at bedside despite the resident being on thickened liquids. Record review showed severe wt loss over 30 and 90 days, and the facility attributed the loss to hyperthyroidism and med changes while the RD notes did not address that diagnosis or the methimazole.
A resident had an order for lorazepam 0.5 mg q6h PRN for end-of-life care, anxiousness, and SOB, but received lorazepam 2 mg per dose on seven occasions. Corporate nursing staff confirmed the med was given at the higher dose instead of the ordered dose, and the error was not identified in a timely manner.
Inaccurate and incomplete resident records were found for multiple residents. Documentation was missing for scheduled 1:1 visits, a post-fall assessment listed the wrong fall time and a DNR POST form was absent, PEG feeding and water flush amounts were entered incorrectly on the MAR, a resident’s weight was charted with a major discrepancy, and a readmission skin assessment failed to capture bruising, a skin tear, IAD, and multiple DTIs.
A resident was transferred to the hospital for unresponsiveness and low BP, but the record did not contain a completed transfer form with the resident’s status, VS, Dx, allergies, meds, treatments, or other required information for the receiving facility. A corporate nurse stated she could not locate documentation of what information was conveyed and that a transfer form should have been completed and sent with the resident.
Enteral feeding orders for a resident were not followed as written. The feeding pump was observed off in the morning, then later restarted at the ordered rate, but the pump had not been cleared after the prior feeding and showed only 1,105 mL infused instead of the expected total. An RN confirmed the pump was not cleared per the order and stated there was no way to determine when the feeding would be complete if the pump was not cleared after each feeding.
A resident with cancer and severe pain reported uncontrolled pain and said staff sometimes did not return after he used the call light for pain medication. Records showed delayed initiation of morphine after admission, missed and delayed doses of scheduled and PRN pain meds, and an LPN confirmed the scheduled morphine dose was late but did not assess or address the resident’s pain during the encounter.
Controlled Substance Count Discrepancy: The facility failed to properly account for controlled meds when a count of a resident’s Tramadol did not match the administration record. An RN reviewed the locked med drawer and confirmed the discrepancy but could not explain it. The resident was receiving Tramadol QID for pain.
A multi-dose insulin vial on the med cart was found with two different opening dates and two different expiration dates written on the box and vial. An RN confirmed the conflicting labels and that the earlier expiration date had already passed based on the package insert.
Failure to offer a pneumococcal vaccination to a resident who was eligible for the vaccine. Record review showed the resident was due for a PCV20 vaccination, but it was not offered, and a corporate nurse confirmed the omission.
Oxygen was not provided as ordered for two residents. One resident was observed with the O2 concentrator running, but the tubing was not connected to the concentrator or the nasal cannula. Another resident was observed receiving O2 at 4 L/min by NC, although the physician order was for 2 L/min; an IP nurse confirmed the incorrect setting.
Inaccurate Documentation of Enteral Feeding Volumes: Two residents with enteral feeding orders had MAR entries that did not match the ordered pump rates or total daily volumes. Documentation included inconsistent amounts, missing amounts, and totals that exceeded or differed from the prescribed intake. The RD of Clinical Ops confirmed the recorded enteral feeding amounts did not correlate with the orders and could not explain the discrepancies.
Wet nesting of baking pans was observed during a kitchen check when two baking pans were found stacked while still wet. The Dietary Manager confirmed the pans should have been fully dried before storage and stacking. The report stated this practice can support bacterial growth and contaminate food prepared in the pans.
Improper Storage of Ice Scoop in Ice Chest: An ice scoop was observed stored inside the ice chest with clean ice on the F wing. An RN confirmed the scoop was not stored properly to prevent the spread of infection.
A resident's POST form stated she did not want CPR if her heart stopped, but the EMR contained a physician order for CPR that did not align with her directive. The RDCO confirmed the order needed to be updated to reflect the resident's wishes regarding CPR.
Failure to report and investigate possible neglect occurred when a resident was sent to the ER for being unresponsive and the hospital record documented conflicting staff accounts about when the resident was last responsive. The DON said she did not investigate because she believed the report was not true, and the NHA and RDCO confirmed the event was not reported or investigated as neglect, despite the facility policy requiring immediate reporting and investigation of alleged neglect.
Failure to report potential neglect involving a resident who was sent to the ER for unresponsiveness. The ER record noted conflicting accounts from facility staff about when the resident became unresponsive, while the DON stated she did not read the report and did not investigate because she believed it was not true. The NHA and RDCO confirmed the event was not reported or investigated as neglect.
Inaccurate MDS Dialysis Assessment: A resident stated he was receiving dialysis, and the physician’s orders showed dialysis had been ongoing since admission. However, the MDS assessment incorrectly indicated the resident was not receiving dialysis, and the MDS nurse confirmed the assessment should have reflected dialysis treatment.
A resident with dementia, severe impaired cognitive function, unsteadiness, weakness, incontinence, hearing difficulty, pain, and multiple other conditions had a fall-risk care plan that included Dycem under the wheelchair cushion and a laminated call-light reminder sign. During observation with the DON, the wheelchair had no Dycem or cushion, and no reminder sign was present; the DON agreed the interventions were not in place.
An opened multiuse vial of Tubersol PPD was found in a medication room refrigerator without a date showing when it was opened. An LPN confirmed the vial had not been dated, and the pharmacy-delivered vial was being stored in the room with no further details provided.
A resident with a urinary catheter had a urine culture that tested positive for ESBL, but the attending physician was not notified of the result in a timely manner. This lack of notification and follow-up led to a delay in treatment and the postponement of a scheduled surgical procedure. The issue was confirmed by the facility's administrator, who acknowledged the absence of documentation showing physician notification.
Two nurse aides failed to wear required isolation gowns while transferring a resident on Enhanced Barrier Precautions, despite clear signage and physician orders. Both staff members misunderstood the infection control signage, associating it with fall risk rather than EBP, resulting in non-compliance with the facility's infection control policy.
A facility did not thoroughly investigate an allegation of neglect after a resident was reported by his sister and an outside healthcare provider to have arrived at a medical appointment in soiled clothing with a strong odor of urine. The facility failed to contact the ambulance company or the receiving healthcare facility as part of their investigation, relying only on internal staff statements and not obtaining external documentation until prompted by a surveyor.
A resident's urine culture indicating ESBL was not acted upon in a timely manner, resulting in a delay in both infection treatment and a scheduled ureteroscopy with stone removal. The lack of documented physician notification and follow-up led to the cancellation of the procedure, which was only performed after appropriate treatment was eventually started.
Two nurse aides attempted to use a mechanical lift as a transport device to move a resident from the hallway to her bed after a shower, despite manufacturer warnings that the lift is not intended for transport. The surveyor intervened before the transfer occurred, preventing potential harm. The incident was determined to be immediate jeopardy due to the unsafe practice.
The facility failed to provide adequate nursing staff, resulting in delayed care for residents. A resident was left in soiled linens for over an hour, another was left in a precarious position in the dining room, and a third was delayed in attending a meeting due to insufficient staff. Staff interviews revealed chronic understaffing, particularly on weekends, leading to incomplete tasks and resident care being compromised.
The facility failed to meet professional standards in food storage, preparation, and dishwashing practices. Observations included undated juice pitchers, improperly stored produce, and soiled kitchen areas. The dishwashing machine consistently operated below recommended temperatures, and additional issues were found with labeling and cleanliness. These deficiencies had the potential to affect a significant number of residents.
A facility failed to maintain resident dignity and respect by not knocking before entering a resident's room and delaying meal service for two residents compared to their roommates. An LPN admitted to not following protocol, and the delay in meal service was due to trays not being sent from the kitchen, resulting in a ten-minute wait for the affected residents.
The facility failed to provide adequate education and informed consent for psychotropic medications and care refusals for three residents. A resident received high-risk medications without documented education on risks and alternatives. Another resident frequently refused care, including tube feedings and wound care, without a comprehensive care plan or documented education on refusal risks. A third resident's informed consent form for psychotropic medications was incomplete, lacking details on conditions, benefits, and side effects.
The facility failed to ensure residents were aware of meal options and had adequate staffing to attend activities. Residents reported not knowing about available menu choices, and a resident was delayed in attending a meeting due to insufficient staff to assist with her transfer. The 'always available' menu was not accessible, impacting residents' rights to self-determination.
The facility was found to have deficiencies in maintaining a clean and homelike environment. Observations revealed stained ceiling tiles and dusty air vents in the dining room, as well as an unclean PTAC unit in a resident's room. The Administrator and Maintenance Director confirmed these findings, indicating a failure to adhere to cleaning schedules and professional standards.
The facility failed to include schizoaffective or bipolar disorder diagnoses in the PASARR for three residents prior to admission. One resident's PASARR omitted a schizoaffective disorder diagnosis, another's incorrectly indicated no current diagnosis despite having bipolar disorder, and a third resident's PASARR was not completed prior to admission and omitted a schizoaffective disorder diagnosis. Administrators acknowledged these oversights.
The facility failed to develop and implement comprehensive care plans for residents, leading to deficiencies in addressing specific medical and care needs. A resident with PTSD lacked a care plan, while another experienced falls without adequate risk management. Inaccurate fall risk assessments and incomplete care plans for respiratory and hearing impairments were also noted. Administrators acknowledged these issues, highlighting a need for improved care planning.
The facility failed to update care plans for several residents, leading to deficiencies in care. A resident with severe cognitive impairment was not offered activities as per their care plan. Another resident, at high risk for skin breakdown, was found on a deflated air mattress without privacy, and their care plan did not address increased risk factors. A third resident's care plan was not updated to reflect frequent medication refusals, and another resident's aggressive behaviors were not addressed in their care plan for several months.
The facility failed to provide adequate ADL care to residents, as evidenced by long, unclean fingernails and infrequent bathing. A resident reported not receiving a bath for days, resulting in long nails with a brown substance underneath. Another resident had greasy hair and infrequent documented baths. Despite requests for nail care, residents' nails remained unaddressed, and staff were uncertain about care schedules. These issues indicate a systemic failure in maintaining residents' hygiene.
The facility failed to provide care consistent with professional standards for three residents, leading to deficiencies in their treatment and care. A resident receiving hospice services was not assessed in person before a medication change, and non-pharmacological interventions were not attempted. Another resident experienced falls due to inadequate care planning, and a third resident was left unattended in a chair for hours, highlighting failures in monitoring and care planning.
The facility failed to provide a safe environment and adequate supervision, resulting in multiple falls and injuries among residents. A resident experienced falls leading to hospitalization, with care plans not reflecting their need for assistance. Another resident was left exposed and unattended, with incomplete post-fall evaluations and inaccurate risk assessments. A third resident suffered a traumatic injury due to improper assistance, highlighting issues with staff education and care planning.
The facility failed to maintain accurate daily staff postings, affecting more than a limited number of residents. Discrepancies were found between the scheduled and actual number of Nurse Aides (NAs) working on specific days. The staff posting sheets were not updated to reflect the accurate number of staff, as confirmed by the Administrator.
The facility failed to document behavior monitoring as ordered for three residents on psychotropic medications. A resident with orders for Trazadone, Geodone, and Buspirone had missing documentation for behavior monitoring related to refusal of care and anxiety. Two other residents with orders for Sertraline, Trazadone, Depakote, Risperdal, and Olanzapine also had missing behavior monitoring documentation. The administrator acknowledged the oversight during interviews.
The facility failed to provide routine dental care for two Medicaid-funded residents. One resident reported discomfort from a loose tooth and had significant dental buildup, with no dental consults since admission. Another resident showed signs of dental decay and confirmed mouth pain, yet no dental consults were arranged. The facility's policy requires assistance in obtaining routine dental services, which was not followed.
A resident was found lying on a deflated air mattress, exposed and only wearing a brief, with the call light on. The air mattress cord was unplugged, and multiple staff members passed by without offering assistance or covering the resident. A wound nurse eventually covered the resident after being prompted by a surveyor. The resident had moderate cognitive impairment and lacked capacity due to a CVA.
A resident was involved in multiple altercations with others, including striking one and squeezing another's arm. The facility failed to document required one-on-one supervision and did not implement timely interventions to prevent further incidents.
A resident receiving hospice services was administered Lorazepam for terminal agitation without proper assessment or documentation of non-pharmacological interventions. The hospice nurse did not assess the resident in person before recommending the medication, and the facility's nursing staff reported a lack of hospice education. The facility's documentation showed multiple instances of Lorazepam administration without documented non-pharmacological interventions, and the administrator confirmed these deficiencies.
A facility failed to report an alleged abuse incident involving a resident who verbally abused and attempted to hit a nurse during a skin assessment. The incident was not reported to the State Agency, as the administrator did not interpret it as abuse but as a response to the care provided.
The facility failed to investigate and address abuse allegations involving a resident who was involved in altercations with others. One resident reported being struck, but no statement or interview was conducted. Another incident involved arm grabbing, witnessed by others, but supervision documentation was missing. Allegations were marked unsubstantiated due to the resident's lack of capacity.
A facility failed to document a resident's hearing impairment and use of hearing aids accurately on the MDS. The resident reported excessive earwax buildup, preventing hearing aid use, and resorted to using scissors for removal. The care plan lacked documentation of hearing needs, and there were inconsistencies in the MDS. Staff were unaware of the resident's actions and the removal of a flushing device ordered by the resident.
A facility failed to ensure the accuracy of the MDS assessments for a resident, resulting in a discrepancy between the MDS and the care plan. The MDS incorrectly indicated no oral or dental problems, while the care plan noted issues with decayed and blackened teeth. This was confirmed during an interview with the Administrator and a corporate witness.
A facility failed to update the PASARR for a resident with new diagnoses of Dementia with other unspecified behaviors and schizoaffective disorder. The resident was admitted with these diagnoses, but the PASARR, dated years prior, did not reflect these updates. The facility's administrator confirmed the need for an updated PASARR.
The facility failed to meet the activity needs of two residents, as one resident was not offered activities matching their interests, and another, with mobility issues, was not provided with any activity materials. Both residents had care plans outlining their preferences, but records showed minimal engagement, indicating a lack of implementation of the care plans.
Incomplete and Unimplemented Care Plans
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for four residents. For Resident #1, the care plan did not include the diagnosis of Major Depressive Disorder, single episode moderate, and Corporate Nurse #222 confirmed the diagnosis was not included. For Resident #43, the comprehensive care plan contained conflicting hygiene interventions: one focus initiated for refusal of hygiene care later added that the resident prefers bed baths, while another focus related to ADL deficits later added that the resident prefers showers twice a week on night shift. During interview, the resident stated she prefers bed baths in the evening after supper, and Corporate Nurse #220 confirmed the conflicting care plan interventions regarding hygiene preferences. For Resident #15, the care plan identified the resident as totally dependent for eating, but observations showed the resident was frequently left without feeding assistance. On multiple meal observations, the resident’s tray remained largely untouched, staff placed the tray on the over-bed table and left without assisting, and the resident asked for help eating because he could not get the food to his mouth. Review of ADL flow sheets showed that from 11/14/25 through 11/12/26, the resident was dependent for eating at 74 of 177 meals, or 41.8% of the time. For Resident #93, the care plan included an intervention for the bed to be in the lowest position related to fall risk, but an observation found the resident resting in bed with the bed not in the lowest position, and Corporate RN #220 agreed the care plan had not been implemented.
Failure to Provide Required Assistance With Eating and Bathing
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for ADLs received needed assistance with eating. Resident #15 had a care plan intervention stating he was totally dependent and required 1 staff assist for eating, but observations on multiple meal occasions showed his tray left in front of him without feeding assistance. On one occasion, his noon meal remained largely untouched on the over-the-bed table hours after it was served, and on other occasions staff set up the tray and left the room without providing feeding help. During another lunch observation, the resident had chocolate pudding on his hand, his food was barely disturbed, and he asked the surveyor for help eating because he could not get it. He made the same request later when attempting to eat a frozen nutritional supplement and was struggling to do so. The facility also failed to provide the bathing assistance required for Resident #51. The resident stated that showers were not always provided and sometimes occurred every two weeks. Review of the shower and bathing task report showed showers and bed baths were documented on several dates, but the record did not show twice-weekly showers as preferred in the comprehensive care plan. The care plan identified the resident as totally dependent for showering and bathing, and the corporate nurse confirmed the documentation did not show the required shower frequency and no refusals were documented in the task report or progress notes.
Failure to Provide Feeding Assistance and Accessible Fluids
Penalty
Summary
The facility failed to ensure a resident with a care plan indicating he was totally dependent for eating received consistent feeding assistance and adequate access to fluids. The resident had a history of hyperthyroidism and was observed on multiple occasions with meals still largely untouched while staff placed the tray on the over-bed table and left the room without providing feeding help. On one occasion, the resident asked the surveyor for help eating because he could not get his lunch, and on another occasion he asked for help with his frozen nutritional supplement because he could not eat it on his own. The resident also did not have fluids available at bedside as observed by surveyors. Multiple observations found that only drinks on meal trays were present, with no additional water or fluids accessible between meals. When interviewed, the resident stated staff did not bring him drinks between meals and that he had to wait until the next meal to get a drink. Staff gave conflicting explanations about whether thickened liquids could be left at bedside and whether the resident had a pitcher or only cups brought intermittently. Survey observations of other residents with thickened liquids showed bedside water containers were present for them, while this resident did not have accessible fluids during the observations. Review of the resident’s record showed significant weight loss over time, including a 5.95% loss in 30 days and a 12.15% loss in 90 days, both described as severe. The ADL flow sheets showed he was coded as dependent for eating only part of the time, and a comparison of meal intake showed that when he received feeding assistance and was documented as totally dependent, he usually consumed most of his meals, while when he was documented as independent he often consumed little of his meal. The facility attributed the weight loss to hyperthyroidism and medication changes, but the dietitian’s notes did not mention the hyperthyroidism or methimazole despite multiple assessments.
Medication Administered at Incorrect Dose on Multiple Occasions
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for Resident #149. The resident had an order for lorazepam 0.5 mg, one tablet by mouth every six hours as needed for end-of-life care, anxiousness, and shortness of breath for 14 days. Record review showed that the resident instead received lorazepam 2 mg, one tablet by mouth every four hours as needed for anxiety, on seven occasions across multiple days. On 01/07/26, Corporate Nurse #220 told the surveyor that the medication error was identified while reviewing the resident’s medication orders and controlled substance administration record. Corporate Nurse #229 later confirmed that lorazepam was administered at 2 mg instead of the ordered 0.5 mg on seven occasions. The facility failed to identify and correct the medication administration error in a timely manner.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents reviewed during the survey. The record review and staff interviews showed that Resident #73 had no documentation of scheduled 1:1 visits even though the care plan called for them five times per week, and the Activity Director stated staff were only marking the 1:1 tab when a resident required a 1:1 sitter. This indicated the scheduled visits were being provided according to the care plan but were not being documented correctly. Resident #149’s record contained a post-fall assessment that listed the wrong date and time of the fall, and the medical record did not contain the POST form even though the resident’s code status was DNR. Corporate RN #220 confirmed the POST form was missing from the record and that the post-fall evaluation did not reflect the correct time of the fall. Resident #6, who received nutrition through a PEG tube due to stroke and dysphagia, had MAR entries in which feeding amounts and water flush amounts were mixed up, with documentation showing 660 ml where 1155 ml should have been recorded and vice versa on multiple dates. Resident #12’s weight was documented as 260 pounds on one date and 151 pounds on another, reflecting a loss of 109 pounds in less than a week, and Corporate RN #220 stated she would review the post-dialysis note to correct the weight entry. Resident #8’s readmission nursing assessment documented no skin issues, but a wound note from the same readmission described scattered bruising and scabs, a skin tear, IAD, and three DTIs to the heels and sacrococcygeal area. Corporate RN #220 confirmed the readmission assessment was not accurate and that the wounds and skin findings should have been captured on the nursing assessment.
Missing Transfer Information Sent With Hospital Transfer
Penalty
Summary
The facility failed to ensure that appropriate information was communicated to the receiving healthcare institution when Resident #8 was transferred to the hospital. The facility policy titled Transfer and Discharge Policy stated that a transfer form would be completed and sent with a resident being transferred to the hospital, and that the form would include patient status, recent vital signs, current diagnoses, allergies, reasons for transfer, practitioner contact information, representative information, medications and treatments, relevant laboratory or radiological findings, immunization status, special instructions or precautions, special resident risks, and other information needed for a safe and effective transition of care. Review of Resident #8's medical record showed the resident was transferred to the hospital due to unresponsiveness and low blood pressure. The record did not contain a completed transfer form documenting the information needed to communicate the resident's condition and care needs to the hospital. Corporate Nurse #220 stated she was unable to locate documentation of the information conveyed to the hospital when the resident was transferred and stated a transfer form should have been completed and sent with the resident.
Enteral Feeding Pump Not Cleared Between Feedings
Penalty
Summary
Resident #9, who was receiving nutrition by enteral feeding, had physician orders directing that the tube feeding be turned off at 8:00 a.m. if the total volume of 1,400 mL had infused, the pump be cleared, and the total documented. The record also included an enteral feed order for Jevity 1.5 at 70 mL/hr via enteral pump starting at 12:00 p.m. and running until 1,400 mL had infused. A third order repeated that the tube feeding was to be turned off at 8:00 a.m. if 1,400 mL had infused and the pump cleared and total documented. On observation, the resident was resting in bed at about 9:00 a.m. and the feeding pump was off. At 12:45 p.m., the nurse had started the feeding that was due to begin at 12:00 p.m., and the pump was running at the ordered rate of 70 mL per hour. The pump showed that only 1,105 mL had been infused, and Corporate Registered Nurse #220 confirmed that the pump had not been cleared after the resident's last feeding as directed in the order. She stated there was no way to determine when the feeding would be complete if the pump was not cleared after each feeding.
Delayed and Missed Pain Medication Administration
Penalty
Summary
Provide safe, appropriate pain management for a resident who requires such services was not ensured for Resident #149. On admission, the resident had a documented pain score of 9/10 on the verbal pain scale and reported having cancer, severe pain, and that pain medication helped when given. The resident stated he sometimes did not receive pain medication, usually activated his call light 30 minutes before medication was due, and said staff responded but did not return. At the time of interview on 01/06/2026, the resident rated his pain 7/10 and reported his last morphine dose had been given the previous evening, although it was ordered every 12 hours. Record review showed the resident did not receive pain medication until more than nine hours after admission despite severe pain. Physician orders included morphine 30 mg every 12 hours for intractable pain and oxycodone 15 mg every 4 hours as needed for pain. The MAR showed missed and delayed administration of pain medication, including multiple days without PRN oxycodone. During interview, an LPN confirmed the scheduled morphine dose was late and stated he would need to contact the physician for a one-time order to administer it. When the LPN entered the room during the surveyor interview, the nurse obtained vital signs and noted the resident was on neurological checks due to a fall, but did not assess pain, discuss pain control, or address the overdue pain medication.
Controlled Substance Count Discrepancy
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was deficient because the facility did not have a system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. During an inspection of the F odd medication cart, RN #29 was present while Individual Resident's Controlled Substance Administration Records were reviewed and the amount of medication remaining on the record was compared with the actual tablets in the locked drawer. For Resident #21, the record showed 32 tablets of Tramadol remaining, but only 31 tablets were found in the locked drawer. RN #29 confirmed the discrepancy but could not explain it. The Tramadol had last been signed out on the Controlled Substance Administration Record at 4:22 AM, and the MAR showed the resident received Tramadol four times daily for pain at 4:00 AM, 10:00 AM, 4:00 PM, and 10:00 PM.
Improper Labeling of Multi-Dose Insulin Vial
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles when a multi-dose vial of Humulin Regular insulin for Resident #90 was found on the evening medication cart with two different opening dates and two different expiration dates written on both the box and the vial. During observation on 01/12/2026 at 10:23 AM, RN #29 was present when the cart was inspected and confirmed that the insulin had conflicting dates: one opening date of 12/10/25 with an expiration date of 01/07/26, and another opening date of 01/04/26 with an expiration date of 02/02/26. The box had been filled by the pharmacy on 11/22/25, and the earlier expiration date had already passed according to the package insert requirement that opened vials be used within 31 days or discarded.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the pneumococcal vaccination to Resident #4. Record review showed the resident was eligible for a pneumococcal 20 vaccination in 09/2025, but the vaccination was not offered. Corporate Nurse #220 later confirmed that the vaccination had not been offered to the resident.
Oxygen Not Administered Per Physician Orders
Penalty
Summary
The facility failed to ensure oxygen was administered according to physician orders for two residents. Resident #8 was observed in bed with the oxygen concentrator running at 2 liters per minute, but the oxygen tubing was rolled up on the bed and was not connected to the concentrator or to the resident’s nasal cannula. An RN confirmed the tubing was not connected and stated she would obtain new tubing and a nasal cannula. Resident #149 was observed receiving oxygen at 4 liters per minute via nasal cannula, but record review showed a physician order for 2 liters per minute. The IP Nurse confirmed the ordered rate was 2 liters per minute and acknowledged the oxygen was set at 4 liters per minute at the time of observation.
Inaccurate Documentation of Enteral Feeding Volumes
Penalty
Summary
The facility failed to ensure enteral tube feeding was provided in accordance with professional standards of practice because the amount of enteral feeding infused was not accurately recorded. The deficiency involved 2 of 2 residents reviewed for tube feeding care, Resident #1 and Resident #8. The report states that the documented amounts of enteral feeding on the MARs did not correlate with the ordered daily volumes for either resident. For Resident #8, physician orders written on 01/31/25 directed Jevity 1.5 via pump at 80 mL/hr for 10 hours, with a total volume of 800 mL, and included instructions to confirm the programmed rate and total volume and to clear the volume fed in the last 24 hours back to 0. Review of the MARs for June through September 2025 showed multiple entries documenting amounts such as 1600 mL, 984 mL, 550 mL, 2828 mL, 0 mL, 100 mL, and 300 mL. On 09/10/25, the Regional Director of Clinical Operations confirmed these documented amounts did not match what the resident was ordered to receive daily and could not explain the discrepancies. For Resident #1, physician orders written on 08/21/25 directed Jevity 1.5 via pump at 70 mL/hr for 20 hours with a total volume of 1400 mL, along with instructions to confirm the programmed rate and total volume and to clear the total volume fed in the last 24 hours back to 0. The MARs for August and September 2025 showed documented amounts including 800 mL, 1680 mL, 1000 mL, 700 mL, 2100 mL, 0 mL, 1400 mL, 1397 mL, and 1120 mL, with some entries missing an amount altogether. After the order was changed on 09/05/25, the MARs continued to show inconsistent documentation across day and night shifts. On 09/11/2025, the Regional Director of Clinical Operations confirmed the enteral feeding amounts had not been documented accurately and could not explain the discrepancies.
Wet Nesting of Baking Pans Observed in Kitchen
Penalty
Summary
The facility failed to ensure that baking pans were stored in a sanitary manner by stacking them while still wet. During a kitchen observation with the Dietary Manager, two baking pans were observed stacked while wet, which was identified as wet nesting. The report states that wet nesting can support bacterial growth and contaminate food prepared in the pans. The Dietary Manager confirmed that the pans should have been completely dried before storage and stacking.
Improper Storage of Ice Scoop in Ice Chest
Penalty
Summary
The facility failed to ensure safe infection control practices were followed when an ice scoop was observed stored inside the ice chest with the clean ice on the F wing. During the observation on 9/08/25 at 3:30 PM, Registered Nurse #300 confirmed that the scoop was not stored properly to prevent the spread of infection.
Advance Directive Order Did Not Match Resident's CPR Wishes
Penalty
Summary
Resident #151 had a Physician Orders for Scope of Treatment (POST) form completed by the resident and signed by the Nurse Practitioner that indicated she did not want CPR if her heart stopped, while also indicating she would want full intervention prior to her heart stopping. A review of the medical record also found a physician order dated [DATE] that read CPR and directed staff to perform CPR should the resident's heart stop. This order did not match the resident's POST form. During an interview, the Regional Director of Clinical Operations confirmed the order in the electronic medical record needed to be updated to reflect the resident's wishes regarding CPR.
Failure to Report and Investigate Possible Neglect
Penalty
Summary
Failure to implement the facility’s Abuse, Neglect, and Misappropriation policy occurred when a report suggesting possible neglect involving Resident #145 was not reported or investigated. The policy stated that any report of alleged abuse or neglect must be identified, reported to the supervisor, investigated timely, and immediately communicated to the DON and Executive Director, with required notifications completed as needed. In this case, Resident #145 was a closed record review for hospitalization and had been transferred to the ER from the facility for being unresponsive. The hospital emergency department record, which had already been scanned into the resident’s electronic record before the survey, documented that the resident arrived at the ER with complaints of unresponsiveness and was described as a sepsis patient with hypotension, tachycardia, and altered mental status. The record also noted differing accounts from the nursing facility, including a CNA report that the resident had been unresponsive since 7:00 a.m. and another account that it had been since about 10:00 a.m. The DON stated she had not read the report and did not investigate because she knew it was not true, citing MAR documentation showing the resident drank part of a Mighty Shake at 10:43 a.m. The NHA and RDCO later confirmed the matter was not reported or investigated and stated they did not consider it neglect.
Failure to Report Potential Neglect Involving Resident Unresponsiveness
Penalty
Summary
The facility failed to identify and report a situation of potential neglect involving Resident #145. The resident was sent to the emergency room on 07/18/25 at 1:10 PM with the transfer reason documented as unresponsive. A scanned Emergency Department record in the medical chart, faxed to the facility at 8:30 AM and available before the survey began, stated the resident arrived at the ER at 1:38 PM and was brought in by EMS with complaints of unresponsiveness. The ER record also noted the resident arrived as a sepsis case with hypotension, tachycardia, and altered mental status, and that there were differing stories from the nursing facility about when the resident became unresponsive. During interview, the DON stated she had not read the ER report indicating the resident had been unresponsive since 7:00 AM or 10:00 AM and said she knew that was not true because the MAR showed the resident drank some of a mighty shake at 10:43 AM. She agreed no investigation was done because she believed the report was not true and because she had seen the resident that day. Later, the NHA and RDCO confirmed the situation was not reported and stated they knew it was not the case, had discussed the resident's decline in the morning meeting, and did not report or investigate it as neglect.
Inaccurate MDS Dialysis Assessment
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for Resident #135 in the area of dialysis. During an interview, the resident stated he was receiving dialysis treatments, and review of the physician’s orders showed he had been receiving dialysis since admission. However, the resident’s MDS assessment with ARD 08/27/25 indicated that he was not receiving dialysis treatments. On 09/09/2025, the MDS Nurse confirmed that the MDS assessment was incorrect and should have indicated that the resident was receiving dialysis treatments.
Fall-Prevention Care Plan Not Implemented
Penalty
Summary
Resident #16’s care plan for falls was not implemented. The resident’s record showed a fall-risk care plan initiated on 09/15/23 and revised on 05/20/25, with a goal that the resident would not sustain major injury related to falls through the review date. The care plan identified dementia with severe impaired cognitive function, unsteadiness on feet, muscle weakness, episodes of incontinence, difficulty hearing, episodes of pain, hypertension, panic disorder, anxiety, osteoarthritis, anemia, depression, a history of CVA, use of medications with side effects that increase fall risk, and poor safety awareness. Interventions included Dycem under the cushion of the wheelchair and a laminated sign in the room to remind the resident to use the call light. During observation with the DON, the resident was resting in bed, the wheelchair was beside the bed, and there was no Dycem in the wheelchair, no cushion, and no laminated sign reminding the resident to use the call light. The DON agreed the interventions were not in place.
Undated Tubersol Vial Stored in Medication Refrigerator
Penalty
Summary
The facility failed to store medications in accordance with accepted standards of practice when an opened multiuse vial of Tubersol Purified Protein Derivative was found in the building 2 medication room refrigerator without a date indicating when it was opened. During inspection, the vial was observed with LPN #84 present, and the nurse confirmed that it had not been dated. The vial had been delivered by the pharmacy on 07/09/25, and the medication package insert states that a vial of Tubersol that has been entered and in use for 30 days should be discarded. The facility census was 139.
Failure to Notify Physician of Positive ESBL Urine Culture Result
Penalty
Summary
The facility failed to notify a resident's attending physician of a urine culture result that identified the presence of ESBL in the resident's urine. The medical record review showed that a urine culture was obtained as ordered, and the result, which indicated ESBL and recommended contact precautions, was verified and printed. However, there was no documentation that the physician was notified of this result until over two weeks later, when a nurse documented contacting the physician after being informed by an outside physician's office that a scheduled surgery could not proceed due to untreated ESBL. The nurse then obtained an order to change the Foley catheter and collect a new urine sample. This lack of timely physician notification and follow-up on the positive ESBL result led to a delay in treatment and the postponement of a scheduled ureteroscopy with stone removal. The resident ultimately received the procedure nearly a month later than originally planned. The Nursing Home Administrator confirmed that there was no documentation of physician notification at the time the initial lab result was received.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
During a complaint investigation, it was observed that two nurse aides entered the room of a resident who was under Enhanced Barrier Precautions (EBP) due to a PEG tube and a wound, as indicated by physician orders. The signage on the resident's door clearly instructed staff to wear gloves and a gown when performing care activities such as transferring the resident. Despite these instructions, both nurse aides only donned gloves and did not wear isolation gowns while transferring the resident to bed. When questioned, both nurse aides demonstrated a lack of understanding regarding the meaning of the signage and the yellow sticker by the resident's name, incorrectly associating it with fall risk rather than infection control precautions. The Nurse Practice Educator confirmed the intended meaning of the signage and the yellow sticker, which was to identify the resident as requiring EBP. The failure to follow the facility's infection control policy and the lack of staff awareness regarding EBP protocols were directly observed during the care of this resident.
Failure to Thoroughly Investigate Allegation of Resident Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who was reported by his sister to have left for a medical appointment in an unclean state, with unchanged socks and inadequate hygiene. Although the facility promptly reported the incident and collected statements from staff and the resident, they did not verify the allegation beyond these internal accounts. The investigation did not include contacting the ambulance company that transported the resident or the healthcare facility where the appointment took place, despite the sister's previous complaints and the external facility's subsequent report to the survey agency. Upon review, it was found that when the resident arrived at the outside healthcare facility, staff there observed that he smelled strongly of urine, and his socks and clothing were soiled and adhered to his feet. The facility's social workers and the Nursing Home Administrator confirmed that they had not reached out to the ambulance company or obtained the external facility's consult until prompted by the surveyor. The resident was known to have frequent incontinence and refused to wear briefs, a fact acknowledged by both staff and his sister, but this information was not adequately incorporated into the investigation process.
Delay in Addressing Lab Results Leads to Postponed Procedure
Penalty
Summary
The facility failed to ensure timely follow-up and treatment of a resident's laboratory results, specifically regarding urine cultures ordered to monitor for infection. The first urine culture, obtained as ordered, revealed the presence of ESBL and included instructions to follow contact precautions. Despite the results being available and verified, there was no documented evidence that the physician was notified or that treatment was initiated until over two weeks later, when a nurse documented contacting the physician and receiving new orders. Progress notes indicated that the lack of timely action on the lab results led to uncertainty about whether the infection had been treated. As a result of this delay, a scheduled ureteroscopy with stone removal was canceled because the infection had not been addressed. The resident ultimately received the required procedure nearly a month later, after a second urine culture and appropriate antibiotic treatment were initiated. The deficiency was confirmed by the Nursing Home Administrator, who acknowledged the lack of documentation regarding physician notification and treatment initiation.
Improper Use of Mechanical Lift as Transport Device Creates Immediate Jeopardy
Penalty
Summary
The facility failed to ensure the resident environment was as free from accident hazards as possible when two nurse aides prepared to use a total mechanical lift as a transport device for a resident after a shower. The resident was placed on a shower bed in the hallway outside her room, and one nurse aide began hooking the lift pad to the mechanical lift, intending to wheel the resident into her room while suspended in the lift. The surveyor intervened before the transfer could occur, after confirming with the nurse aide that this was his usual practice due to space constraints in the room. The resident's room was crowded with her bed, her roommate's bed, a fall mat, an over-bed table, and two wheelchairs, making maneuvering difficult. The Invacare Reliant 450 lift manual and warning labels clearly state that the lift is not intended as a transport device and should only be used to transfer individuals from one resting surface to another, not for moving them across distances or over uneven surfaces. Despite these instructions, the nurse aide attempted to use the lift inappropriately, which was only prevented by the surveyor's intervention. The incident was determined to have placed the resident in an immediate jeopardy situation due to the risk associated with improper use of the mechanical lift.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple incidents involving inadequate care and delayed responses. Resident #139's healthcare surrogate reported that the resident had a bowel movement and pressed the call light for assistance, but no staff responded for over an hour, resulting in the resident being left in soiled linens. Similarly, Resident #23 was observed in a precarious position in the dining room for an extended period without assistance, as staff were unsure of the assigned aides. Resident #6, the resident council president, was delayed in attending a meeting due to insufficient staff to assist her out of bed, highlighting the ongoing staffing issues. Staff interviews further corroborated the deficiency, with multiple nurse aides reporting chronic understaffing, particularly on weekends, leading to incomplete tasks and residents being left unbathed or soiled. The aides expressed feelings of being overworked and burned out, with some leaving or reducing their hours due to the workload. Despite reporting these concerns to management, staff indicated that no effective solutions had been implemented, exacerbating the situation and impacting resident care.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to adhere to professional standards in the storage, preparation, distribution, and serving of food, as observed during a survey. In the kitchen, several issues were identified, including undated pitchers of juices stored in the prep cooler, produce and other items placed directly on the floor in the freezer and dry stockroom, and a milk cooler with standing milk and dried rings. Additionally, bowls were stored upright and uncovered, and expired sugar cookies were found in the walk-in freezer. Opened cereal bags were not properly marked with expiration dates, and the kitchen dish-room floors and walls were visibly soiled with rust and remnants of food. The facility's dishwashing practices were also found to be deficient. The low-temperature dishwasher was observed to have wash temperatures below the manufacturer's recommended minimum of 140 degrees Fahrenheit, with rinse temperatures also falling short of the required 120 degrees Fahrenheit. This issue was consistent over several months, as evidenced by the review of dish machine logs from August through October, which showed numerous instances of wash and rinse temperatures not meeting the guidelines. The maintenance director acknowledged the low rinse temperatures and attributed the issue to the depletion of hot water due to constant use in the kitchen. Additional observations included a visibly soiled floor in the entranceway to the kitchen and a steam table with remnants of food and debris. In Building 2, a bottle of ranch dressing was found without a label or date of opening. These deficiencies in food storage, cleanliness, and equipment maintenance had the potential to affect more than a limited number of residents in the facility, which had a census of 181 at the time of the survey.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents by not adhering to proper protocols during interactions. In one instance, a Licensed Practical Nurse (LPN) entered the room of a resident without knocking or announcing themselves, which is a breach of the resident's right to privacy and respect. The LPN admitted to normally knocking but failed to do so on this occasion, indicating a lapse in maintaining the standard of care expected in such interactions. Additionally, the facility did not ensure timely meal service for two residents, leading to a delay in their lunch being served compared to their roommates. The LPN assisting with the meal service acknowledged that the trays for these residents were not sent from the kitchen and confirmed that their roommates received their meals approximately ten minutes earlier. This delay in meal service further exemplifies the facility's failure to treat residents with the dignity and respect they deserve, as it resulted in an unnecessary wait for their meals.
Deficiencies in Informed Consent and Care Planning
Penalty
Summary
The facility failed to provide adequate education and informed consent regarding the use of psychotropic medications and the risks associated with refusal of care for three residents. Resident #93 was administered multiple high-risk medications for conditions such as anxiety, depression, and hypertension, but there was no documentation that the resident or their representative was informed about the risks, benefits, or alternative treatment options. The facility's policy required resident involvement in care planning, but this was not adhered to, as acknowledged by the facility administrator. Resident #163, who had multiple health issues including a stage 4 pressure ulcer, frequently refused care such as tube feedings and wound care appointments. Despite the facility's policy to involve residents in care planning and document refusals, there was no comprehensive care plan addressing the resident's refusals, nor was there documentation of education provided to the resident or their representative about the risks of refusing care. The Director of Nursing and Unit Manager confirmed that the lack of documentation and care planning could place the resident at risk for worsening health conditions. Resident #174 was prescribed psychotropic medications, but the informed consent form was incomplete, lacking details about the specific conditions, expected benefits, and potential side effects of the medications. The facility administrator acknowledged the oversight, indicating a failure to ensure that the resident's representative was fully informed. This lack of thorough documentation and communication highlights deficiencies in the facility's processes for managing psychotropic medication use and ensuring informed consent.
Failure to Provide Menu Options and Activity Access
Penalty
Summary
The facility failed to ensure that residents were aware of and had access to menu options, impacting their right to make choices about significant aspects of their life. Residents reported not knowing they had meal choices, with some stating they would not eat if they disliked the food. The Dietary Manager and Activity Director confirmed that the 'always available' menu was not included in the daily event sheet distributed to residents, and it was observed that the menu was posted at an inaccessible height for residents in wheelchairs. Additionally, the facility did not provide adequate staffing to assist residents in attending activities of their choice. A resident, who is the Resident Council President, expressed difficulty in attending a scheduled meeting due to insufficient staff to assist with her transfer from bed. Despite expressing a desire to attend the meeting, she was delayed by over 35 minutes because only one aide was available, and she required a full lift. The deficiency affected multiple residents, with some relying on family members to provide meals due to dissatisfaction with the facility's food options. The lack of communication and accessibility regarding meal choices, combined with staffing shortages, hindered residents' ability to exercise their rights to self-determination and participate in activities, as evidenced by interviews and observations during the survey process.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment, as evidenced by observations made during a survey. In the dining room of Building 1, several ceiling tiles were noted to have large circular stains, and the air handler and return vents were covered with a brownish-black dusty substance. These conditions were confirmed by the Administrator during an interview, who acknowledged the visible stains and soiling of the air handlers and vents. Additionally, in the room of a resident, the Packaged Terminal Air Conditioner (PTAC) unit was found to be unclean, with filters full of dust and debris and slats covered in a black substance. The Maintenance Director confirmed that the PTAC unit had not been cleaned according to the facility's schedule, indicating a lapse in adherence to professional standards for maintaining a clean environment.
Failure to Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASARR) for three residents included their diagnoses of schizoaffective disorder or bipolar disorder prior to their admission. Resident #134 was readmitted with a diagnosis of schizoaffective disorder, bipolar type, which was not included in the PASARR dated 12/13/23. This omission was confirmed by Administrator #13. Similarly, Resident #99's PASARR dated 06/01/24 incorrectly indicated no current diagnosis, despite the resident having a diagnosis of Affective Bipolar Disorder as of 03/27/24. Administrators #186 and #13 acknowledged this oversight during an interview. Resident #28 was admitted with a diagnosis of schizoaffective disorder, bipolar type, dated 04/25/23, but the PASARR dated 10/01/23 did not list this diagnosis. Additionally, a completed PASARR prior to admission was not provided. Administrator #186 agreed that the PASARR should have been completed before admission and should have included the diagnosis. These findings indicate a failure to accurately document and review residents' mental health diagnoses in the PASARR process, which is crucial for ensuring appropriate care and services.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific medical and care needs. For instance, a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) did not have a care plan addressing this condition, despite it being present upon admission. The Licensed Social Worker acknowledged the absence of a care plan and intended to initiate one after consulting with the resident's family. Another resident experienced multiple falls, resulting in hospitalization and a fracture, yet the care plan did not adequately address the risk factors or update interventions post-fall. The Director of Nursing and Administrator recognized that the care plan lacked necessary updates and interventions to prevent further falls. Another resident was observed with fall prevention measures in place, such as bilateral mats, but the care plan did not reflect the resident's risk factors, including the use of high-risk medications and external devices. The Director of Nursing admitted that the fall risk assessments were inaccurate and that the care plan did not incorporate identified risk factors. Additionally, a resident was left unattended in a dining room for several hours, leading to a positioning concern that was not addressed in the care plan. The Director of Nursing was unaware of the issue until it was brought to their attention during the survey. Further deficiencies were noted in the care plans of residents requiring respiratory care and those with hearing impairments. A resident with a tracheostomy had an incomplete care plan regarding oxygen delivery, leading to an incident where the oxygen tubing was not properly attached. Another resident reported excessive earwax buildup affecting their hearing aid use, but the care plan did not address hearing impairment or ear care. The facility administrators acknowledged inconsistencies in the resident's records and the lack of appropriate interventions in the care plans. Additionally, a hospice resident's care plan did not document the involvement of hospice staff in care conferences, despite the resident receiving hospice services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for several residents, leading to deficiencies in care. Resident #93, who has severe cognitive impairment, expressed that they were not offered activities or materials of interest, despite their care plan indicating such interventions. The Activity Director confirmed that materials were only provided upon request and acknowledged the care plan should have been updated to reflect the resident's refusal to participate in activities. Resident #163, who has multiple co-morbid conditions and is at high risk for skin breakdown, was found lying on a deflated air mattress, exposed and without privacy. The resident's care plan did not address their refusal of care or the increased risk factors for skin breakdown. The Director of Nursing acknowledged that the care plan was not updated when the resident's Braden score indicated a higher risk for skin breakdown, and no new interventions were implemented. Resident #120's care plan was not updated to reflect their frequent refusal of medications, which occurred on multiple occasions over two months. Additionally, Resident #139's care plan was not revised to address aggressive behaviors until several months after they were first documented. The facility's failure to update care plans in a timely manner for these residents resulted in deficiencies in addressing their individual needs and conditions.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to dependent residents, as evidenced by observations and interviews with four residents. Resident #3 reported not receiving a bath for days, resulting in extremely long fingernails with a brown substance underneath and long, jagged toenails. Despite the facility's policy requiring routine nail hygiene during baths or showers, the resident's nails remained untrimmed over multiple days. Similarly, Resident #153's hair appeared greasy, and the resident reported infrequent bathing, with records indicating only two documented baths since August, despite a care plan specifying regular shower days. Resident #93 also had long fingernails with a brown substance underneath, and despite repeated requests for nail care, the resident's nails remained unaddressed. A nurse assistant admitted uncertainty about the frequency of nail care and how to ensure the resident received it. Resident #41's family member highlighted the resident's long, dirty fingernails, which were not cleaned despite multiple requests. The Clinical Manager acknowledged the need for improvement in nail care but was unsure of the facility's nail-cutting schedule. These observations and interviews indicate a systemic failure to provide necessary ADL care, particularly in maintaining residents' nail hygiene.
Deficiencies in Resident Care and Monitoring
Penalty
Summary
The facility failed to provide care consistent with professional standards for three residents, leading to deficiencies in their treatment and care. Resident #139, who was receiving hospice services, had an order for Lorazepam to manage terminal agitation. However, the hospice nurse did not assess the resident in person before recommending the medication change, relying instead on the facility's nursing staff's judgment. The resident was involved in altercations with other residents, and non-pharmacological interventions were not attempted before administering the medication. Additionally, there were multiple instances where Resident #139 did not receive medications as ordered, including Lasix, Ativan, Norco, and others, on specific dates. Resident #93 experienced two falls, resulting in hospitalization and a diagnosis of a wedge compression fracture. The facility had identified risk factors for falls upon admission, but the care plan did not address these adequately. The care plan lacked updates to reflect changes in the resident's functional abilities and did not include interventions for high-risk medications, previous falls, or cognitive impairments. The facility was aware of the resident's history of falls and fractures but failed to implement effective interventions to prevent further incidents. Resident #23 was found leaning dangerously in a chair for an extended period without being checked on by CNAs. The resident, who has advanced dementia and requires total assistance, was left unattended in the dining room for several hours. The care plan for Resident #23 did not adequately address the resident's positioning needs or communication problems. The facility's failure to monitor and reposition the resident appropriately was acknowledged by the DON, who was unaware of the positioning concern until it was observed by surveyors.
Inadequate Supervision and Care Planning Leads to Multiple Falls and Injuries
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for several residents, leading to multiple falls and injuries. Resident #93 experienced two falls resulting in hospitalization with a wedge compression fracture. Despite being assessed as needing maximum assistance with transfers, the care plan did not reflect this need, and interventions were not updated post-fall. The care plan also failed to address risk factors such as high-risk medications and cognitive impairments, and the root causes of falls were not thoroughly investigated. Resident #163 was observed with inadequate privacy and supervision, lying exposed in bed with the call light on and unattended by staff. The care plan did not accurately reflect the resident's risk factors, including the use of external devices like a feeding tube and Foley catheter. Post-fall evaluations were incomplete, and the facility failed to update the care plan with new interventions after falls occurred. Additionally, the documentation of neurological checks was inconsistent, raising concerns about the accuracy of fall risk assessments. Resident #240 was involved in an incident where a nurse aide attempted to roll the resident alone, contrary to the care plan's requirement for two-person assistance. This led to the resident slipping out of bed and sustaining a traumatic subdural hemorrhage. The facility's investigation was inconclusive, and staff education on proper assistance was questioned. Other residents, such as Resident #88 and Resident #141, also faced issues with inadequate supervision and care planning, including a lack of smoking assessments and failure to ensure call bells and non-skid footwear were within reach.
Inaccurate Daily Staff Postings
Penalty
Summary
The facility failed to maintain accurate daily staff postings, which has the potential to affect more than a limited number of residents. During a review conducted at approximately 12:00 PM on 10/16/2024, discrepancies were found between the facility's daily staff postings and the actual number of Nurse Aides (NAs) working on specific days. On 04/20/24, the staff posting indicated 31 NAs were scheduled, but only 25 were actually working. On 04/28/24, 29 NAs were scheduled, but only 21 were present. Similarly, on 05/11/24, 33 NAs were scheduled, but only 25 were working. The staff posting sheets had not been updated to reflect the accurate number of staff in the facility. These irregularities were confirmed by the Administrator at approximately 3:30 PM on 10/16/24.
Failure to Document Behavior Monitoring for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that physician orders for behavior monitoring were completed as ordered for three residents. Resident #28 had orders for Trazadone, Geodone, and Buspirone, with specific behavior monitoring instructions for refusal of care, crying episodes, and anxiety. However, behavior monitoring was not documented on several occasions between August and September. Similarly, Resident #75 had orders for Sertraline, Trazadone, Depakote, and Risperdal, with two sets of behavior monitoring instructions for irritability, withdrawal, and other behaviors. Documentation was missing for specific shifts in September. Resident #174, with orders for Sertraline, Trazadone, and Olanzapine, also had missing behavior monitoring documentation for tearfulness and refusal of care on several shifts in September and October. During interviews, the facility's administrator acknowledged the lack of documentation and agreed that the behaviors were not monitored as ordered. This deficiency was identified during a long-term care survey process, highlighting the facility's failure to adhere to physician orders for behavior monitoring, which is crucial for residents receiving psychotropic medications. The facility census at the time was 181, and the deficiency affected three out of five residents reviewed for unnecessary medications and psychotropic medication regimen reviews.
Failure to Provide Routine Dental Care for Residents
Penalty
Summary
The facility failed to provide routine dental care for Medicaid-funded residents, specifically affecting two residents. Resident #5 reported that she was unable to access her toothbrush and expressed discomfort due to a loose tooth. Observations revealed significant dental buildup and missing or broken teeth. A review of her records showed no dental consults since her admission in November 2022, despite an assessment indicating obvious cavities or broken teeth. The facility's policy mandates assistance in obtaining routine dental services, which was not adhered to in this case. Similarly, Resident #71 exhibited signs of dental decay, with red-tinged spots observed on her pillowcase near her mouth. She confirmed experiencing mouth pain, yet no dental consults had been arranged for her. Interviews with the Director of Nursing confirmed the lack of dental services for both residents, highlighting a failure to comply with the facility's policy on providing necessary dental care.
Resident Dignity Not Maintained
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #163, during a survey observation. The resident was found lying on a deflated air mattress with the call light on, indicating a need for assistance. The air mattress cord was unplugged and lying on the floor. The resident was only wearing a brief, without any other clothing, and was exposed to staff, other residents, and visitors passing by the hallway. No blanket or curtain was used to provide privacy. Multiple staff members walked past the resident's room without stopping to offer assistance or to cover the resident. A wound nurse, identified as WN #21, was standing near the room and acknowledged the situation when approached by the surveyor. The nurse then entered the room to cover the resident after obtaining consent. The facility's policy on resident rights emphasizes treating all residents with dignity and respect, which was not adhered to in this instance. A review of the resident's Brief Interview for Mental Status (BIMS) indicated a moderate impairment with a score of 9.0, and the resident was noted to lack capacity due to disorientation from a cerebral vascular accident (CVA). This lack of capacity may have contributed to the resident's inability to address the situation independently, highlighting the importance of staff intervention to maintain the resident's dignity.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse due to resident-to-resident interactions involving a specific resident. Resident #139 was involved in multiple altercations with other residents, including Resident #110 and Resident #119, over a period from May 7, 2024, to May 21, 2024. In one incident, Resident #110 reported being struck by Resident #139, but the facility did not obtain a written statement or conduct an interview with Resident #110. The facility was not aware of this incident until three days later, on May 10, 2024, and no interventions were implemented to prevent further incidents. In another incident, Resident #139 grabbed and squeezed Resident #119's arm in the dining room, an action witnessed by three other residents. Although Resident #139 was placed on one-on-one supervision immediately after the incident, the facility failed to document this supervision on May 22, 2024, as required. The facility's administrator acknowledged the missing documentation, indicating a lapse in ensuring the safety and supervision of residents involved in altercations.
Failure to Ensure Resident is Free from Chemical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints, as evidenced by the administration of Lorazepam (Ativan) without proper assessment and documentation of non-pharmacological interventions. The resident, who was receiving hospice services, had an as-needed order for Lorazepam oral concentrate for terminal agitation and restlessness. However, the medication was administered following altercations with other residents, without documented attempts of non-pharmacological interventions or proper behavior monitoring. The hospice nurse did not assess the resident in person before recommending the medication change, relying instead on the facility staff's reports. The hospice nurse admitted to not visiting the resident until the day after the medication was administered. Furthermore, the facility's nursing staff reported that hospice education on identifying terminal agitation was not provided, and hospice orders were often given over the phone without in-person assessments. The facility's documentation revealed multiple instances where the resident received Lorazepam without documented non-pharmacological interventions. The facility administrator confirmed the lack of behavior monitoring and non-pharmacological interventions before administering the medication. Additionally, hospice documentation was missing from the resident's records, further indicating a lack of proper assessment and documentation procedures.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse and neglect, specifically an unwitnessed fall with injury and an allegation of staff-to-resident verbal abuse. During a review of a resident's medical record, a progress note detailed an incident where a nurse, while performing a weekly skin assessment, was verbally abused by the resident who felt pain during peri-care. The resident cursed at the nurse and attempted to hit the nurse with a bed control. Despite this incident, the facility did not report it to the State Agency. During an interview, the facility's administrator confirmed the incident was not reported, stating they did not interpret the situation as abuse but rather as a response to the care provided.
Failure to Investigate and Address Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate and address allegations of abuse involving three residents. Resident #139 was involved in altercations with four different residents, including Resident #110 and Resident #119, over a period from May 7 to May 21, 2024. On May 7, Resident #110 reported being struck by Resident #139, but the facility did not obtain a written statement or conduct an interview with Resident #110. The facility was not made aware of the incident until May 10, 2024, and no interventions were implemented to prevent further incidents. On May 21, 2024, Resident #139 was involved in another altercation with Resident #119, where Resident #139 grabbed and squeezed Resident #119's arm in the dining room, witnessed by three other residents. Although Resident #139 was placed on one-on-one supervision immediately, the facility's Medication Administration Record for May 2024 lacked documentation confirming the supervision was maintained on May 22, 2024. Despite these incidents being witnessed, the facility marked the allegations as unsubstantiated, citing Resident #139's lack of capacity. The Social Worker acknowledged not obtaining statements from the victims, contributing to the deficiency.
Inaccurate MDS Documentation of Hearing Impairment
Penalty
Summary
The facility failed to accurately document a resident's hearing impairment and use of hearing aids on the Minimum Data Set (MDS). The resident, identified as #148, reported having excessive earwax buildup that prevented the use of hearing aids and required monthly removal. Despite the resident's attempts to manage the condition, including ordering a flushing device that was subsequently taken away by staff, the facility did not schedule an audiologist appointment since the resident's admission. The resident resorted to using scissors to remove earwax, a fact unknown to the staff until the survey. The resident's care plan did not reflect the hearing impairment or the need for earwax care, and there were inconsistencies between the Admission and Quarterly MDS regarding the use of hearing aids. Interviews with the resident and staff revealed a lack of awareness and action regarding the resident's hearing needs. The administrative staff acknowledged the discrepancies in the MDS and the absence of a care plan addressing the resident's hearing issues, as well as the removal of the flushing device without a clear reason or alternative solution provided.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for a resident, leading to a discrepancy between the MDS and the resident's care plan. During a record review, it was found that Section L of the MDS for a resident, with an Assessment Reference Date of August 4, 2024, incorrectly indicated 'No' to oral or dental problems with own natural teeth. However, the care plan for the same resident documented that they had oral and dental problems, specifically decayed and blackened teeth. This inconsistency was confirmed during an interview with the Administrator and a corporate witness.
Failure to Update PASARR with New Diagnoses
Penalty
Summary
The facility failed to update the Pre Admission Screening and Resident Review (PASARR) for a resident with new diagnoses of Dementia with other unspecified behaviors and schizoaffective disorder. This deficiency was identified during a medical record review and staff interview. The resident was admitted to the facility with these diagnoses, which were documented on 10/31/22. However, the PASARR provided by the facility, dated 02/08/11, did not reflect these updated diagnoses. During an interview, the facility's administrator confirmed that the PASARR should have been updated and re-submitted for review to include these new diagnoses.
Failure to Provide Adequate Activity Program for Residents
Penalty
Summary
The facility failed to provide a program to meet the needs and interests of its residents, as evidenced by the experiences of two residents during the Long-Term Care Survey Process. Resident #147 expressed disinterest in the available activities, stating that they were not offered any materials or opportunities that matched their interests, such as coloring books, playing cards, or outdoor activities. Despite having a care plan that included various activities of interest, the resident's participation records showed only one group activity attended and daily individual relaxation activities, with no documented one-on-one visits. Similarly, Resident #93 reported a lack of engagement in activities due to mobility issues and stated that no one offered them any activities or materials. Observations confirmed the absence of any activity materials in their room. The resident's care plan included various interests and preferences, but the Activity Director admitted to not documenting any offers of activities or materials. The resident's participation records indicated self-directed activities for 59 out of 60 days, with only one documented one-on-one activity, highlighting a failure to implement the care plan effectively.
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What surveyors actually found near you
We read the 97 citations issued within 25 miles in the last 12 months — 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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Nursing homes near Beckley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Lodge | 3.1 mi | ★★★★★ | 17 | 0 |
| Majestic Care Of Beckley | 3.3 mi | ★★★★★ | 7 | 0 |
| Raleigh Center | 7.4 mi | ★★★★★ | 13 | 0 |
| Hilltop Center | 10 mi | ★★★★★ | 15 | 0 |
| Hidden Valley Center | 14.1 mi | ★★★★★ | 9 | 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.