Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cabell Healthcare Center during CMS and state inspections, most recent first.
Incomplete care plans and unimplemented fall intervention: A resident with PTSD did not have that diagnosis or related interventions included in the care plan, and another resident receiving furosemide did not have diuretic therapy addressed in the care plan. A third resident had a fall intervention requiring a reaching device, but the device was not in the room or with the resident and was later found at the bottom of the closet; an RN stated it did not appear the resident was using it and was unsure the resident could use it.
A facility failed to follow physician orders for three residents. One resident’s evening blood glucose checks were not documented on multiple occasions, another resident was signed for insulin administration even though the recorded blood sugar was below the ordered threshold, and a third resident’s ordered right-hand splint was not in place during several observations even though the TAR showed it as applied.
Incomplete and inaccurate resident records were documented for multiple residents. One resident had BP readings charted in the left arm despite an order not to use that arm because of an AV fistula, two residents had flawed capacity forms with missing or conflicting entries, and another resident’s TAR was still being signed for a knee brace the resident was no longer wearing and said had been discontinued. The DON and Administrator acknowledged the documentation issues.
A facility failed to ensure two residents with indwelling urinary catheters had privacy covers on their urine collection bags to maintain dignity. One resident had a Foley catheter for urinary retention and another had a suprapubic catheter for neurogenic bladder; in both cases, the bags were observed hanging in view without covers and urine was visible, and an IP later confirmed the missing privacy bags.
A resident was transferred to the hospital for abdominal pain, but no transfer form was found in the record. The facility's policy required a transfer form with key clinical and contact information, and the DON confirmed that no form was sent to the receiving hospital and no documentation showed the required information was conveyed.
Inaccurate MDS Catheter Assessment: A resident with a suprapubic catheter for neurogenic bladder was observed with a catheter urine collection bag, but the quarterly MDS incorrectly indicated no indwelling urinary catheter. The MDS RN later confirmed the assessment should have reflected the catheter.
A resident with hemiplegia and hemiparesis had an active order to wear a L hand splint as tolerated, but the order was missing from the MAR/TAR and the brace was not being consistently tracked. The resident reported the splint had gone to laundry and was not available for a period of time, and during observation the brace was found in a bathroom basket rather than on the resident, with the resident stating no one had offered to put it on that day.
An unlocked treatment cart was observed unattended in the 200 hallway, and an RN confirmed it should be locked when staff are not present. The cart contained wound care cleansers and creams that the RN said could be hazardous to residents. The ADON stated the facility had no written policy for locking the treatment cart.
A resident with a suprapubic catheter had the urine collection bag lying on the floor of the room during repeated observations. The facility's catheter care policy instructed staff to ensure the collection bag was not on the floor, and an IP later confirmed the bag was still on the floor.
Medication administration errors exceeded the allowed rate, with 2 errors in 29 opportunities. An LPN crushed enteric coated aspirin into applesauce for one resident, even though it was on a list of medications not to be crushed, and an RN gave pantoprazole to another resident while breakfast was present, despite the order indicating it should be given before breakfast.
Infection control practices were not maintained when a resident on EBP did not have the required door signage posted despite orders for EBP related to a foley catheter, PICC line, and wound care needs. In a separate event, an RN handling meds touched a tablet with bare hands after it fell on the med cart, contrary to the facility’s med administration policy.
A resident who was dependent on staff for ADL care was not provided with scheduled showers or bed baths for seven consecutive days, despite being listed on the facility's shower schedule. The DON acknowledged that nurse aides did not follow the posted schedule, and a regional RN confirmed the lapse in care.
A resident’s PASARR did not include all psychiatric diagnoses. Record review showed Generalized Anxiety Disorder and hallucinations were omitted, even though the resident was being treated with Klonopin for anxiety and Seroquel for bipolar disorder. The SSD confirmed the diagnoses were not all listed on the PAS.
A resident discharged from the hospital with urology diagnoses had no documented urology follow-up arranged, and was later found with a Foley catheter in place and bloody urine after pulling the catheter out with the balloon intact. Another resident had a documented blood glucose of 29 with no progress note, no MD notification, no recheck, and no documentation of treatment to raise the glucose level, despite being at risk for hypoglycemia.
A resident with decreased vision and a history of eye trauma was seen by an eye doctor and prescribed new glasses, but the facility did not follow through to obtain them. The resident was observed wearing eyeglasses in poor repair, the BOM confirmed no remedial adjustment had been made for the glasses, and the DON was unaware of the adjustment process. The resident's son later said he had not been contacted and wanted his mother to have new glasses.
A resident’s personal refrigerator was found with no documented temp check since the prior day and with two expired yogurt packages inside. RN and the DON confirmed the refrigerator contents were not in compliance with the facility’s food storage policy, which required daily monitoring and removal of expired items.
Inaccurate resident weight documentation was identified for a resident after record review showed large fluctuations in recorded weights over a short period. The RN reviewed the chart and stated there did not appear to be another issue with the weights, but that the entries looked like a documentation error. Facility policy required reweighing a resident when a weight varied by 5 lbs or more.
Incomplete Care Plans and Unimplemented Fall Intervention
Penalty
Summary
The facility failed to develop complete care plans for three residents reviewed for care plan accuracy. Resident #2 had an active diagnosis of Post-Traumatic Stress Disorder (PTSD), but the care plan did not include PTSD or any related interventions. During interview, the Director of Social Services confirmed that PTSD was not addressed in the care plan and stated that it should have been care planned. Resident #7 had a physician order for furosemide 40 mg twice daily for hypertension, but the comprehensive care plan did not include a focus or interventions related to diuretic use. The existing care plan focus, initiated earlier, addressed risk for dehydration and included interventions such as encouraging fluids, notifying the medical provider for signs and symptoms of dehydration, and obtaining labs per medical provider order, but it was not revised to reflect the diuretic therapy. Resident #67 had a fall intervention care plan that included a reaching device, but observation showed the device was not in the resident's room or in the resident's possession; it was later found at the bottom of the closet. The RN stated it did not appear the resident was using it and was unsure whether the resident was capable of using it.
Failure to Follow Physician Orders for Blood Glucose Monitoring, Insulin Administration, and Splint Use
Penalty
Summary
The facility failed to follow physician orders for three residents. One resident had an order for Accucheck fingerstick blood glucose monitoring with notification parameters for results less than 60 or greater than 400, but the evening glucose results were not documented on multiple dates in July 2026. The MAR for the evening monitoring did not include a line for recording the blood glucose level, and the Assistant Director of Nursing confirmed that the evening glucose levels had not been documented on those dates. Another resident had an order for Novolog insulin 5 units before meals and at bedtime only if the blood sugar was greater than 150, but the MAR showed insulin was signed as given on several occasions when the recorded blood glucose levels were below 150. The Director of Nursing confirmed the insulin was signed as given despite the lower blood sugar values and stated she could not prove the insulin was not administered. A third resident had an order for a right hand carrot splint to be worn as tolerated every day and night shift for contracture of the right hand, but the splint was not in place during multiple observations even though the TAR showed it had been signed off as being in place twice daily. The ADON confirmed the splint was not in place and later placed it in the resident’s hand after locating it in the room.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents. For one resident with an AV fistula in the left arm and an order not to obtain blood pressures, lab draws, or IV access in that arm, the Weights and Vitals Summary documented blood pressures being obtained in the left arm on several dates. The resident stated staff did not attempt to obtain blood pressures in the left arm, and the Administrator acknowledged the documentation for the left arm. The facility also had incomplete or conflicting capacity documentation for two residents and an inaccurate TAR for another resident. One resident’s Physician’s Determination of Capacity form was incomplete because neither the capacity nor incapacity box was checked, and the Administrator acknowledged the incomplete document. Another resident’s capacity form contained conflicting entries, with the physician checking that the resident demonstrated capacity to make decisions while also certifying that the patient had been informed of being determined incapacitated and that a medical power of attorney representative or surrogate decisionmaker may make decisions. In addition, a resident’s TAR continued to be signed for a left hinged knee brace even though the resident was no longer wearing it, stated the orthopedic doctor had discontinued it, and the DON confirmed the resident was not wearing the brace and that the TAR had been signed for a device no longer in use.
Urinary catheter bags left uncovered
Penalty
Summary
The facility failed to ensure residents with indwelling urinary catheters had their urine collection bags concealed with a privacy cover to maintain dignity. This deficiency involved two residents reviewed for catheter care, Resident #93 and Resident #82, both of whom had physician orders to provide a privacy bag for their catheter drainage systems. Resident #93 had an indwelling Foley catheter ordered to continuous drain for urinary retention, and Resident #82 had a suprapubic catheter ordered to continuous drain for neurogenic bladder. During observation, Resident #93’s catheter collection bag was hanging on the side of the bed facing the door, with no privacy cover and urine visible in the bag. The same condition was observed again on a later observation, and the Infection Preventionist confirmed the bag still did not have a privacy cover. Resident #82’s suprapubic catheter urine collection bag was also observed without a privacy cover, with urine visible in the bag, and this condition was again confirmed later by the Infection Preventionist. No further information was provided through the completion of the survey process.
Missing Transfer Documentation
Penalty
Summary
The facility failed to document that required transfer information was conveyed to the receiving hospital when Resident #46 was transferred for abdominal pain. The facility policy titled, Transfer and Discharge Policy, stated that a transfer form would be sent with the resident or as soon as practicable in an emergency transfer and would include patient status, current diagnoses, allergies, reason for transfer, practitioner contact information, representative contact information, current medications, treatments, relevant lab and radiological findings, recent immunizations, special instructions, special risks, and comprehensive care plan goals. Review of Resident #46's electronic health record showed the resident was transferred to the hospital on [DATE] due to abdominal pain, but no transfer form was found in the record. The DON confirmed on 07/20/26 at 11:48 AM that a transfer form had not been sent to the receiving hospital when the resident was transferred on 04/03/26, and there was no documentation showing the required information had been conveyed.
Inaccurate MDS Catheter Assessment
Penalty
Summary
The facility failed to ensure a complete and accurate MDS assessment for catheter status for Resident #82. The resident had a physician’s order dated 03/10/25 for a suprapubic catheter, #18 Fr with a 6 mL balloon to continuous drain, with the diagnosis of neurogenic bladder and instructions to provide a privacy bag. During observation on 07/13/26, Resident #82 was seen with a suprapubic catheter urine collection bag. However, the quarterly MDS assessment with ARD 06/02/26 indicated that the resident did not have an indwelling urinary catheter. On 07/14/26, the MDS RN confirmed that the assessment was incorrect and should have indicated that the resident had an indwelling urinary catheter.
Failure to Track and Provide Ordered Hand Splint Use
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility was not ensured for a resident with limited ROM. Resident #64 had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and had an active physician order for a left hand splint to be worn as tolerated. During interview, the resident stated the brace had gone to laundry and had not been seen for a while, and that the resident liked to wear it at night when sleeping when available. Record review showed the splint order was not included on the MAR or TAR from February 2026 to the present. When observed, the resident was not wearing the hand brace; it was lying in a basket in the bathroom. The resident stated the brace had been in the bathroom overnight and that no one had offered to put it on that day. An RN later stated the resident said she wore the brace the prior night and had just put it back on, and that the order had now been updated to appear on the TAR for accountability.
Unlocked Treatment Cart Left Unattended
Penalty
Summary
The facility failed to ensure the area was as free from accident hazards as possible when a treatment cart in the 200 hallway was found unlocked and unattended. On 07/14/2026 at 9:39 AM, the cart was observed unlocked with no staff in attendance in the hallway. When the surveyor alerted RN #17 two minutes later, she confirmed the cart was unlocked and stated it should be locked when staff were not present. The cart was inspected and a drawer contained cleansers and creams used in wound care, and RN #17 confirmed these items could be hazardous to residents. On 07/15/26, the ADON stated the facility had no written policy regarding locking the treatment cart.
Catheter Collection Bag Left on Floor
Penalty
Summary
Failure to provide catheter treatment and care within accepted standards of practice was identified for Resident #82, who had a suprapubic catheter. The facility policy titled, "Catheter Care," instructed staff to check that the collection bag was not on the floor. During observation on 07/13/26 at 3:08 PM, Resident #82's urinary collection bag was noted lying on the floor of the resident's room. The same condition was observed again on 07/14/26 at 9:54 AM, when the urine collection bag continued to be lying on the floor. On 07/14/2026 at 1:25 PM, the Infection Preventionist confirmed that the urine collection bag was lying on the floor and stated she would move it off the floor.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with 2 errors observed in 29 medication administration opportunities for an error rate of 6.9 percent. The deficient practice involved two of three residents reviewed for medication administration, Resident #14 and Resident #60, during observation, record review, and staff interview. For Resident #14, an LPN was observed preparing morning medications and crushed the resident’s medications into applesauce, including enteric coated aspirin 325 mg. The LPN stated she thought a list of medications that should not be crushed was on the medication cart but could not locate it. The DON later provided an ASCP list of medications not to be crushed, which included enteric coated aspirin. For Resident #60, an RN administered pantoprazole while the resident had her breakfast tray present, even though the order stated the medication was to be given in the morning before breakfast. The DON confirmed the order was for before breakfast and stated she would ask the physician if it needed to be given before breakfast.
Infection Control Lapses During EBP Signage and Medication Administration
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. For Resident #93, the facility had a policy for Enhanced Barrier Precautions (EBP) stating that signs would be posted on the resident door to communicate EBP status to staff and visitors. The resident had physician orders for EBP related to an indwelling foley catheter and, later, a PICC line to the right upper extremity and a right below-the-knee amputation wound, with EBP required during dressing, bathing, showering, transferring, personal hygiene, linen changes, brief changes, and toileting assistance. On 07/13/26 and again on 07/14/26, the resident’s room did not have signage indicating EBP, and the Infection Preventionist confirmed the sign had not been posted after the order was revised. The facility also failed to maintain infection control practices during medication administration for Resident #60. The medication administration policy stated not to touch the medication when opening a liquid or dose pack. During observation, an RN poured medications from a packet into a medication cup, and when one tablet fell onto the top of the medication cart, the RN picked it up with bare hands and placed it into the cup. The RN stated, "I shouldn't have touched that. Sorry." The DON later confirmed the nurse should not have touched the tablet with bare hands.
Failure to Provide Scheduled ADL Assistance
Penalty
Summary
A dependent resident was not assisted with activities of daily living (ADLs) as required. The resident was observed lying in bed and appeared unkempt. Review of the facility's shower schedule indicated the resident was to receive showers on Tuesdays and Fridays during the day shift. Documentation and staff interviews confirmed that the resident did not receive a shower or bed bath for a period of seven days. The Director of Nursing stated that the shower schedule was not followed by nurse aides, and this was corroborated by a regional RN who verified the lack of ADL care during the specified period.
PASARR Missing Psychiatric Diagnoses
Penalty
Summary
The facility failed to provide a Pre-admission Screening and Resident Review (PASARR) that included all psychiatric diagnoses for Resident #10. Record review showed the PASARR dated 02/22/24 did not list Generalized Anxiety Disorder, documented as of 02/08/17, or Hallucinations, documented as of 01/02/25. The resident was being treated with Klonopin for anxiety and Seroquel for bipolar disorder, which includes hallucinations. During interview on 08/07/25 at 10:41 AM, the Social Services Director confirmed that all diagnoses were not listed on the PAS.
Failure to Provide Follow-Up Care After Hospitalization and Critical Blood Glucose
Penalty
Summary
The facility failed to provide needed care and services for Resident #4 after the resident was discharged from an acute care facility on 07/01/25 with diagnoses of prostatitis, urinary tract infection with hematuria, hydronephrosis, and hydroureter. On 08/05/25, the Director of Nursing stated the facility could not find the resident’s urology follow-up appointment, and the resident was observed with a urinary Foley catheter in place and dark tea-colored bloody urine in the drainage bag. Nursing staff stated the resident had pulled the Foley catheter out with the balloon intact the night before, and the DON stated the office was closed and they had tried to call three times without an answer. No follow-up appointment had been scheduled until after surveyor intervention, and the DON later stated the appointment was scheduled for 08/08/25. The facility also failed to provide follow-up care for Resident #70 after a critically low blood glucose reading. Record review showed a blood glucose of 29 documented on 07/28/25 at 9:55 PM, with no progress notes, no documentation that the physician was contacted, no glucose recheck, and no documentation that anything was given to raise the blood glucose level. The care plan identified the resident as at risk for hypoglycemia. The DON stated she recalled the incident and spoke with the nurse, who said she may have forgotten to add a zero and meant 290 instead of 29, but there was no documentation to confirm that explanation or any corrected blood glucose documentation.
Failure to Ensure Access to Vision Services and Replacement Eyeglasses
Penalty
Summary
The facility failed to ensure a resident received access to vision services and assistance to obtain usable eyeglasses. Resident #21 was observed wearing eyeglasses in poor repair, with the right lens scratched or broken near the center. The resident had been seen by an eye doctor in house for decreased vision in both near and far vision, with the right eye worse than the left, and the consultation included a prescription for new glasses. The consult also noted a history of trauma with a BB gun to the right eye. The record stated that new glasses would be ordered pending insurance/payer approval, but the facility did not follow through to ensure the glasses were obtained. The Business Office Manager confirmed there had not been a remedial adjustment for the glasses. The DON stated the eye doctor's office sent an invoice for the glasses and that staff had spoken with the resident's son, who was said not to want to pay at the time; however, the DON did not know what a remedial adjustment was. The resident's son later stated no one had called him about the glasses, that he wanted his mother to have anything she needed, and that he would not have refused the glasses.
Improper Storage and Monitoring of Resident Food
Penalty
Summary
The facility failed to ensure that personal food items stored in a resident’s room were kept at the correct temperature and were not expired. Resident #14 had a personal refrigerator in the room that had not had its temperature checked since 08/02/25, and two packages of yogurt were found expired on 07/20/25. These findings were observed during survey and confirmed by RN #59, who agreed the refrigerator contents were not in compliance. The facility policy for resident food storage required daily monitoring of refrigerated storage duration and disposal of food stored for 7 days or more, and the DON and Corporate Regional Nurse confirmed that the refrigerator should have had the temperature checked and recorded daily and the expired items removed.
Inaccurate Resident Weight Documentation
Penalty
Summary
The facility failed to provide an accurate and complete record for one resident’s weights. For Resident #4, the record review showed weights documented from 06/23/25 through 08/03/25, including 190.8 on 06/23/25, 156.6 on 07/02/25, 154.8 on 07/06/25, 176.7 on 07/20/25, 175.5 on 07/27/25, and 173.8 on 08/03/25. The Regional RN was notified of the discrepancies in the documented weights and stated that the record should be reviewed and that there may have been an issue with the scales. After reviewing the weights, the Regional RN stated that there did not appear to be any other issue with the residents’ weights during that time and that it looked like there was an error in documenting the weights. The facility policy reviewed stated that if a weight varies by 5 pounds or more, the resident should be reweighed to verify the weight.
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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 Culloden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Putnam Center | 8.1 mi | ★★★★★ | 10 | 0 |
| Teays Valley Center | 8.3 mi | ★★★★★ | 17 | 0 |
| Lincoln Healthcare Center | 9.3 mi | ★★★★★ | 0 | 0 |
| St. Mary's Hospital | 16.6 mi | ★★★★★ | 2 | 0 |
| Huntington Health And Rehabilitation Center | 17.8 mi | ★★★★★ | 19 | 0 |
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