Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Charleston Healthcare Center during CMS and state inspections, most recent first.
A facility failed to keep call lights within reach for two residents. One resident was lying in bed with the call light on the floor, and another was sitting in a wheelchair with the call light under the chair and unable to reach it. A nurse aide confirmed both call lights were out of reach, and each resident’s care plan directed staff to place the call light within reach.
A resident had multiple acute transfers, and after losing capacity to make her own medical decisions, she was transferred again following a fall. Although she received a transfer notice and bed hold notice, the resident's designated representative or POA was not informed in writing of the reason for the transfer/discharge and did not receive the bed hold notice after the change in capacity.
A resident with Bipolar II Disorder added after admission did not have an updated PASRR reflecting the diagnosis. The most recent PASRR did not list or check Bipolar Disorder in Section 30, and the DON confirmed the omission during record review.
A resident’s comprehensive care plan was not updated in a timely manner after a change in mental capacity. When the surveyor reviewed the record, the plan still stated the resident had capacity to make her own medical decisions, and it was only updated after the surveyor requested it. The DON acknowledged the update was made after the request.
A resident’s care plan and diet order indicated NPO, but the MAR included an oral Norvasc order for HTN. The Administrator confirmed the NPO status, the oral med order, and the NPO care plan, showing the resident’s orders and care plan did not match.
IV tubing was found not dated for two residents during survey observations. One resident had an IV line in use without a date, and the DON and unit manager confirmed the omission. Another resident had medication running through an IV line that was not labeled with the date and time, and the nurse removed the set after the medication finished. Facility policy required IV tubing to be labeled with the date, time, and initials and changed every 24 hours.
Surveyors found multiple sanitation issues in the kitchen and storage areas, including dirty trash cans, soiled hand sanitizer bottles, unclean hotel pans, food debris in drains, gnats, and greasy film on major equipment. Staff confirmed inconsistent cleaning practices and lack of a specific cleaning schedule, resulting in unsanitary conditions that could affect all residents receiving food from the kitchen.
The facility did not ensure timely assessment and treatment of pressure ulcers or implement prevention measures for three residents at risk. One resident with significant mobility issues did not consistently have heels floated as required by the care plan, while another was admitted with a pressure ulcer that was not promptly assessed or treated. A third resident developed a deep tissue injury, and preventive interventions were only added after the injury was found. The DON confirmed delays in both assessment and implementation of necessary interventions.
Two residents were exposed to accident hazards: one had a bed with a six-inch gap at the footboard posing an entrapment risk, and another had an aerosol cleaning product left on their overbed table, which could be accessed by others. The facility did not have documentation that families were informed about prohibited products, and one resident lacked capacity to make medical decisions.
Several residents did not have fresh ice water at their bedside as required, and a dependent resident experienced significant weight loss due to lack of documented feeding assistance over an extended period. The DON confirmed both the absence of water and the lack of meal assistance documentation.
A resident who was totally dependent on staff for eating did not have their need for feeding assistance consistently documented over several weeks, as required by their care plan. Additionally, interventions for impaired skin integrity, including floating heels and a turn/reposition schedule, were not implemented until after a deep tissue injury was identified. The DON confirmed these deficiencies in care plan implementation.
A resident who was totally dependent for feeding and personal hygiene did not consistently receive documented assistance with meals and missed multiple showers or bed baths over several days. The DON confirmed the lack of documented feeding assistance and hygiene care during the periods identified.
A resident was readmitted from the hospital with a recommendation in the discharge summary to obtain a BMP and CBC within one week. The facility did not perform these labs or consult the attending physician about the recommendation, as staff only reviewed the discharge instructions and not the full summary. The omission was confirmed by the Interim DON.
A resident with a documented allergy to betadine had physician orders for skin prep to treat a pressure ulcer, but a nurse practitioner's weekly notes on multiple occasions incorrectly recorded the use of betadine instead of the prescribed treatment. The DON confirmed the documentation errors in the resident's medical record.
A resident developed contractures in her left arm and hand due to the facility's failure to schedule timely orthopedic follow-up appointments and obtain necessary documentation. Additionally, an LPN failed to administer prescribed medications to multiple residents, leaving pill packets unopened. The facility's investigation confirmed these deficiencies, which were reported to health authorities.
A facility failed to create a care plan for a resident at risk of dehydration, who had a history of UTI and depression. The resident reported not drinking water and relying on coffee and ice chips, which were inconsistently provided. Despite receiving IV fluids for fluid volume depletion, there was no care plan addressing dehydration risk, as confirmed by the DON.
The facility failed to maintain an effective infection prevention and control program. Clean mop heads were improperly dried in a dirty area, an LPN mishandled medication by picking up a dropped pill with bare hands, and a resident's breathing treatment mouthpiece was left unprotected. These actions indicate lapses in infection control practices.
A resident was found with the call light out of reach during a survey, despite staff presence. The facility's policy mandates that call lights be accessible to residents to communicate needs, but this was not adhered to, as confirmed by a Unit Manager RN.
A resident's preference for female caregivers was not consistently honored, as documented in her care plan. Despite expressing discomfort with male caregivers, a male NA was assigned to her multiple times. The DON acknowledged the preference but cited assignment practices based on seniority as the reason for the oversight.
A facility failed to thoroughly investigate an incident where a resident, with a history of hemiplegia and requiring a feeding tube, was found with fruit in her bed, contrary to her NPO diet orders. Witness statements were collected, but the facility did not substantiate the neglect allegation. Additionally, there was confusion over a request for scrambled eggs, which was not documented accurately, and the resident's dietary restrictions were not followed.
The facility failed to update a resident's care plan to reflect their Do Not Resuscitate (DNR) status, as the care plan inaccurately indicated a Cardiopulmonary Resuscitation (CPR) code status. This discrepancy was confirmed by the DON during a survey process.
A resident with a POST form indicating no CPR was mistakenly given CPR due to an outdated care plan labeling them as full code. Despite the resident's advance directive, CPR was initiated when they became unresponsive, and EMS later confirmed with the resident's daughter to cease life-saving measures.
A used razor was found on a bathroom sink in a resident's room, indicating a failure to maintain a hazard-free environment. The Facility Scheduler acknowledged the issue, and the DON confirmed the razor should not have been left there.
A resident at risk for dehydration due to a history of UTI and depression did not have their hydration needs adequately addressed by the facility. The resident preferred coffee and ice chips over water, and ice chips were not consistently provided. The facility only tracked fluids during meals, neglecting intake between meals, leading to the resident requiring IV fluids for dehydration.
A resident's dentures were damaged over a year ago, resulting in two missing front teeth, but the facility failed to arrange a dental appointment for repairs. The Medical Records Coordinator was unaware of the issue due to the absence of a consultation request. The resident's care plan acknowledged the broken dentures but did not indicate any pain or eating difficulties.
The facility failed to meet the nutritional needs of residents by serving food items they were allergic to or disliked. A resident allergic to lemon was served lemon products due to inconsistent dietary cards. Another resident with an egg allergy received meals containing eggs, and a third resident who dislikes eggs, chicken, and fish was repeatedly served these items. The issues were confirmed by facility staff, indicating a failure in the dietary management system.
A resident with a complex medical history, including hemiplegia and dysphasia, was found with fruit in her bed despite having an NPO diet order. The facility's investigation suggested the resident's brother brought the fruit, and there was confusion over a request for scrambled eggs, which was mistakenly linked to the resident. The facility failed to ensure the resident's diet was followed according to physician's orders.
The facility failed to maintain sanitary conditions in food preparation and service, affecting all residents on an oral diet. A resident found a piece of foil in an egg sandwich, and beverage containers used during lunch service were unlabeled, undated, and appeared unclean. The Dietary Director acknowledged these issues and stated that the containers should have been properly labeled and dated.
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in care documentation. One resident's records inaccurately documented meal assistance levels, while another lacked a documented anxiety diagnosis despite being care planned for it. Additionally, a critical error occurred when a resident's 'Do Not Resuscitate' order was not reflected in their care plan, resulting in CPR being administered against their wishes.
A facility failed to complete a physician discharge summary for a resident discharged to home. The medical record review revealed the absence of a physician's note on the discharge date, although a nurse note documented the discharge process. The DON acknowledged this oversight and confirmed that other residents had their physician discharge notes completed.
A facility failed to thoroughly investigate an alleged abuse incident involving a resident with a BIMS score of 00, indicating cognitive impairment. The incident, reported by a nurse, involved alleged verbal abuse by a nurse aide. The investigation lacked crucial details and documentation, and the Administrator admitted to not obtaining a written statement from the reporting nurse, acknowledging the investigation's inadequacy.
The facility failed to ensure accurate and current Daily Staffing Posting information and did not maintain the data for the required 18 months. Discrepancies were found between the Daily Punches data and the Daily Staffing Posting, and the facility incorrectly included administrative staff hours in direct care hours without proper documentation. Additionally, the facility did not keep original documents reflecting real-time changes due to staff absences.
The facility failed to ensure the resident environment remained free of accident hazards. An emergency exit door on unit EB2 was fully blocked by large dietary carts and a trash can. The Activities Director acknowledged the blockage and confirmed it was unsafe for evacuation.
The facility failed to maintain sanitary conditions in the kitchen, with the steam table, lids, and plate warmer found heavily soiled with grease buildup and old food debris. Additionally, two maintenance workers were observed working in the food preparation area without hair coverings. The Dietary Manager confirmed these observations.
A facility failed to maintain an infection control program when an LPN picked up a dropped pill with a bare hand and administered it to a resident along with other medications. The LPN acknowledged the mistake when questioned.
The facility failed to offer the Pneumococcal vaccine to eligible residents, as identified during a record review and staff interview. Four residents did not receive the PVC 20 vaccine despite being eligible, and the Infection Preventionist confirmed this oversight.
A housekeeper entered a resident's room without knocking and remained on her cell phone, failing to seek the resident's permission and showing a lack of respect for the resident's dignity. The housekeeper stated that knocking did not matter as most residents could not hear or talk.
The facility failed to update care plans to reflect the current status of skin issues for three residents. Care plans indicated various skin conditions, but weekly assessments showed no current skin issues. The DON confirmed the inaccuracies in the care plans.
The facility failed to administer medications as prescribed, notify physicians of significant changes in residents' conditions, and provide educational information about the RSV vaccine. Several residents experienced issues such as elevated blood glucose levels, missed bowel movements, and late or unavailable medications.
The facility failed to include a care plan addressing the provision of meals before, during, and/or after dialysis treatments for a resident. The resident had a physician's order for dialysis three times a week, but the care plan did not account for meals on dialysis days. This was confirmed by the DON.
The facility failed to ensure accurate and complete medical records for two residents during transfers to acute care facilities. Discrepancies in transfer dates were confirmed by the DON, who acknowledged that the errors had not been noticed before.
Call Lights Left Out of Residents’ Reach
Penalty
Summary
The facility failed to ensure residents' call lights were within reach, despite its policy stating that call light or bell access will be within reach as one method for residents to communicate needs to staff. Resident #129 was lying in bed when the call light was observed on the floor during interview, and a nurse aide confirmed it was out of reach. Resident #129's care plan directed staff to place the call bell within reach and remind the resident to call for assistance. Resident #146 was sitting in a wheelchair beside the bed and reported wanting to get back in bed after sitting for a long time; the resident's call light was under the wheelchair and could not be reached to obtain assistance. A nurse aide also confirmed that this call light was out of reach. Resident #146's care plan directed staff to place the call light within reach and remind the resident to call for assistance if cognitively intact.
Failure to Notify Representative of Transfer and Bed Hold Information
Penalty
Summary
The facility failed to notify the resident's representative in writing of the reason for transfer/discharge and failed to provide a copy of the bed hold notice for Resident #19. Record review showed the resident had three acute transfers in the prior 120 days, including transfers from 01/29/26 to 02/03/26, 02/22/26 to 03/01/26, and 03/04/26 to 03/10/26. During the first two transfers, the resident had the capacity to make her own medical decisions and was provided a transfer notice and bed hold notice. The resident lost capacity on 03/02/26, and when she was transferred again on 03/04/26 after a fall at the facility, she was provided a transfer notice and bed hold notice; however, because her capacity had changed two days earlier, her designated representative or Power of Attorney should have been informed. This was reviewed with the DON on 04/02/26 at approximately 10:40 AM.
PASRR Not Updated for Newly Documented Bipolar Diagnosis
Penalty
Summary
The facility failed to ensure an updated Preadmission Screening and Resident Review (PASRR) was completed for Resident #153 after a diagnosis of Bipolar II Disorder was added to the resident’s medical chart following admission. Resident #153 was admitted in 08/2024, and Bipolar II Disorder was added to the diagnosis list on 04/04/2025. On 04/01/26, the resident’s chart was reviewed and the most recent PASRR dated 11/21/2024 did not list or check Bipolar Disorder under Section 30. During review with the DON on 04/01/26, the DON confirmed that Bipolar II Disorder was not listed or marked on the most recent PASRR.
Delayed Update to Care Plan After Change in Decision-Making Capacity
Penalty
Summary
The facility failed to update Resident #19’s comprehensive care plan in a timely manner after a significant change in her mental capacity. Resident #19’s capacity to make her own medical decisions changed on 03/02/26, but when the medical record was reviewed on 03/31/26, the comprehensive care plan still stated that she had capacity to make her own medical decisions. The surveyor requested a copy of the care plan on 04/01/26, and the next morning the facility provided a version showing it had been updated on 04/01/26 to reflect that the resident no longer had capacity. The surveyor reviewed this documentation change with the DON on 04/02/26, and the DON acknowledged that the update was made only after the surveyor requested the care plan.
Mismatch Between NPO Order and Oral Medication Order
Penalty
Summary
The facility failed to ensure that Resident #56’s physician orders and care plan matched for a resident ordered Nothing By Mouth (NPO). On 03/31/2026, record review showed the care plan listed an NPO diet order and directed staff to administer medications per physician orders and flush before and after medication administration per order. The resident’s diet order also stated NPO diet, NPO texture, and NPO consistency. However, a medication order for Norvasc Tablet (amLODIPine Besylate) directed that 5 mg be given by mouth one time a day for HTN. On 04/01/2026, the Administrator confirmed the NPO order, the oral medication order, and the NPO care plan.
IV Tubing Not Dated
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections when IV lines were found without dates. During the resident interview process, Resident #108 was observed with an IV line in use that was not dated, and the Director of Nursing and unit manager confirmed there was no date on the IV line. A second observation found Resident #60 with medication running through an IV line that was not labeled with the date and time; before staff could confirm the line, the nurse removed the set because the medication had finished. The DON stated, "I'll go look at it and get it fixed." The facility policy, "Changing IV administration Set" dated 02-2009 and revised 02-2019, states that IV tubing must be changed every 24 hours and that IV tubing must be labeled with the date, time, and initials.
Failure to Maintain Sanitary Kitchen and Storage Areas
Penalty
Summary
Surveyors observed multiple sanitation and cleanliness deficiencies in the facility's kitchen and storage areas. A 50-gallon trash can with a lid was found at the entrance of the dining room, visibly soiled with a dry white substance and food debris. In the storage area, ten one-gallon bottles of hand sanitizer were noted to be covered in a brown dried substance, and two hotel pans with lids had a dried white substance on them. Two additional 50-gallon trash cans between the storage area and dish room also had dried food debris on their lids. Gnats were seen flying in the kitchen, and the dish room floor drain was wet with visible food debris. Major kitchen equipment, including the stove, oven, fryer, tilt skillet, and steam table, were all observed to have a dried, greasy film. The ice machine had a dust-like substance inside the lid, and the floor by the tilt skillet had a wet, slimy substance, with another area of the floor showing a dried, black substance. Staff interviews confirmed awareness of the issues, with the dietary manager acknowledging the presence of old hand sanitizer bottles and the need for cleaning. The dietary manager stated there was a monthly cleaning schedule for major equipment but expected staff to clean visible dirt as needed. The administrator confirmed that there was no specific cleaning schedule, with some items cleaned after each meal, daily, weekly, or monthly. These observations and staff statements indicate that the facility failed to maintain a clean and sanitary environment for food storage, preparation, and service, potentially affecting all residents receiving nourishment from the kitchen.
Failure to Timely Assess, Treat, and Prevent Pressure Ulcers
Penalty
Summary
The facility failed to ensure timely assessment and treatment of pressure ulcers, as well as the implementation of prevention measures for residents at risk. For one resident with a history of traumatic brain injury, contractures, and functional quadriplegia, the care plan included floating heels to prevent pressure injuries. However, observations on two separate occasions revealed that the resident's heels were not floated while in bed, and staff confirmed this intervention was not consistently implemented. Another resident was admitted with a blackened area on the left toe, but the initial assessment and treatment orders for the pressure ulcer were not obtained until the day after admission. The DON confirmed that LPNs are responsible for obtaining treatment orders, but staging of pressure ulcers should be performed by an RN, which was not done promptly. Additionally, a third resident developed a deep tissue injury to the right heel while in the facility, and skin integrity interventions such as floating heels and a turn/reposition schedule were not added to the care plan until after the injury was identified. The DON confirmed that these interventions were not in place prior to the discovery of the pressure injury, and that the injury was acquired in-house. These findings demonstrate a lack of timely assessment, intervention, and prevention practices for pressure ulcers among residents reviewed.
Failure to Maintain a Safe Environment Free from Accident Hazards
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, as evidenced by two separate incidents involving two residents. In one case, a resident's bed was observed to have a six-inch gap between the footboard and the end of the mattress, which posed a risk for entrapment. The Registered Nurse of Clinical Operations confirmed the presence of the gap, and no gap filler was found in the room. The Director of Plan Maintenance measured the gap and acknowledged that gap fillers are typically used when beds are extended for taller residents, but could not confirm when the bed had been extended for this resident. In another instance, a resident was found lying in bed with an aerosol spray can of Clorox Fabric Sanitizer on the overbed table. Although the table was not within the immediate reach of the resident, the product could have been accessed by other residents entering the room. The facility's RN stated that the product was not used by the facility and was likely brought in by the resident's family. The safety data sheet for the product indicated it could cause respiratory, eye, and skin irritation, as well as gastrointestinal symptoms if ingested. The resident's assessment showed they were rarely understood and lacked capacity to make medical decisions. There was no documentation that the family had been notified about prohibited products.
Failure to Provide Adequate Hydration and Nutrition
Penalty
Summary
The facility failed to ensure that residents maintained acceptable levels of hydration and nutrition. During a complaint survey, it was observed that four residents did not have fresh ice water at their bedside, despite the facility's stated practice of providing three ice water passes per day and two additional drink passes by activities staff. An observation conducted with the DON confirmed that these residents lacked ice water at their bedside during the afternoon, and the DON acknowledged that the residents should have had access to ice water at that time. Additionally, a review of records for a dependent resident revealed that documentation of feeding assistance was missing for numerous meals over a period of approximately two months. The resident, who required assistance with meals, experienced a significant weight loss of 26.2 pounds, equating to a 15.78% decrease in body weight over 53 days. The DON confirmed that the meals were not documented as dependent, despite the resident's need for assistance.
Failure to Implement Care Plan for Feeding Assistance and Timely Skin Integrity Interventions
Penalty
Summary
The facility failed to implement the care plan for a resident who was documented as totally dependent on staff for eating. A review of meal documentation from July through September revealed numerous instances where the resident's need for total assistance during meals was not recorded as required. The Director of Nursing (DON) confirmed that the care plan regarding feeding assistance was not implemented, as the documentation did not reflect the resident's dependent status for multiple meals over an extended period. Additionally, the facility did not develop or implement appropriate interventions for impaired skin integrity in a timely manner. The resident developed a deep tissue injury (DTI) to the right heel, and skin integrity interventions such as floating the heels and a turn and reposition schedule were not added to the care plan until after the injury was identified. The DON confirmed that these interventions were not in place prior to the discovery of the DTI, indicating a delay in care planning and implementation for skin integrity.
Failure to Provide ADL Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide necessary assistance with activities of daily living (ADLs) for a dependent resident. Record review revealed that the resident, who was documented as totally dependent for feeding, did not have appropriate documentation of feeding assistance for multiple meals over an extended period. Specifically, from mid-July through early September, there were numerous instances where meals were not documented as dependent, despite the resident's need for assistance. During this time, the resident experienced a weight loss of 26.2 pounds from admission through early September. The Director of Nursing (DON) confirmed that the resident was dependent for meals and that the required assistance was not documented for the identified meals. Additionally, the same resident was found to be totally dependent for showers and baths. The records indicated that the resident did not receive a shower or bed bath for two separate periods: one lasting ten days and another lasting seven days. The DON confirmed that on these occasions, the resident did not receive the necessary hygiene care. These findings were based on record reviews and staff interviews conducted during the survey process.
Failure to Follow Up on Hospital Discharge Lab Recommendations
Penalty
Summary
The facility failed to follow up on a hospital discharge recommendation for a resident who was readmitted from the hospital. The hospital discharge summary specified that a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) should be obtained one week after discharge. However, these laboratory tests were not performed, nor was there documentation that the attending physician was consulted regarding the need for the labs. The Interim DON confirmed that the nursing staff only reviewed the discharge instructions and not the full summary, which led to the omission. There was no evidence in the medical record that the physician addressed the hospital's recommendation for follow-up lab work.
Inaccurate Medical Record Documentation for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure complete and accurate medical records for one of three residents reviewed for pressure ulcer care. A physician's order was in place for the use of skin prep on a resident's left great toe pressure injury, and the resident's medical record documented an allergy to betadine. However, the wound nurse practitioner's weekly notes on three separate occasions incorrectly documented that the pressure ulcer was being treated with betadine instead of the ordered skin prep. This documentation error persisted until subsequent notes correctly reflected the use of skin prep. The Director of Nursing confirmed that the nurse practitioner's documentation was inaccurate regarding the treatment used for the resident's pressure ulcer, despite the known allergy.
Failure in Follow-Up Care and Medication Administration
Penalty
Summary
The facility failed to provide appropriate follow-up care for a resident who suffered a fall and sustained a fracture in her left arm. After the fall, the resident was supposed to have a follow-up appointment with an orthopedic doctor within 1-2 weeks, but the appointment was not scheduled until much later. Additionally, the facility did not ensure transportation for the resident to attend the follow-up appointment, nor did they obtain the necessary documentation from the orthopedic consultation. As a result, the resident did not receive the recommended range of motion exercises, leading to the development of contractures in her left arm and hand. In another incident, the facility failed to administer prescribed anticonvulsant and narcotic pain medications to multiple residents. An LPN was responsible for the medication administration but did not give the medications as scheduled. The LPN had signed out the medications on the Medication Administration Record (MAR) but did not actually administer them. This oversight was discovered when another nurse found unopened pill packets in the medication cart. The residents were assessed for adverse effects, and no harm was reported. The facility's investigation confirmed the failure to administer medications and the lack of follow-up care for the resident with the arm fracture. The incidents were reported to the appropriate health authorities, and the facility acknowledged the deficiencies in care. The failure to ensure timely medical appointments and proper medication administration were significant lapses in the facility's duty to provide adequate care to its residents.
Failure to Develop Care Plan for Dehydration Risk
Penalty
Summary
The facility failed to develop a care plan for a resident who had suffered fluid volume depletion, which is a deficiency in meeting the resident's needs. The resident, who had a history of urinary tract infection (UTI) and depression, conditions that increase the risk of dehydration, did not have a care plan focus area for dehydration. During an interview, the resident mentioned not drinking water and relying on coffee and ice chips, which were not consistently provided. A nurse's note indicated a new order for intravenous fluids due to fluid volume depletion, yet there was no care plan addressing dehydration or the risk of dehydration. The Director of Nursing confirmed the absence of a care plan for dehydration risk.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. In the laundry room, clean mop heads were improperly hung to dry in the dirty laundry area, as there was no designated space for drying them elsewhere. This was acknowledged by the laundry room worker, who understood that clean items should not be in the dirty area but had no alternative solution. Additionally, during medication administration for a resident, an LPN dropped several pills on the medication cart without a barrier and subsequently picked up a dropped pill with bare hands, placing it back into the medication cup. This action was noted by the surveyor, and the LPN acknowledged the mistake. Furthermore, another resident's breathing treatment mouthpiece was left connected to oxygen and placed on a bedside chair without a protective barrier, which was not addressed by the respiratory therapist who had just completed the treatment.
Call Light Inaccessibility for a Resident
Penalty
Summary
During a Long-Term Care survey, it was observed that the facility failed to ensure the call light was accessible to a resident, identified as Resident #120. On the initial facility tour, the surveyor noted that the resident was lying in bed with the head elevated, but the call light was not within reach, as it was hanging between the headboard and the mattress. This observation was made around 11:45 AM, and despite staff entering the room shortly after, a subsequent observation at 12:15 PM revealed that the call light remained out of reach. An interview with the Unit Manager Registered Nurse confirmed the call light's inaccessibility. The facility's policy, provided by the Administrator, clearly stated that call light access should be within reach of residents to communicate their needs to staff.
Failure to Honor Resident's Preference for Female Caregivers
Penalty
Summary
The facility failed to honor a resident's preference for female caregivers, as documented in her care plan. During an interview, the resident expressed discomfort with male caregivers and stated she would not allow them to care for her. Despite this, a review of the daily assignment sheets revealed that a male Nursing Assistant was assigned to her on multiple occasions. The Director of Nursing acknowledged the resident's preference but explained that assignments were made based on seniority, resulting in the male Nursing Assistant often being assigned to the resident.
Failure to Investigate Allegation of Neglect and Follow Dietary Orders
Penalty
Summary
The facility failed to conduct a thorough investigation of a reported incident involving a resident who was found with chopped fruit in her bed, which was against her physician's orders. The resident, who had a history of hemiplegia, aphasia, and required a feeding tube, was on a Nothing By Mouth (NPO) diet. Despite this, her brother reported that he had her laughing and spitting up chunks of fruit. The facility collected witness statements from a nurse aide, an LPN, and an assistant cook, but did not substantiate the allegation of neglect in their five-day follow-up report. The Director of Nursing (DON) later stated that the investigation focused on the fruit and believed the brother brought it in, but there was no evidence of this in the investigation documentation. Additionally, there was confusion regarding a request for scrambled eggs for the resident, which was not in line with her dietary restrictions. The assistant cook reported receiving a call for scrambled eggs for the resident, but the DON clarified that the request was for another resident and that the kitchen staff had mixed up the names. Despite this clarification, the investigation documentation did not reflect these details, and the resident's physician orders indicated she was NPO, highlighting a failure to follow dietary orders and properly document the investigation findings.
Failure to Revise Care Plan for Advanced Directives
Penalty
Summary
The facility failed to revise the care plan for a resident in the area of advanced directives. This deficiency was identified during a Long-Term Care Survey Process, where it was found that the care plan for a resident, identified as having a Do Not Resuscitate (DNR) status on their post form, was not updated accordingly. Instead, the care plan inaccurately indicated that the resident had a Cardiopulmonary Resuscitation (CPR) code status. This discrepancy was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the code status in the care plan did not match the resident's documented DNR status.
Failure to Follow Advance Directives for CPR
Penalty
Summary
The facility failed to provide emergency care in accordance with a resident's advance directives. A resident had a Virginia Post Orders to Health Care (POST) form indicating they did not want cardiopulmonary resuscitation (CPR) in the event of no pulse and no breathing. However, the resident's care plan was not updated to reflect this directive and incorrectly indicated the resident was a full code. As a result, when the resident became unresponsive with no pulse or respirations, CPR was initiated by a registered nurse, contrary to the resident's documented wishes. The sequence of events documented by the nurse included the application of an Ambu bag with supplemental oxygen, the use of an Automated External Defibrillator (AED), and multiple attempts at CPR. Despite these efforts, the resident remained without a pulse, and emergency medical services (EMS) were called. The resident's daughter was notified, and EMS confirmed with her to cease life-saving measures. The time of death was determined shortly thereafter. The Director of Nursing acknowledged the error in the care plan and the inappropriate initiation of CPR, which was not in line with the resident's advance directives.
Used Razor Left on Resident's Bathroom Sink
Penalty
Summary
The facility failed to maintain the environment as free of accident hazards as possible, as evidenced by a used razor being left on the bathroom sink in a resident's room. This was observed on 10/28/24 at 11:18 AM. The Facility Scheduler confirmed the presence of the razor shortly after and indicated they would address the issue. The following day, the Director of Nursing was informed and confirmed that the razor should not have been left on the sink. The facility census at the time was 145 residents.
Failure to Address Resident's Hydration Needs
Penalty
Summary
The facility failed to adequately recognize, evaluate, and address the hydration needs of a resident, identified as Resident #68, who was at risk for dehydration. The resident expressed a preference for coffee and ice chips over water and reported that ice chips were not consistently provided. Despite having a history of a urinary tract infection (UTI) and depression, both of which increase the risk for dehydration, these factors were not considered in the resident's hydration risk evaluation. The resident had previously required intravenous fluids due to fluid volume depletion, indicating a significant hydration issue. The facility's Director of Nursing admitted that they only tracked fluids consumed during meals and did not account for fluids consumed between meals. A Licensed Practical Nurse confirmed that the resident did not drink water and relied on ice chips for hydration, which were provided more frequently after the resident received IV fluids. The facility's failure to monitor and ensure adequate fluid intake for the resident, especially given their medical history and expressed preferences, contributed to the deficiency in care.
Failure to Obtain Timely Dental Services for Damaged Dentures
Penalty
Summary
The facility failed to promptly obtain needed dental services for a resident with damaged dentures. The resident reported having two missing teeth from his upper front dentures, which were damaged over a year ago while eating tough meat provided by the facility. Despite the resident's dissatisfaction with the appearance of his dentures, the facility had not arranged for a dental appointment to repair them. The Medical Records Coordinator was unaware of the issue, as she had not received a consultation request to schedule a dental appointment for the resident. The resident's care plan noted the broken dentures but did not indicate any pain or eating difficulties, only the need for oral care and dental consultation as needed.
Failure to Accommodate Resident Allergies and Preferences
Penalty
Summary
The facility failed to meet the nutritional needs of several residents by serving them food items they were allergic to or disliked. Resident #31, who is allergic to lemon, reported being served lemon products on multiple occasions, despite his care plan and medical records indicating this allergy. The dietary cards for Resident #31 were inconsistent, sometimes listing an allergy to lemon and other times only to lemonade. The Food Service Director acknowledged the discrepancies and confirmed that the resident was served lemon products on specific dates. Resident #68, who is allergic to eggs, received meals containing eggs, although her meal ticket clearly indicated the allergy. The Corporate Dietary Manager identified an issue with the meal tracker system not pulling over allergy information correctly. Additionally, Resident #10, who dislikes eggs, chicken, and fish, was repeatedly served these items, as confirmed by her dietary history and meal tickets. The Director of Nursing confirmed these findings, highlighting a failure in the facility's dietary management system to accommodate resident preferences and allergies.
Failure to Follow Physician's Diet Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident's diet was followed according to the physician's orders. Resident #122, who had a diagnosis of hemiplegia, hemiparesis following cerebral infarction, aphasia, dysphasia requiring a feeding tube, and apraxia, was found with chopped fruit in her bed. This incident occurred despite the resident having a physician's order for a Nothing By Mouth (NPO) diet, which was later updated to a pureed texture and thin liquids for pleasure feeding. The resident's brother reported that he had given her the fruit, which led to her spitting up chunks of it. The investigation into the incident revealed that the facility did not substantiate the allegation of staff providing the fruit, as it was believed that the brother brought it in. Additionally, there was confusion regarding a request for scrambled eggs, which was mistakenly attributed to Resident #122. The Director of Nursing clarified that the kitchen staff had mixed up the resident's identity when reporting the request for extra food. Despite these findings, the facility failed to ensure the resident's diet was adhered to as per the physician's orders, leading to a deficiency in care.
Sanitation Issues in Food Preparation and Service
Penalty
Summary
The facility failed to ensure food was prepared and served under sanitary conditions, potentially affecting all residents receiving an oral diet. During a lunch meal service observation, a resident bit into an egg sandwich and found a piece of foil inside. The Dietary Director acknowledged the presence of the foil and indicated he would investigate how it ended up in the sandwich. Additionally, during another lunch service observation, three beverage serving containers on a cart were used to serve drinks to residents. These containers were not labeled or dated for expiration, and their exteriors appeared unclean. The Dietary Director identified the beverages as tea, fruit juice, and punch, and admitted that the containers should have been labeled and dated.
Inaccurate Medical Records and Care Plan Discrepancies
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents, leading to discrepancies in their care documentation. For Resident #34, the medical records inaccurately documented the level of assistance required for meals, despite the resident being dependent on tube feeding for all nutrition and fluid intake. The medication administration records for September and October 2024 incorrectly indicated varying levels of physical assistance, ranging from independent to requiring assistance from two or more persons. This inconsistency was confirmed by the Director of Nursing, who acknowledged that the resident was indeed dependent for all meals. For Resident #75, the facility's records failed to include a diagnosis of anxiety, despite the resident being care planned for anxiety and having an order for anxiety side effect monitoring and medication. The Director of Nursing confirmed that the resident should have had a documented diagnosis of anxiety. Additionally, for Resident #139, there was a critical discrepancy between the resident's POST form, which indicated a 'Do Not Resuscitate' order, and the care plan, which incorrectly listed the resident as a full code. This error led to the initiation of CPR when the resident became unresponsive, contrary to the resident's documented wishes. The Director of Nursing acknowledged the mismatch between the care plan and the POST form.
Failure to Complete Physician Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was completed by the physician for a resident discharged to home. During a record review, it was found that Resident #151 was discharged on 04/25/24, but the medical record did not include a physician discharge note for that date. A nurse note documented the discharge process, including a body audit and medication instructions, but lacked the physician's summary. The Director of Nursing acknowledged the absence of the physician's discharge note during an interview and confirmed that other discharged residents had their physician discharge notes completed at the time of discharge.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of abuse involving a resident, identified as Resident #75, who was not cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 00. The incident was reported on 03/06/24, but the investigation was not completed until 03/16/24, and it was ultimately deemed unsubstantiated. The report lacked essential details such as the date and time of the incident. During an interview, the Administrator admitted that no written statement was obtained from the nurse who initially reported the alleged verbal abuse by Nurse Aide #57, acknowledging that the investigation was not conducted thoroughly.
Inaccurate and Incomplete Daily Staffing Postings
Penalty
Summary
The facility failed to ensure the Daily Staffing Posting information was accurate and current, and also failed to maintain the Daily Staffing Posting data for a minimum of 18 months. Discrepancies were identified between the Daily Punches data and the Daily Staffing Posting for specific dates, with inaccuracies ranging from 30 to 77.5 hours. The Administrator was unable to explain these discrepancies, despite both data sources coming from the same system. Additionally, the Administrator incorrectly included the hours of Unit Managers RN and LPN, who are categorized as administrative staff, in the direct care hours without providing supportive documentation for the specific hands-on care tasks they performed during their shifts. This was against the CMS policy, which requires reporting based on the employee's primary role and official categorical title. Furthermore, the facility did not maintain the original Daily Staffing Postings that reflected real-time changes due to staff absences from call-outs or illnesses. The Administrator admitted that the original documents were not kept, and only updated versions were available, which did not accurately reflect the actual staff absences. This failure to maintain accurate and current staffing data and to keep records for the required 18 months had the potential to affect all residents currently residing at the facility.
Blocked Emergency Exit
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible. During a tour of the facility, the egress directly in front of the emergency exit door on unit EB2, located off from the dining room and activity area, was found to be fully blocked by large dietary carts and a large trash can. This blockage was observed at 1:24 PM on 1/23/24. The Activities Director (AD) acknowledged the blockage and confirmed that it was not safe for evacuation in the event of an emergency. The AD immediately began moving the items away from the blocked emergency exit.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety, specifically regarding sanitary conditions and the prevention of foodborne illness. During a kitchen tour, the steam table, lids, and plate warmer were found to be heavily soiled with grease buildup and old food debris. Additionally, two maintenance workers were observed working on the plate warmer in the food preparation area without hair coverings. The Dietary Manager confirmed these observations during an interview.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by an incident involving a Licensed Practical Nurse (LPN) during a medication pass. The LPN was observed pulling medication for a resident and dropped a pill on the med-cart, which did not have a barrier. The LPN picked up the pill with a bare hand and placed it back in the cup with other medications, subsequently administering all the pills to the resident. The medications given included Fexofenadine 180 mg, Metoprolol 50 mg, Myrbetriq 25 mg, and Valsartan 160 mg. When questioned, the LPN acknowledged that she should not have picked up the pill with a bare hand.
Failure to Offer Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer the Pneumococcal vaccine to eligible residents, as identified during a record review and staff interview. Specifically, four out of five residents reviewed for immunizations did not receive the PVC 20 vaccine despite being eligible. Resident #143, admitted on an unspecified date, had received the Pneumonia vaccine 23 on 10/12/12. Resident #19, also admitted on an unspecified date, had received multiple Pneumococcal vaccines, including PREVNAR 13 in 09/2016, Pneumococcal in 12/2009, and Pneumococcal Polysaccharide in 05/2015. Resident #100 and Resident #120, both admitted on unspecified dates, had no records of receiving any Pneumococcal vaccines. On 01/23/24, the Infection Preventionist (IP) confirmed that all four residents should have been offered the PVC 20 vaccine, as recommended by the CDC if five years or more have passed since the last PVC 13 or PVC 23 vaccination.
Failure to Respect Resident's Dignity and Privacy
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity when a housekeeper entered a resident's room without permission and remained on her cell phone throughout the visit. On 01/23/24 at 9:42 AM, Housekeeper #170 was observed entering room [ROOM NUMBER] without knocking and talking on her teal-colored phone. The housekeeper continued to talk on her phone while in the room and did not seek the resident's permission before entering. When questioned, Housekeeper #170 stated that it did not matter if she knocked because most residents either could not hear or talk. This incident was discussed with the Director of Nursing later that day, but no further information was provided.
Failure to Update Care Plans for Skin Issues
Penalty
Summary
The facility failed to revise care plans to reflect the current status of skin issues for three residents. Resident #73's care plan indicated excoriation to the bilateral buttock, but weekly skin assessments showed no current skin issues. Similarly, Resident #40's care plan mentioned open MASD, while assessments indicated no skin issues. Resident #31's care plan noted MASD to the inner buttocks, but assessments also showed no current skin issues. The Director of Nursing confirmed that the care plans were incorrect and that none of the residents had any skin issues at the time of the review.
Medication and Physician Notification Deficiencies
Penalty
Summary
The facility failed to administer medication as prescribed by the physician, including not offering the RSV vaccine when available, not completing neuro checks, and not notifying the physician of significant changes in residents' conditions. For instance, Resident #147 had an elevated blood glucose level of 660, and although the nurse administered the ordered dose of insulin, there was no documentation of the physician being notified or a change in condition assessment completed. Additionally, the facility did not follow up with the additional insulin dose ordered by the Telehealth Physician, and the blood glucose level was not rechecked one hour after administering insulin as standard practice dictates. The facility also failed to notify physicians of residents' requests to go to the emergency room and changes in bowel movement patterns. Resident #147 requested to be transferred to the emergency room after an elevated blood glucose level, but there was no documentation that the nurse had paged a physician for an order to transfer the resident. Similarly, Resident #7 and Resident #10 did not have bowel movements for several days, and there was no documentation of the physician being notified or a bowel protocol being initiated. Furthermore, the facility did not follow physician's orders for vital signs, blood glucose checks, and medication administration. Resident #60 did not have vital signs obtained as ordered, and Resident #147 did not have blood glucose checks or insulin administered as prescribed. Additionally, several residents, including Resident #75 and Resident #126, had medications administered late, and Resident #14 and Resident #59 had medications that were not available for administration. The facility also failed to provide educational information about the RSV vaccine to residents, as none of the 141 residents had been informed about the risks and benefits of receiving the vaccine.
Lack of Dialysis Meal Plan in Resident Care Plan
Penalty
Summary
The facility failed to have a care plan addressing the provision of meals before, during, and/or after dialysis treatments for a resident who required such services. Medical record review of the resident's medical record found a physician's order for dialysis every Tuesday, Thursday, and Saturday with a chair time at 6:40 am. However, the resident's dialysis care plan did not include any provision for meals on dialysis days. This deficiency was confirmed during an interview with the Director of Nursing, who verified the absence of a dialysis meal plan in the resident's care plan.
Inaccurate and Incomplete Medical Records for Resident Transfers
Penalty
Summary
The facility failed to ensure medical records were accurate and complete for two of three residents reviewed under the care area of discharges. For Resident #66, a record review revealed that the resident was transferred to an acute care facility on 01/23/24 at 9:20 AM, but the transfer form incorrectly indicated the transfer date as 12/19/23 at 9:27 AM. The Director of Nursing (DON) confirmed the discrepancy during an interview, stating that the documentation showed the last time the resident was sent out to the acute care facility, and the error had not been noticed before. For Resident #31, multiple discrepancies were found in the transfer forms. The resident was transferred to an acute care facility on 12/07/23 at 10:00 PM, but the transfer form incorrectly indicated the date as 02/22/20 at 9:50 AM. Another record review showed the resident was transferred on 01/03/24 at 5:26 PM, but the transfer form indicated the date as 12/07/23 at 10:26 PM. The DON confirmed these errors during an interview, stating that the documentation was showing the last time the resident was sent out to the acute care facility and that these errors had not been noticed before.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 105 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charleston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Oak Ridge Llc | 2.3 mi | ★★★★★ | 0 | 0 |
| Thomas Hospitals Skilled Nursing Unit | 2.8 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Acres | 4 mi | ★★★★★ | 5 | 0 |
| Arthur B Hodges Center, The | 4.2 mi | ★★★★★ | 0 | 0 |
| Marmet Center | 6.5 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Charleston Healthcare Center.
100% money-back within 48 hours.
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.