Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mercer Healthcare Center during CMS and state inspections, most recent first.
Care plans were not accurately developed or implemented for several residents with oxygen needs, PTSD, dementia, and epilepsy. One resident received oxygen at a higher flow rate than ordered, another had a new epilepsy diagnosis not added to the care plan, a resident with documented trauma history had no PTSD care plan, and a dementia intervention for a wheelchair cup holder was listed but not in place.
Activities program did not meet resident needs and interests for multiple residents. One resident wanted more 1:1 conversation but had very limited documented 1:1 activity time, another resident with severe cognitive impairment had minimal documented group participation despite a care plan to encourage involvement, and a third resident said he was not being told about church and group activities even though his MDS and activity preferences showed strong interest in them.
A resident with dementia and no decision-making capacity signed a POST form changing end-of-life wishes even though the prior POST had been signed by the MPOA and directed full treatment and CPR. The DON confirmed the resident lacked capacity when the form was signed.
A resident's MPOA did not receive timely NOMNC notice of the end of Medicare-covered skilled services. Facility policy required notice at least 2 days before the last covered day, but the phone notification was made after coverage had already ended, and the Social Services Designee confirmed the MPOA was not notified in advance.
The facility failed to provide complete transfer documentation for two residents sent to an acute care facility. The Interact Hospital Transfer Form did not include advanced directives or a medication list with last administration times, and the Acute Care Transfer Document Checklist was left unmarked; progress notes also did not show what was sent to the receiving provider.
A resident’s quarterly MDS failed to include epilepsy in Section I Current Diagnoses even though the diagnosis was documented in the medical record. During review with the MDS RN, she acknowledged that epilepsy should have been marked and was missed.
PASARR and MDS diagnoses were not aligned for two residents. One resident had dementia with mood disturbance, major depressive disorder, and adjustment disorder, but the PASARR only listed behavioral disturbance and adjustment disorder while the MDS checked depression and dementia; the resident was also receiving escitalopram for depression. Another resident had major depressive disorder, dementia, epilepsy, and anxiety, but the PASARR marked only dementia under other related conditions while the MDS included depression and major depressive disorder. The NHA stated the Director of Admissions was responsible for keeping PASARRs up to date.
A resident had an order to notify the MD if blood sugar was less than 60 or greater than 400, but several MAR readings were above the ordered limit and the progress notes did not show that the MD was notified. The DON confirmed the lack of notification in the progress notes.
A resident was observed receiving supplemental O2 via nasal cannula at 3.5 L/min, while the physician order specified 2 L/min. The flow rate was 1.5 L/min above the ordered setting when the discrepancy was identified by nursing staff.
The facility failed to accurately complete resident records for two residents. One resident lacked capacity and had an MPOA designated, but hospice admission paperwork was signed by the resident's sister instead of the MPOA. Another resident was observed wandering in a wheelchair into other residents' rooms, and an LPN confirmed this happened frequently, yet the behavior log did not document any wandering or rummaging despite the care plan noting those behaviors.
The facility failed to ensure a safe environment for three residents by not adhering to fall prevention protocols. A resident's over-the-bed table was improperly placed, exposing them to potential injury. Another resident's room contained unsafe medical supplies, and a third resident's fall prevention measures were not consistently implemented. The DON confirmed these deficiencies during observations.
A facility failed to monitor the effectiveness of pain medication for a resident, who reported constant pain. The resident had an order for Oxycodone-Acetaminophen to be given every eight hours as needed. However, the medication was administered five times without checking its effectiveness, as confirmed by the DON.
The facility failed to adhere to professional standards for storing and labeling multi-use insulin vials. Inspections revealed that several vials were not dated upon opening and were not discarded after 28 days, as required. This involved multiple residents who were still receiving these medications, and the issue was confirmed by LPNs during the survey process.
The facility failed to provide food in the appropriate consistency for residents requiring modified diets. During a meal service, kielbasa sausage was served without being ground, affecting several residents on mechanical and advanced diets. Additionally, a resident with a right-hand contracture struggled to eat whole pork chops and turkey slices, as their meals were not modified to accommodate their needs.
The facility failed to maintain cleanliness in the A and B hall pantries, with ice machines found unclean and a microwave rusting. The CDM acknowledged the need for cleaning and replacement.
The facility failed to conduct thorough investigations into abuse/neglect allegations, with incomplete resident statements and incorrect documentation. A resident was reported as interviewed despite being hospitalized at the time. The facility has a history of similar deficiencies, with repeated citations for inadequate investigations.
A facility failed to honor a resident's right to receive meal trays in a dignified manner. It was observed that a resident's meal tray was served approximately six minutes after their roommate received theirs. This delay was confirmed in an interview with the Administrator, who acknowledged that the resident should have been served and assisted with eating immediately after the roommate's tray was delivered.
A facility failed to thoroughly investigate an abuse allegation involving a resident. The investigation was incomplete, with undated statements lacking proper documentation and a discrepancy in resident identification. Additionally, the resident was not present during the alleged interview, as they were hospitalized, leading to a deficiency finding.
A facility failed to accurately code a resident's discharge location on the MDS. The resident was transferred to another LTC facility, but the MDS incorrectly indicated a discharge to a short-term hospital. This error was confirmed by the NHA during a survey.
A facility failed to refer a resident with a newly diagnosed major depressive disorder for a level II PASARR review. The diagnosis was added to the resident's electronic medical record, but the last PASARR was completed months earlier, and no referral was made. The DON acknowledged the error during an interview.
The facility failed to implement care plans for two residents. One resident's over-the-bed table was improperly placed on a fall mat, posing a hazard, while another resident, with a history of trauma, was assigned female caregivers despite a care plan specifying same-sex caregivers. The DON acknowledged the issues, noting no alternative interventions for the first resident and a lack of male caregivers for the second.
A facility failed to update a resident's care plan after a three-day intervention of Q one-hour checks for elopement risk. The resident, identified as an elopement risk due to dementia, had interventions in place, but the care plan was not revised after the checks were completed. The DON confirmed the oversight during an interview.
A facility failed to complete an Activity Preference Assessment for a resident within the required seven days post-admission. The assessment was delayed until well after the specified timeframe, as identified during a survey. The DON provided documentation outlining the requirement, and the AD acknowledged the oversight.
The facility failed to follow physician orders for two residents. An LPN administered Vitamin D3 without a specified dosage for a resident, and another resident was given a straw despite an order against it. The DON confirmed the lack of dosage specification, and a Medical Records Worker removed the straw after being alerted. The order for the straw was later changed, and a Speech Therapist confirmed the resident could safely use straws.
A resident with dementia and major depressive disorder exhibited aggressive behaviors, but the facility failed to provide necessary psychiatric consultations or effective interventions. Despite documented behaviors, there were no psychiatric services involved, and the care plan lacked specific strategies to address the resident's needs.
A resident with dementia and major depressive disorder exhibited aggressive behaviors, but the facility failed to provide necessary psychiatric consultations or comprehensive social services. The care plan did not adequately address the resident's psychiatric needs, and interventions were limited to redirection by the LSW.
A resident received Aripiprazole without a current order due to a pharmacy error and an LPN's failure to verify medications against the MAR. The resident had a history of schizoaffective disorder and was previously prescribed Aripiprazole, but the order was to discontinue it. The error was identified when the DON confirmed the absence of a current order.
A resident reported not having upper dentures due to cost and experiencing pain with bottom teeth, making it hard to chew. Despite these issues being noted upon admission, the resident stated that no one had discussed dental coverage or dentures with them, indicating a lack of communication and action from the facility to address dental needs.
A resident was served a lunch tray while asleep, and it remained untouched for nearly an hour. Upon waking, the resident ate the cold food, as confirmed by a nursing assistant who did not reheat the tray before serving.
A resident with a contracture in his dominant hand did not receive a required plate guard during meals, as per physician's orders. This resulted in food spillage on his clothing and bedside table. The resident confirmed the plate guard was only sometimes provided, and a therapist acknowledged its absence.
A facility failed to accurately record a resident's DNR status in the electronic medical record. The resident's POST form indicated a DNR status with Selective Treatments, but the physician orders and dashboard documented CPR. An LPN mentioned using the POST form or dashboard to find lifesaving preferences, but a review showed discrepancies between these records.
The facility failed to implement Enhanced Barrier Precautions for a resident with an indwelling urinary catheter and did not ensure proper hand hygiene during pressure ulcer dressing changes for another resident. An LPN confirmed the need for EBP, and the DON acknowledged the necessity of hand hygiene between wound sites.
Care Plans Not Updated or Implemented for Oxygen, PTSD, Dementia, and Epilepsy
Penalty
Summary
Failure to develop and/or implement complete care plans was identified for residents with PTSD, oxygen therapy, dementia-related interventions, and epilepsy. Resident #5 was observed receiving oxygen via nasal cannula at 3.5 liters per minute, while the physician's order indicated 2 liters per minute, and RN #5 confirmed the observed flow rate did not match the current order or care plan. Resident #82 was diagnosed with epilepsy on 03/27/2026, but the current care plan had not been updated to include epilepsy as an area of focus, with no goals or interventions/tasks in place for that diagnosis; the DON identified the MDS RN as responsible for the care plan, and the MDS RN stated the diagnosis should have been included and was missed. Resident #79 was admitted with a diagnosis of PTSD, but the care plan did not mention PTSD. The DSS stated the diagnosis was not care planned because she was unaware of any triggers and the family was not sure, while psychiatric evaluations documented trauma history, including a car wreck at age 6 and sexual abuse by her father, and later noted the resident was angry due to past trauma. Resident #9's dementia care plan included an intervention for a cup holder on the wheelchair, but the resident was observed multiple times without a cup holder, and the Director of Rehab stated the cup holder should have been on the wheelchair and was not.
Activities Program Did Not Meet Resident Needs and Interests
Penalty
Summary
The facility failed to provide a program of activities to meet the needs and interests of each resident for three residents reviewed. One resident stated he wished someone would come into his room to talk with him and said that visits from Activities had not happened in a long time. His care plan included a goal for 1:1 activities of choice and companionship for conversation, but the Activities Department did not list him among residents receiving one-on-one activities, and his activity participation record showed only one documented 1:1 activity in May and one in June. An Activities Leader acknowledged that she spent time speaking with him while passing meal trays and at other times, but the record did not reflect regular 1:1 activity participation. Another resident’s care plan included an intervention to offer and encourage attendance and involvement in facility activities, and the care plan also stated she was self-directed for activities. Her MDS showed a BIMS score of 1, indicating severe impairment in daily decision-making, and Section F indicated it was somewhat important for her to do things with groups of people and go outside when the weather was good. The activity participation log showed only two group activities in the last three months, with all other activities documented as independent and no refusals of group activities listed. A third resident stated he was not attending church services and group activities because he was not being told about them. His MDS and activity preference interview showed that group activities, Bible study, and religious services were very important to him, but the activity log showed only two group activities and did not document refusals for the religious activities he did not attend.
POST Form Signed by Resident Without Capacity
Penalty
Summary
The facility failed to ensure Resident #83's Virginia Physician's Orders for Scope of Treatment (POST) form was signed by the resident's medical power of attorney while the resident lacked decision-making capacity. The resident's last capacity evaluation showed disorientation and an inability to process information due to dementia, and the Director of Nursing confirmed the resident did not have capacity when he signed the POST form changing his end-of-life wishes. The previous POST form had been signed by the resident's MPOA and indicated full treatment and CPR.
Late Notice of Medicare Non-Coverage to MPOA
Penalty
Summary
The facility failed to provide adequate notice of the last covered Medicare A days to Resident #127's Medical Power of Attorney (MPOA). The facility policy stated that the Notice of Medicare Non-Coverage (NOMNC) would be provided at least 2 days in advance of the last covered day to allow time to appeal if the beneficiary chose. For Resident #127, the NOMNC stated that Medicare coverage of current skilled services would end on 03/04/26, but the telephone notification to the MPOA was not made until 03/06/26 at 10:00 AM. During an interview, the Social Services Designee confirmed that the MPOA was not notified at least 2 days in advance of the end of Medicare-covered skilled services.
Missing Transfer Documentation
Penalty
Summary
The facility failed to provide required transfer information for continuity and coordination of care when residents were sent to an acute care facility. For Resident #120, who had an unplanned acute transfer to the ER after abnormal vital signs, the facility used an Interact Hospital Transfer Form but did not include a copy of the resident’s advanced directives or a list of medications with the last administration time, or the MAR. The Acute Care Transfer Document Checklist was present, but it was not marked to show what documents accompanied the resident, and the progress notes for the transfer did not state what information was sent. The same issue occurred for Resident #10, who lacked capacity to make medical decisions and had impaired communication skills. This resident had two transfers to an acute care facility for acute respiratory symptoms, and the facility again used an Interact Hospital Transfer Form without including a copy of the resident’s advanced directives or a medication list with last administration times, or the MAR. The checklist for documents to accompany the resident was not marked for either transfer, and the progress notes for those transfer dates also did not document what information was sent to the receiving provider.
MDS omitted epilepsy diagnosis
Penalty
Summary
The facility failed to ensure an accurate assessment when Resident #82’s quarterly MDS did not include epilepsy in Section I Current Diagnoses, even though the resident was diagnosed on 03/27/2026 with epilepsy, unspecified, not intractable, without status epilepticus. Resident #82 had been admitted to the facility on [DATE], and the diagnosis was listed in the medical management record as DX #8 During Stay. The last quarterly MDS was completed on 04/30/26, but epilepsy was not check marked on the assessment. During review with the MDS RN on 06/17/2026, she stated she would look into it, and then acknowledged that epilepsy should have been marked and was missed.
PASARR and MDS diagnoses were not matched for two residents
Penalty
Summary
The facility failed to coordinate the PASARR with the MDS for two residents by not including a diagnosis of major depressive disorder on the most recent PASARR, even though the diagnosis was present in the medical record and reflected on the MDS. For Resident #52, the record showed vascular dementia with mood disturbance, major depressive disorder, and adjustment disorder with mixed disturbance of emotions and conduct. The most recent PASARR completed at an acute care facility listed behavioral disturbance and adjustment disorder under other related conditions, but did not check major depressive disorder. The resident was receiving escitalopram for depression, and the MDS completed later checked depression and non-Alzheimer's dementia, with adjustment disorder also typed in. The resident's care plan documented depression and dementia as focus areas. For Resident #82, the medical record documented major depressive disorder, recurrent, mild, unspecified dementia, epilepsy, and generalized anxiety disorder. The most recent PASARR completed by the facility marked only other related conditions and specified dementia, but did not mark major depression under the diagnosis section. The MDS completed later checked non-Alzheimer's dementia and depression, and major depressive disorder, recurrent, mild was added under other active diagnoses. Survey review also identified that the NHA stated the Director of Admissions was responsible for keeping PASARRs up to date, and the PASARRs were reviewed with the Director of Admissions during the survey.
Failure to Notify MD of Out-of-Range Blood Sugars
Penalty
Summary
The facility failed to notify the physician when Resident #130’s blood sugars were outside the ordered parameters. The resident had an order dated 06/04/25 to notify the MD if blood sugar was less than 60 and/or greater than 400. Review of the June 2025 MAR showed blood sugar readings of 424 on 06/07/25, 480 on 06/11/25, 476 on 06/20/25, and 431 on 06/21/25, and the progress notes did not document that the physician was notified for these out-of-range results. During interview, the DON confirmed that, according to the progress notes, the physician was not notified of blood sugars outside the ordered parameters.
Oxygen Therapy Not Administered per Physician Order
Penalty
Summary
Facility failed to ensure oxygen therapy was administered according to the physician's order and the resident's care plan for Resident #5. During observation, the resident was receiving supplemental oxygen via nasal cannula, and the oxygen concentrator was found set at 3.5 liters per minute. The physician's order reviewed for the resident specified oxygen at 2 liters per minute via nasal cannula, making the observed flow rate 1.5 liters per minute higher than ordered. The discrepancy was brought to the attention of facility nursing staff RN #5, and the concentrator setting was then verified and adjusted to the ordered rate.
Inaccurate resident records and behavior documentation
Penalty
Summary
The facility failed to ensure Resident #83's medical record was accurately completed. Resident #83 had a Physician's Determination of Capacity form dated 11/18/25 showing lack of capacity due to dementia, disorientation, and inability to process information, and a surrogacy selection form dated 11/17/25 naming a Medical Power of Attorney as the healthcare surrogate. However, when Resident #83 was admitted to hospice care on 12/3/25, the hospice Long Term Care Status Form was signed by Emergency Contact #2, the resident's sister, rather than the MPOA. The DON confirmed in interview that the hospice admission paperwork was not signed by Resident #83's MPOA. The facility also failed to accurately document Resident #9's wandering behavior. Resident #9 was observed wandering in her wheelchair through the facility and into other residents' rooms, and an LPN confirmed this occurred frequently. Although the care plan stated that Resident #9 wandered throughout the facility and entered others' rooms needing redirection, the June 2026 Behavior Monitoring log showed no wandering or rummaging behaviors, and the DON confirmed the documentation was not correct.
Failure to Maintain Safe Environment and Adhere to Fall Prevention Protocols
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for three residents. For Resident #47, the over-the-bed table was consistently placed on the fall mat beside the bed, exposing the resident to potential injury from the table's metal bottom and wheels in the event of a fall. Despite acknowledgment from an LPN and discussions with the Director of Nursing (DON) and Administrator, no alternative interventions were attempted to make the resident's water more accessible without compromising safety. Resident #56's room contained a bottle of Povidone Iodine Prep Solution on the dresser, which was later found in a drawer with other medical supplies, contrary to safety protocols. The DON confirmed these items should not have been in the resident's room. For Resident #71, the care plan included several fall prevention measures, such as a weighted blanket, hipsters, and fall mats, which were not consistently in place during observations. The DON confirmed the absence of these items, indicating a failure to adhere to the resident's care plan designed to prevent falls.
Failure to Monitor Pain Medication Effectiveness
Penalty
Summary
The facility failed to monitor the effectiveness of pain medications for a resident in accordance with professional standards of practice. This deficiency was identified during a Long-Term Care Survey Process for a resident who reported experiencing constant pain. The resident had an order for Oxycodone-Acetaminophen to be administered every eight hours as needed for pain, starting from November 2024. A review of the Medication Administration Reports for November 2024, December 2024, and January 2025 revealed that the medication was administered five times without subsequent monitoring of its effectiveness. The Director of Nursing confirmed that the effectiveness of the pain medication was not monitored according to the Medication Administration Records.
Failure to Properly Label and Store Insulin Vials
Penalty
Summary
The facility failed to store and label medications in accordance with professional standards of care, specifically concerning multi-use vials of insulin. During an inspection of the A2 and B1 hallway medication carts, it was observed that several vials of insulin, including aspart, Lantus, and Novolog, were not dated when first accessed, and some were not discarded 28 days after opening as required. This was confirmed by the Licensed Practical Nurses (LPNs) present during the inspection. The facility's policy requires that the opened date be recorded on the vial, and the expiration date be determined based on the manufacturer's guidelines, which were not adhered to in these instances. The deficiency involved multiple residents who were still receiving these medications, including residents identified as #83, #85, #80, #62, #51, #61, and #57. The vials lacked packaging inserts, which are necessary to verify the expiration dates, and the handwritten expiration dates on some vials were either illegible or incorrect. This oversight in medication management was identified through random opportunities for discovery during the survey process, indicating a systemic issue with the facility's adherence to medication storage and labeling protocols.
Failure to Provide Food in Appropriate Consistency for Residents
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual dietary needs of residents, as observed during a noontime meal service. Specifically, kielbasa sausage was served to residents on the A unit without being ground, despite the requirement for mechanical and advanced diets. The district food manager discovered the oversight after the meal had been served, and it was confirmed that the dietary manager had not prepared ground kielbasa, mistakenly believing it was not necessary. This affected several residents who required ground meat, as indicated by the Consistency Census Report. Additionally, Resident #37, who has a right-hand contracture and is aphasic, was observed struggling to eat whole pork chops and turkey slices during meal times. The resident's Minimum Data Set indicated the need for assistance due to the contracture, yet the meals were not modified to accommodate this need. The resident was unable to eat the meat served, as confirmed by observations and interviews with the resident and the administrator.
Sanitation Issues in Pantry Equipment
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the A and B hall pantries, specifically concerning the ice machines and a microwave. During an observation, the ice machines in both pantries were found to be unclean, with the grates covered in a white scaly substance and an accumulation of water and a brown slimy substance underneath. The Certified Dietary Manager (CDM) acknowledged the need for cleaning. Additionally, the microwave in the B hall pantry was observed to be rusting, and the CDM agreed that it required replacement. These deficiencies were identified during a facility census of 120 residents.
Repeated Deficiencies in Investigation Process
Penalty
Summary
The facility failed to conduct complete and thorough investigations into allegations of abuse/neglect, as evidenced by a review of a facility-reported incident involving a resident. During the investigation, statements from several residents were found to be incomplete, with missing dates and unclear identification of the staff member who took the statements. Additionally, a statement was incorrectly attributed to one resident but signed by another. Notably, the initial report indicated that the social worker had interviewed the resident involved in the incident, but it was later discovered that the resident was not present in the facility at the time, as they had been sent to the hospital the day before. The facility has a history of being cited for similar deficiencies in past surveys, with three instances of failing to thoroughly investigate allegations noted in previous reports. Despite the administrator's acknowledgment of the ongoing issues with the investigation process and the need for more involvement, the same deficiencies were identified during the current survey. This pattern of repeated citations suggests a lack of effective corrective action and oversight in addressing the quality deficiencies related to investigations.
Failure to Serve Meal Trays in a Dignified Manner
Penalty
Summary
The facility failed to honor a resident's right to receive meal trays in a dignified manner. During the Long-Term Care Survey process, it was observed that a resident's meal tray was served approximately six minutes after their roommate received theirs. This delay was confirmed in an interview with the Administrator, who acknowledged that the resident should have been served and assisted with eating immediately after the roommate's tray was delivered.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. The incident was reported to have occurred at the facility, and the investigation process was found to be incomplete and inconsistent. The facility interviewed several residents who were in similar conditions to the resident involved in the allegation. However, the statements collected from these residents were not properly documented, as they were undated and lacked identification of the employee who took the statements. Additionally, there was a discrepancy in one of the statements, where the name of one resident was at the top of the form, but it was signed by another resident. Furthermore, the initial report indicated that the social worker had interviewed the resident involved in the allegation, but no statement from this resident was found. Upon further investigation, it was revealed that the resident was not present in the facility at the time the social worker claimed to have conducted the interview, as the resident had been sent to the hospital a day prior. The social worker later clarified that the initial report should have stated that he spoke with the resident's representative instead. This lack of thorough investigation and documentation led to the deficiency identified during the survey process.
Inaccurate Discharge Location Coding on MDS
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident's discharge location, as identified during a long-term care survey. Specifically, the Discharge Minimum Data Set (MDS) for a resident was inaccurately coded. The resident's medical record indicated a transfer to another long-term care facility, but the MDS was incorrectly coded to reflect a discharge to a short-term general hospital. This discrepancy was confirmed during an interview with the Nursing Home Administrator, highlighting a failure in accurately documenting the resident's discharge destination.
Failure to Refer Resident for Level II PASARR Review
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed serious mental health disorder for a level II review, as required by the pre-admission screening and resident review (PASARR) program. This deficiency was identified during a record review and staff interviews, where it was found that a major depressive disorder was added to the electronic medical record of a resident on November 4, 2024. However, the last PASARR was completed on June 3, 2024, and no subsequent referral for a level II review was made. During an interview, the Director of Nursing acknowledged the oversight.
Failure to Implement Care Plans for Accident Hazards and Same-Sex Caregivers
Penalty
Summary
The facility failed to implement the care plan for Resident #47 regarding accident hazards in his room. Observations on multiple occasions revealed that the resident's over-the-bed table was placed on the fall mat beside his bed, exposing the metal bottom and wheels, which posed a risk if the resident were to fall out of bed. Despite the care plan's directive to ensure the resident's room was free of potential visible hazards, the table remained on the mat. The LPN acknowledged the table's placement and stated it was usually there because the resident needed to reach his water. The Director of Nursing (DON) confirmed that no alternative fall interventions had been attempted to make the water more accessible without placing the table on the fall mat. The facility also failed to implement the care plan for Resident #99, which specified the need for same-sex caregivers due to the resident's history of physical trauma and risk for impaired psychosocial well-being. A review of the nursing assistant assignment sheets showed that the resident was consistently assigned a female caregiver, contrary to the care plan's intervention. During an interview, the DON admitted that the facility did not have male caregivers available and was unaware of why the care plan included this requirement.
Failure to Revise Care Plan for Elopement Risk
Penalty
Summary
The facility failed to revise the care plan for a resident identified as an elopement risk due to dementia and wandering behaviors. The resident's care plan included interventions such as applying a secure device, assessing for basic needs, and providing diversionary activities. An intervention for Q one-hour checks was initiated for a three-day duration starting on 07/09/24. However, the care plan was not updated after the three-day period, as confirmed by the Director of Nursing (DON) during an interview. The deficiency was discovered during a record review and staff interview conducted on 01/23/25. The DON acknowledged that the care plan should have been revised after the three-day period of Q one-hour checks, but it was not. This oversight was identified as a failure to update the care plan in accordance with the resident's current needs and interventions, as the checks were no longer necessary after the specified duration.
Failure to Timely Complete Activity Preference Assessment
Penalty
Summary
The facility failed to provide an ongoing program of activities to support the needs of each resident, as evidenced by the lack of a timely Activity Preference Assessment for a resident. The resident was admitted on an unspecified date, but the activity preference interview was not completed until November 11, 2024, which was beyond the required seven-day period post-admission. This deficiency was identified during a long-term care survey process. The Director of Nursing provided documentation indicating that the Activity Preference Assessment should be completed within seven days of admission or readmission and then annually. The Activity Director acknowledged that the assessment should have been completed by the seventh day.
Failure to Follow Physician Orders for Medication Dosage and Dietary Restrictions
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For Resident #42, a Licensed Practical Nurse (LPN) administered Vitamin D3 from a floor stock bottle without a specified dosage in the physician's order. The order, written on 01/11/25, instructed to give one tablet by mouth daily for vitamins but did not specify the dosage. This oversight was confirmed by the Director of Nursing on 01/22/25, indicating a lack of clarity in the medication administration process. For Resident #88, a physician's order dated 11/29/24 specified a regular diet with dysphagia advanced texture, thin liquids consistency, double entree portions, and no straws. However, on 01/27/25, the resident was observed with a straw in a Styrofoam cup, contrary to the order. A Medical Records Worker confirmed the discrepancy and removed the straw with the resident's permission. The order was later changed to allow straws, and a Speech Therapist confirmed the resident was safe to use them. These incidents highlight lapses in following physician orders and ensuring accurate communication among staff.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, leading to a deficiency in maintaining the highest practicable physical, mental, and psychosocial well-being. The resident, who has diagnoses including dementia with mood disturbance, generalized anxiety disorder, and major depressive disorder with psychotic features, exhibited behaviors such as verbal and physical aggression. Despite these behaviors being documented over a period of time, the facility did not have any psychiatric consultations recorded in the resident's medical record, indicating a lack of appropriate psychiatric intervention. Additionally, the care plan for the resident identified risks related to impaired psychosocial well-being and outlined interventions such as using same-sex caregivers and removing clothing slowly. However, there were no social service notes addressing how the facility was assisting the resident with his behaviors and psychiatric issues. Interviews with staff, including the Director of Nursing and a Licensed Social Worker, revealed that the resident had not been seen by psychiatric services since admission, and there were no personal interventions in place to manage his aggressive behavior effectively.
Failure to Provide Medically-Related Social Services for Resident
Penalty
Summary
The facility failed to provide necessary medically-related social services to a resident, identified as Resident #99, to help achieve the highest practicable physical, mental, and psychosocial well-being. Resident #99 has a history of dementia with mood disturbance, anxiety, generalized anxiety disorder, and major depressive disorder with psychotic features. A review of the resident's behavior monitoring and interventions report revealed that the resident exhibited behaviors on 15 days since October 1, 2024, and had 13 additional behavior notes from nursing. Despite these documented behaviors, the resident's medical record lacked any psychiatric consultations. The care plan for Resident #99 identified a risk for impaired psychosocial well-being due to a history of physical trauma and aggressive behaviors. However, the interventions listed, such as using a same-sex caregiver and removing clothing slowly, did not address the resident's psychiatric needs. Interviews with the Director of Nursing and the Licensed Social Worker confirmed that the resident had not been seen by psychiatric services since admission and had no personal interventions for aggressive behavior. The social worker's approach was limited to redirecting the resident to sit down, indicating a lack of comprehensive social services to address the resident's needs.
Medication Error Due to Lack of Verification
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of a medication without a current physician's order. During a medication administration observation, an LPN administered medications to a resident, including Aripiprazole, which was not listed in the resident's current Medication Administration Record (MAR). The resident had a history of being prescribed Aripiprazole for schizoaffective disorder, but an order to gradually reduce and then discontinue the medication had been made previously. Despite this, the pharmacy continued to dispense the medication, and the LPN did not verify the absence of a current order before administration. The error was identified when the Director of Nursing (DON) confirmed that the resident's physician's orders did not include Aripiprazole. The pharmacy acknowledged their mistake in not updating the order to discontinue the medication. However, the LPN's failure to cross-check the medications with the MAR before administration contributed to the error. This oversight had the potential to affect the resident's health, as the medication was administered without a valid order.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to ensure that residents were provided with necessary dental services, as evidenced by the case of one resident out of four reviewed for dental services during the Long-Term Care Survey process. The resident expressed during an interview that they did not have upper dentures due to the high cost and were experiencing pain with their bottom teeth, which sometimes made it difficult to chew. A record review indicated that the resident had reported mouth or facial pain and difficulty chewing upon admission. Despite these issues, the resident stated that no one had discussed dental coverage or dentures with them, highlighting a lack of communication and action from the facility to address the resident's dental needs.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable temperatures, as observed during a survey. A resident was served a lunch tray at 12:55 PM while asleep, and the tray was left untouched until 1:50 PM when a nursing assistant entered the room. The nursing assistant stated that trays are usually left for about an hour if not eaten. The resident woke up at 2:10 PM, expressed hunger, and began eating with a butter knife before being given a spoon by the nursing assistant. By 2:30 PM, the resident had eaten most of the food and commented that it was cold. The nursing assistant confirmed that the tray was not reheated before the resident ate it.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide ordered assistive eating devices for a resident, identified as Resident #51, who required a plate guard to assist with eating due to a contracture in his dominant right hand. On two separate occasions, the resident was observed eating without the necessary plate guard, resulting in food on his clothing and bedside table. The resident's physician's orders, dated 01/06/25, specified the need for a plate guard as part of his regular diet with dysphagia advanced texture and thin liquids consistency. Despite these orders, the resident did not receive the plate guard, which he confirmed was only sometimes provided, and acknowledged that it helped him feed himself. A therapist confirmed the absence of the plate guard during the survey process.
Inaccurate DNR Status Recording in Medical Records
Penalty
Summary
The facility failed to accurately record the Do Not Resuscitate (DNR) status of a resident in the electronic medical record. The resident's POST form, which was signed and dated, indicated a DNR status with Selective Treatments. However, the physician orders and the dashboard in the electronic health care record documented CPR instead. During an interview, an LPN stated that she would refer to either the POST form or the dashboard in the medical record to find a resident's lifesaving preferences. A record review revealed a discrepancy between the dashboard and the POST form, indicating a failure to maintain consistent and accurate records of the resident's DNR status.
Inadequate Infection Control and Hand Hygiene Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Specifically, Resident #51, who had an indwelling urinary catheter, did not have the required EBP signage on his door, nor was personal protective equipment (PPE) readily available at his doorway. This oversight was confirmed by Licensed Practical Nurse (LPN) #82, who acknowledged the need for EBP due to the resident's condition but did not provide further information on corrective actions during the survey process. Additionally, the facility failed to ensure proper hand hygiene during pressure ulcer dressing changes for Resident #31. Registered Nurse (RN) #75 was observed performing dressing changes on multiple pressure ulcer sites without performing hand hygiene between glove changes. Despite changing gloves several times, RN #75 did not sanitize her hands when moving between different wound sites, which was acknowledged as necessary by the Director of Nursing (DON). This lack of adherence to hand hygiene protocols during wound care was noted as a deficiency in the facility's infection control practices.
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What surveyors actually found near you
We read the 61 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bluefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westwood Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Bluestone Health And Rehabilitation | 1.3 mi | ★★★★★ | 35 | 1 |
| Bland County Nursing & Rehab Center | 6.6 mi | ★★★★★ | 8 | 0 |
| Glenwood Healthcare Center | 7.8 mi | ★★★★★ | 0 | 0 |
| Princeton Health Care Center | 9.8 mi | ★★★★★ | 10 | 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 August 2026) and official state health department websites.