Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Moundsville Healthcare Center during CMS and state inspections, most recent first.
Two residents experienced deficiencies in medical record documentation: one had a care plan that inaccurately reflected dietary preferences regarding egg consumption, while another had inconsistent documentation of incontinence status despite having an indwelling urinary catheter. The DON confirmed the documentation errors and noted that some CNAs were new and required further training.
Medication carts were left unlocked and unattended on two halls while an LPN was away from the cart. One LPN left the cart unlocked while responding to a resident calling out, and another LPN stated she thought she had locked the cart. The facility policy stated medication carts should not be left unlocked, and the DON confirmed carts should be locked whenever unattended.
Incomplete documentation of pain management was identified for a resident receiving Tramadol. The MAR did not match the controlled substance record for multiple administrations, and several doses were removed from supply without being recorded on the MAR. When pain was documented, non-pharmacological interventions were sometimes not attempted or were listed only by number without explanation, and the record did not consistently show the resident’s pain level or whether the medication was effective. The DON confirmed the discrepancies and missing documentation.
A resident’s care plan noted a caffeine-free diet due to religious beliefs, but the dietary order only reflected a lacto-ovo vegetarian diet. Dietary slips listed coffee and tea at lunch and dinner, and the FSD confirmed the facility’s coffee and tea contained caffeine. The resident’s MPOA stated that avoiding caffeine was an absolute religious requirement.
Food was not served at an appetizing temperature and was not palatable. A resident reported that hot food was lukewarm and another said the food was bad. A tray check found an egg salad sandwich and milk served at low temperatures, and surveyors found diced potatoes lacked seasoning. Staff also confirmed they often had to reheat one resident’s food because it was cold at the point of service.
Failure to provide evening snacks: Residents reported they were not offered a bedtime snack unless they asked, and one resident said he was not getting enough food and preferred juice or tea instead of kool aid. At resident council, attendees said snacks were not available even when requested because they were kept in the kitchen, and during an evening observation multiple residents and staff confirmed no snack was offered.
Food Storage and Sanitation Deficiencies: The DON acknowledged multiple food safety and sanitation failures, including soiled kitchen and dining room equipment, dirty storage areas, spoiled and outdated food items, and numerous unlabeled or undated foods and ingredients. Observations also found cleaning cloths not stored in sanitizer, a meat slicer left uncovered, wet nesting tumblers on a beverage cart, and paint chipping and peeling on the kitchen ceiling and exhaust hood.
Failure to notify the physician of a resident's low O2 sats and refusal of BiPAP. A resident with CHF, acute hypoxic respiratory failure, and COPD had O2 sats of 89% while on 6 L NC. Staff attempted BiPAP, but the resident did not tolerate it, said he could not breathe, and was returned to NC per request. The record had no evidence that the attending physician was notified, and the DON confirmed no proof of notification was available.
Failure to protect resident record privacy during med pass. An LPN was observed leaving a computer screen unlocked and shift report sheets visible on the 200 hall medication cart while caring for a resident who had been calling out. The DON later confirmed the screen should have been locked and the shift report sheets covered.
The facility failed to provide a written Notice of Transfer/Discharge to two residents who were transferred to the hospital for aspiration pneumonia. Although an Acute Transfer Letter was scanned into the record, it did not include appeal rights, instructions for obtaining and submitting an appeal, or the LTC Ombudsman contact information.
A resident had a PASARR on file, but after admission the medical record was updated with new diagnoses including vascular dementia, anxiety disorder, psychotic disorder, and auditory hallucinations. The Administrator confirmed a new PASARR should have been completed when these diagnoses were added.
A resident’s admission PASARR did not reflect the resident’s Major Depression Disorder. The PASARR marked current diagnosis and major mental illness as NONE, and the SW stated the diagnosis had not been captured on the admission PASARR and a new PASARR had not been completed.
Failure to assess and treat a pre-existing pressure ulcer: A resident admitted with a right buttock pressure ulcer did not have the wound documented on the admission nursing eval or H&P, and no pressure ulcer assessment was completed on admission. The NP later identified the wound as a stage 3 ulcer, but treatment orders were not written until later and nursing treatment did not begin until the next day; the TAR showed no treatment was provided initially, and the first RN skin grid assessment was delayed.
An LPN handling meds for a resident dropped a pill, picked it up with a bare hand, and split a potassium chloride tablet with bare hands despite the facility policy requiring no direct contact and gloves for splitting tablets. In a separate observation, a used urinal was found improperly stored in a bathroom, lying on top of urinary supplies in a basin instead of being bagged.
Failure to Follow Approved Menus and Recipes: Surveyors found that the kitchen made random substitutions instead of serving the foods listed on the approved menu and tray tickets. A dessert, a vegetable, and a potato side were each replaced with different items, and the HCSG District Manager acknowledged the substitutions.
A resident with a history of exit-seeking behavior eloped from the facility and was found two blocks away. Despite previous warnings and an alarm system, the facility failed to prevent the elopement, placing the resident at risk. The alarm was not responded to promptly, and video evidence was unavailable, contributing to the deficiency.
A resident eloped from the facility through an emergency exit, and the incident was not addressed for 30 minutes. The facility's administrator could not confirm if the alarms were functioning at the time, and video evidence was unavailable. A live test showed the alarm system was operational, but the keypad to disable the alarm was not clearly visible.
Two residents experienced inadequate pain management due to the facility's failure to provide appropriate interventions and medication. One resident with a humerus fracture received only Tylenol, which was ineffective, while another resident's pain was not regularly assessed or treated despite having a prescription for Acetaminophen. Staff interviews confirmed a lack of awareness and proactive management of the residents' pain.
The facility failed to maintain an effective infection prevention program, impacting water management, laundry, and meal services. The water management program lacked documentation to prevent waterborne pathogens, and the laundry area lacked proper separation and ventilation. Additionally, a nurse aide improperly handled a meal tray, indicating a lack of infection control understanding. These issues potentially affected all 120 residents.
A resident's preference for day showers was not consistently honored, leading to dissatisfaction. Despite repeated requests to avoid night showers due to discomfort with wet hair, the facility alternated the schedule to balance shower distribution between shifts, as confirmed by staff interviews.
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in communication, nutrition, pain management, and the use of positioning devices. One resident's care plan omitted the use of a necessary communication tool, another experienced significant weight loss without proper notification, and a third used a pommel cushion without an order or care plan documentation.
The facility failed to meet the activity needs of two residents. One resident was not assisted into their wheelchair, preventing participation in group activities, while another remained in bed due to discomfort from a lift sling and lack of a chair. Staff confirmed the absence of necessary equipment and facilitation for group activity participation.
A facility failed to follow professional standards for tube feeding, as a resident's MAR showed inconsistencies in documenting tube feeding bolus administration. The resident had a physician's order for tube feeding if oral intake was less than 50%, but records lacked clear documentation of whether the bolus was given. An LPN confirmed the documentation errors, indicating a deficiency in the facility's practices.
The facility failed to store food safely, with several items in the kitchen's refrigerator and freezer found to be out of date, potentially leading to foodborne illness. The Dietary Manager confirmed the expired items, which included chicken noodle soup, sliced cheese, Parmesan cheese, pepperoni, and tomato sauce. This failure to adhere to the facility's food storage policy could affect more than a limited number of residents.
The facility failed to provide timely and dignified meal service to residents, as observed in several instances. A resident received her meal tray after her roommate, despite her complaints, due to disorganized tray distribution. Another resident was served significantly later than others at her table, and a third resident received her meal much later than her roommate due to incorrect tray placement. Staff interviews confirmed the lack of order in meal service.
A resident was not provided with a geriatric chair for transportation to activities, despite expressing a desire to participate and discomfort with the mechanical lift sling. Staff confirmed the absence of a chair, and there were no orders for one. Additionally, the facility failed to post the Ombudsman's contact information at a level accessible to residents in wheelchairs, as confirmed by observations and the administrator.
A confidentiality breach occurred when an RN left a computer screen displaying resident information unattended in the hallway. The RN, who was administering medication, acknowledged the mistake upon returning to the cart, noting it was an unusual oversight.
A facility failed to ensure an accurate MDS assessment for a resident who had a fall resulting in a fractured hip. The MDS incorrectly indicated no falls since the prior assessment, which was later confirmed as an error by the MDS RN.
A facility failed to invite a resident's representative to care plan conferences, as required. The representative attended only one conference in the past year, shortly after the resident's admission. The DSS confirmed that the task of sending invitations was neglected after the ADON left. A review of sign-in sheets showed the representative attended one out of six conferences.
A resident with a broken shoulder reported severe pain and inadequate pain management at the facility. Despite the absence of a physician's order, an LPN administered Tylenol, which did not alleviate the pain. The resident was informed that additional Tylenol was unavailable for several hours. The DON and Administrator were notified of the medication administration without a proper order.
A resident with a contracture and muscle pain in her left hand did not have a physician-ordered palm guard in place during multiple observations. The care plan required the use of a palm guard, but it was found in the laundry and not returned for two days. The interim DON was unaware of any refusal by the resident to wear the guard, and the TAR inaccurately indicated it was applied. An LPN confirmed the guard was eventually retrieved and placed on the resident.
The facility failed to store insulin in accordance with professional standards, as two medication carts contained vials of Lantus insulin opened for more than 28 days. A resident's insulin vial in the 600 hallway cart was opened on 02/28/24, and another resident's vial in the 300 hallway cart was opened on 02/25/24. Both residents had daily insulin orders, and the product information specifies a 28-day usage period for opened vials.
The facility failed to maintain complete and accurate medical records for two residents. One resident's refusal to wear heel protectors was not documented, despite staff acknowledging the refusal, and the Treatment Administration Record inaccurately showed compliance. Another resident's care plan included PTSD, but this diagnosis was missing from their medical records, as confirmed by the administrator.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the care plan documented by activity staff stated that the resident did not eat meat, fish, eggs, or caffeine due to religious beliefs. However, the dietary order specified a lacto-ovo vegetarian diet, which includes eggs and dairy. The resident's Medical Power of Attorney confirmed that eggs were an important part of the resident's diet, and the Director of Activities acknowledged that the care plan needed updating to accurately reflect the resident's current dietary preferences, which included eggs. For another resident, record review revealed multiple inaccuracies in the documentation of bladder incontinence status. Despite the resident having an indwelling urinary catheter for obstructive uropathy, documentation inconsistently recorded the resident as incontinent on several dates, rather than indicating that continence could not be rated due to the catheter. The Director of Nursing verified the presence of the indwelling catheter and recognized the need for additional training for CNAs, as some were new and had not documented the resident's status correctly.
Unlocked Medication Carts Left Unattended
Penalty
Summary
The facility failed to ensure medication carts were locked when nurses were not in attendance, as required by its Medication Administration policy, which states, "Do not leave medication cart unlocked." On 12/10/25 at approximately 8:50 AM, an observation on the 200 hall found a medication cart unlocked and unattended for about three minutes while LPN #127 was in Resident #15's room after the resident was calling out. LPN #127 stated, "I went into the room when the resident was calling out. I know I shouldn't have left my cart unlocked." Later that morning, at approximately 9:12 AM, another observation on the 600 hall found a medication cart unlocked and unattended for about six minutes. LPN #33, who was responsible for the 600 hall medication cart, stated, "I thought I had locked it." The DON confirmed that the medication cart should be locked at all times when unattended.
Incomplete Documentation of Pain Medication Administration
Penalty
Summary
Documentation of pain management for a resident receiving Tramadol was not completed in accordance with professional standards of practice. For Resident #90, the record showed multiple instances in which Tramadol was removed from the controlled substance supply, but those administrations were not recorded on the MAR. On 11/29/25, the resident had a pain level of 8, non-pharmacological interventions of repositioning, conversation, and redirection were attempted, and the medication was documented as effective; however, the MAR did not reflect the administration. The controlled substance record also showed additional Tramadol removals on 11/21/25, 11/22/25, 11/23/25, 11/24/25, 11/28/25, 11/29/25, and 11/30/25 that were not documented on the MAR, and the resident’s pain level, interventions, and medication effectiveness were not documented for those occasions. Review of the December 2025 MAR showed further Tramadol administrations that were documented inconsistently. On 12/01/25, the resident had a pain level of 8 and no non-pharmacological interventions were attempted, though the medication was effective. On 12/08/25, the resident had a pain level of 5, non-pharmacological interventions were listed only as numbers 1 and 4 without explanation, and the medication was effective. On 12/09/25, the resident had a pain level of 8, no non-pharmacological interventions were attempted, and the medication was effective. The controlled substance record showed additional Tramadol removals on 12/04/25, 12/05/25, 12/06/25, 12/07/25, 12/08/25, and 12/09/25 that were not recorded on the MAR. The DON confirmed the discrepancies between the MAR and the controlled substance record and confirmed that the medical record lacked documentation of pain level, non-pharmacological interventions, and effectiveness for the administrations not documented on the MAR.
Failure to Honor Caffeine-Free Religious Diet
Penalty
Summary
The facility failed to accommodate a resident’s dietary needs related to religious beliefs. Resident #110’s care plan stated that the resident did not ingest caffeine because of her religious beliefs, but the dietary order only listed a Lacto-Ovo Vegetarian Diet. A lacto-ovo vegetarian diet excludes meat, poultry, and fish, but it does not address a caffeine-free requirement. The resident’s Medical Power of Attorney stated that remaining caffeine-free was an absolute requirement due to the resident’s religious beliefs and that the resident had been fervent about avoiding caffeine throughout her life. Review of the resident’s dietary slips showed coffee and tea listed for every lunch and dinner meal. The Food Service Director stated that the facility’s coffee and tea contained caffeine and that the dietary slip would need to be updated to reflect caffeine free.
Food Served at Improper Temperature and Not Palatable
Penalty
Summary
Food and drink were not served at a palatable, attractive, and safe appetizing temperature. Resident #42 stated during interview that the food "sucks" and that hot food was "lukewarm at best," and Resident #51 stated that the food was bad. During a tray temperature check on the 200 hall, the Food Service Director and District Manager recorded an egg salad sandwich at 65.4 degrees F, with two cartons of milk on the tray at 57.6 degrees F and 59.1 degrees F. Three surveyors also tasted the diced white potatoes and found them not palatable and lacking seasoning. Resident #99 stated that food was always cold and staff would heat it in the microwave, and Staff #8 and Staff #98 confirmed they frequently had to reheat that resident's food because it was cold at the point of service.
Failure to Provide Evening Snacks
Penalty
Summary
The facility failed to ensure a substantial/nourishing snack was provided between the evening meal and breakfast for residents who wanted one. Resident #115 reported during interview that he was not offered a bedtime snack and only received one if available and if he asked for it. Resident #39 reported that he was not given enough food, preferred juice and tea instead of kool aid, said the food was often cold, and stated that bedtime snacks were not provided unless residents asked for them. During an interview with the DON, she said she would discuss extra portions with the dietician. At the resident council meeting, residents raised concerns about snacks and stated they did not receive snacks and did not get them even when they asked because the snacks were kept in the kitchen and the kitchen was not always accessible. During the evening observation, multiple residents, including residents with documented cognitive intactness or capacity, stated they had not been offered an evening snack but would have liked one. Several staff members interviewed during the same evening also stated they had not offered residents an evening snack.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards, and it also failed to maintain equipment in safe operating condition. During an initial walkthrough of the kitchen and nourishment room, the Director of Dining acknowledged multiple sanitation and storage issues, including cleaning cloths left on counters instead of in sanitizer, chipped and cracked cool check containers, soiled surfaces on the reach-in cooler, stove top, grease trap, steamer, convection ovens, can opener, knife rack, microwave, toaster, juice machine nozzles, handwashing sink, and dining room refrigerator, as well as dirty shelves and debris in multiple food storage and preparation areas. The observation also identified spoiled potatoes with gnats and juice on the floor, employee beverage storage in the dry food room, trash receptacles without liners, and a meat slicer left uncovered while not in use. The report also documented numerous food labeling, dating, and storage problems, including opened or prepared foods and ingredients without open dates, use-by dates, or proper labels, as well as several items that were outdated. These included shrimp, ravioli, beef patties, oatmeal raisin cookies, cream of chicken soup, sliced American cheese, tomatoes, parmesan cheese, beef base, mustard, Italian dressing, egg salad, homemade cole slaw, roll dough, chicken gravy mix, raisin bran, toasted oats, dry white rice, spices, angel food cake, whipped spreads, and a Lunchable in the dining room refrigerator. Additional concerns included wet nesting tumblers on a beverage cart, a soiled scoop stored on top of the popcorn maker, and paint chipping, cracking, and peeling on the kitchen ceiling and exhaust hood.
Failure to Notify Physician of Low Oxygen Saturation and BiPAP Refusal
Penalty
Summary
The facility failed to consult a resident's physician when the resident experienced a change in condition related to low oxygen saturation levels. Resident #125 was admitted as a skilled care patient with diagnoses including congestive heart failure, acute hypoxic respiratory failure, and an acute exacerbation of COPD. The record showed an order for oxygen at 1-5 L via nasal cannula continuously every shift for COPD/shortness of breath. A nurse's note documented oxygen saturations of 89% while the resident was on 6 L oxygen via nasal cannula, and an attempt was made to place the resident on BiPAP. The resident did not tolerate BiPAP, stated he could not breathe, said he had never used it at home and only in the hospital, and was returned to nasal cannula per his request. Frequent coughing was also documented. There was no evidence in the electronic medical record that the attending physician was notified of the resident's low oxygen saturations and refusal to wear BiPAP. During interview, the DON confirmed the facility was unable to produce evidence that the physician had been notified of the resident's low O2 sats and refusal to wear BiPAP.
Failure to Protect Resident Record Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure privacy and confidentiality of medical records for Resident #15 during medication administration. On 12/10/2025 at 8:50 AM, an observation on the 200 hall showed a computer screen left unlocked and written shift report sheets visible to anyone passing by the medication cart. At 8:53 AM, LPN #127 exited Resident #15’s room into the hallway and stated that the resident had been calling out, and that the computer screen should not have been left unlocked and the shift report sheets should not have been visible. At 9:35 AM, the DON was notified and confirmed that the computer screen should have been locked and the shift report sheets should have been covered.
Failure to Provide Required Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide residents or their resident representatives with a written Notice of Transfer/Discharge when residents were transferred to the hospital. Record review showed that Resident #25 was transferred to the hospital for aspiration pneumonia, and the electronic medical record contained a scanned Acute Transfer Letter, but there was no separate Notice of Transfer/Discharge letter in the record. Resident #123 was also transferred to the hospital for aspiration pneumonia, and the record likewise contained a scanned Acute Transfer Letter but no separate Notice of Transfer/Discharge letter. During interview, the Administrator stated that the facility had combined the prior Notice of Transfer/Discharge form and the bed-hold form into one form. The Administrator acknowledged that the Acute Transfer Letter did not include the resident's appeal rights, including the name, address, and telephone number of the entity receiving appeal requests, information on how to obtain an appeal form and assistance with completing and submitting the appeal hearing request, or the name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.
Failure to Complete New PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for a resident who developed newly evident mental health diagnoses after admission. Record review showed the resident had a PASARR dated 03/07/23, and later diagnoses were added to the medical record, including vascular dementia, anxiety disorder, psychotic disorder, and auditory hallucinations. During the survey, the Administrator confirmed that these diagnoses were added after admission and that a new PASARR should have been completed. The Administrator also stated that Social Services had started a new PASARR.
PASARR Did Not Reflect Resident’s Depression Diagnosis
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one resident reviewed. Resident #32 was admitted with a diagnosis of Major Depression Disorder, but the admitting PASARR marked Section III Question 30, Current Diagnosis, as NONE and also marked Section V Question 40, Major Mental Illness (MI) or Suspected MI, as NONE. During interview, the Social Worker stated that the resident’s Major Depression Disorder diagnosis had not been captured on the admission PASARR and that a new PASARR had not been completed.
Failure to Assess and Treat a Pre-Existing Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for a resident admitted with an existing right buttock pressure ulcer. The resident was admitted with skin integrity issues, but the admission nursing evaluation documented only non-pressure skin issues, and the physician’s history and physical also noted only bruising with no pressure wound identified. A progress note on admission referenced a report from the hospital that the resident had a stage 2 wound covered by a border foam dressing, but there was no documented pressure ulcer assessment at that time. On 12/1/25, the NP identified a pre-existing ulcer of the right buttock and completed a wound assessment report documenting a stage 3 pressure ulcer measuring 1 cm x 1 cm x 0.3 cm and present on admission. Physician orders for treatment were written on 12/1/25 to begin on 12/2/25, and the care plan reflected that the resident had been admitted with a stage 3 pressure ulcer. The treatment administration record for November showed no treatment was provided for the right buttock pressure ulcer, and the first skin grid pressure assessment by the facility RN was not completed until 12/8/25. The DON and wound care nurse confirmed there was no documentation that the pressure ulcer had been assessed on admission, no documented pressure ulcer assessment until 12/1/25, and treatment was not ordered until 12/1/25 and not started until 12/2/25.
Infection Control Lapses During Medication Handling and Urinal Storage
Penalty
Summary
The facility failed to maintain an infection prevention and control program during medication administration when an LPN handling medications for Resident #15 dropped a white round pill, picked it up with a bare hand, and then broke a potassium chloride 20 mEq pill with bare hands. The facility’s medication administration policy stated not to touch medication when opening a liquid or dose pack and that gloves must be worn for splitting tablets. During the observation, the LPN stated that the pill should not have been picked up with a bare hand and that gloves should have been worn when breaking the potassium chloride tablet. The DON was later notified and confirmed the medication should not be picked up or broken with bare hands. The facility also failed to ensure proper storage of a used urinal in Resident #7’s bathroom. During an observation, a used urinal was found laying on top of a foley insertion kit and a foley drainage bag inside a pink bath basin, and the urinal was not in a proper storage bag. An LPN removed the urinal, urinary supplies, and basin from the bathroom and stated that the urinal should be bagged and not left laying on top of the urinary supplies in a bath basin. The DON was later notified and confirmed the urinal was not stored properly.
Failure to Follow Approved Menus and Recipes
Penalty
Summary
The facility failed to meet residents’ nutritional needs in accordance with established national guidelines by not following the approved menu and recipes. During observation, record review, and staff interview, surveyors found that the kitchen made random substitutions of food items instead of serving the foods listed on the menu and tray tickets. On the lunch meal on 12/08/25, carrot cake with cream cheese frosting was listed on the menu, tray tickets, and facility postings, but angel food cake was served instead. On 12/09/25, buttered green peas were listed, but whole kernel corn was served instead. On 12/10/25, garlic and rosemary roasted red skin potatoes were listed, but diced white potatoes were served instead. The District Manager for HCSG acknowledged each substitution at the times noted in the report.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide a safe environment for a resident, leading to an elopement incident. The resident, who had a history of attempting to exit the building and displaying aggressive behavior, managed to leave the facility unattended. On the day of the incident, the resident was found two blocks away by an off-duty staff member and was subsequently returned to the facility. The resident's behavior included agitation, verbal aggression, and physical threats towards staff, which were documented in the facility's records. The incident occurred despite previous warnings of the resident's intentions to leave the facility. Staff notes indicated that the resident had expressed a desire to 'break out' and had been redirected by staff, but these measures were insufficient to prevent the elopement. The facility's alarm system, which was supposed to alert staff to unauthorized exits, was not responded to in a timely manner, and the administrator could not confirm if the alarms were functioning at the time of the incident. Video evidence of the elopement was unavailable as it was only retained for two weeks. The facility's failure to prevent the resident's elopement placed the resident at risk and resulted in an Immediate Jeopardy situation. The lack of immediate response to the alarm and the inability to provide video evidence of the incident were significant factors in the deficiency. The resident's continued agitation and combative behavior after returning to the facility further highlighted the need for a more effective supervision and intervention strategy to ensure resident safety.
Removal Plan
- The facility completed training with all staff.
- Training included increased behavior/elopement education.
- All staff have the responsibility to notify appropriate team members if they observe an increase or change in residents' behaviors.
- Different departments have different interactions with residents daily and assist with providing the best care possible by ensuring clear communication is had between departments.
- CNA's can create clinical alerts for nursing to review and managers can report in daily meetings.
- It is every staff member's responsibility to investigate the situation if they hear an alarm going off.
- If a door is found to be open, a headcount is to be initiated by each nurse on their respective hall.
- Staff were expected to complete a post-test that included three questions.
Failure to Investigate Resident Elopement
Penalty
Summary
The facility failed to thoroughly investigate the elopement of a resident, which was identified as a deficiency by surveyors. The incident occurred when the resident exited the facility through the front door via an emergency exit at 7:03 PM and was not noticed until 7:35 PM when an off-duty RN alerted the staff. The facility's administrator could not confirm if the doors were alarmed at the time of the incident and could not provide video evidence as it was only retained for two weeks. The administrator stated that the alarms were functioning properly when tested after the event. During the survey, the surveyors requested a live test of the alarms, which demonstrated that the emergency delayed egress on the door was functioning as designed, with a shrill alarm audible around the door's proximity. A repeater alarm was also audible at the nurse's station, indicating that the alarm system was operational. However, the surveyors noted that the keypad to disable the alarm was not clearly visible from the door, and a staff member was observed rushing to disable the alarm without initially identifying the reason for the alarm.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for Resident #318, who had been experiencing severe pain due to a right humerus fracture since their admission on 03/11/24. Despite the resident's complaints of pain, the facility did not have any orders for non-pharmacological interventions or pain medications other than Tylenol, which was not effective. The resident's pain was not adequately addressed, and there was a lack of proper documentation and follow-up on the resident's pain management needs, as confirmed by interviews with the resident and staff. Resident #75 also experienced inadequate pain management. The resident reported pain in her legs and hand, but her care plan and medical records lacked evidence of regular pain assessments or administration of prescribed pain medication. Although the resident had an order for Acetaminophen, there was no record of it being administered, nor were there any pain assessments documented in her chart. Interviews with staff revealed a lack of awareness and proactive management of the resident's pain. The deficiencies in pain management for both residents highlight a failure in the facility's processes to assess, document, and address pain effectively. The lack of timely and appropriate interventions, as well as the absence of pain assessments and medication administration, contributed to the residents' continued discomfort and unmet care needs. These findings were brought to the attention of the Director of Nursing and the Administrator, who acknowledged the issues identified during the survey.
Inadequate Infection Control in Water, Laundry, and Meal Services
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which is crucial for preventing the development and transmission of communicable diseases, including COVID-19. During a review of the facility's water management program, it was found that documentation was not maintained to prevent the growth of waterborne pathogens. Specifically, the facility lacked a detailed description of the building's water system, including a flow diagram identifying areas where Legionella control measures are necessary. The Maintenance Director confirmed that the facility did not maintain the water management program. Additionally, the facility's laundry services were found to be inadequate in preventing cross-contamination. An observation revealed that there was no sealed separation between the soiled and clean laundry areas, and the air flow vent was not operational, which was confirmed by the Laundry Supervisor. Furthermore, during meal services, a nurse aide was observed placing a tray back on a clean cart after a resident refused the meal, indicating a lack of understanding of proper infection control practices. These deficiencies had the potential to affect all 120 residents in the facility.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor the choices of a resident by not scheduling showers during the resident's preferred time of day. The resident expressed a preference for day showers to avoid going to bed with wet hair, a request that was not consistently honored. Despite the resident's repeated requests and stated preferences, the facility continued to alternate the resident's shower schedule between day and night shifts without providing a clear explanation for the changes. Interviews with staff, including an LPN and a nurse aide, confirmed the resident's dissatisfaction with the shower schedule. The staff acknowledged the resident's preference for day showers but indicated that the schedule was altered to accommodate another resident's request, resulting in an uneven distribution of showers between shifts. This inconsistency in honoring the resident's choice led to the deficiency noted during the survey process.
Deficiencies in Care Planning for Communication, Nutrition, Pain, and Positioning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, leading to deficiencies in communication, nutrition, pain management, and the use of positioning devices. For one resident with hearing difficulties, the care plan did not include the use of a wipe-off board, which was a necessary tool for effective communication. This omission was confirmed by the facility administrator after it was brought to their attention. Another resident experienced a significant weight loss of 14.92% over one month, yet there was no documentation in the medical chart indicating that the physician or the resident's representative had been notified, as required by the care plan. Additionally, this resident reported pain in their legs and hand, but the care plan lacked any pain assessments, which were supposed to be conducted regularly according to the care plan. A third resident was observed using a pommel cushion in their geriatric chair, but there was no order or care plan documentation for this device. A registered nurse confirmed that the cushion had been in use for about a month to prevent the resident from falling out of the chair. The facility administrator acknowledged the absence of an order or care plan for the pommel cushion.
Failure to Facilitate Resident Participation in Activities
Penalty
Summary
The facility failed to provide a program of activities that met the physical, mental, and psychosocial well-being of its residents, specifically affecting two residents. Resident #23 expressed that they were unable to attend activity programs because they were not assisted into their wheelchair. The resident's care plan indicated a preference for group activities, but records showed no participation in such activities for three consecutive months. Additionally, there was no documentation of activity preference interviews in the resident's current medical chart, and the facility administrator acknowledged the absence of group participation records. Resident #93 reported being unable to get out of bed due to discomfort from the mechanical lift sling and the lack of a chair for mobility. Observations confirmed that the resident remained in bed over two days, and interviews with staff revealed that the resident did not have a wheelchair or geriatric chair available. The Director of Rehabilitation confirmed the absence of a chair, stating it was removed because the resident never got up. The Activities Leader also confirmed that activities were only offered in the resident's room, as no one facilitated their participation in group activities.
Deficiency in Tube Feeding Documentation and Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for tube feeding, specifically for a resident who had a physician's order for tube feeding bolus if oral intake was less than 50% of meals. The Medication Administration Record (MAR) for the resident showed inconsistencies in documentation, with check marks indicating tube feeding bolus administration without specifying whether it was actually given. Additionally, there were instances where the resident's meal intake was less than 50%, yet the documentation did not clearly indicate if the tube feeding bolus was administered as required. The Licensed Practical Nurse (LPN) confirmed that the check marks on the MAR were meant to indicate that the meal intake percentage was obtained and tube feeding bolus was administered if necessary. However, the records lacked specific documentation of the amount of tube feeding the resident received each day. The LPN acknowledged that the dinner documentation was incorrect and that there was no record of the actual tube feeding amounts administered, highlighting a deficiency in the facility's documentation practices for tube feeding administration.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, which could potentially lead to foodborne illness affecting more than a limited number of residents. During an initial tour of the facility's kitchen, several items in the dietary walk-in refrigerator and freezer were found to be out of date. Specifically, chicken noodle soup, sliced cheese, and Parmesan cheese in the refrigerator had use-by dates that had passed. Additionally, pepperoni and tomato sauce in the freezer were also out of date, with the pepperoni showing signs of spoilage by being brown in color. The Dietary Manager confirmed that all these items were indeed out of date. The facility's policy on food storage, which references F-812, requires staff to inspect food items upon delivery for safe transport and quality, and to ensure proper storage, labeling, and dating of perishable foods, which was not adhered to in this instance.
Failure to Ensure Timely and Dignified Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal service, as observed in multiple instances. Resident #69 experienced a delay in receiving her meal tray, which was served after her roommate had already been served, despite her vocal complaints. Nurse Aide #63 confirmed that trays were served in no specific order, indicating a lack of organization in meal distribution. Similarly, Resident #100 was served her meal tray significantly later than other residents at the same table, resulting in her being served after others had nearly finished their meals. Nursing Assistant #60 acknowledged that trays were supposed to be served in order by table, but this was not happening due to the kitchen's disorganization. Additionally, Resident #75 received her meal tray much later than her roommate, Resident #23, due to the trays being placed incorrectly on the meal cart. The Dietary Manager and the Administrator both noted previous attempts to address this issue, but the problem persisted.
Failure to Provide Necessary Accommodations and Accessible Ombudsman Information
Penalty
Summary
The facility failed to accommodate the needs of a resident by not providing a geriatric chair for transportation to activities and other needs. The resident expressed discomfort with the mechanical lift sling and a desire to participate in activities like Bingo, but remained in bed over multiple observations. Interviews with staff, including a registered nurse and the Director of Rehabilitation, confirmed the absence of a chair for the resident. The Director of Rehabilitation mentioned that a bariatric geri-chair was previously available but was removed due to the resident not getting up, and there were no current orders for a wheelchair or geriatric chair. Additionally, the facility did not have the Ombudsman's contact information posted at a level accessible to residents in wheelchairs. Observations confirmed that the information was not at eye level for these residents, and the facility administrator acknowledged this issue. The deficiency in posting the Ombudsman's information could potentially affect more than a limited number of residents.
Confidentiality Breach: Unattended Computer Screen
Penalty
Summary
The facility failed to protect the confidentiality of resident records when a computer screen displaying resident information was left unattended in the hallway. This incident occurred at approximately 04:01 PM on 04/02/24, when a Registered Nurse (RN) was administering medication and left the computer screen on. Upon returning, the RN acknowledged the oversight, expressing surprise and noting it was an unusual occurrence for them.
Inaccurate MDS Assessment for Resident with Fall
Penalty
Summary
The facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for a resident reviewed for falls. The resident had a fall on February 4, 2024, resulting in a fractured right hip. However, the Significant Change/Medicare Five Day MDS Assessment with an Assessment Reference Date of February 16, 2024, incorrectly indicated that the resident had not experienced any falls since the prior assessment. This error was confirmed by the MDS Registered Nurse, who acknowledged that the MDS should have reflected the fall with a major injury.
Failure to Invite Resident Representative to Care Plan Conferences
Penalty
Summary
The facility failed to ensure that the resident and/or their representative was invited to care plan conferences, as required. This deficiency was identified during a random opportunity for discovery in the Long-Term Care Process. Specifically, the representative of a resident reported that they had only attended one care plan conference in the past year, which occurred shortly after the resident's admission to the facility. The Director of Social Services confirmed that the responsibility for sending out invitations to care plan conferences had been neglected after the departure of the Assistant Director of Nursing, who previously managed this task. A review of the care conference meeting sign-in sheets corroborated that the representative had only attended one out of six conferences in the past year.
Medication Administered Without Physician's Order
Penalty
Summary
The facility failed to provide care within acceptable standards by administering medication without a physician's order. This deficiency was identified during a long-term care survey process involving 30 residents, with one resident, identified as Resident #318, being directly affected. Resident #318 reported experiencing severe pain since their arrival at the facility due to a broken shoulder that had not healed over two and a half months. Despite their complaints of pain, the facility only provided Tylenol, which was ineffective, and there were no documented orders for any pain management interventions, including Tylenol. An interview with an LPN revealed that Tylenol was administered to Resident #318 without a physician's order, acknowledging the need to obtain an order for PRN Tylenol. The resident expressed dissatisfaction with the pain management, stating that they were told additional Tylenol was unavailable for several hours after the initial dose. The Director of Nursing and the Administrator were informed of the situation, highlighting the facility's failure to adhere to proper medication administration protocols.
Failure to Ensure Use of Palm Guard for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #8, had a palm guard in place as ordered by the physician to prevent further decrease in range of motion. During multiple observations over several days, it was noted that the resident did not have the palm guard on her left hand, despite having a contracture and experiencing muscle pain in her left hand and shoulder. The care plan for Resident #8 included the use of a palm guard on her left hand, with instructions to remove it only for hygiene purposes. However, the palm guard was not observed on the resident during the surveyor's visits. The interim Director of Nursing (DON) was unaware of the resident's refusal to wear the palm guard and attempted to investigate the situation. It was later discovered that the palm guard was in the laundry, and there was no documentation in the resident's medical record indicating refusal to wear it. The Treatment Administration Record (TAR) inaccurately reflected that the splint was applied on the resident on the days it was missing. An LPN confirmed that the palm guard was in the laundry and was not returned for two days, but it was eventually retrieved and placed on the resident.
Improper Storage of Insulin in Medication Carts
Penalty
Summary
The facility failed to store medications in accordance with professional standards of practice, specifically regarding the storage of insulin. During an inspection, two out of three medication carts were found to contain vials of Lantus (glargine) insulin that had been opened for more than 28 days, which exceeds the recommended usage period. For Resident #65, an opened vial of Lantus insulin was found in the 600 hallway medication cart with an opening date of 02/28/24, confirmed by RN #119. Similarly, for Resident #51, an opened vial of Lantus insulin was found in the 300 hallway medication cart with an opening date of 02/25/24, confirmed by LPN #89. Both residents had physician's orders for daily insulin administration, and the product information for Lantus insulin specifies that opened vials should be used within 28 days.
Incomplete and Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to ensure complete and accurate medical records for two residents. For one resident, there was a physician's order to apply heel protectors while in bed and at rest, every shift, and as needed for pressure relief. However, observations over several days showed the resident was not wearing the heel protectors, and staff confirmed the resident refused to wear them. Despite this, the Treatment Administration Record inaccurately indicated that the resident wore the heel protectors every shift. For another resident, the care plan included a diagnosis of Post-traumatic Stress Disorder (PTSD), but this diagnosis was not documented in the resident's medical records. The administrator acknowledged the missing diagnosis and confirmed that it should have been included in the records. These deficiencies highlight a lack of accurate documentation and record-keeping in the facility.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 122 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Moundsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continuing Healthcare Of Shadyside | 2.9 mi | ★★★★★ | 6 | 0 |
| Country Club Retirement Ctr Iv | 6.7 mi | ★★★★★ | 18 | 0 |
| Continuous Care Center Wheeling Hospital | 9.9 mi | ★★★★★ | 0 | 0 |
| Rolling Hills Rehab And Care Ctr | 10.1 mi | ★★★★★ | 9 | 0 |
| Peterson Rehabilitation And Healthcare | 10.6 mi | ★★★★★ | 8 | 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.